Ejection fraction under ____ is preop risk for noncardiac operations because perioperative MI risk his high.
35%
Goldman’s index of cardiac risk lists the findings that predict trouble in surgery. Name them in order of importance (8)
(1) JVD (2) recent MI (3) premature ventricular contractions/arrhythmias (4) age >70yo (5) emergecy surgery (6) aortic valvular stenosis (7) poor medical condition (8) surgery w/in chest/abdomen
Usually _____ is more commonly assessed for cardiovascular risk in surgery
functional status
JVD indicates ______; tx preceding surgery
congestive heart failure; ACEIs, ß blockers, digitalis, diuretics
Risk of mortality due to recent transmural or subendocardial MI is ____ in first 3 months then _____ after 6 months
40%; 6%
What do you do if pt has had recent MI?
defer surgery until after 6months if possible; if you cant’, admit to ICU a day before surgery to “optimize cardiac variables”
MCC increased pulmonary risk due to compromised ventilation
smoking [COPD]
Compromised ventilation sxs
high PCO2, low FEV1
If pt is smoker/COPD before surgery, must ____
stop smoking 8 weeks before and have intense respiratory therapy
What does respiratory therapy consist of? (4)
PT, expectorants, incentive spirometry, humidified air
(A) Which 2 clinical findings are used to predict operative mortality in pts w/ liver dz? (B) Laboratory findings?
(A) encephalopathy, ascites (B) serum albumin, INR, bilirubin
Child class looks at presence and severity of liver disease pre-op. Class A has ___ mortality risk, Class B has ____ and Class C has ____
10%, 30%, 80%
Define severe nutritional depletion
loss of 20% obdy wt over couple of months, serum albumin
Tx preop for severe nutritional depletion
4 or 5 days preop nutritional support (preferably via gut)
______ is an absolute contraindication to surgery
Diabetic coma
(3) things must be achieved before operating on someone w/ diabetic coma
(1) rehydration (2) return UOP (3) at least partial correction of acidosis and hyperglycemia [must treat sepsis if have it!! otherwise can’t operate at all]
Malignant hyperthermia can develop after administration of ____ or ____
halothane; succinylcholine
Sxs Malignant hyperthermia
Temp >104, metabolic acidosis, hypercalcemia; may have family hx
Tx Malignant hyperthermia
dantrolene, 100% O2, correction of acidosis, cooling blankets; MUST watch for dev of myoglobinuria!!
Bacteremia is seen w/in _____ of invasive procedures
30 to 45 minutes
Sxs bacteremia; dx/tx
chills, fever spike >104; blood culture x 3 and start empiric abx
MCC postop fever (101-103)
atelectasis, pneumonia, UTI, DVT, wound infection, deep abscess [in descending order]
If deep breathing, coughing, postural drainage and incentive spirometry fails to fix atelectasis postop, tx w/ ____
bronchoscopy
Pneumonia will occur about ____ postop if ateclectasis not resolved. Dx includes ____ and ___. Tx w/ abx
3 days; CXR; sputum culture
UTI produces fever on postop _____. Dx includes ___ and ____. Tx w/ abx
day 3; UA; urinary cultures
DVT produces fever on postop _____. Dx includes ___ of deep leg/pelvic veins. Tx w/ ____
day 5; Doppler studies; heparin
Wound infection produces fever on postop _____. PE shows erythema, warmth, tenderness. Tx w/ abx if there is only ____, if there is ____, open and drain first. Ddx w/ ____ imaging
day 7; cellulitis; abscess; sonogram
Deep abscesses produce fever on postop _____. Dx includes ___ of subphrenic, pelvic or subhepatic area. Tx usually w/ ___
day 10-15; CT; percutaneous radiologically guided drainage
MC trigger of periop MI; detected by ____ or _____ on EKG
hypotension; ST depression; T-wave flattening
When it happens, MI usually occurs _____ posop, showing up as ____ only in one-third of cases
within first 2-3 days; chest pain
Best dx for MI; Tx postop MI
troponin; clot busters and/or emergency angioplasty/stent
MI postop mortality greatly exceeds MI not associated w/ surgery by _____
50 to 90%
PE typically occurs around postop _____ in the elderly and/or immobilized pts.
day 7
Sxs PE
pleuritic pain w/ sudden onset and SOB; anxiety, diaphoresis, tachycardic w/ prominent distended veins in neck/forehead
PE arterial blood gases show ____ and ____
hypoxemia; hypocapnia
Std dx for PE; Std tx PE
CT angio; heparinization
Tx of PE if PE recurs while anticoagulated or if anticoagulation is contraindicated
heparinization + IVC filter (Greenfield)
When can you NOT use compression devices to prevent PE?
pt w/ LE fracture
Risk factors of PE where anticoagulation is indicated (5)
(1) age >40 (2) pelvic/leg fractures (3) venous injury (4) femoral venous catheter (5) anticipated prolonged immobilization
_____ is a hazard in awake intubations in combative pts w/ full stomach.
Aspiration
Aspiration can be ____ immediately or lead to _____ of tracheobronchial tree subsequent to pulmonary failure or secondary pneumonia
lethal; chemical injury
Prevention aspiration postop
NPO and antacids before induction
Tx aspiration
lavage/removal of particulates/acid w/ bronchoscopy followed by bronchodilation and respiratory support
Intraoperative _____ can develop in pt w/ traumatized lungs (punctures by broken ribs) once they are subjected to positive pressure breathing
tension pneumothorax
Sxs of intraop tension pneumothorax
progressively more difficult to “bag”, BP steadily declines, CVP steadily rises
Tx of intraop tension pneumothorax
needle inserted through ant chest wall into pleural space; formal chest tube placed later
First thing to suspect when postop pt gets confused/disoriented is ____. May be secondary to ____. Check blood gases and provide respiratory support
hypoxia; sepsis
ARDS is seen in pts w/ complicated postop course, often complicated by ____. Clinical sxs. There is NO evidence of ____
sepsis; bilateral pulmonary infiltrates, hypoxia; congestive heart failure
Tx ARDS
PEEP [extensive pressures can result in barotrauma] and tx of sepsis
Delirium tremens usually occurs postop _____ in alcoholics. Sxs.
day 2 or 3; confused, hallucinations, combative
Tx delirium tremens
benzodiazepines or IV alcohol (5% in 5% dextrose)
Hyponatremia can cause ____ if quickly [in hours] induced by liberal administration of sodium-free fluids [D5W] in postop pt w/ high levels of ADH [triggered by response to trauma]
confusion, convulsions, coma, death
Prevent hyponatremia postop due to increased ADH; Mortality if occurs is high. ____ are vulnerable. Tx
including sodium in IV; young women; hypertonic saline and osmotic diuresis (mannitol)
Surgical damage to _____ with unrecognized DI can cause hypernatremia postop. ____ can also cause this.
posterior pituitary; unrecognized osmotic diuresis
Sxs hypernatremia; Tx
large, unreplaced UOP, rapid wt loss, rapidly rising serum sodium; rapid fluid replacement, “cushion” it by D5-1/2 or D5-1/3 NS [not D5 only]
______ is a common cause of coma in cirrhotic pt w/ bleeding esophageal varices who undergoes _____ shunt
ammonium intoxication; portocaval
_____ should be done 6 hours postop if no spontaneous voiding occured; ____ indicated at second/third day of consecutive catheterization
In-and-out bladder catheterization; Foley
Zero urinary output is usually a mechanical problem cause ed by a _____ catheter
plugged or kinked
Low UOP is (defined as _____) in the presense of nml perfusing pressure represents either ____ or ____.
Ddx low UOP uses fluid challenge, which is ____. Dehydrated pts will have _____. Acute renal failure pts will have _____.
bolus 500 mL IV fluid infused over 10-20 min; temporary increase in UOP; no increase UOP
In dehydrated pt, urinary sodium will be ____ whereas in a patient with acute renal failure, it will be _____. When looking at fractional excretion of sodium (FeNa), renal failure will have FeNa ____.
40 mEq/L; >1
Sxs Paralytic ileus (nml after first few days of abd surgery)
absent bowel sounds, no flatus, mild distension, no pain
Paralytic ileus prolonged by _______.
hypokalemia
Mechanical bowel obstruction usually dx as postop ileus is noticed on postop _____ when still no BM. Xrays will show _____.
days 5, 6 or 7; dilated loops of small bowel w/ air-fluid levels
Confirmatory dx of mechanical bowel obstruction. Tx.
abdominal CT w/ transition pt btwn proximal dilated bowel and distal collapsed bowel at site of obstruction; sx
“Paralytic ileus of the colon”, aka ______, is poorly understood and very common. Usually seen in _____
Ogilvie syndrome; elderly sedentary pts who are further immobilized [post hip fracture sx, etc]
Sxs Ogilvie syndrome
large abd distension (tense, nontender) w/ imaging showing massive dilated colon
Tx Ogilvie syndrome; ____ should be avoided b/c side effects can be lethal if colon is actually obstructed
fluid and electrolyte correction, colonoscopy to suck out air and place long rectal tube; neostigmine
Wound dehiscence can be seen postop _____, usually after _____. Fluid is salmon-colored (peritoneal fluid).
day 5; open laparotomy
Tx wound dehiscence
must be taped securely until promt reop to prevent envisceration or ventral hernia can occur
Envisceration; MCC
skin opens and abd contents fall out; when pt strains, coughs or gets out of bed
Temp tx envisceration before emergency reop
kept in bed w/ bowel covered w/ large sterile dressings soaked w/ warm saline
Wound infections usually occur postop ____.
day 7
_____ are when bowel contents leak out through wound or drainage site. Complications include _____ (1) if they do not drain completely to outside and _____(3) if they do.
Fistulas of GI tract; sepsis; fluid/electrolyte loss, nutritional depletion, erosion/digestion of belly wall
Complications of fistulas of GI tract related to location and volume of fistula. The problems are nonexistent in _____, manageable in ______ w/ low-volume (200-300 mL/day) output and awful in _____ w/ high-volume (several liters) output.
distal colon; high GI fistulas (stomach, duodenum, upper jejunum): high GI fistulas
Nature will heal GI fistula if the following is absent. (Steroids will also prevent healing)
[FETID] foreign body, epithelialization, tumor, infection/irradiated tissue/IBD, distal obstruction
Tx GI fistulas
electrolyte replacement, nutritional support, compulsive protection of abdominal wall (ostomy bags)
Every 3 mEq/L that the serum sodium concentration is above 140 represents about _____ of water loss.
one liter
If hypernatremia occurs slowly, the brain will adapt. Tx should be corrected _____ using ______
rapidly (in hrs); D5-1/2 NS
If hypernatremia occurs rapidly (as in ____ or _____), CNS symptoms will develop. Tx w/ ______ or even ____
osmotic diuresis; DI; D5-1/3 NS; D5W
Hyponatremia can occur when pt has too much _____, for example, in postop water intoxication or paraneoplastic condition secreted by tumors; Hyponatremia can also occur due to losing large amts _____ [tonicity] fluids from GI tract
ADH; isotonic
If hyponatremia occurs rapidly, the brain cannot adapt. Tx should include _____ hypertonic saline
3% or 5%
If hypernatremia occurs slowly, the brain will adapt. Tx should include ____.
water restriction
If hypernatremic dehydrated pt losing GI fluids, _____ [tonicity] fluids for volume restoration should be used. ___ should be used if there is alkalosis. ____ should be used if there is acidosis or normal pH.
isotonic; normal saline; lactate Ringers
Renal failure and aldosterone antagonists will cause _____ hyperkalemia, whereas crushing injuries, dead tissue and acidosis will cause ______ hyperkalemia.
slow-onset; fast-onset
Ultimate tx hyperkalemia; tx while waiting (3)
hemodialysis; (1) 50% dextrose + insulin (pushing K into cells) (2) NG suction/exchange resins (sucking it out of GI tract) (3) IV Ca+ (neutralizing its effect on cellular membrane; quickest)
DDx Metabolic acidosis
fixed acids [DKA, lactic acidosis, low-flow states], loss of buffers [loss bicarb fluids from GI tract], inability of kidney to eliminate fixed acids [CKD]
In metabolic acidosis, an anion gap 10-15 indicates that _______.
acids are piling up (no loss of buffers)
Tx Metabolic acidosis
tx underlying problem, can temp tx w/ admin of bicarb ONLY if that is initial prob
If too much bicarb is administered to a metabolic acidotic pt, can cause ___
rebound alkalosis
In long-standing acidosis, ______ leads to a deficit that doesn’t become obvious until acidosis is corrected; therefore must be prepared to replace ____ as part of therapy of acidosis
renal loss of K+; K+
Metabolic alkalosis is due to _____ or ______
loss of acid gastric juice; excessive admin of bicarb/precursors
Std tx metabolic alkalosis; sometimes ____ or ___ needed.
abundant intake KCl (5-10 mEq/h) will correct problem; ammonium chloride; 0.1 N HCl
____ due to impaired ventilation and ___ due to abnormal hyperventilation. Recognized by abnormal PCO2. Therapy directed at improving or reducing ventilation.
Respiratory acidosis; respiratory alkalosis
What imaging is used to see if a lung lesion is an old scar or a rapidly dividing lung mets
PET scan