_______is the most important anesthetic complication. Anesthesia causes an uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms
... [Show More] the body's capacity to supply oxygen, remove CO2, and regulative body temperature.
Malignant hyperthermia
If patient is hyperkalemic (normal range 3.8-5.0), how should you treat the patient?
treat with glucose/insulin, and calcium +/-bicarb
_______is the reversing agent for opiods.
Naloxone
_______is the reversing agent for benzodiazipines.
Flumazenil
What is the best indicator used to monitor nutritional status?
prealbumin - every 2-3 days
Intervention:
_________require central access and indicated when no enteral feeding for > 7 days.
TPN - total peripheral nutrition
The _________is the most important part of the history before surgery.
cardiac history -- history of MI, unstable angina, valvular disease
In patients with known cardiac disease, aggressive intraoperative lowering of myocardial oxygen demand with ____ has been shown in RCT's to improve outcomes and should be used.
beta blockers
When accessing cardiac disease prior to surgery, what is the most important thing to access?
aortic stenosis -- crescendo diastolic rumble at apex
Guidelines for the use of antibiotics include administration within _______ of surgery and redosing after 4 hours. What is the abx of choice?
1 hour
Abx of choice: cefazolin for all except colorectal then cefazolin/metronidazole
Pre-op -- Metabolic disease/syndrome -- what are the 5 criteria?
3/5 to diagnose:
1 - diabetes
2 - central obesity
3 - HTN
4 - high serum triglycerrides
5 - low HDL levels
______should be monitored before surgery bc it is a stimulant and vasoconstrictor -- can lead to severe tachycardia
Cocaine
Pre-Op -- What are the indications for EKG and CXR?
EKG - men >40, women>50, known CAD, DM, or HTN
CXR - age >50, known cardiac or pulmonary disease
What are the 5 classic "W's" of post operative fever?
W - wind (atelectasis)
W - water (UTI)
W - wound (wound infection)
W - walking (DVT/thrombophlebitis)
W - wonder drugs (drug fever)
If the post op fever occurs within the first 24 hours of surgery, what is the most likely cause?
wind/atelectasis
If the post op fever occurs within days 3-5 post op, what is the most likely cause?
water/UTI, catheter related phlebitis, pneumonia
If the post op fever occurs within days 5-10 post op, what is the most likely cause?
wound infection, pneumonia, abscess, infected hematoma, C diff colitis, anastomotic leak, DVT, peritoneal abscess, drug fever, PE, parotitis
_______is the most common pathogen in wound infections and around foreign bodies.
Staph aureus
_______invades the inner ear and enteric tissues as well as the lung.
Klebsiella
______organisms are often found together with anaerobes.
Enteric organisms ie. enterobacteriaceae and enterococci
Among the anaerobes, ___&___are often present in surgical infections and _____species are major pathogens in ischemic tissue.
Bacteroides & Peptostreptococci; Clostridium
___&___are usually nonpathogenic surface contaminants but may be opportunistic.
Some fungi and yeast cause abscesses in sinus tracts.
Pseudomonas & Serratia
History of recent surgery, trauma, cancer, prolonged immobilization, or oral contraceptive use increases the risk of ____.
DVT - deep vein thrombosis
What is Homan's sign?
pain on passive dorsiflexion of ankle
What is the test of choice for DVT?
doppler ultrasound
How is the D-dimer text useful?
It is good at ruling a DVT out (if the text is negative) but not rule it in
Tx of DVT --
1. Initiate use of ____or____to what dose?
2. Overlap with the use of ____to what therapeutic range?
3. Why overlap therapies?
DVT
1. Initiate Heparin to PTT of 0.3-0.7 U/mL or LMWH wo monitoring.
2. Overlap with warfarin to INR between 2-3.
3. Overlap therapies to decrease changes of hypercoagulable state.
The most common cause of SIRS (systemic inflammatory response syndrome) is sepsis. What are the criteria for dx of SIRS?
At least 2 of the following:
1. temp >38C or <36C
2. tachy >90
3. tachypnea > 20 breaths/minute
4. PCO2 <32mmHg
5. WBC > 12,000/uL or <4000/uL
After sepsis, what are the next two most common causes of SIRS?
pancreatitis and drugs
What is the difference between hypovolemia and dehydration?
hypovolemia is loss of both water and sodium while dehydration is loss of intracellular water or deficit with hypernatremia -- dehydration occurs when patient can not adjust water intake for water loss
What are the clinical signs of dehydration and hypovolemia?
tachycardia, hypotension, pale skin, increased capillary refill time, dizziness, faintness, nausea, thirst, decreased urine output -- in hypovolemia, urine will demonstrate low sodium concentration
What are 2 common conditions with dehydration?
diabetes insipidus (lack of ADH or unable to respond to ADH), fever with increased water loss
Hyponatremia Causes
_______ = cirrhosis, CHF, nephrotic syndrome, massive edema
_______=states of severe pain or nausea, trauma, brain damage, SIADH
_______=prolonged vomiting, decreased oral intake, severe diarrhea, diuretic use
Misc causes = factitious hyponatremia, hypothyroidism, adrenal insufficiency, malnourished states, primary polydipsia
Hypervolemic, Euvolemic, Hypovolemic
What are the two most common treatments for hyponatremia?
Other less common treatment?
salt tabs and fluid restriction; vasopressin receptor antagonist in SIADH, CHF, and cirrhosis
Hypernatremia is almost always due to _______. Therefore, what is the treatment?
dehydration; rehydrate!
What s/s can result in a hyperkalemic patient?
cardiac arrhythmias (tall peaked T waves) and weakness
If the potassium level is above 6meq/L or the patient has EKG changes, what treatments can lower K temporarily?
calcium gluconate, sodium bicarbonate, insulin and glucose, kayexalate (takes longer to be effective)
______&______ is extremely effective in decreasing potassium.
Dialysis and furosemide
Hypokalemia is usually due to ________, hypomagnesemia, alkalosis, high aldosterone levels. How is it treated?
potassium loss; replacement must be slow!!!
Mild loss: oral KCl supplements or K containing foods
Severe loss: IV supplementation - rate 10mEg/hr
Causes of ________are VITAMIN D METABOLIC DISORDERS, abnormal PTH function, primary hyperparathyroidism, Lithium, malignancy, disorders related to high bone turnover rates (hyperthyroidism, prolonged immobilization, thiazide use, vit A intoxication, Pagets dz of bone, multiple myeloma), renal failure
hypercalcemia
How should hypercalcemia be treated?
fluid and diuretics, bisphosphonates, and calcitonin
_______is usually caused by ineffective PTH (chronic renal failure, absent active vit D, ineffective active vit D, pseudohypoparathyroidism), deficient PTH.
Hypocalcemia
How should hypocalcemia be treated?
intravenous calcium gluconate, Tums
Increased CO2, hypoventilation, or decreased pH is aka ___.
respiratory acidosis
Decreased CO2, hyperventilation, or increased pH is aka ___.
respiratory alkalosis
Increased H+ or HCO3 loss, DKA, lactic acidosis is aka ___.
metabolic acidosis
Loss of H+ is aka ________.
metabolic alkalosis
The d/d of post op ___________can be MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection, pneumo/chyle/hemothorax, or gastritis.
chest pain
Who classically gets silent MI's?
diabetics
How should syncope be initially evaluated?
It is important to distinguish syncope from cardiac arrest from other nonsyncopal conditions causing LOC
Syncope d/d: Prodrome or aura usually associated with ____.
seizures (as is loss of continence)
Cardiac syncope's onset is usually ____without a prodrome. Monitor vitals regularly, EKG, orthostatic challenge, neuro exam etc.
sudden
In a surgery patient with dyspnea on exertion, what should be ruled out?
PE or pneumothorax
What are some chronic dyspnea on exertion causes?
asthma, COPD, interstitial lung disease, myocardial dysfunction, obesity
What are some acute dyspnea on exertion causes?
angioedema, anaphylaxis, foreign objects, airway trauma, pulmonary infection, pleural effusion, peritonitis/ruptured viscous, bowel obstruction
__________is pain, cramping, or both of the lower extremity (usually calf muscle) after walking a specific distance; then resolves for a specific amount of time while standing.
Claudication
What is claudication associated with?
peripheral vascular occlusion
D/D of lower extremity claudication?
neurogenic/nerve entrapment/discs, arthritis, coartation of the aorta, popliteal artery syndrome, neuromas, anemia, diabetic neuropathy pain
A _________is an abnormal dilation of an artery. Involve all layers of the arterial wall.
aneurysm
At what size is surgical repair of aneurysm recommended?
5.5 cm
95% of aneurysms are associated with ___________.
atheroschlerosis -- other causes are trauma, infection, syphilis, & Marfan's syndrome
What is the classic triad of s/s related to ruptured AAA?
abdominal pain, pulsatile abdominal mass, hypotension
Where does the aorta bifurcate?
At the level of umbilicus
Because the ________is often sacrificed during AAA repair, colonic ischemia can occur.
IMA - inferior mesenteric artery
_______is a separation of the walls of the aorta from an intimal tear and disease of the tunica media; a false lumen is formed and a "reentry" tear may occur, resulting in a "double barrel" aorta.
Aortic dissection
Explain the DeBakey classifications (Type 1,2, & 3) of aortic dissections.
DeBakey Type 1 - ascending & descending aorta
DeBakey Type 2 - ascending aorta
DeBakey Type 3 - descending aorta
Explain the Stanford classifications of aortic dissections.
Type A -- ascending +/- descending aorta
Type B - descending aorta [Show Less]