How'll App Flashcards
fluid maintenance rate of elderly
why?
25 mL/Kg
older pts are unlikely to tolerate the robust fluid
fluid maintenance regimen for young?
4 ml/kg for the first 10 kg
2 ml/kg for the second 10kg
1 ml/kg for every kg remaining
blood sugar goal for surgical patients
why?
180-200 mg/dL
can’t risk hypoglycemia- when body is stressed it has slight elevations of glucose that will normalize shortly after surgery
why would you think of an obstruction in a surgical patient
starts to complain of n/v, obstipation and constipation, distention
large surgical history (suggestive of adhesions)
test to determine if pt has obstruction?
CT of abdomen
how do you treat obstruction (N/V)
NG tube
esp Salem Slump
Abdominal pain and urgency to void, but with challenges in initiating and completing micturation
DISTENDED BLADDER
tx of distended bladder
foley Cath
urology consult
low urine output but normal bladder scan
pre-renal (hypovolemia)
5 W of post op fever
Wind (atelectasis, PNA) Water (UTI, iV line) Wound (infxn, abscess) Walking (DVT, PE) Wonder drug (B-lactam abx)
Signs of likely infection: (6)
Fever occurring > 48hrs post-op
Pre-operative trauma
An initial temperature elevation above: 38.6°C (>101.5°F)
Leukocytosis greater than 10,000/L
Post-op BUN of 15 mg/dL+
Poor protoplasm
PE of post op fever
1 check the wound/surgical site
the MC pancreatic carcinoma?
Adenocarcinoma
Where is the MC location of pancreatic carcinoma?
Head of the pancreas, followed by body and then the tail.
What are some genetic variants/risks associated with pancreatic carcinoma?
First degree relative,
BRCA gene, HNP-CC, FAP
social hx risk factors of pancreatic CA
Smoking, Drinking and DM
What is the palpable mass of the RUQ called?
Courvoisier Sign
palpable gall bladder
pancreatitis and jauncie
painless obstructive jaundice due to mass in head of pancreas causing biliary obstruction
pruritus and pancreatic CA
common in pts due to biliary obstruction
Benadryl will not help (not histamine issue)
ERCP stent placement to expand duct
virchow’s node
Palpable cervical node,
most prominently in the medial end of the supraclavicular aspect
blumer’s shelf
presence of metastatic mass in the rectal pouch
sr. Mary joseph’s nodule
Periumbilical subcutaneous nodule
highly suggestive of metastatic disease
what study should be done to evaluate a pancreatic mass?
Abdominal CT with contrast
MRCP would also work
lab marker for pancreatic CA
CA 19-9
> 100 highly specific for malignancy
surgical procedure done to manage pancreatic CA?
What stage is most appropriate?
Whipple
stage 1-2
post - op MI work up
CXR
Cardiac Enzymes
also if symptoms are GI related then CT abdomen and Pelvis w/contrast to ensure it is ok
wound vac
pulls fluid from the wound to reduce swelling and help clean wound to remove bacteria
**promotes granulation tissue development ***
how many days before you can take out a suture:
on head
4-5 days
how many days before you can take out a suture:
UE/LE
5-7 days
how many days before you can take out a suture:
Torso
7-10 days
keloid
3-12 months after injury and extend beyond
tx with kenalog (surgical correction
where is MC spot for keloid
earlobe, deltoid, presternal and upper back lesions
kenalog
tx of choice fir keloid
steroid reaction causing skin atrophy
hematoma effect on wound
distort wound edges and impinge on vital structures
blood will leak thru suture
seroma
Fluid, other than pus or blood, which collects at the operative site, delaying healing and increasing the risk of infection.
issue with seroma of groin?
left to resolve on own w/surveillance bc increased risk of infection with aspiration
three phases of wound healing
inflammatory
proliferative
maturation
first cell to enter a wound?
platelet
contact with damaged collagen causes degranulation and release of growth factors to attract cells to wound
What cell predominates in the inflammatory phase?
neutrophils
what effect do PMNs have on wound healing and recovery
PMN’s do not heal the wound and persist presence will delay wound healing
Oxygen free radicals are produced by
macrophages
If the wound is deprived of the following blood cell, delayed wound healing and poor tissue strength should be effected?
A. Platelets
B. Macrophages
C. Neutrophils
D. Lymphocytes
Macrophages
This cell predominates in the proliferative phase of wound healing, and what is it’s role?
Fibroblast: synthesizes and secretes collagen, for wound deposition
GI is a challenge in wound healing why?
heavy bacterial burden
inability to provide adequate “rest” of the system
pH changes in HI
early and marked lysis of collagen
GI healing complication when NOT enough healing occurs
dehiscence, leaks, fistulas
GI healing complication when TOO MUCH healing occurs
strictures/stenosis of lumen (adhesions)
Why does cartilage suffer so greatly following wounding?
It is avascular, must depend on diffusion for adequate nutrient and oxygen supply;
no inflammatory response.
contaminated wound
15% infx rate,
spillage from the GI, GU, and pulm system. + trumatic wounds w/soil
clean contaminated
8% infx rate, including Gi, GU or Pulm system w/o spillage of contents
dirty
35% infx rate, at side of existing abscess and infx
clean wound
3% infx rate, no break in sterile field
abrasion
superficial epithelial loss
no closure just cleaning, tx with petroleum gauze
puncture wound tx
deep tissue injury assessment, valuation for foreign bodies and ongoing infection
tetanus management
avulsion
shearing force and part of wound doesn’t have underlying fat and muscle
closure by anchoring to underlying tissue and finding edges
vermillion border
line up sutures here
found across hair or eyebrow
better cosmetic results
Primary Wound Closure
approximating the epithelial wound edges with suture, staples or adhesive immediately after cleaning and debridement.
done right away
Secondary Wound Closure
The wound is allowed to close by granulation tissue proliferation followed by contraction and epithelialization from the edge of the wound
Tertiary Wound Closure
after a delay of days to a week, the edges of the wound are debrided and closed like a primary closure.
neuroendocrine pancreatic CA
arises out of endocrine tissue of pancreas
typically benign but CAN be malignant
secrete peptides (insulin, glucagon, gastrin, VIP)
Insulinoma + tx
pt presents with recurrent hypoglycemia (insulin) or hyperglycemia (glucagon)
tx with surgical resection
Gastrinoma
large amounts of gastrin produced, increased gastric acid production = refractory PUD
gastrin > 150
ZES tumor found where?
pancreas or duodenum
how do you confirmZES
fasting secretin test
gastrin levels increased .200
VIPoma syndrome
WDHA
Watery Diarrhea
Hypokalemia
Achlorhydria
TXA
interferes with hyperfibrinolysis (excessive clot formation in truama)
CRASH -2 = ok to give if <3 hrs post injury
necrotizing fasciitis
ecchymosis, hemorrhagic bullae, cellulitis, crepitation
pain out of proportion to exam
necrotizing fasciitis tx
aggressive surgical debridement
broad spectrum abx
hyperbaric O2
lab assessment of hyponatremia + tx
FeNa
correction slowly (< 10 mEq/L in 24hrs)
hyperkalemia EKG
Peaked T, flat P, shortened QT,
muscle weakness, respiratory paralysis
hyperkalemia tx
Medications: - Calcium, D50, Insulin-
Loop Diuretric, Albuterol, and Dialysis
hypokalemia s/s
Flat T’s, depressed ST, prolonged PR interval and widened QRS.
fatigue, weakness, paresthesias and an Ileus
tx of hypokalemia
K supplementation
IV or PO (both have bad side effects)
isotonic fluid order that can reduce these electrolyte derangements in the immediate post-operative period?
D5W 1/2 NS + 20mEq KCL @ 75cc/hr
wound dehiscence
rupture of total or partial layers of surgical wound
systemic factors causing dehiscence
DM, renal failure, obesity,
immunosuppression, low albumin, CA, sepsis
when does dehiscence MC occur?
5-8 days post op
how is dehiscence described?
sudden ripping or tearing sensation
local factors causing dehiscence
inadequate closure
increased intraabdominal pressure
deficient wound
how is hepatic CA diagnosed?
ONLY one that doesn’t need Bx
contrast CT scanning
repeat u/s in 3 months
risk factors for HCC
Hepatitis B and C,
Hemochromatosis
Cirrhosis
EtOH/Tobacco, NASH, Alpha1Antitrypsin
factors that are considered protective against HCC?
statin use, white meat/fish, omega 3 fatty acid consumption
how are high risk patients for HCC screened?
RUQ U/s and AFP
what GI CA known to present with fever
Hepatocellular and Cholangiocarcinoma
four neoplastic syndromes in hepatocelluar carcinoma?
- Hypoglycemia,
- Erythrocytosis,
- Hypercalcemia,
- Diarrhea
the four common sites of metastatic spread in hepatocellular carcinoma?
- bone,
- adrenal glands,
- lymph nodes (intra-abdominal)
- lung
Prognostic tool for hepatocellular carcinoma
Child-Pugh Classification
Child-Pugh Score 7-9
B Moderate
Child-Pugh Score 5-6
A Mild
Child-Pugh Score 10-15
C Severe
Child-Pugh Score who gets resection?
Child-Pugh A and B
Child-Pugh Score who gets chemo?
NONE
chemo resistant
Child-Pugh Score who gets transplant?
Child-Pugh c
When the liver is found to have metastatic disease of cancer, but the liver is not believed the primary site- what two areas are believed the source?
Lung and Breast
MC bacteria for PNA
GNR
considering tx for post op PNA, what do you want to cover for?
polymicrobial infection
how do you tx hypoxia?
increased FiO2
how do you tx hypercapnia?
increase minute ventilation
oliguria
UOP < 30 cc/hr or less than 400 mL/day
condition marked by compression of the common hepatic duct by an impacted stone in the gallbladder neck?
Mirizzi Syndrome
Gallbladder CA typically diagnosed?
late stage, intraoperatively
Ideal would be u/s! But unfortunately, not going to happen until late
how do you cure gall bladder CA?
surgical management can be curative
BUT not often done due to late stage presentation
What are the agents that are often used for PCA?
Morphine,
Dilaudid,
Fentanyl
Meperidine
PCA last drug of choice?
Meperidine
avoid in elderly, renal failure, or concurrent MAO inhibitor tx
PCA drug of choice
morphine
What is one vital sign measure that is a limitation for pain management when admitted?
RR <12
Dilaudid
onset of action + duration of action (IM)
onset: 20-30 min
lasts for 4-6 hrs
Dilaudid
onset of action + duration of action (IV)
onset: 5 min
Last: 2-4 hrs
Fentanyl
onset of action + duration of action (IM)
onset: 8 min
last: 1-2 hrs
Fentanyl
onset of action + duration of action (IV)
onset: <1 min
lasts: 0.5-1 hr
MOA for Narcotics?
Binding the receptors in the CNS, increasing pain threshold altering pain reception, inhibits ascending pain pathways
Side effects of Narcotics?
Respiratory and CNS depression, as well as Constipation
How do you want to address constipation w/outpt opioids?
Colace
what must be accomplished prior to pt being discharged
Urinated
Get out of bed
Tolerate small amount of oral intake
MOA + Dose
Promethazine (Phernergan)
H2 blocker and mesolimbic dopinergic
12.5-25 mg
MOA + Dose
Metoclopramide (Reglan)
Blocks dopamine receptors and dependent serotonin receptors
10 mg
MOA + Dose
Ondansetron (Zofran)
Blocks serotonin, working in vagal nerve an central chemoreceptors
4-8 mg
