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