surgery 3

Question 1

instruments that pick up tissue and for closure (graspers)

Answer 1

adson rongeur
pituitary rongeur
pick-ups

Question 2

what are hemostats used for

Answer 2

stop bleeding

Question 3

kelly clamp

Answer 3

used for clamping large amount of tissue in bowl resection- messentery

Question 4

kocher clamp

Answer 4

can grab bone and other firm tissue

Question 5

enteral feeding

Answer 5

NG tube (most common)- short period of time (these put pts at aspiration risk)
NJ tube (nasaljejunal)- reduce reflux, use if impaired gastric motility, short period of time
PEG tube (percutaneus endoscopic gastrostomy) long period of time, indications- stroke, parkinsons, esophageal cancer
Percutaneous jejunostomy tube- early postoperative feedings, used in pts w/ risk of reflux

Question 6

benefits of enteral of parenteral

Answer 6

Enteral feedings lead to more rapid advancement of PO feedings
Fewer infections
Lower costs
Shorter hospital stays
More physiologic way to provide nutrition

Question 7

dumping syndrome

Answer 7

when food leaves the stomach too fast and enters bowel too early
sxs- faintness, palpitations, diaphoresis, pallor, tachycardia and hypoglycemia
tx- slow down infusion of nutrition or change to one w/ more complex carbs

Question 8

parenteral nutrition

Answer 8

used when oral route can not be used

central locations are SVC, IVC, or RA

Question 9

estimating fluid loss

Answer 9

Hourly urine output
Daily weights
Skin turgor, mucus membrane moisture
Orthostatics

Question 10

normal daily maintenance requirements

Answer 10

Water-2500 ml (35 ml/kg)
Sodium-100 mEq
Potassium-60mEq
Chloride-100 mEq
Calories-2000 (25 cal/kg)
(if pt has ng tube these change)

Question 11

colloids

Answer 11

5% and 25% Albumin
Fresh-frozen plasma (FFP)
6% hydroxyethyl starch (Hetastarch)
Dextran-40 10%; Dextran-70 6%

Question 12

isotonic

Answer 12

.9% NaCl

Lactated ringer

Question 13

hypotonic

Answer 13

.45% NaCl

D5 .45% NaCl

Question 14

fluid compartments

Answer 14

intracellular 2/3 (interstitial, intravascular, thirdspace)

extracellular 1/3

Question 15

when determining fluid status

Answer 15

Urine output
Serum Sodium
Urine osmolality (easiest as urine Na)
(bp and edema are also important)

Question 16

ideal fluid for maintenance

Answer 16

0.45% NaCl + 20 mEq KCl

Question 17

estimate fluid requirements for pts w/out fever

Answer 17

obligate fluid loss 1500
for daily- 1500+ 20 mL/kg for each Kg >20 to max of 3900 mL/ day
for hourly- 60 + 1mL/kg for each Kg >20 to max of 3900 mL/day

Question 18

how much do water requirements increase w/ fever

Answer 18

100-150ml/day for each degree fever > 37C

Question 19

hypovolemia due to decreased intake or excess excretion

Answer 19

.45% NaCl until labs back
if Na>145 then switch to .25% NaCl
if Na<138 then switch to .9% NaCl
run at 125 mL/hr unless hemodynamically unstable
renal perfusion should be 30cc/hr (minimum)

Question 20

hypovolemia due to vomitting or diarrhea

Answer 20

0.9% NaCl (NS) until labs are back

If serum Na > 145 change to 0.45% NaCl

Question 21

hypovolemia due to hemorrhage

Answer 21

Bolus 1-2 LITERS 0.9% NaCl (NS) or LR through large bore IVs until labs are back
Continue fluid resuscitation based on vital signs and urine output
Packed Red Blood Cells (PRBC) as soon as available
Monitor electrolytes, ABGs and vitals
Gross estimate of renal perfusion is to make 30cc/hr (minimum) urine

Question 22

rules of 9

Answer 22

head 9
anterior chest 9
anterior abdomen 9
posterior same for total of 18
each arm-9 (anterior 4.5 post 4.5)
each leg 18 (ant 9 post 9)
groin 1

Question 23

fluid calc for burn

Answer 23

4 x weight in kg x % TBSA burn
Give ½ of that volume in first 8 hours
Give other ½ in next 16 hours

isotonic fluids are fluids of choice

Question 24

great way to watch fluid status

Answer 24

keep weighing the pt

Question 25

history for water depletion

Answer 25

if water depletion- thirst and hypernatremia
intravascular depletion-bp,hr, jvp, cool extremities, dry mucous membranes
ecf depletion- skin turgor, sunken eyeballs, weight

Question 26

fluid maintenance for kids

Answer 26

Maintenance fluid volume 24 hour period
Weight 10kg to 20kg – 1000mL for first 10kg of body weight plus 50mL/kg for any increment of weight over 10kg

Weight from 20 to 80kg – 1500mL for first 20kg of body weight plus 20 mL/kg for any increment of weight over 20 kg up to a maximum of 2400mL daily

Maintenance fluid needed on an hourly basis:
Weight < 10kg – 4mL/kg per hour

Weight >10kg to 20kg – 40mL/hour for first 10kg of body weight plus 2 mL/kg per hour for any increment of weight over 20kg

Weight >20kg to 80kg – 60mL/hour for first 20kg of body weight plus 1 mL/kg per hour for any increment of weight over 20kg to a maximum of 100 mL/hour, up to maximum of 2400mL daily

Question 27

signs of volume depletion

Answer 27

lack of jvp at 45
tacycardia
oliguria
postural hypotension
orthostatics
decrease skin turgor
dry mucous membrane
organ failure

Question 28

signs of volume overload

Answer 28

HTN
increased jvp
gallop rhythm
edema
pleural effusion
pulmonary edema
organ failure