Surgery Principles Flashcards
1
Q
PreOp:
When to stop aspirin and NSAIDs
A
Aspirin (irrev COX)- need to stop 7-10 days before
NSAIDS are reversible- can stop 2 days before
2
Q
PreOP:
Patient’s ECG shows previous MI, but he has no knownledge of it and is chest pain freee
A
previous MI increases risk of post op MI
workup with cardiac consult, exercise stress test to detect ischemia
if signs of ischemia are present, then cardiac cath may be necessary prior to surgery
3
Q
Pre OP:
Patient has diabetes
A
patient will be NPO after midnight, should be given IV fluids with dextrose
patients who are taking oral hypoglycemic agents should not recieve their medication the morning of surgery
if patient has glucose level greater than 250 in type 1, give 2/3 dose of NPH and regular insulin. if less than 250, then one half the morning dose given
4
Q
Pre Op:
Patients with low hematrocrit
A
surgery should be POSTPONED, and cause of anemia should be discovered (colorectal cancer most common cause, look for other GI blood loss)
5
Q
Pre Op:
Patient with high hematocrit
A
Patient may be dehydrated- postpone surgery and hydrate patient (to figure out dehydration look for poor skin turgor and dry mouth)
Polycythemia also possible (PCV, EPO secretion, COPD) -should be diagnosed and treated before surgery
6
Q
Preop:
Patient is 100lbs overweight
A
complete evaluation with ABGs, pulmonary function
if elective surgery can be postponed, otherwise epidural anesthesia and aggresive post op pulm care to avoid **atelectasis **
7
Q
perioperative blood glucose levels
A
100-250 mg/dL
8
Q
Periop:
Patient with high blood pressure (180/110)
A
diastolic pressure greater than or equal to 110 is a risk factor for malignant HTN, acute MI, CHF
B blockers should be used won day of surgery
9
Q
PreOP Pulm:
how long should a patient abstain from smoking before an elective surgery to decrease risk of post op complications
A
6-8 weeks
10
Q
What does an ABG of :
PaO2 less than 60 indicate
PaCO2 more than 45 indicate
A
pulm HTN
assoc with increased perioperative morbidity
11
Q
what to do in a case of patient with severe COPD with acute cholecysitis
A
Patient has high risk of acute pulmonary failure with surgery
CXR to check for pneumonia
If surgery necessary- minimize duration of anesthesia. Prevent atelectasis by immedicte mobilization post-op
choice of operation- CHOLECYSTOSTOMY- where large drainage to resolve acute sepsis may be preferred
12
Q
Five factors used to predict risk for cardiac complications after vascular surgery
A
Q waves on ECG
history of ventricular ectopy
history of angina
diabetes mellitus
older than 70
13
Q
Patient with diabetes, older than 70 with resting pain in right foot. ischemia of leg will be managed with a bypass from femoral artery to distal tibial vessels.
a) assessment?
b) if he had an MI 3 years ago
c) 3 weeks ago?
d) LBBB
e) had CABG 2 y ago
A
a) cant do stress test, so use persantine thallium stress test or dobutamine ECG
b) reinfarction with prior history of MI can be high. Pt should be given a stress test. If ischemia is present- cardiac cath
c) surgery shoul d be delayed if acute MI was within 30 days!
d) suggests unederlying ischemia
e) may be beneficial- reduce cardiac complications in pts unergoing non cardiac surgery
14
Q
Major abdominal surgery effect oon VC and FRC
A
Vital capacity reduced by 50%, FRC reduced by 30%
15
Q
what to give patient with asthma who must undergo operation during acute exacerbation
A
twice usual dose of PO steroids, or 1mg/kg methyl prednisone preop and then q6h
16
Q
postoperative risk of respiratory failure in COPD pt
A
PCO2>50
17
Q
prophylaxis for high risk DVT
A
perioperative subcutaneous heparin reduces risk of DVT and PE
18
Q
Post Op:
PaO2/FiO2 <200
PCWP <19, no CHF
Bilateral infiltrates and acute lung injury
A
ARDS
Management:
PEEP
Pressure limited ventilation
permissive hypercapnia (g
Prone position
19
Q
highest morbidity and mortality of all pulmonary complications
A
pneumonia
20
Q
patient ECG shows 6 PVCs per minute…cardiac risk?
A
indicates ventricular dysfunction, increased cardiac mortality associated wit risk of arrhythmia
use stress test or echo to evaluate left ventricular function
21
Q
cardiac risk in pt with loud carotid bruit
A
carotid duplex study needed
likely severe internal carotid stenosis
22
Q
PreOp end organ assessment in patient with diabetes
A
1) Nephropathy- poor response to hypovolemia, risk of contrast induced renal damage
2) autonomic neuropathy- risk of gastroparesis- increased risk of aspiration during intubation
23
Q
what procedure may be needed for pts with high grade carotid stenosis prior to surgery
A
carotid endarterectomy
surgical procedure used to prevent stroke, by correcting stenosis (narrowing) in the common carotid artery. Endarterectomy is the removal of material on the inside (end-) of an artery.
24
Q
which oral hypoglycemic needs to be stopped 2-3 days prior to surgery unlike most others which can be stopped the night before?
A
chlorpropamide (1st gen SU)
25
Ankle Brachial index (ABI)
is 0.2
ABI is systolic BP in legs/systolic in ARMS
a low number indicates peripheral vascular disease
higher risk of ulcers, gangrene
NEED PERIPHERAL REVASCULARIZATION, esp with coronary hx.
26
Child's classicication of cirrhosis
A B C
using ascites, total bilirubin, encephalopathy, nutrition, albumin
operative mortality
A= 2%
B= 10%
C= 50%
27
preop control of ascites
potassium sparing diuretics, sodium and water restriction
need pt in compensated state
28
What liver factors would delay surgery?
classification in child group C, presence of acute alcoholic hepatitis
29
pt needing a hernia repair has ascites. You notice ascites fluid leaking from the umbilical hernia
higher risk of bacterial peritonitis, mortality rate high due to infection.
IV antibiotics and emergent hernia repair
30
Estmating preoperative creatinine clearance
(140-age) \* wt / 72\* creatinine
31
most common complication in dialysis patients
Tx
hyperkalemia (renal failure)
Tx: IV calcim, d50, insulin, bicarbonate, albuterol, kayexalate
32
lab value for intrinsic renal damage
for ATN
Pre-renal damage
Intrinsic= FeNa \> 1
ATN- specific gravity1.010
Pre-renal: UNa\<10
33
intraoperative bleeding in CKD patient
platelet dysfunction due to uremia can contribute, so transfusion with platelets wont help
ddAVP used acutely, but may have loss of action (increase vWF, increased aggregation)
FFP
post op hemodialysis to reduce uremia
34
possible reason for hypotension in renal failure patients
glucocorticoid deficiency due to previously taken steroids
tx with hydrocortisone intraoperatively
35
managing hyperkalemia in renal failure pt
will see peaked T waves
give calcium gluconate to stabilize cardiac membranes
insulin and glucose to reduce protassium levels
hemodialysis likely needed
36
management for pts with valvular heart disease or cardiomyopathy
perioperative monitoring with pulmonary artery catheter, arterial line, and transesophageal echo
37
What is a bowel prep and its complications
preop bowel preparation before colectom= decrease fecal mass and bacterial content in colon
along with a clear liquid diet
nonabsorbable antibiotics (neomycin, erythromycin) also used
complication-
golytely (polyethylene glycol)- causes no net absrption or secretion- have volume washout. safe. May have dehydration
phospho-soda: contraindicated in diabetics (has sugar) and in pts with salt restricted diets. hypertonic sodium phosphate draws fluid, also loss of bicarb= metabolic acidosis
magnesium citrate- poorly absorbed,. Patients with renal disease may not be ale to clear mg.,
38
order of return of bowel function
small intestine, then stomach, then colon
39
Measurable and Unmeasurable Intraoperative fluid losses
Measurable: estimated blood loss (EBL), amount of fluid given intraoperatively, and urine output
assuming patient did not get blood in OR, need to replace every 1mL of EBL with 3mL of isotonic fluid
(because about 2/3 of IV fluid given leaves the intravascular space)
Unmeasurable: evaporation (long procedures)- must be estimated
40
Maintenance fluid measurement post-op
Based on body weight
First 10 kg--- 100 mL/kg/24h
Next 10----50 mL/kg/24h
Beyond 20----20 per kg
ex: 70kg patient= (100\*10) + (50\*20) + (20ml/g\* 50)= 2500 ml/24h
41
what type of fluids replaced in 1st 24 h after large intraoperative blood loss
lactated ringers solution of 0.9 normal saline
since loss is isotonic, replace with isotonic solution
42
why do IV fluid requirement decrease with recovery post-op
more and more fluid from third space accumulation comes back into intravascular space with recovery of normal fluid movement
43
Normal urine output per hour
what if devpt of 400ml/hr and develops BP of 80/60
Normal- 0.5-1ml/kg/hr
Now has either renal disease with inability to concentrate urine, DI,
postobstructive diuresis- usually self limited, and returns to normal 1-2 days
urine with low osm indicates pathologic conc defect, urine with higher osm suggests osmotic diuresis
44
post op fever with :
a) bilateral crackles
b) burning on urination, wbcs in UA
c) pus on venipuncture site
a) atelectasis- most common source of fever in immediate post op. CXR- need to use incentive spirometry (patient breathes in deeply from device and holds breath- increased pressure pops open the alveoli)
cxr may also show pneumonia, pulmonary edema (usually nnot with fever)
B) UTI
c) SUPPURATIVE PHLEBITIS- infected thrombus in the vein around the catheter. remove catheter and surgically excising infected vein. IV abx
45
pt has a segment of necrotic bowel resected. on the 5th day post-op, u notice intestinal contents draining from the wound. Why?
could be a leak at the jejunostomy site, breakdown of anastomoses, or missed enterotomy
surgical reexploration with signs of peritonitis. CT to rule out intra-abdominal collection- can be drained.
if fistula present, can be maintained non-op- NPO and giving TPN, measure fistula output daily.
46
factors associated with failure of fistula to heal
Foreign body in wound
Radiation damage to the area
Infection or IBD
Epithelialization of fistulous tract
Neoplasm
Dstal Bowel Obstruction
47
patient should not lift heavy weights until which week post op
about 6 weeks
collagen and crosslinking occuring, need final tensile strength
48
patient with a small, sore, red area on wound , draining small amounts of pus
stitch abscess- infection of suture
can explore area under local anesthesia
49
patient has raised, hypertrophic wound
usually stabilizes, and does not enlarge- reassure patient, and can use steroid injections and local pressure dressings
if spreading outside area of incision= keloid. same tx as above
50
split thickness skin graft
with a second intention wound, can use skin (epidermis and part of dermis) from a remote site. this graft can revascularize from the granulation tissue
are more susceptible to trauma than normal skin
51
peak of collagen production in wound healing
starts at 10 hours, peaking at 5-7 days
52
type of cells present in wounds that heal by secondary intention
myofibroblasts- contraction of wound, and increased scarring
53
wound classification examples
a) uncomplicated hernia repair with no mesh
b) elective colectomy
c) perforated colon requiring emergent colectomy
a) no mesh= clean
b) clean-contaminated (low probability of infection with stool, but still involving the alimentary tract
(clean contaminated- clean but involving respiratory, alimentary, genital, or urinary)
c) contaminated wound (leave wound open and once granulation has occured, close wound and monitor)
54
when to give antibiotics with operations?
not everyone gets them!
used in cases involving brief, predictable exposure to bacteria
implantation of device or prostheses
impaired host defenses
poor blood supply
single dose 1 hr preop and single dose post op
55
which mass accounts for most of ICF
skeletal muscle mass (slightly lower intracellular fluid in females for this reason)
56
degrees of dehydration
Mild= 3% adults, 5% kids
Moderate, and severe
Moderate deficit- sleepiness, apathy, slow responses, decreased food consumption, hypotension, tachycardia, collapsed veins,
soft small tongue with wrinkling, mild temp decrease
severe deficit- decreased reflexes, stupor, ileus, hypotension, cold extremities, sunken eyes. marked temp decrease
57
how may a patient with severe sepsis with peritonitis may be missed?
if he is volume depleted- will be afebrile and have normal WBC
sx will manifest dramitically when ECF restored
58
colloid vs crysalloid
crystalloid- used in most cases for initial bolus (20mg/kg) for volume expansion of intravascular space
with equilibration, 2/3 of any volume will stay intravascularly
colloid- used to STIMULATE LIVER FOR ALBUMIN RELEASE
stays mainly in intravascular space
indicated if hypovolemia persists after 2L of crystalloid given, or patients with excess na and water are hypovolemic (CHF, ascites), patients with liver disease, severe hemorrhage
59
causes of hypotonic volume excess
inappropiate NaCl depleted solution given
third spacing (shift of ECF from plasma to interstitial/transcellular spaces)
increased ADH with surgical stress or SIADH
60
CNS signs of volume excess
GI
CV
Tissue Signs
No CNS SIGNS!
GI- edema
CV- increased pressures, CO, loud heart sounds, functional murmurs, gallops, pulmonary edema
Tissue- putting edema, rales, vomiting, diarrhea
Tx: furosemide (10-50 mg), with K replacement as needed
61
causes and how to replace ongoing fluid loss
replace one half of the usual ongoing losses allong with assumed maintenance and rehydration fluid
causes:
-fever- (each C above 37 add about 2-3 ml/kg/day loss)
vomiting, NG tube, fistulas
hird space
burns
osmotic diuresis due to urea, mannitol, glucose
62
most common cause of normovolemic hyponatremia
SIADH
inappropriately concentrated urine (\>100 mOSm/kg)
euvolemia
glucocorticoid def (addisons) can cause ADH hypersecretion
hypothyroidism cuases decreased CO and GFR= leadin to increased ADH release
63
changes in calcium fractions based on pH
overall 50% non ionized (plasma protein binding),
5% non ionized (binding other things)
45% ionized
Acidosis increases ionized fraction while alkalosis decreases it
64
estimating basal energy expenditure in patients with swan-ganz catheters
(SaO2-SvO2) \* CO\* Hb\* 95
Males usually at 25kcal/kg//day
Females at 22
Multiply this by desired goal
- Nonstressed: 1.2
- Postop: 1.5
- Trauma, sepsis, burns: 1..6-2
- Fever: 12% increase per C
65
Enteral feeding complications
Diarrhea (exclude infections, dilue hypertonic formulas)
Aspiration (add methylene blue to resp secretions for color, check with glucose strips, keep HEAD ELEVATED AT 45deg)
Obstruction of feeding tube (improper flushing, inappropriate meds- suucralfate, psyllium)
High gastric residual volumes
Obstruction
gastoparesis, ileus (esp with opiates and anti-cholinergics)
esophagitis (NG tubes)
66
causes of NORMAL GAP anion gap metabolic acidosis
HARD UP
Hyperparathyroidism
Adrenal insufficiency, anhydrase inhibitors
Renal tubular acidosis
Diarrhea
Ureteroenteric fistula
Pancreatic fistula
67
Rules of thumb for acute acid-base disorders
MAcid: PCO2 drops about 1.5
Malk: PCO2 rises about 1.0
Respacid: HCO3 rises 0.1
respalk: HCO3 drops 0.3
68
which organ should be monitored closely in "cold" shocks
cold= cardiogenic or hypovolemic shock. svr increases, and clamps down vessels including renal arteries, so look for renal failure
69
Classification of Hypovolemic Shock
Class 1
\<20% of circulating blood volume lost. slight tachycardia, normal BP and UO
Class 2
20-40% loss, have tachycardia, increased capillary refull, orthostasis, hypotension, agitation
Class 3
all of the above + LETHARGY AND DECREASED UO
70
distinguishing hypovolemic vs cardiogenic shock
both have decreased CO, cold skin
Hypovolemia: low PCWP (low fluids overall), with increased SVR due to hypotension
Cardiogenic: high PCWP (fluid buildup due to pump failure), with also increased SVR
71
Intermittent Mandatory ventilation
when patient initiates a breath= vent gives pressure support, with TV determined by the patients inspiratory effort
if patients doesnt initiate, hten a set TV is given (like assist controlled ventilation)
72
diagnostic criteria for ARDS
1) Bilateral, fluffy infiltrates on chest xray
2) Refractory hypoxemia
3) no evidence of heart failure (PCWP \<18)
73
ratio for FFP: PRBC for transfusion
1: 1.5
74
admission to burn center for
a) pts under 10 or over 50
b) pts of other ages
c) key sites
a) more than 10% body surgace area
b) more than 20% BSA
c) significant burns to face, hands, feet, genitalia, skin over major joints, perineum
full thickness burns of \>5% BSA at any age, also significant electrical or chemical injury
75
An adult male is brought in with second degree burns of chest, abdominal wall, anterior right leg and perineum.
estimate TBSA burned
rule of nines used
ADULT
Trunk/Chest- 18 (anterior and posterior)
Each leg- 9 (anterior and posterior)
each arm- 4.5 (anterior and posterior)
head- 4.5% ant and post each
child- 10% trunk, 7% head, 8% legs
76
when to apply cold saline soaks for burns
for analgesia if less than 25% BSA
watch for hypothermia
77
How mmuch fluid should a 60kg female with 25% TBSA burn recieve during the first 24h
change for next 24h?
Parkland formula
lactated ringers solution at 4ml/kg/%BSA burn
= 4 \*60\*25= 6000ml
1/2 given in first 8 hr
rest over next 16 h
next 24h: use D51/2NS and give albumin if pt is hypotensive
78
under 15- parkland values
Lactated ringers first 24 h at 3Ml (instead of 4)/kg/%BSA
as in adults give 1st half in 8hrs
79
Initiail assessment = AMPLE
Allergies
Medications
Previous illnesses
Last Meal
Events surrounding injury
80
what glasgow score indicated coma
8 or less
81
what should be done for trauma with rib fracture resulting in a simple pneumothorax
insert a finger into pleural space to assure that its not the peritoneal cavity and then insert a large diameter chest tube
place a water seal with suction and do serial CXRs
82
pt with a simple pneumothorax also has
what is a laceration on the chest wall that penetrates through to the lung and sucks air
sucking chest wound- should be sealed with an occlusiive dressing
insert chest tube at a different location
83
after insertion of a chest tube, a large amount of air continues to leak into the chest tube over the next 6 hours. `
major airway injury with disruption of a bronchus or trachea. need bronchoscopy, thoracotomy, partial lung resection
84
next step after patient continues to remain hypotensive and unstable despite adequate fluid resuscitation
the most important priority is search for underlying cause----urgent laparotomy or thoracotomy
invasive monitoring (central line and peripheral line) delays definitive therapy---only do it if it was fast
85
Classification of shock
1- \<15% blood loss, normal BP and HR
2- 15-30%, normal BP, increasing HR
3- 30-40%, low BP, high HR
4-
86
how should a pregnant woman presenting with hypotension be examined
on her left side, to relieve the compression of the IVC which can show a non hemodynamic cause of hypotension and reflex tachycardia
87
next step if find blood when trying to put an urinary catheter in
possible urethral injury
in male: do a rectal exam searching for prostatic injury before catheterization
for finding injury: retrograde cystourethrogram
88
how to evaluate cervical spine in a comatose, disoriented, or combative patient
MRI
89
How to assess cervical spine
1) neck immobilization
2) palpate along posterior aspect of neck
3) assess motor and sensory function of arms and legs
4) lateral cervical spine radiograph
90
18yo male in MVA has priapism
indicate fresh spinal cord injury
other signs: loss of anal sphincter tone, loss of vasomotor tone, bradycardia (lose SNS), intestinal ileus
91
indication to perform emergent thoractomy in patient with a lateral stab wound
if close to vital structures and if 1500ml blood evacuated via tube thoracostomy in a small amount of time
also if rate of blood loss is greater than 200ml/hr for 3 hours
92
thoracic stab wount below nipple on left side
diaphragmatic injuries maybe missed on initial survey
if suspect- explore throughout abdomen
93
next step after finding a widened mediastinum on portable anteroposterior film
what is the gold standard?
need a posteroanterior CXR
gold std: aortic angiography (also dynamic CT of chest)
94
assessment of a gunshot wound
need to have a preop radiograph to determine location of bullet.
mark entrance and exit wound with radio-opaque marker.
abdominal exploration for gunshot wound to abdomen is mandatory
95
diagnostic peritoneal lavage useful in which case of abdominal injury?
when dx is not clear and hemodynamic instability present
DPL can miss injuries to retroperitoneal structures such as duodenum and pancreas
96
what is considered a postive diagnostic peritoneal lavage (DPL) and what is it an indication for?
if 10ml or more of gross blood present on opening the peritoneum= + = exploration
also positive DPL with high number of WBC, appearance of bile
97
patient develops hypotension with a fractured pelvis
assess rapidly with FAST
-if fluid/blood present---do abdominal exploration
if note, risk of pelvic bleeding which may not be detected.
-PELVIC ANGIOGRAM, control by EMBOLIZATIOn
98
managment of splenic laceration-
- try to preserve spleen to avoid post-splenectomy sepsis
- avoid blood transfusions if it can be avoided
- FOR grade 3 or lesser=observe
others need exploration
99
why is infarction a rare problem when embolizing a portion of the spleen after a splenic laceration
rich collaterals from short gastric vessels
100
rupture of left kidney with associated retroperitoneal hematoma in an unstable patient
operative intervention required
for stable- go by stage of the laceration
101
a central hematoma in area of SMA associated with potential injury to which structures
abdominal aorta and branches
pancreas
duodenum
102
initial step if there is moderate amount of blood on entering the peritoneum in a patient who had an automabile crash
stop bleeding by packing all four quadrants of abdomen with gauze packs
103
three types of hematomas and management
1) central= retroperitonea, can involve major vasculature, surgically explored
2) flank hematoma (secondary to renal parenchymal injury)- observed in stable patients
3) pelvic hematoma- bleeding located with angiography and embolized
104
when is general hyperventilation reserved for in head injuries
usually not used, unless patient has signs of impending brain herniation like blown pupil
hyperventilation can reduce ICP by inducign vasoconstriction (lesser CO2) but prolonged is dangerous because decreased flow can lead to more ischemia
105
head injury with sodium level of 125 meq/L
brain injury can lead to secretion of ADH (SIADH)
extracellular hypotonicity leads to intracellular edema - can cause severe cerebral edema
tx: water restriction
106
what does hypothermia lead to in post op patient
coagulopathy from platelet dysfunction and prolonged PT and PTT
107
man who sustained liver injury from MVA develops abdominal distension and oliguria
continued hemorrhage and collection of blood in abdomen, with decreased renal blood flow
abdominal compartment syndrome
108
what is the next step if a hypovolemic patient is given a fluid bolus and no response in urine output or BP is seen
measure CVP which gives index of preload of right heart
109
how may a normal CVP still indicate a hypovolemic patient
1) CO is problem
2) CVP which measure right heart assumes that left ventricle also is getting that preload. this may not be true in sick patients, where even with a normal CVP, left heart filling isnt adequate
110
25yo man comes in with acute SOB. PMH includes a stab wound 5 years ago. current exam: hr 125, bilateral rales, JVD, S3 gallop
high output cardiac failure which could have resulted from an undiagnosed AV fistula from the prior injury
111
patient with respiratory distress fails to improve oxygenation after increasing FIo2
worsening ARDS
mucous plug
malposition of endotracheal tube
PE
112
what happens to BP with addition of PEEP to Fio2 in a patient who is having problems with ventilation
PEEP decreases venous return to heart, thus impairing CO, and thus BP
a pulmonary artery catheter may be needed to monitor preload and CO
113
how to rule out airway injury when patient underwent neck trauma
bronchoscopy and laryngoscopy
114
pt with neck trauma has hemiparesis
consider carotid injury/thrombosis.
do an angiogram and then proceed with vascular repair if necessary
115
First
Second
Third
Degree Burns
first- micro injury to superficial epidermis, pain main symptom, resolve in 48-72 hours
second- damage extends through epidermis into dermis. epithelial regneration can still occur, BLISTERS may be present
white= non viable, seen in deeper dermis burns
third- full thickness of skin- white, lack of capillary refill, leathery. need skin graft for repair
116
what should be given in the next 24 hours after initial lactated ringers for fluid replacement for burns
D5W to replace evaporative water loss
0.5ml plasma/% BSA to maintain colloid oncotic pressure
117
why is colloid not given in the first 24 hours of burn
capillaries are leaky, and colloid will leak into extracellular space. colloid is most effective at returning intravascular/plasma volume
118
topical tx of burns
silver sulfadiazine for deeper wounds, occlusive dressings
debridement for third degree
prophylactic abx are not used as they select for resistant organisms. exception: S.aureus, psuedomonas, streptococcus, candida
119
consequence fo circumferential third degree burn of chest
can impair ventilation
120
protein requirement for non depleted patients on TPN
total calories
1.0g/kg/day
total calories 20% above basal energy expenditure
121
measuring daily energy expenditure
indirect calorimetry which involves calcularion of produced O2 and CO2. not really used.
assumption (70kg male)- 30kcal/kg/day \* 70= 2100 kcal/day
122
standard TPN
calories given mainly 70% of dextrose and 30% as fat
(given as 50% dextrose solution)
(fat as 10% or 20% emulsion separate from TPN bag)
protein not for calories,but to replace amino acids being used up
123
most common cause of coma in patients on TPN
hyperglycemic, hyperosmolar non ketotic coma. secondary dehydration following excessive diuresis due to hyperglycemia
124
dry scaly skin on patient with TPN
free fatty acid def
125
at what carboxy-hemoglobin level can significant CNS dysfunction occur
30%
126
when should steroids not be used in burns
in patients with burn GREATER than 10% TBSA
because a burn site can become infectied
steroids can be topically used for first degree burns which heal quickly
127
most appropriate wound management for 30 yo man with second degree burns about 20% tbsa
NEED ro do earlt excision of entire burn wound with autologous skin graft presentation
128
signs of necrotizing surgical wound
- fever, hypotension, tachycardia
- intense pain
- decreased sensitivity around edges
- cloudy gray discharge
- subcutaneous gas (crepitus)
