Medical Knoweledge Flashcards
largest water space in body?
smallest?
intracellular 40%
intravascular
What recylces interstiital cluid and where does it end up?
lymph, vasc
intra v extra predom K vs alb
K intra
alb extra
intracellular cations and anions
extra?
K and mg; protein and phos
na; Cl and bicarb
intavascular overall cation concentration is higher due to
high protein anions
blood transfusion effect on intravasc osm pressure
decrease as water is pushed out by large particle
4-2-1 rule?
1ml/kg first 20 K
2 10K
4 10K
components of NS and LR
definition of oliguria in 70 kg man
Oliguria in a 70-kg man is defined by less than 400 mL of urine produced and excreted in a 24-hour period.
For icu patients what would we prefer hyper vol or hypo and why?
hyper
pulm failure carries 25% mortality while kidney failure 48%
signs of high IV fluid status
High output generally will mean that the body is trying to rid itself of water; surgeons should assist it by decreasing the maintenance fluid rate. Anasarca is another helpful clue, as are the customary vital signs.
How does Pto F ratio help with determining fluid status
poor ratio equals fluid in inteerstitium
usual reason for post op low uopin surg patients
In most, if not all such patients, low urine output postoperatively means that they have deceased renal blood flow from insufficient intravascular volume.
stress dose regimen for adrenal insufficiency
50 mg hydrocortisone q8h
severe hyponatremia s/s
mech
Severe hyponatremia, however, can cause headaches and lethargy; patients can even become comatose or have seizures.
brain cell swelling
3 broad causes of hyponetremia
iatrogenic
brain
lung
bodys normal initial response to hyponatremia?
What volume status is this hindered by
adh suppression
hypovol state causes pituitary to secrete adh
adh secreting tumors
small cell lung and carcinoid
the 3 volume states of hypernatremia and teh causes
Hypovolemic hypernatremia commonly occurs in dehydrated patients with low water intake, high fluid losses such as vomiting, nasogastric tube loss, or diarrhea. Euvolemic hypernatremia is seen in patients with DI (nephrogenic or neurogenic) because of excess loss of urinary free water. Hypervolemic hypernatremia is usually iatrogenic caused by resuscitation with hypertonic solutions or a result of excess mineralocorticoids in Conn or Cushing syndrome.
what controls potassium excretion
RAAS aldosterone
consequences at differing levels of hypokalemia
ve a [K+] lower than 3.5 mmol/L. Hypokalemia is commonly a result of hyperpolarization of the resting potential of the cell. Hyperpolarization interferes with neuromuscular function. Hypokalemia is associated with generalized fatigue and weakness, ileus, atrial arrhythmia, and acute renal insufficiency. On occasion, rhabdomyolysis occurs in patients whose [K+] drops below 2.5 mmol/L. Flaccid paralysis with respiratory compromise can occur as [K+] decreases to less than 2 mmol/L.
2 electrolyte associations with hypok
hypo mg and acidemia
ekg changes with hypo K
arrythmias?
depressed T and U waves
atrial tach, v tach, v fib
why is hypokalemia so stubborn
severe intracellular depletion is needed to show up in serum
why is mg needed for hypok repletion
intracellular co-cation for transport, reduces arrythmia risk
primary clinical problem with hyperK
what is a dangerous level?
usual cause in the hospital
arrythmias – peaked T waves
6-7
renal failure
what is recommended prior to reperfusion of ischemic limb from an elevtrolyte standpoint
bicarb for K
first thing to give for hyperK
mech?
Ca
antagonizes depolarizing effect of K
acidotic hyperK treatment?
bicarb, H out – K in
mainstay of hyperK tx after Ca
insulin and gluc — pushes K into cells via na K ATPase
pending arrest hyperK treatment
Loss of P wave and broad slurring of QRS; immediate effective therapy indicated
Intravenous (IV) infusion of calcium salts
10 mL of 10% calcium chloride during a 10-minute period or 10 mL of 10% calcium gluconate during a 3- to 5-minute period
IV infusion of sodium bicarbonate
50-100 mEq during a 10- to 20-minute period; benefit proportional to extent of pretherapy acidemia
hypoalbumenia does what to calcium in serum
decreases by 0.8 per 1 drop
what can happen to calcium during blood transfusion for trauma
can drop due to citrate load
always give calcium!
3 situations with hyperphosphatemia
uch as those with tumor lysis syndrome, rhabdomyolysis, or chronic renal failure
what coexisting deficiency needs to be fixed to tx hypocalcemia
hypomg
3 tx for hyperphos if renal function impaired
why is this important when trying to fix hyper ca
saline
acetazolimede
hemodialysis
phos dec PTH stim and binds to ca in serum
treatment for chronic hypocalcemia
oral supplement , maybe vit D
tx for hypercalciuria
thaiazide
signs of severe hyper ca
weakness, stupor, and central nervous system dysfunction. In
MCC of hyperca
2 others
what about inpatient vs gen pop
primary hypePTH
malignancy and unregulated PTH
It occurs most commonly with malignant diseases in hospitalized patients and with hyperparathyroidism in the general population.
MC malignant cause of hypercalcemia
breast ca
hypercalcemia s/s
What is secondary hyperPTH
renal disease — remove glands
What is the mechanism of hypercalcemia of malignancy
pTHrp but sometimes actual PTH elevation
causes of hypocalcemia
e hypoparathyroidism after thyroid or parathyroid surgery, vitamin D deficiency, gastric bypass, acute pancreatitis, osteoblastic metastases, massive transfusion, and hyperphosphatemia.
perioral numbness specific for what electrolyte abnorm
hypoca
ekg change with hyperca
short QT
Long term symptoms of hyperca
nephrolithiasis, renal tubular acidosis, and renal insufficiency
hypoca ekg finding
long qt
hyperca treatment
Treatment of hypercalcemia is initially begun with intravenous saline hydration.
Loop diuretics (after normalization of volume status), calcitonin, intravenous bisphosphonates, and glucocorticoids can also be used in severe hypercalcemia.
electrolyte abnormality post liver resection
Significant hypophosphatemia is common following major liver resection, an effect caused by rapid phosphate utilization in the regenerating hepatocytes.
severe hypomg arryhtmia
torsades
First cells to arrive after platelet activation
neutrophils last for 48h
Mp timing in wound healing. Job?
48-96
debris, bacteria, signal fibroblasts
Proliferation phase is characterized by these two cells
What type of collagen is present and what is happening to it
what aids in this
fibroblasts and myo fibroblasts
3, crosslinking
VC
when does remodeling start? Collagen make up? orchestrating cell?
3weeks
3—>1
Mps
Vitamin A in wound healing?
zn deficiency issue?
may reverse poor healing from steroids
poor epithelialization
how long until epithelialization occurs in wound healing?
48h
What is usually the cause of leg ulcers
venous insufficiency
time limits on wound closures leg vs face
18
24
irradiated wounds can be treated with 2 interventions
hyperbaric and flaps
term for cappilary formation in STSG
inoscultation
What needs to be held prior to surgery med wise?
7 days
5 days
48h
24h
Plavix, ticagrelor
warfarin
NOACs
ACE, ARB, heavy diuretics
first cell to arrive on wound scene
what is release by endothelial cells that recruits leukocytes
nps
NO
inr response to injury
tnfa
IL6
IL10
act pro inflam path
Acute phase reactant
anti inflam
post transplant prophylaxis? duration?
gangciclovir and bactrim for 3 - 6 months
clotrimazole for mucocut candi
2 most common bugs for postransplant diarrheal illness
cdiff and cmv
what other body system needs annual check post transplatn
skin
induction therapy focuses on preventing this cell signaling
mainstayt of kidney induction
T cell
antithymocyte globulin
2 big SE for antithymocyte glbulin
what cell is targeted
pancytopenia and virus reactivation
T cell
what are the calcineurin inhibitors?
main SE
Tac and cyclosporine
nephro, HUS(cyclo)
long term steroid choice for transplant
prednisone
immune action of steroids
inhibits nfkb, inhib cytokines and lymph prolif
azathiprine 3 big SE
pancytopenia, BLACK BOX, pancreatitis
what are the 2 transplant antimetabolites
mycophenelate and azothioprine
sirolimus and everolimus mech
never use with what other transplant med
mTOR interferes with IL2
black box with CNI, graft loss and mortality nc
next 2 steps when concerned about liver or kidney rejection
u/s and bx
hyperacute rejection timing and cause
24h
ABO incomp—needs crossmatch
acute rejection timing
what type shows lymphocyte infiltr and necrosis? TX? refractory?
what if bx shows vasculitis
24h-3m
cell mediated type4 hyper sens
steroids
antithymocyte
ab mediated
chronic rejection timing
path?
m to y
interst fibrosis ischemic atrophy, arteriosclerosis
chronic lung rejection presentation
bronch obliterans
MC post transplant window for infeciton
1-6m
4 big opportunistic infections in acute phase
CMV
BK
PCP
mucocut candida
What does BK effect in transplant
tx
uret stenosis, nephritis–>70% fail
red immunosupression
Tx for post transplant lymphoproliferative disorder
red immunosuppression
SSI duration coverage for classification
30 days
AIDs is defined as
HIV with 200 CD4 cells or AIDs defining illness
What to do with periop managment of HIV drugs
continue, a couple of days is fine though
storage life of rbcs
whole blood?
42 days
4 weeks
what is the exception for the hb transfusion threshold
MI
fridge time for ffp
5d
how are cryo and FFP related
cry is made up of fibronectin, factor 8 factor 13, vwf, and fibrinogen
these precipitate out after FFP is thawed
thresholds for certain procedures for platelet count
2 instances of cryoprecipitate use
trauma and DIC(100K)
what do I always forget to give with mass transfusion how often should it be given
Ca every 3-4 units
tx for severe transfusion reaction
stop
steroids
epi
saline
diuretics
bilious vomiting in infant is _____ until proven otherwise.
Imaging?
mid gut volvulus
upper gi only if stable
redness at gastric band port site means….
dg modality?
band erosion
scope
inguinal triangles and borders
MC benign liver tumor
2 primary complications
2 secondary
hemangioma
kasabach merrit and bleeding
GOO and budd chiari
when can triple neurectomy be used for mesh pain
when neuropathic s/s are present
plastic stent overall treatment duration for biliary stricture post injury
replacement sched?
1 year
3-6m
splenectmoy vax sched
whats the diff between pneumoc 13 and 23 — when is each given
number of strains covered
13 initial then 23 2 months later, q 5y 23 admin
obturator hernia treatment algorithm
obturator hernia repair anatomy
desmoid unresectable treatmetn
mech?
sorafenib
TKI
comorbidity reduction in young vs old bariatric patients
greater improvement
for large condyloma lesions, what is the preferred intervention
what limits this
excision
sphincter involvement
another name for microsatellite stable
unstable?
how does this change managment for stage 2 colon cancer
proficient MMR
deficient MMR
if dMMR or high micro instability then patient needs adjuvant
common cause of PPI failure
what cells are affected
skipping doses and not taking with food causing rebound reflux
parietal
new treatment for uncomplicated, no abscess diverticulitis
out[atient obs
SB adenoca risk with common assoc syndromes or diseases
ultrasound benefit for breast ca
better detection of invasive node neg ca
risk increase or dec for breast ca:
breast feeding
older at preg
post partum
dec
inc
inc
first step for trouble shooting poor radiotracer uptake in axilla
The most common cause of failure of radioactive tracer to map to the axilla is injection into the breast parenchyma alone. For this reason, it is recommended to inject the radioactive tracer into the dermal plane. Injecting fluid in the site of the radioactive tracer injection site increases the interstitial pressures and forces more radioactive tracer into the lymphatic channels. Sterile saline or local anesthetic can be used with volumes of 10 to 40 mL.
benefit of neoadj for breast ca
inc eligibility for breast conservation
ATM gene cancers
panc and rbeast
managment of ANY met disease in SLNB following neoadjuvant treatmetn
ax dissection
mucinous ca of breast:
prognosis?
receptors?
who gets it?
good
estrogen
menopausal
2 breast density categories with inc cancer risk
C and D
50-75% dense, 75 up
bariatric weight cutoffs
35 no com
40 comorb
6 characteristics of malnutrition
Decreased energy intake
Weight loss
Body fat loss
Muscle mass loss
Edema
Reduced grip strength
what happens to albumin during inflammation
drops due to catabolism for cysteine
what helps in confirming reliability of our three nutritional acte phase reactants
CRP
for transferrin, albumin and prealbumin
calorie needs per patient state? protein?
normal - 30 - 1
stressed - 35 - 1.5
burns - 40 - 2+
protein glucose and fat kcal per
4, 4, 9
RQ qotients for fat, protein carbs
0.7
0.8
1
nitrogen balance equation
4 supplements cirrhotics might need for their nutrition
phosphate, zn, multi, B1 thiamine
cholestasis nutritional restriction strategy
manganese and cu
4 results of hyper proteinemia
hyperammonemia, met acidosis, dehydration, azotemia
high gastric output mineral deficiencies
mag, ca, B12, iron
bariatric surgery mineral deficiencies
Thiamine, fe, cu, zn, se, thiamine, folate, VB12, VD
better tube feeding strategy for diabetics
bolus
Main benefit of EN in critical illness
timing for tbi ? general?
specific effect on burn patients
improved immune health, improved outcomes
48 h; 24-48
less ileus
what is osmotic diarrhea caused by with EN
sorbitol
arginine in critical care nutrition
Trauma and sepsis deficient
GH
T cells
AA synth
omega 3s in icu nutrition
eicosanoids such as prostaglandins, thromboxanes, and leukotrienes via oxygenation and lipoxygenase enzymes from the n-6 arachidonic acid metabolic pathway, producing less reactive molecules
EN modulated Ig
IGA
Major metabolic fuel of enterocytes, colonocytes and immune cells
Glutamine
preferred tube feed composition with respiratory failure patients
high fat low carb for RQ
tube feed composition for renal patients
low protein, K , Ph
GS for determining resting energy needs
indirect caloriemtry
3 electrolyte deficiencies with refeeding
ph, mg, k
equation for obese ICU patients
obese floor
2 others
Penn state
mifflin
harris benedict and ireton jones
pneumoperitoneum effect on lungs
what is increased by anethesia to deal with the CO2
Decreased functional residual capacity, increased peak airway pressures, and reduced pulmonary compliance, because increased abdominal pressure pushes the diaphragm cephalad
inc mV
renal effects from pneumoperitoneum
oliguria
unexplained hypercarbia during case may be due to …
gas extrav
coag v cut energy
high f variable
continuous low
ultrasoinc sealing vessel size currently
3mm
hot snare polyp size for colonoscopy
10mm
define type 1 and 2 errors
what does HER2 code for
epidermal growth factor
bevacisumab target and cancer type
VEGF; colon ca
imatinib and sunitinib mechs
TKIs
indications for breast radiation following mastectomy
r large tumors (> 5 cm or T3/T4 tumors, one or more positive lymph nodes, positive margins, and inflammatory breast cancer)
indicatoins for adjuvant chemo in breast ca
ER-negative tumors greater than 1 cm, ER-positive tumors greater than 1 cm with high Oncotype scores, HER2-positive tumors, and lymph node–positive disease.
3 candidates for non breast cancer endocrine therapy
atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ.
when does sarcoma get adj chemo ? rad?
high grade
pos margins
3 indications for thyroid cancer adjuvant? What is it
tumors greater than 4 cm, extrathyroidal extension, and regional lymph node metastases.
RAI
what is oncotype DX used for
ER positive risk strat
who can we omit adjuvant rads on for breast cancer
70 years or older, with T1/T2, node-negative, and ER-positive tumors.
what two thyroid cancers do not respond to RAI
medullary and anaplastic
results of 5 years of imatinib following resection
improved overall survival
rads for R1 sarcoma adjuvant benefit
dec recurrence
benefit of sorafenib
increased overall survival in met HCC
inguinal canal contents in women v men
