SURGERY
Introduction
It
is important to understand that you are going to work extremely long hours
during your clerkship and not to complain about it. The importance of knowing your place will become apparent
quickly. Do not expect to always be
able to see the surgery, or do much more than hold retractors, cut suture, or
operate suction. It is vital that you
always politely introduce yourself to the scrub nurse and circulator when you
enter the OR and ask whether they have gloves and a gown for you before you
scrub in for the case.
OPERATIVE NOTE
1.
Pre-op
diagnosis
2.
Post-op
diagnosis
3.
Findings
4.
Procedure
5.
Surgeon
6.
Assistant(s)
7.
Anesthesia
(type, anesthetist)
8.
Specimen(s)
9.
Estimated
blood loss
10.
Fluids
11.
Tubes/drains
12.
Complications
13.
Miscellaneous/special
meds
POST-OPERATIVE ORDERS
|
Disposition |
Where you want
the patient to go… |
|
Special Recovery Room Requests: labs, CXR, etc. |
|
|
Vitals |
q4h (or as per
routine) |
|
Tubes/Drains |
NG à wall suction, Foley to gravity… |
|
Bed Position |
Elevated to __o |
|
Activity |
where, frequency,
etc. |
|
Diet |
NPO except
sips/chips, clear, regular… |
|
AM Labs |
|
|
Meds |
“6 A’s and home
meds” = analgesics, antibiotics, antiemetics, antacids,
anticoagulants, antiinflammatories |
|
Things specific to operative site |
|
|
Pneumatic anti-embolism stockings |
|
Differential Diagnosis of Abdominal Pain (by location)
|
Right upper
quadrant Cholecystitis Cholangitis Pancreatitis Hepatitis Budd-Chiari
syndrome Subdiaphragmatic
abscess Pneumonia /
empyema / pleurisy |
Right lower
quadrant Appendicitis Inguinal hernia Salpingitis Ectopic pregnancy Inflammatory
bowel disease Mesenteric
adenitis (Yersinia) |
Epigastric Peptic ulcer
disease Gastroesophageal
reflux disease Pancreatitis Ruptured aortic
aneurysm Gastritis Myocardial infarction Pericarditis |
|
Periumbilical Early
appendicitis Bowel obstruction Ruptured aortic
aneurysm Gastroenteritis |
Left upper
quadrant Splenic infarct Splenic abscess Pancreatitis Gastric ulcer Gastritis |
Left lower
quadrant Diverticulitis Inguinal hernia Inflammatory
bowel disease Salpingitis Ectopic pregnancy Irritable bowel
disease |
|
Diffuse:
Causes include gastroenteritis, peritonitis, mesenteric ischemia, bowel
obstruction |
||
Causes of Small Bowel Obstruction
1.
Adhesions from
prior surgery
2.
Hernias
3.
Inflammatory
Bowel DZ
4.
Malignancy-lymphoma,
carcinoid, metast.
5.
Intussusception
Recovery of
Bowel Fx Post-Op: 1) Small
Intest. 2) Stomach 3) Colon
Differential Diagnosis of Surgical Fevers
1. Intraoperative or immediately post-operative
Malignant
hyperthermia (halothane)
Transfusion
reaction
Drug
hypersensitivity
Atelectasis
Aspiration
pneumonia
Endocrine
(Addisonian crisis, thyroid storm, pheochromocytoma)
2. Post-operative fever (any time)
Thrombophlebitis
Deep venous
thrombosis
Drug
hypersensitivity
Transfusion reactions
Central line sepsis
3. Post-operative fever (< 24 hours)
C = Clostridial wound infections
S = Streptococcal wound infections
T = Thyroid problems
A = Addisonian crisis
T = Transfusion reaction
4. Post-operative fever (> 24 hours)
POD# 1-2 = “Wind”
(atelectasis)
POD# 3-4 = “Water”
(urinary tract infections)
² Pneumonia
² IV complications (infection)
² Wound complications (leaking anastamosis,
hematoma)
POD# 4-6 = “Wound”
(wound infections)
POD# 6-10 =
“Walking” (DVT) and “Wonder drugs”
² Abscess
² Drug fever
² Pneumonia
² Wound infections
² C. difficile colitis
² Anastamotic leak
Fluids Management
What’s in a Bag of Fluids? (electrolytes in mEq/L)
|
Fluid |
Na+ |
K+ |
Cl- |
HCO3- |
Ca2+ |
Kcal/L |
Glc (g/L) |
|
½NS |
77 |
-- |
77 |
-- |
-- |
-- |
-- |
|
NS |
154 |
-- |
154 |
-- |
-- |
-- |
-- |
|
D5W |
-- |
-- |
-- |
-- |
-- |
170 |
50 |
|
LR |
130 |
4 |
109 |
28 |
3 |
9 |
-- |
Content of Body Fluids (mEq/L)
|
|
Na+ |
K+ |
Cl- |
HCO3- |
|
Biliary |
145 |
5 |
100 |
35 |
|
Diarrheal |
60 |
35 |
40 |
30 |
|
Gastric |
60 |
10 |
130 |
0 |
|
Ileal |
130 |
5 |
100 |
50 |
|
Pancreas |
140 |
5 |
75 |
115 |
|
Salivary |
10 |
26 |
10 |
30 |
Daily Volume
and Electrolyte Requirements
Daily maintenance
fluids (assuming normal kidneys/heart)
100 cc/kg for the first 10 kg
50 cc/kg for the next 10 kg
20 cc/kg for the remainder
or
4 cc/kg/hr for the first 10 kg
2 cc/kg/hr for the next 10 kg
1 cc/kg/hr for the remainder
Sodium requirement
= 1 – 2 mEq/kg/day
Potassium
requirement = 0.5 – 1 mEq/kg/day
Urine output = 0.5
cc/kg/hr