Term
Total volume of water within the body varies with? decreases with? |
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Definition
Varies with age, sex and proportion of body fat present TBW decreases with obesity (adipose is nearly water-free) |
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Term
Homeostasis: Body maintains strict control of water and electrolyte distribution and acid-base balance as a function of the complex interplay of |
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Definition
cellular membrane forces specific organ activities systemic/local hormonal influences |
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Term
Dominant Cations in human body |
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Definition
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Term
Each fluid compartment maintains electrical neutrality through balance of the concentrations of cations and anions
1) Intracellular Compartment
2)Interstitial & Intravascular Compartments |
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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 |
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Term
forces are the prime determinants of water distribution in body |
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Definition
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Term
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Definition
Number of particles dissolved in a solution
Independent of chemical activity or ionic strength of particles |
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Term
Osmolarity expressed as a concentration
Osmolality expressed as a concentration |
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Definition
= osmoles of solute per liter of solution
= osmoles of solute per kg of solution |
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Term
In plasma, osmolarity is primarily determined by |
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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 |
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Term
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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 |
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Term
Hypertonic alterations
Hypotonic alterations |
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Definition
= ECF more concentrated than ICF, cell shrinkage
= ECF less concentrated than ICF, cells swell |
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Term
What Accounts for Tonicity?
A ------- in tonicity implies a relative water excess whereas an -------- in tonicity implies dehydration |
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Definition
Mainly electrolytes
reduction/increase |
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Term
Recognizing and correcting abnormalities brought about by disease, trauma, and stress are equally important to knowing how to ______normal fluid and electrolyte balance |
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Definition
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Term
What systems regulate fluid volume in the body? |
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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 |
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Term
Fluid Homeostasis: water gain from? water losses from? |
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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 |
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Term
How to Assess Fluid Status? |
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Definition
Urine output vital signs wt changes skin turgor jugular venous distention mucosal membranes rales cxr findings |
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Term
Chronic Volume deficits manifest as? |
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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.) |
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Term
Acute Volume Deficits manifest by? |
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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 |
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Term
Purpose of Fluid/Electrolyte Therapy |
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Definition
Ensure homeostasis of TBW and its constituent solutes |
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Term
Principles for IVF/Electrolyte Replacement |
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Definition
Maintenance Replacement of Losses Resuscitation |
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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 |
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Definition
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Term
Scenarios Requiring Fluid Replacement for Deficits |
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Definition
blood loss from surgery evaporative loss during lengthy surgery Nasogastric output Fistula losses Diarrheal losses Fluid sequestered in operative site (3rd spacing) |
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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 |
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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 |
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Term
IV fluid used when disired to expand ECFV
tonicities close to that of plasma= Isotonic |
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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 |
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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 |
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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 |
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Term
Ideal for the replacement of existing fluid deficits when the serum electrolyte concentrations are abnormal contains: Sodium, Chloride, Lactate, Potassium, Calcium |
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Definition
Lactated Ringers IVF Solution
Note: Disadvantage of this solution relatively low sodium content (130 mEq/L) as compared with plasma |
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Term
Calculation of Maintenance Fluid Requirements adult rule? Pediatric rule? |
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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 |
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Term
3 main types Dehydration
Gold standard: measurement of acute weight loss |
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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 |
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Term
Always Resuscitate with what type of fluids???? |
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Definition
Isotonic Fluids
Bolus 20ml/kg Reassess reassess reassess |
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Term
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Definition
Hypovolmeic (diuretic excess) Euvolemic (SIADH) Hypervolemic (CHF, renal failure)
Do Not Correct Hyponatremia Too Quickly can lead to Central Pontine Myelinosis |
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Term
Hypernatremia - Treatment |
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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 |
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Term
Hyperkalemia
serum K > 5.5 mEq/L
EKG sign Treatment: |
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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 |
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Term
Hypokalemia
Serum Potassium < 3.5 mEq/L 1. Causes
2. what other diorder usually coexists? |
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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 |
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Term
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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, |
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Term
Candidates for Oral Rehydration Therapy |
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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 |
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Term
Due to insulin deficiency and counter regulatory hormone excess
Serum and urine glucose + ketones elevated |
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Definition
Diabetic Ketoacidosis
In acidosis, potassium is driven extracellularly |
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Term
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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 |
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Term
Hypovolemic Shock: Route and Rate of Fluid Administration |
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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 |
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Term
Prioritize: Traumatic injuries usually take precedence over the burns, with the exception of |
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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. |
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Term
What kind of necrosis do burns cause? |
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Definition
Burns cause coagulative necrosis |
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Term
Characteristic “Ebb and Flow” of burns |
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Definition
Ebb: Low metabolism/cardiac output, ↓Temp Flow: hypermetabolism, high cardiac output, hyperglycemia, increased heat production. |
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Term
These are minor burns that only effect the outer epidermis. Example: Sun Burn |
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Definition
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Term
Affect both the outer-layer (epidermis) and the under lying layer of skin (dermis) These burns often affect sweat glands, and hair follicles |
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Definition
2nd Degree Burns (Partial Thickness) |
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Term
Epidermis, dermis and hypodermis Charring of skin or a translucent white color, with coagulated vessels visible just below the skin surface |
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Definition
3rd Degree Burns (Full Thickness)
These burns require debridement of dead tissue and reconstruction with a skin graft or other types of reconstruction |
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Term
Epidermis, Dermis, and destruction to subcutaneous fat |
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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 |
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Term
Estimation of Percent of Body Surface Burned |
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Definition
For adults, use “Rule of Nines”
Pediatric Rule of Nines |
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Term
These burns are always Critical? |
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Definition
Burns to hands, feet, face, genital or with circumferential patterns are critical Inhalation injuries are always critical |
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Term
use moist sterile dressings for immediate management of |
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Definition
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Term
For immediate management of seriousthermal burns use? |
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Definition
Dry dressings
Note: DO NOT make your patient hypothermic DO NOT forget the ABCDE’s |
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Term
Burn patients are at risk for hypothermia, especially burned children. What should you do and not do? |
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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. |
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Term
Indications of inhalation injury usually appears within 2-48 hours after the burn occurred. Indications may include |
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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 |
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Term
earliest consequence of inhalation injury |
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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 |
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Term
A cut is made through the burned tissue with a scalpel or electrocautery medially and laterally to ensure restoration of pulses |
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Definition
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Term
IV Fluid Resuscitation in burns |
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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. |
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Term
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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. |
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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. |
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Definition
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Term
Why use Lactated Ringers instead of Normal saline or D5W for fluid resucitation in buurn paients? |
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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. |
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Term
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Definition
Any burn greater than 10% TBSA Any inhalation injury any trauma patient any elelctrical burn
WHEN IN DOUBT.... OVERTREAT |
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Term
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Definition
to maintain the volume of the patient during the period of hypovolemia |
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Term
Parkland Formula. It is a good formula for two reasons: |
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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. |
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Term
Parkland Formula is used for what and what is it? |
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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 |
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Term
Just Read:
An indwelling bladder catheter is recommended in patients receiving IV fluids ≥ 200 cc/hr to facilitate resuscitation and titration |
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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 |
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Term
DRug of choic for pain control in Burn patients |
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Definition
. Morphine IV is the drug of choice, delivered in incremental doses. |
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Term
Wound Management for burns |
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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. |
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Term
Infection treatment for burns? |
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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 |
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Term
what to know about electrical burns |
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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 |
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Term
Electricity takes the path of least resistance in order of increasing magnitude: |
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Definition
Nerve Blood vessels Muscle Skin Tendon Fat Bone |
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Term
Acids cause________ necrosis
Alkalis cause _________ necrosis allowing deeper penetration |
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Definition
1. coagulation
2. liquefaction |
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Term
what to know about chemical burns |
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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 |
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Term
Hydrofluoric acid is somewhat different from other acids in that it produces a ______________necrosis |
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Definition
a liquefaction
One of the strongest inorganic acids Used mainly for industrial purposes Glass etching Metal cleaning Electronics manufacturing |
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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. |
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Term
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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 |
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Term
Absence of ALL sensation Reversible lack of awareness |
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Definition
Anesthesia
Differs from analgesia Block pain only |
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Term
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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 |
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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 |
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Definition
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Term
Goals of General Anesthesia |
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Definition
Amnesia
Analgesia
Loss of Consciousness
Muscle Relaxation
Weaken Autonomic Nervous System |
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Term
Stages of General Anesthesia |
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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” |
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Term
what stage of General anesthesia
Period between initial administration of anesthesia and loss of consciousness (LOC) |
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Definition
Stage 1(Analgesia) “Induction period” |
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Term
what stage General Anesthesia Period after LOC RR/HR irregular (breath holding) Pupillary dilation Uncontrolled movements |
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Definition
Stage 2 (Delirium) “Excitement period” |
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Term
Zones of a Burn Jackson Burn Model |
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Definition
Zone Hyperaemia: increased blood flow to area. will recover zone stasis little blood flow some will recover Zone coagulation: severe damage wont recover |
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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) |
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Definition
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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 |
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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 |
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Term
Spinal Anesthesia Pros Cons Contraindication |
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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 |
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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 |
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Definition
Epidural (Regional Anesthesia) |
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Term
Epidural Uses Pros Cons Contraindications |
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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 |
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Term
Local anesthetic injected into surrounding nerve trunk/roots |
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Definition
Peripheral Nerve Blocks
Pros: decrease post-op pain & narcotic use Cons: technically difficult, limited time of action, local toxicity, nerve damage |
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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 |
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Definition
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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 |
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Definition
Monitored Anesthesia Care (MAC)
Eye surgery, breast biopsies, small plastic cases, endoscopic procedures MRI/CT scan/Interventional radiology |
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Term
Used for induction/maintenance of general anesthesia Most are irritating to airway/pungent odor Most frequently used to maintain (combination with other medications |
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Definition
Inhalational Anesthetic Agents
Potent halogenated hydrocarbon liquids that readily evaporate into vapors/gases via specialized vaporizes |
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Term
Inhalational Anesthetic Agents
Partial pressure of the anesthetic in alveoli is (directly/indirectily) related to partial pressure in the brain (effect!!) |
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Definition
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Term
at one atmosphere at which 50% of patients do not move in response to a surgical stimulus |
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Definition
Minimum Alveolar Concentration |
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Term
Gas at room temperature rather than liquid, NOT considered a volatile gas! MAC 105% |
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Definition
Nitrous Oxide
Totally impossible to put someone asleep with this Add to anestetic to cut down on potent anesthetics |
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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: |
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Definition
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Term
Displaced halothane in the 1980’s Still used for longer cases |
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Definition
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Term
Most:Non-pungent odor (sweet) great for mask inductions : now used in kids |
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Definition
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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 |
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Definition
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Term
Cause amnesia, but most have no analgesic properties
Large doses> produce anesthesia and unconsciousness Small doses> MAC/sedation |
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Definition
Intravenous Anesthetic Agents Barbiturates Propofol Imidazole Ketamine
Benzodiazepines |
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Term
Predominantly used to relieve pain before, during, and after surgery |
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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 |
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Term
DOes NOT produce unconsciousness, amnesia or provide analgesia “Anesthesia awareness”
Uses: Facilitate intubation Control muscle tone to provide an optimal surgical field |
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Definition
Muscle Relaxants Two classifications Depolarizing Nondepolarizing |
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Term
Depolarizing (only one of these) Muscle Relaxants: |
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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 |
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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) |
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Definition
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Term
Mallampati Classification System Assesses? |
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Definition
Airway Assessment Classes 1-4 Class 3 or 4 airway be afraid: Class 4 glide scope bc very difficult |
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Term
Patient Preparation for surgery 1) Antihypertensives? 2) Insulin? 3)Oral hypoglycemics? 4)most anticoagulants |
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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 |
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Term
Patient Preparation for Surgery
Medications? 1) NSAIDs 2) Diuretics 3) MAOI |
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Definition
1)Hold 48hrs prior to DOS 2) Hold DOS Exception HCTZ used for HTN 3) Discontinue 3 weeks prior to surgery |
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Term
4 techniques commonly used to induce general anesthesia |
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Definition
Routine IV induction Rapid sequence induction (worried about aspiration) Modified rapid sequence induction (fast but give breathe) Inhalation induction |
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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 |
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Definition
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|
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 beMAINTAINED |
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Term
Goals of Maintenance Phase of General Anesthesia |
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Definition
Provide analgesia
Maintain unconsciousness/amnesia
Provide skeletal muscle relaxation/maintain motionless surgical field
Control autonomic nervous system response to noxious stimuli |
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Term
the most stable phase of the anesthesia |
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Definition
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|
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. |
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Definition
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|
Term
Now considered the #1 nutritional problem of the world by World Health Organization |
|
Definition
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|
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 |
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|
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 |
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|
Term
Most commonly performed operation for weight loss in the United States |
|
Definition
“Roux-en-Y Gastrojejunostomy” |
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|
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 |
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Definition
Adjustable Gastric Lap Banding |
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|
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
|
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. |
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|
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 |
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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 |
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Term
DAT: Direct Antiglobulin Test (Coomb’s Test) |
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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) |
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Term
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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 |
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Term
what type of blood product reaction? Usually attributed to CLERICAL ERROR Commonly ABO incompatibility |
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Definition
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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 |
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Definition
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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 |
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Definition
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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 |
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Definition
DIC: Disseminated Intravascular Coagulation |
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Term
Cardiogenic pulmonary edema d/t volume overload and temporally associated with transfusion (esp. large volumes) |
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Definition
TACO-Transfusion Associated Circulatory Overload |
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Term
Occurs during or within 6 hrs of transfusion: fever, hypotension, resp distress NON-cardiogenic pulmonary edema (bilaterally) |
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Definition
TRALI-Transfusion-Related Acute Lung Injury |
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Definition
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Term
Which component do I order? Symptomatic anemia Hgb of 5.0 g/dL: |
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Definition
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Term
Which component do I order? Replacement of multiple clotting factors (burns): |
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Definition
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Term
Which component do I order? Asymptomatic pt w/ hgb of 9.0g/dL |
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Definition
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Term
Chemo pt: plt ct <10,000 platelets |
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Definition
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Term
Which component do I order? Pt w. previous allergic reaction to PRBCs |
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Definition
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Term
Which component do I order? Exchange transfusion |
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Definition
Irradiated Blood Products |
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Term
Which component do I order? Von Willebrand disease: |
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Definition
Von Willebrand disease: clotting factors Cryoprecipitated Antihemophilic Factor |
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Term
Which component do I order?Chemo pt w/severe bacterial infxn-unresponsive to Abx : |
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Definition
Transfusion of Granulocyte Pheresis |
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Term
What blood type is the “universal donor |
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Definition
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Term
What blood type is the “universal recipient”? |
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Definition
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Term
How much should one unit of PLTs raise the PLT ct? |
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Definition
Platelet Increment: Patient platelet count should increase 30-60,000 per single donor platelet. |
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Term
When should I use a blood warmer? Filter? |
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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. |
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Term
Do we transfuse platelets just because the platelet count is low? |
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Definition
No. We transfuse when bleeding is associated with that decreased platelet count. (<50,000 for pre-op, < 20,000 otherwise) |
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Term
Who gets RHIg?•
When is RHIg given?• |
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Definition
Given to ALL Rh neg women who become pregnant to prevent HDN
Given @ 28 wks gestation & w/in 72h postpartum |
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Term
What dictates the BB testing in a pre-op patient? |
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Definition
Likely hood of the blood product needing to be used.
type and screen
type and crossmatch |
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Term
Most transfusion reactions are due to what? |
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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 |
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Term
What are the diagnostic tests for DIC? |
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Definition
Diagnostically: Incr PT/PTT & bleeding time, decr PLTs, + FSPs and + d-Dimer |
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Term
List SSx of HTR.Acute Hemolytic Transfusion Reaction (AHTR) |
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Definition
fever, chills, dyspnea, anxiety, bleeding @ infusion/surgical site, blood in urine, flank pain (renal), hypotension, shock, cardiac arrest, death |
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Term
Acute Hemolytic Transfusion Reaction (AHTR) Tx: |
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Definition
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Term
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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 |
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Term
What solution is used to transfuse RBCs? |
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Definition
Only isotonic saline (0.9%) is recommended for use with blood components. |
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Term
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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 |
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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 |
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Definition
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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 |
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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” |
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Definition
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Term
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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 |
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