Care of the Surgical Patient

Question 1

what abnormal blood results would be seen in a dehydrated pt.?

Answer 1

increase urea

decreased haemocrit

Question 2

what observations will be seen in hypovolemic shock?

Answer 2

increased HR and RR
decreased BP
oliguria

Question 3

daily requirements of water, Na+, Cl-, K+ and glucose

Answer 3

water: 3L
Na+: 150mmol
Cl-: 150mmol
K+: 100mmol
glucose: 125-150g

Question 4

kilocalorie requirements for an adult pt.

Answer 4

25kcal/kg/day
to
45kcal/kg/day if post-op

Question 5

perioperative risk factors for post-op DVT

Answer 5

age
male
corticosteroid use
COPD
recent weight loss
disseminated Cancer
low albumin and low haemocrit
Hx of DVT
trauma
smoking 
hypercoaguable disorders 
COCP

Question 6

intraoperative risk factors for post-op DVT

Answer 6

haemorrhage
injured veins
blood transfusion 
GA
fat emboli 
length of surgery and hence immobility

Question 7

post-operative risk factors for post-op DVT

Answer 7

inactivity 
MI 
coma 
pneumonia 
UTIs

Question 8

how do compression stockings reduce risk of DVT?

Answer 8

reduced vein diameter –> increased pressure –> increased blood flow to heart –> decreased haemostasis and clots

Question 9

what medication is used for thromboprophylaxis due to surgery?

Answer 9

dalteparin 5000U

Question 10

signs of hypoglycaemia

Answer 10

shakiness
dizziness
sweating
hunger
headache 
blurry vision

Question 11

Ax treatment of inpatient UTI

Answer 11

uncomplicated: trimethoprim PO 200mg bd 3 days
complicated: trimethoprim PO 200mg bd 5 days or co-amoxiclav PO 625mg tds (aka Augmentin - is first line in males)

Question 12

Ax treatment of pyelonephritis

Answer 12

co-amoxiclav PO 625mg tds 14 days
if NBM then co-amoxiclav IV 1.2g tds 14 days (switch to oral when possible)
if penicillin allergic then ciprofloxacin PO 500mg bd 7 days
if penicillin allergic and NBM then meropenem IV 500mg qds

Question 13

Ax treatment of meningitis

Answer 13

ceftriaxone IV 2g bd (duration depends on culture) consider also giving dexamethasone sodium phosphate IV 10mg qds
if immunocompromised or >55y/o consider listeria so also give amoxicillin IV 2g 4 hourly

Question 14

Ax treatment of unknown origin sepsis

Answer 14

flucloxacillin IV 1g qds & metronidazole IV 500mg bd & gentamicin IV 7mg/kg of
if penicillin allergic then give meropenem IV 500mg qds

Question 15

Ax treatment of CA pneumonia

Answer 15

CURB Score (CS) 
CS 0-1: amoxicillin PO 500mg tds 
CS 2: amoxicillin PO 1g tds & doxycycline PO 200mg od
CS 3-5: co-amoxiclav IV 1.2g tds & doxycycline PO 200mg od
if penicillin allergic -->
CS 1-2: doxycycline PO 200mg of
CS >3: meropenem IV 500mg qds & doxycycline PO 200mg of
if NBM then sub doxycycline with clarithromycin IV 500mmg bd

Question 16

Ax treatment of HA pneumonia

Answer 16

moderate: co-amoxiclav PO 625mg tds
NBM: co-amoxiclav IV 1.2g tds
penicillin allergic: doxycycline PO 200mg or meropenem IV 500mg qds if NBM

Question 17

Ax treatment of C. Difficile

Answer 17

no markers of severe disease: metronidazole PO 400mg tds 10 days
markers of severe disease: vancomycin PO 125mg qds 10 days

Question 18

Ax treatment of cellulitis

Answer 18

mild: flucloxacillin PO 500mg qds 7 days
severe: flucloxacillin IV 2g tds 7days
if penicillin allergic
mild: doxycycline PO 200mg od 7days
severe: vancomycin 1g ods

Question 19

causes of AKI

Answer 19

pre-renal: hypovolaemia (haemorrhage, GI losses, renal losses, burns), reduced CO (cardiac/liver failure, sepsis, drugs)
renal: drugs (ACEi, NSAIDs), vascular (vasculitis, thrombosis, thromboembolism, dissection), glomerular (glomerulonephritis), tubular (ischaemia, rhabdomyolysis, myeloma, contrast), interstitial (interstitial nephritis)
post-renal: obstruction (renal stones, pyonephrosis, blocked catheter, pelvic mass, enlarged prostate, cervical carcinoma, retroperitoneal fibrosis)

Question 20

what is a massive blood transfusion in adults?

Answer 20

replacement of >1 blood volume in 24hrs or >50% of blood volume in 4hrs
occurs due to severe trauma, ruptured AAA and surgical/obstetric complications
mortality is high due to hypotension, acidosis, coagulopathy, shock and the condition of the pt. the lethal triad = pts with acidosis, hypothermia and coagulopathy

Question 21

what are the components of FFP and cryoprecipitate?

Answer 21

FFP –> plasma frozen to -35C, used to treat large volume bleeds and DIC
cyro –> made from FFP that is frozen and repeatedly thawed to concentrate the clotting factors, used to treat DIC, advanced liver disease, renal/liver failure, and hypofribrinogeneamia

Question 22

list some early and late complications of blood transfusions

Answer 22

early (<24hrs): haemolytic reaction, sepsis, anaphylaxis, circulatory overload, ARDS
late (>24hrs): graft vs host disease, infection, post-transfusion purpura

Question 23

what is assessed in the EWS?

Answer 23

RR
O2 sats
if the pt is on oxygen 
temperature (normal 36.1-38)
systolic BP
HR 
conscious level (AVPU)

Question 24

causes of post-operative pyrexia

Answer 24

early (days 0-5): blood transfusion, cellulitis, UTI, pulmonary atelectasis, physiological systemic inflammatory reaction
late (days >5): venous thromboembolism, pneumonia, wound infection, anastomotic leak, PE (typically occurs day 10-12 when a pt is straining over a stool)

Question 25

causes of increased urea:creatinine ratio

Answer 25

(Drivers Can Use GPS)
Dehydration/prerenal failure
Corticosteroids
GI haemorrhage 
Protein rich diet 
Severe catabolic state

Question 26

causes of decreased urea:creatinine ratio

Answer 26

(i am a SIMPLE SR)
Severe liver dysfunction 
Intrinsic renal damage 
Malnutrition 
Pregnancy 
Low protein diet 
SIADH 
Rhabdomyolysis

Question 27

what increases the risk of having a DVT?

Answer 27

smoking 
immobility 
dehydration 
hyperlipidaemia 
age
female
trauma/ surgery due to stress response and increased clotting
AF
blood abnormalities - HbS/ thalassaemia