The Surgical Patient Flashcards
When is preOp echo concerning?
Evidence of AS
EF less than 35%
When is a stress test positive?
ST depressions > 0.2mV or inadequate response of HR to stress or hypotension
Mallampati Classification
Predicts difficulty of intubation.
Pt is seated with head in neutral position and mouth wide open with tongue out to the max.
Class 1 - 4. 4 = can’t visualize soft palate.
Cardiac risk assessment: Patient less than 35 with no cardiac history
ECG
If normal, nothing more.
Cardiac risk assessment: Pt any age with cardiac history or for patient who is older
ECG
Consider stress test and echo
Contraindications to noncardiac surgery
EF less than 35%
Goldman Index
Tool for cardiac risk assessment. More points = higher risk.
0-5 = class 1 = 1% risk of life threatening complications
6-12 = 5% 13-25 = 11% 25+ = 22%
S3 or JVD (marker of low EF) = 11
MI within 6m = 10 >5 PVCs/min = 7 Rhythm other than sinus = 7 Age > 70 = 5 Emergency = 4 Intrathoracic, intraperitoneal, aortic surgery = 3 AS = 3 Poor general med condition = 3
Which is more important? O2 or ventilation?
Ventilation. We will be make them acidotic during surgery so we care about their ability to blow off CO2
Risk factors for pulm complications
Smokers
COPD/Asthma
ILD (restrictive)
Abnormal PFTs (FEV 60
Obesity
Upper abdominal or thoracic surgery
Long OR time
How do you reduce pulm risks preOp?
QUIT SMOKING. 8w before surgery (initially when you quit, bronchial secretions actually increase and ventilation gets worse)
Optimize bronchodilator therapy
ABG near day of surgery - High CO2 or low O2 are poor indicators
How do you reduce pulm complications after surgery?
IS
Early ambulation
Chest PT
DVT prophylaxis by SCD or SubQ Hep
What percentage of postOp deaths are due to pulm complications?
35%
PFTs that are concerning
FEV1 less than 70%
VO2 more than 20 - that patient is less likely to have pulm complications
Child’s Classification of risk
Liver variables.
A = 2% op mortality B = 10% C = 50%
Ascites (none, controlled, uncontrolled) - look for pancreatitis
Total Bili (less than 2, 2-3, >3)
Encephalopathy (none, min, adv)
Nutrition (exc, good, poor)
Albumin (more than 3.5, 3-3.5, less)
Childs-Pugh and MELD
CP for cirrhosis. MELD for liver transplants.
Tx for elevated scores = transplant.
Pugh adds PT/PTT elevations (check for Warfarin). If Albumin, PT/PTT, Bili, Ascites, or Encephalopathy is present then 40% risk. If all are there, 100%.
How do you provide DVT prophylaxis in someone with an injured leg?
One SCD works just as well as Two (they work by helping to release tPA)
Which pulmonary complication has the highest morbidity and mortality?
Pneumonia. Mortality in elderly patients with postop pneumonia is 50%
How common are atelectasis and pneumonia as complications?
20-40% of all postop patients
PreOp Renal eval
Check BUN and Cr
Estimate Cr clearance
Maintain intravascular volume
Ensure lytes are repleted; correct acidosis
Dialysis patients should be dialyzed within 24hrs of surg
How do you calculate Cr Clearance?
[(140-age) x Ideal body weight in kg] / 72
All that x plasma creatinine (mg/dL)
Dialysis patient mortality
Overall for dialysis dependent patients = 5% regardless of when dialysis was last given
ARF that requires dialysis perioperatively = 50-80%
Morbidity = shunt thrombosis, wound infection, hemorrhage, pneumonia
Why is BUN and Cr so important?
High BUN and Cr indicates loss of at least 75% of renal reserve. Intra and postop hypotension MUST be avoided
Mortality when NH3 > 150
80%
Mortality when INR > 2
40-60%
At what BUN level does bleeding risk go up?
BUN>100 due to platelet dysfunction
Correct with desmopressin (DDAVP)
What is the most common complication of dialysis?
HyperK (33% of patients)
How do you determine source of renal problem?
FENa > 1 = intrinsic renal damage
Specific gravity = 1.010 = ATN
UNa less than 20 in prerenal
PreOp heme labs
CBC
Type and cross
Anemia PreOp
Find the cause
Postpone elective procedures whenever possible. Patients who will not tolerate anemia are those with chronic hypoxia, ischemic heart disease, or cerebral ischemia
Sickle-Cell patients have higher risk of vaso-occlusive crises with operations (not sickle cell trait patients tho)
Minimize risk by maintaining euvolemia
Platelet levels and periop bleeding risks
>150 = good 100-150 = unlikely 50-100 = unlikely with good hemostasis
20-50 = possible excess surg bleeding
10-20 = spontaneous mucosal and cutaneous bleeding
Finding a PreOp coagulopathy
Factor issues should be addressed first (ex hemophilia)
Expect higher PT/PTT in liver patients
Poor prognostic signs during nutritional assessment
Lost 20% of body weight in 3 months (even 10% over 6 months).
Albumin IV. 10days > 5 days.
At what body weights do risks go up?
12% over IBW
Recent change of 10% BW
Antibiotic prophylaxis in general
Single dose 30m prior to incision and again 6h later if operation is ongoing.
Cefazolin
Abx ppx for colorectal/appi
Cefoxitin or Cefotetan
Abx ppx for urologic procedures
Cipro
Abx ppx for head and neck procedures
Cefazolin or Clinda+Genta
Metabolic contraindication to surgery
DKA - look for high gluc and low volume
Give IVF and insulin
Any form of acidosis should be fixed prior to surgery unless the surgery IS the fix
5Ws of Postop fever
Wonder Drugs Wind Water Walking Wound
Fever during surgery
Malignant hyperthermia (response to anesthesia)
Give O2
Dantrolene
Cool IVFs
ppx = FHx
Fever right after surgery
Bacteremia
Dx = BCx Tx = Vanc/Zosyn PPx= sterility
Fever POD1
Atelectasis
Dx=CXR
Tx= -
PPx = IS and out of bed
Fever POD2
Pneumonia
Dx=CXR
Tx = Vanc/Zosyn
ppx = IS and out of bed
Fever POD3
UTI
Dx = UA/UCx. UA shows WBCs, if casts it's pyelo (kidney infx before surg) Tx = abx
ppx = remove foley
Fever POD5
DVT/PE
Dx= US b/l LE Tx = Heparin, bridge to Warf
ppx = Heparin
Fever POD7
Wound infection
Dx = U/S negative Tx = Abx
ppx = sterile and clean
Fever POD10
Wound abscess
Dx = U/S positive Tx = Abx, I/D (culture to pick the abx)
ppx = sterile and clean
Post Op Chest pain
Get EKG, Trops, U/S LE, CTA, ABG
If point to MI - PCI (stent) or Heparin. DONT give tPA bc they’ll die.
If point to PE - heparin to warfarin bridge. IVC filter for a repeat offender who is on warfarin already.
Post Op AMS in a patient who has tumultuous ICU course with white out on CXR
This is ARDS.
Tx = PEEP in ICU for this non-cardiogenic pulm edema
Post Op AMS in patient with low SpO2
This is hypoxia
Give O2 (88-92% goal for COPD, 94+ for everyone else)
Post Op AMS 48-72h into stay
Think DT
- HTN, tachy, tremor
Tx = benzo
Post Op AMS with abnormal BMP
Replete lytes - usually Na and Ca
Normal urine output
0.5cc/kg/hr
Post Op low UO in patient with an urge to void
Obstruction
Do and in-and-out cath. Try to avoid the Foley unless this keeps happening
Post Op low UO in patient without an urge to void
Renal Failure?
No output? Kinked Foley - unkink it or flush it
Some output? Do 500cc NS challenge. If this increases UO then patient was volume down. Give IVFs. If this does nothing then there is intrinsic renal disease.
Post Op abdominal distension ddx
Paralytic ileus vs obstruction vs Oglivie’s
Paralytic ileus
Incidence after GI surg = 5%
In general, await return of bowel function before advancing diets
This is a metabolic derangement. Day 1 will pass no gas and no stool. This is almost EXPECTED.
Dx = KUB. Look for big distended small bowel connecting to large distended large bowl. This is OK as long as everything is distended!
Tx = moving and eating, potassium
Obstruction postop
Usually from adhesions or hernias
Look for an ileus continuing to day 5.
Dx = KUB. Distal to block bowel is thin and compressed. Proximal to block it is distended.
If it is in large bowel, the small bowel will look normal (ileocecal valve prevents air from flowing back)
Tx = surgical emergency ESP if there are peritoneal signs
Oglivie’s
This is a distractor
Ileus of large bowel postop in the elderly.
Dx = KUB
Normal small bowel, big distended colon that takes up entire colon. No obstruction.
Tx = decompress with rectal tube (get air out). Colonoscopy - could be malignancy
Wound dehisense
Failure of fascia only
Leads to hernia
Serosanguinous drainage (pink) on dressing in morning
Dx = clinical Tx = Bind them. Limit straining. Elective surg to correct hernia.
Wound eviceration
Failure of whole wound
Loops of bowel exposed to outside
Dx = clinical Tx = warm saline dressings. Strict bed rest. Go to OR NOW. NEVER PUSH IT BACK IN.
PostOp fistulas
Epithelialized tract btw 2 structures. Think FETID
Foreign body Epithelialization Tumor Irradiation/inflammation/IBD Distal obstruction
Cut it out with LIFT procedure
Order of return of bowel function after surgery
Small intestine then stomach then colon
Risks for C.Dif
Age Nursing home Renal failure Immunocompromised ABx (cefoxitin) Small or Large bowel obstruction GI surgery NG tube > 48h
Tx = PO metro or vanc
Well’s criteria for PE
6 = high
Clinical signs and symptoms of DVT (measured calf swelling and positive homan) = 3
Alt dx less likely than PE = 3
HR > 100 = 1.5
Immobilization or surg in past 4w = 1.5
Previous DVT/PE = 1.5
Hemoptysis = 1
Malignancy (on tx, treated in past 6m or palliative care) = 1
How do you estimate when bowel function will return?
Allow 1 postop day per decade for major abdominal surgery
PreOp patient instructions regarding meds
Aspirin - hold for 10 days (allows platelets to regenerate)
Plavix - hold for 7 days (unless they have drug-eluting stent - holding here may cause MI)
Warfarin - avoid 3 days prior and resume POD2. Admit preop and change to heparin which is then held a couple hrs ahead of surg. OR operate through warfarin
BP meds - continue. ESP B blockers. Hold diuretics the morning of surgery
AntiThyroid - hold on morning of
Thyroid replacement - give on morning of
(Thyroxine half life is a week so it can be held with no real effects)
Oral hypoglycemics - avoid on day of
Insulin - give half usual dose on morning of
PreOp bowel prep
To clear bowel of stool and reduce bacteria count and risk of fecal spillage during GI surg
This is a source of fluid loss so some patients may require IVF if they don’t tolerate this well
