Preop

Question 1

Ejection fraction______ (normal 55%) poses prohibitive cardiac risk for elective non-cardiac operations

Answer 1

<35%

Question 2

In pts with EF of less than 35%

Answer 2

Incidence of peri-operative myocardial infarction (MI) could be as high as
75-85%, and mortality for such an event as high as 50–90%.

Question 3

___________, which indicates the presence of CHF, is the worst single finding predicting high cardiac risK

Answer 3

Jugular venous distention

Question 4

__________is the next worse predictor of cardiac complications. Operative mortality within 3
months of the infarct is 40%, but drops to 6% after 6 months

Answer 4

Recent MI

Question 5

Smoking is by far the most common cause of increased pulmonary risk, and the problem is
compromised ___________

Answer 5

ventilation (high Pco2, low forced expiratory volume in 1 second [FEV1]), rather than compromised oxygenation

Question 6

Cessation of smoking for _________weeks and intensive respiratory therapy (physical therapy,
expectorants, incentive spirometry, humidified air) should precede surgery

Answer 6

8

Question 7

Severe nutritional depletion is identified by one or more of the following:

Answer 7

• Loss of 20% of body weight over 6 months
• Serum albumin <3 g/dL
• Anergy to skin antigens
• Serum transferrin level <200 mg/dl

Question 8

Features of malignant hyperthermia

Answer 8

Temperature >104°F and metabolic acidosis, hypercalcemia, and hyperkalemia also occur

Question 9

Postoperative fever 101–103° F is caused (sequentially in time) by 
1
2
3
4
5

Answer 9

atelectasis, pneumonia, UTI, deep venous thrombophlebitis, wound infection, or deep abscesses

Question 10

Cause of fever on D3 PO

Answer 10

Pnx and UTI

Question 11

Deep thrombophlebitis typically produces fever starting around __________

Answer 11

post-operative day 5.

Question 12

Wound infection typically begins to produce fever around post-operative _________

Answer 12

day 7.

Question 13

Post op MI MR

Answer 13

Mortality is 50-90%and

greatly exceeds that of MI not associated with surgery

Question 14

typically occurs around post-operative day 7 in elderly and/orimmobilized patients.

The pain is pleuritic, sudden onset, and is accompanied by shortness of breath

Answer 14

PE

Question 15

PE ABG

Answer 15

hypoxemia and often hypocapnia.

Question 16

If a PE recurs while anticoagulated or if anticoagulation is contraindicated, place_________

Answer 16

an inferior vena cava (Greenfield) filter to prevent further embolization from lower extremity deep venous thromboses

Question 17

____________ can develop in patients with traumatized lungs once they are subjected to positive-pressure breathing.

Answer 17

Intraoperative tension pneumothorax

Question 18

________ is the first suspect when a post-operative patient becomes confused and disoriented.
________ is another prime cause

Answer 18

Hypoxia

Sepsis

Question 19

Adult respiratory distress syndrome (ARDS) is seen in patients with a complicated post-op
course, often complicated by ________ as the precipitating event

Answer 19

sepsis

Question 20

DT happens on what day post op?

Answer 20

Delirium tremens (DTs) is very common in the alcoholic whose drinking is suddenly interrupted
by surgery. During post-operative day 2 or 3, the patient gets confused, has hallucinations,
and becomes combative

Question 21

mortality is high, especially in

young women; the best management is prevention by including sodium in IV fluids

Answer 21

Acute hyponatremia

Question 22

Surgical damage to the posterior pituitary with

unrecognized diabetes insipidus is a good example causing this

Answer 22

Hypernatremia

Question 23

____________ is a common source of coma in the cirrhotic patient with bleeding
esophageal varices who undergoes a portocaval shunt

Answer 23

Ammonium intoxication

Question 24

Low urinary output (<0.5 ml/kg/hr) in the presence of normal perfusing pressure (i.e., not
because of shock) represents either ______ or ______

Answer 24

fluid deficit or acute kidney injury

Question 25

How to test perfusion in pts with low UO?

Answer 25

A low-tech diagnostic test is a fluid challenge: a bolus of 500 ml of IV fluid infused over 10 or 20 minutes. Dehydrated patients will respond with a temporary increase in urinary output, whereas those in renal failure will not do so

Question 26

A more scientific test for hyponatremia is to measure urinary sodium: it will be__________ in the dehydrated patient with normally functional kidneys, while it will exceed _________ in cases of renal failure

Answer 26

<10 or 20 mEq/L 40 mEq/L

Question 27

In order to calculate the FeNa, plasma and urinary sodium and creatinine must be measured. In acute kidney injury, the ratio______; in hypovolemia it is______

Answer 27

>2 <1.

Question 28

Early mechanical bowel obstruction because of_______can happen during the postoperative period. What was probably assumed to be paralytic ileus not resolving after ____ days is most likely an early mechanical bowel obstruction

Answer 28

adhesions 5-7

Question 29

______________or pseudo-obstruction is a poorly understood (but very common) condition that could be described as a “paralytic ileus of the colon.”

Answer 29

Ogilvie syndrome

Question 30

Usual pts where Ogilvie syndrome is common

Answer 30

``` It does not follow abdominal surgery but is classically seen in elderly sedentary patients (Alzheimer, nursing home) who have become further immobilized owing to surgery elsewhere (broken hip, prostatic surgery). ```

Question 31

Wound dehiscence is typically seen around post-operative day 5 after open laparotomy. The wound looks intact, but large amounts of pink, “salmon-colored” fluid are noted to be soaking the dressing; this is_________

Answer 31

peritoneal fluid.

Question 32

Mx of wound dehiscence

Answer 32

Reoperation is needed to avoid peritonitis and evisceration

Question 33

________ is a catastrophic complication of wound dehiscence, where the skin itself opens up and the abdominal contents rush out

Answer 33

Evisceration

Question 34

Fistula of the GI tract If it does not empty completely to the outside but leaks into a cavity which then leaks out, what will develop?

Answer 34

an abscess may develop and lead to sepsis; complete drainage is the required treatment

Question 35

What is needed to keep the patient alive until nature heals the fistula?

Answer 35

Fluid and electrolyte replacement, nutritional support (preferably elemental diets delivered beyond the fistula), and compulsive protection of the abdominal wall (frequent dressing changes, suction tubes, “ostomy” bags)

Question 36

Every 3 mEq/L that the serum sodium concentration is >140 represents roughly ___________

Answer 36

1 L of water lost.

Question 37

IVF to correct hypernatremia

Answer 37

This is achieved by using D51⁄2 NS | rather than D5W

Question 38

If the hypernatremia develops rapidly (i.e., in osmotic diuresis, or diabetes insipidus), it will produce CNS symptoms (the brain has not had time to adapt), and correction can be safely done with more diluted fluid _________

Answer 38

(D51⁄3 NS, or even D5W).

Question 39

patient who starts with normal fluid volume adds to it by retaining water because of the presence of inappropriate amounts of ______________

Answer 39

ADH (e.g., post-op water | intoxication, or inappropriate ADH secreted by tumors).

Question 40

Another scenario for hyponatremia In the other scenario, a patient who is________________ if he has not received appropriate replacement with isotonic fluids

Answer 40

losing large amounts of isotonic fluids (typically | from the GI tract) is forced to retain water

Question 41

In the case of the hypovolemic, dehydrated patient losing GI fluids and forced to retain water, volume restoration with _____________ will provide prompt correction of the hypovolemia

Answer 41

isotonic fluids (NS or Lactated Ringer’s)

Question 42

Remember that the safe “speed limit” of IV potassium administration is ________

Answer 42

10 mEq/hr.

Question 43

``` The ultimate therapy for hyperkalemia is hemodialysis, but while waiting for it we can help by “pushing potassium into the cells” (_________), sucking it out of the GI tract (NG suction, _________), or neutralizing its effect on the cellular membrane (___________ ```

Answer 43

50% dextrose and insulin exchange resins such as Kayexelate if the patient’s bowels are working IV calcium).

Question 44

Causes of Metabolic Acidosis

Answer 44

• Excessive production of fixed acids (diabetic ketoacidosis, lactic acidosis, low-flow states) • Loss of buffers (loss of bicarbonate-rich fluids from the GI tract) • Inability of the kidney to eliminate fixed acids (renal failure)

Question 45

Metabolic alkalosis occurs from______ and _____

Answer 45

loss of acid gastric juice, or from excessive administration of bicarbonate (or precursors).

Question 46

Mx of Met alk

Answer 46

In most cases, an abundant intake of KCl (5–10 mEq/h) will allow the kidney to correct the problem. Only rarely is ammonium chloride or 0.1 N HCl needed

Question 47

Respiratory acidosis and alkalosis result from _____ and _________

Answer 47

``` impaired ventilation (acidosis) or abnormal hyperventilation (alkalosis). ```