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Surgery > The Surgical Patient > Flashcards

The Surgical Patient Flashcards

1
Q

When is preOp echo concerning?

A

Evidence of AS

EF less than 35%

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2
Q

When is a stress test positive?

A

ST depressions > 0.2mV or inadequate response of HR to stress or hypotension

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3
Q

Mallampati Classification

A

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.

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4
Q

Cardiac risk assessment: Patient less than 35 with no cardiac history

A

ECG

If normal, nothing more.

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5
Q

Cardiac risk assessment: Pt any age with cardiac history or for patient who is older

A

ECG

Consider stress test and echo

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6
Q

Contraindications to noncardiac surgery

A

EF less than 35%

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7
Q

Goldman Index

A

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
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8
Q

Which is more important? O2 or ventilation?

A

Ventilation. We will be make them acidotic during surgery so we care about their ability to blow off CO2

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9
Q

Risk factors for pulm complications

A

Smokers
COPD/Asthma
ILD (restrictive)

Abnormal PFTs (FEV 60
Obesity
Upper abdominal or thoracic surgery
Long OR time

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10
Q

How do you reduce pulm risks preOp?

A

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

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11
Q

How do you reduce pulm complications after surgery?

A

IS
Early ambulation
Chest PT
DVT prophylaxis by SCD or SubQ Hep

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12
Q

What percentage of postOp deaths are due to pulm complications?

A

35%

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13
Q

PFTs that are concerning

A

FEV1 less than 70%

VO2 more than 20 - that patient is less likely to have pulm complications

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14
Q

Child’s Classification of risk

A

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)

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15
Q

Childs-Pugh and MELD

A

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%.

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16
Q

How do you provide DVT prophylaxis in someone with an injured leg?

A

One SCD works just as well as Two (they work by helping to release tPA)

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17
Q

Which pulmonary complication has the highest morbidity and mortality?

A

Pneumonia. Mortality in elderly patients with postop pneumonia is 50%

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18
Q

How common are atelectasis and pneumonia as complications?

A

20-40% of all postop patients

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19
Q

PreOp Renal eval

A

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

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20
Q

How do you calculate Cr Clearance?

A

[(140-age) x Ideal body weight in kg] / 72

All that x plasma creatinine (mg/dL)

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21
Q

Dialysis patient mortality

A

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

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22
Q

Why is BUN and Cr so important?

A

High BUN and Cr indicates loss of at least 75% of renal reserve. Intra and postop hypotension MUST be avoided

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23
Q

Mortality when NH3 > 150

A

80%

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24
Q

Mortality when INR > 2

A

40-60%

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25
Q

At what BUN level does bleeding risk go up?

A

BUN>100 due to platelet dysfunction

Correct with desmopressin (DDAVP)

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26
Q

What is the most common complication of dialysis?

A

HyperK (33% of patients)

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27
Q

How do you determine source of renal problem?

A

FENa > 1 = intrinsic renal damage

Specific gravity = 1.010 = ATN

UNa less than 20 in prerenal

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28
Q

PreOp heme labs

A

CBC

Type and cross

29
Q

Anemia PreOp

A

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

30
Q

Platelet levels and periop bleeding risks

A 
>150 = good
100-150 = unlikely
50-100 = unlikely with good hemostasis

20-50 = possible excess surg bleeding

10-20 = spontaneous mucosal and cutaneous bleeding

31
Q

Finding a PreOp coagulopathy

A

Factor issues should be addressed first (ex hemophilia)

Expect higher PT/PTT in liver patients

32
Q

Poor prognostic signs during nutritional assessment

A

Lost 20% of body weight in 3 months (even 10% over 6 months).

Albumin IV. 10days > 5 days.

33
Q

At what body weights do risks go up?

A

12% over IBW

Recent change of 10% BW

34
Q

Antibiotic prophylaxis in general

A

Single dose 30m prior to incision and again 6h later if operation is ongoing.

Cefazolin

35
Q

Abx ppx for colorectal/appi

A

Cefoxitin or Cefotetan

36
Q

Abx ppx for urologic procedures

A

Cipro

37
Q

Abx ppx for head and neck procedures

A

Cefazolin or Clinda+Genta

38
Q

Metabolic contraindication to surgery

A

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

39
Q

5Ws of Postop fever

A 
Wonder Drugs
Wind
Water
Walking
Wound
40
Q

Fever during surgery

A

Malignant hyperthermia (response to anesthesia)

Give O2
Dantrolene
Cool IVFs

ppx = FHx

41
Q

Fever right after surgery

A

Bacteremia

Dx = BCx
Tx = Vanc/Zosyn
PPx= sterility
42
Q

Fever POD1

A

Atelectasis

Dx=CXR
Tx= -

PPx = IS and out of bed

43
Q

Fever POD2

A

Pneumonia

Dx=CXR
Tx = Vanc/Zosyn

ppx = IS and out of bed

44
Q

Fever POD3

A

UTI

Dx = UA/UCx. UA shows WBCs, if casts it's pyelo (kidney infx before surg)
Tx = abx

ppx = remove foley

45
Q

Fever POD5

A

DVT/PE

Dx= US b/l LE
Tx = Heparin, bridge to Warf

ppx = Heparin

46
Q

Fever POD7

A

Wound infection

Dx = U/S negative
Tx = Abx

ppx = sterile and clean

47
Q

Fever POD10

A

Wound abscess

Dx = U/S positive
Tx = Abx, I/D (culture to pick the abx)

ppx = sterile and clean

48
Q

Post Op Chest pain

A

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.

49
Q

Post Op AMS in a patient who has tumultuous ICU course with white out on CXR

A

This is ARDS.

Tx = PEEP in ICU for this non-cardiogenic pulm edema

50
Q

Post Op AMS in patient with low SpO2

A

This is hypoxia

Give O2 (88-92% goal for COPD, 94+ for everyone else)

51
Q

Post Op AMS 48-72h into stay

A

Think DT
- HTN, tachy, tremor

Tx = benzo

52
Q

Post Op AMS with abnormal BMP

A

Replete lytes - usually Na and Ca

53
Q

Normal urine output

A

0.5cc/kg/hr

54
Q

Post Op low UO in patient with an urge to void

A

Obstruction

Do and in-and-out cath. Try to avoid the Foley unless this keeps happening

55
Q

Post Op low UO in patient without an urge to void

A

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.

56
Q

Post Op abdominal distension ddx

A

Paralytic ileus vs obstruction vs Oglivie’s

57
Q

Paralytic ileus

A

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

58
Q

Obstruction postop

A

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

59
Q

Oglivie’s

A

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

60
Q

Wound dehisense

A

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.
61
Q

Wound eviceration

A

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.
62
Q

PostOp fistulas

A

Epithelialized tract btw 2 structures. Think FETID

Foreign body
Epithelialization
Tumor
Irradiation/inflammation/IBD
Distal obstruction

Cut it out with LIFT procedure

63
Q

Order of return of bowel function after surgery

A

Small intestine then stomach then colon

64
Q

Risks for C.Dif

A 
Age
Nursing home
Renal failure
Immunocompromised
ABx (cefoxitin)
Small or Large bowel obstruction
GI surgery
NG tube > 48h

Tx = PO metro or vanc

65
Q

Well’s criteria for PE

A

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

66
Q

How do you estimate when bowel function will return?

A

Allow 1 postop day per decade for major abdominal surgery

67
Q

PreOp patient instructions regarding meds

A

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

68
Q

PreOp bowel prep

A

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

Surgery (27 decks)

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