114 Section I / Overview and Background Surgical Information

What is the possible conse-	Osmotic diuresis
quence of hyperglycemia in
the patient with hypovolemia?

Why not combine bolus fluids with a significant amount of potassium?

Why should isotonic fluids be given for resuscitation (i.e., to restore intravascular volume)?

Hyperkalemia may result (the potassium in LR is very low: 4 mEq/L)

If hypotonic fluid is given, the tonicity of the intravascular space will be decreased and H2O will freely diffuse into the interstitial and intracellular spaces; thus, use isotonic fluids to expand the intravascular space

What portion of 1 L NS will stay in the intravascular space after a laparotomy?

What is the most common trauma resuscitation fluid?

What is the most common postoperative IV fluid after a laparotomy?

After a laparotomy, when should a patient’s fluid be “mobilized”?

What IVF is used to replace duodenal or pancreatic fluid loss?

In 5 hours, only 200 cc (or 20%) will remain in the intravascular space!

LR

LR or D5LR for 24 to 36 hours, followed by maintenance fluid

Classically, POD #3; the patient begins to “mobilize” the third-space fluid back into the intravascular space

LR (bicarbonate loss)

ELECTROLYTE IMBALANCES

What is a common cause of	Lab error!
electrolyte abnormalities?
What is a major extracellular	Na
cation?
What is a major intracellular	K
cation?

	Chapter 18 / Fluids and Electrolytes 115
HYPERKALEMIA
What is the normal range	3.5–5.0 mEq/L
for potassium level?
What are the surgical causes	Iatrogenic overdose, blood transfusion,
of hyperkalemia?	renal failure, diuretics, acidosis, tissue
	destruction (injury/hemolysis)
What are the signs/	Decreased deep tendon reflex (DTR) or
symptoms?	areflexia, weakness, paraesthesia, paralysis,
	respiratory failure
What are the ECG findings?	Peaked T waves, depressed ST
	segment, prolonged PR, wide QRS,
	bradycardia, ventricular fibrillation
What are the critical values?	K 6.5
What is the urgent	IV calcium (cardioprotective), ECG
treatment?	monitoring
	Sodium bicarbonate IV (alkalosis drives
	K intracellularly)
	Glucose and insulin
	Albuterol
	Sodium polystyrene sulfonate
	(Kayexalate) and furosemide (Lasix)
	Dialysis

What is the nonacute treatment?

What is the acronym for the treatment of acute symptomatic hyperkalemia?

What is “pseudohyperkalemia”?

Furosemide (Lasix), sodium polystyrene sulfonate (Kayexalate)

“CB DIAL K”:

Calcium

Bicarbonate

Dialysis

Insulin/dextrose

Albuterol

Lasix

Kayexalate

Spurious hyperkalemia as a result of falsely elevated K in sample from sample hemolysis

116 Section I / Overview and Background Surgical Information

What acid-base change	Alkalosis (thus, give bicarbonate for
lowers the serum potassium?	hyperkalemia)
What nebulizer treatment	Albuterol
can help lower K level?
HYPOKALEMIA
What are the surgical	Diuretics, certain antibiotics, steroids,
causes?	alkalosis, diarrhea, intestinal fistulae, NG
	aspiration, vomiting, insulin, insufficient
	supplementation, amphotericin
What are the signs/	Weakness, tetany, nausea, vomiting,
symptoms?	ileus, paraesthesia
What are the ECG findings?	Flattening of T waves, U waves,
	ST segment depression, PAC, PVC, atrial
	fibrillation
What is a U wave?

U

What is the rapid treatment?	KCl IV
What is the maximum	10 mEq/hour
amount that can be given
through a peripheral IV?
What is the maximum	20 mEq/hour
amount that can be given
through a central line?
What is the chronic	KCl PO
treatment?
What is the most common	Hypokalemia
electrolyte-mediated ileus in
the surgical patient?

	Chapter 18 / Fluids and Electrolytes 117
What electrolyte condition	Hypokalemia
exacerbates digitalis toxicity?
What electrolyte deficiency	Low magnesium
can actually cause
hypokalemia?
What electrolyte must you	Magnesium
replace first before
replacing K ?
Why does hypomagnesemia	Hypomagnesemia inhibits K reabsorption
make replacement of K	from the renal tubules
with hypokalemia nearly
impossible?
HYPERNATREMIA
What is the normal range	135–145 mEq/L
for sodium level?
What are the surgical	Inadequate hydration, diabetes insipidus,
causes?	diuresis, vomiting, diarrhea, diaphoresis,
	tachypnea, iatrogenic (e.g., TPN)
What are the signs/	Seizures, confusion, stupor, pulmonary or
symptoms?	peripheral edema, tremors, respiratory
	paralysis
What is the usual treatment	D5W, 1/4 NS, or 1/2 NS
supplementation slowly over
days?
How fast should you lower	Guideline is 12 mEq/L per day
the sodium level in hyperna-
tremia?
What is the major complica-	Seizures (not central pontine
tion of lowering the sodium	myelinolysis)
level too fast?
HYPONATREMIA
What are the surgical causes
of the following types:
Hypovolemic	Diuretic excess, hypoaldosteronism,
	vomiting, NG suction, burns, pancreatitis,
	diaphoresis

118 Section I / Overview and Background Surgical Information

Euvolemic	SIADH, CNS abnormalities, drugs
Hypervolemic	Renal failure, CHF, liver failure
	(cirrhosis), iatrogenic fluid overload
	(dilutional)

What are the signs/ symptoms?

What is the treatment of the following types:

Hypovolemic

Euvolemic

Hypervolemic

How fast should you increase the sodium level in hyponatremia?

Seizures, coma, nausea, vomiting, ileus, lethargy, confusion, weakness

NS IV, correct underlying cause

SIADH: furosemide and NS acutely, fluid restriction

Dilutional: fluid restriction and diuretics

Guideline is 12 mEq/L per day

What may occur if you correct	Central pontine myelinolysis!
hyponatremia too quickly?
What are the signs of central	1.	Confusion
pontine myelinolysis?	2.	Spastic quadriplegia
	3.	Horizontal gaze paralysis
What is the most common	Fluid overload
cause of mild postoperative
hyponatremia?
How can the sodium level in	SIADH Sodium Is Always Down
SIADH be remembered?	Here Hyponatremia
“PSEUDOHYPONATREMIA”
What is it?	Spurious lab value of hyponatremia as a
	result of hyperglycemia, hyperlipidemia,
	or hyperproteinemia

	Chapter 18 / Fluids and Electrolytes 119
HYPERCALCEMIA
What are the causes?	“CHIMPANZEES”:
	Calcium supplementation IV
	Hyperparathyroidism (1 /3 )
	hyperthyroidism
	Immobility/Iatrogenic (thiazide
	diuretics)
	Mets/Milk alkali syndrome
	Paget’s disease (bone)
	Addison’s disease/Acromegaly
	Neoplasm (colon, lung, breast,
	prostate, multiple myeloma)
	Zollinger-Ellison syndrome (as part of
	MEN I)
	Excessive vitamin D
	Excessive vitamin A
	Sarcoid
What are the signs/	Hypercalcemia—“Stones, bones, abdomi-
symptoms?	nal groans, and psychiatric overtones”
	Polydipsia, polyuria, constipation
What are the ECG findings?	Short QT interval, prolonged PR interval
What is the acute treatment	Volume expansion with NS, diuresis with
of hypercalcemic crisis?	furosemide (not thiazides)
What are other options for	Steroids, calcitonin, bisphosphonates
lowering Ca level?	(pamidronate, etc.), mithramycin, dialysis
	(last resort)
HYPOCALCEMIA

How can the calcium level be determined with hypoalbuminemia?

What are the surgical causes?

(4-measured albumin level) 0.8, then add this value to the measured calcium level

Short bowel syndrome, intestinal bypass, vitamin D deficiency, sepsis, acute pancreatitis, osteoblastic metastasis, aminoglycosides, diuretics, renal failure, hypomagnesemia, rhabdomyolysis

What is Chvostek’s sign?	Facial muscle spasm with tapping of
	facial nerve (Think: CHvostek CHeek)

120 Section I / Overview and Background Surgical Information

What is Trousseau’s sign?	Carpal spasm after occluding blood flow
	in forearm with blood pressure cuff
What are the signs/	Chvostek’s and Trousseau’s signs, perioral
symptoms?	paraesthesia (early), increased deep tendon
	reflexes (late), confusion, abdominal
	cramps, laryngospasm, stridor, seizures,
	tetany, psychiatric abnormalities (e.g.,
	paranoia, depression, hallucinations)
What are the ECG findings?	Prolonged QT and ST interval (peaked T
	waves are also possible, as in hyperkalemia)
What is the acute	Calcium gluconate IV
treatment?
What is the chronic	Calcium PO, vitamin D
treatment?
What is the possible compli-	Tissue necrosis; never administer
cation of infused calcium if	peripherally unless absolutely necessary
the IV infiltrates?	(calcium gluconate is less toxic than
	calcium chloride during an infiltration)
What is the best way to check	Check ionized calcium
the calcium level in the ICU?
HYPERMAGNESEMIA
What is the normal range	1.5–2.5 mEq/L
for magnesium level?
What is the surgical cause?	TPN, renal failure, IV over supplementation
What are the signs/	Respiratory failure, CNS depression,
symptoms?	decreased deep tendon reflexes
What is the treatment?	Calcium gluconate IV, insulin plus
	glucose, dialysis (similar to treatment of
	hyperkalemia), furosemide (Lasix)
HYPOMAGNESEMIA
What are the surgical	TPN, hypocalcemia, gastric suctioning,
causes?	aminoglycosides, renal failure, diarrhea,
	vomiting

	Chapter 18 / Fluids and Electrolytes 121
What are the signs/	Increased deep tendon reflexes, tetany,
symptoms?	asterixis, tremor, Chvostek’s sign,
	ventricular ectopy, vertigo, tachycardia,
	dysrhythmias
What is the acute treatment?	MgSO4 IV
What is the chronic	Magnesium oxide PO (side effect:
treatment?	diarrhea)
Hypomagnesemia may	Hypokalemia (always fix hypomagnesemia
make it impossible to	with hypokalemia)
correct what other
electrolyte abnormality?
HYPERGLYCEMIA
What are the surgical	Diabetes (poor control), infection, stress,
causes?	TPN, drugs, lab error, drawing over IV
	site, somatostatinoma, glucagonoma
What are the signs/	Polyuria, hypovolemia, confusion/coma,
symptoms?	polydipsia, ileus, DKA (Kussmaul
	breathing), abdominal pain, hyporeflexia
What is the treatment?	Insulin
What is the Weiss protocol?	Sliding scale insulin
What is the goal glucose	80–110 mg/dL
level in the ICU?
HYPOGLYCEMIA
What are the surgical	Excess insulin, decreased caloric intake,
causes?	insulinoma, drugs, liver failure, adrenal
	insufficiency, gastrojejunostomy
What are the signs/	Sympathetic response (diaphoresis,
symptoms?	tachycardia, palpitations), confusion,
	coma, headache, diplopia, neurologic
	deficits, seizures
What is the treatment?	Glucose (IV or PO)

122 Section I / Overview and Background Surgical Information

HYPOPHOSPHATEMIA

What is the normal range	2.5–4.5 mg/dL
for phosphorus level?
What are the signs/	Weakness, cardiomyopathy, neurologic
symptoms?	dysfunction (e.g., ataxia), rhabdomyolysis,
	hemolysis, poor pressor response
What is a complication of	Respiratory failure
severe hypophosphatemia?
What are the causes?	GI losses, inadequate supplementation,
	medications, sepsis, alcohol abuse, renal
	loss
What is the critical value?	1.0 mg/dL
What is the treatment?	Supplement with sodium phosphate or
	potassium phosphate IV (depending on
	potassium level)
HYPERPHOSPHATEMIA
What are the signs/	Calcification (ectopic), heart block
symptoms?
What are the causes?	Renal failure, sepsis, chemotherapy,
	hyperthyroidism
What is the treatment?	Aluminum hydroxide (binds phosphate)
MISCELLANEOUS
This ECG pattern is	Hyperkalemia: peaked T waves
consistent with which
electrolyte abnormality?

	Chapter 18 / Fluids and Electrolytes 123
If hyperkalemia is left	Ventricular tachycardia/fibrillation S
untreated, what can occur?	death

Which electrolyte is an	Calcium
inotrope?
What are the major cardiac	Potassium (dysrhythmias), magnesium
electrolytes?	(dysrhythmias), calcium (dysrhythmias/
	inotrope)
Which electrolyte must be	Potassium
monitored closely in patients
on digitalis?
What is the most common	Hypokalemia
cause of electrolyte-
mediated ileus?

What is a colloid fluid?

What is the rationale for using an albuminfurosemide “sandwich”?

An elderly patient goes into CHF (congestive heart failure) on POD #3 after a laparotomy. What is going on?

What fluid is used to replace NGT (gastric) aspirate?

What electrolyte is associated with succinycholine?

Protein-containing fluid (albumin)

Albumin will pull interstitial fluid into the intravascular space and the furosemide will then help excrete the fluid as urine

Mobilization of the “third-space” fluid into the intravascular space, resulting in fluid overload and resultant CHF (but also must rule out MI)

D5 1/2 NS with 20 KCl

Hyperkalemia

124 Section I / Overview and Background Surgical Information

C h a p t e r 19

Blood and Blood

Products

Define the following terms:
PT	Prothrombin Time: Tests extrinsic
	coagulation pathway
PTT	Partial Thromboplastin Time: Tests
	intrinsic coagulation pathway
INR	International Normalized Ratio (reports
	PT results)
Packed red blood cells	One unit equals 300 ml ( 50 ml); no
(PRBCs)	platelets or clotting factors; can be mixed
	with NS to infuse faster
Platelets	Replace platelets with units of platelets
	(6–10 units from single donor or random
	donors)

Fresh frozen plasma (FFP)

Cryoprecipitate (cryo)

Which electrolyte is most likely to fall with the infusion of stored blood? Why?

What changes occur in the storage of PRBCs?

What are general guidelines for blood transfusion?

What is the rough formula for converting Hgb to Hct?

One unit of PRBC increases Hct by how much?

Replaces clotting factors; (no RBCs/ WBCs/platelets)

Replaces fibrinogen, von Willebrand factor, and some clotting factors

Ionized calcium; the citrate preservative used for the storage of blood binds serum calcium

TCa , c K , T 2,3-DPG, c H (T pH),

TPMNs

Acute blood loss, Hgb 10, and history of CAD/COPD or healthy symptomatic patient with Hgb 7

Hgb 3 Hct

3% to 4%

Which blood type is the “universal” donor for PRBCs?

Which blood type is the “universal” donor for FFP?

What is a type and screen?

Chapter 19 / Blood and Blood Products 125

O negative

AB

Patient’s blood type is determined and the blood is screened for antibodies; a type and cross from that sample can then be ordered if needed later

What is a type and cross?

Define thrombocytopenia.

What are the common causes of thrombocytopenia in the surgical patient?

What can be given to help correct platelet dysfunction from uremia, aspirin, or bypass?

Patient’s blood is sent to the blood bank and cross-matched for specific donor units for possible blood transfusion

Low platelet count ( 100,000)

Sepsis, H2 blockers, heparin, massive transfusion, DIC, antibiotics, spurious lab value, Swann-Ganz catheter

DDAVP (desmopressin)

What common medication	Aspirin (inhibits cyclooxygenase)
causes platelets to
irreversibly malfunction?

What is Plavix®?

Clopidogrel—irreversibly inhibits platelet P2Y12 ADP receptor (blocks fibrin crosslinking of platelets)

What platelet count is	20,000
associated with spontaneous
bleeding?
What should the platelet	50,000
count be before surgery?
When should “prophylactic”	With platelets 10,000
platelet transfusions be	(old recommendation was 20,000)
given?

126 Section I / Overview and Background Surgical Information

What is microcytic anemia	Colon cancer
“until proven otherwise” in
a man or postmenopausal
woman?

Why not infuse PRBCs with lactated Ringer’s?

For how long can packed RBCs be stored?

What is the most common cause of transfusion hemolysis?

What is the risk of receiving a unit of blood infected with HIV?

Calcium in LR may result in coagulation within the IV line (use NS)

About 6 weeks (42 days)

ABO incompatibility as a result of clerical error

1 in 1,000,000

What are the symptoms of a transfusion reaction?

What is the treatment for transfusion hemolysis?

What component of the blood transfusion can cause a fever?

Fever, chills, nausea, hypotension, lumbar pain, chest pain, abnormal bleeding

Stop transfusion; provide fluids; perform diuresis (Lasix) to protect kidneys; alkalinize urine (bicarbonate); give pressors as needed

WBCs

What is the transfusion	21%
“trigger” Hct in young
healthy patients?
What is the widely	30%
considered “optimal” Hct in
a patient with a history of
heart disease or stroke?

When should aspirin administration be discontinued preoperatively?

At 1 week because platelets live 7 to

10 days (must use judgment if patient is at risk for stroke or MI; it may be better to continue and use excellent surgical hemostasis in these patients)

What can move the oxyhemoglobin dissociation curve to the right?

What is the normal life of RBCs?

What is the normal life of platelets?

What factor is deficient in hemophilia A?

How can the clotting factor for hemophilia A be remembered?

Chapter 19 / Blood and Blood Products 127

Acidosis, 2,3-DPG, fever, elevated PCO2 (to the right means greater ability to release the O2 to the tissues)

120 days

7 to 10 days

Factor VIII

Think: “Eight” sounds like “A”

What is the preoperative treatment of hemophilia A?

What coagulation study is elevated with hemophilia A?

How do you remember which coagulation study is affected by the hemophilias?

What factor is deficient in hemophilia B?

How do you remember which factors are deficient with hemophilia A and hemophilia B?

How are hemophilias A and B inherited?

What is von Willebrand’s disease?

How is von Willebrand’s disease inherited?

What is used to correct von Willebrand’s disease?

Factor VIII infusion to 100% normal preoperative levels

PTT

There are two major hemophilias and two t’s in PTT

Factor IX

Think alphabetically and chronologically: A before B—8 before 9

Hemophilia A factor VIII Hemophilia B factor IX

Sex-linked recessive

Deficiency of von Willebrand factor (vWF) and factor VIII:C

Autosomal dominant

DDAVP or cryoprecipitate

128 Section I / Overview and Background Surgical Information

What coagulation is abnormal
with the following disorders:
Hemophilia A	PTT (elevated)
Hemophilia B	PTT (elevated)
von Willebrand’s disease	Bleeding time
What is the effect on the	A hypercoagulable state
coagulation system if the
patient has a deficiency in
protein C, protein S, or
antithrombin III?

What is a “left shift” on a CBC?

What is the usual “therapeutic” PT?

What is the acronym basis for the word WARFARIN?

What is the most common inherited hypercoagulable state?

What is Xigris®?

Juvenile polymorphonuclear leukocytes (bands); legend has it that the old counters for all the blood cells had the lever for bands on the LEFT of the counter

With coumadin, usually shoot for an INR of 2.0–3.0

Wisconsin Alumni Research

Foundation-ARIN

Factor V Leiden

(Think: LEiden LEader)

Activated protein C, which is used in severe sepsis

C h a p t e r 20

Surgical

Hemostasis

What motto is associated	“All bleeding stops”
with surgical hemostasis?
What is the most immediate	Pressure (finger)
method to obtain hemostasis?

What is the “Bovie”?

What is the CUT mode on the Bovie?

What is the COAG mode on the Bovie?

Where should a Bovie be applied to a clamp or pickup to coagulate a vessel?

Should you ever “blindly” place a clamp in a wound to stop bleeding?

Define the following terms: Figure-of-eight suture

Chapter 20 / Surgical Hemostasis 129

Electrocautery (designed by Bovie with Cushing for neurosurgery in the 1920s)

Continuous electrical current

(20,000 Hz); cuts well with a decreased ability to coagulate

Intermittent electrical current (20,000 Hz); results in excellent vessel

coagulation with decreased ability to cut

Anywhere on the clamp/pick-up

No, you may injure surrounding tissues such as nerves

Suture ligature placed twice in the tissue prior to being tied