The Surgical Patient

Question 1

When is preOp echo concerning?

Answer 1

Evidence of AS

EF less than 35%

Question 2

When is a stress test positive?

Answer 2

ST depressions > 0.2mV or inadequate response of HR to stress or hypotension

Question 3

Mallampati Classification

Answer 3

Predicts difficulty of intubation.

Pt is seated with head in neutral position and mouth wide open with tongue out to the max.

Class 1 - 4. 4 = can’t visualize soft palate.

Question 4

Cardiac risk assessment: Patient less than 35 with no cardiac history

Answer 4

ECG

If normal, nothing more.

Question 5

Cardiac risk assessment: Pt any age with cardiac history or for patient who is older

Answer 5

ECG

Consider stress test and echo

Question 6

Contraindications to noncardiac surgery

Answer 6

EF less than 35%

Question 7

Goldman Index

Answer 7

Tool for cardiac risk assessment. More points = higher risk.

0-5 = class 1 = 1% risk of life threatening complications

6-12 = 5%
13-25 = 11%
25+ = 22%

S3 or JVD (marker of low EF) = 11

MI within 6m = 10
>5 PVCs/min = 7
Rhythm other than sinus = 7
Age > 70 = 5
Emergency = 4
Intrathoracic, intraperitoneal, aortic surgery = 3
AS = 3
Poor general med condition = 3

Question 8

Which is more important? O2 or ventilation?

Answer 8

Ventilation. We will be make them acidotic during surgery so we care about their ability to blow off CO2

Question 9

Risk factors for pulm complications

Answer 9

Smokers
COPD/Asthma
ILD (restrictive)

Abnormal PFTs (FEV 60
Obesity
Upper abdominal or thoracic surgery
Long OR time

Question 10

How do you reduce pulm risks preOp?

Answer 10

QUIT SMOKING. 8w before surgery (initially when you quit, bronchial secretions actually increase and ventilation gets worse)

Optimize bronchodilator therapy

ABG near day of surgery - High CO2 or low O2 are poor indicators

Question 11

How do you reduce pulm complications after surgery?

Answer 11

IS
Early ambulation
Chest PT
DVT prophylaxis by SCD or SubQ Hep

Question 12

What percentage of postOp deaths are due to pulm complications?

Answer 12

35%

Question 13

PFTs that are concerning

Answer 13

FEV1 less than 70%

VO2 more than 20 - that patient is less likely to have pulm complications

Question 14

Child’s Classification of risk

Answer 14

Liver variables.

A = 2% op mortality 
B = 10%
C = 50%

Ascites (none, controlled, uncontrolled) - look for pancreatitis

Total Bili (less than 2, 2-3, >3)

Encephalopathy (none, min, adv)

Nutrition (exc, good, poor)

Albumin (more than 3.5, 3-3.5, less)

Question 15

Childs-Pugh and MELD

Answer 15

CP for cirrhosis. MELD for liver transplants.

Tx for elevated scores = transplant.

Pugh adds PT/PTT elevations (check for Warfarin). If Albumin, PT/PTT, Bili, Ascites, or Encephalopathy is present then 40% risk. If all are there, 100%.

Question 16

How do you provide DVT prophylaxis in someone with an injured leg?

Answer 16

One SCD works just as well as Two (they work by helping to release tPA)

Question 17

Which pulmonary complication has the highest morbidity and mortality?

Answer 17

Pneumonia. Mortality in elderly patients with postop pneumonia is 50%

Question 18

How common are atelectasis and pneumonia as complications?

Answer 18

20-40% of all postop patients

Question 19

PreOp Renal eval

Answer 19

Check BUN and Cr
Estimate Cr clearance
Maintain intravascular volume
Ensure lytes are repleted; correct acidosis
Dialysis patients should be dialyzed within 24hrs of surg

Question 20

How do you calculate Cr Clearance?

Answer 20

[(140-age) x Ideal body weight in kg] / 72

All that x plasma creatinine (mg/dL)

Question 21

Dialysis patient mortality

Answer 21

Overall for dialysis dependent patients = 5% regardless of when dialysis was last given

ARF that requires dialysis perioperatively = 50-80%

Morbidity = shunt thrombosis, wound infection, hemorrhage, pneumonia

Question 22

Why is BUN and Cr so important?

Answer 22

High BUN and Cr indicates loss of at least 75% of renal reserve. Intra and postop hypotension MUST be avoided

Question 23

Mortality when NH3 > 150

Answer 23

80%

Question 24

Mortality when INR > 2

Answer 24

40-60%

Question 25

At what BUN level does bleeding risk go up?

Answer 25

BUN>100 due to platelet dysfunction Correct with desmopressin (DDAVP)

Question 26

What is the most common complication of dialysis?

Answer 26

HyperK (33% of patients)

Question 27

How do you determine source of renal problem?

Answer 27

FENa > 1 = intrinsic renal damage Specific gravity = 1.010 = ATN UNa less than 20 in prerenal

Question 28

PreOp heme labs

Answer 28

CBC | Type and cross

Question 29

Anemia PreOp

Answer 29

Find the cause Postpone elective procedures whenever possible. Patients who will not tolerate anemia are those with chronic hypoxia, ischemic heart disease, or cerebral ischemia Sickle-Cell patients have higher risk of vaso-occlusive crises with operations (not sickle cell trait patients tho) Minimize risk by maintaining euvolemia

Question 30

Platelet levels and periop bleeding risks

Answer 30

``` >150 = good 100-150 = unlikely 50-100 = unlikely with good hemostasis ``` 20-50 = possible excess surg bleeding 10-20 = spontaneous mucosal and cutaneous bleeding

Question 31

Finding a PreOp coagulopathy

Answer 31

Factor issues should be addressed first (ex hemophilia) Expect higher PT/PTT in liver patients

Question 32

Poor prognostic signs during nutritional assessment

Answer 32

Lost 20% of body weight in 3 months (even 10% over 6 months). Albumin IV. 10days > 5 days.

Question 33

At what body weights do risks go up?

Answer 33

12% over IBW | Recent change of 10% BW

Question 34

Antibiotic prophylaxis in general

Answer 34

Single dose 30m prior to incision and again 6h later if operation is ongoing. Cefazolin

Question 35

Abx ppx for colorectal/appi

Answer 35

Cefoxitin or Cefotetan

Question 36

Abx ppx for urologic procedures

Answer 36

Cipro

Question 37

Abx ppx for head and neck procedures

Answer 37

Cefazolin or Clinda+Genta

Question 38

Metabolic contraindication to surgery

Answer 38

DKA - look for high gluc and low volume Give IVF and insulin Any form of acidosis should be fixed prior to surgery unless the surgery IS the fix

Question 39

5Ws of Postop fever

Answer 39

``` Wonder Drugs Wind Water Walking Wound ```

Question 40

Fever during surgery

Answer 40

Malignant hyperthermia (response to anesthesia) Give O2 Dantrolene Cool IVFs ppx = FHx

Question 41

Fever right after surgery

Answer 41

Bacteremia ``` Dx = BCx Tx = Vanc/Zosyn PPx= sterility ```

Question 42

Fever POD1

Answer 42

Atelectasis Dx=CXR Tx= - PPx = IS and out of bed

Question 43

Fever POD2

Answer 43

Pneumonia Dx=CXR Tx = Vanc/Zosyn ppx = IS and out of bed

Question 44

Fever POD3

Answer 44

UTI ``` Dx = UA/UCx. UA shows WBCs, if casts it's pyelo (kidney infx before surg) Tx = abx ``` ppx = remove foley

Question 45

Fever POD5

Answer 45

DVT/PE ``` Dx= US b/l LE Tx = Heparin, bridge to Warf ``` ppx = Heparin

Question 46

Fever POD7

Answer 46

Wound infection ``` Dx = U/S negative Tx = Abx ``` ppx = sterile and clean

Question 47

Fever POD10

Answer 47

Wound abscess ``` Dx = U/S positive Tx = Abx, I/D (culture to pick the abx) ``` ppx = sterile and clean

Question 48

Post Op Chest pain

Answer 48

Get EKG, Trops, U/S LE, CTA, ABG If point to MI - PCI (stent) or Heparin. DONT give tPA bc they'll die. If point to PE - heparin to warfarin bridge. IVC filter for a repeat offender who is on warfarin already.

Question 49

Post Op AMS in a patient who has tumultuous ICU course with white out on CXR

Answer 49

This is ARDS. Tx = PEEP in ICU for this non-cardiogenic pulm edema

Question 50

Post Op AMS in patient with low SpO2

Answer 50

This is hypoxia Give O2 (88-92% goal for COPD, 94+ for everyone else)

Question 51

Post Op AMS 48-72h into stay

Answer 51

Think DT - HTN, tachy, tremor Tx = benzo

Question 52

Post Op AMS with abnormal BMP

Answer 52

Replete lytes - usually Na and Ca

Question 53

Normal urine output

Answer 53

0.5cc/kg/hr

Question 54

Post Op low UO in patient with an urge to void

Answer 54

Obstruction Do and in-and-out cath. Try to avoid the Foley unless this keeps happening

Question 55

Post Op low UO in patient without an urge to void

Answer 55

Renal Failure? No output? Kinked Foley - unkink it or flush it Some output? Do 500cc NS challenge. If this increases UO then patient was volume down. Give IVFs. If this does nothing then there is intrinsic renal disease.

Question 56

Post Op abdominal distension ddx

Answer 56

Paralytic ileus vs obstruction vs Oglivie's

Question 57

Paralytic ileus

Answer 57

Incidence after GI surg = 5% In general, await return of bowel function before advancing diets This is a metabolic derangement. Day 1 will pass no gas and no stool. This is almost EXPECTED. Dx = KUB. Look for big distended small bowel connecting to large distended large bowl. This is OK as long as everything is distended! Tx = moving and eating, potassium

Question 58

Obstruction postop

Answer 58

Usually from adhesions or hernias Look for an ileus continuing to day 5. Dx = KUB. Distal to block bowel is thin and compressed. Proximal to block it is distended. If it is in large bowel, the small bowel will look normal (ileocecal valve prevents air from flowing back) Tx = surgical emergency ESP if there are peritoneal signs

Question 59

Oglivie's

Answer 59

This is a distractor Ileus of large bowel postop in the elderly. Dx = KUB Normal small bowel, big distended colon that takes up entire colon. No obstruction. Tx = decompress with rectal tube (get air out). Colonoscopy - could be malignancy

Question 60

Wound dehisense

Answer 60

Failure of fascia only Leads to hernia Serosanguinous drainage (pink) on dressing in morning ``` Dx = clinical Tx = Bind them. Limit straining. Elective surg to correct hernia. ```

Question 61

Wound eviceration

Answer 61

Failure of whole wound Loops of bowel exposed to outside ``` Dx = clinical Tx = warm saline dressings. Strict bed rest. Go to OR NOW. NEVER PUSH IT BACK IN. ```

Question 62

PostOp fistulas

Answer 62

Epithelialized tract btw 2 structures. Think FETID ``` Foreign body Epithelialization Tumor Irradiation/inflammation/IBD Distal obstruction ``` Cut it out with LIFT procedure

Question 63

Order of return of bowel function after surgery

Answer 63

Small intestine then stomach then colon

Question 64

Risks for C.Dif

Answer 64

``` Age Nursing home Renal failure Immunocompromised ABx (cefoxitin) Small or Large bowel obstruction GI surgery NG tube > 48h ``` Tx = PO metro or vanc

Question 65

Well's criteria for PE

Answer 65

6 = high Clinical signs and symptoms of DVT (measured calf swelling and positive homan) = 3 Alt dx less likely than PE = 3 HR > 100 = 1.5 Immobilization or surg in past 4w = 1.5 Previous DVT/PE = 1.5 Hemoptysis = 1 Malignancy (on tx, treated in past 6m or palliative care) = 1

Question 66

How do you estimate when bowel function will return?

Answer 66

Allow 1 postop day per decade for major abdominal surgery

Question 67

PreOp patient instructions regarding meds

Answer 67

Aspirin - hold for 10 days (allows platelets to regenerate) Plavix - hold for 7 days (unless they have drug-eluting stent - holding here may cause MI) Warfarin - avoid 3 days prior and resume POD2. Admit preop and change to heparin which is then held a couple hrs ahead of surg. OR operate through warfarin BP meds - continue. ESP B blockers. Hold diuretics the morning of surgery AntiThyroid - hold on morning of Thyroid replacement - give on morning of (Thyroxine half life is a week so it can be held with no real effects) Oral hypoglycemics - avoid on day of Insulin - give half usual dose on morning of

Question 68

PreOp bowel prep

Answer 68

To clear bowel of stool and reduce bacteria count and risk of fecal spillage during GI surg This is a source of fluid loss so some patients may require IVF if they don't tolerate this well