Chapter 34 - Postoperative management Flashcards by Gary Yang

Benefits of ICU/stepdown units

1) decreased myocardial oxygen demand by 2) expeditious rewarming 3) effective fluid resus 4) effective analgesia 5) meticulous control of hemodynamics 6) careful monitoring 7) appropriate nursing care for diagnosis and treatment of complications

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Reasons to consider post-op ICU/step down stay

1) CAD (EF < 40%, CHF, NYHA 3-4 angina) 2) COPD FEV1 < 1L 3) dialysis dependent 4) SBP < 90 or need pressor 5) intubated needing vent 6) presence of pulmonary catheter, spinal drains 7) hypothermia < 35 C 8) massive transfusion > 3L

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What does CVP measure

1) right atrial pressure 2) estimate of preload inaccurate in COPD or valvular heart disease affected by high PEEP > 12 cm H2O

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Normal CVP

6-12 mmHg measured at end expiration

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Sudden change in CVP suggest

1) pneumothorax 2) cardiac tamponade

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Peripheral art line positioning

midpoint of right atrium 5cm below sternal angle in mid axillary

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Reasons to insert pulmonary artery catheters

1) measure cardiac output 2) cardiac pressure 4) mixed venous oxygen

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How to estimate cardiac output from echo

1) diameter of descending aorta 2) distribution of flow to descending aorta 3) measured flow velocity of blood

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Normal intraabdominal pressure

5-7 mm Hg

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Intra-abdominal hypertension

IAP 12-20 mmHg

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Abdominal perfusion pressure

MAP - IAP

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Abdominal compartment syndrome

constellation of symptoms suggesting organ dysfunction 1) decreased CO 2) high peak airway pressure 3) oliguria 4) IAP > 20

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Risk for abdominal compartment syndrome

1) Fluid resus > 10L crystalloid or >5L colloid 2) transfusion > 10 unit in 24 hr

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Measurement of abdominal compartment syndrome

1) 25-50ml normal saline into catheter 2) end expiration with patient supine

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Target post-operative BP

20 mmHg +/- from baseline deviation of MAP within 20% of baseline

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Hypertensive emergency associated BP

SBP > 179 DBP > 109 can cause acute damage to organs (Crisis)

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Pulse pressure to stroke volume ratio suggestive of hypovolemia

> 10%:15%

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Treatment of acute hypotension

Phenylephrine Dopamine

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Treatment of tachyarrhythmia in hemodynamic stable patient

1) Beta blocker or CCB for rate control 2) IV amiodarone 3) adenosine 4) electrical cardioversion (if unstable)

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Treatment of torsades de pointes

Polymorphic VT with prolonged QT interval Magnesium

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Loss of atrial kick will decrease left ventricular stroke volume by

20-35%

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How often do people revert out of afib after bolus amiodarone

1/3

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Treatment of new afib in hemodynamically stable patients

1) beta blocker 2) amiodarone 3) digitalis 4) cbb electrical cardioversion if unstable

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Detecting cardiac ischemia 3 ways

1) symptoms 2) ECG 3) enzymes

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STEMI definition

1) ECG = ST elevation 0.1 mV (1 mm) in two consecutive leads 2) CK-MB levels elevated 3-12 hours after infarction; peak 24 hour and elevate for 3 days 3) troponin detected 4-12 hours; peak 12-48 hours; elevate 1 week

Medical treatment for STEMI post-cath

1) beta blocker 2) ACEi 3) statins

NSTEMI definition

biomarker indicative of MI without ST elevation

Causes of NSTEMI

transient reduction in coronary blood flow that causes imbalance in myocardial oxygen supply and demand

Hemodynamic target for NSTEMI

block until SBP \> 90 HR \> 50

Two modes of mechanical ventilation

1) controlled 2) supported

Two types of ventilator settings

1) volume control = fixed tidal volume with varialbe pressure 2) pressure control = fixed pressure with variable tidal volume

Tidal volume target on ventilator for protective ventilation

6-8 ml/kg avoid overdistention or derecruitment/atelectasis

Two approaches to ventilation weaning

1) progressive reduction of support 2) spontaneous breathing trials without progressive withdrawal

Setting of weaning

1) pressure support 5-8 cm H2O 2) PEEP at 5 cm H2O 3) O2 at 30 or room

Signs of readiness to be weaned

LACK of distress: 1) resp rate \> 35 for \> 5 min 2) desat \< 90% for \> 30 sec 3) increase or decrease HR +/- 20% for \> 5 min 4) SBP out of 90-180 range 5) other signs of agitation and distress (paradoxical breathing, accessory muscles, diaphoresis

Rate of reintubation

10-15%

Benefit of tracheostomy

1) decrease work of breathing 2) better oral hygiene 3) secretion management 4) improved survival in COPD 5) shorter hospital stay

Disadvantage of tracheostomy

1) procedure complication 2) stomal complication 3) tracheoinnominate fistula 4) tracheoesophageal fistula

Relative contraindication to do percutaneous tracheostomy

1) hypoxic 2) high PEEP 3) obese 4) short neck 5) coagulopathic 6) recent \< 10 days) anterior cervical spine fixation

Physiologic response to hypovolemia

1) tachycardia 2) hypotension 3) low CVP 4) decreased urine output 5) peripheral vasoconstriction

Post-operative coagulopathy tests, problems and treatment

TABLE 34.1

Why does FFP not reduce heparin effect

FFP has antithrombin III which is what heparin acts on

Hemophilia type A and B

A = deficiency of factor 8 B = deficiency of factor 9 C = deficiency of factor 11

Reversal for warfarin

Vitamin K FFP prothrombin complex concentrate

DIC bloodwork will show

1) increased INR 2) increased aPTT 3) thrombocytopenia

Treatment of DIC

Cryoprecipitate if fibrinogen \< 100 mg/dl FFP when other factors \< 25% or abnormal iNR platelet if plt \< 50

Fluid balance in shock workup and treatment

FIGURE 34.2

Transfusion threshold for RBC in CAD or without CAD

70 without CAD 80-90 with CAD

Transfusion of platelets in various situations

Cardiac surgery, bleeding - 100 coagulopathy, bleeding - 50 coagulopathy, no bleed - 20 low risk no bleed - 10

When to give FFP

active bleeding and INR \> 1.5

When to give cryoprecipitate

active bleed and fibrinogen \< 100 mg/dl (\<2.9 mcmol/l)

What's in cryoprecipitate

factor 8, factor 13, vWF

How much platelet in one unit of whole blood

5.5 - 10 x 10^10

how much platelet from 1 unit of platelet pheresis

40 x 10^10 from 6 units of whole blood

Amount of cryoprecipitate needed to raise fibrinogen by 0.5-1.0g/L

1 unit per 5-10kg body weight

Function of recombinant activated Factor 7

1) control bleeding in patients with hemophilia types A + B 2) generates thrombin at site of vessel injury - coagulation

Antifibrinolytic agents

1) Tranexamic acid 2) aminocaproic acid

Effect of antifibrinolytic agents

1) synthetic lysine analogues 2) inhibit plasminogen and plasmin-mediated fibrinolysis

What is aprotinin

Serine protease neutralizes trypsin, plasmin, kallikrein used when fibrinolysis contributes to bleeding

Definition of massive transfusion

replacement of 50% patient blood in 3 hour replacement of 100% patient blood in 24 hours

Causes of coagulopathy in massive transfusion

1) hemodilution 2) hypothermia 3) acidosis due to tissue hypoxia 4) DIC 5) hyperkalemia - RBC lysis 6) hypocalcemia - citrate as anticoagulat

Nutrition goals and feeding key points in ICU

1) determine goal calories 2) give 50-65% goal calorie in first week 3) increase to goal rate 4) permissive underfeeding if BMI \> 30 (goal to 60-70% ideal weight)

Autonomic hyperactivity symptoms in alcohol withdrawal

1) tremulousness 2) sweating 3) nausea 4) vomiting 5) anxiety 6) agitation

Timing of autonomic hyperactivity in alcohol withdrawal

start 24-48 hours peak 3-5 days

Delirium tremens rate

Delirium tremens symptoms

1) fever 2) tachycardia 3) hypertension 4) tremors 5) diaphoresis 6) hallucinations 7) disorientation 8) agitation 9) urinary incontinence

First line treatment for alcohol withdrawal syndrome

Benzodiazepine

Reasons to take thiamine and multivitamin in alcoholics

Prevent Wernicke-Korsakoff syndrome

Richmond agitation sedation scale

10 point scale from -5 to +4 -5 is unarounsable +4 is combative 0 is normal and alert

Three types of delirium

1) hyperactive 2) hypoactive 3) mixed

Non-pharmacologic methods of delirium management

1) minimize risk factors 2) early mobilization 3) sleep protocol 4) timely removal of catheters and lines 5) minimize noise and unnecessary stimuli

Pharmacologic methods of delirium management

1) avoid benzodiazepine - exacerbates 2) haloperidol 3) risperidone 4) quetiapine 5) olanzepine

Chapter 34 - Postoperative management Flashcards

(72 cards)