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Clin Specialties - Surgery > Surgery > Flashcards

Surgery Flashcards

1
Q

If your pt is allergic to eggs or soy what drug should they not get?

A

no propofol

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2
Q

If your pt is allergic to shellfish what drug should they not get?

A

no iodine

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3
Q

Red Man Syndrome can be a SE from what drug?

A

Vanco (IV)

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4
Q

Stevens-Johnson Syndrome can be a SE from what drug?

A

NSAIDs
Sulfa drugs
Antiepileptic drugs

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5
Q

What is the Mallampati Score?

A

score used to predict east of ET intubation

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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

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7
Q

Class 4 Mallampati Score means what?

A

only hard palate is visible (harder intubation)

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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

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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.

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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.

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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.

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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
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13
Q

Which anticoagulants are used in surgery?

A

Unfractionated Heparin
LMV Heparin (Lovenox)
Warfarin (Coumadin)

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14
Q

Which antiplatelet drugs are used in surgery?

A

Clopidogrel (plavix)

ASA (aspirin)

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15
Q

What DOACs are used in surgery?

A

Direct oral anti-coagulants

Abixaban (Eliquis)
Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)

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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

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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)

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18
Q

What is the definition of urgent surgery?

A

life of limb is threatened if not operated on within 24 hours

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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)

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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
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21
Q

What is considered intermediate risk surgery?

A

cardiac risk <5%

examples:

  • carotid endarterectomy
  • head and neck
  • orthopedic
  • prostate
  • intraperitoneal and intrathoracic
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22
Q

What is considered low risk surgery?

A

cardiac risk <1%

examples:
- endoscopic procedures
- superficial procedures
- cataract
- breast

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23
Q

What is the ASA?

A

american society of anesthesiologists

used to assess anesthesia risk

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24
Q

What does ASA 6 mean?

A

a declared brain dead pt whose organs are being removed for donor purposes

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25
Q

What does ASA 3 mean?

A

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

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26
Q

What are the limitations of ASA stratification?

A
  • vague
  • grades mild to severe (what about moderate?)
  • subjective (based on trusting what the pt tells you)
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27
Q

What is RCRI?

A 
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
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28
Q

What is the DASI?

A

Duke Activity Status Index

Self assessment questionnaire to estimate functional capacity

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29
Q

What MET must pt reach in order to be ok to proceed with surgery?

A

> or equal to 4 METs

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30
Q

What is ACS NSQIP?

A

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

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31
Q

What is the most common reason to postpone surgery?

A

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

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32
Q

What is the target HR on BB?

A

resting HR 60-65 bpm

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33
Q

What is the ideal time for pts who smoke to quit smoking prior to surgery?

A

4 weeks prior to surgery

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34
Q

“STOP - BANG”

A 
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
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35
Q

OSA score of 4

A

Obstructive Sleep Apnea score 3-4/8 = intermediate

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36
Q

OSA score of 7

A

Obstructive Sleep Apnea score 5-8/8 = high risk

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37
Q

What are modifications you can do pre-op to decrease pulmonary risks?

A

stop smoking
bronchodilator tx
control infections
weight control

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38
Q

What are modifications you can do intra-op to decrease pulmonary risks?

A

limit anesthesia time
prevent aspiration
limit paralytics
optimal tidal volume, bronchodilation

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39
Q

What are modifications you can do post-op to decrease pulmonary risk?

A

inspiratory maneuvers
early mobilization
mobilize secretions
adequate pain control

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40
Q

What is the most important post-op modification to better improve pulmonary outcomes?

A

early mobilization

get that pt up and walking ASAP

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41
Q

What is the goal BP pre-op for critically ill diabetic pts?

A

120-180 mg/dL

post-op blood sugar control doesn’t appear to be a major factor in post-op complications

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42
Q

What are the major complications post-op for diabetic pts?

A

surgical site infections

increase length of stay

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43
Q

What do you tell a diabetic pt to do with meds morning of surgery?

A

oral anti-hyperflycemics are held the morning of surgery

resumed when taking PO

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44
Q

What glucose level might cause you to cancel the surgery?

A

> 400 (even above 300 is BAD)

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45
Q

What is the frailty score?

A

used to predict post-op mortality risk for geriatric pts

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46
Q

How is obesity defined?

A

BMI >30 kg/m2

severe obesity BMI >40

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47
Q

What is the ideal operative position for a pregnant pt?

A

left lateral decubitus to reduce abdominal aorta compression

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48
Q

Can you give a pregnant pt opioids?

A

yes

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49
Q

Can you give a pregnant pt NSAIDs?

A

no
it has been shown to increase risk of premature closure of ductus arteriosus
given acetaminophen instead
or even opioids

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50
Q

What is one of the most common causes of electrolyte imbalances?

A

Medications

  • diuretics
  • laxatives
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51
Q

What defines acute and chronic hyponatremia?

A

Na < 135 mEq/L

Acute (48 hours)

Chronic (>48 hours)

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52
Q

What can occur if you correct hyponatremia too fast?

A

osmotic demyelination syndrome

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53
Q

What are common causes of SIADH?

A

post op, head trauma
adrenal insufficiency, hypothyroidism
Infectious (PNA, meningitis)
Meds (SSRIs, chlorporpamide)

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54
Q

What is the treatment for SIADH?

A

fluid restrict (<800mL/day)

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55
Q

What is the definition of hypernatremia?

A

Na > 145 mmol/L

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56
Q

What are causes of hypernatremia?

A 
water loss (diarrhea, vomiting, excessive sweating, diuresis, diabetes insipidus)
Reduced water intake (impaired access - elderly bed bound) 
Excessive sodium intake (hypertonic saline, sodium bicarbonate)
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57
Q

What is the treatment for hypernatremia?

A

chronic: 5% dextrose/W @ 1.35ml/hr x pts weight (kg)
acute: 5% dextrose/W @ 3-6ml/hr/kg

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58
Q

What happens if you correct hypernatremia too quickly?

A

cerebral edema, seizures

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59
Q

What is free water deficit?

A

NOT DONE HERE

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60
Q

What is the definition of hypokalemia?

A

K+ < 3.5

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61
Q

What are the possible EKG findings of hypokalemia?

A

U waves
QT prolongation
flat or inverted T waves

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62
Q

What are some causes of hypokalemia?

A 
insulin 
hyperaldosteronism 
vomiting/diarrhea 
dialysis 
diuretics 
beta agonists
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63
Q

What is the treatment for hypokalemia?

A

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

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64
Q

What is the definition of hyperkalemia?

A

k+ > 5.5mmol/L

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65
Q

What are EKG findings for hyperkalemia?

A

peaked T waves
QRS lengthening
Sine waves (on their way to arryhthmia)

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66
Q

What are some causes of hyperkalemia?

A

NOT DONE HERE

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67
Q

What is the treatment for hyperkalemia?

A

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
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68
Q

5-8% water loss sxs

A

dehyrdation

dizzy, fatigue

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69
Q

> 10% water loss sxs

A

mental, physical impairments

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70
Q

> 15-20% water loss sxs

A

fatal

they be dead

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71
Q

dry eyes and dark urine are a sign of what kind of dehydration?

A

moderate

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72
Q

What are crystalloids?

A

NOT DONE HERE

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73
Q

What is the purpose of crystalloids?

A

NOT DONE HERE

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74
Q

What are crystalloid types?

A

NOT DONE HERE

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75
Q

Why might you use isotonic crystalloid?

A

water and salt depletion states (vomiting, diarrhea)
hypovolemic shock
initial therapy DKA
replacing post-op fluids

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76
Q

What crystalloid type do you never want to give to a pts with increased ICP or risk of increased ICP?

A

hypotonic solutions

risk of increase brain edema and ICP

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77
Q

Why might you use hypertonic solutions?

A

NOT DONE HERE

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78
Q

What are the Na+, Cl-, K+ concentrations in LR?

A

130, 109, 4

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79
Q

What are the Na+, Cl-, K+ concentrations in NS?

A

154, 154, -

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80
Q

What are the Na+, Cl-, K+ concentrations in D5LR?

A

130, 109, 4, 50g dextrose

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81
Q

What are the Na+, Cl-, K+ concentrations in D5W?

A

-,-,-, 50g dextrose

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82
Q

What are the Na+, Cl-, K+ concentrations in D5 1/2 NS?

A

77, 77, -, 50g dextrose

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83
Q

What are the Na+, Cl-, K+ concentrations in 3% NS?

A

513, 513, -

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84
Q

What are the Na+, Cl-, K+ concentrations in 5% NS?

A

855, 855, -

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85
Q

What is the most common maintenance fluid used for a healthy adult pt?

A

D5 1/2 NS (77, 77, -, 50g dextrose)

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86
Q

What are colloid solutions?

A

NOT DONE HERE

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87
Q

What are the uses of colloids?

A

hypovolemic shock
adjunct in burn resuscitation
(giving blood products)

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88
Q

What is the fastest way to increase the oxygen delivery capacity to the blood?

A

blood product transfusion

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89
Q

1 unit (300-350cc) of blood does what to the labs?

A

increase Hgb 1g/dL and HCT by 3%

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90
Q

1 unit of platelets (6 pack) increases platelets by _____

A

30,000

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91
Q

TRALI

A

transfusion related acute lung injury

immune reaction - FEVER (30 min - 6 hours post transfusion)

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92
Q

TACO

A

transfusion associated circulatory overload

acute congestive heart failure secondary to transfusion
fluid overload

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93
Q

What is the treatment for TACO?

A

lasix

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94
Q

Primary survey for triage

A 
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
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95
Q

What is a cuffed airway?

A

definitive airway –> only endotracheal tube

not OPA or NPA

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96
Q

What injuries impair ventilation in the short term?

A

tension pneumothorax
flail chest with pulmonary contusion
massive hemothorax
open pneumothorax

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97
Q

Which imaging modality is best to see fractured ribs?

A

CT

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98
Q

What 3 things must you keep in mind with hemorrhage control?

A

blood volume
cardiac output
bleeding

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99
Q

What are you seeing with a pt who has a tension pneumothorax?

A

acute resp. distress
absent breath sounds
hyperresonance
tracheal shift

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100
Q

GCS

A

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
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101
Q

GCS 3 -8

A

unconscious pt
INTUBATE

Give:

  • mannitol
  • moderate hyperventilation
  • hypertonic saline
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102
Q

What is an initial dose of warm fluid bolus for an adult post trauma?

A

1 - 2 Liters

make sure you ask EMS how much they gave in the field

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103
Q

Class 2 hemorrhage

A

greater than 2 L blood loss (DOUBLE CHECK THIS)

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104
Q

What is the preferred method of replacing blood?

A

cross matching but it takes an hour

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105
Q

Type-specific blood can be provided in ____

A

10 minutes

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106
Q

When, during trauma, are you giving Rh negative?

A

females of child bearing age

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107
Q

Massive transfusion?

A

> 10 units of PRBCs within 24 hours of admission

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108
Q

Activated factor VII

A

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

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109
Q

TXA

A

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
Q

“ANY INJURED PT WHO IS _____ AND _____ IS CONSIDERED TO BE IN SHOCK, UNTIL PROVEN OTHERWISE”

A

cool and tachycardic

111
Q

What is the most common cause of shock?

A

hypovolemic

112
Q

What is the first choice treatment of hemorrhagic shock?

A

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
Q

What can cause cardiogenic shock?

A

blunt cardiac injury should be expected when the mechanism of injury to the thorax is rapid deceleration

require constant EKG monitoring

114
Q

FAST

A

focused assessment sonography in trauma

used to identify pericardial fluid and likelihood of cardiac tamponade as cause of shock

115
Q

What is the most common cause of cardiac tamponade?

A

penetrating thoracic trauma

can be confused with tension pneumothorax

116
Q

How can you tell tension pneumothorax from cardiac tamponade?

A

tension - absent breath sounds, tracheal deviation, and hyperresonance of affected himthorax

117
Q

What is the best intervention for cardiac tamponade?

A

thoracotomy

118
Q

What is epinephrines action?

A

agonist of alpha1, beta1, and bet2 receptors

increases MAP by increasing cardiac index and stroke volume, as well as SVR and heart rate

119
Q

Dopamine

A

precursor of norepi and epi

varying effects according to dose infused

used for cardiogenic shock

120
Q

What are the dosages for dopamine?

A

<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
Q

Neurogenic shock

A

NOT DONE HERE

122
Q

Treatment for neurogenic shock

A

NOT DONE HERE

123
Q

Distributive shock

A

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
Q

What is the treatment for septic shock?

A

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
Q

What hemoglobin levels are recommended for RBC transfusion?

A

<7g/dL

target Hgb range of 7-9 g/dL

126
Q

Antithrombin agents are not recommended for _____

A

sepsis or septic shock

127
Q

RSI

A

rapid sequence intubation

most effective way in an emergency situation to intubate a pt

128
Q

RSI medications

A

induction agents -

Ketamine  
Thiopental 
Propofol 
Fentanyl 
Etomidate
Neuromuscular blockers
129
Q

Which induction agent would you use for RSI with hemodynamically unstable pts?

A

Ketamine

Etomidate

130
Q

Which of the induction agents should NOT be used for RSI?

A

Midazolam

131
Q

What 4 views are used for FAST exam?

A

pericardial view
RUQ view
LUQ view
Suprapubic view

132
Q

What is a low sodium diet?

A

2gm Na restriction

indications: CHF, fluid retention, HTN

133
Q

What is the difference between the renal diet for pts on HD vs those not on HD?

A

both are on low sodium (2gm) restriction and phosphorus restriction

non HD pts have to restrict their protein

134
Q

What is the cardiac diet?

A

2gm Na

low fat

135
Q

What is a low residue diet?

A

fiber-restricted diet

indications: certain GI disorders, gastroparesis

136
Q

What is the gold standard to determine calorie and protein needs?

A

indirect calorimetry

if you dont use this you are using calculations that are not as accurate

137
Q

What are some barriers to indirect calorimetry?

A 
leak in system
ECMO
unstable, critically ill
specific brand of vent needed 
recent anesthesia
138
Q

EN vs PN

A

Enteral nutrition - into GI tract

Parenteral nutrition -
into the blood via peripheral or central vein

EN is safer and cheaper

139
Q

For an intubated pt, at what point should you start then on EN feeding?

A

within 24-48 hours of admission

140
Q

What are contraindications of EN?

A 
ethical considerations
short gut syndrome 
hemodynamically instability 
intractable vomiting and diarrhea
GI obstruction, ischemia, bleed
severe acute pancreatitis
141
Q

Short term EN routes

A

oro-gastric
Naso-gastric
naso-enteric

142
Q

What are long tern EN routes?

A

gastrostomy
jejunostomy
transgastric jejunostomy

143
Q

How do you unclog a feeding tube?

A

warm water

if it doesn’t unclog, dissolve 1 tab pancrealipase and NaBicarb in warm water

144
Q

Enteral feeding tubes must be flushed with at least ____ ml water at least ____ times per day for ____

A

30 ml water
4-6 times per day
for tube patency

145
Q

What types of medications can be given via feeding tube?

A

only liquid meds or powders suspended in liquids

146
Q

TPN

A

total peripheral nutrition

PPN - peripheral
CPN - central

147
Q

CPN vs PPN

A

CPN - longer term PN (>10-14 days)

PPN - short term (<14 days)

  • PPN requires diluted, larger volume infusions
  • risk of thrombophelbitis
148
Q

What are the indications for PN?

A
  • short bowel syndrome w/ malabsorption
  • no gut function
  • ischemic bowel
  • paralytic ileus
  • peritonitis
149
Q

What are contraindications of PN?

A

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
Q

What are some complications of PN?

A 
infections
mechanical
-air embolism
-blood in catheter
-cracking/tearing of catheter
-catheter clot
-phlebitis
metabolic 
-hyper/hypoglycemia
-hyperTG
-excessive CO2 production 
-abnormal LFTs
151
Q

NPO Guidelines

A

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
Q

How long prior to non-emergent surgery should you stop eating solid foods?

A

6-8 hours prior

general rule: nothing to eat or drink after midnight prior to surgery except sips of water with necessary meds

153
Q

What is the point of perioperative antibiotic prophylaxis?

A

avoid surgical site infections (SSIs)

154
Q

What are the most common cause of hospital infections?

A

SSIs

surgical site infections

155
Q

SSI definition

A

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
Q

What is the post-op infection rate?

A

2-5%

157
Q

____% of cases of pt death in the postop period are related to SSIs

A

75

158
Q

What requirements must you meet in order to say you have SSI?

A

at least 1 of the following

  • purulent exudate
  • positive culture
  • reopened wound due to signs of infection (pain, redness, swelling)
159
Q

Infection vs colonization

A

the presence of proliferating bacteria without a host response

generally does not impede wound healing in a healthy pt

160
Q

What are the risk factors for SSI?

A

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
Q

“clean” wound classification

A

(<2% SSI risk)

not infected, not inflamed

162
Q

“clean-contaminated” wound classification

A

(2-10% SSI risk)

respiratory, bowel, genital, GI or GU tracts are entered under controlled conditions

163
Q

“contaminated: wound classification

A

(10-20% SSI risk)

open fresh accidental wounds, major breaks in sterile technique or gross spillage from GI tract, + inflammation

164
Q

“dirty” wound classification

A

(>30% SSI risk)

old traumatic wounds with devitalized tissue, or existing clinical infection, pus, or perforated viscera

165
Q

What pathogen is the most common cause of SSI?

A

staph aureus

166
Q

ABX prophylaxis is based on what?

A
  • 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
Q

What is the first line ABX prophylaxis?

A

1st gen cephalosporin (such as cefazolin)

covers gram + like staph, strep

some gram - coverage

good for “clean-contaminated” wounds

168
Q

For which procedures must you add gram - and anaerobic coverage?

A

procedures entering the GI tract, oropharynx, GU, biliary or tracheobronchial tract

cefoxitin or cefotetan singularly

clina + aminoglycoside

cefazolin + metronidazole

169
Q

When is vancomycin used?

A

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
Q

What dosages are used for ABX prophylaxis?

A

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
Q

ABX prophylaxis by definition does not go longer than ____

A

24 hours

172
Q

When should you think about screening pre-op for S. aureus?

A

high risk for complications
cardiac or orthopedic procedures
immunocompromised

173
Q

Universal Protocol (Pre-op)

A

to prevent wrong person, wrong site, wrong procedure

3 elements:

  • pre-procedure verification process
  • marking the procedure site
  • A Time Out (final verification)
174
Q

What is the preop airway assessment?

A 
LEMON
Look 
Evaluate
Mallampati
Obstruction/obesity
Neck mobility
175
Q

What are the 3 phases of anesthesia?

A

induction
maintenance
emergence

176
Q

What is the major con of propofol?

A

hypotension

177
Q

What are the 3 common general anesthesia agents used via IV?

A

propofol
etomidate
ketamine

178
Q

What are the most common general anesthesia IV adjuvants?

A

opiodis: fentanyl
lidocaine
benzo (versed)

179
Q

What are the common general anesthesia inhaled agents?

A

sevoflurane
desflurane
NO

major cause of post op N/V

180
Q

NMBA

A

neuromuscular blockade agents

used to paralyze the pt during surgery or some intubation

only skeletal muscle

181
Q

How is the maintenance phase accomplished with general anesthesia?

A

inhalation agent + NO + oxide + opioid and muscle relaxant

182
Q

What might you see with pts during the emergence phase of general anesthesia?

A

HTN
tachycardia
bronchospasm

mitigate with BB, lidocaine, narcotics

183
Q

Moderate sedation vs deep sedation

A

moderate sedation doesnt require anesthesiologists

pt must be able to maintain airway integrity

184
Q

ABCDEFGHI

A 
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
Q

3Cs of managing crashing patients

A

Control the room
Communicate
Carry on with confidence

(close loop communication)

186
Q

5 causes of post-op fever

A 
5 Ws (days) 
Wind (1) - atelectasis 
Water (3) -UTI
Wound (5) -SSI
Walking (7) - DVT
Wonder (9) - drugs
187
Q

What is the difference between CPAP and BiPAP?

A

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
Q

When do you use CPAP vs BiPAP?

A

CPAP - OSA, caridogenic pulmonary edema (decrease preload and afterload)

BiPAP - COPD, ALS, muscular dystrophy, myasthenia

189
Q

Once you have put a pt on BiPAP how do you know if it is working?

A

obvi the pt will look better, breathing better

Labs:
decrease in PaCO2
increase in pH
correction of respiratory acidosis

190
Q

When do you intubate (vs using BiPAP)?

A 
respiratory arrest (not breathing) 
decreased LOC (lethargic) 
put them on BiPAP without improvement
hemodynamic instability 
clinical suspicion of increased ICP
191
Q

SIRS criteria

A

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
Q

Sepsis

A

SIRS + infection

193
Q

Severe Sepsis

A

Sepsis (SIRS + infection) + end organ damage

194
Q

Septic Shock

A

severe sepsis + hypotension

195
Q

Early vs late response with sepsis

A

Early response = hyperinflammatory response

Late response = hypo-inflammatory response

196
Q

What is your fluid choice for a hyponatremic pt?

A

NS (3% NaCl if severe hyponatremia)

197
Q

What is your fluid choice for a hypernatremic pt?

A

D5 or D51/2NS

198
Q

What is the average age of menopause?

A

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
Q

What questions about past surgery is important to ask when planning another surgery?

A

What pain meds were you given and did they work?
How long did you require pain meds?
How long was your recovery period?

200
Q

Constitutional sxs?

A

fever
chills
sores
rashes

201
Q

What drugs must you specifically ask about when consulting for surgery?

A

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
Q

What are the 3Gs in regards to OTC medications and why do we care?

A

Gingko
Garlic
Goldenseal

all inhibit platelets

203
Q

What differs a true allergy from a side effect?

A

allergy:

  • hives
  • rash
  • itching
  • airway compromise
  • swollen face
  • hypotension

side effects:

  • N/V/D
  • constipation
  • cough
  • easy bruising
204
Q

Red Man syndrome

A

possible skin SE to vancmycin

205
Q

Which drugs can cause Stevens - Johnsons Syndrome?

A

NSAIDS
Sulfa drugs (like bactrim)
AEDs

206
Q

Class 2 Mallampati Score?

A

soft palate, uvula, fauces visible (less so)

207
Q

Class 3 Mallampati Score?

A

soft palate and base of uvula visible

208
Q

Admit orders mneumonic

A

ADC A VANDIMLS

209
Q

When is the consent form signed?

A

at first suggestion

and then again in pre-op holding area once pt has been marked

210
Q

What are the components of surgery informed consent?

A 
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
Q

For which procedures do you have to get informed consent each time, even if pt has already consent before?

A

admin of blood products

212
Q

What are the components of procedure note?

A 
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
Q

What are the components of a bedside procedural timeout?

A 
Identify correct pt/side
Plan for procedure
Special equipment needed
Explain positioning, monitoring
Verify consent obtained
214
Q

What does every consent HAVE TO HAVE?

A

witness

PA/MD
PA/PA
PA/resident
PA/nurse

timed/dated

consider the pt as a “second” witness when proxy is giving consent

215
Q

Parens Patriae

A

court order for when parent refuses medical attention for serious illness or dying child

216
Q

If pt is unable to give consent, who do we turn to next?

A

1st - proxy

2nd - spouse or first degree relative

217
Q

When should you consider getting a competency test when trying to obtain informed consent? How do you do this?

A

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
Q

What is emergency consent?

A

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
Q

Power of Attorney for health care

A

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
Q

Durable Power of Attorney

A

Ability of proxy to continue to make decisions after their death

221
Q

Court Appointed Proxy

A

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
Q

You have a John Doe come in, what do you do for short and long term consent?

A

Short term - 2 MD consent

Long term - court appointed guardian

223
Q

HD #2, POD#1

A

hospital day 2

post op day 1

224
Q

Levaquin #2/8

A

This means the pt is on day 2 of an 8 day course of ABX

225
Q

In the daily progress note, the plan is ideally written how?

A

by organ system

226
Q

Which Pre-op test should you get for a pt with pulmonary PMH?

A

CBC
EKG
CXR
PFTs

227
Q

Which pre-op tests should you get for a pt with hx of CV?

A

CBC
EKG
Echo
Stress test

228
Q

Which pre-op test should you get for a pt with hx of liver disease?

A 
CBC
CMP
LFTs
PT/INR
Hepatitis panel based on LFT results
229
Q

Which pre-op test should you get for a pt with hx of DM?

A

BMP
EKG (remember that DM puts you at risk for CV)
HbA1c

230
Q

Which pts get an EKG as pre-op test regardless of their PMH?

A

pts >50 years of age

231
Q

Emergent vs urgent surgery?

A

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
Q

Time Sensitive surgery

A

delay of 1-6 weeks for further evaluation would negatively affect outcome

233
Q

NYHA

A

New York Heart Association

functional classification

234
Q

ASA class 1

A

normal healthy patient

235
Q

ASA class 2

A 
pt with mild systemic disease 
HTN
control DM w/o organ damage 
mild obesity 
pregnancy
236
Q

RCRI score of 2

A

high risk (7%)

237
Q

RCRI score of 3+

A

high risk (11%)

238
Q

When do you use DASI?

A

if pt has cardiac risk factors or known CAD

in the pre-op work up

239
Q

What is the most important prognostic marker in determine extent of heart failure?

A

functional capacity

240
Q

When is it reasonable to start a pt on prophylactic BBs (assuming they weren’t on them before)?

A

Pts with intermediate or high cardiac risk on stratification
in pts with >3 RCRI risk factors

pts with CAD undergoing vascular surgery

241
Q

How long are pts on prophylactic BBs?

A

during the pre-op period (months?) until POD #30

242
Q

If a pt is normally on BB and statins, should they continue taking them before surgery?

A

yes

243
Q

Ventilation ____weeks has almost 100% chance of getting PNA

A

> 2weeks

244
Q

____ is an important pt-related predictor of pulmonary risk

A

age

risk factor >60y/o

245
Q

Why is TPN not encouraged for pts going in for/after surgery?

A

increase risk of PNA

246
Q

Pt that quit smoking ____ prior to surgery decrease their risk of PNA, SSI, and death

A

4 weeks

247
Q

What kind of post op complication does OSA put a pt at risk for?

A

Pulmonary complications

248
Q

What intra-op measures can be taken to decrease pulmonary complications?

A

decrease anesthesia time

249
Q

What effects can surgery have on a DM pts glucose?

A

can lead to hyperglycemia and ketosis

this is because anesthesia causes neuoedocrine stress releasing epi, glucogan, cortisol, GH, TNF, inflammatory cytokines

250
Q

What is the pre-op blood glucose goal?

A

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
Q

What medications are held the morning of surgery?

A

oral anti-hyperglycemics (to be resumed when pt is PO)

instead, on the morning of surgery the pt will be given NPH

252
Q

A pt on anticoags scheduled for surgery needs what tests done?

A

PT/INR/PTT

253
Q

A pt on diuretics scheduled for surgery needs what tests done?

A

BMP

254
Q

A pt on synthoid scheduled for surgery needs what tests done?

A

thyroid function tests

255
Q

Which risk stratification tools takes into account the type of surgery?

A

NSQIP

256
Q

Prostate surgery has what kind of cardiac risk?

A

intermediate cardiac risk <5%

257
Q

If a pt is obese then what is their ASA score?

A

3

258
Q

Which BP meds should not be taken the morning of surgery?

A

ACEI
ARB
Diuretics

259
Q

What is the most important patient-related predictor of pulmonary risk?

A

age

260
Q

In regards to DM pts, what is more important, their pre-op blood sugar or their post-op blood sugar?

A

pre-op

261
Q

Which drugs are you asking your pt about so you can advise them to stop taking them before surgery?

A 
ACEI 
ARB
Diuretics 
Lispro (DM meds) 
OCP
ASA
NSAIDs
Factor Xa inhibitor
Factor 2 inhibitor
262
Q

How long before surgery should a pt stop taking their OCP?

A

4-6 weeks

263
Q

How long before surgery should a pt stop taking their ASA?

A

7 days

the length of a platelet

264
Q

How long before surgery should a pt stop taking their NSAIDs?

A

3 days

ibuprofen can be taken up to 24 hours prior to surgery but this is not ideal

265
Q

How long before surgery should a pt stop taking their Rivaroxaban?

A

factor 10a inhibitor

stop taking 2-3 days prior to surgery

no bridging needed

266
Q

How long before surgery should a pt stop taking their Dabigatran (pradaxa)?

A

factor 2 inhibitor
stop taking 2-3 days prior to surgery
not bridging needed

267
Q

How long before surgery should a pt stop taking their warfarin?

A

5 days prior

start on bridging therapy with lovenox (LMW heparin)

268
Q

What is praxbind?

A

reversal agent for dabigatran

factor 2 inhibitor

269
Q

What about pts on chronic steroids…how do their meds change prior to surgery?

A

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
Q

A 56 yo male with COPD is having a thyroid nodule removed, what tests are you ordering?

A

CBC
EKG
CXR
Thyroid tests should have already been completed

271
Q

A 39 y/o F with ESRD and DM having kidney transplant, what tests are you ordering?

A 
CBC, BMP 
EKG
Beta HCG 
PT/INR
Type and cross

Clin Specialties - Surgery (11 decks)

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