Module 3: Postoperative Principles

Question 1

Admission to ICU

Answer 1

• 15% surgical procudures requires ICU
• Decision made by surgeon & anesthesiologist
• **Elderly patients or significant comorbidities

Question 2

Delivery of care

Answer 2

**Accurate Data collection: **
* Surgical Procedure
* Patient positioning
* Unexpected Events
**Efficient Among surgeon, Anesthesiologists & Intensivist: **
* Typically informal
Brief and Incomplete

Question 3

Continue Medications

Answer 3

Eye drops (Glycoma)
Antiseizure
Bronchodilators
Thyroid Replaceement

DM agent: add Sliding Scale; levemir

Question 4

Hold Medications

Answer 4

*** Glucorticoids **
* Should be given before Surgery
* Avoid Stress dosing:
* To Avoid : Hyperglycemia, Increased Infection Risk, and wound complications
* Talk to surgen ( ok to Hold )

• Hold CCB, Diuretics, ACE : untile hemodynamically stable post up
• Long Standing Insulin ( lantus or Levimir) , Metoforming, Glyburide: Hold Addd sliding scale SQ or IV, or Levemir
• Maintain Glucose <180 mg/dl

Question 5

Goal for Blood Surgar Post Up

Answer 5

< 180 mg/dl

Question 6

Opiate Management :
**Fentanyl **

Answer 6

For Mechanically Vented Patients.
Analgesia Properities, Rapid Onset, short Sedation.

Question 7

Opiate Management :
Other opiods

Answer 7

Morphine, Dilaudid, Oxycodone, MS Contin

Question 8

Non-Opiate Management

Answer 8

Ketamine
Robaxin
Toradol (check Kidney Function)
Acetaminophed
and/or Gabaptin

Question 8

Quantifying Pain and Sedation

Answer 8

*** Richmond Agitation Sedation Scale (RASSS) **
- Universal language to achieve adequite Sadation
* **Confusion Assessment Methord for the ICU (CAM-ICU) **
- check for delirium

Those scale help to avoid delirium, and shorter stay in ICU

Question 9

Opiate Risk

Answer 9

• Dependance and Withdrawal
  if on medication for > 7 days
• Lethargy
• Depressed Respitory Efforst
• Vomiting and Ileus

Question 11

Equivalent Dose

Answer 11

**Morphine **
Dose: 10 mg
Duration 4 to 5 HRS

**Dilaudid **
Dose: 1.5 mg
Duration : 4 to 5 hrs

**Fentanyl **
0.1 or 100 mcg
1 to 1.5 hrs

Question 12

Fentanyl

Answer 12

• Full-mu receptor agonist
• High Potency, short duration of action, Rapid onset of action
• Lipohilic- ideal drug for transdermal and transmucosal administration
• Biovailability - 50 %
  > **25 mcg/hour trasdernal Fentanyl patch = 1mg/1 hour IV Morphine **
• Ideal for childern and incooperative adults

Super POtent ( only in ICU )

Question 13

Morphine

Answer 13

*** GOLD Standard - For Treatment of Moderate to Severe Pain **
* Full mu-receptor agonist
* Bioavailability: 30 % (PO: IV dose is 3: 1)
Easilty available is wide range of preparations
Most widely used opioids analgesic
CAVEAT : BID /TID : Active Morpphine metabolites

Question 14

Hydromorphone

Answer 14

Semisynthetic opioid, Hydrogenated, of morphine
Full, Potent
Short duratio n

Question 15

Oxycodone

Answer 15

• **Most Utilized opiod worldwide **
• *** IR and ER **
• sustained Release Preperatio of Oxycontin : has 2 phase Release (Immediate and EXtended the the same pill)
  Chronic pain management
  Keep off IV madications

Question 16

Hypothermia
Risk for ?

Answer 16

< 36 C
Riks of deloping
* Coagulopathy and
Hemorrhage

Question 17

Mild Hypothermia

Answer 17

• 32 to 36C or 89.6 to 96.8
• **Passive External Rewarning **: warm Blankets

Question 18

Moderate Hypothermia:

Answer 18

28 to 32 C or 82.4 to 89.6F
Active External Rewarning
Air Warming system

Question 19

Severe Hypothermia

Answer 19

< 28 C
Active **core **rewarming
Warm IV fluids (Crystolids )
Do not warm Blood

Question 20

Assessemtn of Volume status

Answer 20

• **Post Up (I/O ) **
  **Crystalloids : 0.9% +LR (keep eye on Na) **
  Change to NSS
  **MAP >65 **
  **UO >/= 0.5 mg/kg **

*** Echocardium : ** monitor resuscitatio efforts
**Maintenance Fluids : D5 1/2 NS (To prevent Catabolism) **

Question 21

Rapid Shallow Breathing (RSBI)

Answer 21

Predicts successful extubation and suctain off vent
GOAL : < 105 Value ( TV Devided by RR rate )

Question 22

Mechanical Vent

Answer 22

RR 12 to 16
PEEP: 5
FIO : 100% to 40%

**Tidal Volumes: 6ml/kg **

ARD: Neuro blockag (paralize; prone)

Question 23

***Nutrition Requirment

Answer 23

• 25 to 30 kcal /kg/day
  1.2 to 2.5 g/kg/day of protein
  24 to 48 hrs nurtrition

Question 24

Surgical Complications Hemorrhage Overwiew

Answer 24

* **Frequent cause for ICU admission ** * **Persistent Postoperative Hypotension**: ( early sigh for bleeding ) * Early Identification can prevent : Prevent multi Organ Failure Hemodynamic monitoring

Question 25

Surgical Complications **Hemorrhage** Treatement Plan

Answer 25

* blood * Fluid: Isotonic Crystalloids (Avoid * Hypovolic Shock ; MAP >65)

Question 26

Surgical Complications: Pulmonary Embolus Manifestation Hemodynamic Instability

Answer 26

* Origin: Femoral, Iliac, Popliteal Veins **Manifestation: ** * SOB, chest pain, ST. DVT (s/s ) * Altered Ventilation Perfusion RAtio * **Hemodynamic Instability **: - Blockage of main or major branch of PA --> Resulting - in Increase PVR (Increase Pulmonary Vascular Resistance) -Leads to RT Heart Dialation leading to -LV Dysfunction - Rt Heart comprase Left Heaert --> decrease Preload and Decrease CO

Question 27

DX : PE

Answer 27

*** D-Dimer : Will be elevated post-up ** * **DD is protein fragment of blood clot that been dissolved in a body. ** Therefore, D-D elevated with present of PE. CTA (Gold Standard DX for PE ) **VQ Scan : Miss Match * For pt Kidney Issues; or Allergy to Diy * VQ Not Reliable in ICU pt with Disorders: ( COPD, Cystic Fibrosis, Bronchiectasis, Interstadial Lung Diseas) **ECHO **

Question 28

TX PE

Answer 28

Heparing ( PTT 60 to 90 seconds): ICU Lovenoz 1mg/mg BID NOAC IVC Filter (if down leg)

Question 29

Surgical Complications **Anastomotic Leak**

Answer 29

Most Devistating Surgical Complication Result in Mortality and Morbility

Question 30

**Anastomotic Leak Clinical Findings:**

Answer 30

*** fever, ** **Elevated WBC, ****ST, ****Hypotension * Enteric Contents in Perianastomotic drain

Question 31

Anstomotic Leak **Diagnosis : **

Answer 31

*** CT W/PO Or IV contrast** (not Always ask colorectal Surgery ) * Identify leak * Detect other Pathologies

Question 32

Anatomotic Leak Treatment Plan

Answer 32

**Septic shock and Generalized Peritonitis ** Surgical Revision **Hemodynamically Stable** * **Antibiotics and Percutaneous Drainage (zosy +Microfungil (Antifungal ) ** * Endoscopy with Stent Depoyement * Consult: ID, GI, Surgery

Question 33

Intraabdominal Compartment Syndrome Causes

Answer 33

* Severe Abdominal TRauma * Abdominal Surgery * Deep Burns * Obesety * Intraabdoninal or Retroperitoneal Hemorrhage * Excessive Crystalloid or Blood Products **

Question 34

Intraabdominal Hypertension (IAH)

Answer 34

Intraabdominal Pressure > 12mmHG

Question 35

Abdominal Compartemetn Syndrome (ACS)

Answer 35

Incraabdonial Pressure > 20 New or Worseing organ Dysfunction

Question 36

Intraabdominal Compartment Syndrome Clinical Findings

Answer 36

* Tense and distended abdomen * Increased peak airway pressure * or Decrased Tidal Volume * Postoperative persistent** metabolic Acidosis and Shock: Suggest Bowel Ischemia

Question 37

Intraabdominal Compartment Syndrome Diagnosis

Answer 37

CT scan or endoscopy Abdominal pressure measurement

Question 38

Intraabdominal Compartment Treatment : IAH or early ACS?

Answer 38

* N0n Surgically * Decreasing volume resuscitation * Sedation and Neuromuscular blockage

Question 39

Intraabdominal Compartment: ACS

Answer 39

Surgical Decompression via **Celiostomy ** Negative Pressure dressing

Question 40

Surgical Complications Acute Kidney Injury

Answer 40

Increases mortality and Morbidity Emergen or high-risk surgeries

Question 41

Surgical Complications Acute Kidney Injury: **Prerental AKI **

Answer 41

****Hypovolemia d/t bleeding I****mpaired cardiac Function * Cardiac Renal Syndrome

Question 42

Surgical Complications Acute Kidney Injury: **Intrarenal **

Answer 42

**Acute tubular necrosis: ** * Hypovolemia * Shock * nephrotoxic agents

Question 43

Postrenal AKI

Answer 43

**Obstruction to urine Flow Damage to ureters Urinal drainage obstruction ** ****non obstructive **** Have urge cannot go enlarge Prostate : Flomax

Question 44

Surgical Complication Malignant Hyperthermia (MHS_ ) **Overview **

Answer 44

* Severe reaction to anesthesia * Genetic Mutation (Autosoma Dominant : one gene from parent to be affected 50% chanses * Fatall if not treated Promptly

Question 45

Surgical Complication **Malignant Hyperthermia ** Clinical Manifestations

Answer 45

* High body temperature (crasy high) * Rigid muscles or spasms * Tachycardia * Rhabdomyolysis * Acute renal failure * Coagulation issues (clotting and bleeding )

Question 46

Surgical Complication **Malignant Hyperthermia ** Risk Factors :

Answer 46

**Inherited Gene Affected ** Malignant Hyperhtermia Susceptibiltity (MHS) ****RYR1 Mutation: RYR 1 mutation ** **Rarely affected genes **: CACNA1S and STAC 3

Question 47

Surgical Complication Malignant Hyperthermia (MHS) Diagsosis

Answer 47

* Genetic Testing * Muschle Biopsy ** (Tissue subjected to triggering Chemicals )

Question 48

Surgical Complication Malignant Hyperthermia (MHS) Treatment

Answer 48

**Dantrolene ** * 2.5 mg/kg IV bolus TO 10 mg/kg PRN **maintenace OPtion: ** * 1mg/kg IV Q 4 to 6 hrs 0.25 mg/kg /hr IV infusion Oxygen IV fluids x body cooling