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DU PA Sur-Sho/Tra/In

Duke PA Surgery-Shock, Transfusion, and infection

defined as any condition in which there is inadequate delivery of oxygen and nutrients to the tissues to meet metabolic demands Shock
General signs/symptoms of shock mental status changes, acidosis, oliguria, and poor cutaneous perfusion (cool, pale skin).
a function of the cardiac output and the oxygen carrying capacity of the blood Oxygen delivery
divisions of shock failures of the heart, failures of the blood, failure the vessels
hemodynamic responses to compressive cardiac shock decreased cardiac output, increased heart rate, large increase in LV filling pressures
hemodynamic responses to cardiogenic shock large decrease in cardiac output, increase in filling pressures
hemodynamic responses to hypovolemic shock decreased cardiac output, increased heart rate, large decrease in LV filling pressure, increased systemic resistance
hemodynamic responses to septic shock increased cardiac output, increased heart rate, large decrease in systemic resistance
shock due to pump failure can be due to extrinsic compression of the heart, or intrinsic heart failure
results when compression of the great veins or heart itself retards blood return to the heart cardiac compressive shock
examples of cardiac compressive shock pericardial tamponade, tension pneumo, diaphragmatic rupture, positive pressure ventilation
With cardiac compressive shock,in addition to general signs of shock, physical exam reveals hypotension, distended neck veins, pulmonary rales, Kussmaul's sign, and pulsus paradoxus
rise in JVP with inspiration Kussmaul's sign
exaggerated decrease in systolic pressure with inspiration pulsus paradoxus
definitive treatment for cardiac compressive shock correction of the mechanical abnormality
can result from failure of the heart muscle, arrhythmia, valvular or septal defects, or excessive afterload cardiogenic shock
Physical exam of a patient in cardiogenic shock may reveal signs of compensetory volume overload-distended neck veins, pulmonary rales, extra heart sounds, peripheral edema
in cardiogenic shock due to inadequate pumping, improve pump function with inotropes(dopamine, dobutamine), intra-aortic balloon pump
in cardiogenic shock due to excessive afterload, reduce afterload with vasodilators (ACEI's and nitrates
in cardiogenic shock due to arrhythmias, optimize heart rate and rhythm with beta-blockers, anti-arrhythmics, pacemakers
in cardiogenic shock optimize volume status by being cautious with fluid administration, and use diuretics if in CHF
one of the most common causes of shock encountered in the practice of surgery hypovolemic shock
Hypovolemic shock may be due to blood loss as well as from third spacing, protracted vomiting, diarrhea, sweat
the sequestration of fluid into injured soft tissues or bowel third spacing
hypovolemia leads to decreased venous return to the heart and decreased cardiac output
decreased venous return to the heart preload
mild hypovolemia <20% blood volume loss-decreased pulse pressure, postural hypotension, cutaneous vasoconstriction, collapsed neck veins, concentrated urine, hemoconcentration
moderate hypovolemia 20-40% blood volume loss-thirst, tachycardia, moderate hypotension, oliguria
severe hypovolemia >40% blood volume loss-mental status changes, arryhthmias, ischemic EKG changes, profound hypotension
systolic pressure - diastolic pressure = __ pulse pressure
treatment for hypovolemic shock Large-bore IV. Resuscitation should always begin with crystalloid infusion—30 cc/kg (2 liters for most adults) as fast as possible then titrate against signs of clinical improvement. Blood products may be appropriate in situations of blood loss.
loss of venous tone reults in venous pooling with decreased blood return to the heart (preload) and decreased cardiac output
loss of arterial tone results in decreased systemic vascular resistance (SVR) and hypotension.
neurogenic shock is a failure of the autonomic nervous system due to spinal cord injury or regional anesthetics
injury above the level of __ results in a loss of sympathetic tone and adrenergic stimulation T4
physical signs of neurogenic shock may include warm, flushed skin, and bradycardia
in neurogenic shock the loss of venous tone is exacerbated by the loss of muscle tone
treatment of neurogenic shock IV fluids are the initial therapeutic agent since loss of venous tone results in relative hypovolemia. Peripheral vasoconstrictors are often required
Septic shock is a complex phenomenon most commonly due to overwhelming infection from __ but can be due to any type of infection gram negative bacteria
In early septic shock, the response is __ hyperdynamic with tachycardia and increased cardiac output
In late septic shock __ the cardiovascular system decompensates and progresses to a hypodynamic state
Early clinical manifestations of septic shock include __ fever, chills, bounding pulses, and warm, flushed skin in the setting of hypotension
signs of progression to late septic shock are __ Hypothermia, coagulopathy, pulmonary failure (ARDS), and renal failure
definitive treatment of septic shock clearance of the offending infection (surgical debridement or resection, appropriate antibiotic therapy)
Potential indications for the transfusion of blood products • the restoration and maintenance of normal blood volume• the correction of severe anemia• the correction of bleeding and coagulation disorders
effect of administration of one unit of PRBC's Hct increase by 3%
effect of administration of one unit of platelets increases platelets county by __ 40,000
effect of administration of one unit of cryoprecipitate increase in fibrinogen by 3%
indication for administration of PRBC's hypovolemia + anemia, symptomatic anemia
indication for administration of platelets in the presence of bleeding plts <50,000 plts <15,000 (asymptomatic)
indication for administration of FFP bleeding + coagulopathy, coumadin reversal
indication for administration of Cryoprecipitate fibrinogen <100 mg/dL
platelets are given for the correction of thrombocytopenia
indication for administration of platelets for asymptomatic thrombocytopenia plts <15,000
a pool of platelets from six donors six_pack
FFP is given for the correction of the __ vitamin K dependant clotting factors
FFP contains serum clotting factors (except VIII, and V), antithrombin III, fibrinogen, and proteins C and S
is a plasma component that is enriched for high-molecular-weight proteins Cryoprecipitate
is a plasma componenet that is enriched for fibrinogen, factor VIII, factor XIII, and von Willebrand's factor Cryoprecipitate
occur when the recipient possesses antibodies against the donor RBC’s major (A, B, and Rh) or minor (Kell, Kidd, Duffy, et al.) antigens. Hemolytic reactions
acute (major) hemolytic reactions occur at the rate of 1/__ units 20,000
delayed(minor) hemolytic reactions occur at the rate of 1/__ units 500
symptoms of hemolysis apprehension, headache, fever, chills, flank or chest pain, hematuria, and (in severe cases) hypotension
Febrile nonhemolytic reactions may occur against donor WBC's
Disease transmission due to transfusion is a rare but real phenomenon
rates of CMV transmission from blood products __% unless CMV-negative requested 50
rate of HIV transmission from blood products 1/400,000-1/600,000
rate of Hep C transmission from blood products 1/3000-1/6000
rate of Hep B transmission from blood products 1/50,000-1/200,000
__due to the chelating action of the preservative sodium citrate can contribute to coagulopathy and should be corrected Hypocalcemia
__ can be associated with multiple transfusions of PRBC’s. Dilutional coagulopathy
• Some hemolysis of cells occurs during storage and administration, delivering an additional __ load to the recipient potassium
A __ device can filter blood collected during clean procedures and return it to the patient “cell-saver”
• Autotransfusion is an option for elective operations where significant blood loss is expected. The patient should ideally donate more than __ week prior to operation 1
most common congenital abnormality of platelets von Willebrand's disease
five causes of shock cardiogenic, hypovolemic, septic, neurogenic, anaphylactic
MI, cardiomyopathy, valvular disease, rhythm disturbances, Pulm HTN, cardiac tamponade, tension PNX, diaphragm rupture (heart is compresed), PPV Cardiogenic shock
hemorrhage, severe dehydration, vomiting, diarrhea Hypovolemic shock
infection due to GNRs causing SIR, MOF, arterial vasodilation Septic shock
Spinal cord injury above T4 results in loss of sympathetic tone/adrenergic stimulation, regional anesthetics Neurogenic shock
hypersensitivity reaction Anaphylactic shock
initial treatment for cardiogenic shock optimized volume status without overloading lungs, decrease afterload (ACEI, Nitrates), Heart rate control (betablockers, anti-arrhythmics, pacemaker), Inotropy (dobutamine, dopamine, milrinone, IABP, VAD’s, revascularization)
initial treatment for hypovolemic shock fluid resuscitation
initial treatment for neurogenic shock vasoactive agents may be needed, use fluid cautiously (watch for non-cardiac pulmonary edema)
initial treatment for septic shock treat underlying cause, try to identify organism, start broad spectrum empiric therapy, then narrow down when you find out the specific organism
indication for administration of platelets as prevention before surgery plts <15,000
most common reason for ABO mismatch clerical error
minor antigens Kell, Kidd, Duffy
every unit of blood you give __ the patient immunocompromises
hypocalcemia can lead to decreased cardiac contractility, increased bleeding
hyperkalemia in a transfusion patient can be due to hemolysis
be cautious in transfusing patients who are __ immunocompromised (HIV, on steroids, organ transplant)
signs and symptoms of anemia fatigue, tachycardia, hypotension, mental sluggishness/disorientation, and shortness of breath
__ reverses warfarin FFP or Vitamin K
__ may need platelet transfusions no matter what the platelet count bleeding patients whose platelets have been impaired by aspirin or NSAIDs
bleeding after cardiopulmonary bypass may be due to inadequate neutralization of heparin. Giving __ in this setting may worsen the bleeding because __ provides antithrombin III FFP
microvascular bleeding often indicates a platelet defect
__ impairs platelet function and can prolong bleeding hypothermia
blood should never __ be infused with medications or solutions other than saline
__ may result in significant blood loss without obvious bleeding extensive tissue injury
the first BP change seen in hypovolemia. when present it means class II hemorrhagic shock increase in diastolic pressure
systolic hypotension is a sign of class III hemorrhagic shock
agitation is another sign of shock
profound hypotension and apathy are signs of class IV hypovolemic shock
a normal 70 kg man has about __L of blood volume 5
Humoral host defenses antibody, complement
cellular host defenses macrophages, t-cells
What do cytokines do in infection recruit macrophages
phases of wound healing-inflamation days __ 1-10
epithelialization, PMNs & macrophages inflamation phase of wound healing
proliferation phase of wound healing days __ 5-3 weeks
neovascularization, collagen production, granulation tissue, fibroblasts proliferation phase of wound healing
remodeling phase of wound healing weeks __ 3 weeks - 1 year
type III collagen replaced by type I, collagen cross-linking remodeling phase of wound healing
order of arrival of cells to wound PLTs, PMNs, macrophages, fibroblasts, lymphocytes
organism from dog bites streptococcus viridans
organism from cat bites pasteurella
with animal bites consider tetanus, rabies, augmentin, cephalexin
uninfected operative wound in which no inflammation is encounteredthe respiratory, alimentary, genital or infected urinary tract is not entered clean wound
Respiratory, alimentary, genital or urinary tracts are entered under controlled conditionsno unusual complications clean_contaminated wound
open, fresh, accidental wounds; operations with major breaks in sterile technique or gross spillage from the gastrointestinal tracteg. Gunshot wound to colon contaminated wound
old traumatic wounds with retained devitalized tissuethose that involve existing clinical infection or perforated visceraeg. Abscess dirty
perioperative antibiotics are given 1 hour prior to skin incision
choice of antibiotics depends on type of operation
surgical prophylaxis with first generation cephalosporin (Ancef) if no anearobes are expected
surgical prophylaxis with second generation cephalosporin (Cefotetan) if anearobic activity is likely
in a rapidly spreading infection think about necrotizing fasciitis
necrotizing fasciitis can be caused by clostridium perfringens, streptococcus (GABHS)
aka. Strep gangrene, Fournier's gangrene, flesh eating disease necrotizing fasciitis
severe infection that leads to necrosis of the subcutaneous tissue and adjacent fascia necrotizing fasciitis
mortality rate in patients with necrotizing fasciitis __% 40
treatment for __ includes broad-spectrum antibiotics, including Penicillin G,+ aggressive surgical debridement! necrotizing fasciitis
Must have high index of suspicion for __ whenSkin discoloration, necrosis, crepitus, drainage of thinWatery, grayish, foul-smelling fluid present. necrotizing fasciitis
antibiotics usually not helpful with Post-op Wound infection>48 hours 5-10 days post-op
local infection of the dermis and subcutaneous tissue characterized by spreading redness, swelling and pain cellulitis
blanching erythema cellulitis
#1 risk factor for development of pneumonia after surgery bed rest
most common post-operative infection UTI
four W's of fever wind, water, wound, wonder drugs
#1 cause of post op fever atelectasis
atalectasis occurs < post operative day __ 3
uti occurs post operative day __ 3
fever for wound infection occurs post operative day __ 5
Abscess/pus collection in thorax Empyema
diarrhea in the hosptital is usually from infection due to overgrowth of clostridium difficile
Created by: bwyche