Surgery NMS Casebook

general
What type of anesthesia is associated with more pulmonary complications?

inhibit COX, prevent PG synth –> plt dysfunc. 7-10 d
What is the effect of aspirin/NSAIDs and how long prior to surgery do they need to be stopped?

no oral hypoglycemics in AM. Insulin-dep: check glucose in AM. if over 250, give 2/3 of NPH + insulin. If less than 250, give 1/2 of NPH + insulin. delay sx until sugar in ctrl
Pre-surgery prep for pts w/ DM

Maintain antihypertensives on day of sx
What to give for periop htn w/ DBP > 110

6-8 wks. impaired mucus transport in resp epith/cilia –> inc infxn risk
How long prior to surgery to quit smoking? Why quit?

strong fhx, previous MI > 30 d ago, previous NSTEMI, LBBB, CABG > 5 yrs ago, stents > 6 mo ago, angina, > 5 PVCs/min
In what situations is cardiac stress test recommended prior to sx?

bruit, hx of stroke w/ neuro recovery
When is carotid duplex study rec prior to sx?

if emergency, do sx. tx active cardiac conditions (angina, AV block, ventricular/supraventr arrhythmias) first if not emergency. If none, do low-risk sx; if high risk, det func capacity. If < 4 or unknown, decide sx based on number of risk factors.
Noncardiac sx cardiac eval algorithm

Child, MELD
Assessing periop risk in liver failure?

teens – 6%, 20s – 20%, 30s – 50%, > 40 – 70%
MELD scores and 3-mo mortality

6-12 wks
In chronic liver failure, pts should abstain from alcohol for how long prior to sx?

K-sparing diuretics, Na/water restriction
How to ctrl ascites in chronic liver failure prior to sx

continue preop doses w/ stress doses of hydrocortisone PRN
Renal transplant steroid mgmt during sx

plt dysfunc from uremia. ddAVP (vWF release), FFP, estrogens, postop hemodialysis
What may cause intraop bleeding in pt w/ renal issues? How to manage?

ca gluconate, IV insulin, glucose, hemodialysis
Hyperkalemia mgmt

pulm artery catheter, A-line, TEE
What kind of periop monitoring is required in aortic stenosis that can’t be corrected prior to surgery?

prior IE, CHD unrepaired/repaired within 6 mo/repaired w/ residual defects, prosthetic valves, transplant w/ valve disease
Endocarditis prophylaxis indications

all dental for high cardiac risk, invasive resp tract, infected skin/MSK for high cardiac risk
Abx prophylaxis req for what types of surgeries (aside from endocarditis recs)?

EBL x 3 mL isotonic fluid/mL EBL + UOP – IV fluids in OR
Calculating intraop fluid reqs

100 – 50 – 20 rule = mL/24 h
maintenance fluid reqs

hypovol from under-resuscitation or bleeding. Compare postop w/ current hgb/hct. Bladder scan, renal US for obstruction. Check that catheter is patent.
Postop oliguria usu asso w/ what? How to eval?

inc UOP causing dehydration and hypotn. Asso w/ chronic obstruction, edema, CHF, hypertn, wt gain, azotemia
What is postobstructive diuresis?

atelectasis. Tx w/ pulm toilet and IS. avoid w/ postop IS.
Fever plus crackles postop commonly what? How to tx? How to avoid?

infected thrombus in vein cause pus at venipuncture site. remove catheter, surgically excise infected vein
What is suppurative phlebitis? How to tx?

infxn from gas-forming organism
High fever immediately postop req r/o of what?

gram-pos, spore-prod rods. Debride, high-dose penicillin, hyperbaric O2, tetanus shot
How to dx clostridial wound infxn. tx?

if draining appropriately, NPO, TPN, monitor output.
mgmt of small bowel fistula?

FRIENDS – foreign body, radiation, infxn/IBD, epithelialization, neoplasm, distal bowel obstruction, steroids
Factors asso w/ failure of fistula to heal

The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. Client admitted 2 days ago with congestive …

“1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what “”type 2″” means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with …

Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a. 45 units/L b. 100 units/L c. 300 …

A client asks the nurse why the provider bases his medication regimen on his HbA1C instead of his log of morning fasting blood glucose results. Which of the following is an appropriate response by the nurse? A. HB A1C measures …

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