{"id":60,"date":"2013-10-19T16:46:10","date_gmt":"2013-10-19T16:46:10","guid":{"rendered":"http:\/\/www.modestosurgery.com\/surgeryblog\/?p=60"},"modified":"2013-10-19T20:08:56","modified_gmt":"2013-10-19T20:08:56","slug":"perioperative-general-surgery-highlights","status":"publish","type":"post","link":"http:\/\/www.modestosurgery.com\/surgeryblog\/perioperative-general-surgery-highlights\/","title":{"rendered":"Perioperative General Surgery Highlights"},"content":{"rendered":"<h1>Perioperative ICU Topics<\/h1>\n<h3>Transfusion related acute lung injury must be distinguished from cardiogenic and non cardiogenic pulmonary edema and pulmonary contusion.<\/h3>\n<ul>\n<li>TRALI &#8211; acute onset of non-cardiogenic pulmonary edema after transfusion of blood products.<\/li>\n<li>Leading cause of transfusion related fatalities in the US<\/li>\n<li>Occurs within first 6 hours following transfusion<\/li>\n<li>Due to leukocyte antibodies in transfused plasma<\/li>\n<li>Incidence 1:5000<\/li>\n<\/ul>\n<h3>Transfusion related circulatory overload &#8211; diurese early<\/h3>\n<ul>\n<li>Furosemide is a loop diuretic<\/li>\n<\/ul>\n<h3>Intubated patients should be transported in Semi fowler recumbent position, 30 degree head of bead to help prevent ventilator associated pneumonia<\/h3>\n<ul>\n<li>Semi fowler &#8211; knees bent, head of bed not as high as fowler position<\/li>\n<\/ul>\n<h3>Hydration of the patient is an important measure to prevent contrast induced nephropathy<\/h3>\n<h3>With ICU patients with Renal insufficiency, aggressive dialysis does not lead to significant improvements in renal recovery and 30 day mortality rates<\/h3>\n<h3>Analgesics and sedatives may blunt ACTH stimulation test for adrenal insufficiency<\/h3>\n<ul>\n<li>ACTH stim test for asessing the functioning of adrenal glands.<\/li>\n<li>ACTH is made by the anterior pituitary gland which stimulates the adrenal glands to release cortisol, DHEAS, and aldosterone.<\/li>\n<li>Adrenal insufficiency is a potentially life threatening problem<\/li>\n<li>ACTH stimulation test is primarily used to deterine the presence of Addison&#8217;s diaseas and pituitary impairment<\/li>\n<li>Addison&#8217;s disease: Adrenal glands do not produce sufficient steroid hormones. \u00a0Also known as primary adrenal insufficiency.<\/li>\n<li>The test is extremely sensitive to primary adrenal insufficiency but less so to secondary adrenal insufficiency. \u00a0Secondary adrenal insufficiency is caused by deficiency of ACTH.<\/li>\n<\/ul>\n<h3>Precedex: \u00a0use less than 24-48 hours.<\/h3>\n<ul>\n<li><strong>Dexmedetomidine<\/strong> &#8211; a sedative used in ICU which does not cause respiratory depression<\/li>\n<\/ul>\n<h3>Outcomes protonics vs. H2 blockers not that different in stress gastritis prophylaxis<\/h3>\n<h3>Advanced directives in ICU &#8211; pastoral care staff to bring up on initial contact<\/h3>\n<h3>Family like ICU rounds &#8211; transparency<\/h3>\n<h3>Refeeding syndrome &#8211; <strong>low phosphate levels<\/strong> is a hallmark. \u00a0Happens in 10 days or more of not feeding. \u00a0When feeding resumes: \u00a0hyperglycemia &#8211; creates even lower levels by moving phosphate and potassium into cells.<\/h3>\n<h3>Abdominal Compartment Syndrome &#8211; open abdomen immediately with elevated intra-abdominal pressure and renal failure, hypotension, or high pulmonary ventilation pressures.<\/h3>\n<h3>Use of diuretics in ACS (Abdominal Compartment Syndrome) is controversial. \u00a0Some surgeons diurese early to decrease bowel edema and to get the abdomen closed.<\/h3>\n<h3>ICU central lines to be assessed daily and document need for it daily<\/h3>\n<h3>Trauma patients, erythropoetin may predispose to DVT<\/h3>\n<ul>\n<li>Liver production of erythropoetin predominates in the fetal and perinatal period<\/li>\n<li>Renal production is dominant during adulthood<\/li>\n<\/ul>\n<h3>Induced coma clouds the issue of brain death in regards to organ donation.<\/h3>\n<h3>Elderly ICU with hyperactive delirium have better outcomes than those with hypoactive delirium.<\/h3>\n<h3>Elevated CK levels hallmark in <span style=\"color: #993366;\">propofol infusion syndrome<\/span>.<\/h3>\n<ul>\n<li>Potentially and often fatal<\/li>\n<li>cardiac failure, rhabdomyolysis, renal failure, hyperkalemia, hypertriglycerdemia, hepatomegaly.<\/li>\n<li>Maybe caused by impaired mitochondrial function<\/li>\n<li>CK = creatine kinase = present in all muscles<\/li>\n<li>Elevated CK levels indicated muscle damage\/strain &#8211; could be from heart attack or muscles being overworked (ie. weight lifting).<\/li>\n<li>Propofol infusion syndrome is at higher risk when patients are already on catecholamines or corticosteroids.<\/li>\n<\/ul>\n<h3>Inhaled PGE2, selectively vasodiates the pulmonary vasculature, it improves VQ mismatch in severe hypoxemia<\/h3>\n<ul>\n<li>An area with no ventilation (V\/Q = zero) = shunt<\/li>\n<li>The area with no perfusion = dead space<\/li>\n<li>PGE2 = prostaglandin E2<\/li>\n<li>PGE2 softens cervix and causes uterine contraction, causes fever, direct vasodilator, relaxes smooth muscles.<\/li>\n<\/ul>\n<h3>In sepsis, norepinephrine raises heart rate less than dopamine.<\/h3>\n<ul>\n<li>Vasoactive drug use in septic shock<\/li>\n<li>Used to increase blood pressure<\/li>\n<li>Dopamine is the immediate precursor of norepinephrine and epinephrine<\/li>\n<li>Less tachycardic reaction with NorEpinephrine compared to Dopamine.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Perioperative ICU Topics Transfusion related acute lung injury must be distinguished from cardiogenic and non cardiogenic pulmonary edema and pulmonary contusion. TRALI &#8211; acute onset of non-cardiogenic pulmonary edema after transfusion of blood products. Leading cause of transfusion related fatalities in the US Occurs within first 6 hours following transfusion Due to leukocyte antibodies in &hellip; <a href=\"http:\/\/www.modestosurgery.com\/surgeryblog\/perioperative-general-surgery-highlights\/\" class=\"more-link\">Continue reading <span class=\"screen-reader-text\">Perioperative General Surgery Highlights<\/span> <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[64,63,61,62],"tags":[67,66,70,68,71,65,69],"class_list":["post-60","post","type-post","status-publish","format-standard","hentry","category-critical-care","category-icu","category-pearls","category-perioperative","tag-creatine","tag-creatine-kinase","tag-dopamine","tag-muscles","tag-semi-fowler","tag-sepsis","tag-weight-lifting"],"_links":{"self":[{"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/posts\/60","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/comments?post=60"}],"version-history":[{"count":6,"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/posts\/60\/revisions"}],"predecessor-version":[{"id":66,"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/posts\/60\/revisions\/66"}],"wp:attachment":[{"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/media?parent=60"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/categories?post=60"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/www.modestosurgery.com\/surgeryblog\/wp-json\/wp\/v2\/tags?post=60"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}