Surgery Marrow Pg 31-40 (General Surgery)
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Questions and Answers

What is the daily requirement of potassium?

  • 25 mmol/day
  • 75 mmol/day
  • 50 mmol/day (correct)
  • 100 mmol/day

    • Potassium can be replaced on the first day after surgery.

    False

    What are the main types of fluids used in fluid replacement?

    Crystalloids and Colloids

    Normal saline contains __ mmol/day of sodium.

    <p>154</p> Signup and view all the answers

    Match the following fluids with their sodium content:

    <p>Hartmann's solution (RL) = 131 mmol/L Normal saline = 154 mmol/L Gelofusine = Varies Haemaccel = Varies</p> Signup and view all the answers

    Which of the following is a complication that may indicate the need for a RIG procedure?

    <p>Compromised respiratory function</p> Signup and view all the answers

    The PEG procedure is performed using a Seldinger technique.

    <p>True</p> Signup and view all the answers

    What should be done if the aspirate is greater than 75-100 cc before the next meal?

    <p>Withhold the next feed</p> Signup and view all the answers

    The procedure for inserting a gastrostomy tube through the abdominal wall is known as _____ insertion.

    <p>percutaneous</p> Signup and view all the answers

    Match the following steps of the PEG procedure with their descriptions:

    <p>Endoscope advancement = Insertion of the endoscope to visualize the stomach Transillumination = Using light to identify the stomach wall Finger indentation = Applying pressure to locate the stomach Suture fixation = Securing the stomach to prevent movement of the tube</p> Signup and view all the answers

    What is the best indicator for initial fluid requirements in shock monitoring?

    <p>Pulmonary capillary wedge pressure</p> Signup and view all the answers

    A shock index greater than 0.9 correlates with a higher mortality rate.

    <p>True</p> Signup and view all the answers

    What is the normal urine output for adults in fluid resuscitation monitoring?

    <blockquote> <p>0.5 mL/kg/hour</p> </blockquote> Signup and view all the answers

    The primary indicator for fluid resuscitation in adults is urine output greater than ___ mL/kg/hour.

    <p>0.5</p> Signup and view all the answers

    Match the following indicators with their corresponding uses:

    <p>PCWP = Initial fluid requirement Urine output = Fluid resuscitation Shock index = Mortality rate prediction Modified shock index = Sensitivity for shock assessment</p> Signup and view all the answers

    What is a primary risk factor for refeeding syndrome?

    <p>Little or no nutritional intake for more than 10 days</p> Signup and view all the answers

    Hypophosphatemia is considered the main driver of metabolic derangement in refeeding syndrome.

    <p>True</p> Signup and view all the answers

    What is the maximum kcal/kg/day that should be provided in the first 4-7 days to prevent refeeding syndrome?

    <p>10</p> Signup and view all the answers

    The treatment for postoperative fluid requirement for drains is __________.

    <p>RL</p> Signup and view all the answers

    Match the following electrolyte imbalances with their consequences during refeeding syndrome:

    <p>Hypophosphatemia = Metabolic derangement Hypokalemia = Arrhythmia Hypomagnesemia = CHF Hypocalcemia = Increased mortality risk</p> Signup and view all the answers

    What is the earliest sign of overfeeding in a patient on TPN?

    <p>Weight gain greater than 1 kg/day</p> Signup and view all the answers

    Central line related sepsis is the least common complication of TPN.

    <p>False</p> Signup and view all the answers

    Name one common micronutrient deficiency associated with long-term TPN.

    <p>Zinc</p> Signup and view all the answers

    The most common complication of TPN is ______.

    <p>hyperglycemia</p> Signup and view all the answers

    Match the following complications of TPN with their descriptions:

    <p>Catheter related sepsis = Most common complication of TPN Jaundice = Deranged liver enzyme in 25% of long-term TPN use Refeeding syndrome = Potentially serious condition after starting feeding Electrolyte imbalance = Can lead to serious health issues</p> Signup and view all the answers

    Which type of hemorrhage is defined as easy to diagnose and treat?

    <p>Overt hemorrhage</p> Signup and view all the answers

    Hypotension in a patient with an isolated head injury is indicative of hypovolemic shock.

    <p>False</p> Signup and view all the answers

    What is the main difference in the bleeding patterns between arterial and venous bleeds?

    <p>Arterial bleeds spurt blood, while venous bleeds ooze gradually.</p> Signup and view all the answers

    In ________ hemorrhage, diagnosis can be challenging, such as in cases involving the neck or abdomen.

    <p>concealed</p> Signup and view all the answers

    Match the type of arterial bleed with its characteristic:

    <p>Laceration = Increases in tear size and bleeds more Transection = Bleeds less than laceration</p> Signup and view all the answers

    What is the primary use of a PICC line?

    <p>Chemotherapy</p> Signup and view all the answers

    Total Parenteral Nutrition (TPN) solutions typically contain fiber.

    <p>False</p> Signup and view all the answers

    What is the recommended duration for using a PICC line?

    <p>2-3 months</p> Signup and view all the answers

    The typical composition ratio of protein, fat, and carbohydrates in TPN is __________.

    <p>20:30:50</p> Signup and view all the answers

    Match the following TPN types with their characteristics:

    <p>High osmolar = Increased carbohydrates, used in renal failure Low osmolar = Decreased CO2 production, used in pulmonary failure 3 in 1 = All three components in one solution 2 in 1 = Fat and carbohydrates only</p> Signup and view all the answers

    What is the primary goal of Damage Control Resuscitation?

    <p>Coagulation function and coronary perfusion</p> Signup and view all the answers

    Permissive hypotension aims to keep blood pressure at a lower limit of normal.

    <p>True</p> Signup and view all the answers

    Name one medication used to treat coagulopathy during resuscitation.

    <p>Tranexamic acid</p> Signup and view all the answers

    The monitoring of __________ is crucial in assessing cardiovascular function during resuscitation.

    <p>blood pressure</p> Signup and view all the answers

    Match the following resuscitation goals with their corresponding targets:

    <p>Damage Control Resuscitation = Coagulation function, coronary perfusion Perfusion-targeted Resuscitation = Adequate preload and afterload Monitoring during resuscitation = BP, HR, Electrolytes Balanced transfusion = 1:1 RBC and FFP</p> Signup and view all the answers

    What is the primary reason for hemorrhage during surgery?

    <p>Dislodgement of a clot</p> Signup and view all the answers

    Class IV hypovolemic shock is characterized by having a urine output of anuria.

    <p>True</p> Signup and view all the answers

    In Class II hypovolemic shock, what physiological change occurs regarding heart rate?

    <p>Decreased heart rate</p> Signup and view all the answers

    The estimated blood loss in Class I hypovolemic shock is approximately _____ percent.

    <p>0-15</p> Signup and view all the answers

    Match the class of hypovolemic shock with its corresponding characteristic.

    <p>Class I = 0-15% blood loss Class II = 15-30% blood loss Class III = 30-40% blood loss Class IV = &gt;40% blood loss</p> Signup and view all the answers

    Which of the following is a complication related to feeding regime in parenteral nutrition?

    <p>Osmotic diarrhea</p> Signup and view all the answers

    Short bowel syndrome is an indication for parenteral nutrition.

    <p>True</p> Signup and view all the answers

    What is the location of the tip of a central venous line for total parenteral nutrition?

    <p>Superior vena cava just above the right atrium</p> Signup and view all the answers

    The main risk associated with using the _____ vein for central line insertion is pneumothorax.

    <p>subclavian</p> Signup and view all the answers

    Match the following complications of parenteral nutrition with their categories:

    <p>Blockage = Tube related Hyperosmolar feed = Feeding regime related Migration = Tube related Overfeeding = Feeding regime related</p> Signup and view all the answers

    Study Notes

    K⁺ Replacement

    • Not on day 1 of surgery.
    • Injury to cell, which causes an efflux of K⁺.
    • Replaced from day 2.

    Daily Electrolyte Requirements

    • Sodium 50-90 mmol/day
    • Potassium 50 mmol/day
    • Calcium 5 mmol/day
    • Magnesium 1 mmol/day

    Crystalloids

    • Hartmann's solution (RL)
      • Sodium: 131 mmol/l
      • Potassium: 5 mmol/l
      • Chloride: 111 mmol/l
      • Lactate: 29 mmol/l
    • Normal saline
      • Sodium: 154 mmol/l
      • Chloride: 154 mmol/l

    Colloids

    • Gelofusine
    • Haemaccel
    • Hetastarch
    • Blood products

    PEG

    • Seldinger technique.
    • Endoscope advancement
    • Transillumination and finger indentation
    • Transgastric suture fixation of stomach

    Radiologically Inserted Gastrostomy (RIG)

    • Indications:
      • Patients where endoscopy is not possible
      • Compromised respiratory function
      • Compromised oropharyngeal anatomy

    Enteral Nutrition

    • Rate of feeding:
      • Started gradually at 10-20 mL/hr
      • Increased upto 75 mL/hr, if tolerated.
    • Aspirate before subsequent meal:
      • If aspirate is >75-100 cc, withhold next feed to avoid aspiration due to over distention of the stomach.

    Occult Hypoperfusion

    • Normal CVS parameters:
      • HR (normal)
      • SBP (normal)
    • Normal urine output
    • Low MVOS (mixed venous oxygen saturation)
    • Acidosis

    Monitoring of Shock

    • Best indicator for initial fluid requirement: PCWP (Pulmonary capillary wedge pressure)
      • Left-sided heart pressure
      • Swan-Ganz catheter used (more accurate)
      • Difficult to monitor
    • Best indicator for fluid resuscitation: Urine output
      • Adults: > 0.5 mL/kg/hour
      • Children: > 1 mL/kg/hour

    Shock Indices

    • Shock Index:

      • HR / SBP

      • 0.9: Higher mortality rate

    • Modified shock index:

      • HR / MAP (mean arterial pressure)
      • Most sensitive

    CVP

    • Right-sided heart pressure
    • Most commonly used

    Refeeding Syndrome

    • Large quantities of nutrition given to chronically malnourished patients.
    • Pathogenesis:
      • Catabolic state (malnourished state)
        • TPN (large quantity) leads to anabolic state.
      • Anabolic state
        • Influx of PO43−PO_4^{3-}PO43−​, Mg2+Mg^{2+}Mg2+, K+K^+K+, Ca2+Ca^{2+}Ca2+ into cells.
        • Release of insulin.
        • Hypophosphatemia, Hypocalcemia, Hypomagnesemia, Hypokalemia + Fluid overload.
        • CHF, Arrhythmia -> m/c cause of death
    • Hypophosphatemia: Main driver of metabolic derangement.
    • Risk factors:
      • BMI 15% in last 3-6 months
      • Little or no nutritional intake for >10 days.
      • Low potassium, phosphate, or magnesium levels prior to feeding.
    • Prevention:
      • Gradual increase of quantity of feeds.
      • Max 10 kcal/kg/day 4-7 days -> full needs
      • Strict electrolyte monitoring.
      • Thiamine supplementation.

    Post Operative Fluid Requirement

    • Goal-directed therapy:
      • Insensible losses (Breathing, sweating): 30-40 mL/kg/day
      • Ryles tube aspirate: NS + KCl
      • Drains: RL
      • Urine: NS/DNS

    Daily Monitoring

    • Pulse, BP, temperature
    • Body weight, abdominal gain
    • Earliest sign of overfeeding: If > 1 kg/day weight gain.
    • Fluid balance: Input - output charting
    • Type & quantity of food consumed

    Plasma Monitoring

    • Sodium
    • Potassium
    • Urea
    • Creatinine
    • Blood glucose
    • Magnesium
    • Phosphate

    Liver Function Test

    • Once weekly after establishing a stable feeding regime.

    Complications of TPN

    • Central line related:
      • Catheter related sepsis (most common)
        • Confirmation:
          • Blood culture from peripheral line.
          • Endoluminal brush from central line. (Same organism).
          • Catheter tip culture by removing the line.
    • Feeding regime related:
      • Hyperglycemia (most common)
      • Weight gain: Starts after 5-7 days.
      • Cholestasis
      • Deranged liver function (Withheld TPN)
      • Jaundice
        • Deranged liver enzyme: Seen in 25% of long term TPN use. Common in children.
        • Fatty liver (may be seen).
        • Fibrosis: Interstitial failure associated disease (IFALD) may be seen.
        • mx: Lipid free solutions.
    • Micronutrient deficiency:
      • Zinc: most common.
      • Refeeding syndrome.
      • Electrolyte imbalance.
    • Other Complications:
      • Pneumothorax.
      • Arrhythmias.
      • Thrombosis.
      • Air embolism.
      • Migration of line.

    Hypovolemic/Hemorrhagic Shock

    • Most common type of shock.

    Types of Hypovolemic Shock

    • Overt/visible hemorrhage
      • Easy to diagnose and treat.
    • Concealed haemorrhage
      • Difficult to diagnose.
      • Site: Neck/thorax/abdomen/pelvis/long bones.
    • Note:
      • Isolated head injury doesn't give rise to hypovolemic shock.
      • Hypotension in head injury, suspect neurogenic shock (Injury above T6 level).
      • Polytrauma
      • Bruising
      • Massive hemothorax

    Arterial vs Venous Bleed

    ArterialVenousBleedSpurterGradual ooze of bloodHypotensionOccurs earlyOccurs late (D/t compensation)PreventionEarlyLate

    Types of Arterial Bleed

    • Laceration: Vasoconstriction leads to ↑ in tear size. Bleeds more.
    • Transection: Bleeds less.

    Dynamic Fluid Response

    ResponderTransient responderNon responderPR↓↓↓↓↑SBP↑↑↑↑↓JVP↑↑↑↑↓

    Management of Hypovolemic Shock

    • Prioritise coagulation:
      • Recognize active bleeding (Hypotension, transient/non-responder).
    • Damage Control Resuscitation:
      • Goal: Coagulation function, coronary perfusion
      • Damage control surgery
      • Permissive hypotension (Keep BP at lower limit of normal)
      • Balanced transfusion (1:1 RBC and FFP)
      • Treat coagulopathy (Tranexamic acid, platelets, fibrinogen)
      • Monitor:
        • Cardiovascular: BP, HR
        • Electrolytes: Ca2+, K+
        • Coagulation: PT, fibrinogen, ROTEM/TEG
        • Perfusion: pH, base excess, lactate, temperature
    • Perfusion-targeted Resuscitation:
      • Goal: End-organ perfusion
      • Adequate preload and afterload (Fluids and pressors)
      • Thromboprophylaxis
      • Monitor:
        • Cardiovascular: BP, HR, CO, SVR
        • Perfusion: Base excess, lactate, SVO2
        • Organ function: PaO2/FiO2, UO, GCS.
        • Abdominal compartment: IAP
        • ROTEM: Rotational thromboelastometry
        • TEG: Thromboelastography
        • UO: Urine output

    Hemorrhage in Surgery

    OccursReasonDuring SxDislodgement of clot, slippage of knot (Granny's knot)After 7-14 daysSloughing of wall, d/t infection

    Classification of Hypovolemic Shock

    ParameterClass I (0-15%)Class II (mild) (15-30%)Class III (moderate) (30-40%)Class IV (Severe) (>40%)Approximate blood loss0-15%15-30%30-40%>40%Volume (in liters)0.5 litre1 litre1.5 litre>2 litresHeart rateNormal↓↑Non-recordableBlood pressureNormalNormalSBP ↓Non-recordablePulse pressure (SBP-DBP)NormalNormalNarrowNarrowerRespiratory rateNormalNormal↑↑↑Urine outputNormalNormal↓AnuriaMental statusNormalAnxious, thirstyConfusedComaBase deficitNormal−2 to −6 mEq/L−6 to −10 mEq/L>−10 mEq/LFluid replacementOral liquidsIV crystalloidsIV crystalloids + colloidMassive blood transfusion

    Class III Shock

    • Decompensated phase.
    • SBP starts falling.
    • Confused patient.

    Pathophysiology of Class II Shock

    • AKA compensated shock.
    • Blood loss:
      • Activation of sympathetic system: Noradrenaline, Adrenaline.
      • Tachycardia: ↑ HR (Earliest sign)
      • Peripheral vasoconstriction (Shunts blood to vital organs).
      • Cold extremities.

    Response and Management of Shock

    • 500 mL-1 L crystalloid given --- Response checked.
    • ↑ peripheral vascular resistance.

    PICC Line

    • Inserted with ultrasound guidance in peripheral vessel.
    • Tip just above right atrium.
    • Duration: 2-3 months.
    • Uses:
      • Chemotherapy
      • TPN (Total Parenteral Nutrition)
      • Prolonged antibiotics
    • Regular dressing & management is required.

    Total Parenteral Nutrition (TPN) Solution

    • Amount: 1-2 liters over 24 hrs.
    • Composition:
      • 20:30:50 = Protein: Fat: Carbohydrate
      • 3 in 1: All three components
      • 2 in 1: Fat and carbohydrates
      • Trace elements, vitamins can be added.
      • No fiber.
    • Types:
      • High osmolar:
        • Increased carbohydrates
        • Increased CO2CO_2CO2​
        • Increased risk of thrombosis.
        • Used in low volume, low protein states like renal failure.
      • Low osmolar:
        • Decreased CO2CO_2CO2​ production.
        • Used in pulmonary failure.

    Complications of Parenteral Nutrition

    • Tube Related:
      • Blockage.
      • Migration.
      • Leakage.
    • Feeding Regime Related:
      • Osmotic diarrhea
        • Hyperosmolar feed: Rapid transit → Diarrhea.
      • Overfeeding causes aspiration.

    Indications for Parenteral Nutrition

    • Prolonged paralytic ileus (>72 hrs)
    • Non-contracting bowel - No transit of food → Obstruction, vomiting.
    • Short bowel syndrome
    • High output faecal fistula (>500 cc/24 hrs)
    • Acute episode of inflammatory bowel disease: malabsorption
    • Need for bowel rest
    • Initial phase of acute severe pancreatitis

    Routes of Total Parenteral Nutrition

    • Central lines vs peripheral lines: | Route | Subclavian vein | Internal jugular vein | Femoral vein | |----------------|-------------------|-----------------------|---------------| | Central line | Least | Common | Max | | Risk of thrombosis & infection | Least | Max | Max | | Risk of pneumothorax | Max | Max | - | | Ease of insertion | - | - | - | | M/C used in TPN | - | - | - | | M/C used vein overall| - | - | - |

    Assessment After Insertion

    • To visualize the tip:
      • Located in the superior vena cava just above the right atrium
      • Tip in right atrium
      • To rule out pneumothorax
      • Check for Ectopic beats/Arrhythmia

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    Description

    This quiz covers essential concepts related to electrolyte management, including potassium replacement, daily requirements, and intravenous fluid types such as crystalloids and colloids. Additionally, it includes details on radiologically inserted gastrostomy (RIG) and enteral nutrition practices.

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