Surgical Care – Perioperative

• “Never Events” Root cause analysis needed – surgery at wrong site or wrong patient
• Circulating nurses see things differently than surgeons
• Tight glucose control blood glucose 90-110 mg/dl is associated with higher mortality rate in post operative patients than liberal control  <180.
• statement that  >age 60 all need stress test – not valid
• PEG tubes has risk of cellulitis
• Removal of the distal ileum removal steatorrhea, impaired vitamin B12 absorption, and calcium oxalate stones.
• Immunization is not needed hemisplenectomy and nonoperative spleen salvage.
• Patient co-morbidities dictates BKA vs. AKA.  AKA has higher mortality rate.
• Hepatic cirrhosis is now relative rather than absolute contraindication laparoscopic cholecystectomy
• Dehydration occurs after some bowel preps
• Sepsis and dilution from massive transfusions cause thrombocytopenia than heparin induced thrombocytopenia.
• Day 1 post op – can consider feeding younger healthy patients, after colon surgery.
• Today, PA catheters are reserved for cardiac surgery patients and occasional major vascular case with significant CAD and heart dysfunction.
• Contrast induced nephropathy is at highest risk in patients who are hypotensive, chronic renal disease, or congestive heart failure.
• Metformin (Glocophage) – Guidline for withdrawal prior to surgery:  discontinue for at least a day, and then RESTART 2-3 days after po intake (after surgery).  Discontinued before surgery because during withdrawal lactic acidosis can develop high Mortality >50% if not adequately treated.
• Beta blockade may increase stroke risk in high risk cardiac patients
• Hyperkalemia (medical emergency, manage cardiac effects) – quickest way to manage:  give calcium gluconate IV.  On the other hand IV glucose and Insulin useful for shifting potassium into the cell but needs >30 minutes to be effective.  Calcium gluconate doesn’t have effects on potassium levels in the blood, it reduces the excitability of cardiomyocytes.
• In patients who present for emergent surgery with drug eluting stents that have been in place for at least three months, dual aspirin and plavix therapy is maintained.
• Atrial Fib:  Amiodarone or metoprolol after 48 hours can result in good blood pressure results however the patients may still be in atrial fibrillation.  Atrial Fibrillation may correct itself with volume status and electrolyte correction.
• Febrile patients with Staph infection on their central line and blood  – remove their central line catheter as their first line of defense.
• Technical errors occur more often in simple / routine procedures than complicated ones.
• DVT in the arm – location (proximal vs. distal) doesn’t matter in risk of PE.
• Insulin drips (perioperative to maintain glucose control) should be done in the ICU or other monitored setting.
• Hemostatic agents – gel foam with bovine thrombin – are used in the OR for coagulation.
• Give FFP (fresh frozen plasma) when using cell saver for autotransfusion – because when processing blood in the cell saver, there is some depletion of coagulation factors.
• Let alcohol dry before operating to prevent fires.
• Hip fracture patients – get them to OR urgently for repair; otherwise there’s morbidities associated with bed rest.
• Betablockers can be cardioprotective, but take precautions in giving beta blockers to patients with bradycardia, heart blocks, heart failure
• Mechanical bowel prep doesn’t add much to infection reduction in colon surgeries
• MRSA can even be found in skin abscesses of patients who have NOT been exposed to antibiotics.
• NG tubes should be removed as soon as possible to maximize coughing ability and pulmonary toilet.
• Neostigmine causes motility and contraction of the colon – give only if distal colon is not obstructed.
• Fondaparinux seems to have equal ability to prevent DVT compared to other heparin formulations.  Trade name Arixtra.  Chemically related to low molecular weight heparins.  Fondaparinux is a synthetic Factor Xa inhibitor.