Pre And Postop Surgery

Front 1

What are the criteria in Goldman's index of cardiac risk? x8 What is the descending order?

Back 1

i)JVD (evidence of CHF)> ii)recent MI > iii)PVCs or rhythm other than sinus > iv)age>70 > v)emergency surgery > vi)aortic valvular stenosis, poor medical condition, or surgery w/in chest or ab

Front 2

What EF poses cardiac risk for noncardiac operations? What is incidence of periop MI and mortality?

Back 2

i)<35% ii)75-85% iii)55-90%

Front 3

What is worse predictive high cardiac risk pre-op?What should you treat JVD with prior to surgery if possible?

Back 3

i)JVD ii)a)Ca channel blocker b)B blocker c)Dig d)diuretics

Front 4

What is the 2nd worse cardiac risk factor pre-op? What is the best course of action? What should you do if you must do surgery asap?

Back 4

i)recent subendocardial or transmural MI ii)to wait 6 months b/c mortality drops iii)Admit to ICU the day before to optimize cardiac variables

Front 5

If pt has severe progressive angina and needs noncardiac surgery, what should you do?

Back 5

evaluate for possible coronary revascularization before other operation

Front 6

What is the most common cause of increased pulm risk pre-op? What is the problem? What should cause you to evaluate for pulm risk? What should you do in the eval? x2 What is management prior to surgery? x2

Back 6

i)smoking ii)compromised ventilation (high PCO2, low FEV1) and not compromised oxygenation iii)smoking hx or presence of COPD iv)a)start w/FEV1 b)if abnormal, follow ABG v)stop smoking for 8 weeks; intensive respiratory therapy (physical therapy, expectorants, incentive spirometry, humidified air)

Front 7

What are predictors of mortality in hepatic risk pre-op? x4

Back 7

i)bilirubin ii)serum albumin iii)prothrombin time iv)encephalopathy

Front 8

What are criteria of severe nutritional depletion? x4

Back 8

i)loss of 20% of body weight over couple of months ii)serum albumin <3 iii)anergy to skin antigens or iv)serum transferrin level <200mg/dL (or combo)

Front 9

How much time of preop nutritional support do you need to make a big diff in decreasing mortality/morbidity? What is optimal time?

Back 9

i)4-5 days, preferably via gut ii)7-10 days is optimal if can defer surgery

Front 10

What metabolic condition is an absolute contraindication to surgery? How do you treat before surgery? x4 Why would complete restoration fo allt he variables be impossible?

Back 10

i)diabetic coma ii)a)rehydration b)return of UOP c)partial correction of acidosis d)partial correction of hyperglycemia. iii)if indication for surgery is septic process

Front 11

What are causes of postop fever besides 5 W's? x3

Back 11

i)malignant hyperthermia ii)bacteremia due to invasive procedure iii)deep thrombophlebitis

Front 12

What is time course of malignant hyperthermia? what kind of temp? What other things occur? x2 How to treat? x4 What do you watch for?

Back 12

i)after onset of anesthesia ii)>104F iii)a)metabolic acidosis b)hypercalcemia iv)a)IV dantrolene b)100% O2 c)correction of acidosis d)cooling blankets v)watch for myoglobinuria

Front 13

When does bacteremia occur in postop fever? What is it due to? What temperature occurs? How to manage? x2

Back 13

i)w/in 30-45 min ii)invasive procedures (ie: instrumentation of urinary tract) iii)temp up to or >104 iv)a)BCx x3 b)start empiric Abx

Front 14

What are the most common causes of postop fever (101-103) and what is the order sequentially?

Back 14

i)atelectasis ii)pneumonia iii)UTI iv)DVT v)wound infection vi)abscess

Front 15

When does atelectasis occur? what is management? x4 What is ultimate therapy if needed?

Back 15

i)1st POD ii)a)r/o other causes (5W's) b)listen to lungs c)do CXR d)improve ventilation (deep breathing and coughing, postural drainage, incentive spirometry) iii)bronchoscopy

Front 16

When does pneumonia occur? What is management? x2

Back 16

i)after 3 days if atelectasis doesn't resolve ii)a)sputum cultures b)treat w/Abx

Front 17

When does UTI produce fever? What is work up? x2 What is treatment?

Back 17

i)POD 3 ii)a)U/A b)urine cultures iii)treat w/Abx

Front 18

When does DVT occur? What is best diagnostic modality? What to do?

Back 18

i)POD 5 ii)doppler studies of deep leg and pelvic veins iii)anticoagulate w/heparin

Front 19

When does wound infection cause fever? What does PE show? x3 What to do if cellulitis? If abscess? What to use if can't distinguish b/w cellulitis vs abscess

Back 19

i)POD 7 ii)a)erythema b)warmth c)tenderness iii)Abx if cellulitis iv)open and drainage if abscess present v)sonogram

Front 20

When does deep abscess cause fever? What is diagnostic? What is therapeutic?

Back 20

i)POD 10-15 ii)CT scan of appropriate body cavity iii)percutaneous IR drainage

Front 21

What are 2 causes of chest pain postop? When do they occur?

Back 21

i)perioperative MI, occuring during operation 2/2 to hypotension. Postop MI: 2-3 days postop w/CP in only 1/3 of cases ii)PE: POD 7 in elderly, immobilized patients

Front 22

How do you detect periop MI and what are its signs? What is most reliable diagnostic test? How is mortality compared with MI not ass'd w/surgery? What is treatment directed at? What cannot be used in perioperative setting?

Back 22

i)EKG: ST depression; T wave flattening ii) troponins iii)much worse iv)directed at complications v)clot busters

Front 23

What is signs of PE?x4 What do ABGs show? What are 2 tests for diagnosis, and what is gold standard? What do you start treatment with? What do you do if PE recurs while anticoagulated

Back 23

i)a)anxious b)diaphoretic c)tachycardic d)prominent distended veins in neck and forehead (low CVP r/o dx) ii)a)hypoxemia and hypocapnia (if not, then not PE) iii)a)V-Q and b)spiral CT iv)pulm angiogram v)heparinization vi)add IVC filter

Front 24

What are 2 other pulm complications post op besides PE, pneumonia, atelectasis? What situations do they occur in?

Back 24

i)aspiration: hazard in awake intubations in combative pts w/full stomach ii)intraoperative tension pneumothorax: develops in pts w/weakened or traumatized lungs (chronic TB, recent blunt trauma w/punctures by broken ribs) once they are subjected to positive pressure breathing

Front 25

What are the 3 outcomes if aspirate postop? How can you prevent this? What is therapy? x3. What doesn't help?

Back 25

i)a)lethal right away b)get chemical injury and get pulm failure c)get pneumonia ii)Night before induction, NPO and take antacids iii)a)lavage and removal of acid and particulate matter (w/help of bronchoscopy) b)bronchodilators c)resp support iv)steroids

Front 26

What is sign of intraop tension pneumo?x3 How do you trea if still open abdomen? If not open?

Back 26

i)a)increasingly difficult to bag b)BP declines c)CVP steadily rises ii)quick decompression via diaphragm iii)needle thru ant chest wall into pleural space. Place chest tube later

Front 27

What is first thing to suspect when post-op pt gets confused and disoriented? What can it be 2/2 to? What should you do? x2

Back 27

i)hypoxia ii)sepsis iii)a)check ABG b)respiratory support

Front 28

What is precipitating event in ARDS? What type of pts get it? What is signs? x2 What is main part of therapy? What else should you do?

Back 28

i)sepsis ii)pt w/bad postop course iii)a)b/l pulm infiltrates and hypoxia b)no evidence of CHF iv)PEEP, but allow hypercarbia to avoid barotrauma v)source of sepsis sought and corrected

Front 29

When do DTs present postop? What is the scenario? What are symptoms?x3 What do surgeons treat it with, what do psych treat with?

Back 29

i)POD 2-3 ii)alcoholic whose drinking is interuppted by surgery iii)a)confusion b)hallucinations c)become combative iv)a)IV EtOH b)drugs

Front 30

What is scenario of hyponatremia developing in postop patient? What are symptoms? x3 What does chart review show? x3 How to prevent? What to treat w/? x2

Back 30

i)too much Na-free IVF (D5W) w/high ADH levels (response to trauma) ii)a)confusion, b)convulsion c)coma and death iii)a)large fluid intake b)quick wt gain c)rapidly lowering Na concentration (w/in hours) iv)include Na in IVF v)a)small amts of hypertonic saline b)add osmotic diuretics

Front 31

What are some causes surgically that can cause hypernatremia?x2 What will the labs show? x3 What is treatment?

Back 31

i)a)post pit damage w/unrecognized DI b)unrecognized osmotic diuresis ii)a)large, unreplaced urinary output b)rapid wt loss c)rapidly rising serum Na concentration iii)rapid replacement of fluid deficit, but cushion impact on tonicity w/D51/2NS instead of D5W

Front 32

What is a common source of coma in cirrhotic patient w/bleeding esophageal varices who undergoes portocaval shunt

Back 32

ammonium intoxication

Front 33

what is common after surgery in lower abdomen, pelvis, perineum, or groin? What is the main symptom? How is this managed? What is indicated at 2nd consecutive catheterization?

Back 33

i)post op urinary retention ii)urge to pee but can't iii)In and out bladder catheterization done at 6 hrs post-op if no spontaneous voiding occurred iv)indwelling (foley) catheter indicated at 2nd consecutive catheterization

Front 34

What is cause of zero urinary output?

Back 34

Due to mechanical, not biological reason: plugged or kinked catheter

Front 35

What does low urinary output not due to shock due to? x2 How do you diagnose cheaply b/w those 2 causes? What is another way of diagnosing that is more elegant? What is the most elegant way to dx?

Back 35

i)a)fluid deficit(dehydrated) b)ARF ii)bolus 500 mL over 10-20 min: renal failure won't make more pee iii)measure urine Na: less than 10-20 in dehydrated, >40 in ARF iv)FeNA (>1 in ARF)

Front 36

What are the 3 main causes in postop abdominal distension? when do they occur?

Back 36

i)paralytic ileus: 1st few days postop ii)early mechanical bowel obstruction 2/2 to adhesions: assumed if paralytic ileus doesn't resolve after 1 week iii)Ogilvie syndrome: elderly sedentery pts after surgery besides the abdomen

Front 37

What is signs of paralytic ileus?x2 What is symptom? How is it prolonged?

Back 37

i)a)no passing gas b)no bowel sounds ii)abdominal distension but no pain iii)hypokalemia

Front 38

What are signs of obstruction on X ray? How to Diagnose? (describe test) When do you need reoperation?

Back 38

i)Xray: dilated loops of small bowel and air-fluid levels ii)barium tag: ounce of barium given by mouth (or NGT) and followed w/serial X rays iii)If barium hangs somewhere w/o advancing further

Front 39

What is symptom of ogilvie? what does x-ray show? How to treat? x3 What to do if cecum about to blow up?

Back 39

i)abdominal distension (tense but not tender) ii)massively dilated colon iii)a)colonoscopy to suck out gas b)decompress colon c)r/o mechanical cause of problem (it is the age group getting cancer) d)leave long rectal tube in iv)cecostomy or colostomy

Front 40

What is sign of wound dehiscence? What should be done? x3 What else needs to be done surgically?

Back 40

i)wound intact but lots of salmon colored fluid soaks the dressing (peritoneal fluid) ii)a)wound taped securely b)abdomen bound c)mobilization and coughing done w/care iii)reoperation for ventral hernia (not emergency)

Front 41

What are the postop wound problems that can occur?x4

Back 41

i)wound dehiscence ii)evisceration iii)wound infection iv)fistula of GIT

Front 42

What is evisceration? when does it typically happen? x3 How to treat? x3

Back 42

i)after wound dehiscence, skin opens and abdominal contents rush out ii)after a)cough b)strains c)gets out of bed iii)a)keep pt in bed b)bowel covered w/large sterile dressings soaked w/warm saline c)emergency abdominal closure

Front 43

What are the 3 potential problems if fistulas of GIT drain freely (afebrile, no sign of peritoneal irritation)? How are these problems related to location in terms of how much fluid comes out? ≈

Back 43

i)a)fluid and electrolyte loss b)nutritional depletion c)erosion and digestion of belly wall. ii)a)distal colon: nonexistent b)manageable in low volume high in GI tract (up to upper jejunum) c)very bad in fistulas that have high volume high in GIT

Front 44

What is management of fistula? What causes fistula to not heal? x7

Back 44

iii)a)fluid/electrolyte replacement b)nutritional support (preferably elemental diets delivered beyond fistula) c)compulsive protection of abdominal wall (suction tubes, ostomy bags) until fistula heals iv)FETID: foreign body; epithelialization, tumor, infection/irradiated tissue/IBD; distal obstruction

Front 45

How much change in serum Na above 140 equals 1 L lost? If hypernatremia occurs slowly (several days), then what is clinical manifestation? What is therapy for this? Hypernatremia that occurs rapidly (osmotic diuresis or DI) produces what symptoms? How to treat?

Back 45

i)3 meq ii)brain adapted, so just signs of volume loss iii)D51/2NS: needs to correct vol quickly w/only nudge for the tonicity iv)CNS symptoms v)correction can be done w/dilute fluids D51/3NS or D5W

Front 46

What are the 2 scenarios for hyponatremia in surgery? what is therapy for rapidly developing hyponatremia (water intox)? Slowly developing hypoNa? hypovolemic dehydrated patients?

Back 46

i)a)normovolemic that retains water b/c of IADH (postop water intox or SIADH) b)pt losing isotonic fluids (GIT) forced to retain water if he hasn't gotten appropriate fluids ii)get CNS symptoms (brain hasn't adapted), and need hypertonic saline (3-5%) iii)slowly developing due to IADH: brain adapted and should water restrict iv)vol restoration w/isotonic fluids: safely unloads excess water and corrects hypovolemia

Front 47

What are the scenarios for hypokalemia developing slowly? x2 What is most common rapidly developing hypokalemia? How to treat (safe speed limit?)

Back 47

i)a)K lost from GIT (GI fluids have lots of K) b)urine loss (loop diuretic or too much aldo) ii)DKA (K moves into cells) iii)10meq/h of K

Front 48

what are 2 scenarios of hyperkalemia occuring slowly? x2 Rapidly?x3 What is therapy ultimately? What is therapy to help? x3

Back 48

i)kidney can't excrete: a)renal failure b)aldo antag ii)dumped from cells into blood: a)crushing injuries b)dead tissues c)acidosis iii)hemodialysis iv)a)push K into cells (insulin) b)suck out of GIT (resin, NGT) c)neutralize the membrane w/Ca

Front 49

What are groups of causes of metabolic acidosis and examples? x3 What are the pH, HCO3 and base statuses in met acidosis? When do you get anion gap and when don't you? When do you give HCO3 for treatment? What happens in long standing acidosis that must be corrected?

Back 49

i)a)excessive production of fixed acids (DKA, lactic, low-flow states) b)loss of buffers (lose HCO3 from GIT) c)kidney unable to eliminate fixed acids (RF) ii)a)pH: <7.4 b)low HCO3 c)base deficit iii)AG when piling up abnl acids in blood; doesn't exist when problem is loss of buffers iv)if the problem is HCO3 loss, since it will correct when correct HCO3 v)renal loss of K that isn't obvious until correct the acidosis

Front 50

when does metabolic alkalosis occur?x2 What is pH, HCO3, and base status? What will usually correct the problem? What may be needed?x2

Back 50

i)a)loss of gastric juice b)excessive admin of HCO3 or precursors ii)a)high pH, high HCO3, base excess. iii)abundant intake of KCl (b/w 5-10) allows kidney to correct the problem iv)NH4Cl or N HCl