empyema necessitans
Frank Blakemore
William Blakemore. Blakemore Tubes. Sengstaken Tube Manufacturer. Thomas Blakemore; Sengstaken Tubes. Jennifer Blakemore; Jessica Blakemore; Paul Blakemore; Richard Blakemore. Edward Blakemore; Blakemore Sengstaken; Susan Blakemore ...
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.
Read more
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.
Read more
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)
Read more
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.
Parental Nutrition
9 PARENTERAL NUTRITION
Margaret M. McQuiggan M.S., R.D., CNSD, Frederick A. Moore M.D.
1. What is parenteral nutrition?
Show answer
Parenteral nutrition is the provision of protein as amino acids (4 kcal/g), dextrose (3.4 kcal/g), and fat (lipid 20% solution delivers 2 kcal/mL), vitamins, minerals, trace elements, fluid, and sometimes insulin through an intravenous (IV) infusion. Acid-base status may be influenced by the amount of chloride and acetate used in providing sodium and potassium. The concentrations of calcium and phosphorus are limited to avoid precipitation of a calcium phosphate salt.
Nutritional Assessment & Enteral Nutrition. Controversies
CONTROVERSIES
23. How fat is fat?
Show answer
Lean body mass is three times more metabolically active than adipose tissue. Multiple definitions of clinical obesity exist: > 120% ideal body weight (IBW), > 130% IBW, body mass index (BMI) > 30, body fat > 24-28% of body weight in men and > 30-35% in women. Measured weight is a poor indicator of relative adiposity. Self-reported weights or weights reported by family members are often erroneous in the ICU setting. Fluid resuscitation and edema make visual assessment challenging and limit the usefulness of noninvasive technology such as bioelectrical impedance (BIA) for measuring body composition. Although measured energy expenditure in kcal/kg of actual weight may sometimes approach that of normal-weight patients, feeding at the measured body weight level may be associated with profound hyperglycemia, hypercapnea, and the inability to clear triglycerides.
Nutritional Assessment & Enteral Nutrition. Enteral Nutrition
ENTERAL NUTRITION
10. When should enteral nutrition be considered?
Show answer
Always, but especially when a patient is unlikely to meet > 70% of nutritional needs by mouth. Patients who have sustained major head injury (Glasgow Coma Scale score < 8), major torso trauma, major trauma to the pelvis and long bones, or major chest trauma benefit from enteral nutrition. Approximately 85% of postoperative patients (even those undergoing gastrointestinal [GI] surgery) tolerate early enteral feeding (within 24 hours).
Read more
Nutritional Assessment & Enteral Nutrition. Nutritional Assessment
8 NUTRITIONAL ASSESSMENT AND ENTERAL NUTRITION
Margaret M. McQuiggan M.S., R.D., CNSD, Frederick A. Moore M.D.
NUTRITIONAL ASSESSMENT
1. What does a nutritional assessment include? Show answer
Fluids, Electrolytes, Gatorade & Seat
7 FLUIDS, ELECTROLYTES, GATORADE, AND SWEAT
Alden H. Harken M.D.
1. What is hypertonic saline?
Show answer
Normal saline is 0.9% sodium chloride. Hypertonic saline is 7.5% sodium chloride (eight times as concentrated as normal saline).
Read more
Why Get Arterial Blood Gases?
6 WHY GET ARTERIAL BLOOD GASES?
Alden H. Harken M.D.
1. Is breathing really overrated?
Show answer
It may be. A Japanese yoga master survived just fine breathing once per minute for an hour (see reference 1)!
2. Mr. O’Flaherty has just undergone an inguinal herniorrhaphy under local anesthesia. The recovery room nurse asks permission to sedate him. She says that he is confused and unruly and keeps trying to get out of bed. Is it safe to sedate Mr. O’Flaherty?
Show answer
No. A confused, agitated patient in the recovery room or surgical intensive care unit (SICU) must be recognized as acutely hypoxemic until proved otherwise.
3. Mr. O’Flaherty is moved to the SICU, and at 2:00 a.m. the SICU nurse calls to report that he has a Po2 of 148 mmHg on facemask oxygen. Is it okay to roll over and go back to sleep?
What Is Pulmonary Insufficiency?
5 WHAT IS PULMONARY INSUFFICIENCY?
Alden H. Harken M.D.
1. What is pulmonary insufficiency?
how answer
The alveolar-capillary surface of the lung is the size of a singles tennis court. The purpose of the lung is to match alveolar ventilation (Va) to blood flow (Q). Mismatching leads to pulmonary insufficiency.
2. How is Va/Q mismatching characterized?
Show answer
Shunt: decreased ventilation relative to regional blood flow; pulmonary arterial (unoxygenated) blood “shunts” by hypoventilated alveoli
Dead space: decreased pulmonary regional blood flow relative to ventilation
Read more
How to Think About Shock?
4 HOW TO THINK ABOUT SHOCK
Alden H. Harken M.D.
1. Define shock. Show answer
Shock is:
* Not just low blood pressure
* Not just decreased peripheral perfusion
* Not just limited systemic oxygen delivery
Read more
Evaluation & Treatment Of Cardiac Dysrhythmias
3 EVALUATION AND TREATMENT OF CARDIAC DYSRHYTHMIAS
Alden H. Harken M.D.
1. Are cardiac dysrhythmias and cardiac arrhythmias the same?
Show answer
Yes. Some purists will tell you that an arrhythmia can be only the absence of a cardiac rhythm. But these are the same purists who use the word iatrogenic to mean “caused by a physician,” when, of course, the only thing that can truly be “iatrogenic” is a physician’s parents.
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
