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Perioperative Care
Surgery
| Question | Answer |
|---|---|
| 1. Worst finding predicting cardiac risk during surgery. 2. Second worst | 1. Jugular venous distention signifies CHF 2. MI within 6 months |
| First step in evaluating pulmonary risk in patient with COPD or history of smoking. | FEV1 |
| Therapy for ARDS | positive end-expiratory pressure |
| What is the likely cause in the following scenarios: 1. zero post-op urinary output 2. low post-op urinary output | 1. mechanical problem (kinked catheter) 2. fluid deficit (dehydration) or acute renal failure |
| How can you differentiate between dehydration and acute renal failure in the post-op setting. | 1. urinary Na is <10 or 20 in dehydrated patients and > 40 mEq/L in renal failure 2. fractional excretion of Na > 1 in renal disease and < 1 in dehydration |
| Absent bowel sounds, no passage of gas after abdominal surgery | Paralytic ieus |
| 1. Paralytic ileus that has not resolved afer 5 or 6 days. 2. How do you confirm diagnosis? | 1. adhesions leading to mechanical bowel obstruction (should also rule out hypokalemia) 2. X-ray may show dilated small bowel but CT is diagnostic |
| 1. What is Ogilvie syndrome 2. Who does it classically effect? | 1. paralytic ileus of the colon 2. elderly sedentery patients (Alzheimer, nursing home) who have become further immobilized owing to surgery elsewhere |
| What is the cause of hypernatremia post-operatively? | loss of water |
| Every 3 mEq/L that the serum sodium concentration is above __ represents __ L of water lost. | 1. 140 2. 1 L |
| What are some likely causes of mental status changes post operatively? | 1. hypoxia #1 gets blood gas 2. ARDS (commonly follows sepsis) 3. electrolyte imbalance (uremia, sodium, ammonium, glucose) 4. delerium tremens |
| What are some likely causes of post-op nausea and vomiting? | analgesia or anesthesia related; paralytic ileus |
| Most common cause of fever within 24 hours of surgery. How do you treat? | Atelectasis; deep breathing, coughing, postural drainage, incentive spirometry and ultimately bronchoscopy |
| Why are patient required to abstain from solids and liquids prior to surgery? | to decrease the risk of aspiration with intubation |
| How are the following medications handled for surgical patients: 1. aspirin 2. clopidogrel 3. warfarin 4. diuretics | 1. avoid for 10 days preoperatively 2. avoid for 7 days preop 3. avoid for 3 days preop and resume POD #2 4. hold morning of surgery |
| How are the following medications handled for surgical patients 1. β-blockers 2. antithyroid 3. thyroid replacement 4. oral hypoglycemics 5. insulin | 1. continue 2. hold morning of surgery 3. take morning of surgery 4. avoid on day of surgery 5. give half dose on day of surgery |
| Which lab can be evaluated for nutritional risk? | serum albumin below 3 indicated severe nutritional depletion |
| What is the cause of malignant hyperthermia? | anesthetics (halothane, succinylcholine) |
| What is the treatment of malignant hyperthermia? | IV dantrolene, 100% oxygen, cooling blankets, correction of the acidosis. Watch for development of myoglobinuria. |
| What are the 6 causes of post-op fever and the day they are seen? | 1. wind - atelectasis (1) 2. water - UTI (3) 3. walking - DVT (5) 4. wound (7) 5. where - abscess (10) 6. wonder drugs (10+) |
| Workup for possible pneumonia: | 1. chest x-ray 2. sputum cultures 3. Rx with appropriate antibiotics |
| Workup for possible UTI: | 1. urinalysis 2. urinary cultures 3. Rx with antibiotics |
| What is the DDx for chest pain post-operatively. How do you evaluate to distinguish the two? | 1. Myocardial infarction (usually first few post op days) and pulmonary embolism (usually 5+ PODs) 2. troponins (MI), blood gases then spiral CT angio (PE) |
| Patient with chest trauma on ventilation becomes more difficult to bag. BP steadilty declines and CVP rises. | Intraoperative tension pneumothorax - the positive pressure ventilation causes lung to burst at weakened site |
| Patient on POD #3 gets confusion, trembles and becomes combative. What might be the cause and what is the therapy? | 1. Delerium tremens from interruption of daily alcoholism 2. IV benzodiazepines or IV alcohol (rule out hypoxia/sepsis/electrolyte imbalance) |
| What is considered low urine output post-operatively? | less than 0.5 ml/kg/h in the presence of normal perfusing pressure |
| Fifth day post-op laparotomy, large amount of pink, salmon-colored fluid are noted to be soaking the dressing. | Wound dehiscence - wound is breaking open and peritoneal fluid is leaking out; should be taped secure and will need reoperation to avoid ventral hernia |
| Complication of wound dehiscence in which the skin opens up and the abdominal contents rush out. | Evisceration |
| How do is hypernatremia corrected: 1. rapidly developing hypernatremia 2. gradually developing hypernatremia | 1. D5 1/3NS (D5W technically works) 2. D5 1/2NS |
| What is the treatment for: 1. rapidly developing hyponatremia 2. slowly developing hyponatremia | 1. hypertonic saline (3 or 5%) or ringer lactate 2. water restriction |
| 1. Cause of post-op hyperkalemia? 2. immediate treatment 3. permanent treatment | 1. kidney failure, out of cells from acidosis or via blood transfusions 2. 50% dextrose + insulin + IV calcium 3. hemodialysis |
| What is the differential for hyperkalemia following trauma? | 1. dead tissue 2. renal failure |
| 1. Correction of metabolic acidosis 2. Correction of metabolic alkalosis | 1. sodium bicarbonate immediately corrects but underlying cause must be addressed 2. KCl |
| If patient has JVD, what needs to be done before they can be scheduled for surgery? | treat the congestive heart failure: ACE inhibitors, beta-blockers, digitalis and diuretics |
| How long should you wait for an operation if a patient has had a myocardial infarction? | 6 months |
| How do you preoperativeley evaluate the pulmonary risk of a current smoker or COPD patient? | 1. evaluate FEV1 with pulmonary function tests 2. if FEV1 is abnormal, perform blood gases to evaluate PCO2 |
| If patient is found to have decreased pulmonary function, what should be done prior to surgery? | smoking cessation for 8 weeks and intensive respiratory therapy (PT, expectorants, incentive spirometry, humidified air) |
| What levels of the following indicate hepatic risk during operation: 1. bilirubin 2. albumin 3. prothrombin | 1. above 2 2. below 3 3. above 16 |
| Management for a patient that has lost >20% of their body weight over the past 2 months in need of an operation. | 5-10 days of preoperative nutritional support via the gut |
| Fever early on after invasive procedure. | 1. Bacteremia or atelectasis - check WBC count and physical exam 2. then decide on blood cultures x 3 or CXR |
| What are the steps of management of a patient with post-operative fever | 1. Hx and Px 2. CXR 3. Look at wound and IV sites 4. Inquire about urinary tract symptoms |
| Most significant factor for MI intraoperatively. | hypovolemia |
| Treatment of aspiration? | removal of particulate matter with the help of bronchoscopy |
| What can prolong paralytic ileus? | hypokalemia |
| If a wound infection is present, how can you tell if it can be managed with antibiotics or needs surgery? | If pus is present, the wound is far advanced and patient needs surgery. If there is just redness early on in the post-op course, antibiotics can abort the process |
| Which kind of alkalosis does prolonged vomiting cause? | hypochloremic, hypokalemic, metabolic alkalosis |
| What is the most significant cardiac complication of spinal anesthesia? | hypotension as a result of the vasodilation caused by spinal anesthesia |
| How long should aspirin be discontinued prior to a procedure? NSAIDs? | 1. aspirin is irreversible and should be stopped 7-10 days prior to surgery 2. NSAIDs are reversible and should be stopped 2-5 days before surgery |
| 1. How much fluid is given to a patient post-operatively? 2. Why this much? | 1. 3 ml of isotonic fluid for every 1 ml of EBL 2. approximatel 2/3 of fluid administered to the patient leaves the intravascular space |
| What is the calculation for postoperative fluid requirement? | (EBL x 3mL isotonic fluid) + urine output - IV fluid given in the OR |
| What is normal urine output per hour? | 0.5-1 mL/kg/hr |
| What metabolic complication can occur from IV infusion of normal saline? | hyperchloremic acidosis |
| What is neurogenic shock? | disruption of sympathetic system resulting in unopposed vagal outflow and vasodilation |
| Which heart chamber do the following measure: 1. central venous pressure 2. Pulmonary capillary wedge pressure | 1. right atrium 2. left ventricle |
| What is the most severe post op problem of a patient taking glucocorticoids? | long-term glucocorticoid use can suppress the HPA axis. A stressful event, surgery can lead to acute adrenal insufficiency. |
| Initial treatment of DVT? | heparin |
| 1. POD#3 patient has redness and tenderness in middle of wound 2. What should be your next step? | 1. wound infection 2. debride any nonviable tissue |
| When are antibiotics appropriate for wound infections? | only if wound cellulitis appears to be spreading despite wound drainage |
| What process is most important for regaining strength in a wound? | collagen synthesis |
| What is a clean-contaminated wound? | an incision in which the GI, respiratory, or GU tract is entered but the tract is prepared both mechanically and antibacterially |
| What is a contaminated wound? | 1. there was gross spillage of the GI tract 2. GU or biliary tracts were entered in the presence of local infection 3. major break in aseptic technique |
| When can a contaminated wound be closed? | 1. could be left open, treated with saline-soaked gauze and closed once granulation tissue occurs 2. could also close by primary intention and monitor for infection |
| What value indicates hypovolemia: 1. BUN/Cr ratio 2. FeNa | 1. > 20 2. < 1% |
| What is an indication to give fresh frozen plasma in a bleeding patient? | thrombocytopenia (platelets < 50,000) |
| Which fluid replacement do you avoid if the patient is hyperkalemic? | Lactated Ringer |
| 1. Standard maintenance fluid 2. Fluids used to increase intravascular volume | 1. D5 1/2NS 2. Normal saline, lactated Ringer |
| How do you calculate daily fluid maintenance for an individual based on their weight? | 100/50/20 rule - 100 ml/kg for first 10kg - 50 ml/kg for next 10kg - 20 ml/kg for every kg over 20 |
| What do the blood gases of a PE reveal? | 1. hypoxemia 2. hypocapnea |
| What is the management of a GI fistula? | nature will heal the fistula so manage patient by electrolyte replacement, nutrition support, abdominal wall protectionq |
| What prevents a GI fistula from closing? | FETID mneumonic 1. Foreign body 2. Epithelialization 3. Tumor 4. Infection, inflammatory bowel dz 5. Distal obstruction |
Created by:
amichael@siumed.edu
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