Surgery Flashcards
1
Q
If your pt is allergic to eggs or soy what drug should they not get?
A
no propofol
2
Q
If your pt is allergic to shellfish what drug should they not get?
A
no iodine
3
Q
Red Man Syndrome can be a SE from what drug?
A
Vanco (IV)
4
Q
Stevens-Johnson Syndrome can be a SE from what drug?
A
NSAIDs
Sulfa drugs
Antiepileptic drugs
5
Q
What is the Mallampati Score?
A
score used to predict east of ET intubation
6
Q
Class 1 Mallampati Score means what?
A
basically everything in the mouth is visible, should be easier intubation
soft palate, uvula, fauces, pillars visible
7
Q
Class 4 Mallampati Score means what?
A
only hard palate is visible (harder intubation)
8
Q
You see “good” on admit orders, what does this mean per the AHA?
A
VS are stable and WNL. pt is conscious and comfortable. should have excellent prognoisis
9
Q
You see “fair” on admit orders, what does this mean per AHA?
A
VS are stable and WNL. pt is conscious and may be uncomfortable. Indications are favorable.
10
Q
You see “critical” on admit orders, what does this mean per AHA?
A
VS are UNSTABLE and NOT WNL. Pt may be unconscious. Unfavorable outcome likely.
11
Q
You see “critical” on admit orders, what does this mean per AHA?
A
VS are UNSTABLE and NOT WNL. Pt may be unconscious. Unfavorable outcome likely.
12
Q
What is the mnemonic for Admit Orders?
A
ADC A VANDIMILS
Admit to Dx Condition Allergies VS Activity level Nursing orders Diet Interventions Meds Labs Special
13
Q
Which anticoagulants are used in surgery?
A
Unfractionated Heparin
LMV Heparin (Lovenox)
Warfarin (Coumadin)
14
Q
Which antiplatelet drugs are used in surgery?
A
Clopidogrel (plavix)
ASA (aspirin)
15
Q
What DOACs are used in surgery?
A
Direct oral anti-coagulants
Abixaban (Eliquis)
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
16
Q
What is the goal of pre-op risk stratification?
A
to identify co-morbidities in the H and P that may effect the operative outcome
pre-op optimization
avoidance of post-op complications
17
Q
Type and Screen vs Type and Cross
A
Screen: check blood type, RH factor, antibodies
Cross: testing your blood against donor blood to ensure no reaction (takes about 1 hr)
18
Q
What is the definition of urgent surgery?
A
life of limb is threatened if not operated on within 24 hours
19
Q
What is the definition of time-sensitive surgery?
A
delay of 1-6 weeks for further evaluation would negatively affect outcome
could be diverticulitis that you are trying to manage with meds first (more conservative)
20
Q
What is considered high risk surgery?
A
cardiac risk >5%
examples:
- emergent major operations (esp. in elderly)
- aortic or major vascular procedures
- anticipated prolonged procedure with large fluid shifts/loss
21
Q
What is considered intermediate risk surgery?
A
cardiac risk <5%
examples:
- carotid endarterectomy
- head and neck
- orthopedic
- prostate
- intraperitoneal and intrathoracic
22
Q
What is considered low risk surgery?
A
cardiac risk <1%
examples:
- endoscopic procedures
- superficial procedures
- cataract
- breast
23
Q
What is the ASA?
A
american society of anesthesiologists
used to assess anesthesia risk
24
Q
What does ASA 6 mean?
A
a declared brain dead pt whose organs are being removed for donor purposes
25
What does ASA 3 mean?
pts w/ severe systemic disease that is limiting but not incapacitating
ex. stable angina, moderate to severe COPD
the anesthesiologist probably won't want to do surgery on this pt today until it is emergent
26
What are the limitations of ASA stratification?
- vague
- grades mild to severe (what about moderate?)
- subjective (based on trusting what the pt tells you)
27
What is RCRI?
```
revised cardiac risk index (instead of using ASA)
risk of CV complications after surgery
favored for accuracy and simplicity
based on 6 factors:
-surgery risk category
-hx of ischemic heart disease
-hx of CHF
-hx of CVD
-peri-op treatment w/ insulin
-pre-op creatinine >2mg/dL
```
28
What is the DASI?
Duke Activity Status Index
| Self assessment questionnaire to estimate functional capacity
29
What MET must pt reach in order to be ok to proceed with surgery?
> or equal to 4 METs
30
What is ACS NSQIP?
American College of Surgeons - National Quality Improvement Program
used as a risk calculator with 21 patient predictors to predict the chance of pts having 9 different outcomes within 30 days following surgery
31
What is the most common reason to postpone surgery?
pre-existing HTN
HTNs are more likely to experience BP lability during operations which may lead to MI
its okay to take BP meds the morning of surgery with sips (except ACEI, ARB and diuretics) basically you can take BB
32
What is the target HR on BB?
resting HR 60-65 bpm
33
What is the ideal time for pts who smoke to quit smoking prior to surgery?
4 weeks prior to surgery
34
"STOP - BANG"
```
for sleep apnea
S - snoring
T - tired during day
O - obstructed breathing pattern during sleep vs anyone observed you stop breaking at night?
Hight blood Pressure
B - BMI
A - Age > 50
N- Neck circumference >16 inches
G - Gender: male
```
35
OSA score of 4
Obstructive Sleep Apnea score 3-4/8 = intermediate
36
OSA score of 7
Obstructive Sleep Apnea score 5-8/8 = high risk
37
What are modifications you can do pre-op to decrease pulmonary risks?
stop smoking
bronchodilator tx
control infections
weight control
38
What are modifications you can do intra-op to decrease pulmonary risks?
limit anesthesia time
prevent aspiration
limit paralytics
optimal tidal volume, bronchodilation
39
What are modifications you can do post-op to decrease pulmonary risk?
inspiratory maneuvers
early mobilization
mobilize secretions
adequate pain control
40
What is the most important post-op modification to better improve pulmonary outcomes?
early mobilization
| get that pt up and walking ASAP
41
What is the goal BP pre-op for critically ill diabetic pts?
120-180 mg/dL
post-op blood sugar control doesn't appear to be a major factor in post-op complications
42
What are the major complications post-op for diabetic pts?
surgical site infections
| increase length of stay
43
What do you tell a diabetic pt to do with meds morning of surgery?
oral anti-hyperflycemics are held the morning of surgery
| resumed when taking PO
44
What glucose level might cause you to cancel the surgery?
>400 (even above 300 is BAD)
45
What is the frailty score?
used to predict post-op mortality risk for geriatric pts
46
How is obesity defined?
BMI >30 kg/m2
severe obesity BMI >40
47
What is the ideal operative position for a pregnant pt?
left lateral decubitus to reduce abdominal aorta compression
48
Can you give a pregnant pt opioids?
yes
49
Can you give a pregnant pt NSAIDs?
no
it has been shown to increase risk of premature closure of ductus arteriosus
given acetaminophen instead
or even opioids
50
What is one of the most common causes of electrolyte imbalances?
Medications
- diuretics
- laxatives
51
What defines acute and chronic hyponatremia?
Na < 135 mEq/L
Acute (48 hours)
Chronic (>48 hours)
52
What can occur if you correct hyponatremia too fast?
osmotic demyelination syndrome
53
What are common causes of SIADH?
post op, head trauma
adrenal insufficiency, hypothyroidism
Infectious (PNA, meningitis)
Meds (SSRIs, chlorporpamide)
54
What is the treatment for SIADH?
fluid restrict (<800mL/day)
55
What is the definition of hypernatremia?
Na > 145 mmol/L
56
What are causes of hypernatremia?
```
water loss (diarrhea, vomiting, excessive sweating, diuresis, diabetes insipidus)
Reduced water intake (impaired access - elderly bed bound)
Excessive sodium intake (hypertonic saline, sodium bicarbonate)
```
57
What is the treatment for hypernatremia?
chronic: 5% dextrose/W @ 1.35ml/hr x pts weight (kg)
acute: 5% dextrose/W @ 3-6ml/hr/kg
58
What happens if you correct hypernatremia too quickly?
cerebral edema, seizures
59
What is free water deficit?
NOT DONE HERE
60
What is the definition of hypokalemia?
K+ < 3.5
61
What are the possible EKG findings of hypokalemia?
U waves
QT prolongation
flat or inverted T waves
62
What are some causes of hypokalemia?
```
insulin
hyperaldosteronism
vomiting/diarrhea
dialysis
diuretics
beta agonists
```
63
What is the treatment for hypokalemia?
addressing underlying cause
- correct Mg if low
- correct alkalosis if present
- d/c offending meds
- if uncontrolled DM --> replete K+ before insulin therapy
Replace K+ IV vs PO depending on sxs/level
infusion >20 mEq/hr --> must be central line
64
What is the definition of hyperkalemia?
k+ > 5.5mmol/L
65
What are EKG findings for hyperkalemia?
peaked T waves
QRS lengthening
Sine waves (on their way to arryhthmia)
66
What are some causes of hyperkalemia?
NOT DONE HERE
67
What is the treatment for hyperkalemia?
if EKG findings --> CaCl or calcium gluconate IV
K+ shift:
- insulin/glucose
- sodium bicarb
- albuterol inhaled
excrete K+:
- increase UOP w/ loop diuretics and isotonic fluids
- dialysis
- kayexalate
68
5-8% water loss sxs
dehyrdation
| dizzy, fatigue
69
>10% water loss sxs
mental, physical impairments
70
>15-20% water loss sxs
fatal
| they be dead
71
dry eyes and dark urine are a sign of what kind of dehydration?
moderate
72
What are crystalloids?
NOT DONE HERE
73
What is the purpose of crystalloids?
NOT DONE HERE
74
What are crystalloid types?
NOT DONE HERE
75
Why might you use isotonic crystalloid?
water and salt depletion states (vomiting, diarrhea)
hypovolemic shock
initial therapy DKA
replacing post-op fluids
76
What crystalloid type do you never want to give to a pts with increased ICP or risk of increased ICP?
hypotonic solutions
risk of increase brain edema and ICP
77
Why might you use hypertonic solutions?
NOT DONE HERE
78
What are the Na+, Cl-, K+ concentrations in LR?
130, 109, 4
79
What are the Na+, Cl-, K+ concentrations in NS?
154, 154, -
80
What are the Na+, Cl-, K+ concentrations in D5LR?
130, 109, 4, 50g dextrose
81
What are the Na+, Cl-, K+ concentrations in D5W?
-,-,-, 50g dextrose
82
What are the Na+, Cl-, K+ concentrations in D5 1/2 NS?
77, 77, -, 50g dextrose
83
What are the Na+, Cl-, K+ concentrations in 3% NS?
513, 513, -
84
What are the Na+, Cl-, K+ concentrations in 5% NS?
855, 855, -
85
What is the most common maintenance fluid used for a healthy adult pt?
D5 1/2 NS (77, 77, -, 50g dextrose)
86
What are colloid solutions?
NOT DONE HERE
87
What are the uses of colloids?
hypovolemic shock
adjunct in burn resuscitation
(giving blood products)
88
What is the fastest way to increase the oxygen delivery capacity to the blood?
blood product transfusion
89
1 unit (300-350cc) of blood does what to the labs?
increase Hgb 1g/dL and HCT by 3%
90
1 unit of platelets (6 pack) increases platelets by _____
30,000
91
TRALI
transfusion related acute lung injury
immune reaction - FEVER (30 min - 6 hours post transfusion)
92
TACO
transfusion associated circulatory overload
acute congestive heart failure secondary to transfusion
fluid overload
93
What is the treatment for TACO?
lasix
94
Primary survey for triage
```
A - airway with c-spine protection
B - breathing
C - circulation with hemorrhage control
D - disability - neurologic status
E - exposure/environmental control - undress pt but prevent hypothermia
```
95
What is a cuffed airway?
definitive airway --> only endotracheal tube
not OPA or NPA
96
What injuries impair ventilation in the short term?
tension pneumothorax
flail chest with pulmonary contusion
massive hemothorax
open pneumothorax
97
Which imaging modality is best to see fractured ribs?
CT
98
What 3 things must you keep in mind with hemorrhage control?
blood volume
cardiac output
bleeding
99
What are you seeing with a pt who has a tension pneumothorax?
acute resp. distress
absent breath sounds
hyperresonance
tracheal shift
100
GCS
Glasgow Coma Score
```
Eye Opening (E)
4 - spontaneous
3 - to voice
2 - to pain
1 - none
```
```
Verbal Response (V)
5 - normal
4 - disoriented
3 - words, not coherent
2 - no words - only sounds
1 - none
```
```
Motor
6 - normal
5 - localizes to pain
4 - withdraws to pain
3 - decorticate posture
2 - decerebrate
1 - none
```
101
GCS 3 -8
unconscious pt
INTUBATE
Give:
- mannitol
- moderate hyperventilation
- hypertonic saline
102
What is an initial dose of warm fluid bolus for an adult post trauma?
1 - 2 Liters
make sure you ask EMS how much they gave in the field
103
Class 2 hemorrhage
greater than 2 L blood loss (DOUBLE CHECK THIS)
104
What is the preferred method of replacing blood?
cross matching but it takes an hour
105
Type-specific blood can be provided in ____
10 minutes
106
When, during trauma, are you giving Rh negative?
females of child bearing age
107
Massive transfusion?
>10 units of PRBCs within 24 hours of admission
108
Activated factor VII
helps manage hemorrhage when bleeding is unclear
dose - 200 mcg/kg initially followed by a repeat dose of 100 mcg/kg at 1 hour and 3 hours
109
TXA
tranexemic acid
antifibrinolytic agent
can be used in cardiac surgery, prostatectomy, total joint replacements
loading dose: 1g IV over 10 minutes
infusions: 1g over 8 hours
110
"ANY INJURED PT WHO IS _____ AND _____ IS CONSIDERED TO BE IN SHOCK, UNTIL PROVEN OTHERWISE"
cool and tachycardic
111
What is the most common cause of shock?
hypovolemic
112
What is the first choice treatment of hemorrhagic shock?
crystalloid (1st choice)
immediately admin 2 L of isotonic NaCl or LR solution
fluid admin continues until they are stable
also give O negative non-crossmatched blood (2 units rapidly then not response)
113
What can cause cardiogenic shock?
blunt cardiac injury should be expected when the mechanism of injury to the thorax is rapid deceleration
require constant EKG monitoring
114
FAST
focused assessment sonography in trauma
used to identify pericardial fluid and likelihood of cardiac tamponade as cause of shock
115
What is the most common cause of cardiac tamponade?
penetrating thoracic trauma
can be confused with tension pneumothorax
116
How can you tell tension pneumothorax from cardiac tamponade?
tension - absent breath sounds, tracheal deviation, and hyperresonance of affected himthorax
117
What is the best intervention for cardiac tamponade?
thoracotomy
118
What is epinephrines action?
agonist of alpha1, beta1, and bet2 receptors
increases MAP by increasing cardiac index and stroke volume, as well as SVR and heart rate
119
Dopamine
precursor of norepi and epi
varying effects according to dose infused
used for cardiogenic shock
120
What are the dosages for dopamine?
<5mcg/kg/min - vasodilation of the renal, mesenteric, and coronary beds
5-10 mcg/kg/min - beta 1 adrenergic effects include an increase in contractility and HR
>10mcg/kg/min - alpha adgrenergic effects lead to arterial vasoconstriction and increase in BP
121
Neurogenic shock
NOT DONE HERE
122
Treatment for neurogenic shock
NOT DONE HERE
123
Distributive shock
septic, anaphylactic
shock due to infection immediately after injury is UNCOMMON --typically delayed several hours then infection can occur
penetrating abdominal injury --high risk
124
What is the treatment for septic shock?
first 6 hours are CRITICAL
obtain lactate levels
obtain blood cultures )(before ABX)
admin broad-spectrum ABX
Administer 30mL/kg of crystalloid solution for lactate levels of 4mmol/L or higher
initial fluid crystalloid fluid challenge (1-2L) over 30-60 min with additional fluid challenges
125
What hemoglobin levels are recommended for RBC transfusion?
<7g/dL
target Hgb range of 7-9 g/dL
126
Antithrombin agents are not recommended for _____
sepsis or septic shock
127
RSI
rapid sequence intubation
most effective way in an emergency situation to intubate a pt
128
RSI medications
induction agents -
```
Ketamine
Thiopental
Propofol
Fentanyl
Etomidate
Neuromuscular blockers
```
129
Which induction agent would you use for RSI with hemodynamically unstable pts?
Ketamine
| Etomidate
130
Which of the induction agents should NOT be used for RSI?
Midazolam
131
What 4 views are used for FAST exam?
pericardial view
RUQ view
LUQ view
Suprapubic view
132
What is a low sodium diet?
2gm Na restriction
indications: CHF, fluid retention, HTN
133
What is the difference between the renal diet for pts on HD vs those not on HD?
both are on low sodium (2gm) restriction and phosphorus restriction
non HD pts have to restrict their protein
134
What is the cardiac diet?
2gm Na
| low fat
135
What is a low residue diet?
fiber-restricted diet
| indications: certain GI disorders, gastroparesis
136
What is the gold standard to determine calorie and protein needs?
indirect calorimetry
| if you dont use this you are using calculations that are not as accurate
137
What are some barriers to indirect calorimetry?
```
leak in system
ECMO
unstable, critically ill
specific brand of vent needed
recent anesthesia
```
138
EN vs PN
Enteral nutrition - into GI tract
Parenteral nutrition -
into the blood via peripheral or central vein
EN is safer and cheaper
139
For an intubated pt, at what point should you start then on EN feeding?
within 24-48 hours of admission
140
What are contraindications of EN?
```
ethical considerations
short gut syndrome
hemodynamically instability
intractable vomiting and diarrhea
GI obstruction, ischemia, bleed
severe acute pancreatitis
```
141
Short term EN routes
oro-gastric
Naso-gastric
naso-enteric
142
What are long tern EN routes?
gastrostomy
jejunostomy
transgastric jejunostomy
143
How do you unclog a feeding tube?
warm water
if it doesn't unclog, dissolve 1 tab pancrealipase and NaBicarb in warm water
144
Enteral feeding tubes must be flushed with at least ____ ml water at least ____ times per day for ____
30 ml water
4-6 times per day
for tube patency
145
What types of medications can be given via feeding tube?
only liquid meds or powders suspended in liquids
146
TPN
total peripheral nutrition
PPN - peripheral
CPN - central
147
CPN vs PPN
CPN - longer term PN (>10-14 days)
PPN - short term (<14 days)
- PPN requires diluted, larger volume infusions
- risk of thrombophelbitis
148
What are the indications for PN?
- short bowel syndrome w/ malabsorption
- no gut function
- ischemic bowel
- paralytic ileus
- peritonitis
149
What are contraindications of PN?
duration of therapy expected <5 days
aggressive nutrition support not desired by pt
Anorexia or inability to ingest enough nutrients orally (work with the pt)
150
What are some complications of PN?
```
infections
mechanical
-air embolism
-blood in catheter
-cracking/tearing of catheter
-catheter clot
-phlebitis
metabolic
-hyper/hypoglycemia
-hyperTG
-excessive CO2 production
-abnormal LFTs
```
151
NPO Guidelines
pre-op fasting:
- no solid food 6-8 hours prior to non-emergent surgery
- no clears within 2 hours pre-op
- general rule: nothing to eat or drink after midnight prior to surgery except sips of water with necessary meds
feeding tubes: stop tube feeds 8 hours prior to surgery
152
How long prior to non-emergent surgery should you stop eating solid foods?
6-8 hours prior
general rule: nothing to eat or drink after midnight prior to surgery except sips of water with necessary meds
153
What is the point of perioperative antibiotic prophylaxis?
avoid surgical site infections (SSIs)
154
What are the most common cause of hospital infections?
SSIs
| surgical site infections
155
SSI definition
infection related to an operative procedure that occurs at or near the surgical site within 30 days of the procedure
-within 90 days if prosthetic material implanted
156
What is the post-op infection rate?
2-5%
157
____% of cases of pt death in the postop period are related to SSIs
75
158
What requirements must you meet in order to say you have SSI?
at least 1 of the following
- purulent exudate
- positive culture
- reopened wound due to signs of infection (pain, redness, swelling)
159
Infection vs colonization
the presence of proliferating bacteria without a host response
generally does not impede wound healing in a healthy pt
160
What are the risk factors for SSI?
comorbidities: DM, obesity, smoker, immunosuppressed, malnutrition
extremes in age, recent infection, recent surgery
procedure related:
duration of surgery, +/ prosthesis, degree of tissue trauma, need for blood transfusion, perioperative management
surgical environment:
-sterilization
161
"clean" wound classification
(<2% SSI risk)
| not infected, not inflamed
162
"clean-contaminated" wound classification
(2-10% SSI risk)
| respiratory, bowel, genital, GI or GU tracts are entered under controlled conditions
163
"contaminated: wound classification
(10-20% SSI risk)
| open fresh accidental wounds, major breaks in sterile technique or gross spillage from GI tract, + inflammation
164
"dirty" wound classification
(>30% SSI risk)
| old traumatic wounds with devitalized tissue, or existing clinical infection, pus, or perforated viscera
165
What pathogen is the most common cause of SSI?
staph aureus
166
ABX prophylaxis is based on what?
- pathogen most likely encountered for procedure
- appropriate dosage provided at ideal time interval to provide adequate tissue and serum concentrations during the period of potential contamination
- safety
- administration in shortest effective period in order to minimize adverse effects
167
What is the first line ABX prophylaxis?
1st gen cephalosporin (such as cefazolin)
covers gram + like staph, strep
some gram - coverage
good for "clean-contaminated" wounds
168
For which procedures must you add gram - and anaerobic coverage?
procedures entering the GI tract, oropharynx, GU, biliary or tracheobronchial tract
cefoxitin or cefotetan singularly
clina + aminoglycoside
cefazolin + metronidazole
169
When is vancomycin used?
reserved for prophylaxis:
- hospitals in which MRSA is a frequent cause of SSI
- pts with known MRSA colonization
- high risk of MRSA: nursing home, recent hospitalization
170
What dosages are used for ABX prophylaxis?
goal: adequate blood and tissue concentrations at time of incision
recommendations: <120kg: 2gm cefazolin
>120kg: 3gm cefazolin
within 60 minutes of surgical incision (exceptions: fluoroquinolones and vanco should be given within 120 minutes of incision d/t prolonged infusion time)
171
ABX prophylaxis by definition does not go longer than ____
24 hours
172
When should you think about screening pre-op for S. aureus?
high risk for complications
cardiac or orthopedic procedures
immunocompromised
173
Universal Protocol (Pre-op)
to prevent wrong person, wrong site, wrong procedure
3 elements:
- pre-procedure verification process
- marking the procedure site
- A Time Out (final verification)
174
What is the preop airway assessment?
```
LEMON
Look
Evaluate
Mallampati
Obstruction/obesity
Neck mobility
```
175
What are the 3 phases of anesthesia?
induction
maintenance
emergence
176
What is the major con of propofol?
hypotension
177
What are the 3 common general anesthesia agents used via IV?
propofol
etomidate
ketamine
178
What are the most common general anesthesia IV adjuvants?
opiodis: fentanyl
lidocaine
benzo (versed)
179
What are the common general anesthesia inhaled agents?
sevoflurane
desflurane
NO
major cause of post op N/V
180
NMBA
neuromuscular blockade agents
used to paralyze the pt during surgery or some intubation
only skeletal muscle
181
How is the maintenance phase accomplished with general anesthesia?
inhalation agent + NO + oxide + opioid and muscle relaxant
182
What might you see with pts during the emergence phase of general anesthesia?
HTN
tachycardia
bronchospasm
mitigate with BB, lidocaine, narcotics
183
Moderate sedation vs deep sedation
moderate sedation doesnt require anesthesiologists
| pt must be able to maintain airway integrity
184
ABCDEFGHI
```
Airway
Breathing
Circulation
Disability (Check pupils)
Exposure/environment/examination
Finger in every orifice; Female (pregnant?)
Glucose, NG tube (if needed)
Hang fluids/ABX
Inject (tetanus, pain meds)
```
185
3Cs of managing crashing patients
Control the room
Communicate
Carry on with confidence
(close loop communication)
186
5 causes of post-op fever
```
5 Ws (days)
Wind (1) - atelectasis
Water (3) -UTI
Wound (5) -SSI
Walking (7) - DVT
Wonder (9) - drugs
```
187
What is the difference between CPAP and BiPAP?
CPAP is continuous pressure during both inspiration and expiration --function: keep large airways open and prevent alveolar collapse
BiPAP is expiratory pressure with additional pressure during inhlation to help pts breathe in better --function: assists ventilatory muscles
188
When do you use CPAP vs BiPAP?
CPAP - OSA, caridogenic pulmonary edema (decrease preload and afterload)
BiPAP - COPD, ALS, muscular dystrophy, myasthenia
189
Once you have put a pt on BiPAP how do you know if it is working?
obvi the pt will look better, breathing better
Labs:
decrease in PaCO2
increase in pH
correction of respiratory acidosis
190
When do you intubate (vs using BiPAP)?
```
respiratory arrest (not breathing)
decreased LOC (lethargic)
put them on BiPAP without improvement
hemodynamic instability
clinical suspicion of increased ICP
```
191
SIRS criteria
Systemic inflammatory response criteria (must have 2 of the 4 criteria)
tachypnea (>20)
tachycarida (>90)
temperature >100.4 or <95.0
WBC >12,000 or <4,000 (leukocytosis or leukopenia)
192
Sepsis
SIRS + infection
193
Severe Sepsis
Sepsis (SIRS + infection) + end organ damage
194
Septic Shock
severe sepsis + hypotension
195
Early vs late response with sepsis
Early response = hyperinflammatory response
Late response = hypo-inflammatory response
196
What is your fluid choice for a hyponatremic pt?
NS (3% NaCl if severe hyponatremia)
197
What is your fluid choice for a hypernatremic pt?
D5 or D51/2NS
198
What is the average age of menopause?
51
Why is this important?
if a pt has a uterus, and cannot confirm post-menopausal --> must Ro pregnancy with beta HCG before surgery
199
What questions about past surgery is important to ask when planning another surgery?
What pain meds were you given and did they work?
How long did you require pain meds?
How long was your recovery period?
200
Constitutional sxs?
fever
chills
sores
rashes
201
What drugs must you specifically ask about when consulting for surgery?
anticoagulants
ASA
NSAIDs (concerned about kidney, stomach bleeding, HTN)
Steroids (concerned about peri-op adrenal insufficiency
Herbals/OTCs (concerned about fish oil, vit E, Gigko, Garlic, Goldenseal)
202
What are the 3Gs in regards to OTC medications and why do we care?
Gingko
Garlic
Goldenseal
all inhibit platelets
203
What differs a true allergy from a side effect?
allergy:
- hives
- rash
- itching
- airway compromise
- swollen face
- hypotension
side effects:
- N/V/D
- constipation
- cough
- easy bruising
204
Red Man syndrome
possible skin SE to vancmycin
205
Which drugs can cause Stevens - Johnsons Syndrome?
NSAIDS
Sulfa drugs (like bactrim)
AEDs
206
Class 2 Mallampati Score?
soft palate, uvula, fauces visible (less so)
207
Class 3 Mallampati Score?
soft palate and base of uvula visible
208
Admit orders mneumonic
ADC A VANDIMLS
209
When is the consent form signed?
at first suggestion
| and then again in pre-op holding area once pt has been marked
210
What are the components of surgery informed consent?
```
Procedure defined
(Including all necessary devices and lines/tubes)
Reasonable alternatives
Who is performing (primary surgeon/PA)
Risks and frequencies
Benefits
Probability of success
Expected post-op course
Comprehension of terms
```
211
For which procedures do you have to get informed consent each time, even if pt has already consent before?
admin of blood products
212
What are the components of procedure note?
```
Date, time
Indications
Performed by
Procedure performed
Anesthesia used
Details of procedure
(Time out
Technique
How pt tolerated)
Complications
Device or implant sticker
Plan for confirmation
(Ex. CXR post intubation)
```
213
What are the components of a bedside procedural timeout?
```
Identify correct pt/side
Plan for procedure
Special equipment needed
Explain positioning, monitoring
Verify consent obtained
```
214
What does every consent HAVE TO HAVE?
witness
PA/MD
PA/PA
PA/resident
PA/nurse
timed/dated
consider the pt as a "second" witness when proxy is giving consent
215
Parens Patriae
court order for when parent refuses medical attention for serious illness or dying child
216
If pt is unable to give consent, who do we turn to next?
1st - proxy
| 2nd - spouse or first degree relative
217
When should you consider getting a competency test when trying to obtain informed consent? How do you do this?
Abrupt change in mental status
When pt refuses recommended treatment
Hasty decision making
At risk population, dementia, extremes of age, neurological conditions
Questionnaires done by primary care MD, psych, geriatrician
218
What is emergency consent?
Two MD consent” --health care provider treater a pt without formal consent if:
Pt is incapable of making informed decision
The treatment is of emergency medical nature
Another persons who has legal authority to give consent is not immediately available
AND
The attending MD determines that the pt faces a substantial risk of death and tx can not be delayed trying to obtain consent
219
Power of Attorney for health care
Appointed person to make medical decisions on your behalf when you can not speak or incapacitated. Made during sound mind. Sometimes called proxy, agent, or surrogate
220
Durable Power of Attorney
Ability of proxy to continue to make decisions after their death
221
Court Appointed Proxy
If family is unable, unavailable or unwilling to make proxy decision then a doctor or family member can petition for a judge to court appoint a healthcare proxy to make decisions on your behave while incapacitated (usually a lawyer)
222
You have a John Doe come in, what do you do for short and long term consent?
Short term - 2 MD consent
| Long term - court appointed guardian
223
HD #2, POD#1
hospital day 2
| post op day 1
224
Levaquin #2/8
This means the pt is on day 2 of an 8 day course of ABX
225
In the daily progress note, the plan is ideally written how?
by organ system
226
Which Pre-op test should you get for a pt with pulmonary PMH?
CBC
EKG
CXR
PFTs
227
Which pre-op tests should you get for a pt with hx of CV?
CBC
EKG
Echo
Stress test
228
Which pre-op test should you get for a pt with hx of liver disease?
```
CBC
CMP
LFTs
PT/INR
Hepatitis panel based on LFT results
```
229
Which pre-op test should you get for a pt with hx of DM?
BMP
EKG (remember that DM puts you at risk for CV)
HbA1c
230
Which pts get an EKG as pre-op test regardless of their PMH?
pts >50 years of age
231
Emergent vs urgent surgery?
Emergent - life or limb is threatened if not in OR in 6 hours (just time to pull labs, no risk stratification)
Urgent - life or limb is threatened if not in OR in 24 hours
232
Time Sensitive surgery
delay of 1-6 weeks for further evaluation would negatively affect outcome
233
NYHA
New York Heart Association
functional classification
234
ASA class 1
normal healthy patient
235
ASA class 2
```
pt with mild systemic disease
HTN
control DM w/o organ damage
mild obesity
pregnancy
```
236
RCRI score of 2
high risk (7%)
237
RCRI score of 3+
high risk (11%)
238
When do you use DASI?
if pt has cardiac risk factors or known CAD
| in the pre-op work up
239
What is the most important prognostic marker in determine extent of heart failure?
functional capacity
240
When is it reasonable to start a pt on prophylactic BBs (assuming they weren't on them before)?
Pts with intermediate or high cardiac risk on stratification
in pts with >3 RCRI risk factors
pts with CAD undergoing vascular surgery
241
How long are pts on prophylactic BBs?
during the pre-op period (months?) until POD #30
242
If a pt is normally on BB and statins, should they continue taking them before surgery?
yes
243
Ventilation ____weeks has almost 100% chance of getting PNA
> 2weeks
244
____ is an important pt-related predictor of pulmonary risk
age
| risk factor >60y/o
245
Why is TPN not encouraged for pts going in for/after surgery?
increase risk of PNA
246
Pt that quit smoking ____ prior to surgery decrease their risk of PNA, SSI, and death
4 weeks
247
What kind of post op complication does OSA put a pt at risk for?
Pulmonary complications
248
What intra-op measures can be taken to decrease pulmonary complications?
decrease anesthesia time
249
What effects can surgery have on a DM pts glucose?
can lead to hyperglycemia and ketosis
this is because anesthesia causes neuoedocrine stress releasing epi, glucogan, cortisol, GH, TNF, inflammatory cytokines
250
What is the pre-op blood glucose goal?
in critically ill pts its 120-180
strictly controling it (90-110) can cause more harm than good
anesthesiologist will check blood sugar every hour in the OR
251
What medications are held the morning of surgery?
oral anti-hyperglycemics (to be resumed when pt is PO)
| instead, on the morning of surgery the pt will be given NPH
252
A pt on anticoags scheduled for surgery needs what tests done?
PT/INR/PTT
253
A pt on diuretics scheduled for surgery needs what tests done?
BMP
254
A pt on synthoid scheduled for surgery needs what tests done?
thyroid function tests
255
Which risk stratification tools takes into account the type of surgery?
NSQIP
256
Prostate surgery has what kind of cardiac risk?
intermediate cardiac risk <5%
257
If a pt is obese then what is their ASA score?
3
258
Which BP meds should not be taken the morning of surgery?
ACEI
ARB
Diuretics
259
What is the most important patient-related predictor of pulmonary risk?
age
260
In regards to DM pts, what is more important, their pre-op blood sugar or their post-op blood sugar?
pre-op
261
Which drugs are you asking your pt about so you can advise them to stop taking them before surgery?
```
ACEI
ARB
Diuretics
Lispro (DM meds)
OCP
ASA
NSAIDs
Factor Xa inhibitor
Factor 2 inhibitor
```
262
How long before surgery should a pt stop taking their OCP?
4-6 weeks
263
How long before surgery should a pt stop taking their ASA?
7 days
| the length of a platelet
264
How long before surgery should a pt stop taking their NSAIDs?
3 days
ibuprofen can be taken up to 24 hours prior to surgery but this is not ideal
265
How long before surgery should a pt stop taking their Rivaroxaban?
factor 10a inhibitor
stop taking 2-3 days prior to surgery
no bridging needed
266
How long before surgery should a pt stop taking their Dabigatran (pradaxa)?
factor 2 inhibitor
stop taking 2-3 days prior to surgery
not bridging needed
267
How long before surgery should a pt stop taking their warfarin?
5 days prior
start on bridging therapy with lovenox (LMW heparin)
268
What is praxbind?
reversal agent for dabigatran
factor 2 inhibitor
269
What about pts on chronic steroids...how do their meds change prior to surgery?
They stay on their steroids...their body has suppressed their HPA axis and are unable to make their own cortisol
surgery is a stressful time on the body so ideally they would be producing more cortisol but that's not possible so you might give them a "stress dose" right before surgery of cortisol
270
A 56 yo male with COPD is having a thyroid nodule removed, what tests are you ordering?
CBC
EKG
CXR
Thyroid tests should have already been completed
271
A 39 y/o F with ESRD and DM having kidney transplant, what tests are you ordering?
```
CBC, BMP
EKG
Beta HCG
PT/INR
Type and cross
```
