Surgery - Pre and Post Op Care, Electrolytes Flashcards Preview

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Flashcards in Surgery - Pre and Post Op Care, Electrolytes Deck (56):
1

How to decrease risk of surgical site infections

Hair removal w/ clippers (not razors)

Warm room temperature (will have more blood flow to skin)

Tight blood flucose control

Abx ppx

2

Common causes of post-op fever and the days of these causes

5Ws = wind, water, walking, wound, wonder drugs

1-2 d = Atelectasis (#1), PNA

3-5 d = UTI

4-6 d = DVT

5-7d = wound infection

> 7d = medications (drug fever)

3

Most common cause of post-op drug fever

Anticonvulsants
TMP/SMX

4

How much isotonic fluid do you give per amount of blood lost?

3 mL!

If lose 500 mL blood, give 500 x 3 = 1500 mL isotonic fluid (NS or LR)

5

normal urine output

0.5-1 mL/ kg / hr

6

Most common cause of fever in immediate post op period

2nd most common?

1 - Atelectasis

2 - UTI

7

Preop characteristics of pts likely to experience postop ischemia after noncardiac surgery

1. JVD - tx w ACEi, Bblockers, digitalis, diuretics

2. MI in last 6 mo (< 6% after 6 mo, 40% within 3 mo)

>70yo
Mitral regurg / aortic stenosis
> 5 PVC / min
Tortuous or calcified aorta
EF < 35%

8

Perioperative stroke results...

mortality after post op stroke is high

NOT related to hx of multiple strokes or poststroke TIAs

9

Transfusions of blood through
- hypotonic solutions
- ringers lactate

what happens?

Hypotonic (D5W / NS)
- swelling of erythrocytes and lysis

Ringers lactate
- has Ca and causes clotting in IV line --> PE can happen

10

How long after cig abstinence do you get improvement in postop respiratory morbidity?

6-8 weeks

11

Preop hepatic risk - predictors of mortality

Bilirubin
Serum albumin
PT
Ascites
Encephalopathy

12

Tx malignant hyperthermia

T > 104

Quickly finish surgery
Stop anesthesia
Hyperventilate w/ 100% O2
+ IV dantrolene
alkalinize urine to prevent myoglobin precipitation

13

When do you see bacteremia post op?

Tx?

30-45 mins after

BCx x 3
Start empiric abx

14

When do you get periop MI?

within 1st 2-3 days post op

Trend troponins

Greater mortality than non-surgery induced MI

Tx directed at complications (no tPA)

15

Pulmonary embolus findings

Tachycardia (1st sign)

SOB
Diaphoretic

ABG
- hypoxemia
- hypogapnia

16

1st thing suspect when post op pt gets confused and disoriented?

Other things?

#1 = Hypoxia ; Can be 2/2 sepsis

Others:
ARDS
DTs
Hyponatremia
Hypernatremia
Ammonium intoxication (in cirrhotic pts)

17

AKI FeNa of:
-prerenal
- renal
- postrenal

Prerenal < 1

Renal > 2

Postrenal > 2

18

AKI BUN/Cr of:
-prerenal
- renal
- postrenal

Prerenal >20

Renal 15

19

What can paralytic ileus be prolonged by?

Hypokalemia

20

Tx early post op obstruction

- Occurring within 30 days of open operation
- Management is conservative and most resolve spontaneously
- Will not go in early on b/c collagen deposition is happening to fix the cuts made during surgery and that will be very hard to get through. Go back in about 6 weeks is safe

21

Risk of wound dehiscence

Dehiscence is fascia is not properly sewn together

Can get evisceration --> skin opens up and all ab contents flow out

22

Factors assoc w / failure of fistula to heal

FRIEND

Foreign body in wound
Radiation damage to area
Infection or inflammatory bowel disease
Epithelialization of fistulous tract
Neoplasm
Distal bowel obstruction

23

Wound healing process

Inflammation - Proliferation - Remodeling

Inflammatory
- rapid influx of neutrophils
- then monocytes to phagocytose debris and bacteria and secrete TNF, TGF, PDGF, FGF

Proliferation
- angiogenesis + collagen formation
- fibroblasts enter @ day 3 to lay down collagen
- type 3 collagen (elastic fibrils) predominates
- replaced by type 1 collagen (rigid)

Remodeling
- collagen deposition and degradation reach steady state at ~ 1yr

1) Collagen
- needs to be crosslinked by fibroblasts
- fibroblasts also contract w/ SM elements called myofibroblasts --> can result in contractures

2) Growth factors
- PDGF
- neutrophils
- macrophages
- TGF-B
- Epithelial growth factor

24

When do you need perioperative abx?

Contaminated
Clean-contaminated wounds

25

Epithelialization vs wound contraction

Epithelialization responsible for healing of closed incision (usually w/in 48 hrs after incision)

Wound contraction is primary method of closure in open wounds
- can cause 90% reduction in size of open wound but varies if tight skin adherence is present (eg in leg)
- fibroblasts proliferate becoming myofibroblasts and contract wound
- bacteria colonization does not harm process

26

Wound healing cytokines

Injury: platelets release --
- ADP
- TXA
- TGF
- PDGF

Macrophages release -
- IL1
- FGF
- TGF
- EGF
- Plasminogen activator inhibitor

Collagen synthesis initiated and progresses upon stimulation by
IL-1
TNF
TGF

27

Tx hypernatremia

- Volume repletion so that vol is corrected fast but tonicity is slower to correct
- use D5 1/2 NS

28

Tx hyponatremia

If due to SIADH, water restriction

Otherwise, use 3% saline or Ringer lactate

29

Tx hypokalemia

IV K @ 10 mEq/h (try not to exceed)

30

Causes of hyperkalemia

Renal dysfunction
Acidemia
Tumor lysis

31

Tx hyperkalemia

C BIG K

CaCl2 (cell membrane stabilization)

Bicarb
Beta agonist

Insulin (insulin and glucose are the fastest - give glucose too to avoid hypoglycemia)

D50 (glucose)

Kayexalate


Dialysis is ultimate therapy

32

What med for hyperkalemia counteracts myocardial effects of K w/o reducing serum K level?

Calcium gluconate

33

Hypocalcemia
- symptoms
- patho phys

"CATS go numb"- Convulsions, Arrhythmias (QT prolongation), Tetany and numbness/parasthesias in hands, feet, around mouth and lips

The neuromuscular symptoms of hypocalcemia are caused by decreased interaction of calcium with sodium channels.

Since calcium blocks sodium channels and inhibits depolarization of nerve and muscle fibers, diminished calcium lowers the threshold for depolarization

34

Tx hypercalcemia

Hyper Ca results in osmotic diuresis making hyper Ca worse

1) rehydrate w/ normal saline

2) furosemide for Ca diuresis if volume overload

3) + bisphosphonates longterm

4) Tx underlying cause


Only need to manage immediately severe hypercalcemia. Mild and moderate is treated only if symptomatic

35

When see SEVERE hypermagnesemia?

What's the earliest clinical indication of hyperMg?

- Advanced renal failure treated w/ Mg- antacids
- OBs +MgSO4 for preeclampsia

Loss of deep tendon reflexes
- docs give pts MgSO4 until see this

36

Hypermagnesemia clinical findings

HypoTN (arteriolar relaxing)
Paralysis
Resp depression
Changes in Mental status
N/V

37

Hypomagnesemia clinical findings

Like hypo Ca

BUT get torsades!

Paresthesia
Hyperreflexia
Muscle spasm
Tetany
K wasting by kidney
functional hypoPTH --> lowers serum Ca

Happens in malnourished pts, pts w/ large GI fluid losses

38

How to rapidly differentiate hypo Ca vs. hypo Mg

EKG

39

Why do we give D5 1/2 NS + KCl to patients?

How do you calculate how much maintenance fluid to give someone?

Prevent ketosis with glucose!

1/2 Normal saline is hypoosmotic fluid and is maintenance fluid to make it isoosmotic with D5

Calculating maintenance fluid:
4-2-1
1st 10 kg --> give 4 cc/kg/hr
Next 10 kg --> give 2 cc/kg/hr
Remainder of weight --> give 1 cc/kg/hr

Trick for hourly maintenance = 40 + weight (kg)

40

Laproscopic surgery
- risks

- CO2 used in laparoscopy b/c better solubility in blood so less risk of gas embolism. Also noncombustible

Risks for pneumoperitoneum:
o CO2 embolus in pulmonary artery
o HypoTN 2/2 compression of IVC

41

Insulin-dep Diabetic pt pre-op

Check glucose AM of surgery
- better to be slightly increased glucose

If gluc > 250 --> + 2/3 AM dose of NPH + reg insulin

If gluc < 250 --> + 1/2 AM dose

Make sure glucose is below 250 mg/dL preop - delay if not so

42

Hypercalcemia causes

Hyper PTH
mets to bone
Multiple myeloma
Hyper TH
sarcoidosis
Vit A intoxication
Thiazides
RCC
SCC of lung (PTrH)
Hypocalciuric hypercalcemia

43

Secretion of parathyroid hormone is controlled chiefly by

serum [Ca2+] through negative feedback.

Calcium-sensing receptors located on parathyroid cells are activated when [Ca2+] is low.

Gq receptors!!!! PIP

44

hypercalcemia symptoms

Nausea
vomiting
dehydration
lethargy
confusion
kidney stones (#1)
cardiac effects - HTN, LVH, calcification of valves
Peptic ulcers
Pancreatitis

45

Tx hypovolemic hypernatremia
- mild
- severe

Mild: D5W + 1/2 NS

Severe: NS, then switch to 1/2 NS

46

CEntral pontine myleinolysis consequence of

hyponatremia corrected too fast

47

Correct hypernatremia too fast...

Cerebral edema

48

Tx euvolemic or hypervolemic hypernatremia

D5W

IV free water may cause RBC lysis b/c osmotic shock

49

S/E loop diuretics

Hypokalemia
Metabolic alkalosis
Prerenal renal failure

50

Changes in calcium binding w/ pH

Alkalosis (increase pH) --> more albumin binds calcium, therefore less free calcium

Free calcium is the only active form!

51

When can you start heparin/dvt ppx on a post op patient without increased risk of bleeding?

48-72 hrs after operation is safe if they are hemodynamically stable

52

Pt NPO for a while + receiving broad spectrum abx. Starts to bleed from IV site. PT and PTT prolonged. What happened?

Vit K deficiency

No food --> no vit K intake
Abx --> get rid of bacteria --> no make Vit K


PT will usually be more elevated than PTT

53

Meds causing hyperkalemia

Beta blockers
ACE inhibitors, ARBs
Digitalis
Cyclosporine
Heparin
NSAIDs
Succinylcholine
TMP/SMX

54

Causing hypokalemia

Alkalosis
Insulin
Beta agonist

55

S/E TMP

Hyperkalemia

INhibit renal tubular Cr secretion (artificial increase in serum Cr)

56

Tx TCA overdose

Bicarb
- shortens QRS interval

TCA od usually has CNS depression, hypoTN, hyperthermia, and anticholinergic effects (dilated pupils, dry flushed skin, intestinal ileus)