Surgical Infectious Disease. Extra Credit Questions
EXTRA-CREDIT QUESTIONS
25. Should all patients undergoing elective laparotomy receive prophylactic antibiotic coverage?
Show answer
No. Doing so would contribute to driving up the cost of antibiotics and their complication rate and devaluing formerly good drugs by rendering them useless against common flora against which they were once highly potent. Operating room nurses have always classified the kind of operation by its status with respect to microbial exposure: clean, contaminated, or septic. These categories are approximation of the microbial risk exposure, and if additionally are superimposed categories of patient resistance (higher risk associated with aging, obesity or other malnutrition, concomitant drugs, or viral or mycobacterial or neoplastic disease immune compromise), these same strata are called class I, II, and III.
Surgical Infectious Disease. Management Of Surgical Infections
MANAGEMENT OF SURGICAL INFECTIONS
21. What is the drug of choice for the treatment of an abscess?
Show answer
A knife. Surgically drain the abscess. Abscesses have no circulation of blood within them to deliver an antibiotic. The antibiotic, even if injected directly into the abscess, would be worthless because the abscess contains a soup of dead microorganisms and white blood cells (WBCs). Even if the organisms were barely alive, they would not be reproducing and incorporating the antibiotic. The drug most likely would not work at all at the pH and pKa conditions of the abscess environment.
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Surgical Infectious Disease. Prophylaxis
PROPHYLAXIS
17. Should systemic antibiotic prophylaxis be used in elective colon resection?
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Yes, beyond any statistical shadow of a doubt. At least two dozen clinical trials have been carried out using placebo controls against a variety of antibiotics, principally those active against at least the anaerobic-predominant flora, and nearly all have shown a reduction in infectious complications in the antibiotic group. Never again should this point need repeating, and no patient should be placed at risk when systemic antibiotic prophylaxis has been established as the standard of care. No new clinical trials against placebo in this group of patients with known risk can be performed ethically given the confirmed risk reduction.
Other risk groups (e.g., cesarean section after membrane rupture) besides patients undergoing colon resection have been standardized by trials in large patient populations and have shown similar risk reduction. The benefit of prophylaxis has been demonstrated. In other groups of patients that cannot be standardized because of unusual contamination factors or unique factors of host resistance impairment, guidelines for rational prophylaxis should follow similar principles.
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Surgical Infectious Disease. Antibiotics
ANTIBIOTICS
11. Are antibiotics the classic wonder drugs?
Show answer
Only because you wonder if they are going to work, if they are going to cause more harm than good, and if the next generation will be unaffordable or toxic.
Skepticism is healthy with regard to any procedure or agent in heath care but especially with regard to antibiotics, which are embraced almost universally as agents that both prevent and cure infections. The primacy of the host defense in this vital process and the potential interference by the very drugs given credit for infection control are overlooked. We must look critically at the limited role that antibiotics should play in health care and restrain their overuse, which generates even more harm than unnecessary expense.
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Surgical Infectious Disease
15 SURGICAL INFECTIOUS DISEASE
Glenn W. Geelhoed M.D., M.P.H., DTMH
1. Have modern antibiotic developments controlled many, if not most, of the problems of surgical infection?
Show answer
No. In seriously ill surgical patients in intensive care unit (ICU) settings, the problems of sepsis have increased and remain among the principal causes of death in ICU patients, especially those with multiple organ failure and impairments of host defense. Antibiotic treatment may change the biographical sketch of the flora associated with patients’ deaths but cannot overcome the multiple causes of failing host resistance to infection that accompany barrier breeches to microbial invasion and the inflammatory and immunologic responses to the “usual suspects.”
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Properties In Evaluation Of The Acute Abdomen. Surgical Treatment
SURGICAL TREATMENT
22. If the patient is sick (and not getting better), what should be done?
Show answer
After fluid resuscitation, the patient’s abdomen should be explored. An exploratory laparotomy has been touted as the logical conclusion of a complete physical examination.
Properties In Evaluation Of The Acute Abdomen. Lab Stadies
LABORATORY STUDIES
15. How is a complete blood count helpful?
Show answer
1. Hematocrit. If the hematocrit is high (> 45%), the patient is most likely dry or may have chronic obstructive pulmonary disease. If it is low (< 30%), the patient probably has a more chronic disease (associated with blood loss-always do a rectal and test the stool for blood).
2. White blood cell count. It takes hours for inflammation to release cytokines and elevate the white blood cell count. A normal white blood cell count is entirely consistent with significant abdominal trouble. Read more
Properties In Evaluation Of The Acute Abdomen. Physical Exam
PHYSICAL EXAMINATION
7. Are vital signs important?
Show answer
Yes. They are vital. If heart rate and blood pressure are on the wrong side of 100 (heart rate > 100 beats/min, systolic blood pressure < 100 mmHg), watch out! Tachypnea (respiratory rate >16) reflects either pain or systemic acidosis. Fever may develop late, particularly in the immunosuppressed patient who may be afebrile in the face of florid peritonitis.
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Properties In Evaluation Of The Acute Abdomen
14 PRIORITIES IN EVALUATION OF THE ACUTE ABDOMEN
Alden H. Harken M.D.
1. What is the surgeon’s responsibility when confronted by a patient with an acute abdomen?
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1. To identify how sick the patient is
2. To determine whether the patient (a) needs to go directly to the operating room, (b) should be admitted for resuscitation or observation, or (c) can be sent safely home
Surgical Wound Infection
13 SURGICAL WOUND INFECTION
Steven L. Peterson D.V.M., M.D.
1. Why should we worry about surgical wound infection?
Show answer
Approximately 30 million patients undergo surgery each year in the United States, and 20% of these patients acquire at least one nosocomial infection in the postoperative period. Infections at surgical sites are the third most common form of these infections and complicate 1-12% of all operations. The risk of death is four times higher in patients who develop wound infections, and each infection costs $12,000-30,000 to treat.
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Central Venous & Pulmonary Artery Pressure Monitoring
12 CENTRAL VENOUS AND PULMONARY ARTERY PRESSURE MONITORING
Dipin Gupta M.D., Glenn J.R. Whitman M.D., Alden H. Harken M.D.
1. What does a catheter in the central venous circulation measure?
Show answer
All intrathoracic veins have nearly the same pressure. A catheter in the central venous circulation (anywhere) measures this central venous pressure (CVP) (or right atrial pressure). CVP, plus a little right atrial “kick,” pushes blood into the right ventricle. This right ventricular “filling pressure” is also termed preload.
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Oxygen Monitoring & Assessment. Extra Credit Questions
EXTRA-CREDIT QUESTIONS
22. Four hours after your patient undergoes an exploratory laparotomy following a motor vehicle accident, the nurse reports that the patient’s vital signs, urine output, and oxygen transport numbers are normal. Can the patient still be in trouble?
Oxygen Monitoring & Assessment
11 OXYGEN MONITORING AND ASSESSMENT
James B. Haenel R.R.T., Jeffrey L. Johnson M.D.
1. How does a pulse oximeter work?
Show answer
Light-absorption characteristics differ for the four most common circulating species of hemoglobin in adults:
1. Reduced hemoglobin (RHb)
2. Oxygenated hemoglobin (O2Hb)
3. Methemoglobin (Met Hb)
4. Carboxyhemoglobin (CO Hb)
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What Does Postoperative Fever Mean?
10 WHAT DOES POSTOPERATIVE FEVER MEAN?
Alden H. Harken M.D.
1. What is a fever?
Show answer Normal core temperature varies between 36°C and 38°C. Because we hibernate a little at night, we are cool (36°C) just before rising in the morning; after revving our engines all day, we are hot at night (38°C). A fever is a pathologic state reflecting a systemic inflammatory process. The core temperature is > 38°C but rarely > 40°C.
Parental Nutrition. Cotroversies
CONTROVERSIES
20. Does preoperative TPN enhance surgical outcome?
Show answer
It is well documented that malnourished patients are at an increased risk for septic complications, problems with wound healing, longer hospital stays, and increased mortality. However, nutritional status may be a reflection of the severity of disease. Results of studies evaluating preoperative TPN and outcome are variable. Preoperative TPN may decrease the rate of postoperative complications, but not mortality, in moderately malnourished patients with GI cancers. When malnourished GI cancer patients were fed high-kilocalorie TPN only after surgery, complication rates increased. Perioperative enteral nutrition may lower postoperative complications in patients with a variety of cancers. Provision of immune-enhancing diets, when adequately tolerated, may decrease complications and reduce length of hospital stays after surgical resection of upper GI cancer. In elderly, underweight women with hip fractures, supplemental enteral feedings increase functional status, reduce complications, and decrease length of stay. After major abdominal surgery, early enteral nutrition reduces complications, especially wound infection. Further research is needed in homogenous patient populations using current level of feeding practice and glycemic control in order to determine the impact on outcome of perioperative nutritional support.
Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
