5 - Metabolism in surgical patients

Question 1

What is the water percentage in an adult men/women?

Answer 1

60%

50

Question 2

Describe which physical examination features can assist evaluating a patient’s hydration status? 6

Answer 2

mental status
skin turgor
sunken eyes
capillary  filling
tachycardia/BP
urine output

Question 3

Which lab values can assist evaluating a patient’s hydration status? 3

Answer 3

BUN/Cr > 10
elevated hematocrit
metabolic acidosis

Question 4

How much liquid is exerted in daily feces?

Answer 4

250 ml

Question 5

How much liquid is exerted in daily urine?

Answer 5

800-1500 ml

Question 6

How much liquid is exerted in daily insensible loss

(Breathing/skin, heat, mechanical ventilation)?

Answer 6

1500 ml

Question 7

Describe the daily requirement for the following:
water-
Na-
K-
Cl-
glucose-
protein-

Answer 7

water- 2500 ml
Na- 5-10g
K- 40-80 mEq/kg
Cl- 1.5 mEq/kg
glucose- 100
protein- 0.8 g/kg

Question 8

What is the TBW (total body water) in an adult?

Answer 8

2.5 L

Question 9

Which solution will you use for GI secretion loss?

Answer 9

RL

Question 10

Which solution will you use for stomach secretion loss?

Answer 10

half standard + 20 KCL

Question 11

Which solution will you use for pancreatic secretion loss?

Answer 11

RL

Question 12

What is the maintenance fluid for an adult during surgery? 3

Answer 12

first 10 kg- 4cc/kg
second 10 kg- 2cc/kg
extra weight- 1cc/kg

Question 13

What is the maintenance fluids for a 50 kg adult?

Answer 13

40 + 20 + 30 = 90 cc

Question 14

When calculating maintenance fluids for an adult- use the following formula:

Answer 14

60 cc + (weight-20)

Question 15

Which crystalloid solutions do you know? 2

Answer 15

ringer lactate (Hartman)
Normal saline
hypertonic saline

Question 16

What are the characteristics of ringer lactate? 4

Answer 16

• hypotonic
• pH 6.5
• ECF like electrolytes (Na/K/Ca) and HCO3
• used for volume balance

Question 17

What are the characteristics of normal saline? 5

Answer 17

• isotonic
• lower pH than Hartman’s (can cause metabolic acidosis in large volumes)
• contains K
• higher electrolytes (Na/Cl/) level than Hartman’s
• used for renal failure, metabolic alkalosis, brain edema

Question 18

What are the characteristics of hypertonic saline? 2

Answer 18

hyperosmotic

allows fast volume retur

Question 19

Which keloid solutions do you know? 2

Answer 19

natural (albumin/PPF)

synthetic (HES-starch dextrose)

Question 20

What are the indications for keloid solutions? 3

Answer 20

quick volume correction
severe catabolic state (burn)
hypoalbuminemia

Question 21

Describe 5 disadvantages of keloid solution: 5

Answer 21

coagulation disorder
anaphylactic reaction
GFR decrease
pulmonary edema 
osmotic diuresis

Question 22

Which patients should receive 5% glucose solution? 3

Answer 22

infants
premature babies
elders

Question 23

What are the disadvantages of 5% glucose solution? 4

Answer 23

inotropic hyperglycemia and reduced wound healing
it can become hypotonic
osmotic urination
neurological symptoms in cerebral ischemia patients

Question 24

Surgical patients with nutritional deficiency are more likely to suffer from: 5

Answer 24

delayed wound healing
catabolism
decreased function
slower recovery
increased post-op mortality/morbidity

Question 25

What are the criteria for starting with nutritional support to a surgical patient? 5

Answer 25

* malnutrition/chronic disease * involuntary weight loss (>10% in 6 months or 5% a month) * expected blood loss of > 500 ml during surgery FTT (in infants) * katabolic disease (burn/sepsis/trauma/pancreatitis)

Question 26

What are the characteristics of a malnutrition patient?

Answer 26

BMI < 18.5 albumin < 3g% transferrin < 200 mg%

Question 27

What are the indications for enteral feeding? 1 + 3

Answer 27

inability to eat in the following 7 days + >1 meter of intestine+functioning ileocecal valve+airway

Question 28

What are the C/I for enteral feeding post op? 7

Answer 28

``` refractory vomiting/diarrhea bowel obstruction/gastroparesis/paralytic ileus bowel ischemia high output, entero-cutaneouse fistula peritonitis active GIB hemodynamic instability ```

Question 29

NGT (nasogastric tube) is used when feeding < __ weeks.

Answer 29

4

Question 30

When feeding for longer than _ weeks, use __ or __.

Answer 30

gastrostomy | jejunotomy

Question 31

What are the indications for parenteral feeding?

Answer 31

``` C/I for enteral feeding dysfunctional intestine bowel rest (e.g. post severe pancreatitis) ```

Question 32

Describe the two methods for parenteral feeding: 1- 2-

Answer 32

peripheral vein, <1-2 weeks , <850 mOsmol/L | central vein, >1-2 weeks , >850 mOsmol/L

Question 33

What are the disadvantages of parenteral feeding? 5

Answer 33

* mechanical (pneumothorax emboli, thrombosis, bleeding) * infections (sepsis, endocarditis, bacteria migration) * metabolic (hypertriglyceridemia, hyperglycemia) * acalculous cholestasis * re-feeding syndrome (in malnutrition/alcoholic)

Question 34

What happens in re feeding syndrome?

Answer 34

fast shift of P/K/Mg form plasma to cells when feeding malnourished/ alcohol abusers patients

Question 35

What are the clinical signs of re-feeding syndrome? 4

Answer 35

neuromuscular rhabdomyolysis respiratory failure/arrhythmia/ renal failure pancytopenia

Question 36

Name 5 of the neuromuscular signs that can be seen in re-feeding syndrome:

Answer 36

``` lethargy disorientation dysphagia ocular muscle weakness ataxia/seizures ```