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PGY 4 > Post-op Complications > Flashcards

Post-op Complications Flashcards

1
Q

What is the definition of an MI?

A

Rise and fall of troponin above 99th percentile plus one of the following: 1) symptoms 2) ECG evidence (st-t change, LBBB, new q waves) 3) imaging showing loss of viable myocardium or wall motion abnormality

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2
Q

What is the difference between a type 1 and 2 MI?

A

Type 1 - spontaneous due to an unstable coronary plaque

Type 2 - secondary to an extracardiac cause (demand ischemia)

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3
Q

What is the difference between STEMI and NSTEMI?

A

STEMI - major coronary territory or an area that has insufficient collaterals - requires urgent PCI.

NSTEMI - supplies smaller coronary territories or areas supplied by collaterals, PCI only if hemodynamically unstable or worsening symptoms

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4
Q

What percentage of vascular surgery patients have post-op MI (defined by elevated tropnonin?)

A

25%

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5
Q

What is unstable angina?

A

Recurrent or new typical chest pain with no evidence of serum troponin elevation (if trop elevated then its defined as an MI)

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6
Q

What are 3 types of heart failure?

A

1) Heart failured with reduced EF (systolic heart failure) - usually due to MI
2) Heart fialure with sustained EF (diastolic heart failure) - usually due to prolonged HTN and LVH
3) Right ventricular heart failure - usually due to LV failure and severe mitral valve disease or severe lung disease (cor pulmonale)

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7
Q

Which vascular procedure has the highest risk of cardiac morbidity?

A

Aortic surgery (EVAR 1%, Open 15%)

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8
Q

What is the cardiac event rate for lower extremity vascular surgery?

A

Depends on symptoms. CLI = 10% vs claudication 3%

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9
Q

What is the risk of periop cardiac morbidity after carotid surgery?

A

3% (1.5% with stenting)

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10
Q

What do pathologic q waves on an EKG represent?

A

Old MI, more leads = wider area of infarct

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11
Q

What does tall R waves and wide QRS complexes (with or without ST changes), and inverted T waves represent?

A

myocardial hypertrophy or dilation

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12
Q

What is the RCRI?

A

Revised cardiac risk index - 6 independent risk factors:

1-history of cardiac disease

2- history of chf

3- insulin therapy

4-chronic renal impairment

5-cerebrovascular disease

6-major surgery

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13
Q

According to the ACC/AHA, which patients should undergo noninvasive stress testing?

A

Patients with limited functional capacity < 4 METS (unable to climb 2 flights of stairs without chest pain or shortness of breath)

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14
Q

What did the CARP trial study?

A

The benefit of prophylactic PCI/CABG in patients with >70% coronary artery stenoses prior to surgery. There were no differences between patients who underwent coronary revasc compared with patients who did not.

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15
Q

What are 2 major limitations of the CARP trial?

A

1) Did not rigorously follow ACC/AHA screening and a minority of patients had evidence of severe ischemia on noninvasive testing - underpowered
2) Excluded patients wit left main disease (a population who may benefit from coronary revasc)

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16
Q

Should you give patients with CAD betablockade before periop?

A

No - POISE showed doubling of post-op strokes and cochrane review showed no clear evidence that periop prophylactic betablockade improved cardiac morbidity.

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17
Q

How long after PCI/stent should you delay elective non cardiac surgery?

A

30 days afer BMS and optimally 6 months after DES

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18
Q

How do you manage a suspected post-op NSTEMI?

A

1 - consult cardio

2- control heart rate and blood pressure with beta blockers/calcium channel blockers (if sbp > 100)

3- control pain to avoid tachycardia

4-treat tachyarrythmia (aflutter afib)

5- correct anemia, hypoxemia, follow trop

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19
Q

Name 5 common post-op respiratory complications

A

1-PE

2-pulmonary edema

3-aspiration pneumonia

4-pleural effusion

5-exacerbation of underlying disease

(ARDS, Bronchitis, resp failure, TRALI)

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20
Q

Name 5 patient related risk factors that put patients at higher risk of pulmonary complications

A

1-smoking

2-recent resp infection

3-OSA

4-COPD

5-CHF

(Functional dependence, age, ASA 2+, poorly controlled asthma)

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21
Q

Name 5 procedure-related risk factors for post-op pulmonary complications

A

1-longer than 2h

2-peri-op blood transfusion

3-type of anesthesia (local/general)

4-open surgery (over endo)

5-surgical site (aortic confers highest risk)

6- emergency surgery

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22
Q

Name 4 laboratory test risk factors for post-op pulmonary complications

A

1-anemia hgb < 100

2-spO2 < 90%

3-albumin < 35

4-BUN < 21

23
Q

What percentage of anesthetized patients have atelectasis?

A

Up to 90%

24
Q

What is the most common pathogen in ventilator associated pneumonia?

A

Staph aureus

25
Q

What parameters are used in the clinical pulmonary infection score for ventilator associated pneumonia?

A

1 - temp

2 - WBC

3 - Sputum character

4 - CXR

5 - Culture of ET suction

6 - oxygenation (PaO2/FiO2)

26
Q

What is the Berlin definition of ARDS?

A

1- Time: Within 1 week of known clinical insult/worsening resp symptoms

2 - CXR: bilateral opacities

3 - Edema cause: Not fully explained by cardiac/fluid overload

4- Oxygenation - need echo to exclude hydrostatic edema

27
Q

What is cisatracurium used for with respect to resp failure?

A

Neuromuscular blockade - IV infusion for 48 h can help patients with ARDS and a PaO2:FiO2 less than 150.

28
Q

Name the associated causes of renal failure

A
29
Q

Name the associated causes of renal failure

A
30
Q

Name the associated causes of renal failure

A
31
Q

Name the associated causes of renal failure

A
32
Q

Name the associated causes of renal failure

A
33
Q

Name the associated causes of renal failure

A
34
Q

Name the associated causes of renal failure

A
35
Q

Name the associated causes of renal failure

A
36
Q

Name the associated causes of renal failure

A
37
Q

What is ischemic monomelic neuropathy?

A

A rare nerve injury following acute limb malperfusion, characterized by multiple distal axonal infarctoins resulting in motor and sensory mononeuropathies

38
Q

List 4 common causes of unilateral neuropathy

A
  1. Entrapment
  2. Trauma
  3. Ischemia
  4. Vasculitis
39
Q

List 7 common causes of bilateral neuropathy

A
  1. Metabolic (diabetes)
  2. Toxic (etoh, drugs)
  3. Vasculitis
  4. Vitamin deficiency
  5. HIV
  6. Monoclonal gammopathies
  7. Inflammatory or vasculitis
40
Q

What are 3 first-line therapy of drug classes for treating neuropathic pain?

A
  1. tricyclic antidepressants: amytriptiline
  2. gabapentin: doesn’t work for everyone, takes weeks to take effect
  3. SSNRI duloxetine and venlafaxine
41
Q

What is the rate of axonal regeneration?

A

1 mm per day

42
Q

What are the 5 main terminal branches from the brachial plexus of the upper extremity

A
  1. musculocutaneous
  2. median
  3. ulnar
  4. axillary nerve
  5. radial
43
Q

Which nerves are at risk during axillary dissections?

A
  1. musculocutaneous
  2. median
  3. ulnar
44
Q

Which nerve do you have to watch out for in brachial dissections?

A

Median

45
Q

Which nerve lies deep to the basilic vein?

A

Ulnar

46
Q

What are the clinical findings of an axillary nerve injury?

A

Weak shoulder abduction and sensory deficit of deltoid

47
Q

What are the findings associated with median nerve injury?

A

Sensory deficit on radial side of D1234. Weakness in thenar muscles.

48
Q

What are the findings associated with an ulnar nerve injury?

A

Sensory numbness of 5th digit and weak abduction and adduction of fingers

49
Q

What are clinical findings associated with femoral nerve injury?

A

Weakness or paralysis of quads, difficulty with knee extension, reduced patellar reflex, numbness along the course of the saphenous nerve on anteriomedial aspect of thigh

50
Q

What are the phases of wound healing?

A

1 - inflammation

2 - prolipheration

3 - epithelialization

4 - remodelling

51
Q

How can you prevent contrast induced nephropathy?

A
  1. Infusion of bicarb (better than saline in one RCT, NNT 8). Thought to alkalinze renal tubular fluid.
  2. Hold metformin 48 h before contrast and hold diauretics.
52
Q

What is the definition of contrast induced nephropathy?

A

An 25% increase in creatinine within 3 days of contrast admin with no alternate cause

53
Q

What are 4 risk factors for developing contrast induced nephropathy?

A
  1. Pre-existing renal failure (intra-arterial GFR < 60, IV GFR < 40)
  2. Diabetes
  3. Volume > 5 ml/kg
  4. Second contrast dose within 48 hours
54
Q
A

PGY 4 (25 decks)

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