Set 1

Question 1

Ogilvie Syndrome

Answer 1

paralytic ileus of colon; NOT after abd surgery but instead in elderly sedentarry pts that have surgery

large abd distention (tense but non-tender)

Tx: fluids & correct electrolytes then colonoscopy & place long rectal tube

Question 2

Goldman’s Index

Answer 2

findings that predict cardiac trouble

JVD (worst finding; treat with ACEI or BB or diuretics), recent MI, premature ventricular contractions, arrhythmia, >70yo, emergency surgery, aortic stenosis, poor medical condition, & chest or abd surgery

Question 3

Ejection Fraction that is risky

Answer 3

<35% (normal is 55%)

↑risk of peri-op MI (mortality of 55-90%)

Question 4

Delirium Tremens

Answer 4

common in alcoholics that have surgery; occurs 2-3 days post-op

Sx: confusion, hallucinations, combative

Tx: IV benzos

Question 5

Intraoperative tension pneumothroax

Answer 5

ribs get traumatized when exposed to positive pressure ventilation (previous blunt trauma causing broken ribs)

BP declines & CVP (central venous pressure) rises

Tx: decompression through diaphragm if abd surgery OR needle through anterior chest wall; insert chest tube later

Question 6

Metabolic Alkalosis

Answer 6

too much bicarb or loss of gastric juices; pH >7.4, bicarb >25

Tx: abundant intake of KCl so that kidney can correct problem

Question 7

Pulmonary Embolism

Answer 7

• Post-op day 7
• pleuritic chest pain w/ SOB; JVD
• Dx: CT angio (spiral CT w/ IV contrast)
• Tx: heparin
• prevent by preventing DVT

Question 8

Post-Op Urinary Retention

Answer 8

common after lower abd, pelvic, peritoneal, or groin surgery; pt feels need to void but cannot

Tx: straight cath at 6h if no voiding; indwelling cath at 2nd conseecutive catheterization

Question 9

Causes of Disorientation/ Coma in Post-Op patient

Answer 9

• hypoxia- suspect this 1st; may be secondary to sepsis
• Adult Respiratory Distress Syndrome (ARDS)- b/l pulmonary infiltrates & hypoxia w/o CHF; Tx: positive end-expiratory pressure (PEEP)
• Delirium Tremens (alcoholics; 2-3 days post-op)
• Hyponatremia (confusion, convulsions, coma)
• Hypernatremia (confusion, lethargy, coma) caused by large unreplaced water loss (eg: DI)

Question 10

Hypokalemia

Answer 10

develops slowly from loss in GI tract or urine; develops rapidly in DKA

Tx: K+ replacement administered at a rate no more than 10 mEq/h

Question 11

Metabolic Acidosis

Answer 11

excess acids, loss of buffers, or renal failure; pH <7.4 & bicarb <25

anion gap (>20)

Tx: treat the cause; bicarb will treat all but can cause rebound alkalosis if that is not the problem; be prepared to replace K+

Question 12

Why NPO before surgery

Answer 12

reduce risk of aspiration

Question 13

Ammonium Intoxication

Answer 13

causes coma in cirrhotic pt w/ bleeding esophageal varices w/ portocaval shunt

Question 14

Hepatic Risk

Answer 14

• classified using Child class
  
  • Class A = 10% mortality
  • Class B = 30% mortality
  • Class C = 80% mortality
• Predictors- encephalopathy, ascites, serum albumin (normal: 3.5-5 g/dL), prothrombin time (INR), & bilirubin

Question 15

Nutritional Risk

Answer 15

• Severe Nutritional Depletion = loss of 20% of body weight over a few months, serum albumin <3, anergy to skin Ag, or serum transferrrrin <200 mg/dL
• 4-5 days of pre-op nutritional support makes a difference (7-10 days preferred)

Question 16

Wound Dehiscence

Answer 16

5th day post-op after open laparotomy; wound intact but pink salmon colored fluid soaking through dressing (peritoneal fluid)

Tx: tape, wrap, & move w/ care until re-operation to prevent evisceration or ventral hernia

Question 17

Hyperkalemia

Answer 17

occurs slowly in renal failure; occurss rapidly in crushing injuries/ dead tissue/ acidosis

Tx: 50% dextrose & insulin to push K+ into cells or IV calcium to neutralize effects on cell membrane; Ultimately hemodialysis

Question 18

Malignant Hyperthermia

Answer 18

• develops soon after onset of anesthesia; temp >104
• metabolic acidosis and hypercalcemia
• Tx: IV dantrolene & 100% O2

Question 19

Fistulas of GI tract

Answer 19

• concerns for spesis
• Concerns when draining freely: fluid/ electrolyte loss, nutritional depletion, erosion/ digestion of body wall
• Nature will heal them if there is no foreign body, epithelization, tumor, infection, IBD, or distal obstruction (FETID) (steroids also prevent healing)

Question 20

Paralytic Ileus

Answer 20

expected in 1st few days after abd surgery; no bowel sounds, no passage of gas, no pain

Prolonged by hypokalemia

Question 21

Hyponatremia

Answer 21

Rapidly developing causes CNS Sx & requires careful use of hypertonic saline (3% or 5%)

if developed slowly (SIADH) then no CNS effects; Tx: water restriction

Question 22

Pulmonary Risk for Surgery

Answer 22

smoking is most common cause

problem is compromised ventilation (NOT compromised oxygenation)

STOP smoking 8wks before surgery & resp therapy

Question 23

Risk with recent MI

Answer 23

operative mortality: 40% if within 3mo; 6% after 6mo

Question 24

Bacteremia

Answer 24

• fever of 104+ w/in 30-45 min of invasive procedures
• Dx/ Tx: cultures x3; start emperic Abx

Question 25

Hypernatremia

Answer 25

pt has lost water; every 3 mEq/L above 140 is 1L of water lost

Correct volume changes fast but sodium levels slowly (D5½NS) if chronic

If acute then there will be CNS Sx & you can correct w/ more dilute fluid (D5W or D5 1/3NS)

Question 26

Post-Op Fever

Answer 26

• Atelectasis (Wind)- day 1; Tx: bronchoscopy
• Pneumonia- day 3 if atelectasis is not resolved; Tx: sputum culture & Abx
• UTI- (water) fever starts day 3; Tx: Abx
• DVT- (walking); day 5; doppler & heparin
• Wound Infection- (wound); day 7; PE: erythema, warmth, tenderness; sonogram to distinguish cellulitis from abscess if uncertain; Tx: Abx or open and drain