Emma Holliday for Surgery: Part I Flashcards
What absolute findings contradict going in for surgery?
Diabetic Coma, DKA
What poor nutrition findings contradict going to surgery?
Albumin less than 3, transferrin less than 200 and weight loss more than 20%
What severe liver failure findings contradict surgery in the pre-op evaluation?
bili > 2, PT > 16, ammonia > 150, or encephalopathy
Can you get surgery if you smoke?
Stop smoking 8 weeks prior to surgery
If your patient is on a CO2 retainer, what do you need to be sure of in post-op?
Go easy on the O2 in the post-op period, can suppress respiratorydrive
What does Goldman’s Index tell us?
Tells you who is at greatest risk for surgery
6 qualifiers in Goldman’s Index?
- CHF
- MI w/in 6 months
- Arrhythmia
- Old (age >70)
- Surgery is emergent
- AS, poor medical condition, surg in chest/abd
If a patient has CHF, how do you determine if they can have surgery?
Ejection fraction.
If someone has had an MI in the last 6 months, how do you evaluate if they are fit for surgery?
EKG –> stress test –> cardiac cath –> revasc
If someone has AS, poor medical condition, surg in chest/abd, what should you check prior to surgery?
Listen for murmur of AS-
Late systolic, crescendo-decrescendo murmur that radiates to carotids. ↑ with squatting, ↓ with decr preload
5 drugs to stop before surgery
Aspirin NSAIDs vit E (2wks) Warfarin (5 days) –drop INR to less than 1.5 Insulin - Take morning dose only
What is the worry if BUN > 100?
There is an increased risk of post-op bleeding 2/2 uremic platelet dysfunction.
What would you expect on coag pannel with a high BUN?
Normal platelets but prolonged bleeding time
What is “Assist-control” on vent settings?
set TV and rate but if pt takes a breath, vent gives the volume.
What is “Assist-control” on vent settings?
set TV (tidal volume) and rate but if pt takes a breath, vent gives the volume.
You have a patient on a vent…
•Best test to evaluate management?
ABG
If a patient’s PaO2 is low?
Increase FiO2
If a patient’s PaO2 is high?
Decrease FiO2
If PaCO2 is low (pH is high)?
Decrease rate or tidal volume
If PaCO2 is high (pH is low)?
Increase rate or Tidal volume
Which is more efficient to change, tidal volume or rate?
Tidal volume
pH indicating acidosis
Less than 7.4
If your patient’s pH is low, what do you check next
HCO3 and pCO2
If HCO2 and pCO2 are high when pH is low, what do we have going on?
Resp. acidosis
If pH is low, HCO2 is low and pCO2 is low, what’s going on?
Metabolic acidosis
Formula for anion gap
= ([Na+] + [K+]) − ([Cl-] + [HCO3−]) = 16 mEq/L
= [Na+] − ([Cl−] + [HCO3−]) =12 mEq/L
Anion Gap = Sodium - (Chloride + Bicarbonate) (Bicarbonate may also be referred to as “total CO2” or “carbon dioxide”.)
Gap acidosis =
MUDPILES (>12)
M — Methanol
U — Uremia (chronic kidney failure)
D — Diabetic ketoacidosis
P — Propylene glycol (“P” used to stand for Paraldehyde but this substance is not commonly used today)
I — Infection, Iron, Isoniazid, Inborn errors of metabolism
L — Lactic acidosis
E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.)
S — Salicylates
Gap acidosis causes =
MUDPILES (>12)
M — Methanol
U — Uremia (chronic kidney failure)
D — Diabetic ketoacidosis
P — Propylene glycol (“P” used to stand for Paraldehyde but this substance is not commonly used today)
I — Infection, Iron, Isoniazid, Inborn errors of metabolism
L — Lactic acidosis
E — Ethylene glycol (Note: Ethanol is sometimes included in this mnemonic as well, although the acidosis caused by ethanol is actually primarily due to the increased production of lactic acid found in such intoxication.)
S — Salicylates
Non-gap acidosis causes:
So basically they have metabolic acidosis without an anion gap that is abnormal
H = hyperalimentation (e.g., starting TPN). A = acetazolamide use. R = renal tubular acidosis (Type I = distal; Type II = proximal; Type IV = hyporeninemic hypoaldosteronism. D = diarrhea U = uretosigmoid fistula (because the colon will waste bicarbonate). P = pancreatic fistula (because of alkali loss--the pancreas secretes a bicarbonate-rich fluid).
What defines alkalosis?
> 7.4
If I have a pH >7.4, and HCO3 and PCO2 are both low, what do we have
Respiratory alkalosis
If pH is >7.4, and HCO3 and pCO2 are high, what do we have?
Metabolic Alkalosis
If someone is in Metabolic Alkalosis, what do we check next, and what does it indicate?
Check urine [Cl].
Less than 20 means vomiting/NG, antacids, diuretics
More than 20 means weird stuff like Conn’s, Bertter’s, Gittleman’s
What does a decrease in Na mean?
We have gained water
Why do we get edema sometimes but not always when we have volume expansion in the body?
In primary renal Na retention, volume xpansion is modest and edema does not develop because blood pressure increases until Na excretion matches intake.
- Conn’s syndrome (hyperaldosteronism), Cushings, Renal failure, Nephrotic Syndrome
In secondary Na retention, blood pressure may not increase sufficiently to increase urinary Na excretion until edema develops
- Cirrhosis with ascites, peripheal vasodilation, anaphylaxis, allergic rxn, peritonitis, SBO
Causes of volume depletion?
We’re either losing a lot of fluid from the kidneys via urine or fluid in other ways:
- Vomiting, diarrhea, fistulae, GI bleed, burns, cystic fibrosis
Renal losses:
- Diuretics, aldosterone deficiency, bad adrenals
Clinical signs of volume expansion
Edema, pulmonary crackles, ascites, JVD, Hepatojugular reflex, Hypertension
Clinical signs of volume depletion
Orthostatic decrease in blood pressure and increase in pulse rate, devreased pulse volume and venous pressure, loss of axillary sweating, Dry mucous membranes
Normal volume but low sodium?
SIADH, Addisons, hypothyroid
When do we use 3% saline?
Symptomatic (Seizures)
When we give saline too quickly
Central pontine myelinolysis is a concentrated, frequently symmetric, noninflammatory demyelination within the central basis pontis. One theory proposes that in regions of compact interdigitation of white and gray matter, cellular edema, which is caused by fluctuating osmotic forces, results in compression of fiber tracts and induces demyelination. Prolonged hyponatremia followed by rapid sodium correction results in edema.
If we have increased urine sodium, what does it mean?
loss of water.
We worry about cerebral edema.
If we have increased sodium and we are worrying about loss of water, how do we treat it?
Replace with D5W or hypotonic fluid.
4 signs of low calcium
Numbness, Chvostek, Troussaeu, prolonged QT interval
Signs of increased calcium
Bones, stones, groans, psycho.
Shortened QT interval
Low potassium leads to what?
Paralysis, ileus, ST depression, U waves.
Give them Potassium
Someone who is hyperkalemic will present how?
Peaked T waves, prolonged PR and QRS, sine waves
How do we treat hyperkalemia?
- Give Ca-gluconate
- Give insulin with glucose
- Kayexalate, albuterol, sodium bicarb.
Last resort = dialysis
How much maintence IV fluid do we give?
Up to 10 kgs body weight = 100mL/kg/day
10-20 kgs body weight = 50mL/kg/day
Above 20 kgs body weight = 20mL/kg/day
Which is better, enteral or parenteral feeding, and why?
Enteral (normal PO fluids)
Keeps gut mucosa intact and prevents bacteria from translocating
When do we give TPN?
Total Parenteral Nutrition
When gut can’t absorb nutrients secondary to physical or functional loss
People on TPN are at risk for certain issues. What are they?
- Acalculous cholecystitis
- Hyperglycemia
- Liver dysfunction
- Zinc deficiency
And other electrolyte issues
(Clinical note, our interns were the ones regulating the TPN, sometimes the sodium and potassium would be off because of a bad setting. Always be sure to check this. The TPN should make the labs whatever you want them to be)
