Preoperative Care 3

Question 0

Child score classifications for group B?

Answer 0

1. Bilirubin 2.0-3.0
2. Albumin 3.0-3.5
3. Easily controlled ascites
4. Minimal Encephalopathy
5. Good nutrition

Mortality of 10-15%

Question 1

Surgical patient with liver disease – how to determine operative risk?

Factors that would delay surgery?

Answer 1

Child’s score

Child’s score of C, or acute alcoholic hepatitis

Question 2

Patient with liver cirrhosis – proceed with other surgery only if?

Must control ascities with?

Answer 2

1. If compensated liver failure
2. If abstain from alcohol for 6-12 weeks
3. If medically optimized

If ascites controlled with potassium sparing diuretics, and sodium/water restriction

Question 3

Surgical patients with liver failure had hernia surgery delayed. Now;

1. Notices small ulcerated area on the hernia. Cause? Management?
2. Returns to ED with confusion and lethargy. Management?
3. Returns to ED with serous fluid leaking from ulcer on hernia. Management?

Answer 3

1. Possibly due to pressure necrosis (increases risk of rupture). Manage ascites and then repair hernia
2. Tapped ascities, treat with antibiotics if SBP
3. Send fluid for culture, start IV antibiotics immediately, urgent hernia repair

Question 4

Patients with cirrhosis desires hemorrhoid removal – concern?

Answer 4

Hemorrhoid removal is difficult in patients with cirrhosis or portal hypertension (can cause uncontrollable hemorrhage during surgery)

Question 5

Surgical patient with aseptic necrosis for hip replacement – has history of kidney transplant with progressive chronic rejection and creatinine 3.5 – problem? management?

Answer 5

Repairing hip during transplant deterioration may aggravate the rejection

Delay hip repair until transplant function has stabilized or dialysis is begun

Question 6

Surgical patient with aseptic necrosis for hip replacement – has history of renal transplant and chronic rejection – How to prepare for surgery?

Answer 6

1. Dialyze to normalize platelet function, hydration, blood pressure, electrolytes
2. If on steroids for transplant, give perioperative steroids

Question 7

Patient with renal failure has a serum potassium 5.1 from a 2 day old laboratory test – management?

Answer 7

Spikes in potassium can occur chronic renal failure – need to get new measurement

Question 8

Patient with chronic renal failure goes to surgery. Intraoperative bleeding due to “Capillary ooze” – likely cause? management options?

Answer 8

Platelet dysfunction due to your premier

1. Desmopressin to release von Willebrand factor (rapid)
2. Fresh frozen plasma to correct the defect (rapid)
3. Conjugated estrogens (slow onset, long lasting)
4. Post operative hemodialysis

Question 9

Multiple doses of desmopressin may induce?

Answer 9

Tachyphylaxis - loss of hemostatic effect

Question 10

Patient with chronic renal failure goes to surgery. Patient becomes hypotensive without evidence of bleeding – possible cause? special measures?

Answer 10

1. Glucocorticoid deficiency common in renal failure patients who have previously taken steroids

Do you hydrocortisone intraoperatively and postoperatively

Question 11

Patient with renal failure undergoes surgery – immediate postoperative potassium is 7.1 and he’s producing 10 mL per hour of urine – management?

Answer 11

1. ECG to determine if hyperkalemia is physiologically important
2. If peaked T waves, give calcium gluconate followed by IV insulin and glucose
3. Likely will need hemodialysis

Question 12

Surgical patients with chronic mitral valve stenosis that is well compensated – complications of mitral valve stenosis? Considerations during surgery?

Answer 12

Complications – pulmonary hypertension, right heart failure, atrial fibrillation

1. Maintain intravascular volume, and avoid any increases in pulmonary vascular resistance (hypoxemia, hypercapnia, acidosis)
2. Avoid tachycardia because it decreases diastolic filling time
3. All patients with valvular heart disease should receive prophylactic antibiotics

Question 13

Surgical patients with chronic mitral stenosis and CHF exacerbation one month ago – consideration regarding surgery? If urgent surgery, will need? Less useful?

Answer 13

1. mitral valve stenosis with underlying CHF increase mortality to 20%
2. If surgery is urgent, will need intraoperative monitoring (A-line and TEE)
3. Pulmonary artery catheter is not useful because pressure gradient between pulmonary capillary wedge pressure and LV EDP is distorted in MS

Question 14

Surgical patients with no aortic stenosis and grade IV systolic murmur – Before elective surgery? For urgent surgery?

Answer 14

cardiac assessment and possible valve replacement

Perioperative hemodynamic monitoring with pulmonary artery catheter, A-line, TEE

Question 15

when to consider bacterial endocarditis prophylaxis? And antibiotics to use?

Heart surgeries that don’t need endocarditis prophylaxis?

Answer 15

Dental work, respiratory tract, esophageal – amoxicillin or clindamycin or cephalosporin or clarithromycin

G.I./GU – ampicillin + gentamicin with ampicillin post procedure; vancomycin + gentamicin

Also for heart valves, prosthetic vascular grafts

Not recommended for CABG, MVP without regurgitation, pacemakers,

Question 16

Purpose of bowel prep? Supplements?

Answer 16

Decrease fecal mass and bacterial content of colon

Non-absorbable antibiotics – neomycin or erythromycin

Question 17

Golytely?

Answer 17

Polyethylene glycol – causes no net absorption or secretion of ions (no change in electrolyte/water balance)

Question 18

Fleets Phospho-Soda

Answer 18

Hypertonic sodium phosphate solution draws fluid into interstitial lumen

Contraindicated in diabetics, patients are predisposed to metabolic acidosis, potassium loss

Question 19

Magnesium citrate? Mechanism of action? Avoid in patients with? If toxic levels, use?

Answer 19

osmotic agent that draws fluid into bowel lumen

patients with renal failure (unable to clear magnesium from bloodstream)

Calcium gluconate if levels reach five