5 categories of pre-op and post-op care
An ejection fraction of ________ poses prohibitive cardiac risk for non-cardiac operations (increases MI or mortality)
(Normal = 55%)
What contributes to increased risk of cardiac complications? (8)
Goldman's index of cardiac risk -
- recent MI (within 6 months) -
- PVC or rhythm other than sinus -
- age >70 -
- emergency surgery -
- aortic stenosis -
- poor medical condition -
- Chest/Abd surgery
What 2 factors are the greatest predictors for cardiac complications during surgery?
recent MI (within 6 months)
What should you treat JVD with prior to surgery (4)
ACEi, ß blockers, digitalis, and diuretics
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
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)
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
Hepatic predictors of mortality during surgery? (5)
[Albumin < 3] or Ascites
[Bilirubin > 2]
encephalopathy (NH3 >150)
[PT > 16]
How is severe nutritional depletion defined as? (3)
- >20% wt. loss over couple months
- [Albumin < 3 ]
- [Transferrin < 200]
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
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%)
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
Patient experiences severe wound pain and T 104˚F a few hours after surgery. What happened?
think GAS GANGRENE
Patient develops post op fever 103˚F after surgery. What is the differential? (5)
1. atelectasis---> pneumonia
3. Deep thromboplebitis
4. Deep Abscess
5. wound infection
most common source of post-op fever and when does it occur? Dx?
atelectasis, day 1
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
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
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
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
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]
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
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!
When does PE typically occur post-op? Dx? Tx?
[day 7 Post Op]
Dx: [spiral CT angio]
When is an IVC filter indicated (2)?
- Recurring PE even while on AntiCoag
- AntiCoags are cx
How do you prevent thromboembolism/PE? What rules out PE dx?
[SCD (Sequential Compression Devices)] + AntiCoag
low CVP excludes PE
When is anticoagulation indicated in the prevention of thromboembolism/PE (4)?
- [Venous damage/catheter (especially femoral)]
- LE Fracture (Pelvis / Leg)
- > 40 yo
How do you prevent aspiration (2)?
NPO and antacids
How do you treat aspiration (3)?
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"