PreOp/PostOp Care (Alice) Flashcards
(156 cards)
1
Q
6 predictors of surgical cardiac complications
what level of serum creatinine?
A
ischemic heart dz
CHF
cerebrovascular dz
high risk operation
pre op tx w. insulin
pre op SCr > 2.0
2
Q
5 other rf for surgical cardiac complications
A
age
smoking
abnl cardiac stress test
long term bb therapy
COPD
3
Q
pre op management of pt w. rheumatic heart dz
A
prophylactic abx
4
Q
who should get a pre op EKG
A
all pt’s >/= 40 yo
5
Q
2 indications for noninvasive stress testing prior to noncardiac operations
A
active cardiac conditions: unstable angina, recent MI, significant arrhythmias, severe valvular dz
high risk vascular ops
6
Q
6 indications for coronary revascularization prior to noncardiac ops
A
-significant left main coronary artery stenosis
-stable angina w. 3 vessel coronary dz
-stable angina w. 2 vessel dz
-significant proximal LAD coronary artery stenosis w. EF < 50% OR ischemia on noninvasive testing
-high-risk unstable angina or NSTEMI
-acute STEMI
7
Q
why may it be dangerous to give a COPD pt supplemental O2 during surgery
A
pt relies on relative hypoxia for respiratory drive -> supplemental O2 may remove this drive
8
Q
when should smokers stop smoking prior to surgery
A
at least 8 weeks prior
9
Q
mc perioperative complications involve which system
A
pulmonary
pcc: post op pulmonary complications
10
Q
2 determinants of pulmonary perioperative risk
A
lung dz
operative site
11
Q
pre op management of COPD pt
A
minimum of one week of aggressive treatment:
-smoking cessation
-abx if purulent sputum
-bronchodilators
12
Q
t/f: pt w. well controlled asthma is not at higher risk for perioperative complications
A
t!
but poorly controlled asthma is high risk
13
Q
pre op management of poorly controlled asthma
A
-step up therapy
-systemic steroids if FEV < predicted value or personal best
-pre elective surgery goals: wheezing free, peak flows > 80% predicted or personal vest
14
Q
intubation consideration for pt’s w. poorly controlled asthma
A
-SABA 2-4 puffs vs nebulizer w.in 30 mins before intubation
+/- systemic steroids
15
Q
preop management of pulmonary fibrosis pt (3)
A
treat infxns
remove sputum
smoking cessation
16
Q
pre op management of acute lower respiratory tract infxns (tracheitis, bronchitis, pna)
A
-elective surgeries are contraindicated!
-emergent surgeries: humidification, removal of secretions, bronchodilators, abx
17
Q
location of operation for operative pulmonary risk
A
high to low:
torachotomy
upper abdomen
lower abdomen
periphery
18
Q
what test is used for pre op pulmonary function eval
A
- spirometry to measure FEV
- if low FEV: measure response to bronchodilators, obtain ABGs
19
Q
spirometry indications for increased risk for pulmonary complications (2)
A
FEV1 < 50% of normal
PaCO2 > 45 mm
20
Q
surgeries lasting > _ are associated w. higher risk of pulmonary complications
A
3-4 hr
21
Q
greatest risk ops for pulmonary complications (3)
A
upper abd
open aortic aneurysm repair
head/neck
22
Q
lung protective ventilation should be used for _ ops, and involves _
A
abdominal ops
low tidal volume ventilation
23
Q
post op management of pulmonary complications (3)
A
lung expansion
incentive spirometry
early mobilization
24
Q
what is atelectasis
A
collapse of alveoli
25
7 rf for atelectasis
intubation
high flow O2
COPD
smoking
abd/thoracic surgery
oversedation
poor pain control
26
5 sx of atelectasis
| PE and CXR findings
fever
decreased breath sounds
rales
tachypnea/tachycardia
increased densities on CXR
27
mc cause of fever POD 1-2
atelectasis
28
prevention for atelectasis (7)
pre op smoking cessation
incentive spirometry
good pain control
coughing
early ambulation
NT suctioning
chest physiotherapy
29
what is post op pulmonary failure
respiratory impairment w.:
increased RR
SOB
dyspnea
30
indications for intubation/ventilation (3)
-unconscious
-excessive wob
-progressive hypoxemia despite supplemental O2: PaO2 < 55, pH < 7.3, RR > 35
31
4 causes of post op pleural effusion
fluid overload
pna
diaphragmatic inflammation
subphrenic abscess
32
tx for absorption atelectasis
nitrogen
33
what is a non rebreather mask
| O2 concentration + bag type
100% O2 w. reservoir bag
34
max FiO2 delivered by nonrebreather mask
80-90%
35
PaO2 to O2 sat equivalents
PaO2 40, 50, 60 = O2 sat 70, 80, 90
36
each liter of increased NC O2 increases FiO2 by _
3%-4%
37
max flow for NC O2
6 L
38
BG levels > _ are a predictor for surgical site infxn
140
39
best management of post op hyerglycemia
IV insulin
40
DM pt's are at higher risk for _ post oc complications
cardiac
41
management of periop hyperglycemia (2)
IV short acting insulin
SQ SSI (sliding scale insulin)
42
patient-related conditions associated w. higher risk for surgical infxns (11)
advanced age
DM
malnutrition
smoking
obesity
immunosuppressive therapy
systemic steroids
PVD
malignancy/anti neoplastic tx
HIV/AIDS
liver failure
renal failure
43
what is virchow's triad
stasis
hypercoagulable states
trauma
44
4 hypercoagulable states that Smarty PANCE stresses
| hint, one is a blood disorder
factor V leiden
cancer
OCP + smoking
pregnancy
45
imaging for DVT: first line vs gs
first line: duplex US
gs: venography
46
tx for DVT
| post-op I am thinking?
IV heparin bridge to warfarin
47
is DVT mc in left or right iliac vein
left
48
what surgery is especially high risk for post op DVT
colorectal
49
what 2 scoring systems are used to assess probability of developing post op DVT
caprini score
american college of chest physicians
50
heparin prophylaxis for DVT reduces risk for what 3 complications
wound hematomas
mucosal bleeding
reoperation
51
smoking w.in _ of surgery increases risk of complications
| Basically if you had not quit smoking w/in this amount of time
1 year
52
best pharm for perio-op smoking cessation
bupr**op**ion
| when **op**, use bupr**op**ion
53
screening rec for lung ca
**low dose** **CT** annually for adults **50-80 yo** w. a **20 pack/year smoking hx** and **currently smoke** or have quit in the **last 15 yr**
54
when can lung ca screening stop
| Hint: x years w/out smoking is one of them
no smoking x 15 years
contraindication lung surgery
55
3 types of NRT
patch
gum
lozenges
56
NRT recommended for people who smoke 25 or more cigs/day
gum
57
NRT recommended for pt's who smoke w.in 30 min of waking up
lozenges
| helps your breath smell better?
58
what should be avoided w. NRT gum
acidig beverages
59
s.e of nicotine patches
| and what you should do as a result
vivid dreams/insomnia
-> remove at bedtime
60
2 meds for smoking cessation
varenicline (chantix)
bupropion (zyban, wellbutrin)
61
moa for bupropion
enhances noradrenergic and dopaminergic release
62
how does varenicline work (3)
reduces withdrawal sx
reduces reward aspects
63
surgical problems associated w. SUD (7)
| substance abuse disorder
venous access
arterial injury
DVT
abscess formation
gas gangrene
compartment syndrome
neuropraxia
64
who should be screened pre op for SUD
all pt's
65
NIAAA definition of AUD
> 2 drinks/day for men
> 1 drink/day for women or >/= 65
66
CAGE questionnaire
cut down?
annoyed?
guilt?
eye opener?
67
how many drinks may cause BAC >/= 0.08
2
68
complications of stimulant use
greater pressor/intubation response
need for more anesthetic
69
complications fo volatile solvent abuse (4)
cardiomyopathy
dysrhythmia
sensitivity to sympathomimetics
myocardial dpn
70
PCA usually involves what analgesic
morphine
71
pharm for SUD (7)
naltrexone
acamprosate
disulfiram
topiramate
methadone
buprenorphine
naltrexone
72
what are the 6 w's of post op infxn
wind: atelectasis
water: UTI
wound: infxn
walking: thrombophlebitis
wonder drugs: anesthetic/sulfas causing fever
whopper: abscesses -> ileus, anastomotic leaking
73
mc nocosomial infxn in hospital setting
UTI
74
mc pathogen associated w. post op infxn
staph
75
mcc of infxn > 72 hr post op
staph infxn
76
mcc of superficial vs deep thrombophlebitis
superficial: intravascular catheter
deep: indwelling catheter
77
tx for post op atelectasis
incentive spirometry
mucolytics
expectorants
SABA/LABA
*best tx is prevention: smoking cessation*
78
tx for post op DVT
LMWH
heparin contraindication: greenfield filter
79
definition of post op fever
> 38.5/101.5
80
timeline of 5 w's
wind: 24-48 hr
water: anytime after POD 3
wound: mc after pod 5
walking: pod 7-10
wonder drugs: anytime
81
mcc of post op atelectasis
cytokine release from tissue damage
82
4 causes of post op fever < 24 hr post op
**atelectasis**
cytokine release
strep vs clostridial infxn
anastomotic leak
83
4 causes of fever POD 3-5
UTI
PNA
IV site infxn
wound infxn
84
cause and tx of fever intraoperatively
malignant hyperthermia
dantrolene
85
cause of fever POD 5-10 (lots!)
wound infxn
pna
abscess
infected hematoma
cdiff
anastomotic leak
DVT
peritoneal abscess
drug fever
PE
abscess
parotitis
86
causes of wound infxn POD 1-2
strep clostridia
*painful bronze-brown wound weeping*
87
3 anytime causes of post op fever
IV site infxn
central line infxn
meds
88
surgical site infxns mc occur POD
5-7
89
common bacteria associated w. surgical site infxns
**staph - mc**
e.coli
enterococcus
90
what makes you think of clostridium infxn
bronze-brown weeping tender wound
91
management of surgical site infxn (5)
remove sutures/staples
rule out fascial dehiscence
pack wound open
cultures
abx
92
wounds that have been opened due to infxn usually heal by
secondary intention
93
what is a clean contaminated wound
operation on GI or respiratory tract w.o unusual contamination or entr into biliary or urinary tract
94
what is a contaminated wound (4)
acute inflammation
traumatic wound
GIT spillage
major break in sterile technique
95
what is a dirty wound (3)
pus present
perforated viscus
dirty traumatic wound
96
what factors influence the development of infxns (8)
foreign body
decreased blood flow
excessively tight sutures
excessive bovie (tissue destruction)
ops > 2 hr
hypothermia in OR
hematoma/seroma
dead space
97
pt factors that increase rate of infxn
uremia
hypovolemic shock
vascular occlusive states
advanced age
distant area of infxn
98
4 indications for abx after drainage of subcutaneous abscess
DM
surrounding cellulitis
prosthetic heart valve
immunocompromised
99
what type of operation increases risk for AKI
cardiac
100
how to reduce risk of AKI (2)
push fluids
avoid NSAIDs/IV contrast
101
what should you avoid adding to fluids in the first 24 hr post op
K+
*it is already high from stress*
102
3 indications for urinary catheter placement
long procedure
urologic/pelvic surgery
need to monitor fluid balance
103
what electrolyte d.o causes prolonged QT
hypocalcemia
104
what electrolyte d.o causes short QT
hypercalcemia
105
what electrolyte d.o causes tall T waves
hypomagnesemia
106
what electrolyte d.o causes prolonged PR interval and wide QRS
hypermagnesemia
107
sx of hyponatremia (6)
peripheral/presacral edema
pulmonary edema
JVD
htn
decreased Hct
decreased BUN/Cr
108
2 high risk pt pops for hyponatremia
etoh
malnourished
109
3 types of hyponatremia
hypervolemic
hypovolemic
euvolemic
110
4 causes of hypervolemic hypoNa
CHF
nephrotic syndrome
renal failure
cirrhosis
111
causes of hypovolemic hypoNa
renal vs non renal sodium loss
112
3 causes of euvolemic hypoNa
SIADH
steroids
hypothyroid
113
consequences of acute hypoNa (3)
brainstem herniation
coma
sz
114
sx of chronic hypoNa
motor/gait dysfxn
falls
115
consequence of correcting chronic hypoNa too quickly
osmotic demyelination syndrome
116
tx for hypoNa:
asymptomatic:
moderate:
severe:
asymptomatic: fluid restriction
moderate: IVNS, +/- diuretics
severe: 50 mL bolus 3% NS
117
goal for chronic hypoNa correction
118
6 causes of hyperNa
diarrhea
burns
diuretics
hyperglycemia
dm insipidus
deficit of thirst (elderly)
119
5 sx of hyperNa
poor skin turgor
dry mm
flat neck veins
hypotn
BUN:Cr > 20:1
120
tx for hyperNA
D5W
121
2 consequences of correcting hyperNa too quickly
cerbral edema
pontine herniation
122
presentation of diabetes insipidus
low urine Na
high serum Na
polyuria
123
2 types of diabetes insipidus
neurogenic (central)
nephrogenic
124
what causes neurogenic diabetes insipidus
deficient secretion of vasopresin (ADH) from posterior pituitary
125
what causes nephrogenic diabetes insipidus
kidneys are unresponsive to vasopressin (ADH)
think lithium vs renal dz
126
3 causes of hyperK
AKI
late CKD
meds
127
tx for hyperK (4)
insulin
sodium bicarb
glucose
calcium gluconate
128
why must hyperK w. EKG changes must be treated asap
sine waves -> v-tach -> v-fib
129
2 causes of hypoK
diuretics
cushing's
130
tx for hypoK
replace Mg first
oral vs IV K+
131
what fluid should you not use when correcting hypoK
dex containing fluids
*this will stimulate insulin release and shift K+ into the cell -> worse hypoK*
132
mcc of hypoCa
**hypoparathyroidism**
other: thyroid surgery, renal dz
133
involuntary contraction of the muscles in the hand and wrist after compression of the upper arm
trosseau's sign -> hypoCa
134
tapping the cheeck ellicits twitching of the facial muscles
chvostek sign -> hypoCa
135
tx for hypoCa
IV calcium gluconate
vs
calcium chloride
136
lab findings of hypoCa
low: Ca, PTH
elevated: phosphate
137
mcc of hyperCa
**hyperparathyroidism**
also:
sarcoidosis
TB
paget dz
metastatic ca
multiple myeloma
138
presentation of hyperCa
stones
bones
abdominal groans
psychiatric moans
139
labs of hyperCa
elevated: Ca, PTH
low: phos
140
tx for hyperCa
IV NS
furosemide
141
hyperCa in elderly is _ until proven otherwise
cancer
142
presentation of hypoMg
muscle weakness
hyperreflexia
tachycardia
143
EKG finding of hypoMg
torsades
prolonged QT
wide QRS
144
tx for hypoMg
acute: IV Mg
chronic: oral Mg
145
tx for hyperMg
IV isotonic saline
+/- diuretics
146
cause of hyperphos
CKD
147
tx for hyperphos
replace Ca
restrict K+
148
4 sx of hyphoPhos
weakness
muscle/bone pain
osteomalacia
rickets
149
norma range:
pH
PCO2
HCO3
pH: 7.34-7.45
PCO2: 35-45
HCO3: 20-26
150
5 causes of respiratory acidosis
**lungs fail to excrete CO2:**
pulmonary dz
neuromuscular dz
drug induced hypoventilation
opiates
barbituates
151
7 causes of respiratory alkalosis
**excessive ellimination of CO2:**
tachypnea
PE
fever
hyperthyroid
anxiety
salicylate intoxication
septicemia
152
causes of metabolic acidosis w. increased anion gap
**mudpiles:**
methanol
uremia
dka
paraldehyde
infxn
lactic acidosis
ethylene glycol
salicylates overdose
153
2 types of metabolic acidosis
increased anion gap >16
low anion gap < 16
154
3 causes of metabolic acidosis w. low anion gap
diarrhea
pancreatic/biliary drainage
renal tubular acidosis
155
3 causes of metabolic alkalosis
vomiting
bulimia
overdose of antacids
156
what 2 organs play a major role in maintaining pH in the body
lungs
kidneys
