Flashcards in Preoperative Care 3 Deck (20):
Surgical patient with liver disease – how to determine operative risk?
Factors that would delay surgery?
Child's score of C, or acute alcoholic hepatitis
Child score classifications for group B?
1. Bilirubin 2.0-3.0
2. Albumin 3.0-3.5
3. Easily controlled ascites
4. Minimal Encephalopathy
5. Good nutrition
Mortality of 10-15%
Patient with liver cirrhosis – proceed with other surgery only if?
Must control ascities with?
1. If compensated liver failure
2. If abstain from alcohol for 6-12 weeks
3. If medically optimized
If ascites controlled with potassium sparing diuretics, and sodium/water restriction
Surgical patients with liver failure had hernia surgery delayed. Now;
1. Notices small ulcerated area on the hernia. Cause? Management?
2. Returns to ED with confusion and lethargy. Management?
3. Returns to ED with serous fluid leaking from ulcer on hernia. Management?
1. Possibly due to pressure necrosis (increases risk of rupture). Manage ascites and then repair hernia
2. Tapped ascities, treat with antibiotics if SBP
3. Send fluid for culture, start IV antibiotics immediately, urgent hernia repair
Patients with cirrhosis desires hemorrhoid removal – concern?
Hemorrhoid removal is difficult in patients with cirrhosis or portal hypertension (can cause uncontrollable hemorrhage during surgery)
Surgical patient with aseptic necrosis for hip replacement – has history of kidney transplant with progressive chronic rejection and creatinine 3.5 – problem? management?
Repairing hip during transplant deterioration may aggravate the rejection
Delay hip repair until transplant function has stabilized or dialysis is begun
Surgical patient with aseptic necrosis for hip replacement – has history of renal transplant and chronic rejection – How to prepare for surgery?
1. Dialyze to normalize platelet function, hydration, blood pressure, electrolytes
2. If on steroids for transplant, give perioperative steroids
Patient with renal failure has a serum potassium 5.1 from a 2 day old laboratory test – management?
Spikes in potassium can occur chronic renal failure – need to get new measurement
Patient with chronic renal failure goes to surgery. Intraoperative bleeding due to "Capillary ooze" – likely cause? management options?
Platelet dysfunction due to your premier
1. Desmopressin to release von Willebrand factor (rapid)
2. Fresh frozen plasma to correct the defect (rapid)
3. Conjugated estrogens (slow onset, long lasting)
4. Post operative hemodialysis
Multiple doses of desmopressin may induce?
Tachyphylaxis - loss of hemostatic effect
Patient with chronic renal failure goes to surgery. Patient becomes hypotensive without evidence of bleeding – possible cause? special measures?
1. Glucocorticoid deficiency common in renal failure patients who have previously taken steroids
Do you hydrocortisone intraoperatively and postoperatively
Patient with renal failure undergoes surgery – immediate postoperative potassium is 7.1 and he's producing 10 mL per hour of urine – management?
1. ECG to determine if hyperkalemia is physiologically important
2. If peaked T waves, give calcium gluconate followed by IV insulin and glucose
3. Likely will need hemodialysis
Surgical patients with chronic mitral valve stenosis that is well compensated – complications of mitral valve stenosis? Considerations during surgery?
Complications – pulmonary hypertension, right heart failure, atrial fibrillation
1. Maintain intravascular volume, and avoid any increases in pulmonary vascular resistance (hypoxemia, hypercapnia, acidosis)
2. Avoid tachycardia because it decreases diastolic filling time
3. All patients with valvular heart disease should receive prophylactic antibiotics
Surgical patients with chronic mitral stenosis and CHF exacerbation one month ago – consideration regarding surgery? If urgent surgery, will need? Less useful?
1. mitral valve stenosis with underlying CHF increase mortality to 20%
2. If surgery is urgent, will need intraoperative monitoring (A-line and TEE)
3. Pulmonary artery catheter is not useful because pressure gradient between pulmonary capillary wedge pressure and LV EDP is distorted in MS
Surgical patients with no aortic stenosis and grade IV systolic murmur – Before elective surgery? For urgent surgery?
cardiac assessment and possible valve replacement
Perioperative hemodynamic monitoring with pulmonary artery catheter, A-line, TEE
when to consider bacterial endocarditis prophylaxis? And antibiotics to use?
Heart surgeries that don't need endocarditis prophylaxis?
Dental work, respiratory tract, esophageal – amoxicillin or clindamycin or cephalosporin or clarithromycin
G.I./GU – ampicillin + gentamicin with ampicillin post procedure; vancomycin + gentamicin
Also for heart valves, prosthetic vascular grafts
Not recommended for CABG, MVP without regurgitation, pacemakers,
Purpose of bowel prep? Supplements?
Decrease fecal mass and bacterial content of colon
Non-absorbable antibiotics – neomycin or erythromycin
Polyethylene glycol – causes no net absorption or secretion of ions (no change in electrolyte/water balance)
Hypertonic sodium phosphate solution draws fluid into interstitial lumen
Contraindicated in diabetics, patients are predisposed to metabolic acidosis, potassium loss