preop and post op

Question 1

when is EF too low for surgery

Answer 1

under 35. incidence of preoperative MI would deb 75-85% and mortality for that would be 55-90%

Question 2

what is the single worst finding producing high cardiac risk for surgery

Answer 2

JVD- indicates CHF. if at all possible, tx with ACE inhibitors, BB, digitalis, and diuretics should precede surgery

Question 3

what is the second worst predictor of cardiac complications

Answer 3

recent transmural or subendocardial MI. operative mortality within 3 months of the infarct is 40%, but it drops to 6% after 6 months, but it drops 6% after 6 months

Question 4

what is the problem that smoking poses to preop

Answer 4

compromised ventilation (high PCO2, low FEV1) rather than compromised oxygenation. must stop smoking for 8 weeks and intensive respiratory therapy precede surgery

Question 5

predictors of mortality in hepatic risk pre-op

Answer 5

bilirubin (hepatocellular function) serum albumin, PT, ascites, encephalopathy

Question 6

onset of anesthesia (halothane or succinylcholine)-> temp>104

Answer 6

malignant hyperthermia! also metabolic acidosis and hypercalcemia. Tx: IV dantrolene, 100% oxygen, correction of acidosis, cooling blankets

Question 7

what should you do if bacteria within 30-45 minutes of invasive procedures (instrumentation of the urinary tract

Answer 7

do blood culture x3 and start empiric antibiotics

Question 8

post op fever

Answer 8

atelectasis, PNA, URI, DVT, wound infection, deep abscess

Question 9

post op patient gets confused and disoriented

Answer 9

hypoxia! could be secondary to sepsis. check blood gas and give respiratory support.

Question 10

trauma post op patient gets lots of IV D5W. gets condusion, convulsions, and death. what happened?

Answer 10

hyponatremia! high levels of ADH in response to trauma. D5W has no sodium.

Question 11

surgical damage to posterior pituitary with unrecognized diabetes insidious. pt has confusion, lethargy and coma.

Answer 11

hypernatremia.

Question 12

post op patient has to pee but can’t.

Answer 12

post op urinary retention is very common. in and out bladder catheterization should be done at 6 hours post op if no spontaneous voiding has occurred. indwelling foley is indicated at 2nd or 3rd consecutive catheterization.

Question 13

post op pt has low urinary output (less than 0.5 ml/kg/hr. next steps (low tech)

Answer 13

give bolus of 500 mL IV fluid over 10 to 20 minutes. dehydrated pts will have temp increase in urien output while those in renal failure will not.

Question 14

fancier ways to check about low urine output

Answer 14

check urinary sodium- less than 10 or 20 in dehydrated pt with good kidneys, and greater than 20 in renal failure. FENA>1 in renal failure.

Question 15

no bowel movements 5-7 days post op

Answer 15

no longer paralytic ileum. now its early mechanical bowel obstruction. X-rays show dilated loops of small bowel and air fluid levels. abdominal CT shows transition point. need surgery.

Question 16

elderly sedentary pt with large abdominal dissension and X-rays show massively dilated colon

Answer 16

rule out fluid and electrolyte prob (hypokalemia worsens paralytic ileus). rule out mechanical obstruction radiologically or endoscopically. OGILVIE (paralytic ileum of colon)! give neostigmine to restore colonic motility. can also use long rectal tube.

Question 17

fifth day post op, wound is intact with large amounts of pink salmon colored fluid

Answer 17

wound dehiscence. fluid is peritoneal fluid. tx: tape wound securely, bind the abdomen, make arrangements for prompt reapportion to prevent evisceration now or ventral hernia later on

Question 18

evisceration

Answer 18

wound dehiscence complication. skin opens up and abdominal contents rush out. usually when pt coughs, strains, or gets our of bed. cover bowel with large sterile dressings soaked in warm saline and emergency abdominal closure.

Question 19

when are wound infections seen

Answer 19

7th day post op

Question 20

how to fix fistula

Answer 20

prevent foreign body, epithelialization, tumor, infection, irradiatied tissue, IBD

Question 21

how does fluid lost relate to hypernatremia numerically

Answer 21

every 3meq that the serum sodium is above 140 represents 1L of fluid lost

Question 22

how to correct hypernatremia

Answer 22

correct volume rapidly while nudging the tonicity. use D50.5 instead of D5W.

Question 23

how to fix hypokalemia

Answer 23

develops slowly when K is lost from GI tract or in urine from loop diuretics or too much aldo. safe speed limit of IV K is 10mEq/h

Question 24

a cirrhotic man is bleeding from duodenal ulcer. surgical intervention is being considered. he has a total bilirubin of 3.5, INR of 2 (prothrombin time of 28), a serum albumin of 2.5, and he has ascites and encephalopathy. further management should be.

Answer 24

an alternate therapy bc he is not a surgical candidate. 40% mortality is predictable with EITHER bili>2, albumin16, or encephalopathy. 80-85% mortality is predictable if 3 of the above are present, or with either bili>4, albumin150.

Question 25

POD5, wound begins soaking dressings with clear salmon colored fluid with no particular odor. at this time you should…

Answer 25

tape and bind the wound securely while planning surgical reclosure.

Question 26

55 yo old HIV positive man has a fun gating mass growing out of the anus and rock hard enlarged lymph nodes on both groins. for the past 6 months he has noticed blood on the toilet paper and coating the outside of the stools. he has lost wt and looks emaciated and ill. he probably has.

Answer 26

SCC of the anus. HIV+ men who has anal sex. fungating mass out of anus and metastatic inguinal nodes felt. dx with bx. TX= NIGRO CHEMORADIATION PROTOCOL, followed by surgery if there is a residual tumor. 5 week chemoradiation protocol has a 90% success rate, so surgery is rarely required.

Question 27

shortly after onset of a general anesthetic with inhaled halothane and muscle relaxation with succinylcholine, a patient develops a rapid rise in body temp to 104F. metabolic acidosis and hypercalcemia are also noted. a fam member died under anesthesia a couple of years ago.

Answer 27

malignant hyperthermia! develops shortly after onset of anesthetic (halothane or succinylcholine). temp>104F. metabolic acidosis and hypercalcemia can also occur. tx: IV dantrolene (ryanodine receptor antagonist- stops muscle spasms), 100% O2, correction of acidosis, cooling blankets. watch for development of myoglobinuria.