Final Exam Flashcards
How long does it take for an empty stomach after clear liquids?
2 hours
How long does it take for an empty stomach after breast milk?
4 hours
How long does it take for an empty stomach after infant formula?
< 3 months = 4 hours
> 3 months = 6 hours
How long does it take for an empty stomach after nonhuman milk?
6 hours
How long does it take for an empty stomach after a light meal?
6 hours
What conditions increase aspiration risk by elevating intra-abdominal pressure?
Morbid obesity and pregnancy
What conditions increase aspiration risk by delaying gastric emptying?
Gastroparesis
Pregnancy
Abdominal trauma
Total body water is ____ intracellular and ______ extracellular. Of extracellular fluid, _____ is intravascular and _____ is extravascular
2/3 intracellular
1/3 intracellular
1/4 intravascular
3/4 extravascular
Plasma volume is approximately ______% of TBW
8.3%
Daily maintenance fluid requirements
100 ml per kg for first 10 kg
50 ml per kg for second 10 kg
20 ml for remaining
Hourly maintenance fluid requirements
4 ml per kg for first 10 kg
2 ml per kg for second 10 kg
1 ml per kg for remaining kg
For patients with compromised pulmonary, cardiac, or renal function, fluids should be run at _______ levels to prevent ________ _________
Lower
Fluid overloading
Surgical patients require _____ mEq/kg/d of sodium for maintenance
1-2
Surgical patients require ______ mEq/kg/d of potassium for maintenace
0.5-1
Lactated Ringers contain which electrolytes?
Na K Cl Bicarb Ca
Signs of fluid shifts out of intravascular space
Changes in blood pressure, heart rate, central venous pressure
Decreased urine output
Signs of volume excess
Weight gain, pulmonary edema, peripheral edema, S3 gallop
Fever < ______ is common after surgery. It is usually due to the _________ stimulus of surgery and will resolve spontaneously
103.5
Inflammatory
Post op fever is commonly due to the release of ________ which are a response to tissue trauma
Cytokines
Cytokines are produced by _________, ________, and ________ ______.
Monocytes
Macrophages
Endothelial cells
Fever-associated cytokines are _____, _____, _____, and ________
IL-1
IL-6
TNF-alpha
IFN - gamma
Differential diagnosis of a post op fever
Wind (atelectasis, pneumonia) Water (UTI, anastomotic leak) Wound (wound infection, abscess) Walking (DVT, PE) Wonder-drug or what did we do
What post-op day does atelectasis normally occur?
POD #1
What post-op day does pneumonia normally occur?
POD #3
What post-op day does a UTI or anastomotic leak normally occur?
POD #3
What post-op day does a wound infection or abscess normally occur?
POD #5
What post-op day does a DVT or PE normally occur?
POD #7
Risk factors for atelectasis
Painful abdominal or thoracic incision Smoking Pulmonary disease (asthma, cystic fibrosis) Obesity Respiratory muscle weakness
How to differentiate pneumonia from atelectasis?
Single sided, sputum production, elevated WBC, and temp curve that progresses upward
Risk factors for post-op UTI
Catheter use during surgery Delays in bladder emptying due to anesthesia Bladder manipulation during surgery Female gender Older age Diabetes Immobilization
Things to consider with an early fever
Necrotizing fasciitis Malignant hyperthermia Anastomotic leak Pulmonary embolism MI Allergic Rxn EtOH withdrawal
Most common bacterial agents of necrotizing fasciitis
Clostridiuim perfringens
Group A B-hemolytic streptococcus
Treatment for necrotizing fasciitis
Resuscitation
Pen G
Surgical debridement
Treatment for malignant hyperthermia
Resuscitation
Rapid cooling
IV dantrolene
Physical assessment for post-op fever
- Check the wound or surgical site
- Lung sounds, heart/abd/extremity exam
- Check IV sites, central line, foley tubes
Raise the threshold for CNS toxicity of local anesthetics
Benzodiazepines
ADRs of sedation, disorientation
Benzodiazepines
Tolerance observed in patients with chronic use of alcohol
Barbiturates
Agents pentobarbital and thiopental
Barbiturates
ADRs of cardiac and respiratory depression (monitoring is very important)
Barbiturates
Avoid in porphyria
Barbiturates
Etomidate has hypnotic but not ______ properties. Must follow with ______ and _______ ______ drugs
Analgesic
Analgesic and muscle relaxant
ADRs of hypotension, cardiac dioxide retention, suppresses corticosteroid synthesis at adrenal cortex
Etomidate
Often included in rapid response or intubation kits, induces sleep for 5 minutes
Etomidate
ADRs of respiratory depression, N/V, constipation
Opioids
Often used for emergency surgical procedures (ER use with orthopedic indications, use in children)
Ketamine
Associated with unconsciousness, analgesia, and amnesia
Ketamine
ADRs of hallucinations, bad dreams, increased muscle tone/rigidity
Ketamine
Lipophilic anesthetic, cannot see through it
Propofol
Used often in neuro ICU
Propofol
ADRs of significant respiratory depression, hypotension, and injection site pain
Propofol
ADRs of N/V, malignant hyperthermia, caution in patients with renal/hepatic dysfunction
Inhaled anesthetics
Agents include nitrous oxide, sevoflurane, isoflurane, desfurane
Inhaled anesthetics
Lidocaine, bupivacaine, prilocaine, dibucaine
Amino amides
Frequently used in epidurals
Bupivacaine
Suppository use for pain relief and analgesia for hemorrhoids
Dibucaine
Benzocaine, cocaine, procaine, tetracaine
Amino esters
Concentration, max dose, onset, and duration of lidocaine
1-2%
4.5-5 mg/kg
< 2 min
0.5-1 hour
Concentration, max dose, onset, and duration of lidocaine with epinephrine
1-2%
7 mg/kg
< 2 min
4-6 hours
Concentration, max dose, onset, and duration of bupivacaine
0.25%
2.5 mg/kg
5 min
2-4 hours
Concentration, max dose, onset, and duration of bupivacaine with epinephrine
0.25%
max 225 mg
5 min
3-7 hours
ADRs of CNS effects (seizures), bradycardia, arrhythmias, respiratory arrest, burning sensation, skin discoloration, tissue necrosis/sloughing, neuritis
Local anesthetics
ADRs of hematoma, infection, headache
Spinal anesthesia
Risk factors that affect pain control in perioperative settings
Preoperative pain (higher baseline) Anxiety Genetics Female gender Opioid tolerance
Reduce opioid requirements and may contribute to lessened PONV when used
NSAIDs and COX-2 inhibitors
Ketorolac, ibuprofen, naproxen
NSAIDs
Celecoxib
COX-2
Ketorolac has a limit of ____ days for patients
5
Used in ICU setting for sedation and in anesthesia for brief procedures
Dexmedetomidine
Often times completely locked down by hospitals, has sedative, anxiolytic and analgesic properties
Dexmedetomidine
ADRs of monitoring HR, blood pressure, and sedative effects
Dexmedetomidine
Risk factors for PONV
Female gender Motion sickness/previous PONV Non-smoking status Post-op use of opioids Use of inhaled anesthetics
Pre operative approach of PONV
Benzodiazepines for anxiolysis Compassionate interaction with staff Aprepitant Dexamethasone Pre-hydration
Intra operative approach to PONV
Use of regional anesthetics Propofol Analgesia (non-opioid) Ketamine Anti-emetic therapy
Pharmacologic treatment for PONV
Serotonin antagonists Neurokinin inhibitors Steroids Antihistamines Butyrophenones Benzodiazepines
ADRs of HA, diarrhea, constipation, arrhythmias
Serotonin Antagonists
Ondansetron, Granisetron
ADRs of HA, diarrhea, weakness, dizziness
Neurokinin Inhibitors
Aprepitant
Administered pre-anesthesia reduces nausea and vomiting up to 48 hours after surgery
Neurokinin Inhibitors
Aprepitant
ADRs of dizziness, mood change, nervousness
Steroids
Dexamethasone
ADRs of sedation, confusion, dry mouth, urinary retention
Antihistamines
Dimenhydrinate, promethazine
ADRs of prolonged QT interval (black box), hypotension, tachycardia, extrapyramidal symptoms
Butyrophenones
Droperidol
Types of burns
Thermal
Electrical
Chemical
Radiation
Four crucial assessment of burns
- Airway management
- Evaluation of other injuries
- Estimation of burn size
- Diagnosis of CO and cyanide poisoning
Consider intubation in burns if:
Suspect airway injury
Full thickness burns to the face/mouth
Circumferential chest burns
Steps to take for burn patients
Large-bore IVs and begin fluids ASAP (high risk for intravascular fluid loss)
May need central venous access
Transfer in clean dry blankets
Treat the pain and anxiety (benzodiazepines)
In burn patients, there is no need for ___________ but there is need for _________
Prophylactic abx
Tetanus booster
__________ is the most common type of burns in pediatrics
Scalding
_______ are the most common cause for hospital burn admissions
Flames
Burn: only epidermal layer. Dry, red, painful, blanching. Typically heal in 3-6 days. NO blisters.
Superficial (1st degree)
Burn: usually very painful and do blister
Partial-thickness (2nd degree)
Superficial vs deep partial thickness
Burn: painless, non blanching, do NOT spontaneously heal
Full-thickness (3rd degree)
Burn: may extend into tissue, fascia, muscle, bone, organs
4th degree
Burns TSA for adults
Chest and back: 18% Arms: 9% Legs: 18% Hands: 1% Head: 9%
Burns TSA for kids
Chest and back: 18% Arms: 9% Legs: 14% Hands: 1% Head: 18%
Parkland formula for burns
LR 4cc x kg x %BSA = amount given in 24 hours
Half over the first 8 hours, over half over the next 16 hours
Circumferential burns to the chest or limbs
Check pulses frequently, escharotomy may be needed
Consider intubation
IV fluids typically given for burns
LR
Burns > ____% BSA get fluids
10%
Large amounts of NS could cause ______________
Hyperchloremic acidosis
Most widely used as prophylaxis against infection with burns
Silver sulfadiazine
Important to know that silver sulfadiazine destroys ____________
Skin grafts