Pre And Post Op Dr Bishoy Flashcards
Function of heparin
Formation of complex between antithrombin and activated thrombin factor 7,9,10,11,12
Antidote of heparin
Protamine sulfate but has risk of hypersensitivity reaction
Antidote of heparin
Protamine sulfate but has risk of hypersensitivity reaction
Clearing time of low molecular heparin
Within 2 hours
But must be stoped 6 hours before surgery
Clearing time of low molecular heparin
Within 2 hours
But must be stoped 6 hours before surgery
Antidote of benzodiazepine
Flumazenil
By completing at GABA binding site
Propofol
Rapid onset
Antiemetic
Moderate myocardial depression
Thiopental sodium
Extremely rapid onset so rapid induction
Rapid metabolism so not for maintenance
*Marked myocardial depression
Little analgesic effect
Ketamine
Nightmare
Little myocardial depression
Etomidate
Loves heart but hates Adrenal
(Favourable cardiac profile but adrenal suppression)
No analgesia
Not emecics
Before and after thyroid surgery we should check….
Vocal cord function
What is used for visualizing parathyroid during surgery
Methylene blue
Which drugs needed for pheochromocytomas
Alpha and beta blockers
Drug needed for coverage during carcinoma tumor
Octreotide
Bowl preparation needed for which type of colorectal surgery
Left side surgery
Stages of wound healing
Hemostasis: minutes to hours
Inflammation: one to five days
Regeneration: seven days to two months
(Fibroblast growth factor and Platelet derived growth factor stimulates Fibroblast to produce collagen and angiogenesis occurs)
Remodeling: six weeks to one year
(Fibroblast differentiates into myofibroblast and this facilitates wound contraction also there is regression of blood vessels)
Importance of inferior epigastric artery during surgery
Maybe injured during laparoscopy port insertion of drainage tube
Nerve injury during pelvic surgery and it’s effect
Pelvic autonomic nerve and this may cause impotence
Name of Formula for fluid requirement and calculation in children and young people
Holiday-Segar formula
For first 10 kg:100ml/kg/day
Next 10 kg:50ml/kg/day
Above 20kg:20ml/kg/day
For a week
1st day 50-60ml/kg/day(roughly)
2nd day add 10 ml so 60-70 ml/kg/day
3rd another 10ml upto 100 ml top
Time of transfusion of platelet in ITP patient during splenectomy
Just after ligation of splenic artery
Too soon will be ineffective
Too late will cause bleeding
Time of transfusion of platelets in ITP patient during splenectomy
Just after ligation of splenic artery
Too soon will be ineffective
Too late will cause bleeding
Action of warfarin
On vitamin K
So inhibiting factor 2,7,9,10 and protein C
Analgesia after orchidopexy
*Cadudal block is very effective
But spinal block and epidural block will be inspiring,TAP(trans abdomen plane) block may cover inguinal canal but not generally reliable
What to do in an old man of prostate cancer with vertebral body metastasis not responding to analgesia?
Radiotherapy to lumber spine
What are the compliications of TURP (trans urethral resection of prostate)?
Urethral stricture
Retrograde ejaculation
Perforator of prostate
Cause of TURP syndrome
This occurs when too much of the fluid (normal saline/glycine) used to wash the area around the prostate during the procedure is absorbed into the bloodstream. Initial symptoms of TURP syndrome include: feeling or being sick. confusion.
What are the triads of TURP/TUR syndrome and triads of symptoms?
Hyponatremia
Fluid overload
Glycine toxicity
Symptoms-
Hypertension
Beautiful
Changes in mental status
Route of administration of dopamine and dobutamine for inotropic effect
Via central line with close monitoring
Most commonly used inotropes
Dobutamine
Dopamine
Glucagon
Basic ports makes of laparoscopic surgery
Mainly 3
Section
Radiation
Instrumentation
Broviac line vs Hickman line
Port of Broviac in tunneled under skin so less chance of infection than Hickman’s outside skin port
A Broviac/Hickman central venous line is a special intravenous (IV) line inserted under the skin on the chest wall and into a large vein that leads to the heart. It’s used in children and teens who need IV therapy for a long time. CVLs are helpful for: • chemotherapy and other medications.
While smaller lumen Broviac catheters have been used successfully for blood withdrawal, their small lumen sizes increase the chance of clotting.The larger Hickman single- lumen catheter is intended for both infusion of I.V.fluids, medications, and nutritional solutions, and for withdrawal of blood samples.
Broviac line vs Hickman line
While smaller lumen Broviac catheters have been used successfully for blood withdrawal, their small lumen sizes increase the chance of clotting.The larger Hickman single- lumen catheter is intended for both infusion of I.V.fluids, medications, and nutritional solutions, and for withdrawal of blood samples.
What is the difference between a peripheral IV and a central venous catheter?
Central lines and peripheral IVs enter your body through different veins. Central lines enter a large vein in your chest, neck, arm or groin. It’s usually a deep vein that’s not close to the surface of your skin. Peripheral IVs enter a vein close to your skin’s surface in your hand or arm.
Toxicity of aminoglycoside
Ototoxicity
Nephrotoxicity
Risk factors of DVT
Surgery greater than 90 minutes at any sites
Surgery greater than 60 minutes at hips and lower limbs
Acute inflammatory process in abdominal cavity
Expected significant reduction in mobility
Age over 60
Known malignancy
Thrombophilia
Previous thrombosis
BMI>30
Taking HRT or even contraceptives
Varicose veins with phlebitis
How to do mechanical thromboprophylaxis?
Early mobilization after surgery
Compression stockings(contraindicated in peripheral s artery disease)
Intermittent pneumatic compression device
CAUSES of voice and respiratory difficulty after thyroid surgery
Recurrent laryngeal nerve injury
Laryngeal edema
Confined hematoma(Rx: put drain tube)
Contraindications of lidocaine
Cardiac arrhythmia
With anti arrhythmic drugs
What to do immediately in hypervalent
Fluid resuscitation by normal saline and sometimes adding diuretics with normal saline
ECG changes in hypercalcemia
Shortening of QT interval
Disease like drug for neuropathic passion
Pregabalin
What is suxamethonium
Depolarizing neuromuscular blocker. It inhibits the action of acetylcholine at NM junction. It is degraded by plasma cholinesterase and acetyl cholinesterase. It has the fastest onset and shortest duration of action. It produces generalized muscle contact prior to paralysis
Adverse effect off suxamethonium
Hypercalcemia
Malignant hyperthermia(treated with dantrolene)
Some non depolarizing neuromuscular blockers and there reversal drug
Atracurium
Pancuronium
Rocuronium
These are reversed by neostigmine
Volume correction fluid of this space loss
Hartsol not normal saline(risk of hyperchloremic metabolic acidosis)
American society of anesthesiologist grading system
Grade 1: no physiological or biochemical dysfunction in other words normal human being
Grade 2: mild to moderate systems dysfunction
Grade 3: severe
Grade 4: patient with severe systems disease or illness that threatens his life
Grade 5: more severe and will not survive without surgery and add little e for emergency
4 forms of consent
- For adults like for GA(consciousness is impaired)
- Adults on behalf of a child for GA(mother and father can always give consent but in case of non-biological, name has to be on birth certificate )
- Adult or child for local anesthesia(condo is not impaired
- Adults lack capacity to provide consent
Capacity is
Patients can receive, underwear and retain information. Patients believe the information to be true. Patients can analyze the information about what you are going to do to make a decision.
Levels of evidence
5(lowest). From experience
4. From presenting some cases results
3. From correlation and comparison of studies and some techniques
2. From at least one randomized control trial like any new experiment with time to time follow up and the longer the better also the larger the scale of patients the better
1(strongest). From metaanalysis results (combining all the topics you are going to search for) of randomized control trial
What type of drug is atropine
Muscarinic receptors antagonist by competing muscarinic acetylcholine receptor
What type nerve is blocked by atropine
Parasympathetic
What type nerve is blocked by atropine
Parasympathetic
Why atropine was being used for premedication therapy
It reduces bronchial and salivary secretion
Bradycardia is reduced by increased vagal tone
Other effects are urine retention and pupillary dilatation
Thromboprophylaxis for children undergoing closure of loop colostomy
Mechanical like early mobilization
What determines resistance of tissue during electrocautery
Water content or moisture of tissue
Types of electrocauterization
Cutting : low voltage non modulated sinusoidal wave meaning 100% on causing rapid heat production with vaporization not giving tissue enough time to form coagulum. Vaporization only occurs at boiling temperature.Vaporization takes place over the entire liquid.)
#Coagulation/Desiccation: high voltage sporadic current meaning 6% on causes drying off tissue giving enough time to form coagulum by evaporation ultimately resulting in hemostasis. (Evaporation can occur at any temperature evaporation takes place only at the surface of the liquid)
#Blending: between cutting and coagulation . Three types of blending.
Blend 1 is 50% on
Blend 2 is 40% on
Blend 3 is 25% on
So more blend is more coagulation
#Fulguration: prove is away from the tissue. Low amplitude of high voltage with list superficial tissue destruction.
Pethidine or morphine in biliary colic
Pethidine
It is more lipid soluble and produce less biliary track spasm than morphia
What drug is used to prevent long term pussy operative cognitive impairment
Benzodiazepine
Factors facilitate pussy operative cognitive impairment
Old age
Prolong duration of surgery
Post operator infection
biochemical disturbance
Route of administration of metaraminol
Peripheral line
Other inotropes and vasopressors can only be administered via central line
*Metaraminol is a pure alpha-1 adrenergic receptor agonist. It’s a synthetic sympathomimetic vasopressor that works by constricting blood vessels in the periphery, which increases blood pressure. Metaraminol can also indirectly release norepinephrine from storage sites.
Metaraminol can be used to treat hypotension, especially as a complication of anesthesia. It can also be used to treat shock and sympathetic nervous system failure, which can be caused by spinal injury or anesthesia.
Pulmonary pressure in cardiogenic shock
Often high
Receptors of noradrenaline and adrenaline
Noradrenaline only alpha receptor so can increase heart rate only
Adrenaline both alpha and beta receptors so can increase both heath rate and peripheral vascular resistant
NB: beta receptors are inhibitory except for heart
IV Fluid in children with high output ileostomy
Normal saline(0.9%) with potassium
Most common adverse effect of FFP
Urticaria
Most common adverse effect of packed RBC
Pyrexia
One of contraindications of tracheostomy
Coagulopathy
Time of onset,symptoms and manager of graft versus host reaction after blood transfusion
4-30 days
Diarrhoea, fever, erythroderma , abnormal liver function test
Mx is steroid therapy
NB: this reaction may occur in an immunocompromised person if blood is not irradiated
SOFA score
The SOFA score uses
*Po2(Partial pressure of oxygen in arterial blood, which can be measured using an arterial blood gas sample. PaO2 can also be calculated as the partial pressure of oxygen in the alveoli.)
*Fio2(Fraction of inspired oxygen, which is an estimate of the oxygen content a person inhales. FiO2 is expressed as a fraction, not a percentage.)
#The ratio of PaO2 to FiO2, also known as the P/F ratio, is a common index used to evaluate oxygenation. The P/F ratio is used to classify the severity of acute respiratory distress syndrome (ARDS) and acute lung injury (ALI). A P/F ratio of less than 300 indicates ALI, and a P/F ratio of less than 200 indicates ARDS. However, the P/F ratio doesn’t account for the respiratory efforts patients make to maintain arterial blood oxygenation, such as tachypnea and hyperpnea.
*Platelet
*Bilirubin
*Cardiovascular system
*GCS
*Creatinine
*Urine output
The Sequential Organ Failure Assessment (SOFA) score is a scoring system that measures the severity of organ function in critically ill patients. It was developed in 1994 and is based on the performance of six organ systems:
Respiratory, Cardiovascular, Hepatic, Coagulation, Renal, and Central nervous system.
Each organ system is given a score from 0 (normal) to 4 (most abnormal), and the total score ranges from 0 to 24. The SOFA score is calculated after 24 hours of ICU admission and every 48 hours thereafter.
The SOFA score has been widely used in clinical practice and research. Some sub-scores and the total score have been related to survival, and the change in score, or delta SOFA, has been found to have a strong correlation with ICU mortality. For example, one study found that at 48 hours, patients with a SOFA score of 0–1 had a mortality rate of 1.1%, while patients with a SOFA score of 10–11 had a mortality rate of 13.6%.
Fluid for preterm
Initially 10% dextrose
Difference between dopamine and dobutamine
Dopamine beta 1,and dopa receptors
*There are five types of dopamine receptors, which include D1, D2, D3, D4, and D5. Each receptor has a different function and is found in different locations. The function of each dopamine receptor[4]: D1: memory, attention, impulse control, regulation of renal function, locomotion.
#Dobutamine alpha 1, beta 1 and 2 with also longer duration of action
*Dobutamine raises blood pressure solely by increasing cardiac output, whereas dopamine raises blood pressure via peripheral vasoconstriction
What type of stuff is milrinone
Milrinone is a medication indicated for cardiac support in patients with acute heart failure, pulmonary hypertension, or chronic heart failure. It improves cardiac contractility (inotropy) and cardiac relaxation (lusitropy) and induces vasodilation.
It is phosphodiesterase inhibitory and increases cAMP
Metabolic disorder of salicylic poisoning
Mixed
#Respiratory alkalosis
*Salicylates directly stimulate the medullary respiratory center, which can lead to respiratory alkalosis early in the poisoning process.
and
#Metabolic acidosis
*Salicylates can also disrupt cellular metabolism, which can lead to the accumulation of organic acids like lactate. This can cause a high anion gap metabolic acidosis. Metabolic acidosis can also be caused by volume depletion from excessive vomiting.
Stages of ARDS
Acute Respiratory Distress Syndrome (ARDS) is a response to various causes that progresses through three overlapping stages:
#Exudative: The first phase, which can occur within the first seven days, is an acute inflammatory stage that begins with direct or indirect lung insults. Alveolar macrophages release inflammatory cytokines, which stimulate neutrophils to migrate to the lungs. The neutrophils accumulate in the alveoli and become activated, releasing pro-inflammatory mediators that damage the alveolar-capillary barrier, increase vascular permeability, and damage pneumocytes.
#Proliferative: This phase is characterized by improved lung function and healing.
#Fibrotic: This is the final phase, which signals the end of the acute disease process. It’s mainly characterized by the formation of scar tissue in the lungs and a prolonged need for ventilation. Not everyone progresses to the fibrotic stage.
Signs of noncardiogenic pulmonary edema
Heart normal and wedge pressure by Swan-Ganz catheter must be <18mmHg
Severe hypoxemia with bilateral pulmonary infiltrates
Mx of ARDS
Treat underlying cause
Antibiotic
Negative fluid balance(diuretics)
Positive end expiratory pressure ventilation
Mechanical ventilation using low tidal volume (conventional tidal volume may cause lung injury sure to existing scar)
CAUSES of ARDS with symptoms
Sepsis
Direct lung injury
Acute pancreatitis
Long bone fractures
Head trauma
Symptom
Sudden dyspnoea may cause multicolor organ failure if untreated for days
Very common toxicity of halothane
Hepatotoxicity
Histamine release caused by which anesthetic
Not vecuronium and suxamethonium
Why is the femoral route avoided for TPN?
Risk of sepsis
So preferred route is internal jugular vein
Acute dystonic state contraindicated drug
Anti dopaminergic
Use procyclidine to reverse this event
ECG changes in hyperkalemia
First to appear peaking of T wave
Then
Lost P wave
Wide QRS
Ventricular fibrillation
First sign of wound dehiscent
Serosanguinous Fluid
Then remove 1 or 2 stitches and dressing
Plasma has a high risk of
Transfusion associated lung injury by microvascular damage
Temperature of packed RBC before transfusion
Room temperature
Frozen can cause hypothermia
But packed RBC can cause pyrexia
Temperature of packed RBC before transfusion
Room temperature
Frozen can cause hypothermia
But packed RBC can cause pyrexia
Cause of hypocalcemia after FFP or platelet transfusion
They contain anticoagulant which may chelate calcium
Cause of hypocalcemia after FFP or platelet transfusion
They contain anticoagulant which may chelate calcium
Adverse effects of packed RBC stirred over 4 to 5 weeks
Hyperkalemia
After rupture releasing 5 to 10 mlmol K
Which type of endotracheal tube is used in children
Uncuffed to reduce risk of tracheal inquiry
What to do in case of oliguria sure to hypovolemia
Fluid challenge
#A fluid challenge is a diagnostic procedure that involves giving a patient a small amount of intravenous fluid over a short period of time to assess their cardiovascular response. The goal is to determine if the patient has a preload reserve that can be used to increase their stroke volume with more fluids, or if they have cardiac failure or a full intravascular volume, in which case more fluids could make things worse.
A fluid challenge is considered the “gold standard” for assessing fluid responsiveness and is indicated for patients with hypotension or oliguria. The procedure involves:
Infusing crystalloids or colloids at a rate of 500 mL over 20–30 minutes
Measuring changes in the patient’s cardiovascular parameters, such as cardiac index and stroke volume (SV)
Considering an increase in cardiac index of at least 15% as a positive response
If the patient responds to the first challenge, with an increase in SV or cardiac output (CO) of at least 10–15% above baseline, additional fluid challenges can be given to maximize SV and CO. However, there are some limitations to fluid challenges, including the risk of harm from fluid overload and difficulty controlling for other factors that may affect the results.
What is cardiac index
Cardiac index (CI) is a hemodynamic measurement that compares the heart’s performance to a person’s size by relating their cardiac output to their body surface area. It’s calculated by dividing cardiac output by body surface area and is measured in liters per minute per square meter (L/min/m2). A normal CI is between 2.5 and 4 L/min/m2.
Metabolic abnormalities in refeeding syndrome and how to feed
Hypo-
Phosphate
Potassium
Magnesium
And
Abnormal fluid balance
These can lead to organ failure
Feed by
59% of energy requirement
#Here are some ways to calculate energy requirements for food:
*Basal metabolic rate (BMR)
To calculate BMR, use the equation BMR = Wt × 24 × 0.9. Basal metabolic rate (BMR) is measured in energy units per unit time, such as joules per hour per kilogram of body mass (J/(h·kg)), milliliters of oxygen per minute (ml O2/min), or watts (joule/second).
*Physical activity level (PAL)
To calculate energy requirements, multiply PAL by BMR. For example, if a male has a PAL of 1.75 and a BMR of 7.10 MJ/day, his energy requirement would be 1.75 × 7.10 = 12.42 MJ/day.
(1 joule = 0.24 calories)
#Lifestyle Example PAL
Extremely inactive Cerebral palsy patient <1.40
Sedentary Office worker getting little or no exercise 1.40-1.69
Moderately active Construction worker or person running one hour daily 1.70-1.99
Vigorously active Agricultural worker (non mechanized) or person swimming two hours daily 2.00-2.40
Extremely active Competitive cyclist >2.40
Drug for trigeminal neuralgia
Carbamazepine
Drug for trigeminal neuralgia
Carbamazepine
Drug for neuropathic pain
Amitriptyline
Drug for diabetic neuropathy
Duloxetine
Platelet may cause what type of bacterial infection
Gram positive
RBC may cause what type of bacterial infection
Gram negative
Procaine and benzocaine are of which group and metabolized by what
Amino ester group
Metabolized by pseudocholinesterase
Drug interaction of lidocaine
Beta blocker
Ciprofloxacin
Phenytoin
Toxicity of lidocaine
Initially CNS overactive
Then depression
Cardiac arrhythmia
Contraindications of adding adrenaline with lidocaine
MAO and TCA antidepressants
Relation between laparoscopic surgery and hyperbaric
High pressure of pneumonitis may cause systems hypotension
But 1st look for vascular occlusion or catastrophe
Types of antibiotics
*Cell wall anthesis inhibitors
Penicillin, cephalosporin
*Protein synthesis inhibitors
Aminoglycosides(ototoxic, nephrotoxic), chloramphenicol, macrolides (azithromycin, erythromycin, clarithromycin), tetracycline, fusidic acid
*DNA synthesis inhibitors
Quinolone (Ciprofloxacin), metronidazole, sulfonamides, trimethoprim
*The synthesis inhibitors
Rifampicin
