T H E S U R G I C A L P A T I E N T

Question 1

2 anti-hypertensives to hold day of surgery

Answer 1

Diuretics, possibly ace inhibitors. This is because they can cause dangerous hypovolemia and/or hypotension.

Question 2

Most common drug allergy

Answer 2

Antibiotics

Question 3

Describe ASA Physical Status Classification System

Answer 3

Classifies patient’s preoperative physical status, but is NOT predictive of anesthetic risk. It does NOT depend on the surgery planned.

Question 4

ASA P1

Answer 4

Normal, healthy patient.

Question 5

ASA P2

Answer 5

Pt with mild systemic disease

Question 6

ASA P3

Answer 6

Patient with severe systemic disease

Question 7

ASA P4

Answer 7

Pt wit severe systemic disease – constant threat to life

Question 8

ASA P5

Answer 8

Moribund pt not expected to survive without operation

Question 9

ASA P6

Answer 9

Declared brain-dead pt whose organs are being removed for donor purposes

Question 10

ASA E

Answer 10

Indicates emergency surgery; designation is used in addition to P codes

Question 11

Describe Mallampari classification system and the proper positioning of pt when tested.

Answer 11

Predicts difficulty of intubation and is tested with pt in sitting position, head held in neutral position, mouth wide open, and tongue protruding to maximum.

Question 12

Mallampari class I

Answer 12

Visualization of soft palate, faces, uvula, anterior and posterior tonsillar pillars

Question 13

Mallampari class II

Answer 13

visualization of soft palate, faces, uvula.

Question 14

Mallampari class III

Answer 14

visualization of soft palate, bass of uvula.

Question 15

Mallampari Class IV

Answer 15

Non-visualization of soft palate

Question 16

For cardiac risk assessment in a pt >35 y.o. with no history of heart disease, what needs to be obtained prior to surgery?

Answer 16

ECG

Question 17

When is a stress test positive?

Answer 17

Stress test is positive if ST depression > 0.2 mV or if inadequate response of HR to stress or hypotension.

Question 18

When is an ECHO concerning?

Answer 18

Evidence of aortic stenosis or ejection fraction < 35%.

Question 19

If pt requires CABG prior to GI surgery, how long should you wait between?

Answer 19

30 days.

Question 20

Characteristics of peri-operative MI

Answer 20

Mortality rate is approximately 25%.
Generally happen within 3 days of surgery and are often asymptomatic. They are associated with intraoperative HTN or hypotension or tachycardia.

Question 21

Which form of valvular disease is the only type found to affect mortality in surgery?

Answer 21

Aortic –when area of orifice is 50 mmHg. You should assess valvular function with an echo before surgery as the pt may need valve replacement first.

Question 22

Endocarditis ppx for patients with MVP or prosthetic valves

Answer 22

30 min prior to incision: ampicillin + gentamicin (or vanco + genta, if PCN allergic)
6 hours post-incision: amoxicillin or 2nd dose of amp + gentamicin

Question 23

Characteristics of aortic stenosis

Answer 23

Harsh murmur @ right second intercostal space, radiates to carotids.
Presents with angina, dyspnea on exertion, syncope.

Question 24

2 conditions that put you at moderate risk for endocarditis

Answer 24

Hypertrophic cardiomyopathy, MVP

Question 25

2 conditions that put you at high risk for endocarditis

Answer 25

Prosthetic valve, congenital anomalies such as Tetralogy of fallot

Question 26

3 arrhythmias that have much higher mortality risk during surgery

Answer 26

SVT, A fib, A flutter

Question 27

Pt should have a preop CXR if greater than what age?

Answer 27

40

Question 28

Name 2 instances in which you should obtain pre-op spirometry and ABG

Answer 28

If pt has risk factors for pulmonary complications or will be undergoing upper abdominal surgery (major abdominal surgery decreases vital capacity by 50% and FRC by 30%)

Question 29

Management if operation must occur during acute asthma exacerbation

Answer 29

Give 2x usual PO dose of steroids or 1 mg/kg methylprednisone preop, then every 6 hrs.

Question 30

Procedures that are high risk for DVT/PE (3)

Answer 30

Orthopedic, pelvic, abdominal CA surgeries. In general, long duration of surgeries put you at higher risk.

Question 31

How do SCDs work to prevent DVTs?

Answer 31

Sequential compression devices stimulate endothelial cell fibrinolytic activity. Also, 1 SCD should work as well as 2 if 1 leg is injured.

Question 32

4 defining concepts of ARDS

Answer 32

Acute lung injury.
Bilateral infiltrates; normal tissue interspersed with diseased tissue.
PaO2/FiO2 < 200
PCWP < 19; no CHF.

Question 33

Mgmt. of ARDS

Answer 33

Positive end expiration pressure trial. Pressure limited ventilation.
Permissive hypercapnia. Keep pt in prone position.

Question 34

Mgmt of pulmonary edema

Answer 34

O2, upright position, furosemide, swan-ganz catheter (possibly)

Question 35

Mgmt of fat embolism

Answer 35

Immobilize (splint) fx and consider corticosteroids.

Question 36

Which pulmonary complication has the highest morbidity and mortality?

Answer 36

Pneumonia

Question 37

What complication do some diabetics face during intubation?

Answer 37

Pts with autonomic neuropathy will be more likely to have gastroparesis, therefore being more likely/susceptible to aspiration during intubation.

Question 38

Which oral hypoglycemic should be stopped 2-3 days prior to surgery?

Answer 38

Chlorpropamide –it is a long-acting sulfonylurea. Others can be continued until morning of sx.

Question 39

How to estimate preop creatinine clearance

Answer 39

[(140-age) x wt]/72 x creatinine

Question 40

4 risk factors for development of acute renal failure

Answer 40

renal ischemia
exposure to nephrotoxins such as contrast dye
sepsis
CHF

Question 41

3 ways to determine source of renal problem

Answer 41

FeNa > 1 = intrinsic
Specific gravity = 1.010 in ATN
UNa < 10 in pre-renal

Question 42

Order of organs in return of bowel function

Answer 42

Sm intestine – > stomach – > colon

Question 43

How can we estimate when bowel function return will occur?

Answer 43

Allow 1 post-op day per decade for major abode surgery

Question 44

2nd line for tx of C dif

Answer 44

vanco

Question 45

3 types of pets that will not tolerate anemia well

Answer 45

Chronic hypoxia
Ischemic heart disease
Cerebral ischemia

Question 46

How much does 1 unit of platelets increase platelet count by?

Answer 46

5,000-10,0000.

Question 47

How much will PT decrease when warfarin is withheld?

Answer 47

PT will decrease by 2 sec/day when warfarin is withheld.

Question 48

3 options for pts on warfarin pre-op

Answer 48

Avoid 3 days prior to sx and resume POD#2.
Admit preop and change to heparin which can be held a couple hours ahead of time.
Change to LMWH (SQ).

Question 49

Mgmt of thyroid medications prior to surgery.

Answer 49

Anti-thyroid medications should be held the morning of sx. Thyroid replacement rx should be administered the morning of.
Note: half life of thyroxine is 7 days; therefore, can be held for several post op days without much effect.

Question 50

Abx prophylaxis given for general surgery

Answer 50

Cefazolin

Question 51

Abx prophylaxis given in colorectal and appendectomies

Answer 51

Cefoxitin or cefotetan

Question 52

Abx prophylaxis given in urological procedures

Answer 52

Ciprofloxacin

Question 53

Abx prophylaxis given in head and neck procedures:

Answer 53

Cefazolin OR clindamycin + gentamicin