Archive for the ‘Surgery’ Category

Surgical HO Guide

Posted: February 17, 2013 by gerardloh in Surgery

Dear friends and fellow colleagues,

I compiled a new surgical guide, however it is not as complete as I like it to be as Surgical was quite an eventful posting, I was rather busy till the end. I have now moved on to my 5th posting…hence I doubt I’ d have any time to check and update it anytime soon. Nevertheless, I’m sharing it and hopefully it may be of some help. Will update it again once I’m free. Do let me know if there are any mistakes or things to add on. Thanks!

hoguide

The “gangnam” cartoon is in celebration of the Surgical Night, memories which will remain with me for a long time to come. Not to forget the lion dance. Thank you General Surgery Hospital Ampang! My favourite posting so far.

DSC_0231

Gong Xi Fa Chai!

Basic things you need to know in surgery department

Posted: October 2, 2012 by kiamseong in Surgery

Things you need to know in surgical dept

(i)     ABG interpretation

Norms

pH 7.35-7.45

pO2 80-100 mmHg

pCO­2 35-45 mmHg

HCO3 22-26

*To convert mmHg to kPa divide 7.5

(ii)    If pH>7.45

pCO2 < 35

HCO3 >26

Respiratory Alkalosis

Metabolic Alkalosis

Hyperventilation

-stroke

-SAH

-meningitis

-anxiety

-hyperthermia

-PE

-salicylates poisoning

-profuse vomiting

-hypoK

-burn

(iii)  If pH<7.35

pCO2 > 45

HCO3 <22

Respiratory Acidosis

Metabolic Acidosis

         NAGMA                          HAGMA

Respiratory failure -RTA

-Diarrhoea

-Addison ds

-Pancreatic fistula

-NH­4 ingestion

-Drug-acetazolaminde

Increase in organic acid production

-lactoacidosis-shock, sepsis,hypoxia

-uric acid

-ketone-DM, alcohol

-drug – metformin, metanol

*anion gap = [ Na + K ]– [ Cl + HCO3 ]

(iv)  Oxygen dissociation curve

Left side of curve – ­pH ¯T ¯DPG (2,3 dephosphoglycerate)
Right side of curve – ¯pH ­T ­DPG (2,3 dephosphoglycerate)

p50 – point where saturation of Hb reaches 50% (at pO2=26.6)

ICU point (PaO2, SaO2) = (60mmHg, 91%) = lowest acceptable paO2 in ICU patient because further drop beyond this point lead to drastic drop in SaO2

Mixed venous point at SaO2 = 75%

(v)   Indication for intubation

ü  To deliver positive pressure ventilation

ü  Airway protection from aspiration

ü  During surgical procedures involving neck and head in non-supine position

ü  Neuromuscular paresis

ü  Procedures increases intracranial pressure

ü  Profound disturbance n consciousness

ü  Severe pulmonary and multi-systemic injury

(i)     Content in each pint of solution

Sol. Content Na K Ca Cl HCO3
NS NaCl 9g (0.9%) 150 150
HS NaCl 4.5g (0.45%) 77 77
D5% Dextrose 50g/L
D10% Dextrose 100g/L
HM NaCl + KCl + CaCl2 + Na lactate 131 5 2 111 29
3%Sal NaCl 30g (3%) 513 513

(ii)    Dehydration

Mild Moderate Severe
Adult 5% 7.5% 10%
Paeds* <3% 3-9% >9&

*according to Acute Diarrhoea Protocol 2011

(iii)  Fluid requirement

Total = Maintenance + Deficit + On-going losses

Maintenance = 40cc/kg/day

For Paeds: (use Holliday Segar Formula)

4cc/kg/h for 1st 10 kg

2cc/kg/h for next 10 kg

1cc/kg/h for subsequent kg

Deficit = 10 X % X Body wt

*replace over 12 hrs

On-going losses = losses from RT Aspiration, Drainage, third space loss, plasma loss etc

*usually replace per shift with HM/NS

In all head injury patient – give only NS

In burn patient – Parkland correction by HM

In paeds patient – usually use HSD5%

(iv)  Assess degree of dehydration based on

–           Mental status

–           Eye – sunken eye/crying with tears

–           Breathing

–           Mucosa/tongue

–           Skin turgor

–           Pulse volume

–           PR/BP

–           CRT

–           Periphery warm/cold

–           Urine output *good UO = 0.5-1cc/kg/h

(v)   Na requirement

Total requirement = Maintenance + Deficit

Maintenance = 2-3mmol/kg/d

Deficit (in mmol)= (140-x) X Wt X 0.6

*to convert to g, divide with 23.3

(vi)  K requirement

Total requirement = Maintenance + Deficit

Maintenance = 0.5-1mmol/kg/d

Deficit (in mmol)= (4-x) X Wt X 0.4

*to convert to g, divide with 13.3

Rules of K correction:

Rate should not > 1.5g per hour

Concentration should not > 3g in 1L (1.5g in 500ml)

If hypoK – use Mist KCl 15ml TDS

If severe hypo – load 1g KCl in 100cc NS over 1 hr

Or 2g KCl in 200cc NS over 2 hr

*make sure take ECG/put on cardiac monitoring during loading AND repeat RP post loading 2 hrs

If hyperK – use oral Kalimate 15g TDS

If severe hyper – “insulin chase”

ü  IV Ca Gluconate 10% 10cc over 2-5 min then

ü  IV Dextrose 50% 50cc then

ü  IV Actrapid 10unit

ECG changes

Hypo K Hyper K
Flat T wave

Narrow QRS

ST depression

U wave

Small P

Tall tented T wave

Widen QRS complex

Ventricular tachy/fibrillation

(vii)          Hyperglycaemia

DKA HHS/HONK
Absolute insulin deficiency Relative insulin deficiency
Dx:-pH < 7.3

-Dxt > 14

-Blood Ketone > 2 (get a ketone stick)

Dx:- Serum osmolarity >320

– Dxt >33

*Osm = 2(Na+K)+Glu+Urea

Principle of management:

  1. Fluid resuscitation – 2 large bore IV cannula (green 18G or grey 16G) in 2 antecubital fossa – 1 for maintenance, 1 for bolus
  2. Insulin therapy (not to start first if K less than 3.3), target Dxt in DKA 8-11, HHS 14-16 then ½ dose of insulin, if hypo – do not stop insulin, instead to use D10% drip
  3. Correction of electrolytes – BUSE & VBG 4hrly, make sure good urine output and no ECG evidence of hyperK when planning to load K
  4. Treat underlying causes (sepsis, MI etc)

*Indication of HCO3 – if HCO<10 give 100meq (10 Amp NaHCO3)

*if resolved and patient tolerating orally – to change to basal bolus regime 0.5-0.8u/kg/d and titrate with overlapping 1-2hrs with IVI sliding scale

(viii)           Preparing DM patient for elective and emergency surgery

Elective Emergency
Minor Major Treat DKAPostpone surgery until RBS <20 unless life threateningAim 7-11 mmol/L during surgeryGive D5% or DS + 20mmol KCl 8hrly + IVI insulin sliding scale
OHA – give normal regimeInsulin – omit on day of surgeryDXT QID OHA – omit long acting (glibenclamide)DXT QID* If RBS >15, to start insulin sliding scale

Workshop 2009/10 Handouts

HOW was established in the summer of 2009, founded by Dr. Christopher Sheng and Dr. Ng Kean Seng.

Our objectives were clear, to collect and compile as much details and experiences possible on the Housemanship service in Malaysia. Clearly, a lot of us overseas graduates are not used to the local system and methods. Terms may differ and protocols vary.

Here, you may download the guides completed by doctors of the House Officers Workshop. Please note that these guides were done by medical students and serves as a guide only. Hopefully, these materials will assist you during your Housemanship service!

1. Obstetrics and Gynaecology

2. Medicine 

3. Paediatrics

4. Orthopaedics

5. Surgery

6. Guide Medicine Workshop

7. General List of Recommended Antibiotic

8. Medical abbreviations

House Officers Workshop Malaysia goes online! Content to be updated soon…