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Surgery EOR > Pre/Post Op > Flashcards

Pre/Post Op Flashcards

1
Q

when does DVT MC occur post-op

A

days 3-5

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2
Q

positive Homan sign

A

pain to the calf with dorsiflexion of foot

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3
Q

dorsiflexion

A

the action of raising the foot upwards towards the shin

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4
Q

if you think someone may have a DVT what screening modality FIRST

A

LE Doppler US

If there is low probability –> D Dimer first; if positive then US

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5
Q

most commonly used prophylactic measures for DVT before surgery

A

anticoagulation therapy such as low-dose unfractionated heparin 2 hours before surgery and every 8 to 12 hours after surgery until the patient is mobile along with intermittent pneumatic compression

pts should be mobile ASAP

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6
Q

What risk factors make up the Virchow triad?

A

Venous stasis, endothelial damage, and hypercoagulability

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7
Q

what veins are MC affected by DVT in LE

A

superficial femoral and popliteal veins in the thigh
the peroneal and posterior tibial veins

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8
Q

Examples of causes of vascular endothelial injury from virchows triad

A

surgery (total hip replacement), central venous catheterization, and trauma. In upper extremity DVT, endothelial injury due to central venous catheter, pacemaker, or injection drug use is the major causative factor

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9
Q

for what D Dimer level should an US be ordered

A

greater than 500 mg/L

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10
Q

definitive dx DVT

A

venography, but it is associated with increased risks and is rarely used in the clinical setting

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11
Q

study of choice for diagnosing PE

A

CT angiography

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12
Q

what do you use to diagnose PE if CT angiography is unavailable or contraindicated

A

ventilation-perfusion lung scan

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13
Q

What is phlegmasia alba dolens?

A

A rare complication of deep vein thrombosis (DVT) in pregnancy where the leg turns milky white

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14
Q

where does a pulmonary embolism arise from

A

often arises from thrombi in the systemic venous circulation or the right side of the heart but can also arise from invasive tumors in the venous circulation

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15
Q

what things cause a hyper coagulable state for virchows triad

A

autoimmune diseases, malignancy, use of oral contraceptives, pregnancy, genetic disorders such as factor V Leiden, and protein C or S deficiency

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16
Q

what things cause venous stasis for virchows triad

A

immobilization, chronic venous insufficiency, varicose vein, and paresis due to stroke

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17
Q

sx pulmonary embolism

A

sudden onset of dyspnea accompanied by pleuritic chest pain, apprehension, cough, hemoptysis, and diaphoresis

may have concomitant DVT

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18
Q

PE for pulmonary embolism

A

tachycardia
tachypnea
crackles
low grade fever

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19
Q

what D Dimer level can exclude a pulmonary embolism

A

< 500 ng/mL

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20
Q

what criteria score can rule out PE

A

well’s score

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21
Q

what will EKG show for PE

A

ECG shows sinus tachycardia and nonspecific ST-T findings. The classic S1Q3T3 (large S wave in lead I, Q wave in lead III, inverted T wave in lead III) that indicates cor pulmonale is seen in a minority of patients with pulmonary embolism

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22
Q

what will chest radiograph show for PE

A

nonspecific abnormalities such as Westermark sign (vascular cutoff sign) and Hampton hump (pleural-based wedge infarct), although they may also be normal

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23
Q

A normal chest X-ray in the presence of _______ is suspicious for pulmonary embolism

A

hypoxia

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24
Q

what will a ventilation-perfusion lung scan show for PE

A

perfusion defects with normal ventilation

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25
Q

what is the imaging test of choice for PE

A

CT pulmonary angiography
Pulmonary angiography is gold standard but not used commonly due to wide use of CT pulmonary angiography

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26
Q

what med is often given initially for PE tx

A

LMWH

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27
Q

when is Inferior vena cava filter used for tx of PE

A

used in hemodynamically stable patients who have failed or cannot tolerate anticoagulation

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28
Q

Patients who are at high risk for major bleeding events may be managed with

A

intermittent pneumatic compression or early ambulation, or, when chemical prophylaxis is used, very close monitoring for bleeding events

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29
Q

Wells Criteria for PE

A

signs and symptoms of deep vein thrombosis (3 points), PE is the most likely diagnosis (3 points), heart rate > 100 bpm (1.5 points), immobilization ≥ 3 days or surgery in the previous 4 weeks (1.5 points), previous objectively diagnosed DVT or PE (1.5 points), hemoptysis (1 point), and malignancy with active treatment in the past 6 months or under palliative care (1 point)

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30
Q

wells score of 0-4

A

PE unlikely

this score + negative D dimer = rule out PE

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31
Q

wells score > 4

A

PE likely
further workup warranted

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32
Q

when should fibrinolytic therapy be administered for PE

A

Fibrinolytic therapy should only be administered in unstable patients who demonstrate refractory hypotension and who do not have contraindications to thrombolysis

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33
Q

What is the McGinn-White sign?

A

S1Q3T3 pattern on ECG associated with pulmonary embolism

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34
Q

Vitamin K-dependent clotting factors include

A

factors II, VII, IX and X

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35
Q

how is warfarin efficacy measured

A

prothrombin time or international normalized ratio (INR)

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36
Q

pt on warfarin: If the INR is greater than the goal but less than 5

A

skip the next dose

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37
Q

pt on warfarin: If the INR is 5–10 and the patient is not at risk of bleeding

A

skip the next 1-2 doses

you can administer vitamin K if they are about to undergo surgery

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38
Q

pt on warfarin: If the INR is > 10 and there is no bleeding or a low-moderate risk of bleeding

A

hold warfarin
administer vitamin K

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39
Q

pt on warfarin: life-threatening bleed

A

hold warfarin
administer vitamin K
administer fresh frozen plasma

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40
Q

are pts w DM more likely to become hyper or hypoglycemic after surgery

A

hyperglycemic - maybe due to stress?

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41
Q

how long should metformin be withheld before surgery

A

24 h

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42
Q

how long should sulfonylureas be withheld before surgery

A

48-72 h

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43
Q

how long should ASA be stopped before surgery

A

one week

44
Q

should beta blockers or levothyroxine be D/C before surgery

A

no

45
Q

What is the best way to manage hyperglycemia during surgery?

A

A continuous intravenous insulin infusion

46
Q

sx hypoglycemia

A

neurogenic symptoms (palpitations, tremor, hunger, sweating, and anxiety) and neuroglycopenic symptoms (irritability, weakness, drowsiness, headache, confusion, convulsions, coma, and even death)

47
Q

dx hypoglycemia

A

serum blood glucose falls below 60 mg/dL

48
Q

when does cognitive impairment develop for hypoglycemia

A

when blood glucose levels are < 50 mg/dL

49
Q

Whipple triad

A

history of hypoglycemic symptoms, a fasting glucose level of 45 mg/dL, and immediate recovery on the administration of glucose

50
Q

what is the Whipple triad suggestive of

A

insulinoma

51
Q

if pt can’t eat or drink, how should you treat hypoglycemia

A

IV dextrose

glucagon can also be administered

52
Q

what does protein status help predict

A

wound healing and the risk of surgical complications

53
Q

Protein status is often measured by the following three laboratory measures:

A

serum albumin, serum transferrin, and serum prealbumin

54
Q

what can be used to assess short-term changes in nutritional status

A

prealbumin

55
Q

True or false: parenteral nutrition is preferred over enteral nutrition

A

False, enteral nutrition is preferred when possible

56
Q

RF for stable angina

A

tobacco use, hypertension, hyperlipidemia, diabetes mellitus, and obesity

57
Q

common sx of stable angina

A

deep, radiating chest pain that is triggered by a period of exertion and is relieved by rest

this is a common presenting symptom of coronary artery disease

58
Q

diagnostic testing for stable angina

A

obtaining a baseline ECG and serum cardiac markers such as troponin

59
Q

tx stable angina

A

Management of anginal symptoms includes the use of beta-blockers, calcium channel blockers, long-acting nitrates (such as isosorbide mononitrate), ivabradine, and ranolazine. Antiplatelet therapy, such as aspirin or clopidogrel, and a lipid-lowering agent, such as atorvastatin or rosuvastatin, should be initiated to prevent future cardiovascular events.

Patients with symptoms refractory to pharmacologic management should undergo coronary artery revascularization

60
Q

when should unstable angina be suspected

A

Unstable angina should be suspected in a patient with chronic angina with increasing frequency, duration, or intensity of chest pain; a patient with new-onset angina that is severe and worsening; or a patient with angina at rest.

61
Q

sx unstable angina

A

retrosternal chest pain or “pressure” that occurs at rest. Chest pain may radiate to the jaw, arms, back, shoulders, or epigastrium and may be associated with dyspnea, nausea, diaphoresis, or syncope

62
Q

diagnosis of unstable angina

A

esting ECG, which may show a normal sinus rhythm but may also show ST segment depressions. Stress test with ECG often shows signs of ischemia, such as ST segment depression, although stress test should not be done during an acute episode. Laboratory studies reveal normal cardiac enzymes, including normal troponin and CK-MB

recheck cardiac markers after 6 hours

63
Q

tx unstable angina

A

Nitroglycerin and morphine can be administered for pain control. Because unstable angina has a risk of progressing to myocardial infarction, aggressive medical management is indicated. Mortality-lowering therapy includes dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, heparin, and a beta-blocker. Oxygen therapy should be given if the patient is hypoxic. Cardiac catheterization or revascularization should be performed within 1 to 2 days of admission, depending on the response to medical therapy and the results of a stress test. After acute management of unstable angina, the patient should continue daily aspirin, beta-blocker (metoprolol), nitrates, and a statin regimen

64
Q

initial interventions for a STEMI

A

stabilizing the patient, continuous cardiac monitoring, measuring serial troponins, aspirin 325 mg, sublingual nitroglycerin tablets, a beta-blocker, and a statin

65
Q

what is the most important aspect of STEMI treatment

A

restoration of myocardial blood flow

66
Q

primary reperfusion therapies for STEMI

A

Primary percutaneous coronary intervention (PCI) and fibrinolytic therapy

67
Q

which of the primary reperfusion therapies for STEMI is preferred

A

PCI is preferred if it can be performed within 120 minutes of first medical contact. Patients with symptom onset of < 2 hours in whom PCI cannot be performed in a timely manner should receive a fibrinolytic therapy (e.g., tenecteplase, reteplase, alteplase) with close monitoring and transfer to a facility where PCI can be performed

68
Q

initial medical tx after dx of STEMI is confirmed

A

Aspirin and a P2Y12 receptor blockers such as ticagrelor or prasugrel

anticoagulation therapy such as unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux

69
Q

The most common indications for urgent preoperative dialysis are

A

hyperkalemia and volume overload

70
Q

what EKG changes are consistent with hyperkalemia

A

tall and peaked T waves
shortened QT interval
ST segment depression

when more severe:
prolonged PR interval
decreased or disappearing P waves
widening of the QRS complex

71
Q

who should undergo dialysis before surgery

A

Patients who have hyperkalemia with a potassium of at least 6.3 mEq/L or who have any level of hyperkalemia with electrocardiogram changes must be dialyzed prior to surgery

72
Q

in patients who do need dialysis, how before surgery should they undergo dialysis?

A

2 hours before – but ideally the day before

73
Q

sx hyperkalemia

A

muscle weakness, flaccid paralysis, cardiac dysrhythmias, and ileus

74
Q

in what pts is hyperkalemia MC

A

advanced kidney disease
Addison disease
Rhabdomyolysis
Burns
infection
vigorous exercise
metabolic acidosis
ACE’s
Potassium sparing diuretics (Spironolactone)

75
Q

treatment for hyperkalemia when stable and no kidney impairment

A

calcium chloride
Intravenous insulin
dextrose
sodium bicarbonate
a beta-agonist such as albuterol

76
Q

which of the therapies for hyperkalemia helps to stabilize the heart

A

calcium chloride

77
Q

when is hemodialysis used to tx of hyperkalemia

A

renal impairment
unstable

78
Q

other meds that can help excrete potassium

A

Loop diuretics and sodium polystyrene

79
Q

Medical comorbidities that increase the risk of surgery

A

diabetes (especially insulin-dependent patients)
hypertension
chronic kidney disease cerebrovascular disease peripheral artery disease ischemic heart disease

80
Q

Surgeries with high cardiac risk

A

laparoscopic total abdominal colectomy with ileostomy breast reconstruction with free flap
open cholecystectomy
open ventral hernia repair of incarcerated or strangulated hernia
Whipple procedure

81
Q

what are the models that can provide a percentage risk of perioperative cardiovascular events

A

revised cardiac risk index (RCRI) and the American College of Surgeons surgical risk calculator (ACS-SRC)

82
Q

what percentage would place a pt in the “high percentage” category for cardiac risks for surgery

A

risk of death at least 1%

83
Q

Common postoperative pulmonary complications include

A

atelectasis, pneumonia, and venous thromboembolism

84
Q

Atelectasis

A

the loss of lung volume caused by lung tissue collapse

85
Q

Physical exam findings for atelectasis

A

bronchial breathing and hypoxemia

86
Q

chest XR for atelectasis

A

tracheal shift toward the affected side

87
Q

first line post-op interventions to prevent pulmonary complications

A

incentive spirometry
chest physical therapy

88
Q

what days post-op does postoperative pneumonia tend to occur

A

days 5-10

89
Q

what is the most common pulmonary complication among patients who die after surgery

A

postoperative pneumonia

90
Q

sx post-op pneumonia

A

cough, fever, leukocytosis, and increased secretions

may need more oxygen

91
Q

Physical exam findings pneumonia

A

tachypnea, increased work of breathing, and adventitious breath sounds, including rales or crackles and rhonchi. Increased tactile fremitus, egophony, and dullness to percussion also suggest pneumonia

92
Q

Risk factors for developing postoperative pulmonary complications include

A

advanced age, prolonged surgery time, heart failure, smoking, asthma, and chronic obstructive lung disease

93
Q

prevention of pulmonary complications in those with well-controlled asthma if endotracheal tube is needed

A

administration of an inhaled rapid-acting beta-agonist or nebulized treatment within 30 minutes prior to surgery if endotracheal intubation is needed

94
Q

What should the peak expiratory flow rate be for patients with asthma before elective surgery

A

greater than 80% of their predicted value

95
Q

An infection is considered community-acquired if one of the following is true:

A

the infection is diagnosed in an outpatient setting, there is no prior MRSA infection, there is no recent history of hospitalization, and there are no indwelling catheters or other percutaneous medical devices present

96
Q

tx for hospital acquired MRSA

A

IV Vanc

97
Q

tx for community acquired MRSA

A

clindamycin, trimethoprim-sulfamethoxazole, and tetracyclines

bc remember you can’t use beta lactams

98
Q

when is central venous access indicated

A

patients with difficult IV access, hemodynamic monitoring, administration of vasopressors, extended administration of antimicrobial therapy, parenteral nutritional support, or chemotherapy

99
Q

what are the three ways through which you can gain central venous access

A

internal jugular vein, subclavian vein, or femoral vein

100
Q

for central venous access: which vein has the lowest risk of infection and thrombosis

A

subclavian vein

101
Q

for central venous access: which vein has the highest risk of pneumothorax

A

subclavian vein

102
Q

for central venous access: which vein is associated with the highest risk of thrombosis

A

femoral vein

103
Q

for central venous access: which vein is associated with the highest risk of infection

A

femoral vein

104
Q

Maintenance fluids

A

meeting the daily requirements for fluid and electrolyte intake, including correcting any deficits already present

105
Q

preferred fluids in pre-op pts

A

lactated ringers

106
Q

preferred fluids if ongoing fluid loss

A

Normal or half-normal saline

107
Q
A

Surgery EOR (7 decks)

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