Principles Flashcards
Criteria for septic shock dx
Evidence of infection
Refractory hypotension (hypotension despite adequate fluid resuscitation and cardiac output)
Two more of ff
Tachypnoea or on BG PCO2<32mmHg
WCC <4000 or >12000
HR>90bpm
Temp >38 or <36
Causes of death in fistulas
Malnutrition
Sepsis
How to classify fistulas
Anatomical position: gastro cutaneous or colon cutaneous
Precipitating pathology: iatrogenic, TB, malignancy
Volume Output: High >500ml a day or Low <200ml a day
Causes of enterocutaneous fistulas
Crohns
Adhesiolysis
Retook laparotomy
Malignancy
TB
Spontaneous
Management principles for a fistula
Control output : stoma therapy
Adequate fluids
Correct electrolytes
Manage sepsis
Aggressive nutrition (dietician)
Multidisciplinary ☑️
Types of shock
Hypovolemia: blood loss
Cardiogenic: myocarditis, endocarditis, arrhythmia, MI)
Obstructive: temponade, pneumothorax
Distributive: sepsis, anaphylaxis, neurogenic shock
4 stages of shock
- Initial: hypoxia, metabolic acidosis from build up of lactic acid.
- Compensatory: hyperventilation (from acodosis), increased BP (due to vasoconstriction), RAAS system activated, blood diverted to vital organs.
- Progressive: compensatory mechanisms fails, increased metabolic acidosis, prolonged vasoconstriction compromises vital organs
- Refractory: vital organs fail and shock can no longer reversed
Commonest cause of septic shock
Endotoxin producing gram negative bacilli
Commonest cause of septic shock
Endotoxin producing gram negative bacilli
Management of Shock
Airway and Oxygen
Circulation: volume administration
Early antibiotics (take blood for investigations first)
Rapid source identification
Support of major organ dysfunction (eg DVT prophylaxis, glucose, stress ulcer prophylaxis, analgesia and sedation, mech vent for lung sepsis)
Complications of surgery
Respiratory:
Atelectasis
Pneumonia
Aspiration
ARDS
PE
Pneumothorax
Pleural effusion
Tx: preventative, optimise ei stop smoking, physio, review meds, steroids short course, bronchodilators, physio and early mobilisation post op. NB CXR, Pulmo func tests and ABG pre op.
Cardiac
Ischemia
MI
Death
(RF: AS, Recent MI, Arrhythmia, HF, Arrhythmia, Angina)
Tx: optimise prior to surgery, ECG, stress ECG, CXR, Ejec fraction or coronary angiogram
GIT complications
Ileus: tx conservative, healed 2-5 days
Constipation
Wound complications
Intraabdominal sepsis: Tx drainage by relocating laparotomy
Enterocutaneous fistula
Stress gastritis
Acute GI dilatation
Jaundice
Pancreatitis
Acute cholecystitis
Enterocolitis
Haemorrhage
-Primary haemorrhage: during surgery continues during post op
-Reactional: within 24h of surgery
-Secondary haemorrhage: 7-14 days post op. usually result of infection and false aneurysm.
Tx: aggressive fluid resusc, collect coagulation deficits
Deep Vein thrombosis
RF: hypercoagulable eg malignancy, oral contraceptive, prev DVT, obese, varicose veins, pelvic fractures HF, >60yo
Tx: prevention, low, oral contraceptive withdrawal. Pneumatic leg compression device, LMWH clexane.
Wound Complications
1. Wound infection
Tx: Ab, drain infected areas?
2. Wound dehiscence/rupture along surgical incision
Tx: urgent repair, some conservative first with sterile dressing then skin grafting
3. Wound sinus
Tx: remove foreign objects, necrotic tissue, drain residual
4. Enterocutaneous fistula
Tx: control output with stoma, fluids, electrolytes, mx sepsis, nutrition -dietician then conservative until it closes or surgical closure if fails
Causes of pyrexia with days post op
Atelectasis 0-3
Pneumonia 3-7
Phlebitis 3-5
UTI 4-10
Wound sepsis 4-10
DVT 5-10
Causes of derilium post op
DIMTOP
Drugs: Benzo, opiates
Drug withdrawal
Infection/ septicaemia
Ischemia of CNS: Stroke,TIA
Metabolic: hypo/hyperglycemia, hyponatremia, acute renal or liver failure
Trauma of CNS: subdural, extramural
Oxygen deficiency: hypoxia
Psych illness
Pain uncontrolled
Tx: Do ABG, glucose, electrolytes
Stress response to surgery
- ADH
- Aldosterone
- Cortisol
- Catecholamines
- Cytokines
Fluid losses in the post op period
- Blood from trauma or surgery= hypovolemia
- Insensible losses: evaporation from prolonged exposure in laparotomy or thoracotomy
- Third space loses: capillary leak of protein rich serum. ascites, dermatitis, pleural effusion.
- External losses: gastrointestinal losses NGT, vomiting, diarrhoea, stoma