OME Surgery
4 common differentials for AMS in the post op patient
1. hypoxemia (ARDS, pneumonia, PE) - PEEP and oxygen support for ARDS, abx for pneumonia, heparin for PE) 2. electrolyte (hyper Na, Ca) - treat with hypotonic fluids 3. sundowning (elderly) treat with atypical antipsychotic 4. Delerium Tremens (alcoholic hx) - treat with benzodiazepines
ideal length of treatment for malnutrition prior to elective surgery
10 days
When to start smoking cessation before surgery
8 weeks
Worrying urine output after surgery
< 0.5cc per kg per hour
What are the soft signs of PE
ABG with hypoxic hypocapnia , clear xray
fever post op day 10-14 with erythema and purulent drainage at surgical site
Abcess (get US or CT to confirm)
What is dehiscence? How do you manage?
Apply warm saline dressings (best next step)NEVER PUSH BACK IN emergent re-operation
For catheter related UTI, what abx do you start with
CTX
How do you manage ogilvie syndrome
Colonoscopy and rectal tube (possibly stigmine if rectal tube fails)
metabolic derangemeny that is an absolute contraindication to surgery
DKA (check sugars prior to surgery)
What causes fistulas?
F - foreign body R - radiation I - inflammation (crohns) E - epithelization N - neoplasm D - distal obstruction
Best prognostic indicator for preop surgery eval for lung
FEV1/FVC Then do ABG (CO2 retention worse)
Worst prognostic indicator of Goldman index
JVD
Contraindications to surgery
MI within 6 mo and EF below 35%
How do you manage the risk of MI post op (notice timeline!!!)
Make sure they are on tele - they are often silent Do not give clot blusters (Tissue plasminogen activator (tPA) Tenecteplase. Alteplase. Urokinase. Reteplase. Streptokinase)
In post op care, what two things should be on your differential with chest pain
PE and MI
What things do you evaluate for Child-Pugh score
Path: MELD, Child-pughPt: albumin (decreased), PT/PTT (elevated), total bili(increased), ascites, encephalopathyif any 1=40%; all=1--% and tx: liver transplant
When to suspect malignant hyperthermia What to do
Presurgery make sure to ask about family history
treatment for fistula
Resect Fistula Diversion Fix underlying Cause (FRIEND) Reconnect
fever on post op day 3 is likely to be [blank]
UTI (get U/A and culture)
if prealbumin and CRP are normal but albumin is low that indicates [blank]
albumin synthesis pathology (liver disease, not malnutrition)
most likely cause of fever on post op day 1
atelectasis
fever right after an abdominal surgery is likely to be due to [blank], and diagnostic tool would be [blank]
bacteremia blood cultures
fever on post op day 7 with erythema spreading around the surgical site, and diagnostic test to order
cellulitis (get ultrasound to rule out abscess)
painless jaundice with MRCP showing string of beads sign, suspected diagnosis and treatment
cholangiocarcinoma - ERCP with bx for diagnosis and resection for treatment
what must be done before treating achalasia confirmed by barium swallow and manometry
endoscopy with bx to rule out pseudoachalasia
Malnutrition
failed anergy skin test weight loss >20% albumin <3
treatment for post op day 5 DVT/PE
heparin to warfarin bridge
fever and cough on post op day 2 is likely to be [blank]
hospital acquired pneumonia (treat with vanc and zosyn)
treatment for atelectasis in post op
incentive spirometer ambulation If not improved, get...
thin wall distended gallbladder seen on ultrasound, felt on examination, patient does not complain of pain, but is jaundiced, consider [blank] and order [blank]
pancreatic cancer (courvousier's sign) - order CT scan of abd (if normal consider MRCP, if also normal consider cancer at ampulla of vater) to diagnose use endoscopic ultrasound with bx treatment: whipple procedure - prognosis poor
