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Preop/Postop Flashcards

1
Q

when can a patient eat prior to major surgery

A

NPO after midnight the night before or for at least 8 hours before surgery

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2
Q

classic signs of 3rd spacing (2) + treatment

A

tachycardia + decreased UOP

Tx = IV hydration with isotonic fluid

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3
Q

Tobacco use/dependance is associated with 4 complications of surgery

A
  1. postoperative wound complications
  2. general infections
  3. neuralgic and pulmonary complications
  4. INCREASED RISK OF ICU ADMISSION AND MORTALITY
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4
Q

ideal time to stop smoking prior to surgery

A

MONTHS - at least > 8 weeks

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5
Q

what to do for an active smoker at time of surgery

A

nicotine patch

takes several hours to reach adequate blood level of nicotine

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6
Q

preoperative Risk Assessment (8)

A
  1. Exercise capacity
  2. Age
  3. Medications used
  4. Obesity
  5. OSA
  6. Alcohol
  7. Smoke
  8. Personal/Family hx of anesthetic complications
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7
Q

6 components of Revised Cardiac risk index (RCRI)

A
  1. high risk surgery
  2. history of heart disease
  3. h/o compensated OR prior HF
  4. h/o CVA
  5. DM treated w/ insulin
  6. CKD w/ Cr >2 @ baseline
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8
Q

____ increases risk for postoperative pulmonary complications.

  • – Most pts are undiagnosed
  • – high prevalence in Bariatric pts
  • – screen using STOP-BANG
A

OSA

Snore loudly
Tired/fatigue most of the day
Observed by others to stop breathing
Pressure (BP) high

BMI >35
Age >50
Neck circumference > 43cm (17 in)
Gender - male

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9
Q

Alcohol/ Drug misuse - best time to stop before surgery

A

4+ weeks

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10
Q

patients with Asthma and COPD:

  • Pulmonary Postoperative risk increases when _____
  • High risk of prolonged mechanical ventilation and mortality if ____
A
  • FEV1 < 1.5

- FEV1 < 1.0

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11
Q

Adrenal Suppression:

- Chronic steroid use for _____ = assess need for stress dose steroids

A

> 2 weeks over prior year

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12
Q

MC postoperative pulmonary complication

A

Atelectasis

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13
Q

common pulmonary complication, can be 2/2 allergy or histamine release due to morphine, treat with bronchodilators

A

Bronchospasm

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14
Q

occurs within first 5 days postop. increased risk for antibiotic resistant bacteria

A

pneumonia

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15
Q

preoperative Pulmonary Function tests (PFTs) indicated for (3)

A
  1. Dyspnea of unclear etiology
  2. Exercise intolerance
  3. COPD or asthma if unclear the treatment has been optimized.
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16
Q

patient with CAD: MI

- emergent surgery vs elective

A
  • emergent = lifesaving procedures done regardless of cardiac risk
  • elective = wait 4-6 weeks following MI
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17
Q

patients with CAD who are asymptomatic OR with Stable MILD angina

A

DO NOT NEED to postpone surgery

but DO NEED Beta Blockers to decrease Perioperative cardiac risk

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18
Q

patient with Stable Angina and preoperative assessment reveals need for CABG or PCI

A

plans for elective surgery should be postponed

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19
Q

Hypertension before elective surgery

A

< 140/ 90

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20
Q

patients w/ HTN have higher risk for

A

labile BP and hypertensive emergencies during surgery and immediately following extubation

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21
Q

patient with decompensated HF undergoing elective surgery

A

wait 1 week AFTER optimization before proceeding with elective surgery

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22
Q

Critical Aortic Stenosis

A

periop mortality 50%
– echo findings of aortic valve area < 0.7 and/or mean gradient of 50 mmHg/ peak gradient of 80 mmHg

– clinician should delay surgery (unless emergency) and consider preop valve replacement

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23
Q

HARD STOP: patients with ACTIVE cardiac issues that should NOT undergo elective surgery (5)

A
  1. Unstable Angina
  2. NSTEMI/STEMI
  3. High grade arrhythmias
  4. Decompensated HF
  5. Symptomatic valvular heart disease (AS)
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24
Q

Antihypertensives: ACEI, ARBs, Diuretics

A

ALL should NOT be taken on day of surgery

ACEI/ARB - resume once patient euvolemic postoperative

Diuretics = resume when pt on CLD+

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25
Q

6 meds patients may continue perioperatively

A
  1. BB
  2. CCB
  3. Alpha2 agonist (clonidine)
  4. Digoxin
  5. PPI/ H2B
  6. Inhaled Beta agonists (albuterol, salmeterol) and Inhaled Anticholinergics (ipratropium, tiotropium)
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26
Q

patients should hold this medication the evening prior to surgery

A

theophylline

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27
Q

Statins

A

continue perioperatively

- patients undergoing cardiac surgery should be started on one even if hours prior to surgery

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28
Q

Oral Contraceptives

A

stop 4-6 weeks prior to surgery

restart 2 weeks post op

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29
Q

Adrenal insufficiency + Minor surgical procedure

A

usual steroid dose

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30
Q

adrenal insufficiency + Moderate surgical procedure

A

usual morning dose
then 50 mg Hydrocortisone IV prior to procedure
and 25 mg IV q8 Hrs for 24 hours
then resume regular regimen

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31
Q

Adrenal insufficiency + Major Surgery

A

usual morning dose
then 100 mg IV Hydrocortisone prior to surgery
then 50 mg IV q8 Hrs for 24 hours
then taper dose by half per day til maintenance dose reached

32
Q

elective surgery should be avoid in the first month following diagnosis of

A

thromboembolism

33
Q

when to stop and restart anticoagulants:

  • bridging heparin
  • lovenox
A
  • UH: stop 5 hours prior; restart 24 hours post op

- LMWH: stop 24 hours prior; restart 48 hours post op

34
Q

preop INR

A

< 1.5

  • Coumadin stopped 5 days prior
  • Vitamin K can be given if emergency surgery (reverses Coumadin) [or Kacentra or FFP]
35
Q

von Willebrand Disease

A

Desmopressin around the time of surgery (DDAVP)

36
Q

preop CBC

A
  • s/s of anemia

- anticipated significant blood loss during procedure

37
Q

preop Serum Electrolytes

A
  • certain meds (warfarin, digoxin) 2/2 associated Potassium abnormalities
38
Q

preop serum creatinine

A
  • all patients > 40 yrs
39
Q

preop blood glucose

A
  1. personal or FHx of DM

2. undergoing bypass grafting for PVD, AAA repair or CAD

40
Q

preop liver enzymes

A

if clinical s/s of liver dysfunction

41
Q

preop coagulation studies

A
  1. pts taking anticoagulants

2. pts w/ severe biliary or liver dysfunction

42
Q

preop EKG

A
  • all pts > 40 yrs
43
Q

preop CXR

A
  • pts > 50 yrs undergoing high risk surgery

- all comers with h/o significant cardiopulmonary disease

44
Q

preop pregnancy test

A

all women of childbearing age undergoing surgery

45
Q

preop cardiac risk assessment is based on what 3 elements?

A
  1. Patient specific variables (how much risk does the pt bring to surgery?)
  2. Exercise Capacity
  3. Surgery specific risk (How much risk does the surgery pose?)
46
Q

Evaluating for underlying cardiac disease that is not yet clinically apparent:
preop cardiac risk assessment: How do we (ACC and AHA) determine Functional Capacity

A

POOR exercise tolerance = INABILITY TO PERFORM 4+ METS OF ACTIVITY WITHOUT SYMPTOMS

– poor exercise tolerance may then determine need for preop noninvasive cardiac testing (pends on inherent risk of procedure)

47
Q

Elective surgery after MI
1) Balloon angioplasty

2) Bare-metal intracoronary stent
3) Drug-eluting stent

A

1) Balloon angioplasty
- - postpone sx 2-4 weeks after placement
- - continue ASA perioperatively if possible

2) Bare-Metal stent
- - postpone sx 4-6 weeks after placement
- - continue ASA perioperatively if possible

3) Drug-Eluting Stent
- - no surgery for 1 year after stent placement
- - continue ASA perioperatively if possible
- - restart Thienopyridine ASAP postoperatively

48
Q

preop workup of patient with DM (4)

A
  1. EKG
  2. A1C if not done w/in 4-6 weeks
  3. Serum Creatinine
  4. Fasting Glucose
49
Q

post op glycemic targets for non-critically ill patients with DM

A

110 - 180 mg/dL

50
Q

Peri op management of DM patient who is well controlled on diet alone

A

no particular therapy except SSI (sliding scale insulin) + avoid dextrose containing IV fluids

51
Q

Peri op management of DM pt on PO agents or non-insulin injectables

A

continue w/ regular regimen day before surgery but

HOLD the morning of surgery

52
Q

DM patients on LONG ACTING INSULIN (detemir, Glargine)

A

take 1/3 - 1/2 of normal dose on the DAY OF surgery

continue this dose post op until pt has returned to normal diet.

expect poor glucose control post op and the need for SSI

53
Q

POST OP + DM:
– Sulfonylureas

– Metformin

– TZDs

– SGLT2

– DPP4 inhibitors

A

1) Sulfonylureas = restart only AFTER RETURN TO NML DIET 2/2 increased risk of hypoglycemia
2) Metformin = contraindicated if risk of renal hypo perfusion// lactate accumulation // tissue hypoxia
3) TZD = worsen fluid retention and peripheral edema (can precipitate HF)
4) SGLT2 = restart AFTER NORMAL DIET AND 24+ HOURS AFTER SURGERY
5) DPP4 = restart AFTER RETURN OF NORMAL BOWEL FUNCTION 2/2 their ability to decrease GI motility = worsen post op ileus

54
Q

Clean Wound

A

no break in sterile technique + NOT GI, GU, or pulmonary sx

55
Q

Any GI, GU, or Pulmonary sx WITHOUT spillage of contents

A

Clean-contaminated wound

56
Q

Contaminated wound

A

GI, GU, or pulmonary sx WITH spillage of content.

– Traumatic wounds with soil and particulate matter in the wound

57
Q

Dirty wound

A

pre existing infection in the area of the surgery (abscess, infected wounds)

58
Q

fluid (other than pus or blood) that collects at operative site

A

SEROMA

    • delay healing
    • increase risk of infection
    • small seroma = aspirated + compression dressing
    • groin seroma = observation 2/2 incr risk infxn if aspirated
59
Q

Dehiscence: MC happens on POD ____ when wound strength is at its weakest

60
Q

Post op fluids: young/middle aged vs elderly

A

young/middle aged = 4:2:1 rule
– ex: 70kg male = 4mL/kg/hr for first 10 kg = 40 mL; 2mL for second 10 kg = 20mL; 1mL for subsequent kg = 50mL
=== 40mL + 20mL + 50mL = 110mL/Hr**

elderly = 25mL/kg over 24 hours

61
Q

POST OP Fluid management:

  • Fluid may shift (3rd space) from vasculature to area of injury for _____
  • if gastric, intestinal, or pancreatic secretions are drained, ____ AND ____ need to be replaced
A
  • 2-3 days

- water AND ELECTROLYTES

62
Q

post op Hyponatremia

A

etiology:
1. excess Na loss
2. excess H2O loss
3. advanced cardiac, renal or liver dz

sxs vary - focal weakness, ataxia, AMS

order serum/urine Na + Osmolarity

tx = SLOW correction = no more than 10 mEq/L in 24 HOURS 2/2 risk of OSMOTIC DEMYELINATION

63
Q 
Post op patient with: 
EKG: 
-- prolong PR
-- Wide QRS
-- depressed ST
-- Flat T

sxs:
- Ileus
- Fatigue
- Weakness
- paresthesias

A

HYPOKALEMIA

tx =
replace PO if possible (taste, nausea) or can give IV (burns)

* MUST ALSO REPLACE MAGNESIUM*

64
Q

post op Hyperkalemia treatment

A 
loop diuretics, 
Calcium gluconate, 
Amp D50, 
10 U regular insulin, 
Dialysis
65
Q

MCC of post op fever in the first 48 hours

A

atelectasis

sxs = Fever + Tachycardia + Tachypnea + Hypoxia

66
Q

post op Pneumonia

A

> 50% is due to Gram Negative rods and will often be Polymicrobial

67
Q

post op MI is most likely in patients with (4)

A
  1. CHF
  2. known Cardiac disease
  3. > 70 yrs
  4. arteriosclerosis surgery
68
Q

____ and ____ in the post op period = PREDISPOSE PT TO POST OP MI**

A

Hypoxia and HoTN

69
Q

5 Ws of post op fever

A
  1. Wind = atelectasis, PNA, PE, aspiration w/ pneumonitis
  2. Water = UTI, IV line infection
  3. Wound = infxn and abscess (MC POD 4+)
  4. Walking = DVT and PE
  5. Wonder Drug/ What did we do?
    - - Beta lactam antibiotics**
70
Q

actual or anticipated duration of not able to receive enteral nutrition for 5-14 days

A

indication for TPN

71
Q

3:1 TPN

A

lipids + Amino Acids + Dextrose

72
Q

TPN in CKD patients

A

restrict TPN protein = prevent Uremia

73
Q

TPN: Special electrolyte adjustments for

  1. Metabolic Alkalosis
  2. Metabolic Acidosis
A
  1. Alkalosis = Na and K given as CHLORIDE SALTS

2. Acidosis = Na and K given as ACETATE SALTS (acetate converted to Bicarb**)

74
Q

the ONLY compatible insulin for TPN

A

regular insulin!!

    • humulin
    • novolin
    • actrapid
75
Q

Propofol + TPN

A

lipid emulsion = hypertriglycerides = Pancreatitis

76
Q

refeeding syndrome

A

cardiac/ respiratory failure

– Decreased PO4, K, Mg

77
Q

TPN: PICC line preferred vs peripheral line

A

PICC complication = S. aureus, Candida

Peripheral = risk Phlebitis. do not exceed osmolarity >900

Surgery (7 decks)

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