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Questions and Answers
What is the daily requirement of potassium?
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.
Potassium can be replaced on the first day after surgery.
False (B)
What are the main types of fluids used in fluid replacement?
What are the main types of fluids used in fluid replacement?
Crystalloids and Colloids
Normal saline contains __ mmol/day of sodium.
Normal saline contains __ mmol/day of sodium.
Match the following fluids with their sodium content:
Match the following fluids with their sodium content:
Which of the following is a complication that may indicate the need for a RIG procedure?
Which of the following is a complication that may indicate the need for a RIG procedure?
The PEG procedure is performed using a Seldinger technique.
The PEG procedure is performed using a Seldinger technique.
What should be done if the aspirate is greater than 75-100 cc before the next meal?
What should be done if the aspirate is greater than 75-100 cc before the next meal?
The procedure for inserting a gastrostomy tube through the abdominal wall is known as _____ insertion.
The procedure for inserting a gastrostomy tube through the abdominal wall is known as _____ insertion.
Match the following steps of the PEG procedure with their descriptions:
Match the following steps of the PEG procedure with their descriptions:
What is the best indicator for initial fluid requirements in shock monitoring?
What is the best indicator for initial fluid requirements in shock monitoring?
A shock index greater than 0.9 correlates with a higher mortality rate.
A shock index greater than 0.9 correlates with a higher mortality rate.
What is the normal urine output for adults in fluid resuscitation monitoring?
What is the normal urine output for adults in fluid resuscitation monitoring?
The primary indicator for fluid resuscitation in adults is urine output greater than ___ mL/kg/hour.
The primary indicator for fluid resuscitation in adults is urine output greater than ___ mL/kg/hour.
Match the following indicators with their corresponding uses:
Match the following indicators with their corresponding uses:
What is a primary risk factor for refeeding syndrome?
What is a primary risk factor for refeeding syndrome?
Hypophosphatemia is considered the main driver of metabolic derangement in refeeding syndrome.
Hypophosphatemia is considered the main driver of metabolic derangement in refeeding syndrome.
What is the maximum kcal/kg/day that should be provided in the first 4-7 days to prevent refeeding syndrome?
What is the maximum kcal/kg/day that should be provided in the first 4-7 days to prevent refeeding syndrome?
The treatment for postoperative fluid requirement for drains is __________.
The treatment for postoperative fluid requirement for drains is __________.
Match the following electrolyte imbalances with their consequences during refeeding syndrome:
Match the following electrolyte imbalances with their consequences during refeeding syndrome:
What is the earliest sign of overfeeding in a patient on TPN?
What is the earliest sign of overfeeding in a patient on TPN?
Central line related sepsis is the least common complication of TPN.
Central line related sepsis is the least common complication of TPN.
Name one common micronutrient deficiency associated with long-term TPN.
Name one common micronutrient deficiency associated with long-term TPN.
The most common complication of TPN is ______.
The most common complication of TPN is ______.
Match the following complications of TPN with their descriptions:
Match the following complications of TPN with their descriptions:
Which type of hemorrhage is defined as easy to diagnose and treat?
Which type of hemorrhage is defined as easy to diagnose and treat?
Hypotension in a patient with an isolated head injury is indicative of hypovolemic shock.
Hypotension in a patient with an isolated head injury is indicative of hypovolemic shock.
What is the main difference in the bleeding patterns between arterial and venous bleeds?
What is the main difference in the bleeding patterns between arterial and venous bleeds?
In ________ hemorrhage, diagnosis can be challenging, such as in cases involving the neck or abdomen.
In ________ hemorrhage, diagnosis can be challenging, such as in cases involving the neck or abdomen.
Match the type of arterial bleed with its characteristic:
Match the type of arterial bleed with its characteristic:
What is the primary use of a PICC line?
What is the primary use of a PICC line?
Total Parenteral Nutrition (TPN) solutions typically contain fiber.
Total Parenteral Nutrition (TPN) solutions typically contain fiber.
What is the recommended duration for using a PICC line?
What is the recommended duration for using a PICC line?
The typical composition ratio of protein, fat, and carbohydrates in TPN is __________.
The typical composition ratio of protein, fat, and carbohydrates in TPN is __________.
Match the following TPN types with their characteristics:
Match the following TPN types with their characteristics:
What is the primary goal of Damage Control Resuscitation?
What is the primary goal of Damage Control Resuscitation?
Permissive hypotension aims to keep blood pressure at a lower limit of normal.
Permissive hypotension aims to keep blood pressure at a lower limit of normal.
Name one medication used to treat coagulopathy during resuscitation.
Name one medication used to treat coagulopathy during resuscitation.
The monitoring of __________ is crucial in assessing cardiovascular function during resuscitation.
The monitoring of __________ is crucial in assessing cardiovascular function during resuscitation.
Match the following resuscitation goals with their corresponding targets:
Match the following resuscitation goals with their corresponding targets:
What is the primary reason for hemorrhage during surgery?
What is the primary reason for hemorrhage during surgery?
Class IV hypovolemic shock is characterized by having a urine output of anuria.
Class IV hypovolemic shock is characterized by having a urine output of anuria.
In Class II hypovolemic shock, what physiological change occurs regarding heart rate?
In Class II hypovolemic shock, what physiological change occurs regarding heart rate?
The estimated blood loss in Class I hypovolemic shock is approximately _____ percent.
The estimated blood loss in Class I hypovolemic shock is approximately _____ percent.
Match the class of hypovolemic shock with its corresponding characteristic.
Match the class of hypovolemic shock with its corresponding characteristic.
Which of the following is a complication related to feeding regime in parenteral nutrition?
Which of the following is a complication related to feeding regime in parenteral nutrition?
Short bowel syndrome is an indication for parenteral nutrition.
Short bowel syndrome is an indication for parenteral nutrition.
What is the location of the tip of a central venous line for total parenteral nutrition?
What is the location of the tip of a central venous line for total parenteral nutrition?
The main risk associated with using the _____ vein for central line insertion is pneumothorax.
The main risk associated with using the _____ vein for central line insertion is pneumothorax.
Match the following complications of parenteral nutrition with their categories:
Match the following complications of parenteral nutrition with their categories:
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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
- Catabolic state (malnourished state)
- 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.
- Confirmation:
- Catheter related sepsis (most common)
- 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.
- High osmolar:
Complications of Parenteral Nutrition
- Tube Related:
- Blockage.
- Migration.
- Leakage.
- Feeding Regime Related:
- Osmotic diarrhea
- Hyperosmolar feed: Rapid transit → Diarrhea.
- Overfeeding causes aspiration.
- Osmotic diarrhea
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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