Surgery Marrow Pg 31-40 (General Surgery)

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to Lesson

Podcast

Play an AI-generated podcast conversation about this lesson

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 (B)

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 (C)</p> Signup and view all the answers

The PEG procedure is performed using a Seldinger technique.

<p>True (A)</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 (B)</p> Signup and view all the answers

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

<p>True (A)</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 (A)</p> Signup and view all the answers

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

<p>True (A)</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 (B)</p> Signup and view all the answers

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

<p>False (B)</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 (D)</p> Signup and view all the answers

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

<p>False (B)</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 (B)</p> Signup and view all the answers

Total Parenteral Nutrition (TPN) solutions typically contain fiber.

<p>False (B)</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 (A)</p> Signup and view all the answers

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

<p>True (A)</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 (A)</p> Signup and view all the answers

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

<p>True (A)</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 (C)</p> Signup and view all the answers

Short bowel syndrome is an indication for parenteral nutrition.

<p>True (A)</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

Flashcards are hidden until you start studying

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

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Quiz Team

More Like This

Fluid & Electrolyte Management Quiz
21 questions
Fluid and Electrolyte Management Quiz
48 questions
Use Quizgecko on...
Browser
Browser