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Flashcards in The Surgical Patient Deck (68)
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1

When is preOp echo concerning?

Evidence of AS
EF less than 35%

2

When is a stress test positive?

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

3

Mallampati Classification

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.

4

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

ECG

If normal, nothing more.

5

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

ECG

Consider stress test and echo

6

Contraindications to noncardiac surgery

EF less than 35%

7

Goldman Index

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

8

Which is more important? O2 or ventilation?

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

9

Risk factors for pulm complications

Smokers
COPD/Asthma
ILD (restrictive)

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

10

How do you reduce pulm risks preOp?

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

11

How do you reduce pulm complications after surgery?

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

12

What percentage of postOp deaths are due to pulm complications?

35%

13

PFTs that are concerning

FEV1 less than 70%

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

14

Child's Classification of risk

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)

15

Childs-Pugh and MELD

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%.

16

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

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

17

Which pulmonary complication has the highest morbidity and mortality?

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

18

How common are atelectasis and pneumonia as complications?

20-40% of all postop patients

19

PreOp Renal eval

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

20

How do you calculate Cr Clearance?

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

All that x plasma creatinine (mg/dL)

21

Dialysis patient mortality

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

22

Why is BUN and Cr so important?

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

23

Mortality when NH3 > 150

80%

24

Mortality when INR > 2

40-60%

25

At what BUN level does bleeding risk go up?

BUN>100 due to platelet dysfunction

Correct with desmopressin (DDAVP)

26

What is the most common complication of dialysis?

HyperK (33% of patients)

27

How do you determine source of renal problem?

FENa > 1 = intrinsic renal damage

Specific gravity = 1.010 = ATN

UNa less than 20 in prerenal

28

PreOp heme labs

CBC
Type and cross

29

Anemia PreOp

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

30

Platelet levels and periop bleeding risks

>150 = good
100-150 = unlikely
50-100 = unlikely with good hemostasis

20-50 = possible excess surg bleeding

10-20 = spontaneous mucosal and cutaneous bleeding