PreTest Surgery: Pre- and Postoperative Care

Question 1

<p>Review the symptoms of hypermagnesemia as levels rise. </p>

Answer 1

<p>•Loss of DTRs
•Flaccid paralysis
•Hypotension
•AMS </p>

Question 2

<p>What are the two most common causes of hypermagnesemia? </p>

Answer 2

<p>•Iatrogenic (giving MgSO4 to treat preeclampsia)

| •Advanced renal failure with magnesium supplementation</p>

Question 3

<p>Urine sodium less than \_\_\_\_\_\_\_\_ mEq/L is indicative of prerenal azotemia. </p>

Answer 3

<p>20 </p>

Question 4

<p>Early signs of hypomagnesemia include \_\_\_\_\_\_\_\_\_\_\_\_\_\_.</p>

Answer 4

<p>tetany, hyperreflexia, prolonged QT, and paresthesias </p>

Question 5

<p>Describe the standard prophylactic antibiotic regimen. </p>

Answer 5

<p>A single dose of parenteral antibiotics no greater than 1 hour prior to the incision

Colon surgeries warrant an additional oral dose against anaerobes and aerobes as part of the bowel prep. </p>

Question 6

<p>What does "uncompensated metabolic alkalosis" mean? </p>

Answer 6

<p>The pCO2 is normal (i.e., around 40). If the pCO2 were elevated to compensate, then it would be metabolic alkalosis with respiratory acidosis. </p>

Question 7

<p>How do you treat heparin-induced thrombocytopenia? </p>

Answer 7

<p>Cease the heparin and switch to a non-heparin agent: bivalirudin, lepirudin, or dabigatran </p>

Question 8

<p>A patient develops bleeding three hours post-op from the wound. Coagulation labs are normal with the exception of decreased fibrinogen. What is the likely cause? </p>

Answer 8

<p>Incomplete control of bleeding in the surgical incision </p>

Question 9

<p>Any signs of \_\_\_\_\_\_\_ (a cardiac condition) warrant further workup before elective surgery. </p>

Answer 9

CHF

Question 10

<p>How are DVTs in pregnant women treated? </p>

Answer 10

Heparin or enoxaparin

Remember that warfarin is a teratogen.

Question 11

<p>List the four SIRS criteria. </p>

Answer 11

• T: > 38ºor < 36º
• HR: > 90
• RR: > 20 or PaCO2 < 32
• WBC: > 12,000 or < 4,000

Question 12

<p>Patients receiving massive transfusions for hemorrhagic shock require what two additional things? </p>

Answer 12

Platelets and FFP

Research shows that patients arriving in hemorrhagic shock are generally coagulopathic and need FFP. Additionally, transfusions lead to dilutional thrombocytopenia.

Question 13

<p>In patients who've had bowel surgery and are expected to have prolonged recoveries, it's best to start J-tube feeds \_\_\_\_\_\_\_\_\_\_\_\_\_\_.</p>

Answer 13

within 24 hours

It used to be thought that the bowel was paralyzed after bowel surgery and needed days to recover, but new research shows that the bowel can start absorbing within 24 hours afterward. Those who are well nourished can go up to ten days without feeds, so only those with prolonged recoveries should do so.

Question 14

What lab values and vital signs suggest adrenal insufficiency?

Answer 14

• Hypoglycemia
• Hyperkalemia
• Hyponatremia
• Fever
• Hypotension

Question 15

A patient has a clotting factor disorder and requires surgery. When should you administer FFP?

Answer 15

On call to surgery

The half-life of clotting factors is as little as 4 hours for some of the proteins.

Question 16

Review the mnemonic for fistula formation.

Answer 16

Two lumens become FRIENDS through a fistula: 
•Foreign bodies
•Radiation
•Inflammation
•Epithelialization of the tract
•Neoplasm
•Distal obstruction
• Steroids

Question 17

True or false: give FFP to hemophiliacs prior to surgery to treat bleeding.

Answer 17

False

FFP has factors VIII and IX, but the quantities are too small to adequately treat bleeding. You need to give DDAVP and aminocaproic acid (an inhibitor of tPA) to treat the bleeding.

Question 18

When do you need to stop aspirin and the other NSAIDs prior to elective surgery?

Answer 18

• Aspirin: 1 week
• Other NSAIDs: 3-4 days

ASA is irreversible and thus inhibits them for longer.

Question 19

A patient presents after sigmoid resection with new-onset hydronephrosis. What diagnostic should they get?

Answer 19

Intravenous pyelogram (for suspected ureteral injury)

Question 20

What are the two tiers of calcium replacement?

Answer 20

• Mild: oral calcium gluconate

* Severe: IV calcium gluconate

Question 21

List ways to reduce the likelihood of postoperative wound infection.

Answer 21

• Treat any underlying infections prior to surgery
• Maximize host immune status: reduce steroid/immunosuppressants if possible; optimize nutritional status; minimize hospital stay
• Minimize tissue damage and incision length
• Use closed drainage systems

Question 22

What ratio of fluid replacement to blood loss is standard for NS, LR, and colloid?

Answer 22

• NS: 3:1
• LR: 3:1
• Colloid: 1:1

Question 23

If you need to replace a lot of volume in a Jehovah’s Witness, you should use ____________.

Answer 23

LR

NS can cause non-AG metabolic acidosis in those receiving liters of fluid, whereas LR doesn’t.

Question 24

They give you a question that says “long-term hospitalized patient is losing lots of fluid through his NG” and then ask about fluid replacement. What’s the correct answer?

Answer 24

Replace the NG fluid with LR and then do maintenance rate.

Question 25

Why do you give bicarb in those with hyperkalemia?

Answer 25

The mild alkalosis causes a shift of potassium into cells.

Question 26

True or false: hypoglycemia is an early sign of sepsis.

Answer 26

False

Sepsis causes a surge of stress hormones: epinephrine, cortisol, and glucagon. This leads to an early hyperglycemia in both diabetic and nondiabetic patients with sepsis.

Question 27

List three features of early sepsis.

Answer 27

• Tachypnea
• Flushing / peripheral vasodilation
• AMS

Question 28

Hemolytic transfusion reactions lead to ________________.

Answer 28

hypotension and oliguria

Question 29

How do you treat hemolytic transfusion reactions?

Answer 29

Aggressive fluid resuscitation and mannitol

The main worry is that hemolyzed RBC membranes will lead to glomerular damage. Thus, you need administer fluid and mannitol to stimulate diuresis which will clear the nephrons.

Question 30

How do calorie replacements vary in starvation, after surgery, during organ failure, and after a massive burn?

Answer 30

• Starvation: decrease by 10% (due to decreased metabolic rate)
• After surgery: increase by 10%
• Organ failure: increase by 50%
• Massive burn: increase by 100%