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Surgery > Pre-Op and Post-Op Care > Flashcards

Pre-Op and Post-Op Care Flashcards

1
Q

Pre-Op EF <35%

A

prohibitive cardiac risk for noncardiac operations.

incidence periop MI is 75-85%, morality 55-90%.

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2
Q

Goldman’s Index of Cardiac Risk

A 
JVD = 11 pts
MI within last 6 months = 10 pts
PVC or arrhythmia = 7 pts
>70yrs = 5 pts
emergency surgery = 4 pts
aortic valvular stenosis, poor medical condition, or surgery within chest/abd = 3 pts
Risk of cardiac complications:
up to 5 pts = 1%
up to 12 pts = 5%
up to 25 pts = 11%
over 25% = 22%
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3
Q

JVD

A

shows CHF, worst finding, predicts high cardiac risk

Tx: ACEI, beta blockers, digitalis, diuretics

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4
Q

Recent Transmural or subendocardial MI

A

40% risk of mortality within 3 months of surgery

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5
Q

Increased Pulmonary Risk

A

Cause: smoking
effect: compromised ventilation, high PCO2, low FEV1
Tx: stop smoking 8 wks before operation, resp therapy

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6
Q

Hepatic Risk

A

predictors: bilirubin, serum albumin, prothrombin time, ascites, encephalopathy
40% mortality: with either bilirubin >2, albumin 16, or encephalopathy
80-85% mortality: if three or more predictors present, bilirubin >4, albumin 150.

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7
Q

Severe Nutritional Depletion

A

loss of 20% of body weight in a few months, serum albumin <200.
Tx: 4-10 days perop nutritional support.

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8
Q

Diabetic Coma

A

absolute contraindication to surgery

Tx: rehydrate, increase urinary output, correct acidosis and hyperglycemia

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9
Q

Malignant Hyperthermia

A

after onset of anesthetic (halothane or succinylcholine)
temp >104F, metabolic acidosis, hypercalcemia.
May have family history.
Tx: IV dantrolene, 100% oxygen, correct acidosis, cooling blankets.
Watch for myoglobinuria.

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10
Q

Bacteremia

A

within 30-45 minutes of invasive procedures.
chills and temp >104F.
Dx: blood cultures
Tx: empiric antibiotics

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11
Q

Gas gangrene

A

rare cause of severe wound pain and high fevers within hours of surgery

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12
Q

Post-Op Fever 101-103F

A 
from:
atelectasis
pneumonia
UTI
DVT
wound infection
deep abscesses
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13
Q

Atelectasis

A

most common post op fever POD1.
Dx: chest x-ray, improve ventilation
Tx: bronchoscopy

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14
Q

Pneumonia

A

POD3 fever if atelectasis not resolved.
Dx: infiltrates on CXR, sputum cultures
Tx: abx

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15
Q

UTI

A

POD3 fever
Dx: UA, urine cultures
Tx: abx

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16
Q

DVT

A

POD5 fever
Dx: Doppler studies of deep leg and pelvic veins
Tx: heparin

17
Q

Wound Infection

A

POD7 fever
PE: erythema, warmth, tenderness.
Dx: sonogram
Tx: abx if cellulitis, open and drain abscess

18
Q

Deep Abscess

A

subphrenic, pelvic, subhepatic
POD 10-15 fever
Dx: CT
Tx: drainage via radiology

19
Q

Perioperative MI

A

During operation:
most commonly triggered by hypotension
Dx: EKG shows ST depression, T-wave flattening

Post-op:
POD 1-3 with chest pain.
Dx: troponin
Tx: for complications, emergency angioplasty, coronary stent

20
Q

Pulmonary Embolus

A

POD7 in elderly or immobilized patients
Features: pleuritic chest pain, sudden onset, SOB, anxious, diaphoretic, tachycardic, prominent distended veins in neck and forehead.
Dx: arterial blood gases have hypoxia and hypocapnia, pulmonary angiogram, spiral CT/CT angio
Tx: heparin, IVC filter
Prevention: compression devices, anticoagulation
Risk factors: age >40yr, pelvic or leg fracture, venous injury, femoral venous catheter, anticipated prolonged immobilization.

21
Q

Aspiration

A

hazard in awake intubations in combative patients with full stomach.
Can cause tracheobronchila tree injury, pulm failure, secondary pneumonia.
Prevention: NPO, antacids
Tx: lavage and removal of acid and particulates via bronchoscopy, bronchodilators, resp support

22
Q

Intraoperative Tension PTX

A

in pt with traumatized lungs on positive pressure breathing.
Features: BP declines, CVP rises
Tx: needle decompression, chest tube.

23
Q

Disorientation/Coma Post op

A
  1. hypoxia secondary to sepsis.
    a. check blood gases, provide resp support.
  2. ARDS when complicated post op course usually with sepsis.
    a. bilat pulm infiltrates, hypoxia, no CHF.
    b. tx is PEEP, treat sepsis
  3. delirium tremens in alcoholics on POD 2-3
    a. have hallucinations, become combative.
    b. tx: IV benzos, IV alcohol
  4. hyponatremia if fast infusion of sodium free IVF in postop pt with high ADH.
    a. confusion, convulsions, coma/death
    b. large fluid intake, weight gain, low serum Na
    c. prevent by Na in IVF
    d. high mortality
    e. tx: small amounts hypertonic saine, osmotic diuretics
  5. hypernatremia if large water loss from osmotic diuresis.
    a. large urinary output, weight loss, high serum sodium
    b. tx: rapidly replace fluid with D5 1/2 or D5 1/3 normal saline.
  6. ammonium intoxication in cirrhotic pt with bleeding varices and portocaval shunt
24
Q

Post Op Urinary Retention

A

usually from surgery in abd, pelvis, perineum, groin.
Features: feels like need to void but can’t.
Tx: in and out catheterization at 6hr post op, foley if still can’t after 3 catheterizations.
No output: mechanical problem. look for plugged or kinked catheter.
Low output: (40 in renal failure, FENa >1 in renal failure.

25
Q

Paralytic Ileus

A

in first few days post op.
neg BS, neg flatus, mild distension, no pain.
prolonged by hypokalemia.

26
Q

Early Mechanical Bowel Obstruction

A

from adhesions during post op.
Usually assumed paralytic ileus that doesn’t resolve by POD5-7.
Dx: x-ray shows dilated loops of small bowel and air-fluid levels, CT abd shows transition btw proximal dilated bowel and sital collapsed bowel.
Tx: surgery

27
Q

Ogilvie Syndrome

A

paralytic ileus of colon.
in elderly sedentary patients.
Features: large abd distention with massively dilated colon.
Dx: x-ray shows dilated colon
Tx: after rule out obstruction and correct fluid and electrolytes, do endoscopy and then give IV neostigmine to restore motility.

28
Q

Wound Dehiscence

A

POD5 after laparotomy
Features: large amounts pink, salmon colored fluid on dressing, wound looks intact.
Tx: tape wound securely, bind abd, reoperate.

29
Q

Evisceration

A

complication of wound dehiscence.
skin opens up and abd contents rush out when pt coughs, strains, gets out of bed.
Tx: keep in bed, large sterile dressings soaked in saline, emergency closure.

30
Q

Fistulas of GI Tract

A

bowel contents leak out through wound or drain.
Can cause sepsis, needing drainage.
Drain freely leads to fluid and electrolyte loss, nutritional depletion, erosion/digestion of belly wall.

31
Q

Hypernatremia

A

Cause: lost water or developed hypertonicity.
Happens slowly = brain adapts and will show volume depletion.
a. tx: volume repletion slowly using D5 1/2 NS.
Rapid = from osmotic diuresis or diabetes insipidus, causes CNS symptoms.
a. tx: correct with D 1/3 NS or D5W

32
Q

Hyponatremia

A
  1. high ADH from post op water intoxication or inappropriate ADH secretion by tumor.
    a. tx: water restriction if slow. rapid = hypertonic saline
  2. losing large amounts of isotonic fluids retains water if doesn’t get enough isotonic fluids.
    a. tx: isotonic fluids
    water intoxication causes CNS symptoms
33
Q

Hypokalemia

A

slowly when lost through GI tract or in urine and not replaced.
rapidly when moves into cells (DKA correction).
Tx: potassium replacement 10mEq/h.

34
Q

Hyperkalemia

A

slowly when kidneys can’t excrete potassium (renal failure or aldosterone antagonists.
rapidly when dumped into blood (crushing injries, dead tissue, acidosis).
tx: hemodialysis, 50% dextrose and insulin, NG suction, IV calcium.

35
Q

Metabolic Acidosis

A

from excessive production of fixed acids (DKA, lactic acidosis, low-flow states), loss of buffers, or inability of kidney to eliminate fixed acids.
Features: pH <25, base deficit.
a. anion gap if abnormal acids build up.
Tx: give bicarb/lactate/acetate, treat underlying condition.
a. watch K+ and replace if necessary

36
Q

Metabolic Alkalosis

A

loss of acid gastric juice or giving too much bicarb.
Features: pH >7.4, serum bicarb >25, base excess.
Tx: KCl, ammonium chloride, 0.1 HCl

37
Q

Respiratory Acidosis and Alkalosis

A

impaired ventilation = acidosis
abnormal hyperventilation = alkalosis
Features: abnormal PCO2 (low in alkalosis, high in acidosis), abnormal pH.
Tx: acidosis = improve ventilation; alkalosis = reduce ventilation.

Surgery (11 decks)

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