SURGERY NOTES Part 2

1. Apa significantnya I/O chart? Kalau negative balance kenapa?Kalau positive balance pula kenapa?

Input usually in ICU Staff Nurse akan chart :medication/Inotrops/Ryles Tube Feeding/Oral intake/IV Drip

Output : Urine from CBD/condom catheter/Blake drain/Ileoconduit/Stoma

Input - output : Balance

Usually when a lot of positive balance up to +1000 or 2000, possible we will reduce IV drip because to prevent fluid overload. So need to check lung to auscultate any bibasal crepitation, check any pedal edema or not.

If negative balance( indicate more loss than the intake), if patient not on IVD, we might consider start IV maintainance because afraid patient will dehydrated.

If patient not take orally at all, we can calculate fluid requirement for patient based on body weight.

BWx 30@35/kg/Day

Eg 70 X 30 ml = 2100, estimated about 4 pint. If patient bigger, can give 5 pint. If patient take orally about 500, reduce IV drip accordingly.

2. Flagyl nak cover apa? Cefobid?

Flagyl we want to cover anerobes

Cefobid also cover for anerob, and gram pos and negative. We usually cover for GI organism in surgery.. most common antibiotic used is these two.

If patient still sepsis despite long antibiotic, usually we will upgrade to IV Meropenam or other antibiotic, also depend on sensitivity(others: IV Vancomycin, Fluconazole, Rocephine, Augmentin)

3. Differential diagnosis abdominal pain?

4. GCS?

Kalau nak tahu full mark, ikut ejaan huruf dalam bahasa melayu

Eye : Mata (4) - Spontaneous, Verbal, Pain, No

Verbal : Mulut (5), Oriented, Confuse, Word, Sound, No

Motor : Tangan (6)- Obey, Localize Pain, Withdraw, Flexion, Entend, No

5.  Underwater sealed untuk chest tube?

Lubang di botol kena tutup ke buka? Yang mana kena sambung di patient, yang mana perlu sentiasa buka lubangnya supanya udara mengalir? Bila kena clamp?

Bila kena unclamp? If full nak kena buang air ke tukar je terus botol? Mula-mula kena isi sterile water how much in the bottle? Macam mana nak ambil sample sebab takut induce pneumothorax pula kalau buka?

There are 3 hole in underwater sealed bottle (Chest Tube)

1. The biggest hole - Need to close, to prevent infection. Usually before connected to the patient, we use this hole to fill up the bottle by sterile water (300cc - not more and not less)

2. Vacuum : This smaller hole should be open, so that the air will go out here, in case of pneumothorax, air will not entraped in the bottle alone, which is no function we do chest tube if the air not go out, rite?

3. Patient : this hole will connected to the tube then to the patient

We must make sure tube connected to the patient with correct hole, because if we put tube in the vacuum hole, air susequently will be vacuum from the bottle to the patient.

6. Triple assesment in breast examination?

• History (including risk factor) + Physical Examination

• Mammogram @ Ultrasound

If age less than 40 do ultrasound

If more than 40 y.o more dense breast, maybe not suitable to do USG, so need to do mammogram

• Biopsy - histology eg : 

Fine Needle Aspiration Cytology (FNAC)

7. Ranson score in pancreatitis?

What blood need to take during admission and what score to write on 48 hour? What other score? IMRIE, BISAP Score?

8. If patient SOB or chest pain, how to attend? Fever?

9. Macam mana nak tukar stoma bag?

Yang ni kena belajar dengan wound nurse, terbaik diorang buat. Ada kena gunting ikut stoma shape. Kemudian lettakkan stoma paste sebelum lekatkan gam stoma bag, to prevent excoriation of skin.

10. Dressing, bila guna povidone, bila hydrocyn? Bila guna bactigrass? Boleh ke soaked gauze then close the wound if wound banyak discharge?

Sometime we use either one if wound dirty, full of seropurulent discharge. Use either povidone or hydrocyn. Hydrocyn agak mahal, sometime tak ada stok.

Cara guna hydrocyn, kita cuci dulu wound guna sterile water, then soak hydrocyn then apply to wound yang ada slough, ideally put there about 5-10 min, because it will make slough softer, easier to dressing, cleaner.

Then lastly dont put gauze with soaked agen dressing like povidone or hydrocyn, because if wound have discharge, it will not absorbed to that gauze (because already soaked by hydrocyn), so pus discharge akan meleleh dan dressing kita akan mudah soaked, easy direct contact with environment.

11. Kenapa patient neurosurgery post op day 1 biasanya mereka order nak repeat CT brain plain? Bukan ke dah op ke?

If case haemorhage, post decompression, we want to see how much haemorrage there left, any complication (worsening haemorage or infarction post op)

12. Why patient MVA ada minimal SDH, then treat conservatively then kena repeat balik CT Brain?

Usually we repeat 24 post first CT Brain , to see progression of the haemorrhage, if static and gcs improve, maybe patient can be dischege 2-3 days later. If worsen, might need to do operation.

13. Patient yang poor gcs recovery, then we decide bring pt home post tracheostomy, what equipment that family must prepared before pt brough back home?

• Ripple Matress

• Bed

• Suction

• Oxygen - if patient still need oxygen long term

• Pampers/Susu

14. Guarding abdomen, sign of what?

Peritonitis

15. If drain nil, kena make sure radivac functioning or not, tube blocked or not. How to make radivac functioning? Macam mana nak tahu? Nak tengok apa?

Gambar - Yang macam spring warna hijau tu, kena make sure macam spring yang ditekan - thats indicator radivac functioning.(on the left side, radivac in vacuum state- functioning)

16. Biasanya apa MO akan bagi kalau patient tacycardia, tapi no fever, and BP lowish? If hypovolumic before start on inotrop? Fluid apa? Make sure patient not on what disease before “playing” with fluid?

Some cases they give normal saline, some give hartmann, most of the time I saw they gave Harmann solution. To run fast harmann or run over 30 minutes or 1 hour.

If still BP not pick up, usually we start double strength noradrenaline (8mg double strength, 16 mg adalah Quadristrength)

17. Kalau nak request CTPA tro pulmonary embolism biasanya radiologist akan tanya apa? D dimer? Wells Score DVT/ PE ?

Prolong immobilization?

Recent surgery?

Different calf diameter Right and Left?  (Well score DVT) - ifmore than 3 cm difference

Others

18. Patient post removal parathyroid and total thyroidectomy, what medication usually will be given if persistently low ca level?

Corrected calcium level? —

[(40 - pt albumin) x 0.02] + Pt Calcium

IV infusion Calcium Gluconate

Calcium Lactate

Calcium Carbonate

Calcitriol

If very low calcium, we will check calcium level 6 Hourly, titrate IVI Calcium Gluconate accordingly.

I ampule calcium gluconate

- 10 ml contain 950 mg

- Usually post op start undiluted ca gluconate 5cc/H, then change based on corrected calcium level.

Sign hypocalcemia?

Chvostek Sign - tapping facial nerve to stimulate it near anterior ear lobe - positive finding > twitching lip at corner of mouth

Carpopedal spasm

Symptom

Perioral numbness

Numbness over finger

Muscle weakness

Check also:

⁃ Hematoma

⁃ Change of voice @ hoarseness

20. Normal urine output?

0.5 to 1cc/Kg/Hour

Kalau patient estimated body weight 70kg, then urine output pt 10 atau 20 cc je, kita boleh tahu dah patient oliguric, tengok urea creat patient, worsening or not, takut patient AKI... then tengok VBG, specifically Bicarb and PH, to look for metabolic acidosis.

19. If patient on diuresis, mo plan to give half replacement for every loss per shift, what and how to give?

Kalau pm review noted patient urine 2000 per shift, we can give 2 pint Hartman (Replace 1000), but just slow, not necessarily run fast, run 1 pint over 2-3 hour should be okey.

20. How to off drain in pt post thyroidectomy + breast (mastectomy and axillary clearance)?

1. Thyroidectomy

Off vacum first - off radivac bottle, disconnect it from drain, then only we off the drain located in operation site

If not, the vacuum condition inside the operation site (wound) will allow blood to accumulate thus cause hematoma to patient - then subsequently cause obstruction, sob and so on.

2. MAC

- Mastectomy + Axillary Clearance

Usually pt will have 2 drain

At the breast (B)

And

At the axilla (A)

Usually we remove B drain first, because take time to axillary drain to lessen the fluid, if taken off too early, there will be accumulation of lymphatic fluid, swollen the upper limb.

Mac drain also need to off the vacuum first, then only off the drain. To prevent hematoma.

21. When want to off drain?

Depends on surgeon

Some of them see the pattern drain chart, if it lesser day by day or drain come out nil, they might want to off...some hospital take 30cc, or less than 50 cc to consider off it.

But make sure vacuum of radivac functioning, sometime its not drain because blocked tube or the bottle not in vacuum condition.

22. Should patient with hemithyroidectomy we check calcium level post op, and give L thyroxine?

Not necessarily.

Because we have 4 parathyroid gland, and even we do hemithyroidectomy, we try to reserve the parathyroid gland, keep it back, and if 2 parathyroid gland incidentally not function, patient still have another 2 parathyroid.So, in hemithyroidectomy no need to repeat calcium everyday. Unless total thyroidectomy, need to monitor calcium, as s/sx hypocalcemia)