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Surgery EOR: Preoperative / Postoperative
Care Questions with 100% Correct Answers
| Latest Version | Verified
When can a patient eat prior to a major surgery? - ✔✔NPO after midnight or at least 8 hours What risks should be discussed with all patients and documented on the consent form for a surgical procedure? - ✔✔Risk: Bleeding, infection, anesthesia, scars If a patient is on anti-HTN meds should the patient take them on the day of the procedure? - ✔✔Yes Should a patient who smokes cigarettes stop before an operation? - ✔✔Yes - improvement is seen in just 2 - 4 weeks of smoking cessation What lab test must all women of childbearing age have before entering the OR? - ✔✔B-Hcg and CBC What is a preop colon surgery "bowel prep"? - ✔✔Bowel prep with a colon cathartic (GoLYTELY), oral abx (neomycin, erythromycin), IV antibiotic before incidsion What must you always order preoperatively for you patient undergoing a major surgery? - ✔✔1. NPO/IVF
- Preop abx
- Type and cross blood (PRBCs) What electrolyte must you check preoperatively if a patient is on hemodialysis? - ✔✔Potassium Who gets a preop EKG? - ✔✔Patients over 40 or undergoing cardiac procedure
What is the most important preoperative eval performed by the surgical team? - ✔✔H&P - no documentation exists linking a reduction in mortality and morbidity to routine lab testing in otherwise healthy patients undergoing elective procedures Detailed H&P prior to surgery including special attention to... - ✔✔Hx of CVA, heart dz, pulm dz, renal dz, liver dz, GI d/o, DM, prior surgeries, bleeding problems, clotting problems, difficulty w/ anesthesia, nutrition, etoh, illicit drugs What is an ASA score? - ✔✔American Society of Anesthesiologists (ASA) classification system which stratifies the degree of perioperative risk for patients Describe the ASA classification system - ✔✔ASA 1: Normal healthy patient ASA 2: Patient with mild systemic disease ASA 3: Patient with severe systemic disease ASA 4: Patient with severe systemic disease with a constant threat to life ASA 5: Moribound patient who are not expected to survive without an operation ASA 6: Brain dead patient Mouth PE important to note - ✔✔Teeth - if loose worry about intubation Tongue - think sleep apnea if large Jaw - TMJ could be difficult intubation Mallampati score Airway concerns with surgery - ✔✔Tracheal deviation - can be issue for maintaining airway during surgery Neck concerns with surgery - ✔✔If >17in there is concern for sleep apnea, masses, deformities, ROM Mallampati score - ✔✔Classifies how open the airway is 1 - Can see the uvula, no prob w/ intubation
Goldman criteria points - ✔✔ 0 - 5 = Class I 6 - 12 = Class 2 13 - 25 = Class 3
25 = Class 4 Preop lab assessment for cardiac disease? - ✔✔Resting LV function Ambulatory EKG monitoring Exercise stress test or nuclear stress test Stress echo Patients with an EF <___% are at greatest risk for complications during surgery - ✔✔<35% What are indications for preop coronary angiography? - ✔✔Patients with suspected left main disease, triple vessel coronary occlusive disease, or unstable coronary syndromes (high risk patients) What is appropriate medical therapy for CAD prior to surgery? - ✔✔BB, CCBs, nitrates to ensure myocardial oxygen demand does not exceed supply What do patients with a history of rheumatic heart disease require prior to surgery? - ✔✔Prophylactic antibiotics to prevent endocarditis What should you do if you find your patient to have carotid artery disease? - ✔✔Endorterectomy prior to surgery - wait 6 months before operation if possible What are the 2 big things to worry about in surgery w/ a cardiac patient - ✔✔1. Catecholamine surge which causes an increase in myocardial o2 demand
- Suppression in the fibrinolytic system which leads to thrombosis What kind of murmurs are usually benign? - ✔✔Short, soft, systolic murmurs that are asymptomatic often don't require further investigation
What are risk factors for postop pulmonary complications (PPC)? - ✔✔Advanced age Elevated ASA class CHF Functional dependence COPD Sleep apnea Smoking status Low arterial O2 sat Anemia Upper abdominal/thoracic operations Duration of operations over 2 hours Emergency surgery Routine preop labs/tests for pulmonary disease? - ✔✔CBC EKG CXR CXR screening guidelines - ✔✔All > Patients with cardiac/lung disease Patients undergoing thoracic procedure Patient education to reduce risk of PPC? - ✔✔Use of incentive spirometry Deep inspiration Coughing Smoking cessation Early mobilization Oral hygiene
Antibiotics Surgical intervention if serious When should DVT prophylaxis be started? - ✔✔Preoperatively because it is thought that thrombosis starts as early as at the induction of anesthesia What is the Caprini score? - ✔✔Elaborate risk factor index for DVT What is Wells Criteria? - ✔✔Predicts risk for PE What are VTE prophylaxis options? - ✔✔Unfractionated heparin Enoxaparin (low molecular weight heparin) Warfarin Fondaparinux SCDs Greenfield filter insertion Dextran How is unfractionated heparin dosed for DVT prophylaxis? - ✔✔5000 units given SQ every 8 or 12 hours until patient is fully ambulatory How is LMWH dosed for DVT prophylaxis? - ✔✔40mg SQ daily started 12 hours before or soon after the procedure and continued till patient is fully ambulatory or up to 14 days post op What is the preferred DVT prophylaxis method for trauma patients or those with abdominal or pelvic cancer? - ✔✔Lovenox How is Warfarin dosed for DVT prophylaxis? - ✔✔Will vary from patient to patient. Goal INR is 2-3. Primarily used in ortho patients
How is fondaparinux dosed for DVT prophylaxis? - ✔✔2.5mg given SQ dialy starting 6 hours post op. Adjustment is needed in patients with renal insufficiency What should not be used as DVT prophylaxis? - ✔✔Nonfitted thromboembolic stockings - they can actually promote a tourniquet effect so only fitted stockings should be used (if at all) Recommended DVT prophylaxis for surgery with Caprini score of 0 (low risk)? - ✔✔None Recommended DVT prophylaxis for surgery with Caprini score of 1-2 (low risk)? - ✔✔LMWH LDUH (low dose unfractionated heparin) MP (mechanical prophylaxis) Recommended DVT prophylaxis for surgery with Caprini score of 3-4 (moderate risk)? - ✔✔MP Recommended DVT prophylaxis for surgery with Caprini score of >5 (high risk) and low risk of bleeding? - ✔✔LMWH LDUH MP Recommended DVT prophylaxis for surgery with Caprini score of >5 (high risk) and high risk of bleeding?
- ✔✔MP Recommended DVT prophylaxis for surgery with Caprini score of >5 (high risk) and low risk of bleeding but LMWH/LDUH is contraindicated? - ✔✔Low dose ASA Fondaparinux MP Recommended DVT prophylaxis for abdominal/pelvic surgery for cancer with Caprini score of >5 - ✔✔LMWH for 4 weeks
In general when do you consider giving a blood transfusion? - ✔✔Hemoglobin < Why is it important to ask about tobacco, alcohol, and illicit drug use/substance abuse? - ✔✔It heightens awareness about the possibility of postoperative withdrawal. In general, patients should be advised to refrain from taking illicit drugs for at least a couple of weeks before an operation What are signs of a wound infection? - ✔✔Systemic manifestations: fever, chills, malaise/fatigue, tachycardia, tachypnea Local manifestations: erythema, discharge. heat, pain Wound dehiscence What are risk factors for wound infection? - ✔✔Malnutrition Advanced age Immunosuppressive drugs Prolonged hospitalization Recent abx use Obesity Catheters Poor tissue perfusion Steroids Radiation What are the 4 classes of wounds? - ✔✔Clean Clean contaminated Contaminated Dirty What are examples of clean wounds? - ✔✔Breast biopsy
Inguinal hernia repair What are examples of clean-contaminated wounds? - ✔✔GI, GU, GYN organs entered but no gross contamination What are examples of contaminated wounds? - ✔✔Perforated appy Colectomy for diverticulitis Perforated bowel/ulcer Penetrating GI trauma What are dirty wounds? - ✔✔Traumatic wounds Burns older than 72 hours Free colon perforation When should antibiotics be administered before incision? - ✔✔Within 1 hour before incision What antibiotic is recommended for surgical prophylaxis for the majority of clean surgical procedures? What is an alternative to this? - ✔✔Cefazolin (Ancef) - can use Vancomycin if there is an allergy to cephalosporins Which antibiotic should be administered to cover bacteroides? - ✔✔Metronidazole Which antibiotics are used for class 1 wounds? Class 2? 3? - ✔✔ 1 - 1st gen cephalosporin 2 - 1st, 2nd, 3rd gen cephalosporin depending on procedure 3 - 2nd gen cephalosporin or Zosyn + metronidazole What are some adjuvant prophylaxis measures besides antibiotics to prevent SSI? - ✔✔Use of warming blankets to enhance tissue perfusion Chlorhexidine soap showers Sterile technique
What ions balance K? Na? - ✔✔K is balanced by PO Na is balanced by Cl What is the main protein in intravascular fluid? - ✔✔Albumin - it is the main cause of the high colloid osmotic pressure of serum which regulates fluid distribution between two extracellular compartments What regulates the body's volume status and electrolyte composition? How? - ✔✔The kidneys - by modulating how much free water and Na+ is reabsorbed from the renal filtrate. Antidiuretic hormone (ADH), also known as arginine vasopressin, is the chief regulator of osmolality. What hormone regulates Na levels? - ✔✔Aldosterone - increased levels causes increased retention of Na What causes hypovolemia in the surgical patient? - ✔✔Loss of isotonic fluids in the setting of hemorrhage, gastrointestinal losses (eg, gastric suctioning, emesis, and diarrhea), sequestration of fluids in the gut lumen (eg, bowel obstruction, ileus, and enteric fistulas), burns, and excessive diuretic therapy What are some assessments to determine volume status? What is the #1 assessment? - ✔✔Blood pressure - # Pulse Edema Skin turgor - (less useful in elderly) Mucous membranes - (less useful in elderly) Hematocrit Fractional excretion of Na BNP BUN/Cr ratio (>20) How do patients clinically present with hypovolemia? - ✔✔Thirsty Decreased urinary output
Tachycardia Fatigue Muscle cramps Dizziness Hypotension If severe: ischemia, shock, lethargy, AMS What labs confirm hypovolemia? (4) - ✔✔Hct - will be high Serum albumin - high Urinary Na - decreased Urea - increased How do you treat hypovolemia? - ✔✔IV isotonic fluid (LR). Coexistent electrolyte abnormalities should be addressed simultaneously. What causes hypervolemia? - ✔✔Often occurs after treatment of shock with colloid and crystalloid fluids, with or without attendant renal failure. It also occurs in the postoperative period as ADH is secreted in response to nonphysiologic stimuli, disrupting its role in regulation of osmolality. How does ADH lead to hypervolemia? - ✔✔High physiologic levels of ADH have a vasoconstrictive effect, leading to a decreased filtered Na+ load and thus greater Na+ and water retention. This secretion of ADH typically ceases 2-3 days after the surgical insult, after which ADH levels return to an appropriate level and patients experience a so-called "autodiuresis." What comorbidities can exacerbate hypervolemia in the surgical patient? - ✔✔Heart failure, liver disease, renal disease, and malnutrition Clinical features of hypervolemia? - ✔✔Hypertension Decreased arterial O2 sat Basilar crackles JVD
What are signs/symptoms of hypernatremia? - ✔✔Similar to hypovolemia AMS Tachycardia Dry mucous membranes Lack of salivation, lacrimation, urination Hypotension Lethargy Hyperreflexia How do you treat hypernatremia? - ✔✔Identify underlying cause Free water administered orally (or IV D5). Replace 50% in first 24 hours then the rest over 48 hours. What do you have to be cautious of when treating hypernatremia? - ✔✔Replacing water too quickly - can cause cerebral or pulmonary edema. What is hyponatremia? - ✔✔Water in excess of Na (Serum is too dilute). Plasma Na is <135. Causes of hyponatremia in the surgical patient? - ✔✔Common in surgical patients postoperatively, as ADH is secreted in response to pain, nausea and vomiting, opiate administration, and positive-pressure ventilation. When do signs/symptoms of hyponatremia start to occur? - ✔✔< What are signs/symptoms of hyponatremia? - ✔✔Often asymptomatic if chronic/mild If acute: Subtle mental status changes Increased risk for falls in elderly Seizures Coma
Lethargy Hyporeflexia How do you treat acute hyponatremia? - ✔✔If acute (<24 hours), give 100mL bolus of 3% NaCl and repeat Q10 min for up to 3 times until symptoms resolve. Fluid restriction, monitor volume status, calculate Na deficit What can occur if you correct hyponatremia too quickly? - ✔✔Central pontine myelinolysis - demyelination of axons causing neurologic damage What are two factors that determine K concentration? - ✔✔1. Acid-base homeostasis. H and K+ are exchanged between the intracellular and extracellular spaces, thus disturbances of acid-base balance tend to cause disturbances in serum K+
- Size of the total body K+ pool. Intracellular stores of K+ are large, but may be exhausted, especially in the setting of prolonged Acidosis and hyperglycemia cause K to do what? - ✔✔Shift out of the cells What drugs enhance excretion of K? - ✔✔Loop diuretics Thiazides What is hyperkalemia? At what level does it become symptomatic? - ✔✔K >5.0 mEq/L. Usually has to be
6.5 to show symptoms. What are causes of hyperkalemia in the surgical setting? - ✔✔Crush injuries, burns and other catabolism-inducing events Renal insufficiency Adrenal insufficiency Excessive K+ administration Acidosis
RAAS agents and K sparing diuretics can be used as well. What electrolyte should you check with hypokalemia? - ✔✔Mg - hypomagnesemia may cause hypokalemia refractory to parenteral adminstration. Therefore Mg should be corrected with K. What is the role of Mg in the body? - ✔✔Mg is an essential cofactor in many of the most important biochemical reactions in the body. ATP must be bound to Mg2+ to be biologically active. Mg2+ is required for every step of DNA transcription and translation, nerve conduction, ion transport and Ca2+ channel activity Where is Mg mostly found in the body? - ✔✔Bones, the rest is intracellular. Excess is excreted by the kidneys What will an EKG show with hypokalemia? - ✔✔Flattened T waves Increased U waves ST depression PVCs What is hypermagnesemia? - ✔✔Mg > 2.2 mEq/L What is the cause of hypermagnesemia in the surgical setting? - ✔✔Rare in the surgical setting, but may develop in acute renal failure. What are clinical features of hypermagnesemia? - ✔✔Usually asymptomatic Hyporeflexia Muscle weakness Hypotension Respiratory depression N/V Flushing
Arrhythmias What will EKG show with hypermagnesemia? - ✔✔Wide QRS Prolonged PR Prolonged QT How do you treat hypermagnesemia? - ✔✔If hypermagnesemia is significant and causing EKG changes: 10 - 20mL of 10% calcium gluconate IV over 10 min Saline diuresis and IV furosemide Dialysis if severe What is hypomagnesemia? - ✔✔Mg <1.8 mEq/L What causes hypomagnesemia in the surgical setting? - ✔✔Body stores are depleted due to diminished intake and impaired absorption. Commonly associated with chronic alcoholism, diarrhea, diuretics, nutritional deficiencies What are sign/symptoms of hypomagnesemia? - ✔✔Hypokalemia refractory to parenteral K+ administration. Hypomagnesemia may cause sedation, muscle paralysis, tetany, seizures, and coma. What will EKG show with hypomagnesemia? - ✔✔Prolonged PR, QT Wide QRS How do you treat hypomagnesemia? - ✔✔Mg sulfate IV or IM What is the role of Ca in the body? - ✔✔Many functions - from maintenance of bone strength to neuromuscular function. Half of serum Ca2+ is protein-bound, chiefly to albumin. The unbound fraction is physiologically active, while the bound fraction is not. Free Ca is held constant by vitamin D, parathyroid hormone, calcitonin, acid-base balance, and PO43− homeostasis
