Pestana Pre/Post-Op care Flashcards by Brian McCalister

5 categories of pre-op and post-op care

cardiac
pulmonary
hepatic
nutritional
metabolic

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An ejection fraction of ________ poses prohibitive cardiac risk for non-cardiac operations (increases MI or mortality)

<35%

(Normal = 55%)

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What contributes to increased risk of cardiac complications? (8)

Goldman’s index of cardiac risk -

JVD
recent MI (within 6 months) -
PVC or rhythm other than sinus -
age >70 -
emergency surgery -
aortic stenosis -
poor medical condition -
Chest/Abd surgery

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What 2 factors are the greatest predictors for cardiac complications during surgery?

JVD

recent MI (within 6 months)

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What should you treat JVD with prior to surgery (4)

ACEi, ß blockers, digitalis, and diuretics

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What should you do for someone who requires surgery, but had an MI 4 months ago?

admit to ICU day prior to surgery to optimize cardiac variables

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What is the most common cause of increased pulmonary risk during surgery and why?

SMOKING. It compromises VENTILATION and results in high PCO2, low FEV1)

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What should you recommend for a current smoker with COPD tht requires surgery?

quit smoking for 8 weeks with intensive respiratory therapy prior to surgery

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Hepatic predictors of mortality during surgery? (5)

[Albumin < 3] or Ascites

[Bilirubin > 2]

encephalopathy (NH3 >150)

[PT > 16]

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How is severe nutritional depletion defined as? (3)

>20% wt. loss over couple months
[Albumin < 3]
[Transferrin < 200]

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What is a metabolic risk that is absolutely contraindicated to surgery

diabetic coma - must rehydrate, resume urinary output, and at least partial correction of acidosis and hyperglycemia must be achieved before surgery

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Patient develops 104˚F shortly after he was put under anesthesia. What happened?

What other signs would you look out for (3)?

What should you do (4)?

think MALIGNANT HYPERTHERMIA, esp. with halothane or succinylcholine

Sx: metabolic acidosis + hypercalcemia + myoglobinuria

Tx: DACO (Dantrolene/Acidosis correction /Cooling blankets/O2 100%)

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Patient develops chills and spikes to 104˚F shortly after he awakens from pyeloplasty What happened? What should you do (2)?

think BACTEREMIA, esp since he underwent instrumentation of the urinary tract

Tx: [blood culture x3] + empiric abx

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Patient experiences severe wound pain and T 104˚F a few hours after surgery. What happened?

think GAS GANGRENE

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Patient develops post op fever 103˚F after surgery. What is the differential? (5)

Post-Op Fever:

atelectasis—> pneumonia
UTI
Deep thromboplebitis
Deep Abscess
wound infection

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most common source of post-op fever and when does it occur? Dx?

atelectasis, day 1

Dx: bronchoscopy

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what happens if atelectasis is not resolved after 3 days? next best step in management?

increased risk of PNEUMONIA (fever, infiltrates on CXR) Mgmt: sputum cultures + appropriate antibiotics

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When does pneumonia, if present, typically produce fever post-op? next best step in management?

[day 3 Post Op] (think - 3 syllables)

Mgmt: sputum cultures + appropriate antibiotics

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When does a UTI, if present, typically produce fever post-op? next best step in management?

[day 3 Post Op] (think - 3 letters)

Mgmt: UA, UC, antibiotics

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When does thrombophlebitis, if present, typically produce fever post-op? next best step in management?

[day 5 Post Op] (think - 5 syllables)

Mgmt: doppler + heparin

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When does [wound infection], if present, typically produce fever post-op? next best step in management?

[day 7 Post Op] (think - infection has 8 letters)

Mgmt: [cellulitis=abx] vs. [Abscess=IND]

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When does deep abscesses, if present, typically produce fever post-op? next best step in management?

day 10-15 (think - deep abscesses has 13 letters) Mgmt: percutaneous radiologically guided drainage

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When does perioperative MI typically occur post-op? next best step in management (2)? Cx?

day 2-3 Mgmt: troponin levels + [Coronary stent: angioplasty].

tPA in perioperative setting = Cx!

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When does PE typically occur post-op? Dx? Tx?

[day 7 Post Op]

Dx: [spiral CT angio]

Tx: heparin

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When is an IVC filter indicated (2)?

1. Recurring PE even while on AntiCoag 2. AntiCoags are cx

How do you prevent thromboembolism/PE? What rules out PE dx?

[SCD (Sequential Compression Devices)] + AntiCoag ## Footnote **low CVP excludes PE**

When is anticoagulation indicated in the prevention of thromboembolism/PE (4)?

1. [Venous damage/catheter (**especially femoral**)] 2. LE Fracture (Pelvis / Leg) 3. immobilization 4. \> 40 yo

How do you prevent aspiration (2)?

NPO and antacids

How do you treat aspiration (3)?

- Lavage removal - BronchoDilators - Respiratory Support

When can intraoperative tension pneumothorax develop? What are the immediate signs of of this (3)?

when patients with traumatized lungs are subjected to (+) pressure ventilation steady decline in BP + increase in CVP + becomes more difficult to "bag"

Ski trauma patient undergoing a surgery has a steady decline in BP, increase in CVP, and becomes more difficult to bag - what should you consider and what should you do immediately?

intraoperative tension pneumothorax Tx insert needle through the anterior chest wall into the pleural space to relieve the pressure

What is the first thing you should consider if a post-op patient becomes confused and disoriented? Dx method? Tx?

HYPOXIA / [Dx: blood gases] / [Tx: Respiratory Support] ## Footnote *Also Check Na+ and NH3*

Patient with bilateral pulmonary infiltrates, hypoxia, with no evidence of CHF. What is the usual precipitating event?

ARDS - usually due to sepsis

Management of ARDS (2)?

[PEEP (Positive End Expiratory Pressure)] + Treat Sepsis

Alcoholic Pt who becomes [confused + combative + hallucinations]. What is the usual precipitating event? Next best step in management?

DELERIUM TREMENS IV benzodiazepines

Which *Electrolytes* are associated with confusion post-op?

imbalance of **Na+** vs. **NH3**

What typically causes hypOnatremia post op? What are some sign to look out for in the chart (3)?

liberal administration of sodium-free IVF chart review: large fluid intake, quick weight gain, rapidly lowering serum Na concentration (hours)

Prevention of hyponatremia in a post-op patient

Always include Na in IVF

Treatment of hyponatremia in a post-op patient?

small amounts of hypertonic saline + osmotic diuretics

What causes hypernatremia post op? What are some sign to look out for in the chart?

rapidly induced by large, unreplaced water loss (ie surgical damage to posterior pituitary, unrecognized osmotic diuresis) chart review: large, unreplaced urinary output, rapid weight loss, rapidly rising Na concentration

Treatment of hypernatremia in a post-op patient?

D5 1/2 NS

What type of post-op patients would you normally see ammonium intoxication? Tx (2)?

cirrhotic patients with bleeding esophageal varices who undergoes TIPS surgery Tx: Lactulose (converts NH3 --\> NH4+) RifaXimin (DEC intraluminal NH3)

Management of a post-op patient who complains of the need to void, but cannot do it

bladder catheterization at 6 hrs post-op or foley catheter after 2 or 3 days of consecutive catheterization

Zero urinary output from a catheter is typically caused by....

mechanical problem (plugged or kinked catheter)

Low urinary output from a catheter is typically caused by.... ___ or \_\_\_\_

fluid deficit or acute renal failure

What are 3 different ways to differentiate between fluid deficit or acute renal failure that is causing low urinary output

1) fluid bolus of 500mL infused over 10-20min - dehydrated patients will respond with temporary increase in UO while patients with ARF will not 2) UNa - dehydrated patient 40mEq/L 3) FENa - dehydrated patients 1

signs of paralytic ileus

decreased/absent bowel sounds no passage of gas MILD distension, but no pain

paralytic ileus can be prolonged by this electrolyte abnormality

hypokalemia

if normal bowel function does not resume within 5-7 days post-op, what should you consider? next best step management?

mechanical bowel obstruction Tx: abdominal CT (transition point noted at site of obstruction), surgical intervention

What is ogilvie syndrome? What patient population is it normally seen in?

paralytic ileus of the colon - typically in elderly, sedentary patients who have become further immobilized owing to surgery elsewhere

Sx ogilvie syndrome? Management of these patients?

LARGE abdominal distension Mgmt: correct fluid/electrolytes, r/o mechanical obstruction PRIOR to IV neostigmine to restore colonic motility

sequelae of GI fistulas that do not drain completely (leaks into a cesspool that then leaks out)

sepsis

3 sequelae of GI fistulas that do not drain completely (pt is afebrile + no signs of peritoneal irritation)

fluid + electrolyte losses nutritional depletion erosion + digestion of abdominal wall

Management of GI fistulas

FEN support suction tubes and ostomy bags until nature heals the fistula

What will prevent fistulas from healing?

F.E.T.I.D.S Foreign bodies Epithelialization Tumor Infection, Irradiated tissue, IBD Distal obstruction Steroids

a serum sodium of 143 represents how much water lost from body?

1 L of water (rule of thumb: every 3mEq that serum sodium [] is above 140 represents roughly 1 L of water lost)

Rapid development of hypernatremia should be treated with:

D5 1/2NS (rapid volume repletion with minimal changes in tonicity)

Slow development of hypernatremia should be treated with:

D5 1/3NS or D5W

Rapid development of hyponatremia (ie water intoxication) should be treated with:

hypertonic saline

Slowly developing hyponatremia (ie SIADH) should be treated with:

water restriction

Hypovolemic, dehydrated patients losing large amounts of GI fluids become hyponatremic. Why is that? How are these patients managed?

they are forced to retain H2O Mgmt: isotonic saline or LR solution

3 main causes of **slow** development of hypokalemia

GI losses (massive diarrhea, since GI fluids have high K content) excess loop diuretics excess aldosterone

Main cause of **rapid** development of hypokalemia

correction of DKA (insulin drives K+ into cells)

How fast should you replete K?

10 mEq/h

2 main causes of slow development of hyperkalemia

renal failure aldosterone antagonists

Main causes of rapid development of hyperkalemia

K is dumped from the cells into blood (cell lysis secondary to crush injuries or dead tissue, acidosis)

Treatment of hyperkalemia 5

1) hemodialysis 2) dextrose + insulin 3) NG suction 4) kayxelate 5) IV Calcium

3 main causes of metabolic acidosis

1) excess production (DKA, lactic acidosis, low-flow states) 2) loss of buffers (diarrhea) 3) Renal failure (DEC elimination of fixed acids)

treatment of metabolic acidosis 3

treat underlying cause +/- HCO3 administration ( if the etiology is HCO3 loss) replace K

Why is it that bicarbonate administration in the treatment of metabolic acidosis is not

it's a temporary measure and may cause rebound alkalosis once the underlying problem is corrected

2 main causes of metabolic alkalosis

loss of gastric juice excess intake of bicarbonate

treatment of metabolic ALKolosis

KCl (5-10 mEq/hr)

Breakdown for Lung Physical findings

Pestana Pre/Post-Op care Flashcards

(73 cards)