Preoperative and Postoperative Management Flashcards
When does third spacing occur postoperatively?
What are the classic signs of third spacing?
Third-spaced fluid tends to mobilize back into the intravascular space around POD 3
Tachycardia and decreased urine output
What is the treatment for third spacing?
IV hydration with isotonic fluids
A 67-year-old man is undergoing preoperative evaluation for a coronary artery bypass grafting procedure. You are assessing his nutritional status. Which of the following protein measurements best assesses short-term nutritional status?
A) Albumin
B) Globulin
C) Prealbumin
D) Transferrin
Prealbumin
The half-life of prealbumin is shorter (2–3 days) than albumin (18–20 days) and transferrin (8–9 days), thus prealbumin can be used to assess short-term changes in nutritional status.
Nicotine is associated with what dermatologic complication post-operative?
Poor Wound Healing
A patient who smokes and is willing to quit smoking prior to surgery what pharmacologic treatment should be provided?
Buproprion
Nicotine replacement therapies should not be used. Buproprion needs to be on board 2-3 weeks prior to be effective.
Smoking does not increase risk for which one of the following postoperative complications?
A) Pneumonia
B) Myocardial ischemia
C) Nausea and vomiting
D) Wound infection
E) Nonunion of fractured bones
Nausea and vomiting
When should Buproprion be initiated in regards to a known quit date?
One week prior to quit date so that drug can reach steady state
What is the most common cause of post-operative fever in the first 48 hours?
Atelectisis
What are the 5 W’s of post-operative fever?
- Wind (atelectasis)
- Water (UTI)
- Wound (wound infection)
- Walking (DVT)
- Wonder drugs/whopper (drugs/abscess)
What is the most appropriate IV fluid for a preoperative patient who is NPO?
A) 5% dextrose in water
B) Half-normal saline
C) Lactated Ringer solution
D) Normal saline
Lactated Ringer Solution
What are the risks associated with overloading fluids prior to surgery?
- Extra vascularization of fluid into the respiratory and GI tracts
- Edema that can delay wound healing
- Volume overload that dilutes clotting factors
A 56-year-old man is admitted to the hospital for wound care of an infected right leg. Two sets of blood cultures are positive for Escherichia coli. Intravenous antibiotics are started. The next day, the patient develops tachycardia, hypotension, altered mental status, and shortness of breath. Epistaxis, gingival bleeding, and hematemesis are noted. Further examination reveals the presence of petechiae and purpura as well as diffuse thromboses. His platelet count on admission 24 hours ago was 145,000/mcL but is now 79,000/mcL. Which of the following laboratory findings is most consistent with the suspected diagnosis?
A) Decreased aPTT and increased fibrinogen
B) Decreased factor V and normal factor VIII
C) Decreased PT and elevated factor VIII
D) Increased fibrin degradation products and schistocytes
Increased fibrin degradation products and schistocytes
The patient in the vignette above has signs and symptoms of disseminated intravascular coagulation (DIC). Increased fibrin degradation products and schistocytes on peripheral smear are consistent with the diagnosis of DIC. DIC is a life-threatening condition characterized by uncontrolled intravascular coagulation, secondary fibrinolysis, and consumption of coagulation factors and platelets. Infection, malignancy, obstetric complications and disorders, trauma, vascular disease, and liver disease can cause DIC.
What is the most common cause of DIC?
Infection (sepsis)
What medications provide protection from postoperative GI bleeding?
H2 Blockers and PPI’s
Should a contaminated case be closed via primary wound closure?
No, the skin should not be closed
To avoid Wernicke’s encephalopathy in alcoholics, when do you give glucose?
AFTER thiamine administration
All patients with hypocalcemia should have what other lab value drawn?
Serum albumin to distinguish true hypocalcemia from factitious hypocalcemia)
Which diabetes medication is associated with lactic acidosis?
Metformin
What are the most common indications for urgent preoperative dialysis?
- Hyperkalemia with EKG changes
- Volume overload
Due to the high risk for developing postoperative venous thromboembolism (VTE), patients undergoing colorectal surgery should be given what as prophylaxis?
- Intermittent pneumatic compression
- Low-molecular-weight heparin
A 78-year-old man with a history of metastatic prostate cancer presents with worsening dyspnea. CT pulmonary angiography confirms two subsegmental pulmonary emboli. He weighs 70 kg and is started on LMWH 70 mg subcutaneous twice daily. Four days later, his dyspnea acutely worsens, and he becomes tachypneic after walking a distance of three feet. SpO2 is 88% on room air, and the remainder of his vitals are stable. His ECG and troponin and BNP levels are unremarkable. Repeat CT pulmonary angiography shows an additional segmental pulmonary embolism. Which of the following is the best next step in management?
A) Anticoagulation with low-molecular-weight heparin intravenous
B) Anticoagulation with low-molecular-weight heparin subcutaneous and apixaban PO
C) Inferior vena cava filter
D) Thrombolysis with r-tPA
Inferior vena cava filter
Inferior vena cava filter may be used in the treatment of pulmonary embolism (PE) in hemodynamically stable patients who have failed or cannot tolerate anticoagulation.
What is Virchow’s Triad?
- Vascular endothelial injury
- Stasis
- Hypercoagulable state
When does postoperative pneumona typically present?
Within 5 post-op days
Is preoperative treatment with insulin associated with a higher surgical cardiac complication?
Yes
