Surgery: Injury, Fluids and Metabolism Flashcards
Definition of normal anion gap and it’s formula.
Anion Gap= Na - (Cl+ HCO3)
Normal anion gap is lesser than or equal to 12mmol/ L
At what stage of dehydration is hypotension seen?
Hypotension and thready pulse is seen in severe dehydration (11-15% body weight lost as water).
Moderate dehydration means 6-10% lost as water) Severe thirst Nausea Dry axilla and groin Tachycardia Orthostatic hypotension Low CVP Poor skin turgor Apathy Oliguria Hemoconcentration
Which of the following would most likely cause normal anion gap metabolic acidosis?
a. Renal insufficiency
b. Diabetic ketoacidosis
c. Lactic acidosis
d. Ureterosigmoidoscopy
d. Ureterosigmoidoscopy
NAGMA is to HARDUP (Hyperalimentation-Acetazolamide-Renal tubular acidosis-Diarrhea-Ureteroenteric fistula-Pancreaticoduodenal fistula)
Causes HCL administration Bicarbonate loss GI losses Renal tubular acidosis Carbonic anhydrase inhibitor
Which of the following is not a cause of high anion gap metabolic acidosis?
a. Exogenous acid production through renal insufficiency.
b. GI losses in cases of diarrhea
c. Exogenous acid ingestion
d. None of the above
HAGMA = MUDPILES
Causes
- Exogenous acid ingestion (Methanol, ethylene glycol and methanol)
- Endogenous acid production (Ketoacidosis, lactic acidosis, and renal insufficiency)
M U D P I L E S
Methanol Uremia (Renal Failure) Diabetic ketoacidosis Propylene glycol and paraldehyde Infection, iron and isoniazid Lactic acidosis Ethylene glycol Salicylates
Triad of milk alkali syndrome
The milk-alkali syndrome consists of the triad of 1. HYPERCALCEMIA ,2. METABOLIC ALKALOSIS and 3. RENAL INSUFFICIENCY associated with the ingestion of calcium and absorbable alkali.
Hypercalcemia causes a vasoconstriction-induced decline in glomerular filtration rate (GFR) and activation of the calcium-sensing receptor in the medullary thick ascending limb, resulting in natriuresis and volume depletion. The combined effects of increased alkali intake, decreased GFR, and volume depletion lead to metabolic alkalosis.
Symptoms of hypernatremia are rare until serum sodium concentration exceeds ______.
In hypernatremia, symptoms occur at 160mEq/L serum sodium concentration.
In hyponatremia, symptoms do not occur until serum sodium level is 120mEq/L.
What are the four families of adhesion molecules?
Selectins
Immunoglobulins
Beta (CD18) integrins
Beta (CD29) integrins
Choosing an ECF expander among the electrolyte solutions for parenteral administration would require preparation near 280mOsm. Which of the following would the IV of choice?
a. LR or PNSS
b. PNSS or D5LR
c. D5NS or D5LR
d. D5 0.25% NaCl
answer is a. LR (280mOsm) or PNSS (308mOsm)
What is the most common cause of extracellular deficit among surgical patients?
Loss of GI fluid from nasogastric suction, vomiting, diarrhea or enterocutaneous fistula.
Correction of asymptomatic hyponatreamia should increase by no more than what rate?
Answer. No more than 0.5 mEq/l/hr to a maximum of 12 mEq/l/d
For hypernatremia and symptomatic hyponatremia correction, it should he no more than 1mEq/l/h
True or false.
A 100lbs patient with unintentional weight loss of 9lbs within 6months is considered significant.
False.
1 week: 2%
1 month: 5%
3 months: 7.5 %
6 months: 10%
More than that, it’s called severe weight loss
Compute for the ideal body weight of a 5 feet and 1inch tall woman using the Modified Broc’s formula.
105 lbs or 47.3kgs
What is the basal caloric requirement of a normal healthy adult?
25-30kcal/kg/day
The following are seen in the Ebb phase of surgical metabolism;
a. Increased BMR
b. Decreased BMR
c. Mobilization of energy stores
d. Positive nitrogen balance.
answer. b decreased BMR (since the body tries to repair and conserve energy reserves)
There are two phases the Ebb and Flow (catabolic and anabolic) in surgical metabolism
1-2 days post injury: EBB PHASE: Conservation
1-2 weeks post operative-CATABOLIC: Mobilization
Months: ANABOLIC: Replacement or recovery
Surgical patients who are in a lot of stress like burn patients need how many grams of CHON per kg/day?
a. 1.2
b. 1.5
c. 2
d. 2.5
Answer is d. 2.5
Note the correction factor (protein) was asked not the calorie factor correction/ adjusment above BEE.
If CHON,
- 2 mild stress
- 5 moderate stress
- 0 severe sepsis
- 5 burns
Which of the following could be a possible complication of prolonged parenteral nutrition?
a. Microcytic anemia
b. Scaly dermatitis and loss of hair
c. Glucose intolerance
d. Diffuse eczematoid rash at intertriginous areas.
e. Intestinal mucosal granulation
Answer is E
A. Copper deficiency
B. Essential fatty acid deficiency
C. Chromium deficiency
D. Zinc deficiency
Management in potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding.
Management if Refeeding Sydrome: SLOW initiation in the first week (50% of requirements based on dry weight)
High doses of protein intake may lead to the following except;
a. Hypertonic dehydration
b. Azotemia
c. Dehydration
d. Acidosis (metabolic)
e. Hyperglycemia
D. Hyperglycemia
This is seen in overfeeding with glucose infusion also hypertriglyceridemia and hepatic steatosis.
Four stages of hemostasis
Vascular constriction
Platelet plug formation
Fibrin formation
Fibrinolysis
Earliest ECG finding in cases of hyperkalemia (above 3.5-5 mEq/L).
Answer. High peaked T waves
followed by widened QRS, P wave flattening, PR interval prolongation, sine wave formation and Vfib
This binds to potassium in exchange of sodium, hence used in cases of hyperkalemia. What is this cation-exchange resin?
Kayexalate
When ECG changes are present such as peaked t waves and p wave flattening in the setting of hyperkalemia, this solution can be administered.
Calcium Gluconate (5-10mL of 10% solution)
The following are manifestations of hypokalemia except;
a. Ileus
b. Constipation
d. Vomiting and diarrhea
e. Cardiac arrested
Vomiting and diarrhea is a manifestation of hyperkalemia
At what concentration is hypercalcemia symptomatic?
When it exceeds 12mEq/L
Treatment: Volume repletion and brisk diuresis with normal saline
