T H E S U R G I C A L P A T I E N T Flashcards
2 anti-hypertensives to hold day of surgery
Diuretics, possibly ace inhibitors. This is because they can cause dangerous hypovolemia and/or hypotension.
Most common drug allergy
Antibiotics
Describe ASA Physical Status Classification System
Classifies patient’s preoperative physical status, but is NOT predictive of anesthetic risk. It does NOT depend on the surgery planned.
ASA P1
Normal, healthy patient.
ASA P2
Pt with mild systemic disease
ASA P3
Patient with severe systemic disease
ASA P4
Pt wit severe systemic disease – constant threat to life
ASA P5
Moribund pt not expected to survive without operation
ASA P6
Declared brain-dead pt whose organs are being removed for donor purposes
ASA E
Indicates emergency surgery; designation is used in addition to P codes
Describe Mallampari classification system and the proper positioning of pt when tested.
Predicts difficulty of intubation and is tested with pt in sitting position, head held in neutral position, mouth wide open, and tongue protruding to maximum.
Mallampari class I
Visualization of soft palate, faces, uvula, anterior and posterior tonsillar pillars
Mallampari class II
visualization of soft palate, faces, uvula.
Mallampari class III
visualization of soft palate, bass of uvula.
Mallampari Class IV
Non-visualization of soft palate
For cardiac risk assessment in a pt >35 y.o. with no history of heart disease, what needs to be obtained prior to surgery?
ECG
When is a stress test positive?
Stress test is positive if ST depression > 0.2 mV or if inadequate response of HR to stress or hypotension.
When is an ECHO concerning?
Evidence of aortic stenosis or ejection fraction < 35%.
If pt requires CABG prior to GI surgery, how long should you wait between?
30 days.
Characteristics of peri-operative MI
Mortality rate is approximately 25%.
Generally happen within 3 days of surgery and are often asymptomatic. They are associated with intraoperative HTN or hypotension or tachycardia.
Which form of valvular disease is the only type found to affect mortality in surgery?
Aortic –when area of orifice is 50 mmHg. You should assess valvular function with an echo before surgery as the pt may need valve replacement first.
Endocarditis ppx for patients with MVP or prosthetic valves
30 min prior to incision: ampicillin + gentamicin (or vanco + genta, if PCN allergic)
6 hours post-incision: amoxicillin or 2nd dose of amp + gentamicin
Characteristics of aortic stenosis
Harsh murmur @ right second intercostal space, radiates to carotids.
Presents with angina, dyspnea on exertion, syncope.
2 conditions that put you at moderate risk for endocarditis
Hypertrophic cardiomyopathy, MVP
2 conditions that put you at high risk for endocarditis
Prosthetic valve, congenital anomalies such as Tetralogy of fallot
3 arrhythmias that have much higher mortality risk during surgery
SVT, A fib, A flutter
Pt should have a preop CXR if greater than what age?
40
Name 2 instances in which you should obtain pre-op spirometry and ABG
If pt has risk factors for pulmonary complications or will be undergoing upper abdominal surgery (major abdominal surgery decreases vital capacity by 50% and FRC by 30%)
Management if operation must occur during acute asthma exacerbation
Give 2x usual PO dose of steroids or 1 mg/kg methylprednisone preop, then every 6 hrs.
Procedures that are high risk for DVT/PE (3)
Orthopedic, pelvic, abdominal CA surgeries. In general, long duration of surgeries put you at higher risk.
How do SCDs work to prevent DVTs?
Sequential compression devices stimulate endothelial cell fibrinolytic activity. Also, 1 SCD should work as well as 2 if 1 leg is injured.
4 defining concepts of ARDS
Acute lung injury.
Bilateral infiltrates; normal tissue interspersed with diseased tissue.
PaO2/FiO2 < 200
PCWP < 19; no CHF.
Mgmt. of ARDS
Positive end expiration pressure trial. Pressure limited ventilation.
Permissive hypercapnia. Keep pt in prone position.
Mgmt of pulmonary edema
O2, upright position, furosemide, swan-ganz catheter (possibly)
Mgmt of fat embolism
Immobilize (splint) fx and consider corticosteroids.
Which pulmonary complication has the highest morbidity and mortality?
Pneumonia
What complication do some diabetics face during intubation?
Pts with autonomic neuropathy will be more likely to have gastroparesis, therefore being more likely/susceptible to aspiration during intubation.
Which oral hypoglycemic should be stopped 2-3 days prior to surgery?
Chlorpropamide –it is a long-acting sulfonylurea. Others can be continued until morning of sx.
How to estimate preop creatinine clearance
[(140-age) x wt]/72 x creatinine
4 risk factors for development of acute renal failure
renal ischemia
exposure to nephrotoxins such as contrast dye
sepsis
CHF
3 ways to determine source of renal problem
FeNa > 1 = intrinsic
Specific gravity = 1.010 in ATN
UNa < 10 in pre-renal
Order of organs in return of bowel function
Sm intestine – > stomach – > colon
How can we estimate when bowel function return will occur?
Allow 1 post-op day per decade for major abode surgery
2nd line for tx of C dif
vanco
3 types of pets that will not tolerate anemia well
Chronic hypoxia
Ischemic heart disease
Cerebral ischemia
How much does 1 unit of platelets increase platelet count by?
5,000-10,0000.
How much will PT decrease when warfarin is withheld?
PT will decrease by 2 sec/day when warfarin is withheld.
3 options for pts on warfarin pre-op
Avoid 3 days prior to sx and resume POD#2.
Admit preop and change to heparin which can be held a couple hours ahead of time.
Change to LMWH (SQ).
Mgmt of thyroid medications prior to surgery.
Anti-thyroid medications should be held the morning of sx. Thyroid replacement rx should be administered the morning of.
Note: half life of thyroxine is 7 days; therefore, can be held for several post op days without much effect.
Abx prophylaxis given for general surgery
Cefazolin
Abx prophylaxis given in colorectal and appendectomies
Cefoxitin or cefotetan
Abx prophylaxis given in urological procedures
Ciprofloxacin
Abx prophylaxis given in head and neck procedures:
Cefazolin OR clindamycin + gentamicin
