Surgery Shelf

Absolute Contraindications to Surgery
Diabetic Coma, DKA

Nutritional Contraindications to Surgery
Albumin < 3 Transferrin < 200 Weight Loss < 20%

Liver Contraindications to Surgery
bilirubin > 2
PT > 16
Ammonia > 150 or encephalopathy

When should a smoker quit prior to surgery?
stop smoking8 weeks has shown improvement

Goldman’s Index & factors
Preoperative Risk During surgery, weighs risk and benefits during surgery (CHF, MI, Arrhythmia, Age > 70, Aortic Stenosis )

Heart Contraindications for Surgery
Ejection Fraction < 35% MI within 6 months (abnormal EKG --> stress test –> cath –> revasc)

Aortic Stenosis murmur
Late systolic crescendo decresendo

Which medications to stop and how soon before surgery
NSAIDS, Vit E, ASA – 5 to 7 days before surgery
Metformin – to prevent lactic acidosis
Warfarin –> 5 days INR should be < 1.5 or use vit K to reverse take 1/2 morning dose of insulin if diabetic

Dialysis before surgery
pt should recieve 24 hours before surgery

BUN > 100 prior to surgery?
Platelets normal but bleeding time +++
Needs dialysis, toxins will interfere with function of platelets

Assist Control Vent Settings
set TV and rate
if patient takes a breath, the vent gives volume

Pressure Support Vent Settings
pt rules rate but a boost of pressure is given
important setting for weaning

CPAP settings
pt needs sufficient resp drive
alveoli stays open

pressure given at end of cycle to keep alveoli open
used in ARDS or CHF

Best test to evaluate management of pt on ventilator
regularly check ABG, look at PaO2, PaCO2

patient on vent, ABG = PaO2 low
increase the FiO2

patient on vent, ABG = PaO2 high
decrease the FiO2
(too much oxygen leads to free radical damage)

patient on vent, ABG = PaCO2 is low (high pH)
decrease the tidal volume
(increasing resp rate also increasing dead space ventilation)

patient on vent, ABG = PaCO2 is high (low pH)
increase the tidal volume
(not wasting any O2 on dead space)

pH is less than 7.4

acidosis, HCO3 is high and PCO2 is high
respiratory acidosis

acidosis, HCO3 is low and PCO2 is low
metabolic acidosis

anion gap calculation, normal value?
(Na – [Cl + HCO3])
normal is 8 to 12

anion gap acidosis
methanol, uremia, dka, pyraldehyde, isoniazid, ethylene glycol, salicylates

non anion gap acidosis
diarrhea, diurectic, RTAs

alkalosis, HCO3 is low and PCO2 is low
respiratory alkalosis

alkalosis, HCO3 is high and PCO2 is high
metabolic alkalosis

metabolic alkalosis – urine chloride < 20
vomiting, NG

metabolic alkalosis – urine chloride > 20
Conn’s Bartter’s

low Na, high volume status
fluid overload from CHF, Nephrotic syndrome, cirrhosis

low Na, low volume status
diuretics or vomiting

low NA, normal volume status
SIADH –> paraneoplastic for lung cancer

treatment of hyponatremia
fluid restriction, diurectics

treatment of hyponatremia with low volume status
normal saline

when to use 3% Na+
symptomatic (seizures)
Na+ 110

why to slowly correct hyponatremia
Central Pontine Myolinolysis
(brain will shrink due to hypotonic ECF in the pons)

how fast to replete/dilute Na+
12 to 24 mEq per day
.5 to 1 mEq per hour

replace with D5W or hypotonic fluid

why to slowly correct hypernatremia
cerebral edema

Hypocalcemia signs/symptoms
Numbness, Chvostek, Trousseau signs, prolonged QT interval

Hypercalcemia signs/symptoms
Bones, stones, groans, psychosis, shortened QT interval

Hypokalcemia signs/symptoms
Paralysis, ileus, ST depression, U waves
Give K+ maximum rate 40 mEq/hr

Hyperkalcemia signs/symptoms
Peaked T waves, prolonged PR and QRS
Calcium gluconate, insulin and glucose, albuterol/b agonist DIALYSIS

Maintenance IVF of choice
D5 1/2 NS, + 20 KCl

Calculating daily requirement of IVF
first 10 – 100mL/kg/day
next 10 – 50 mL/kg/day + 1000
above 20 – 20 mL/kg/day + 1500

4:2:1 rule
first 10 kg – 4 ml/kg/hour
next 10 kg – 2 ml/kg/hr + 40
over 20 kg – 1 ml/kg/hr + 60

when to use TPN
problem with gut absorption

risks of TPN
acalculous cholecystitis
liver dysfunction
zinc deficiency, electrolyte disturbances

benefits of enteral feeds over TPN
keeps gut mucosa intact, prevents bacterial translocation

What is the most common indication for intubation? Altered mental status When there is a need for an airway, but possible neck injury, what do you do? Airway anyway! Make sure the spine is steady! WE WILL WRITE A CUSTOM …

Metabolic Acidosis? a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body, in which the pH falls to less than 7.35 Causes of Metabolic Acidosis? – Diabetic …

Calcium 8.6-10.2 Chloride 96-106 WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample Magnesium 1.5-2.5 Phosphate (Phosphorus) 2.4-4.4 Potassium 3.5-5.0 Sodium 135-145 pH (arterial) 7.35-7.45 PaCO₂ 32-48 HCO₃ or HCO₂ …

pH H+=how many hydrogens there are Acidic a LOT of Hydrogens (H+) or not enough bicarb WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU FOR ONLY $13.90/PAGE Write my sample Alkaline not enough hydrogen (H+) …

Isotonic Fluid same concentration as body fluid -0.9%NaCl; D5W solution; Lactated ringer solution; ringers solution Hypotonic IV Fluids -2.5% Dextrose in Water -0.45% NS -Not for head injuries WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR …

respiratory acidosis pH < 7.35, CO2 > 45, HCO3 > 26 = compensation respiratory acidosis definition increase in H+, lowering pH, and creating an excess of H2CO3 WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY FOR YOU …

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