武功密笈

小黃藏書

1. General Considerations:

1). Nutrition:

Ÿ Indications for Nutrition Support:

Ÿ Route of Administration:

? Enteral Nutrition should be considered primarily.

- Contraindications: intestinal obstruction, GI bleeding, diarrhea, etc.

‚ TPN

2). Fluid and Electrolytes: (簡略之approach的方式)

Ÿ Major extracellular electrolytes: Na⁺ and Cl^-; Major intracellular electrolyte: K⁺;

Major extracelluar buffer used in acid-base balance: bicarbonate-carbonic acid system

Ÿ Evaluation:

? History: (Is there any underlying diseases/conditions?)

Eg. Renal disease, chronic starvation, severe illness, severe cardiac disease,

severe diabetes, high fever, acute blood loss, GI loss, bowel obstruction, etc.

‚ Physical Examination:

• Ht: 每á /â 1%各代表extracellular fluid deficit/excess 0.5L
• Serum Chemistry:

V Serum Na⁺: 每á /â 3mmol/L各代表extracellular fluid deficit/excess 1L

V BUN/Cr: 正常為10/1, 若> 20/1,則代表extracellular fluid contraction

V Serum Osmolarity: normal range 290-300 mOsm

2Na⁺ + glucose (mg/dL) /18 + BUN (mg/dL) /2.8

á /â 各代表extracellular fluid deficit/excess

V Urine Na⁺:

< 15 mEq/L 代表extracellular fluid contraction

> 30 mEq/L 代表extracellular fluid excess或renal failure/insufficiency

V Urine Osmolarity:

> 400 mOsm 代表extracellular fluid contraction

ß 代表extracellular fluid excess或renal failure/insufficiency

　

	Cause of Abnormalities	Management
High Fever	Increased lung and skin loss of free water	Replacement of free water (eg. D5W)
Perspiration	Loss of water typically with 1/3 osmolarity of plasma	Replacement of D5W, or D5/0.25 normal saline if excessive
Acute Blood Loss		Replacement of ¬ Isotonic Fluid: 0.9N/S, L/R.,or ­ Plasma Expander: albumin, dextran, hetastarch solution (ie.6HES).,or ® Blood Transfusion
GI Fluid Loss	- Gastric: hypotonic - Stomach~Colon: isotonic - Severe diarrhea: isotonic	Replacement of D5/0.45 normal saline + KCl 20mEq
Bowel Obstruction Fistula, Ileostomy	Seqestration of fluid 1-3L/day in the GI tract	Replacement of Isotonic Saline or L/R
Hyponatremia S/S: nausea, vomiting, lethargy, seizure. When< 120-125 mEq/L	Extracellular fluid excess with Renal or cardiac failure	correct underlying disease water restriction with diuretics
	Extracellular fluid deficit with Decreased serum Na+ Eg. Vomiting, NG decompression, Diarrhea, etc.	Replacement with isotonic fluid And KCl
	SIADH secondary to head trauma, Lung or brain tumor, or stress.	water restriction correct underlying disease
Hypernatremia Life-threatening When> 160 mEq/L S/S: disorientation, Seizure, ICH, death	Extraculluar fluid deficit with excessive extrarenal water loss, diabetes insipidus, high fever, iatrogenic salt loading, etc.	correct underlying disease replacement with free water, eg. D5W, oral or intravenous.
Hypokalemia S/S: neuromuscular, Cardiovascular, Digitalis intoxication When< 3 mEq/L	- GI loss (vomiting, diarrhea, etc.) - Renal loss (renal tubular diseases) - prolonged K-free IVF	K replacement: oral form is preferable iv form: no more than 10mEq/h
Hyperkalemia S/S: mainly CV When> 7 mEq/L	- Renal impairment - Adrenal insufficiency - K-sparing diuretic - marked tissue breakdown	calcium gluconate 保護heart sodium bicarbonate 1amp + D50 with or without insulin kayexalate, or kallimate po or enema hemodialysis if mx. above fail
Respiratory Acidosis	Hypoventilation: 1). CNS depression 2). Airway and lung impairment	restoration ventilation control of excess dioxide production
Respiratory Alkalosis	Hyperventilation: 1). CNS excitation 2). Excess ventilator support	Correction or hyperventilation
Metabolic Acidosis	Excess loss of base: 1). Excess Cl versus Na 2). Increased bicarbonate loss Increased nonvolatile acids: 1). Lactic, ketoacidosis 2). Uremia 3). Dilutation acidosis	increase Na load waste give bicarbonate for pH< 7.2 restore buffers, protein, hemoglobin
Metabolic Alkalosis	Excess loss of Cl and K: 1). GI loss of Cl 2). Diuretics 3). Hypokalemia 4). Extracellular fluid contraction Increased bicarbonate: 1). Excess intake	increase Cl content K replacement Diamox to waste bicarbonate vigorous volume replacement occasional 0.1 N HCl as needed

3). Pain Management:

4). Antibiotic Prophylaxis:

² GYN Procedures with Increased Risks of Postoperative Infections:

- vaginal hysterectomy, abdominal hysterectomy, surgical treatment of pelvic abscess

or inflammation, selected cases of pregnancy termination,

and radical surgery for gynecologic cancers.

1. Postoperative Infections:

¬ Risk Factors for Infectious Morbidity:

- lack of perioperative antibiotic prophylaxis, contamination of the surgical field from infected

tissues or from apillage of large bowel contents, an immunocompromised hose, poor nutrition,

chronic and debilitating severe illness, poor surgical technique, and preexisting focal or

systemic infection.

¬ Sources of Postoperative Infections:

- lung, urinary tract, surgical site, pelvic side wall, vaginal cuff, abdominal wound,

and sites of indwelling intravenous catheters.

¬ Febrile Mobidity:

- Definition: BT ³ 38^oC on 2 occasions at least 4 hours apart in the postoperative period,

excluding the first 24 hours.

- Assessment:

À History: any risk factors? any potential signs of infections?

Á Physical Examination: focus on the potential sites of infections

¶ inspection of pharynx, a thorough pulmonary examination, palpation of the kidneys

and the costovertebral angles for tenderness, inspection and palpation of the

abdominal incision, examination of sites of intravenous catheters, examination of the

extremities for evidence of deep venous thrombosis or thrombophlebitis.

 PV:

¶ to identify a mass consistent with a pelvic hematoma/abscess, ant to look for signs of

pelvic cellulites.

à Laboratory Survey: CBC/DC, U/A, U/A, etc.

Ä Image Study:

- CxR: if suspecting pneumonia

- IVP: if CV angle tenderness (+) and U/A (-), to R/O ureteral damage

- Barium Enema or GI Series: to R/O bowel injury

- CT: if persistent fever without a clear localizing source

1). UTI:

- most common kind of postoperative infections

- Symptoms: frequency, urgency, dysuria; headache, malaise, nausea, and vomiting (for APN)

- Diagnosis: on the basis of urine culture

- Pathogens:

most common: E. coli,

others: Klebsiella, Proteus, and Enteribacter species.

Recurrent UTI: Klebsiella, Pseudomonas, etc.

- Treatment: hydration and antibiotics

The use of urinary tract catheters should be minimized.

2). Pulmonary Infections: ~ Hospital-Acquired Pneumonia

- Risk Factors:

extensive or prolonged atelectasis, preexistent chronic obstructive pulmonary disease,

severe or debilitating illness, central neurologic disease causing an inability

to clear oropharyngeal secretions effectively, and nasogastric suction

- Preventive Measures: early ambulation and aggressive management of atelectasis

- Pathogens: G(-) organisms 佔了40-50%

- Assessment: lung examination, sputum Gram stain and culture, CxR, etc.

- Treatment:

j postural drainage

k aggressive lung toilet

l antibiotics:

ought to cover G(+) and G(-) organisms,

and to cover Pseudomonas organisms in the use of assisted ventilation.

3). Phlebitis:

- intravenous catheter-related infection

- The intravenous site should be inspected daily and the catheter should be removed

if there is any associated pain, redness, or induration.

- Prevention: sterile technique, change of catheter at least every 3 days

- Diagnosis: presence of fever, pain, redness, induration, or a palpable venous cord.

- Treatment:

j prompt removal of any catheters from the infected vein

k warm, moist compression

l antibiotic with antistaphylococcal agents if sepsis occurring

4). Wound Infections:

ì To Decrease The Incidence of Wound Infections:

j short preoperative hospital stay

k hexachlorophene showers prior to surgery

l minimizing shaving of the wound site

m use of meticulous surgical technique

n decreasing operative times as much as possible

o bringing drains out through sites other than the wound

p dissemination of information to surgeons regarding their wound infection rates

ì Symptoms/Signs:

- usually noted after the fourth postoperative day

- fever, erythema, tenderness, induration, and purulent drainage

ì Management:

j opening the infected portion of the wound above the fascia,

with cleasing and debridement of the wound edges as necessary

k wound care: debridement, CD bid-tid and prn

ì Delayed Primary Wound Closure:

- may be used in contaminated surgical cases

j leaving the wound open above the fascia at the time of the initial surgical procedure

k vertical interrupted mattress sutures through the skin and subcutaneous layers

(3 cm apart, not tied)

l wound care until the wound is noted to be granulating well

m tiring the sutures and approximating the skin edges with staples

5). Vaginal Cuff Cellulitis and Pelvic Cellulitis:

À Vaginal Cuff Cellulitis:

- Symptoms/Signs: erythema, induration, tenderness, and occasionally

purulent discharge over vaginal cuff.

- Treatment: often self-limited and not requiring treatment

À Pelvic Cellulitis: usually the extension of vaginal cuff cellulitis

- Symptoms/Signs: fever, leukosytosis, and pain localized to the pelvis

in addition to those related to vaginal cuff cellulitis

- Treatment:

j broad-spectrum antibiotic therapy with coverage for G(-), G(+), and anaerobic organisms

k vaginal cuff opening and draining if excessive purulent discharge or mass (+)

dependent drainage or drain tube insertion

Remove the drain tube when draining ˜ , fever (-), and symptoms (-)

6). Intraabdominal and Pelvic Abscess:

A Causes: usually as a secondary complication of hematoma

A Pathogens:

- usually polymicrobial; mainly from the vaginal tract, but also derived from

the GI tract, particularly when the colon has been entered at the time of surgery

A Diagnosis:

- Symptoms/Signs: persistent fibrile episodes

- PE and PV: A mass may be palpable if located deep in the pelvis

- Lab. Data: leukocytosis

- Image Studies: CT, Echo (fluid collection), etc.

A Management:

À surgical evacuation and drainage

Á parental antibiotics:

a). initially: ampicillin + gentamicin + clindamycin, or others.

b). then based onf pus Gram stain and culture (for aerobes and anaerobes)

　

7). Necrotizing Fascitis:

] Pathogenesis:

Polymicrobial Infections of the Dermis and Subcutaneous Tissue

Release of Bacterial Enzymes

　

---

To Skin To Systemic Circulation

　

---

Septic Shock,

Liqeufactive Noninflammatory Acid-Base Disturbance,

Necrosis Intravascular Multiorgan Impairment, etc.

Coagulation or Thrombosis

　

Ischemia and Necrosis

of Subcutaneous Tissue and Skin

　

Anesthesia in the Involved Skin

Due to Distruction of Superficial Nerves

] Risk Factors:

DM, HTN, Immunocompromised Status, Peripheral Vascular Diseases, Obesity, Alcoholism,

And Intravenous Drug Abuse.

] Symptoms/Signs:

¬ Pain

­ Skin Manifestation:

pain, tenderness, erythema, warm

edema

cyanotic, blistered

gangrenous, sloughing spontaneously

anesthesia, subcutaneous gas

　

® Systemic Manifestation:

dehydration, septic shock, DIC, multiorgan failure, etc.

] Diagnosis: based on pathology (Diagnostic Criteria are listed in p568.)

] Treatment:

¬ early recognition and diagnosis:

frozen-section biopsy/biopsy; Gram stain and culture for aerobes and anaerobes

­ immediate initiation of resuscitative measures:

correction of fluid, e^-, acid-base, and hematologic abnomalities

® aggressive surgical debridement and redebridement as necessary

‾ broad-spectrum antibiotic therapy, then based on specimen Gram stain and culture

° supportive care and wound care

　

2. GI Complications:

1. Ileus:

v Associated Factors:

the opening of the peritoneal cavity, manipulation of bowels,

prolonged surgical procedures, infection, peritonitis, electrolyte disturbance.

v Symptoms/Signs:

nausea, vomiting, abdominal distension, decreased bowel sounds.

v Evaluation:

Abdominal Examination: bowel sound, pain/tenderness/rebound tenderness?

PV: any pelvic abscess/hematoma contributing to the ileus

Plain Abdomen (supine and upright):

Dilated loops of small and large bowels, air-fluid level in the upright position

v Management:

À nasogastric tube decompression

Á appropriate replacement of fluid and electrolyte, monitoring of serum chemistries

 follow-up of plain abdomen

à Remove nasogastric tube then try liquid diet if improved.

Ä Seek other causes of ileus if not improved during the first 2-3 days of medical treatment

eg. ureteral injury, peritonitis from pelvic infection, unrecognized GI tract injury

with peritoneal spillage, fluid and electrolyte inbalence (hypokalemiz, etc.)

2. Small Bowel Obstruction:

v Causes:

most common: adhesion to the operation site

others: entrapment of the small bowel into an incisional hernia and and unrecognized

defect in the small bowel of large bowel mesentary

v Clinical Manifestation:

initially similar to ileus

progressive distnesion and abdominal pain despite initial management

fever, leukocytosis, acidosis

v Management:

À conservative management as those for ileus

Á further evaluation after several days of conservative management

eg. barium enema, UGI series, etc.

 May consider TPN if resolution is prolonged and the patient’s nutritional status is

marginal.

à Perform laparotomy if medical treatment fails.

r Conservative medical management of postoperative small bowel obstruction

usually results in complete resolution.

3. Colonic Obstruction:

v Causes:

- extrinsic impingement: always associated with malignancy

- intrinsic colonic lesions

v Clinical Manifestation:

- Symptoms/Signs: abdominal distension

- Plain Abdomen: dilated colon and enlarged cecum

- Barium Enema, Colnoscopy,etc.

v Management: usually requiring surgical decompression (colectomy or colostomy)

r Conservative management of colonic obstruction is not appropriate,

because the complication of colonic perforation has an exceedingly high mortality rate.

4. Diarrhea:

v Causes:

1). Natural course postoperatively as GI tract returning to its normal function and motility

2). Pathologic process (prolonged and multiple episodes of diarrhea)

eg. impending bowel obstruction, colonic obstruction, pseudomembranous colitis

v Evaluation of Excessive Diarrhea:

1). Stool Samples: for ova and parasites, bacterial culture and Clostridium difficile toxin

2). Plain Abdomen

3). Proctoscopy and Colonoscopy

v Management:

1). In cases of obstruction ’ as those mentioned previously

2). In cases of infectious diarrhea antibiotics and replacement of fluid and electrolyte

3). In cases of Clostridium difficile-associated pseudomembranous colitis:

? DC antibiotics unless they are needed for another severe infections.

‚ intravenous antibiotic: metronidazole (Anergn), or vancomycin

ƒ If diarrhea abates, DC iv antibiotic, then give oral antibiotic for several months

5. Fistula:

v Symptoms/Signs:

similar to those of small bowel obstruction or ileus, but more prominent component of fever.

v When fever is associated with GI dysfunction postoperatively, evaluation should include early

assessment of the GI tract for its continuity.

v When fistula is suspected, the use of water-soluble gastrointestinal contrast material is advised

to avoid the complication of barium peritonitis

v Management: (略)

　

1. Thromboembolism Prophylaxis:

à 40% of all deaths following gynecologic surgery are directly attributed to pulmonary emboli.

à Most deep vein thrombosis occurs intraoperatively and in the first 72 hours postoperatively.

à Risk Factors of Postoperative Thrombolic Complications:

advanced age, nonwhite race, increasing stage of malignancy, history of deep vein thrombosis,

low extremity edema or venous stasis changes, presence of varicose vein, being overweight,

history of radiation therapy, increased anesthesia time, increased blood loss, and the need for

transfusion in OR.

à Prophylaxis:

(used intraoperatively and for the first 5 days postoperatively)

à Recognition of Deep Vein Thrombosis:

Symptoms/Signs: pain, edema, erythema, prominent vascular pattern of the superficial veins

Venogram: “gold standard” of diagnosis, moderately uncomfortable

Impedance Plethysmography:

Doppler Ultrasound: intravenous clots

à Recognition of Pulmonary Embolism:

Symptoms/Signs: chest pain, hemoptysis, shortness of breath, tachycardia, and tachypnea

ABG, EKG, and CxR:

Ventilation-Perfusion Lung Scan: decreased perfusions in areas of adequate ventilation

à Treatment:

j Deep Vein Thrombosis: immediate anticoagulant therapy

a). Heparin 5000 unit v., then v. 1000 units/hour for 10 days

b). Keep APTT 1.5-20 ´ control level

c). Coumadin for at least 3 months

k Pulmonary Embolism:

a). immediate anticoagulant therapy, identical to that outlined for the treatment of

deep vein thrombosis, should be initiated.

b). Respiratory support, including oxygen and bronchodilators and an intensive care setting, may be necessary.

c). Pulmonary Embolectomy

d). Pulmonary artery catheterization with the administration of thrombolytic agents.

e). Vena cava interruption

　

1. Management of Medical Problems: (略)