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USMLE2 Surgery 4

Pre/Post Op

What is the fractional excretion of sodium (FENa)? What does it tell you? % of the sodium filtered by kidney which is excreted in the urine. Low --> Na retention --> non-kidney prob such as volume depletion or low output heart failure. Hi --> Na wasting due to acute tubular necrosis or other causes of intrinsic renal failure.
What is the formula for the fractional excretion of sodium (FENa)? (Na[ur] x Cr[pl])/(Na[pl] x Cr[ur]) x 100
Interpretation of FENa <1% - prerenal (hypovolemia), >1 ATN or kidney damage
dopamine - low dose D1 receptors - dilating blood vessels, increasing blood flow to renal, mesenteric, and coronary arteries; and increasing overall renal perfusion. Dopamine therefore has a diuretic effect.
dopamine - intermediate dose positive inotropic and chronotropic effect through increased β1 receptor activation. It is used in patients with shock or heart failure to increase cardiac output and blood pressure.
dopamine - high dose "pressor" dose. vasoconstriction, increases systemic vascular resistance, and increases blood pressure through α1 receptor activation; but can cause the vessels in the kidneys to constrict to the point where they will become non-functional
When is the cardiac risk for a non-cardiac operation too great? when EF is less than 35% (nl is 55%)
What is the worst finding that predicts high cardiac risk? What is the second worse? JVD, MI within the last 6 months
What to do if pre-op pt has elevated JVD? Tx with ACE inhibitors, beta-blockers, dig, and diuretics BEFORE surg.
Operative mortality within 3 months of an MI? Within 6 months? 40%, down to 6% after 6 months
what should be done if someone must go into surgery but had an MI in the last 6 months admit to ICU a day before to optimize cardiac variables
Pt needs noncardiac surg but is having severe progressive angina. What to do? eval for coronary revascularization before the other operation.
What is the most common cause of increased pulmonary risk in surg? smoking (compromised ventilation)
What should a smoker do before going into surgery? quit smoking 8 months before, intensive respiratory therapy
What is the risk of a peri-operative cardiac event if the Goldman's index is <5, <12, <25, >25? 1, 5, 11, 22% risk
Hepatic Risk - what is correlated with 40% mortality going into surgery? (bili, alb, PT, mental status) What if a pt has three of these variables? How about 4? bili >2 OR albumin <3 OR PT > 16 or encephalopathy. If have three --> 80% mortality. If 4 --> 100% mortality.
Hepatic Risk - what is correlated with 80% mortality going into surgery? (bili, alb, PT, mental status) bili >4 OR albumin <2 OR blood ammonia > 150
What points to severe nutritional depletion? What to do before surg? wt loss (by 20% in few months), alb <3, anergy to skin antigens, transferrin <200. 4 or 5 days preoperative nutritional support makes a big difference.
What is an absolute contraindiation to surgery? What must you have before taking the pt to surgery in this case? diabetic coma. Must have rehydration, return of UOP and at least partial correction of acidosis and hyperglycemia
anesthetics implicated in development of malignant hyperthermia halothane and succinyl choline
Tx of malignant hyperthermia in surgery. What must you watch for? IV dantrolene, 100% O2, correction of acidosis, and cooling blankets. Watch for development of myoglobinuria.
How to tx wound infection? If only cellulitis, then abx. If abscess, then open and drain. If you can't figure out which it is, use US.
Treatment of Aspiration PNA 1. BAL, 2. bronchoscopy (removal of acid and particulate matter), 3. broncho dilators, 4. respiratory support. NO steroids!
Tx of delerium tremens IV BZ's
ogilvie syndrome. What is it? How to dx? How to tx? elderly sedentery pts (Alzh, nursing hm) --> non-abd surg --> further immobilization post surg --> large abd, non tender, distension --> xrays show dilated colon. Colonoscopy to suck out gas, decompress colon, r/u colon CA. Leave long rectal tube in.
Post op pt with large amounts of salmon colored fluid soaking the dressings. What is it and what do you do? Wound dehiscence. Salmon fluid is peritoneal fluid. If not infected, tape it up and careful of pt moving or coughing.
What would cause a GI tract fistula not to heal on its own? FETIIID - forein body, epithelializaiton, tumor, infection, irradiated tissue, IBD, distal obstruction
Looking at Na level, how do you know how much water a pt has lost? Every 3 mEq/L above 140 represents 1L water lost
Created by: christinapham



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