Review for PA's Surgery Section
mneumonic for emergent situations pt hx gathering prior to surgical procedure?
E-events preceding the emergency
meds that most likely culprits for increased bleeding?
what herbal supplements can interfere with coats and cause increased bleeding?
most important pre-op exam that can be performed is __________?
when should a CBC be considered in the pre-op pt?
if pt has S/S compatible with anemia or if EBL predicted for procedure is significant
what pts should you consider ordering e'lytes on in the pre-op stage?
pts taking certain meds like warfarin or digoxin because of the assc w/potassium abnormalities and toxicity
not indicated in pts w/o medical problems
useful in post-op eval
mneumonic for taking a drug history pre-operatively?
D-dispensed (by doc or other med/dental provider)
R-recreational (alcohol, tobacco, street drugs, anabolic steroids)
U-user (OTC's, herbal supplements)
G-gynecologic (OC's HRT)
S-senstivities (focus is on drug sensitivities rather than allergies)
what naturally decreases serum creatinine levels?
age and decreased muscle mass
what is creatinine a marker of?
who should get a serum creatinine pre-operatively
all pts over 40
also if they will be given nephrotoxic agents (contrast, exc), if intraoperative hypotension is anticipated, or if cross-clamping of the aorta will be performed.
whose glucose should be checked prior to surgery?
-those with PMHx or FHx of DM
-pts undergoing bypass grafting for PVD
when would you order liver enzymes in the pre-op pt?
only is S/S of hepatic dysfxn present
what is the best determinate of bleeding tendencies during surgery?
HISTORY!!!!!! ask your pt!!!!!
incidence of asymptomatic UTI's?
what pt population is recommended to get a pre-op ECG and why?
all pts 40yr and older
rationale is that pre-op MI and arrhythmias are assc with higher M&M
silent MI's are most common in what two pt populations?
elderly and DM pts
who should have a CXR prior to surgery?
pts older than 60
all pts, regardless of age, with hx of pulmonary or cardiac dz
what are the recommendations for preoperative spirometry?
recommended in pts being eval'd for thoracic or upper abdominal surgery and its that have a hx of smoking or dyspnea
indicated in abdominal surgery if pulm dz is poorly controlled or if the extent of dz is unclear
who needs an ABG preoperatively?
not routine but if there is evidence of severe underlying cardiopulmonary dz or to confirm acid-base disturbance
what should be used before considering an ABG?
who needs a pregnancy test preoperatively?
all women of childbearing age
what is the name of the system used for assessing cardiac risk in the surgical pt?
Detsky's modified cardiac risk index
explain the points within Detsky's modified cardiac risk index and what they correlate with?
Class I- (0-15 points)-low cardiac risk
Class II- (20-30 points)-intermediate cardiac risk
Class III (31+ points)-high cardiac risk
clinical predictors of significant cardiac risk include?
recent MI (w/in 30 days)
unstable or severe angina
active heart failure
high-grade AV block
symptomatic ventricular arrhythmias w/ underlying dz
supraventricular arrhythmias w/ uncontrolled rate
severe valvular dz
what is Virchow's triad?
used for assessing risk of DVT
stasis, hypercoagulablility , and intimal damage
who is at high risk for DVT's postoperatively?
pts older than 70
surgery lasting 2 hours or more
which type of surgery should you NOT give DVT prophylaxis agents that alter blood coag's?
Lee's revised cardiac risk index score interpretation?
0 points-class I, very low
1 points- class II, low
2 points-class III, moderate
3 points-class IV, high
classification by the American Society of Anes. (ASA)
class I-healthy pt, no medical problems
class II- mild systemic dz
Class III-severe systemic dz, but not incapacitating
Class IV-severe systemic dz that is constant threat to life
Class V-moribund, not expected to live 24 hr regardless of operation
what type, dose and timing is used for DVT prophylaxis options?
sequential compression devices
define a malnourished pt
someone who has lost more than 10% of his/her lean body mass and-or has not had adequate nutritional intake for more than 7 days
expected risks of malnutrition include increased incidence of?
when might increased nutritional requirements present?
-hypermetabolic/catabolic response seen in systemic inflammatory response syndrome
-tumor necrosis factor-a has been shown to enhance muscle catabolism and promote pt cachexia in metabolic stress.
clinical features of malnutrition
weight loss, reduction of SQ fat stores, wasting
decreased cognitive fxn may be assc
subtle changes in skin and hair occur, esp with essential fatty acid deficiency syndromes
what cardiac manifestations can occur as a result of malnutrition?
decreased myocardial mass
decreased stroke volume
what will happen within the respiratory system due to malnourishment?
catabolism of major respiratory muscles, with decreased vital capacity and difficulty in extubation of pts
what happens to the GU tract as a result of malnourishment?
atrophy of villi with bacterial overgrowth
overgrowth of bacteria plus mucosal dysfxn may result in bacterial translocation and subsequent multi system organ dysfxn
what can happen as a result of bacterial translocation
linked with the occurrence of bacterial translocation from the gut
what happens to the immune system as a result of malnourishment?
impaired cell-mediated and humoral immunity
what happens in relation to wounds in the presence of malnourishment?
-poor wound healing
-increased incidence of infection, dehiscence, and evisceration
in severe malnutrition, what 2 things may develop?
marasmus or kwashiorkor
what diagnostic studies can be checked to eval malnutrition?
creatinine height index
total lymphocyte count
above list all may abnormal in malnutrition
BMI, arm circumference, and nitrogen balance are good for measuring overall status.
complications of malnutrition (3)