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Perioperative Care

Surgery

QuestionAnswer
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