#2 worst predictor of high cardiac

risk. manage?

recent transmural or subendocardial MI.

defer surgery 6 mos

5 factors used to predict risk for cardiac

complications after vascular surgery

1. Q waves on ECG
2. h/o ventricular ectopy requiring tx
3. h/o angina
4. DM (pt taking meds)
5. age >/ 70

advantage to Golytely (polyethylene

glycol electrolyte solution)

causes no net absorption or secretion of ions,

and thus no change in electrolyte or water
balance

all patients with valvular heart

disease should receive what preop?

prophylactic antibiotics for the prevention of

subacute bacterial endocarditis

antibiotics used in bowel prep

oral nonabsorbable- neomycin,

erythromycin

ASA classification

bacterial endocarditis prophylaxis

regimen

1- normal healthy
2- mild systemic diz, no limitations
3- mod to sev systemic diz, some limitations
4- sev systemic diz, constant threat to life, functional limitations
5- moribund. not expected to survive 24 hrs with or w/o surgery
6- braindead, organs are being harvested
E- procedure is an emergency

dental/oral/resp/esoph- amoxicillin 1 hr before (if allergic,

clindamycin/cephalosporin/clarithromycin)
GI- ampicillin and gent 30 min before and ampicillin 6 hr after (if
PCN allergic vanco and gent 30 min before w/o follow up)

blood clots in bladder

bladder irrigation with 3 way Foley catheter

(be sure to do malignancy work up as well)

Carotid endarterectomy has what %

risk of cardiac events

1-5% (intermediate)

Child's Class B (Liver failure)

Bili 2-3, Albu 3-3.5, Ascites easily controlled,

Encephalopathy minimal, Nutrition good,
Mortality 10-15%

Chronic liver failure its should abstain from

alcohol for ____ wks before surgery. How to
control ascites? How to normalize PT?

6-12
potassium-sparing diuretics (epithelial Na ch blockers- amiloride, triamterene; aldosterone
antagonists- spironolactone, eplerenone) and sodium and water restriction
(recheck electrolytes prior to surgery since diuretics can cause abnormalities)
give vitamin K

Clostridium perfringens causes

gas gangrene/cellulitis and

necrotizing fasciitis

DBP >/ 110 is a risk factor for?

development of cardiovascular complications

such as malignant HTN, acute MI, CHF

diabetic pt to have surgery, what IV

fluids when pt is NPO after MN?

IV fluids with dextrose

dog bite what to do

leave open except in areas with rich

blood supply and the face

drop of pus on skin at venipuncture exit site.

what's the condition, what's the cause, how
to treat?

suppurative thrombophlebitis
infected thrombus in vein and around indwelling catheter
surgically excise infected vein to the first patent, non
infected collateral branch, give IV abx, leave wound open

EF that's risky

under 35%

factors associated with failure of

fistula to heal
FEV1 of ___ can tolerate _____
pulm resection
Fleets Phospho-Soda is
contraindicated in

FRIEND- foreign body, radiation damage,

infection/IBD, Epithelialization of fistulous
tract, Neoplasm, Distal bowel obstr
0.6 L; wedge
1 L; up to lobectomy
2 L; up to pneumonectomy
diabetics, and patients on salt-restricted diets
(lose fecal fluid--> lose bicarb--> exacerbates K loss;
may have to correct metabolic acidosis and K)

for an elective procedure, aspirin should be

d/c for __ dys prior and NSAIDS for ___ dys

7-10; 2
both can cause platelet dysfunction due to inhibition of
cyclooxygenase, preventing prostaglandin synthesis
(aspirin's effect is irreversible)

GI fistula does not heal after 5-6

weeks

surgical repair

good spinal anesthesia may lead to fewer

____ complications than general anesthesia

pulmonary

growth factors involved in wound

healing (in order of appearance)

PDGF (chemotactic for fibroblasts, neutrophils, macrophages)

TGF-B (increases collagen synthesis)
basic FGF (hastens wound contraction)
EGF (stimulates epithelial migration and mitosis, speeds wound
epithelialization)

how may Clostridium cause

hemolysis

hemagglutinin and hemolysin toxins

it produces

How to do intraoperative monitoring

in pt with mitral valve stenosis

arterial line, TEE

(pulmonary artery catheter is no good; pressure gradient
across mitral valve distorts relationship between pulm cap
wedge press and LVEDP)

how to dx clostridial wound infection

culture wound, see gram+ spore

producing rods

how to give prophylactic abx

singe dose 1 hr preoperatively, single

dose postop

how to ID severe nutritional depletion

manage?

loss of 20% body weight

albumin <3
anergy to skin antigens
transferrin <200
4-5 (7-10 is better) days nutritional support before surgery

how to know if hyperkalemia is

physiologically important. what to do

peaked T waves on EKG

IV calcium gluconate. Then IV insulin and
glucose, hemodialysis if necessary

how to prevent IV inflammation or

cellulitis

rotate IV insertion sites every 4 days

how to treat platelet dysfunction due

to uremia?

desmopressin (ddAVP)- releases vWF from endothelial cells and

increases spreading and aggregation of platelets; FFP; conjugated
estrogens (slow onset but work up to 2 wks); postoperative hemodialysis
note- platelet transfusion WILL NOT help

Hypertensive patient, should he

receive his meds the day of surgery

Yes. Especially if it's a beta-blocker, because

they have a high rate of rebound HTN if
withheld

hypotension in the OR in a pt with renal

failure who has previously taken steroids

hydrocortisone intraoperatively and postop

(hypotn due to glucocorticoid deficiency)

intestinal contents draining from wound

after pt has had segment of necrotic bowel
resection. next step

no signs of peritonitis- CT scan to check for intra-abdominal collection. if there- drain

percutaneously under CT guidance. if not there and fistula is draining- manage as
enterocutaneous fistula- make NPO, give TPH, measure fistula output daily, measure serum
electrolytes daily. Fistula should heal in several weeks.
signs of peritonitis- surgical reexploration

magnesium citrate is contraindicated

in

patients with renal failure (who can't clear large amounts

of Mg from the bloodstream--> CNS depression, loss of
DTRs, give calcium gluconate for tox)

major drawbacks of general

anesthesia; major plus

increased incidence of pulmonary complications

mild cardiodepression; it provides a secure airway

most common cause of fever in

immediate postop period

atelectasis

most common cause of increased pulm risk?

what is the problem?
manage?
Next step after exercise stress test (or substituted
test) shows reversible ischemia (i.e., arterial blockage
you can do something about).

smoking
compromised ventilation (high PCO2, decreased FEV1)
eval FEV1, if abn, eval ABGs. stop smoking 8 wks,
respiratory therapy before surgery

Cardiac cath (aka coronary angiography) to determine

whether coronary revascularization (PTCA, CABG) is
necessary prior to surgery

normal urine output for an adult

0.5-1 ml/kg/hr

patient has hemoptysis while in

hospital

if he had it before hospitalization- likely malignancy

if he had it for the first time in hospital- likely PEpulmonary embolus (esp in setting of immobilization)

Patient with rest pain, needing

revascularization. What should we
investigate?

coronary artery disease and carotid artery disease,

because atherosclerosis affects entire vasculature, not
just lower extremities

post op surgery wound has fluctuance

this suggests a fluid collection beneath the skin, remove

some staples and drain pus. Culture the wound, irrigate
and pack with wet to dry dressings 2x/dy. ONLY use abx
if cellulitis.

pre-op patient with polycythemia

vera. steps?

normalize hematocrit with hydration

and phlebotomy

predictors of hepatic mortality

bili >2 (>4 is worse)

albumin <3 (<2 is worse)
PT >16
encephalopathy (blood ammonia >150)

Preop patient with COPD, how to

manage

ABGs on RA- PaO2 less than 60 is pulm HTN, PaCO2 more than 45 assoc
with increase preoperative morbidity. If not urgent, use spirometry,
bronchodilator therapy, etc to improve pulm status prior to surgery. If
you have to operate, do the above, minimize anesthesia duration,
mobilize pt postop asap to prevent atelectasis

Preop pt has 6 PVCs on EKG what to

do?

stress test, ECHO

DO NOT give prophylactic antiarrhythmics

Preop pt has afib

cardioversion to normal sinus rhythm or betablockers to control heart rate. Anticoagulation pre
and possibly post surgery

preop pt with aortic stenosis, what to

do

elective surgery- cardiac assessment and possibly valve

replacement first
urgent surgery- intraop monitoring (pulm art cath, art
line, TEE)

Preop pt with loud carotid bruit or h/o

stroke with good neurologic recovery

Carotid duplex study

If 70-99% stenosis, carotid endarterectomy

Preop Surgery pt with h/o non Q

wave MI- what to do?

exercise stress test (or substitute) to check for reversible ischemia. If so,
CORONARY BYPASS is necessary before surgery.
(Non Q-wave MI- non transmural infarct, meaning that the affected
myocardium is at risk for further infarction during and after surgery)

pt to have surgery has had previous MI.

steps?

cardiology consult and exercise stress test. If positive-->

cardiac cath to determine if coronary revascularization is
required prior to surgery

Pt with acute cholelithiasis needing surgery

(cholecystectomy) but has severe COPD, how
to manage

can do open cholecystectomy instead

of lap; or cholecystostomy

spinal anesthesia may be more dangerous

in what type of patients, and why?

valvular or heart problems (including diabetic vascular diz with

neuropathy); loss of peripheral vasoconstrictor ability or ability to
increase cardiac output when necessary, thus hypotension may
occur as a result of the vasodilation caused by spinal anesthesia

Standard preop tests

1. CBC
2. electrolyte panel
3. ECG- men above 40, women above 55, or regardless of age if known
h/o cardiac diz
4. CXR

Tests to substitute for exercise stress

test in pt with rest pain

persantine thallium stress test

dobutamine ECHO

to do for diabetic coma

...

treat Clostridium inf

high dose penicillin G, debridement

tetanus immunization

treat uti

TMP/SMX, ciprofloxacin

type of anesthesia to use in obese

person

epidural

what arrhythmia poses minor

preoperative cardiac risk

atrial fibrillation

What arrhythmias pose major

preoperative cardiac risk

high-grade AV block
symptomatic ventricular arrhythmias
uncontrolled supraventricular arrhythmias

what chronic disease poses intermediate

preoperative cardiac risk

DM

what diabetic meds can you give the

morning of surgery?

injectable insulin only (if blood sugar >250 give 2/3 of dose; if less, give
1/2 of dose). No oral agents.

What non cardiac surgical procedures

have low risk of cardiac events?

endoscopy, breast procedures,

cataract extraction

which coag is an indicator of hepatic

fcn

PT- prothrombin time

Why is laparoscopic surgery

contraindicated in severe COPD?

may lead to increased CO2 absorption

into blood--> increases pulmonary work

why must IV fluid requirements

decrease during the recovery period

pt begins to mobilize fluid from 3rd space

accumulation (increasing fluid in intravascular space)
prevent pulmonary edema

worst single finding predicting high

cardiac risk. tx?

jugular venous distension (indicates CHF)

abdd- ACE inh, beta blockers, digitalis,
diuretics before surgery