Pre/Post Op Care - 12% Flashcards
Cardiac Disease
Prior hx of MI - 5 to 10% risk of postop MI
- Preop EKG on all 40yo+
- current unstable angina = avoid elective surgeries
- control stage 3 HTN prior to sx
- take BBs, CCBs, statins, a-agonists on day of procedure
- ACE-I and ARBs - hold night before sx unless for HF or poorly controlled HTN
- hold diuretics morning of sx
- if + rheumatic heart dz => prophy abx therapy Cefazolin, Cefuroxime, Vanc, clinda
- refer to cardiologist for stress test or echo
Non-invasive stress testing before noncardiac ops for pts with
- active cardiac conditions (ACS, arrhythmias or severe valvular dz)
- clinical risk factors, poor functional capacity
Coronary revasc in
- LCA stenosis
- stable angina w/ 3 coronary vessel dz
- stable angina with > 2 vessel dz
- Significant proximal LAD coronary artery stenosis w/ EF <50% or ischemia
- High risk unstable angina or non ST seg elevation MI, or STEMI
Deep Venous Thrombosis
Clot formation in veins, pain in calf
Virchow’s Triad
- Stasis - post surgical, immobility, venous insufficiency
- Hypercoaguable states - factor V Leiden, cancer, OCP+Smoking, preg
- Trauma - surgery cellulitis
Sxs
- edema of one extremity
- positive Homan’s sign
Dx
- Venous Duplex US - first line
- D Dimer - if negative r/o DVT
- Venography - gold but rarely done
Tx
- IV Heparin => switch to Warfarin
- Recurrent DVT req’s lifetime anticoag
Electrolyte Disorder
Na, K, Ca
Hyponatremia
- <135 mmol/L
- muscle cramps and seizures - look at volume status
- No sxs - free water restriction
- Mod hypoNa - IV NS or loop
- severe = hypertonic 3% saline
Hypernatremia
- Na >145 mmol/L
- Incr BUN/Cr ration >20:1
- Tx - IV D5W
- rapid correction = cerebral edema and pontine herniation
Hyperkalemia
- >3 to 5.5 mEq/L
- Peaked T waves, prolonged QRS, muscle fatigue
- Tx = Insulin, sodium bicarb and glucose, calc gluconate
Hypokalemia
- <3.5 mEq/L
- Muscle cramps, constipation, flattened/inverted T waves, U waves
- Tx - don’t use Dextrose containing fluid, replace K
- replace Mg
Hypocalcemia
- < 8.4 mg/dL; ionized fraction of Ca < 4.4mg/dL
- QT prolongation, Trousseau’s sign, Chvostek’s sign
- Low Ca, Low PTH, high phosphate
- prolonged QT
- Tx - IV ca Gluconate
Hypercalcemia
- > 10.5 mg/dL
- Stones, bones, abd groans, psychiatric moans, EKG, shortened QT intvl
- Tx - IV normal saline and furosemide
Electrolyte Disorder
Mg, Phos
Hypomagnesemia
- Mg < 1.5 mg/dL
- muscle weakness, incr DTR, tetany, prolonged QTR, wide QRS, peaked T waves
- a/w hypoKalemia
- Tx - IV Mg Sulfate - acute, or PO if chronic
Hypermagnesemia
- Mg > 2.5 mg/dL
- diminished DTRs, respiratory failure, CNS depression, hypotension, bradycardic, , heart block, prolonged QT, PR and widened QRS
- Tx - IV Isotonic Saline
Hypophosphatemia
- < 2.5 mg/dL
- Weakness, cardiomyopathy, ataxia, rhabdo, hemolysis, bone pain, osteomalacia
- Tx - IV potassium phosphate or sodium phosphate replacement
Hyperphosphatemia
- > 4.5 mg/dL
- eti - CKD
- asymptomatic, or calcifications, heart block
- Tx - aluminum hydroxide - phosphate binder
Fluid/Volume Disorders
Volume overload or depletion
Reduced kidney fx post-op, esp after cardiac procedures
- Reduce risk - push lfuids, avoid NSAID and IV contrast
Maintenance Fluid
- pt wt x 30 = fluid over 24 hrs
- Incr req’s if fever, hyperventilation
- daily maintenace for sensible and insensible los s= 1500-2500mL
2000-2500mL of 5% Dextrose NS or LR daily
-
dont add K during first 24 hrs (incr from surgery stress)
- then add 20mEq K/mL
- If extra renal losses >1.5L/d, measure electrolytes and compensate fluid
- Replace post op ionized serum Ca for thyroidectomy or parathyroidectomy
- Urinary cath if
- long procedure
- performing urologic or lower pelvic sx
- need to monitor fluid balance
Hematologic Disease
Anticoagulation Use
- Aspirin, warfarin, clopidogrel - d/c 7 d prior to surgery
- Pre-op aspirin continue for high risk CAD pts
- Thienopyridines/ticlopidine or clopidegrol for CVA prophy - dc 7 to 10 d before
- PO anticoag stopped 3-5d before sx; heparin may be administered until 6 hrs before operation
- resume Heparin 36-48 hrs postop w/ PO anticoags
Hematologic Disease
Risk of VTE
Higher rates of DVTs in general surgery and colorectal patients
Scoring system - developing postop VTE
- Caprini Score for VTE
-
American College of Chest Physicians (ACCP)
- Very low risk - ambu alone
- Low risk - mechanical prophy w/ intermittent pneumatic compression devices (IPC)
-
Moderate Risk - bridging anticoags +
- LMWH OR unfr/SQ Hep OR IPC
-
High risk - briding anticoags +
- IPC + LMWH (enoxaparin/lovenox) or SQ/unfr Hep
- 4 mos LMWH for abd resections or pelvic malignancies
- if patient is on warfarin -> hold 1 wk prior to sx, put on LMWH/Enoxaparin, remain on LWMH 1wk post op before returning to warfarin
- IPC + LMWH (enoxaparin/lovenox) or SQ/unfr Hep
Metabolic Disease
Hx of DM, adrenal insufficiency
Assess at admission for DM and blood glucose testing
- manage stress/surgery induced diabetes discharge planning
- Blood glucose can be elev periop d/t emotional and physio stress
- ele postop blood gucose level = higher chance of surgical site and post op infx
- surgical site if >140 mg/dL predictor of infx
- IV insulin - best for periop glucose control
- higher risk of concomitant heart disease
- tx w/ Periop hyperglycemia - IV short acting insulin or SQ sliding scale insulin
Postop glycemic control
- Normal - 90 to 100 mg/dL preferred; control w/ IV Insulin
- Mod control = 120 to 200 mg/dL
Postop monitoring for Hyper/hypoglycemia, poor healing and wound issues, CVD x2 for M, x4 for W
Post-Operative Fever
6 Ws
Wind
- 1-2 d
- atelectasis, PNA, medication??
Water
- 2-3d
- UTI
Wound
- 3-5d
- infection - MC Staph
Walking
- 3-5d
- DVT or VTE
Wonder drugs
- >1 wk post op - anesthesia, sulfa drugs, etc
Pulmonary Disease
COPD, Asthma, Restrictive LD, PNA
COPD
- patient should stop smoking 8 wks before scheduled surgery
- Treat aggressively to achieve best possible baseline function
- minimum 1 week tx = stop smoking, abx for purulent sputum, and bronchodilators
Asthma
- Poorly controled asthma = step up in tx = brief systemic CS if FEV1 or peak flow < predicted value
- elective sx = no wheezing, peak flow > 80% of predicted
- endotrach intubation = rapid acting B-agonist 2-4 puffs or neb within 30 mins before intubation
Pulmonary Fibrosis and Restrictive Lung Disease
- Tx infection
- removal of sputum
- smoking cessation
Acute Lower Respiratory Tract Infections (tracheitis, bronchitis, PNA)
- absolute contraindications to elective sx
- emergency sx
- humidification of inhaled gas
- remove lung secretions
- continued administration of bronchodilators and abx
Pulmonary Disease
General
MC perioperative complications; stop smoking at least 1mo before sx
Two determinants of risk = operative site (higher site = more complications) and presence of lung disease
Control asthma
- pts w/ mild pulm dz undergoing non abd or thoracic sx = do not need PFT
-
Simple spirometry w/ measured FEV
- if FEV is reduced, measure response with bronchodilators and ABGs
- Increased risk if FEV1 < 50% of nl and PaCO2 > 45mm
-
Simple spirometry w/ measured FEV
Tx:
-
Pre-op
- cigarette cessation
- abx for Lower RTI
-
Intra-op
- Gen Anesth >3-4 hrs = higher risk
- Low Tidal Volume ventilation (6 to 8mL per kg of predicted bw; PEEP at 6 to 8cm of water, recruitment maneuvers q 30m)
-
Post-Op
- pain control for early ambulation
- incentive spirometry/ deep breathing
Substance Abuse
- Venous Access = damage veins d/t IVDU, thrombosed superficial veins
- Arterial Injury = to get deep venous access - can cause arterial injury
- risk at Femoral region - critical ischemia
- Abscess formation & gas gangrene
- Tissue compression and crush injury
- Refrain from illicit drug use - a few weeks before sx
- Quit ETOH drinking for at least 1 wk before sx
Tobacco Use/Dependence
a/w higher risk of complications, delayed wound healing
Pt should stop smoking at least 8 wks before sx; nicotine gum not allowed
Cessation Benefits
- reduce vasoconstruction and irregular HR
- More O2 to surgical wound sites, less clotting
Helping pt quit
- Bupropion - begin 1-2 wk before quit date
- Nicotine gym or lozenges on day of surgery instead of cigarette
Tremors ddx
Rest Tremors
- Parkinson’s Dz
- Wilson’s dz
- Essential Tremor
Postural and Action (Terminal) Tremors
- Physiological
- Exaggerated physio
- Stress, fatigue, anxiety, emotion
- Endocrine - hypoglycemia, thyrotoxicsis, pheochrom
- Drugs - B-agonist, dopamine ago, amph, lithium, valproate, TCA, etoh wdraw
- Essential tremor - familial or sporadic
- Primary writing tremor
- CNS disorder
- W/ peripheral neuropathy
- Charcot-Marie-Tooth
- Cerebellar tremor
Kinetic (Intention) tremor
- Cerebellar outflow (dentate nucleus and superior cerebellar penducle
Wound Infections
btwn 5th and 10th after surgery
MC - S aureus, E coli, Clostridium (bronze-brown weeping tender wound)
Sxs:
- pain at incision site
- erythema, drainage, induration
- warm, fever
Dx
- CBC, leukocytosis
- blood cultures
Tx
- Remove skin sutures/staples
- send wound culture
- admin abx
- delayed closure - wound open by infx - heal by secondary intention
