Term
Total volume of water within the body
varies with?
decreases with? |
|
Definition
Varies with age, sex and proportion of body fat present
TBW decreases with obesity (adipose is nearly water-free) |
|
|
Term
| Homeostasis: Body maintains strict control of water and electrolyte distribution and acid-base balance as a function of the complex interplay of |
|
Definition
cellular membrane forces
specific organ activities
systemic/local hormonal influences |
|
|
Term
| Dominant Cations in human body |
|
Definition
|
|
Term
Each fluid compartment maintains electrical neutrality through balance of the concentrations of cations and anions
1) Intracellular Compartment
2)Interstitial & Intravascular Compartments |
|
Definition
1) Potassium is dominant cation
Anions are inorganic and organic phosphates, polyvalent proteins
-Sodium is dominant cation
-Neutrality maintained by balanced amts of Chloride and Bicarb anions
~ 7% of plasma is protein (anionic albumin) and cannot permeate the plasma membrane, thus vital to maintaining intravascular volume
-Small amounts of potassium, calcium, and magnesium make up the remainder of the cations present in the ECF |
|
|
Term
| forces are the prime determinants of water distribution in body |
|
Definition
|
|
Term
|
Definition
Number of particles dissolved in a solution
Independent of chemical activity or ionic strength of particles |
|
|
Term
Osmolarity expressed as a concentration
Osmolality expressed as a concentration |
|
Definition
= osmoles of solute per liter of solution
= osmoles of solute per kg of solution |
|
|
Term
| In plasma, osmolarity is primarily determined by |
|
Definition
sodium and accompanying anions, urea and glucose
Normal serum osmolarity = 285 mOsm/L
Because water is freely diffusible across the semipermeable membrane, the osmolarity of the ICF = ECF |
|
|
Term
|
Definition
Total concentration of solutes which exert an osmotic force across a membrane in vivo
Determines movement of water across the cellular membrane
Calculated by considering only the concentration of impermeable solutes in solution |
|
|
Term
Hypertonic alterations
Hypotonic alterations |
|
Definition
= ECF more concentrated than ICF, cell shrinkage
= ECF less concentrated than ICF, cells swell |
|
|
Term
What Accounts for Tonicity?
A ------- in tonicity implies a relative water excess whereas an -------- in tonicity implies dehydration |
|
Definition
Mainly electrolytes
reduction/increase |
|
|
Term
| Recognizing and correcting abnormalities brought about by disease, trauma, and stress are equally important to knowing how to ______normal fluid and electrolyte balance |
|
Definition
|
|
Term
| What systems regulate fluid volume in the body? |
|
Definition
Kidneys: regulate intravascular volume
Posterio pituitary: Osmoreceptors detect smaller changes in osmolarity regulate release of ADH
Baroreceptors: detect small changes in pressure play a small role in volume homeostasis
RAAS system: renin release from Jux cells of afferent arteriol in response to drop in Bp, volume, Na,
angiotensin releases aldosterone to increase sodium reasorb and K excretion |
|
|
Term
Fluid Homeostasis:
water gain from?
water losses from? |
|
Definition
Gain: consumption 2-3L water/day (liquid and solids), 400-500ml water by oxidative metab of fats and proteins
Loss: urine 800-1500 ml/d, feces 250ml/d, Insensible loss (evap skin) increases by 10% for each 1degree C increase in body temp |
|
|
Term
| How to Assess Fluid Status? |
|
Definition
Urine output
vital signs
wt changes
skin turgor
jugular venous distention
mucosal membranes
rales
cxr findings |
|
|
Term
| Chronic Volume deficits manifest as? |
|
Definition
Decreased skin turgor
Weight loss
Sunken eyes
Hypothermia
Oliguria
Tachycardia
Orthostatic hypotension
Serum BUN and Creatinine may be elevated
(BUN:Creat > 15:1) Ratio will be elevated
Hematocrit may be elevated 5-6% per liter of volume deficit (less fluid more viscos appearance of elev.) |
|
|
Term
| Acute Volume Deficits manifest by? |
|
Definition
Hypotension
Tachycardia
Tachypnea
Signs of end-organ hypoperfusion
Oliguria
Altered mental status (in the face of shock both oliguria and Alt ment status)
Severe volume deficits
Skin mottling
acidosis |
|
|
Term
| Purpose of Fluid/Electrolyte Therapy |
|
Definition
| Ensure homeostasis of TBW and its constituent solutes |
|
|
Term
| Principles for IVF/Electrolyte Replacement |
|
Definition
Maintenance
Replacement of Losses
Resuscitation |
|
|
Term
| -------- solution (i.e. LR) is highly effective in restoring circulating volume ( most effective to restore volume), but NS (0.9% NaCl) is commonly used as well |
|
Definition
|
|
Term
| Scenarios Requiring Fluid Replacement for Deficits |
|
Definition
blood loss from surgery
evaporative loss during lengthy surgery
Nasogastric output
Fistula losses
Diarrheal losses
Fluid sequestered in operative site (3rd spacing) |
|
|
Term
Aimed at replacing fluids normally lost during the course of a day
Calculation of__________ fluid replacement does not include replacement of either preexisting deficits or ongoing additional losses |
|
Definition
Maintenance Fluid Therapy
Normal average-sized adult requires 2500mL of maintenance fluids daily
If patient is febrile, maintenance fluids increase by 10% for each degree above 37.2 °C |
|
|
Term
IV fluid used when disired to expand ECFV
tonicities close to that of plasma= Isotonic |
|
Definition
0.9% NaCl (NS)
Note: Free water given in states of ECF depletion can lead to dangerous hyponatremia
D5W (5% dextrose in water), ½ NS, D5 ½NS deliver free water |
|
|
Term
Used to provide free water
Useful in treatment of severe hypernatremia
Does not deliver unwanted Na, therefore causes ECF overload less readily than saline solutions
used To keep vein open |
|
Definition
D5W IVF
Note: Delivery of medications in a non-diabetic patient
As KVO in ECF overload, it contains no Na and will not further expand ECF as much as saline can |
|
|
Term
Ideal for the replacement of existing fluid deficits when the serum electrolyte concentrations are abnormal
contains: Sodium, Chloride, Lactate, Potassium, Calcium |
|
Definition
Lactated Ringers IVF Solution
Note: Disadvantage of this solution
relatively low sodium content (130 mEq/L) as compared with plasma |
|
|
Term
Calculation of Maintenance Fluid Requirements
adult rule?
Pediatric rule? |
|
Definition
Adult 100/50/20 (10-10-20)
† For elderly patients or patients with cardiac disease, this amount should be reduced to 15 mL/kg/d
Once the daily replacement is calculated, divide by 24 hours/day to get hourly rate
Pediatric: 4/2/1 Rule (10-10-20) this is hourly so you do not divide by 24 hours |
|
|
Term
3 main types Dehydration
Gold standard: measurement of acute weight loss |
|
Definition
Hypotonic or hyponatremic: primary loss of electrolytes (Na)water shifts from vascular space to extravascular spaces
Hypertonic or hypernatremic: primary water loss
Isotonic or isonatremic:
equal loss of water and electrolytes
Most common, effectively equates to hypovolemia |
|
|
Term
| Always Resuscitate with what type of fluids???? |
|
Definition
Isotonic Fluids
Bolus 20ml/kg
Reassess reassess reassess |
|
|
Term
|
Definition
Hypovolmeic (diuretic excess)
Euvolemic (SIADH)
Hypervolemic (CHF, renal failure)
Do Not Correct Hyponatremia Too Quickly can lead to Central Pontine Myelinosis |
|
|
Term
| Hypernatremia - Treatment |
|
Definition
less of a problem in surgery patients than hyponatremia:
Initially, restore circulating volume with isotonic saline solution
Then, correct hypernatremia by administration of free water in form of D5W
Rapid correction of hypernatremia is associated with a significant risk of cerebral edema and herniation |
|
|
Term
Hyperkalemia
serum K > 5.5 mEq/L
EKG sign
Treatment: |
|
Definition
early: peaked T waves
Dictated by the serum level and by ECG changes or symptoms
-Effects of hyperkalemia on membrane potentials can be reduced by increasing calcium levels
-Potassium can be removed by treatment with cation-exchange resin kayexalate (50-100g as enema) or 40 g orally with sorbitol
Most effective method of removing K is hemodialysis |
|
|
Term
Hypokalemia
Serum Potassium < 3.5 mEq/L
1. Causes
2. what other diorder usually coexists? |
|
Definition
Common in surgical patients
1. GI losses from vomiting, diarrhea, fistula
Diuretics
2. Metabolic alkalosis
Note: Muscle weakness and paralysis can occur: Intestinal peristalsis can be impaired and result in intestinal ileus |
|
|
Term
|
Definition
Primary treatment is potassium replacement to increase concentration above 3.5 mEq/L
Route and rate of potassium replacement depends on the presence and severity of symptoms
IV potassium, oral K, |
|
|
Term
| Candidates for Oral Rehydration Therapy |
|
Definition
Mild to moderate dehydration (< 10%)
Age > 4 months
No persistent vomiting
Unlikely to have an underlying cause other than viral gastroenteritis
Isonatremia is present
Serum bicarbonate level > 18 mEq per L |
|
|
Term
Due to insulin deficiency and counter regulatory hormone excess
Serum and urine glucose + ketones elevated |
|
Definition
Diabetic Ketoacidosis
In acidosis, potassium is driven extracellularly |
|
|
Term
|
Definition
Isotonic fluid
Restore intravascular volume and tissue perfusion
To reverse ketoacidosis, insulin treatment must continue despite decreasing serum glucose
To prevent hypoglycemia, glucose infusion when serum glucose < 300 mg/dL |
|
|
Term
| Hypovolemic Shock: Route and Rate of Fluid Administration |
|
Definition
Standard, large (14- to 16-gauge) peripheral IV
Crystalloid solutions for intravascular volume replenishment are typically isotonic
0.9% saline or Lactated Ringer
Patients in shock typically require and tolerate infusion at the maximum rate
watch for pulm edema with rapid infusion; adequate end organ perfusion is best indicated by urine output >.5 to 1 ml/kg/h |
|
|
Term
| Prioritize: Traumatic injuries usually take precedence over the burns, with the exception of |
|
Definition
Airway involvement.
Burns, even those extensive enough that make death likely, will usually not be fatal in the first few hours. However, a missed traumatic injury may be. |
|
|
Term
| What kind of necrosis do burns cause? |
|
Definition
| Burns cause coagulative necrosis |
|
|
Term
| Characteristic “Ebb and Flow” of burns |
|
Definition
Ebb: Low metabolism/cardiac output, ↓Temp
Flow: hypermetabolism, high cardiac output, hyperglycemia, increased heat production. |
|
|
Term
These are minor burns that only effect the outer epidermis.
Example: Sun Burn |
|
Definition
|
|
Term
Affect both the outer-layer (epidermis) and the under lying layer of skin (dermis)
These burns often affect sweat glands, and hair follicles |
|
Definition
| 2nd Degree Burns (Partial Thickness) |
|
|
Term
Epidermis, dermis and hypodermis
Charring of skin or a translucent white color, with coagulated vessels visible just below the skin surface |
|
Definition
3rd Degree Burns (Full Thickness)
These burns require debridement of dead tissue and reconstruction with a skin graft or other types of reconstruction |
|
|
Term
| Epidermis, Dermis, and destruction to subcutaneous fat |
|
Definition
fourth degree burn
It should however be noted that although fourth-degree is not a technical term, it is often used to describe burns that reach muscle and bone |
|
|
Term
| Estimation of Percent of Body Surface Burned |
|
Definition
For adults, use “Rule of Nines”
Pediatric Rule of Nines |
|
|
Term
| These burns are always Critical? |
|
Definition
Burns to hands, feet, face, genital or with
circumferential patterns are critical
Inhalation injuries are always critical |
|
|
Term
| use moist sterile dressings for immediate management of |
|
Definition
|
|
Term
| For immediate management of seriousthermal burns use? |
|
Definition
Dry dressings
Note: DO NOT make your patient hypothermic
DO NOT forget the ABCDE’s |
|
|
Term
| Burn patients are at risk for hypothermia, especially burned children. What should you do and not do? |
|
Definition
| Check the patient’s temperature frequently. Cover the patient with dry, clean sheets, then blankets. Do not apply ice or moisture or any topical microbial agent. Don't break blisters. Broken blisters are more vulnerable to infection. |
|
|
Term
| Indications of inhalation injury usually appears within 2-48 hours after the burn occurred. Indications may include |
|
Definition
Fainting
Fire or smoke present in a closed area
Evidence of respiratory distress or upper airway obstruction
Soot around the mouth or nose
Nasal hairs, eyebrows, eyelashes have been singed
Burns around the face or neck |
|
|
Term
| earliest consequence of inhalation injury |
|
Definition
Upper airway edema
It is commonly seen during the first 6 to 24 hours after injury
Early obstruction of the upper airway is managed with intubation
Initial treatment consists of removing the patient from the toxin and allowing exposure to fresh air or O2
Endotracheal intubation is gold standard |
|
|
Term
| A cut is made through the burned tissue with a scalpel or electrocautery medially and laterally to ensure restoration of pulses |
|
Definition
|
|
Term
| IV Fluid Resuscitation in burns |
|
Definition
Required by patients with > 20% TBSA burned or > 15% TBSA burned in children
Lactated ringers is the solution of choice in adults; D5LR and lacated ringers for children. |
|
|
Term
|
Definition
| Burns of 10% in children or 15% in adults (or greater) are potentially life threatening injuries (because of the risk of hypovolaemic shock) and should have formal fluid resuscitation and monitoring in a burn unit. |
|
|
Term
| Patients with electrical injuries or very deep tissue damage may have myoglobin in their urine, therefore they will require _______ the urine output to flush the kidneys of the large myoglobin cells. |
|
Definition
|
|
Term
| Why use Lactated Ringers instead of Normal saline or D5W for fluid resucitation in buurn paients? |
|
Definition
| LR is most like normal extracellular fluid, Normal saline is okay but too much can cause metabolic acidosis because of the Cl content. D5W is not good bc it does not contain electrolytes and patients are usually glucose intolerant bc of large amnts of adrenaline in the blood stream. |
|
|
Term
|
Definition
Any burn greater than 10% TBSA
Any inhalation injury
any trauma patient
any elelctrical burn
WHEN IN DOUBT.... OVERTREAT |
|
|
Term
|
Definition
| to maintain the volume of the patient during the period of hypovolemia |
|
|
Term
| Parkland Formula. It is a good formula for two reasons: |
|
Definition
It calls for a large amount of fluid
It is easy to remember
Note:Please remember that the resuscitation time is calculated from the time of the burn injury. If a person gets burned at 1:00 A.M. and resuscitation is delayed until 5:00 A.M. that person is 4 hours behind. You will need to increase the rate of the fluid to catch up, in order to get back on schedule. |
|
|
Term
| Parkland Formula is used for what and what is it? |
|
Definition
fluid resuscitation in burn patients
Parkland V = TBSA (%) x Wt (kg) x 2-4cc of Lactated Ringers
Note:
½ the volume of Lactated Ringers is given in the first 8 hours post burn
The remaining volume of Lactated Ringers is given over the next 16 hours
Do not use Normal Saline |
|
|
Term
Just Read:
An indwelling bladder catheter is recommended in patients receiving IV fluids ≥ 200 cc/hr to facilitate resuscitation and titration |
|
Definition
| All of these criteria are important, but this doesn't help you very much if you are in the field. If there is only one criteria which you can assess, it must be urine output |
|
|
Term
| DRug of choic for pain control in Burn patients |
|
Definition
| . Morphine IV is the drug of choice, delivered in incremental doses. |
|
|
Term
| Wound Management for burns |
|
Definition
No ointments or creams should be used prior to the burn surgeon’s assessment of the wound. Clean, dry sheets and/or blankets are sufficient.
Never apply ice to a burn wound
To treat chemical burns, remove contaminated clothing then brush dry chemicals from the skin.
Flush the burned area with copious amounts of water.
Irrigate the eyes copiously with eye irrigant or saline, if necessary. |
|
|
Term
| Infection treatment for burns? |
|
Definition
Prophylactic antibiotics are not generally recommended, unless given for concomitant injuries such as open fractures or penetrating wounds.
All burn patients should receive a tetanus booster if not up to date |
|
|
Term
| what to know about electrical burns |
|
Definition
Most significant injury is within deep tissue
Edema can compromise circulation
Be ready to perform eschar-/fasciotomies
Explore & debride necrotic tissue
May have to re-explore questionable areas
EKG if heart was in conduction path
Follow serial CPK, troponin & urine myoglobin due to possibility of rhabdomyolysis |
|
|
Term
| Electricity takes the path of least resistance in order of increasing magnitude: |
|
Definition
Nerve
Blood vessels
Muscle
Skin
Tendon
Fat
Bone |
|
|
Term
Acids cause________ necrosis
Alkalis cause _________ necrosis allowing deeper penetration |
|
Definition
1. coagulation
2. liquefaction |
|
|
Term
| what to know about chemical burns |
|
Definition
Speed is essential
ABCDE – remove all clothing
Irrigate with 15-20L of water
Brush off any dry powder before irrigation
Alkalis generally cause worse damage
Do not attempt to counteract acid burns using alkali or alkali burns using acid |
|
|
Term
| Hydrofluoric acid is somewhat different from other acids in that it produces a ______________necrosis |
|
Definition
a liquefaction
One of the strongest inorganic acids
Used mainly for industrial purposes
Glass etching
Metal cleaning
Electronics manufacturing |
|
|
Term
|
Definition
Loss of Fluid and electrolytes
Etiology
Generalized increase in capillary permeability with loss into interstitial space (edema)
Returns to normal in 48 hours with resorption of edema and diuresis
Edema: The complications of edema get worse as resuscitation proceeds. Any major burn of an extremity or the torso tends to swell very tightly. |
|
|
Term
|
Definition
Partial thickness burns greater than 10% TBSA
Burns that involve the face, hands, feet, genitalia, perineum, or major joints
Third-degree burns in any age group
Electrical burns, including lightning injuries
Chemical burns
Inhalation injury |
|
|
Term
Absence of ALL sensation
Reversible lack of awareness |
|
Definition
Anesthesia
Differs from analgesia Block pain only |
|
|
Term
|
Definition
General
Regional
Local
Monitored Anesthesia Care (MAC)
Each type has an effect on a part of the CNS resulting in a depression or numbing of nerve pathways |
|
|
Term
Induction of a state of unconsciousness with the absence of pain sensation over the entire body, through the administration of anesthetic drugs that affect the brain
Directly on the central nervous system to temporarily inhibit synaptic transmission |
|
Definition
|
|
Term
| Goals of General Anesthesia |
|
Definition
Amnesia
Analgesia
Loss of Consciousness
Muscle Relaxation
Weaken Autonomic Nervous System |
|
|
Term
| Stages of General Anesthesia |
|
Definition
Stage 1(Analgesia)
“Induction period”
Stage 2 (Delirium)
“Excitement period”
Stage 3 (Surgical Anesthesia)
Return of regular RR/NSR
Stage 4 (Respiratory Paralysis)
“Anesthetic crisis” |
|
|
Term
what stage of General anesthesia
Period between initial administration of anesthesia and loss of consciousness (LOC) |
|
Definition
Stage 1(Analgesia)
“Induction period” |
|
|
Term
what stage General Anesthesia
Period after LOC
RR/HR irregular (breath holding)
Pupillary dilation
Uncontrolled movements |
|
Definition
Stage 2 (Delirium)
“Excitement period” |
|
|
Term
Zones of a Burn
Jackson Burn Model |
|
Definition
Zone Hyperaemia: increased blood flow to area. will recover
zone stasis little blood flow some will recover
Zone coagulation: severe damage wont recover |
|
|
Term
Use of local anesthetic drugs to block a set of nerves responsible for the sensation to a specific area of the body (arm/leg)
Blocking effect occur outside the brain cells (unlike general anesthesia) |
|
Definition
|
|
Term
Small volume (1-3cc) local anesthetic is injected into the subarachnoid space (CSF surrounding the spinal cord)
Placed with spinal need (21-25ga) using sterile technique
Usually single injection
Interruption of sensory, motor & SNS (vasodilated) conduction below level of block |
|
Definition
Spinal Anesthesia:
(Regional Anesthesia)L2-3, 3-4, L4S1: usual places
Catheter can be placed for repeated or continuous medication
Uses: lower extremity, lower abdominal cases, perineal
C-sections
Inguinal hernias
Ankle fracture/knee scopes
PPTL
TURP |
|
|
Term
Spinal Anesthesia
Pros
Cons
Contraindication |
|
Definition
Pro: avoid airway manipulation, maintain consciousness, provides excellent analgesia
Cons: Limited duration of anesthetic effect
PDPH (not as common: post dural headache)
Hypotension
Failure to achieve desired level/depth of anesthesia (“patchy”)
Contraindications
Patient refusal, anticoagulation/coagulopathy (waffarin, asprin: hematoma subdural), systemic infection, infection on back near site of injection, uncooperative/uncommunicative patient |
|
|
Term
Larger volume (5-20 cc) of local anesthetic &/or narcotic injected into epidural space (not CSF)
Placed with us of a large bore hollow needle (18ga Tuohy) and a small indwelling catheter that is injected repeatedly or continuously |
|
Definition
| Epidural (Regional Anesthesia) |
|
|
Term
Epidural
Uses
Pros
Cons
Contraindications |
|
Definition
Uses:
Same as spinal
Longer surgeries
L&D
Post-op pain control (upper abdominal/thoracic)
Pros:
Same as spinal but not limited by time if catheter placed
Cons:
Technically more difficult than spinal
Risk of dural puncture exists due to use larger needle
Larger volume local used (toxicity)
Contraindications:
Same as spinal |
|
|
Term
| Local anesthetic injected into surrounding nerve trunk/roots |
|
Definition
Peripheral Nerve Blocks
Pros: decrease post-op pain & narcotic use
Cons: technically difficult, limited time of action, local toxicity, nerve damage |
|
|
Term
used to block sensation to a very small and specific area of the body
Under skin where incision is to be made
Similar to regional anesthesia but exerts effect on smaller area
Least amount of risk of all types of anesthesia |
|
Definition
|
|
Term
Uses sedatives and other agents, but the dosage is low enough that patients, remain responsive and breathe without assistance
Used alone for nonpainful procedures and often to supplement local anesthetic injections for painful ones |
|
Definition
Monitored Anesthesia Care (MAC)
Eye surgery, breast biopsies, small plastic cases, endoscopic procedures
MRI/CT scan/Interventional radiology |
|
|
Term
Used for induction/maintenance of general anesthesia
Most are irritating to airway/pungent odor
Most frequently used to maintain (combination with other medications |
|
Definition
Inhalational Anesthetic Agents
Potent halogenated hydrocarbon liquids that readily evaporate into vapors/gases via specialized vaporizes |
|
|
Term
Inhalational Anesthetic Agents
Partial pressure of the anesthetic in alveoli is (directly/indirectily)
related to partial pressure in the brain (effect!!) |
|
Definition
|
|
Term
| at one atmosphere at which 50% of patients do not move in response to a surgical stimulus |
|
Definition
| Minimum Alveolar Concentration |
|
|
Term
| Gas at room temperature rather than liquid, NOT considered a volatile gas! MAC 105% |
|
Definition
Nitrous Oxide
Totally impossible to put someone asleep with this Add to anestetic to cut down on potent anesthetics |
|
|
Term
Prototype of modern anesthetics (1950’s)
Unparalleled track record of safety/efficacy
Pleasant aroma (pediatric mask inductions)
“Halothane hepatitis”
Almost completely replaced by newer agents
hallmark for pediatrics: |
|
Definition
|
|
Term
Displaced halothane in the 1980’s
Still used for longer cases |
|
Definition
|
|
Term
| Most:Non-pungent odor (sweet) great for mask inductions : now used in kids |
|
Definition
|
|
Term
VERY RAPID onset of induction & emergence
Very rapid on and off like nitrous
Highly pungent airway irritant : makes cough can’t do inhilation inductions with this |
|
Definition
|
|
Term
Cause amnesia, but most have no analgesic properties
Large doses> produce anesthesia and unconsciousness
Small doses> MAC/sedation |
|
Definition
Intravenous Anesthetic Agents
Barbiturates
Propofol
Imidazole
Ketamine
Benzodiazepines |
|
|
Term
| Predominantly used to relieve pain before, during, and after surgery |
|
Definition
Narcotics
Most common
MSO4: analgesic standard (morphine is called 1)
Alfentanil: 10x more potent MSO4
Fentanyl: 100x more potent MSO4
Sufentanil: 1000x more potent MSO4 |
|
|
Term
DOes NOT produce unconsciousness, amnesia or provide analgesia “Anesthesia awareness”
Uses: Facilitate intubation Control muscle tone to provide an optimal surgical field |
|
Definition
| Muscle Relaxants Two classifications Depolarizing Nondepolarizing |
|
|
Term
| Depolarizing (only one of these) Muscle Relaxants: |
|
Definition
Succinylcholine (only one)
Binds and depolarizes the end-plate acetylcholine nicotine receptors at the NMJ
Onset: 30-60 sec (very short), Duration: 4-6 min |
|
|
Term
Muscle relaxant that Bind to and competitively inhibit the end plate nicotinic receptor at the NMJ
Competitive blockade
Intermediate acting
Rocuronium
Vecuronium
Cisatracurium
All with similar onset (2 min), duration (30-60 min) |
|
Definition
|
|
Term
| Mallampati Classification System Assesses? |
|
Definition
Airway Assessment Classes 1-4
Class 3 or 4 airway be afraid:
Class 4 glide scope bc very difficult |
|
|
Term
| Patient Preparation for surgery 1) Antihypertensives? 2) Insulin? 3)Oral hypoglycemics? 4)most anticoagulants |
|
Definition
| 1)Continue all up to the morning of surgery Exception: ARB’s/ACE inhibitors 2)Regular am dose: HOLD am of surgery 3)Avoid on DOS Metformin should be discontinued 48hrs prior to surgery 4)Hold Coumadin 3days prior DOS, ASA 7dys prio DOS, Plavix 7 dys prior DOs Long-acting: Take 1/2 to 1/3 or hold am of surgery |
|
|
Term
Patient Preparation for Surgery
Medications? 1) NSAIDs 2) Diuretics 3) MAOI |
|
Definition
| 1)Hold 48hrs prior to DOS 2) Hold DOS Exception HCTZ used for HTN 3) Discontinue 3 weeks prior to surgery |
|
|
Term
| 4 techniques commonly used to induce general anesthesia |
|
Definition
Routine IV induction
Rapid sequence induction (worried about aspiration)
Modified rapid sequence induction (fast but give breathe)
Inhalation induction |
|
|
Term
| is performed to gain control of the airway in the least amount of time after the ablation of protective airway reflexes with the induction of anesthesia |
|
Definition
|
|
Term
| The duration of action of IV induction agents is generally 5-10mins after which time spontaneous recovery of consciousness will occur. In order to prolong anesthesia for the duration of the surgery |
|
Definition
| anesthesia must be MAINTAINED |
|
|
Term
| Goals of Maintenance Phase of General Anesthesia |
|
Definition
Provide analgesia
Maintain unconsciousness/amnesia
Provide skeletal muscle relaxation/maintain motionless surgical field
Control autonomic nervous system response to noxious stimuli |
|
|
Term
| the most stable phase of the anesthesia |
|
Definition
|
|
Term
| Emergence is not synonymous with removal of the endotracheal tube or other artificial airway device. This is only performed when the patient has regained sufficient control of his or her airway reflexes. |
|
Definition
|
|
Term
| Now considered the #1 nutritional problem of the world by World Health Organization |
|
Definition
|
|
Term
| Indications for Bariatric Surgery |
|
Definition
Morbid obesity
Patients with BMI >40
Exercise and diet programs have failed
May or may not have utilized adjunctive drug therapy
Obesity-related comorbid conditions |
|
|
Term
Most Common
Types of Bariatric Surgeries |
|
Definition
Gastric Bypass
Both Restrictive and Malabsorptive
Adjustable Gastric Banding
Restrictive
Sleeve Gastrectomy
+/- Biliopancreatic Diversion or Duodenal Switch
Restrictive |
|
|
Term
| Most commonly performed operation for weight loss in the United States |
|
Definition
| “Roux-en-Y Gastrojejunostomy” |
|
|
Term
Goal: Reduce stomach size with an implanted medical device
Restriction of the stomach utilizing a silicone band placed just below the esophagogastric junction, creating a 1-2 ounce pouch
Band is connected to reservoir (port) placed under the skin and is adjusted by addition or removal of saline |
|
Definition
| Adjustable Gastric Lap Banding |
|
|
Term
Goal: Permanent removal of a portion of the stomach
Stomach reduced to 25% -75% of its original size by surgical removal of a large portion of the stomach, following the major curve
Open edges are then stapled together to form a sleeve or tube shaped like a banana
Performed laparoscopically
Irreversible |
|
Definition
Sleeve Gastrectomy
Performed on extremely obese patients with a BMI > of 40 where the risk of performing a gastric bypass or duodenal switch procedure may be too large
No dumping syndrome because the pylorus is preserved |
|
|
Term
| Outcomes of Bariatric Surgery |
|
Definition
Significant long-term loss of weight
Recovery from diabetes
Improvement in cardiovascular risk factors
Reduction in mortality of from 40% to 23% |
|
|
Term
Vertical Gastric Banding
Adjustable Gastric Banding
Restrictive |
|
Definition
Weight loss not as good
↑ Incidence of food intolerance and vomiting
Unable to tolerate ↑ amounts insoluble fiber foods – bezoar formation |
|
|
Term
| Prior to Bariatric Surgery |
|
Definition
Psychiatric screening is essential
Morbidly obese patients often are required to lose weight preoperatively for several reasons, most notably to make laparoscopic surgery an option by reducing the size of the liver for optimal retraction
So many of these patients are also required to undergo “weight management classes” for 3-7 months prior to approval for bariatric surgery |
|
|
Term
| Bariatric Surgery Pre-op Diet |
|
Definition
2-4 weeks prior to surgery
High protein low carb
Replace two meals a day with high protein shake and one sensible meal a day
A factor in the success of any bariatric surgery is strict post-surgical adherence to a healthier pattern of eating |
|
|
Term
| Gastric Bypass Dietary Guidelines |
|
Definition
½ cup food = “meal”
Eventually can consume ¾ to 1 cup
Wait 30-60 minutes to drink after eating; sips are better
Sugar free, fat free
All liquids through straw; no straw
Practice dependent
Multivitamin supplements
Complete multivitamin with iron -chewable/liquid - tid
Chewable calcium with Vit D: 1500 mg/day – 500 mg tid
+ vit B12, iron |
|
|
Term
Eating Status-Post Bariatric Surgery
Fluid Recommendations |
|
Definition
Prevention of dehydration and volume depletion
Minimum of 48-64 fl oz should be consumed by repetitive small sips all day |
|
|
Term
| Bariatric Surgery Adverse Outcomes |
|
Definition
Common problems
Gastric dumping syndrome (20%)
Bloated and diarrhea after eating
Leaks at the surgical site (12%)
Incisional hernia (7%)
Infections (6%)
Pneumonia (4%)
Marginal ulcers (smokers)
Strictures |
|
|
Term
Gallstone formation
Bariatric Surgery Adverse Outcomes |
|
Definition
| Rapid weight loss after obesity surgery can contribute to the development of gallstones as well by increasing the lithogenicity of bile |
|
|
Term
Metabolic bone disease
Bariatric Surgery Adverse Outcomes |
|
Definition
| Explanation: highest concentration of calcium transporters found in the duodenum and now ingested food does not pass through duodenum, causing decrease in serum calcium levels, causing secondary hyperparathyroidism, increase in bone turnover, and a decrease in bone mass. |
|
|
Term
|
Definition
More common in banding proceduresSigns/Symptoms
Postprandial epigastric pain
Vomiting undigested solids
Liquid vomiting |
|
|
Term
| Postoperative Bowel Obstruction |
|
Definition
Volvulus
Bowel obstruction in which a loop of bowel has abnormally twisted on itself |
|
|
Term
|
Definition
Partial or complete mechanical obstruction of the
intestine near the gastrojejunostomy site |
|
|
Term
|
Definition
Slowed gastric emptying, and/or upper gut transit after Roux-en-Y gastrojejunostomy
Signs/Symptoms
Crippling nausea and vomiting |
|
|
Term
Osmotic changes that occur in the duodenum when a highly osmolar load pulls fluid from the vascular system into the duodenum
Associated with the release of vasoactive substances
Result of inappropriate
insulin release after eating
a meal with high sugar
concentrations |
|
Definition
Dumping Syndrome
Precipitated by ingestion of high sugar foods/drinks, providing “negative feedback” to consumption ↑ sugary foods
Common in early post-op period
Disappears 12-18 months post-op |
|
|
Term
the most important factor
Contributes to the development and persistence of metabolic deficiencies
Contributes to insufficient weight loss or weight gain |
|
Definition
| NONCOMPLIANCE is the most important factor |
|
|
Term
| Surgery is not the answer to obesity, early education is the only long term successful strategy for the “western” society |
|
Definition
|
|
Term
| Bariatric Surgery Summary |
|
Definition
Decreases early mortality, co-morbid disease
Significant improvement in quality of life
80% lose > 50% excess weight
For Morbid Obesity – Select criteria
Successful
Safe cost effective programs
Require a team approach
(MD, RD, PhD, etc)
Patients need lifelong follow-up
Very grateful patients and very angry patients |
|
|
Term
Regional Areas of Abdomen
Epigastric organs: |
|
Definition
Liver
Stomach
Pancreas
Abdominal Aorta |
|
|
Term
|
Definition
Transverse colon
Tip of pancreas |
|
|
Term
| Hypogastric / Suprapubic organs: |
|
Definition
Sigmoid Colon
Bladder
Uterus |
|
|
Term
| 3 Main Categories of Abdominal Pain |
|
Definition
Visceral
Parietal
Visceral is from stretching usually from peritoneal.
Referred |
|
|
Term
Caused by compression in and around the organs, or by stretching of the abdominal cavity
Pain originates in abdominal organs covered
Difficult to localize
Movement doesn’t aggrevate it or relieve it different from parietal pain |
|
Definition
|
|
Term
Originates in parietal peritoneum due to inflammation/irritation
Steady
Aching
Aggravated by movement/coughing |
|
Definition
|
|
Term
Felt in more distant sites
Develops as initial pain intensifies
Superficial or deep |
|
Definition
|
|
Term
Detected by nerves in the skin and deep tissues (nociceptors)
Cut in the skin
Stretch a muscle too far
Exercise for a long period of time |
|
Definition
|
|
Term
| 2 Types of Abdominal Pain in Acute Abdomens |
|
Definition
Colicky (crampy), poorly-localized pain
obstruction of the GI tract
Steady, well-localized pain
Ischemia
Perforation
Inflammation
Hemorrhage |
|
|
Term
| Pain is Burning what could it be? |
|
Definition
|
|
Term
| Pain is cramping what could it be? |
|
Definition
Biliary colic
Gastroenteritis |
|
|
Term
| Pain is colicy what could it be? |
|
Definition
Appendicitis with impact feces
Renal Stone |
|
|
Term
| Pain is Aching what could it be |
|
Definition
|
|
Term
| Pain is knifelike what could it be? |
|
Definition
|
|
Term
| Pain is ripping, tearing what could it be |
|
Definition
|
|
Term
| Gradual onset of pain what could it be |
|
Definition
|
|
Term
| Sudden onset of Abdominal pain what could it be? |
|
Definition
| Duodenal ulcer, Pancreatitis Obstruction, Perforation |
|
|
Term
| Abdominal Pain: Physical Exam |
|
Definition
Inspection
Auscultation
Percussion
Palpation
Light
Deep
Guarding - rebound tenderness
Rectal exam
Pelvic exam
Evaluate with light first if they are too sensitive do not do deep palpation |
|
|
Term
Inflammatory dAcute Pancreatitis: Signs/Symptoms
isease of appendix wall
Obstruction of appendiceal lumen ~ 70% |
|
Definition
Appendicitis
Microbiology
Escherichia coli (most common gram neg ~ 67-75%)
Bacteriodes fragilis (most common anaerobe)
Enterococcus and Pseudomonas (hospitalized patients or those receiving prior abx therapy) |
|
|
Term
Abdominal pain
Epigastric initially
Localizes to RLQ or McBurney’s point
McBurney’s point is defined as 2/3s of the distance from the umbilicus to the anterior superior iliac spine
Mild/moderate in severity and diffuse in location, intermittent and colicky early
Over 1-12 hours, pain intensifies, localize |
|
Definition
| Appendicitis: Signs/Symptoms |
|
|
Term
| Appendicitis: Physical Exam |
|
Definition
Pain at McBurney’s point
Rebound
Guarding
Psoas sign
Obturator sign |
|
|
Term
| Referred tenderness and guarding in RLQ with palpation of the LLQ (by pushing bowel contents towards the ileocaecal valve and thus increasing pressure around the appendix) |
|
Definition
|
|
Term
| what sign? Right lower-quadrant pain produced with the patient lying on the left side and then extending or flexing hip against resistance |
|
Definition
|
|
Term
stretching this muscle with passive internal rotation of the thigh with hip in a flexed position
This maneuver will cause pain in the hypogastrium |
|
Definition
Obturator sign
If an inflamed appendix is in contact with the obturator internus, |
|
|
Term
|
Definition
CBC
Leukocytosis (WBC range from 10,000-16,000)
Normal with left shift on differential
U/A
Rule out bladder infection
Pregnancy test
Fever > 38C and WBC > 20,000 often denotes perforation |
|
|
Term
|
Definition
Computed Tomography (CT) Scan
Diagnostic modality of choice for appendicitis |
|
|
Term
| __________remains the mainstay of surgical treatment of uncomplicated acute appendicitis. Laparoscopic approach is becoming most common |
|
Definition
|
|
Term
| Gold standard for treatment of appendicitis is |
|
Definition
is exploratory laparotomy and appendectomy
McBurney’s Incision |
|
|
Term
| these account for 80% acute pancreatitis |
|
Definition
Alcoholism and gallstones
Common
Potentially lethal disease |
|
|
Term
| Acute Pancreatitis: Signs/Symptoms |
|
Definition
Dramatic, sudden, excruciating LUQ, epigastric or umbilical pain that is constant
Knife like!!!
Partially diminished by sitting and leaning forward or lying curled in fetal position |
|
|
Term
Grey Turner’s and Cullen’s signs
2-3 days after onset |
|
Definition
|
|
Term
| Bluish/gray discoloration or bruising of the flanks |
|
Definition
|
|
Term
Blue-black bruising of
the area around the umbilicus due to subcutaneous intraperitoneal hemorrhage. |
|
Definition
|
|
Term
|
Definition
Serum Amylase – elevation suggests diagnosis of acute pancreatitis
Serum Lipase
As sensitive as serum amylase but far more specific as a marker for pancreatitis |
|
|
Term
Acute Pancreatitis: Imaging
what are signs on a plain film |
|
Definition
Sentinel loop
Dilated bowel adjacent to pancreas
Colon cutoff sign
Colonic spasm in area of pancreas
Calcification if chronic pancreatitis |
|
|
Term
| imaging used Evaluate for chronic pancreatitis or pseudocyst |
|
Definition
| ERCP (endoscopic retrograde cholangiopancreatography |
|
|
Term
|
Definition
| Criteria for Severity of Acute Pancreatitis |
|
|
Term
Walled off collection of fluid and debris that disrupts the pancreatic duct
Internal drainage- preferable |
|
Definition
|
|
Term
| surgery done to treat cancerous tumors on the head of the pancreas, malignant tumors involving common bile duct or duodenum near the pancreas |
|
Definition
|
|
Term
| imaging Dependably diagnoses acute pancreatitis |
|
Definition
| Abdominal CT Scan with contrast |
|
|
Term
| 40% acute pancreatitis is caused by this? |
|
Definition
Gallstone Pancreatitis
If patient deteriorates in first 48 hours, ERCP to determine if stone impacted at the ampulla of Vater |
|
|
Term
| Most common surgical condition |
|
Definition
Cholecystitis
95% due to stones
Obstruction of cystic duct which leads to inflammation of the gallbladder |
|
|
Term
Severe, unrelenting RUQ pain or tenderness
Positive Murphy’s sign
Right scapular/infrascapular pain – referred
Epigastric discomfort - referred |
|
Definition
|
|
Term
|
Definition
|
|
Term
| Acute Cholecystitis: Imaging |
|
Definition
Ultrasound is best diagnostic tool
HIDA scans
Helps to determine function
Useful in patients who have a questionable diagnosis
Unnessecary to confirm diagnosis |
|
|
Term
| Cholecystitis: Medical Treatment |
|
Definition
Pain relief is the very important
Patients should be NPO if high level of suspicion
IV antibiotics (Cefuroxime)
Jaundice is present then add Metronidazole.
Make sure you get accurate Is & Os |
|
|
Term
| Acute Cholecystitis: Surgical Intervention |
|
Definition
| Laparoscopic cholecystectomy is surgical treatment of choice |
|
|
Term
|
Definition
Charcot's triad is an indication of cholangitis
Pain
Jaundice
Fever
Infection of the biliary tree
E. coli |
|
|
Term
Blood acts as a cathartic agent in the intestine, promoting
Transit time is less than 14 hours the patient will have hematochezia, and if greater than 14 hours the patient will exhibit melena |
|
Definition
its prompt passage
It roughly takes ~ 14 hours for blood to be broken down within the intestinal lumen |
|
|
Term
| marks the end of the duodenum and the beginning of the jejunum |
|
Definition
|
|
Term
| Initial management of acute hemorrhage in the gastrointestinal tract is |
|
Definition
| the same regardless of the cause of hemorrhage |
|
|
Term
| Determine location of the site of hemorrhage in relation to the |
|
Definition
| ligament of Treitz as this directs evaluation and therapy |
|
|
Term
| Hematemesis indicates hemorrhage |
|
Definition
Upper GI Source of Bleeding
hemorrhage proximal to the ligament to Treitz |
|
|
Term
| Melena, the passage of black tarry stools, is usually (but not always) |
|
Definition
| Upper GI Source of Bleeding |
|
|
Term
| Hematochezia, the passage of bright red blood through the rectum is associated |
|
Definition
|
|
Term
| Hemorrhage after several days of worsening epigastric or upper abdominal pain suggest |
|
Definition
|
|
Term
| Hematemesis or melena after vomiting or retching suggests |
|
Definition
|
|
Term
| Massive, painless upper GI hemorrhage in a patient with cirrhosis suggests |
|
Definition
|
|
Term
| Massive painless lower GI hemorrhage in an elderly patient suggests |
|
Definition
| bleeding from colonic diverticuli |
|
|
Term
Bleeding into the lumen of the proximal GI tract, proximal to the Ligament of Treitz
Most common Cause of an Upper GI Bleed |
|
Definition
Upper GI Bleeding
Peptic Ulcer Disease |
|
|
Term
| Upper GI Bleeding: Medical Treatment |
|
Definition
IVFs (16G or larger) x 2
Foley (monitor fluid status)
NGT suction (determine rate and amount of blood)
Water lavage to remove clots (warm water)
EGD |
|
|
Term
Gastric Ulcers
Surgical Intervention
Indications for doing surgery? |
|
Definition
Distal gastrectomy with excision of the ulcer without vagotomy unless duodenal disease present
ICHOP
Intractability
Cancer (rule out)
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction
Perforation |
|
|
Term
| Surgery indications for Duodenal Ulcers |
|
Definition
Surgery indicated: IHOP
Intractability
Hemorrhage (massive or relentless)
Obstruction (gastric outlet obstruction)
Perforation |
|
|
Term
|
Definition
2/3s with portal hypertension develop esophageal varices
2/3s with esophageal varices bleed |
|
|
Term
| Sclerotherapy or band ligation |
|
Definition
| treat Esophageal Variceal Bleeding |
|
|
Term
| mortality -Massive GI Bleed |
|
Definition
|
|
Term
2 distinct patient groups
Massive GI Bleed |
|
Definition
older with co-morbidities - highest mortality risk
young & alcohol |
|
|
Term
mcc Small Bowel Obstruction
industrialized countries |
|
Definition
| Postoperative peritoneal adhesions (60%) |
|
|
Term
– mcc Small Bowel Obstruction
around the world |
|
Definition
|
|
Term
| 4 cardinal symptoms of obstruction |
|
Definition
Pain
Vomiting
Obstipation (lack of stools,gas)
Distention |
|
|
Term
|
Definition
|
|
Term
Small Bowel Obstruction: Surgical Intervention
Complete
Partial |
|
Definition
Complete
Laparotomy and lysis of adhesions
Partial
Initially observation, NPO, NGT decompression, IVF maintenance/losses |
|
|
Term
| Small-Bowel Obstruction: Strangulated Bowel |
|
Definition
Surgical emergency
Vascular compromise leads to ischemia and necrosis, and death
Absolute indications for surgery
Peritoneal signs
Free air on KUB |
|
|
Term
Implies inflammation +/- infection or perforation of a diverticulum
Distinct from diverticulosis |
|
Definition
|
|
Term
| Acute Diverticulitis: Labs/Imaging |
|
Definition
Labs
Increased WBCs
Imaging
Abd/pelvic CT (best tool)
Avoid barium enema in acute cases |
|
|
Term
| How many episodes of diverticulits warrant resection |
|
Definition
|
|
Term
| Intracranial or Intracerebral Hemorrhage |
|
Definition
| Bleeding into brain parenchyma |
|
|
Term
| Bleeding between the brain and subarachnoid membrane |
|
Definition
Subarachnoid Hemorrhage:
“Worst headache of my life” |
|
|
Term
| Classification for Assessing Subarachnoid Hemorrhage |
|
Definition
|
|
Term
| Biggest risk immediately after initial Subarachnoid Hemorrhage |
|
Definition
|
|
Term
| Subarachnoid Hemorrhage imaging of choice |
|
Definition
CT scan without contrast
Study of choice to detect bleeding |
|
|
Term
Subarachnoid Hemorrhage: Surgical Treatment
Cutting off the flow of blood to the aneurysm
Under anesthesia, a section of the skull is removed and the aneurysm is located |
|
Definition
|
|
Term
| Syndrome of inadequate tissue perfusion |
|
Definition
Shock
Progression of shock results in loss of homeostasis (decompensation) and inability to maintain mean arterial pressure, producing organ dysfunction and hypotension |
|
|
Term
|
Definition
Hypovolemic shock/Hemorrhagic
Cardiogenic
Septic
Neurogenic
Anaphylactic |
|
|
Term
Most common type of shock
causes:
Loss of whole blood
Hemorrhage
Loss of plasma from sequestration of large volumes of fluid outside of intravascular space
Burns
Crush injury
Gut losses
Bowel obstruction
Severe diarrhea |
|
Definition
|
|
Term
Hypovolemic Shock: Labs
Most reliable lab value is |
|
Definition
| measure of metabolic acidosis |
|
|
Term
what type of shock?
Organ hypoperfusion due to decreased cardiac output and mycocardial dysfunction despite adequate intravascular volume |
|
Definition
|
|
Term
what kind of shock?
Documented infection &
hypotension
Etiology
Most common
Gram negative septicemia
Less common
Gram positive septicemia
Fungus |
|
Definition
|
|
Term
hypotension and generalized tissue hypoxia
Form of relative hypovolemia resulting from blood vessel dilation
Septic shock is the major cause of this shock |
|
Definition
|
|
Term
what kind of shock?
Results: inadequate tissue perfusion or neurogenic shock
Parasympathetic dominance results in the following signs and symptoms
Bradycardia
Hypotension
Priapism (in males)
Causes
Spinal cord injury
Complete transection of spinal cord
Partial cord injury with spinal shock
Spinal anesthesia |
|
Definition
|
|
Term
BASE is used in what kind of shock?
B benadryl
A aminophylline
S steroids
E epinephrine |
|
Definition
|
|
Term
measure extrinsic and common pathways
affected by low concentrations of fibrinogen, prothrombin and factors II, V, VII, X |
|
Definition
|
|
Term
measures intrinsic and common pathways
deficiencies in all clotting factors except factors VII and XIII may prolong the aPTT |
|
Definition
| Activated partial thomboplastin time (aPTT) |
|
|
Term
| Assessment of Platelet Function |
|
Definition
Platelet count
Bleeding time
Platelet function analyzer
Bleeding time is the only assessment that does all 3: platelet function, function with clotting coagulation factor, tissue contact factor |
|
|
Term
| Acquired causes of thrombophilia |
|
Definition
cancer
antiphospholipid antibodies
nephrotic syndrome
hyperhomocystinemia |
|
|
Term
| Heritable causes of thrombophilia |
|
Definition
factor V Leiden mutation
protein C deficiency
protein S deficiency
antithrombin III deficiency |
|
|
Term
Testing for thrombophilia should be performed in patients
who have a history of: |
|
Definition
thombotic event before the age of 50
recurrent thrombosis
first-degree relative with thrombotic event before the
age of 50 |
|
|
Term
Recognition of bleeding patterns
Menorrhagia, epistaxis>
Intramuscular, intra-articular (male)>
Subdural in the elderly>
Spreading hematomas in the elderly> |
|
Definition
Menorrhagia, epistaxis>>>>VWD
Intramuscular, intra-articular (male)>>>hemophilia
Petechiae and ecchymoses>>>ITP, platelet disorder
Subdural in the elderly >>>>>warfarin
Spreading hematomas in the elderly>>>acquired hemophilia |
|
|
Term
| Petechiae, Purpura sign of platelet or coag disorder |
|
Definition
|
|
Term
Hematoma, Joint bl
platelet disorder or Coag disorder |
|
Definition
|
|
Term
| Common acquired bleeding disorders: platelets |
|
Definition
1. Thrombocytopenia
2. Platelet function disorders (have enough but they don’t work) |
|
|
Term
| Common acquired bleeding disorders: coagulation |
|
Definition
Clotting factor deficiency
Liver disease
Vitamin K deficiency (iatrogenic or otherwise)
Dilution
DIC
Drug interactions with warfarin |
|
|
Term
| Derived from the PT, normalized for thromboplastin reagent |
|
Definition
|
|
Term
| Prolonged PTT: is it heparin? |
|
Definition
Clues
Very long PTT, normal or slightly long PT
No suspicion of congenital abnormality
No other acquired cause for prolonged PTT
Confirmation
Prolonged thrombin time
Normal Reptilase time
Correction of PTT by Hepasorb or protamine
Heparin assay positive |
|
|
Term
| Non-transfusional treatment of thrombocytopenia and platelet dysfunction |
|
Definition
Desmopressin
Red cell transfusion
Conjugated estrogens
Topical: thrombin, fibrin sealant
Recombinant factor VIIa |
|
|
Term
ABO system
tell me about the Antigens |
|
Definition
Located on RBC membrane
Carbohydrates (antigens)
Codominant inheritance pattern (AB are equal)
Designated A, B, H |
|
|
Term
ABO system
Tell me about antibodies |
|
Definition
Located in serum
IgM proteins
Bind C’
“Naturally” occurring
Designated anti-B & anti-A |
|
|
Term
|
Definition
>44 different antigens with multiple combinations
Rh type-Designated by “D” antigens
Dominant inheritance pattern |
|
|
Term
|
Definition
IgG proteins-CAN CROSS PLACENTA
Immune stimulated (NOT naturally occurring like ABO)
Immune stimulated: have to be exposed to the antigen to get the antibody. You would not have a rxn the very first time you are exposed. But the next time the antibody is already there and you will have a rxn. |
|
|
Term
Simulates anti-D, but does NOT cross the placenta to harm fetus
Attaches to any circulating D positive cells in mother to prevent immune stimulation
Inhibits production of Rh antibodies against fetus.
Given to ALL Rh neg women who become pregnant to prevent HDN
Given @ 28 wks gestation & w/in 72h postpartum |
|
Definition
| Rh Immune Globulin (RhIg or Rhogham) |
|
|
Term
|
Definition
| Red Blood cells, Platelets and White Blood Cells all suspended in Plasma constitute whole blood. |
|
|
Term
Approx. 1/2 the volume of Whole Blood
Same RBC mass therefore same oxygen carrying capacity |
|
Definition
|
|
Term
| Need for blood depends on patients: |
|
Definition
Oxygen delivery: O2 demand
Cardiac Output: Cardiac performance of the patient. Is it compromised?
Hemoglobin concentration: What is the patients H/H?
Hgb and Hct alone do NOT give an adequate assessment of the patient’s need for transfusion of red blood cells. (What else can we look at?) |
|
|
Term
| Each unit of transfused RBCs should increase an adults Hemoglobin by ____g/dl and Hct by ______% |
|
Definition
| Hemoglobin by 1.0 g/dL and the Hct by 3%. |
|
|
Term
| Indications for Transfusion of Packed Red Blood Cells |
|
Definition
Iatrogenic: neonatal transfusions often result from withdrawal of too much blood for testing.
Decreased Bone Marrow Production: Leukemia, aplastic anemia, etc.
Decreased RBC Survival: Hemolytic anemia, etc.
Surgical/Trauma: Excessive bleeding |
|
|
Term
| Fresh Red Blood Cells (<7 days old)transfusion indications |
|
Definition
Neonatal transfusion. Remember why?
Massive Transfusion is defined as replacing the patients entire blood volume within 24 hours. (Remember why fresh blood is important?)
2,3-DPG levels drop within 10 days to 2 weeks of collection to levels that will NOT adequately oxygenate the tissues in these patients. Also want to avoid transfusion of excess K+, ammonia and hemolysis. |
|
|
Term
| Indications for Transfusion of Leukocyte Reduced RBCs |
|
Definition
Febrile non-hemolytic transfusion reactions
Patient history of febrile transfusion reactions
HLA allo-immunization: antibody to HLA antigens
Transfusion related acute lung injury (TRALI)
Transfusion associated Graft vs. Host disease
Transfusion related immune suppression: Removal of WBC’s effectively reduces risk of transmission of CMV and HIV. |
|
|
Term
Process of freezing red blood cells in glycerol with minimal damage to the cell.
Almost free of WBCs, Platelets & Plasma
Ten year Shelf life (expiration date) while frozen |
|
Definition
| Frozen, Deglycerolized RBC |
|
|
Term
Washed Red Blood Cells
Indicated for |
|
Definition
| rare patient with an IgA deficiency (these patients make anti-IgA). Washing the RBC unit removes enough plasma to reduce the risk of anaphylactic reaction. |
|
|
Term
| Frozen and Deglycerolized RBCs |
|
Definition
Long term storage (10 years)
Rare phenotypes, etc.
Intrauterine transfusion: removes plasma & RBC’s |
|
|
Term
| Due to antibody to platelets: don’t transfuse unless absolutely necessary (ITP and TTP). Adding fuel to the fire. |
|
Definition
ITP (idiopathic thrombocytopenic purpura)
TTP (thromboticthrombocytopenic purpura) |
|
|
Term
| drugs or sepsis can also cause platelet refractoriness. |
|
Definition
|
|
Term
|
Definition
Plasma expressed from Whole Blood, needs to be frozen within 8 hours (6 hrs for ACD) of collection for CPDA-1 anticoagulant.
Contains all clotting factors |
|
|
Term
Indications for Transfusion of Plasma Products
Fresh Frozen Plasma (FFP) |
|
Definition
Contains all coagulation factors
Treat multiple coag factor deficiencies such as DIC, liver failure, vitamin K deficiency, or massive transfusion
Good for factor deficiency where there is no suitable clotting factor concentrate: Factor XI deficiency
Contraindicated for volume expansion and protein replacement. |
|
|
Term
|
Definition
| Colloid Solutions Albumin: 5% and 25% Crystalloid Solutions Normal saline and lactated Ringers |
|
|
Term
| Cold insoluble portion of Plasma |
|
Definition
Cryoprecipitated Antihemophilic Factor (Cryo)
Contains at least 80 units of AHF and 150-250 mg Fibrinogen
Also contains Factor XIII and vonWillebrands factor |
|
|
Term
| Indications for Transfusion of Cryoprecipitated AHF |
|
Definition
Primary use: intravenous supplementation of Factor XIII and fibrinogen
Topical Use: Fibrin sealant (glue) in surgery
Factor concentrates (i.e. Factor VIII) have replaced CRYO in many situations because of reduced risk of transmission of disease. |
|
|
Term
| Indications for Transfusion of Granulocyte Pheresis |
|
Definition
Patient should meet the following conditions:
Neutropenia: WBC count <500/mL
Fever for 20-48 hours, positive bacterial or fungal cultures, or progressive parenchymal disease unresponsive to antibiotic therapy.
Myeloid hypoplasia
A reasonable chance for recovery of marrow function.
Component should be irradiated and CMV seronegative. |
|
|
Term
Irradiated Blood Components
Gamma irradiation of component
Purpose: |
|
Definition
| Inactivate donor lymphocytes to prevent Graft Vs. Host disease (GHVD). Only accepted method. |
|
|
Term
| ALL BLOOD COMPONENTS ARE ADMINISTERED THROUGH A |
|
Definition
FILTER!
Necessary to remove any accumulated debris that may be present in the blood component such small clots, fibrin, etc. |
|
|
Term
|
Definition
Test ABO type, Rh type, and antibodies
Antibody Screen- if positive, Ab(s)will be identified (known as Indirect Antiglobulin Testing, or IAT)
Order this when blood usage is fairly unlikely, but still a possibility |
|
|
Term
|
Definition
Type and screen (ABO, Rh, Ab screen (IAT)) ADDITIONALLY, :
RBC units (donor) that are ABO and Rh compatible are chosen from the inventory and “mixed” with a patient serum.
Order this only when transfusion is fairly likely-refer to Surgical Blood Order Schedule |
|
|
Term
| DAT: Direct Antiglobulin Test (Coomb’s Test) |
|
Definition
Looking for C’ on patient RBCs
Looking for C’and Ab bound to patient RBCs
Order when you suspect autoantibodies (AIHA), hemolytic disease of the newborn (HDN), or transfusion reactions (HTR) |
|
|
Term
|
Definition
STOP the transfusion immediately
Open –keep IV open-saline
Check paperwork/armband/unit
Call Physician & Blood Bank
Collect blood & urine samples. Send with remainder of unit, transfusion set/tubing to the Blood Bank as per institutional protocol.
Record all events including times & type of reaction
Monitor patient-Vital signs |
|
|
Term
what type of blood product reaction?
Usually attributed to CLERICAL ERROR Commonly ABO incompatibility |
|
Definition
|
|
Term
what type of blood product reaction?Caused by antibody to WBC antigens
Rise in temp 1° C or more , shaking chills during or up to 4 hrs post transfusion
Give IV fluids and anti-pyretics |
|
Definition
|
|
Term
what type of blood product reaction?
Due to plasma proteins in unit If mild, give antihistamines & resume transfusion as symptoms subside.
If severe-give epinephrine & DO NOT resume
In future, use washed RBCs only |
|
Definition
|
|
Term
A “consumptive coagulopathy”: bleeding and clotting occur simultaneously
It is “managed” and difficult to “turn off”
SSx-bleeding at surgical/IV sites & body orifices-nose, mouth, eyes, ears, rectum, etc
Diagnostically: Incr PT/PTT & bleeding time, decr PLTs, + FSPs and + d-Dimer |
|
Definition
| DIC: Disseminated Intravascular Coagulation |
|
|
Term
| Cardiogenic pulmonary edema d/t volume overload and temporally associated with transfusion (esp. large volumes) |
|
Definition
| TACO-Transfusion Associated Circulatory Overload |
|
|
Term
Occurs during or within 6 hrs of transfusion: fever, hypotension, resp distress
NON-cardiogenic pulmonary edema (bilaterally) |
|
Definition
| TRALI-Transfusion-Related Acute Lung Injury |
|
|
Term
|
Definition
|
|
Term
Which component do I order?
Symptomatic anemia Hgb of 5.0 g/dL: |
|
Definition
|
|
Term
Which component do I order?
Replacement of multiple clotting factors (burns): |
|
Definition
|
|
Term
Which component do I order?
Asymptomatic pt w/ hgb of 9.0g/dL |
|
Definition
|
|
Term
| Chemo pt: plt ct <10,000 platelets |
|
Definition
|
|
Term
Which component do I order?
Pt w. previous allergic reaction to PRBCs |
|
Definition
|
|
Term
Which component do I order?
Exchange transfusion |
|
Definition
| Irradiated Blood Products |
|
|
Term
Which component do I order?
Von Willebrand disease: |
|
Definition
| Von Willebrand disease: clotting factors Cryoprecipitated Antihemophilic Factor |
|
|
Term
| Which component do I order?Chemo pt w/severe bacterial infxn-unresponsive to Abx : |
|
Definition
| Transfusion of Granulocyte Pheresis |
|
|
Term
| What blood type is the “universal donor |
|
Definition
|
|
Term
| What blood type is the “universal recipient”? |
|
Definition
|
|
Term
| How much should one unit of PLTs raise the PLT ct? |
|
Definition
| Platelet Increment: Patient platelet count should increase 30-60,000 per single donor platelet. |
|
|
Term
| When should I use a blood warmer? Filter? |
|
Definition
always use a filter
Blood warmers are available from the operating rooms.
Blood warmers may be used as long as the device has a temperature alarm and visible temperature monitor. Blood warming devices are most appropriate for massive and rapid blood replacement, such as exchange transfusion of the newborn. |
|
|
Term
| Do we transfuse platelets just because the platelet count is low? |
|
Definition
| No. We transfuse when bleeding is associated with that decreased platelet count. (<50,000 for pre-op, < 20,000 otherwise) |
|
|
Term
Who gets RHIg?•
When is RHIg given?• |
|
Definition
Given to ALL Rh neg women who become pregnant to prevent HDN
Given @ 28 wks gestation & w/in 72h postpartum |
|
|
Term
| What dictates the BB testing in a pre-op patient? |
|
Definition
Likely hood of the blood product needing to be used.
type and screen
type and crossmatch |
|
|
Term
| Most transfusion reactions are due to what? |
|
Definition
| The most frequent error leading to transfusion of ABO-incompatible blood is failure of the final patient identification check at the bedside, leading to transfusion of properly labeled blood to a recipient other than the one intended |
|
|
Term
| What are the diagnostic tests for DIC? |
|
Definition
| Diagnostically: Incr PT/PTT & bleeding time, decr PLTs, + FSPs and + d-Dimer |
|
|
Term
| List SSx of HTR.Acute Hemolytic Transfusion Reaction (AHTR) |
|
Definition
| fever, chills, dyspnea, anxiety, bleeding @ infusion/surgical site, blood in urine, flank pain (renal), hypotension, shock, cardiac arrest, death |
|
|
Term
| Acute Hemolytic Transfusion Reaction (AHTR) Tx: |
|
Definition
|
|
Term
|
Definition
STOP the transfusion immediately
Open –keep IV open-saline
Check paperwork/armband/unit
Call Physician & Blood Bank
Collect blood & urine samples. Send with remainder of unit, transfusion set/tubing to the Blood Bank as per institutional protocol.
Record all events including times & type of reaction
Monitor patient-Vital signs |
|
|
Term
| What solution is used to transfuse RBCs? |
|
Definition
| Only isotonic saline (0.9%) is recommended for use with blood components. |
|
|
Term
|
Definition
ID patient/review chart/Verify consent form
Obtain IV access or verify patency of existing
Pre-medicate
Apply Monitors
Administer narcotic
Administer lidocaine
Induction agent
Ascertain LOC (i.e.. Loss of lash reflex)
Tape eyes
Establish patent airway/mask ventilation
Administer neuromuscular blocking agent if intubation planned
Continue mask ventilation with introduction inhalation agent
Monitor PNS/TOF for loss of response
Perform laryngoscopy
Place endotracheal tube (ET)
Verify ET placement
Secure ET
Connect to anesthesia circuit
Initiate mechanical ventilation
8-10ml/Vt. at RR ~ 10-12bpm
Turn on inhalation agent and carrier agent (i.e.. O2, Air, N2O, Helium) of choice
Apply any other necessary monitors |
|
|
Term
| is performed to gain control of the airway in the least amount of time after the ablation of protective airway reflexes with the induction of anesthesia |
|
Definition
|
|
Term
|
Definition
Apply Cricoid pressure (Sellick’s maneuver)
Administer IV induction agent
Administer succinylcholine IMMEDIATELY after IV induction agent even if the patient has not loss consciousness
DO NOT ARTIFICIALLY VENTILATE
Rapidly intubate once SV has ceased or height of twitch diminishes
Maintain cricoid pressure until ETT cuff is inflated and tube position is confirmed |
|
|
Term
Induction type
Able to take patient “deep” rapidly
Avoid stage 2
Spontaneous ventilation is preserved
Effective approach to the adult difficult airway
“Awake Look” |
|
Definition
|
|
Term
|
Definition
Premedicate
Benzodiazepines
Establish IV
Apply monitors
Preoxygenate/denitrogenate
Begin titration of agent via face mask
LOC usually within 1 minute
Achieve sufficient level of anesthesia (stage 3 |
|
|
