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110 Cards in this Set
- Front
- Back
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When does a post op MI usually occur?
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Right after the surgery.
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What are the risk factors for post op MI?
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Pre op CHF
Ischemia on chemical or exercise stress test Age >70yo |
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Signs of hypovolemia post op?
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Restlessness
Anxious Pale Cool skin Tachycardia Orthostasis |
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How do you treat post op hypovolemia?
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Fluid resuscitation (2L of crystalloid)- NS or LR
If that doesn't work give blood *Don't give pressors |
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What is the MCC of LV failure and pulmonary edema?
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Fluid overload and decreased cardiac reserve.
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How do you treat post op LV cardiac and pulmonary edema?
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Shock - ICU, preload and afterload tx
Stable - Dig, Fluid restriction and diuretics |
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What causes post op urinary retention?
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Excessive catecholamine stimulation of alpha adrenergic receptors in smooth muscles of bladder neck and urethra
and Excessive IV fluid admin |
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What are some characteristics of post op urinary retention?
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Cramping
Urgency Lower abd pain Unable to void |
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How is post op urinary retention managed?
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Do a bladder scan. Cath q 6-8hrs.
w/ BPH complications you might send home with a Foley and F/U c/urology. |
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When would an anastomotic leak usu. occur?
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7-14d
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How does an anastomotic leak usu. present and how do you manage it?
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Usu. c/features of intraabd. abcess.
Return to OR and create colostomy. |
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What is the difference btwn an ileus and SBO?
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Ileus - normal neurological control slows, non mechanical.
non- emergent SBO- Mechanical block; can be emergent. |
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How is an ileus managed?
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NG tube maybe to bring out acid that is produced.
Bowel rest. Movement should stimulate return of normal bowel function. Might get a film of abd. |
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How is an SBO managed?
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Use NG suction for a couple of days.
Bowel rest. Complete bowel obstruction - surgery. Might get a film of abd. |
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If you obtain a film of the abd and you see gas in the rectum what does that let you know?
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That something is getting through. If no gas was there you have a probable obstruction.
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What are the first S/S of an anastomotic leak?
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Fever, tachycardia
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If a pt has persistent(chronic pain) at an operative site, what should you think about? How do you manage this?
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Stitch abcess
Granuloma Incision Explore the area; May need to remove a stitch. |
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What is the most common psychiatric complication following surgery?
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Delirium
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Some causes of post op delirium?
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Drugs
Drug combos Metabolic disturbance Hypoxia, sepsis Alcohol/drug withdrawal |
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Due to the fact that you cannot prevent alcohol withdrawal post op what can help?
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Benzos help sx.
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How can you tx post op delirium agitation?
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Haldol 2-25mg PO
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What does the DT(Delirium Tremens) prodrome consist of?
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Diaphoresis
Agitation Hallucination |
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How do you prevent ICU psychosis?
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Decreased noise
Adequate sleep Remove from ICU asap |
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How do you treat DTs?
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Alcohol or benzos
Replace vit B and Mg |
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Breakdown of body fluid by compartment?
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Intracellular (most)
Extracellular a) Interstitial (more than below) b)Intravascular |
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What is ICF made up of?
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Potassium
Organic phosphate Sulfate |
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What is ECF made up of?
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Sodium
Chloride Bicarbonate |
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What is an important propterty of the intravascular compartment as far as proteins are concerned?
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The intravascular compartment contains more Albumin which gives plasma its high colloid osmotic pressure (pulls water in).
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What are the daily maintenance fluid requirements for adults (with normal renal function)?
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Water 2-2.5L/day
Sodium 75meq/day K+ 40-60meq/day Glucose 100Gm/day |
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Important limitations of maintenance fluid therapy?
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Doesn't provide adequate calories
No AA, Fatty acids, or vital micronutrients Cannot be sustained longer than 3-5days |
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What is a crystalloid sol'n and what are the types?
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Aqueous soln of low molecular wt ions: salts
Isotonic: 260-340mOsm Hypotonic: <260 Hypertonic: >340 Normal serum is 285-295 |
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What are the types of isotonic replacement fluids?
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Considered replacement fluid bc same osmo as blood so stays in pipe.
NS and LR |
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What are the tonicity, components, and special considerations with normal saline and LR solns?
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NS: Ton: 308;
Na, Cl (both 154) LR: Ton:273 Na,Cl,K+,Ca2+,Lactate Expand IV compartment Monitor for overload (esp HTN, CHF) Avoid in pts with liver dz or alkalosis- choose NS over LR |
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Which IV soln most closely approximates serum?
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LR
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Which IV solns are considered hypotonic?
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Maintenance fluids
Will move interstitially rather than intracellularly. 1/2NS and D5W |
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What are the tonicity, components, and special considerations with 1/2NS and D5W solns?
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1/2NS: Ton: 154;
Na,Cl(both 77) D5W-5% dextrose in water: Ton: 253 Glucose only Causes fluid shift intracellularly Caution c/ increased ICP Avoid in pts at risk for fluid shifts(burns, trauma, low protein states) |
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Which IV solns are considered hypertonic?
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D5 1/2 NS, D5 1/4NS (peds)
D5NS D5LR |
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What are the tonicity, components, and special considerations with D5 1/2NS, D5 1/4NS (peds), D5NS, D5LR solns?
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D5 1/2 NS, D5 1/4NS(Ton355) (peds):
Ton: 432 Na, Cl, glucose D5NS:Ton(586) Na, Cl, glucose D5LR: Ton(525) Na, CL, K+, Ca2+, Glucose,Lactate Will pull H20 into intravascular space. Use to expand volume (IV compartment). Avoid in DKA pts with cellular dehydration. Caution in pts c/ impaired kidney function or heart fxn. |
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What is the most common IV fluid given to a pt?
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D5 1/2 NS
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What do all of the hypertonic solutions contain?
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Dextrose - sugar.
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What are some clinical manifestations of volume depletion?
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Tachycardia
Low BP-1st orthostatic HTN Narrow pulse pressure Poor skin turgor Dry mucous membranes I&O, body weight |
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In what conditions would you find volume depletion only (no solute deficit)?
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Pts who cannot regulate intake:
Debilitated Comatose Insensible loss from fever Pts on tube feeds c/o H20 supplementation and or with DI |
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What type of hyponatremia would be caused by pure water deficit?
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Hypotonic hypernatremia
Clinical findings: Increased plasma osmo Concentrated urine Low urine sodium Bc of increased serum sodium: Muscle rigidity, Tremors, CNS(lethargy or coma) |
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How do you treat hypotonic hypernatremia due to volume depletion?
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Replace H20 to restore sodium to normal.
Hypotonic, maintenance type fluid. D5W or 1/2NS |
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In what pts is volume and electrolyte deficiency commonly seen?
What are the clinical findings? |
Surgical
Similar to pure volume depletion. Urine Na<10meq/L Concentrated urine Serum chem consistent c/ prerenal azotemia--> BUN/Cr >20:1 |
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Why would you not want to give a patient with alkalosis an IV soln with lactate in it?
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Because the lactate is broken down in the liver and converted to bicarbonate which makes alkalosis worse.
LR and D5LR |
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When a pt has volume and electrolyte depletion what type of fluid would you want to give?
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Isotonic, "Replacement"
If plasma Na+ is normal: LR NS(may cause hyperchloremic acidosis bc plasma bicarb concentration decreases as chloride concentration increases) |
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What type of condition is NS more useful in?
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Hypochloremic metabolic acidosis
PRBC infusion |
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Why is dextrose added to IV fluid?
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To prevent ketosis or hypoglycemia due to fasting.
Women and children more likely. |
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Why does post op volume overload occur?
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Excessive volume in peri operative period when aldosterone and ADH are secreted. (exaggerated with heart failure, renal or liver dz, hypoalbuminemia).
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Clinical manifestations of volume overload? How do you treat this?
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Edema, JVD, Tachypnea, Increased body weight, Increased CVP
Tx= H20 restriction, give hypotonic solution like 1/2 NS |
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What are colloid solutions?
When are they indicated? |
Higher osmo's
Contain complex sugar or protein to maintain colloid osmotic presssure gradient. Indicated= Severe intravascular fluid deficits(hemorrhagic shock) prior to blood transfusion. Severe hypoalbuminemia or conditions with large proteins losses (burns) |
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How is a burn handled as far as IV fluids go? *LR or NS
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Crystalloid for 1st 24 hours then colloid once leaky capillaries close.
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3 types of colloid solns?
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Albumin(blood derived)
synthetic: Dextran Hetastarch |
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How are maintenance fluids calculated?
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First 10kg:100ml/kg/d
Second 10kg:50ml/kg/d Rest of weight:20ml/kg/d Add up and thats your mL of H20 per day. Divide by 24 to get rate per hour. |
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When adjusting IV fluid for Fluid/Electrolyte losses how do you adjust for fever?
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Add more
Every 1 degree over 100F, add 2cc/kg/d |
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When adjusting IV fluid for Fluid/Electrolyte losses how do you adjust for vomiting, diarrhea, blood loss, 3rd spacing?
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Just replace what is lost.
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What IV fluid order is given for Gastric loss(NG tube, emesis)?
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D5 1/2 NS with 20mEq KCL
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What IV fluid order is given for Diarrhea?
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Losing bicarb
D5LR with 15 meq/L KCl. 1L for each 1kg or 2.2lbs lost. Less KCl here than vomiting because LR has some K+. |
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What IV fluid order is given for Pancreatic loss?
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D5LR with 50meq/L, 1amp HCO3
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Roughly the max of K+ that can be given without being in the ICU and doing an EKG?
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20meq
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Generally what type of fluid is a bolus?
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Maintenance fluid.
Just open up line and let it drip in as fast as it will. |
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What, metabolically happens, 12 hrs NPO?
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Plasma insulin starts to fall
Glucagon output increases Hepatic glycogen is converted to glucose. |
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What, metabolically happens, 24 hrs NPO?
What can prevent muscle breakdown in short term fasting? |
Hepatic gluconeogenesis using AAs occurs with peak loss.
AAs are converted to ketones to run on. Replacement of exogenous glucose per day. (100g/d) |
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What, metabolically happens, with prolonged NPO status(days)?
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Fat is broken down to glycerol and fatty acids.
Adaptive ketogenesis - liver produces ketone bodies. Brain can become accustomed to ketone bodies instead of glucose. |
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When is a status of baseline malnutrition defined?
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>10% wt loss in 3months
Norm albumin >3 Can check prealbumin first (normal about 20) |
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How can you calculate nutritional requirements?
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BEE (Basal energy expenditure requirements)
Males: 66.4 + [13.7 x wt(kg)] + [5 x height(cm)] - [6.8 x age] Females: 665 + [9.6 x wt(kg)] + [1.7 x height(cm)] - [4.7 x age] |
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How is BEE affected with no post op complications?
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Normal
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How is BEE affected with mild peritonitis, long bone fx, moderate injury?
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25% above normal
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How is BEE affected with severe injury?
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50% above normal
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How is BEE affected with Burns of 40-100% TBS?
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100% above normal.
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Typical daily nutritional requirements?
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Carbs = min. of 400kcal/day
Protein= 0.8g/kg over 24hrs (60-70g/d) Lipids |
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Difference btwn enteral and parenteral feeding?
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Enteral - Still feeding through gut; by tube- NG, feeding, gastric, or jejun.
Parenteral = Via vein (peripheral or central) |
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What would be 2 indications for enteral feeding?
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Malnourished pts with intact GI tract.
Pts unable to meet 2/3-3/4 of daily needs. |
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What are some contraindications to enteral feeding?
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Short bowel
GI obstruction or bleeding Protracted vomiting/diarrhea Ileus Active GI ischemia requiring bowel rest. |
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A risk of NG tube use?
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Nocosomia pneumonia
Nasal ischemia This is short term. |
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Who would an 'elemental' feeding formula be good for?
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If the pt cannot tolerate high osmo; proteins are already broken into amino acids.
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Who would a 'modular' feeding formula be good for?
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Renal or hepatic failure
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What are gastric residual volumes?
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A way to monitor tube feeding. Is the feeding being absorbed or just sitting there.
>200cc hold feeding then restart. |
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Technical vs functional complications of enteral feeding?
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Technical - clogging of tube
Functional - dont tolerate formula. |
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Peripheral Parenteral Nutrition?
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Lower osmo than TPN. Delivered by IV or PICC line. Subclavian line- can give higher sugar load.
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Total parenteral nutrition?
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For pts who cannot obtain adequate nourishment from GI tract. Minimum 7-10d.
3:1 mixture Protein(AA) Carb(Dextrose) Fat (Soybean/safflower oil) Vitamins and trace elements. |
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Complications of PPN vs TPN?
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Technical and infectious.
TPN: Metabolic. |
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What is the first phase of wound healing?
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1) Inflammatory:1-2d
Cytokines brought to area Attracts platelets and leukocytes (NEUTROPHILS first) These eat debris and put out IL-1 Fibroblasts attracted which lay and secrete collagen network. |
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What is the second phase of wound healing?
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Proliferative phase - 48-72h
Fibroblasts continue to lay collagen over 6wks. Angiogeneisis too. Reform capillary network. Contact inhibition - stops scarring. If this is absent you get keloids. |
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What is the third phase of wound healing?
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Remodeling phase - wks-months
collagen crosslinks added for strength |
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At 6 wks how strong is your wound?
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Should be 70-80% tensile strength.
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What are some factors that affect wound healing?
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Infection
Time Hematoma Necrotic tissue Necrotic tissue Pts health status Meds Blood supply Mech of injury Type of tissue injured Technique |
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3 types of wound healing?
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Primary intention
Secondary intention Tertiary intention |
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What is primary intention?
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Side to side & connect;
Most surgeries closed this way Pretty wound outcome. |
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What is secondary intention?
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Wound closes from middle
Expl: avulsion injury Just cannot pull it together. Use wet to dry dressings. Indicated for a contaminated wound. |
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What is tertiary intention?
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Delayed primary closure
Secondary then close side to side. Expl: Perforated appendix.Waiting for removal of infectious source. |
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What is the usual pre-op antibiotic?
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Anceph - C1
Usu g (+) coverage. Surface bacteria staph and strep. |
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Classification of wounds?(4)
Risk of post op infection? |
Clean(2%) - <6wks
doesnt involve violation of hollow viscus. mole,SCC Clean-contaminated(10%) Viscus purposefully/accidentally violated with minimal spillage. Small bowel or prepped large bowel. Contaminated(20%) - excessive spillage or inflammation or where bacterial count is excessive. appendectomy. Dirty(60%)- Colon perf. |
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What does classification of wounds help with?
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Antibiotic ordering.
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What type of antibotic coverage is needed for a clean wound?
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Staph Aureus, Staph epidermis
None given or 1st gen ceph |
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What type of antibotic coverage is needed for a clean-contaminated wound?
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Enterobacteriaceae, Enterococci, Anerobes
2nd gen ceph (Cephoxitan, Cefotetan) Anaerobic coverage - metronidazol, clindamycin |
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What type of antibotic coverage is needed for a contaminated wound?
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Similar to clean contaminated but larger number of bacteria.
Same as for clean contam. preop and post op regimen too. |
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What type of antibotic coverage is needed for a dirty wound?
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Gross contamination with g+, g-, and anaerobes.
pre-op, post op, and prolonged antibiotic course. |
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Trauma victim with major wound. First important step?
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Still ABCs
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What are motor and sensory checks for L4 nerve root?
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Sensory - medial side of foot
Motor - Foot inversion or dorsiflexion |
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What are motor and sensory checks for L5 nerve root?
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Sensory - dorsum of foot
Motor - Toe extension(up) |
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What are motor and sensory checks for S1 nerve root?
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Sensory: Lateral foot
Motor: Eversion |
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What are motor and sensory checks for radial nerve?
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Sensory: Index finger -on top of hand
Motor:Extension of fingers, wrist ext/dorsiflex |
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What are motor and sensory checks for ulnar nerve?
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Sensory: pinky
Motor: Fanning (ab/ad of fingers) |
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What are motor and sensory checks for Median nerve?
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Sensory: 1st web space
Motor: Thumb flexion and opposition |
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With a wound what important shot should be noted?
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last tetanus
every 10 years unless incident then every 5 |
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What would an xray not pick up, as far as foreign bodies go?
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Wood, fish bone, some cactus spines.
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Classification of a tetanus prone wound?
Age Configuration Depth Mechanism of injury Signs of infxn Devitalized tissue Ischemia/denervate Contaminants |
>6hrs
Stellate, avulsion >1cm Missile,crush,burn, frostbite Present: Signs of infxn Devitalized tissue Ischemia/denervate Contaminants |
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Classification of a non-tetanus prone wound?
Age Configuration Depth Mechanism of injury Signs of infxn Devitalized tissue Ischemia/denervate Contaminants |
<6hrs
Linear, abrasion <1cm Sharp surface Absent: Signs of infxn Devitalized tissue Ischemia/denervate Contaminants |
