Inpatient Medical Management

Question 1

main conditions to manage

Answer 1

pain
bleeding
nausea / vomiting
anxiety
wound VACs
electrolytes

Question 2

pain pathway

Answer 2

local mediators - cytokines, prostagladins, in tissue beds initiate electrical impulses by affarent nerve fibers

fibers synapse on root ganglion

follow tract to thalamus

synapse on somatosensory cortex and limbic system

Question 3

somatic pain
location?
pt. description?
mechanism?
clinical examples?
most responsive tx?

Question 4

visceral pain
location?
pt. description?
mechanism?
clinical examples?
most responsive tx?

Question 5

neuropathic pain?
location?
pt. description?
mechanism?
clinical examples?
most responsive tx?

Question 6

pharmocological agents used in pain management

Answer 6

opioids
NSAIDs
Local Anesthetics
Acetaminophen
Steroids

Question 7

Opioids - general
analgesic effect vis?
risks?

Answer 7

Mu, kappa, and delta receptors located in dorsal horn, brain stem, thalamus, and somatosensory cortex

analgesic effect via ; decrease CA influx at nerve terminals, increased K efflux and inhibition of GABA transmission at brainstem

risks: respiratory depression, N/V - chemoreceptor trigger zone, decreased GI motility, Arteriolar vasodilation, increased smooth muscle tone, itching (histamine release)

Question 8

NSAIDs - general as __ inhibitors?
risks?

Answer 8

prevent edema, erythema, hyperalgesia, and inflammation
Cox 1/2 inhibitors - blocking Arachidonic acid from forming prostaglandins

risks: GI bleeding, kidney damage, decreased effectiveness of ACE inhibitors, beta blockers, and diuretics

Question 9

use of local anesthetics for pain control?

Answer 9

long acting LA’s like marcaine 0.5% w. epi 1:200,000
use of this LA long acting (8-12 hrs) decreases hyperexcitability of CNS and can reduce post-op pain and analgesia

Question 10

details about acetaminophen - include dosage

Answer 10

AKA tylenol
metabolized extensively by the liver CYP450
good for pain relief
NO anti-inflammatory properties
often combined with opioids
650- 1000 mg q4-6 hrs.
4000 mg daily max

Question 11

steroids

Answer 11

inhibit phospholipase A2 inhibiting production of arachidonic acid - step above where NSAIDs play a role
eliminate post-op edema via suppression of arachidonic acid production

has antinociceptive properties at spinal cord and is an antiemetic

risks
- can cause GI bleeding if combined with NSAIDs

Question 12

pre-op and intra-op management ?
include drugs and dosages

Answer 12

Toradol (ketorolac -NSAID) before end of surgery to decrease amount of opioids necessary
- 15-30mg IV q4-6 hrs (120 mg max dose)

if not NO - ibuprofen 400 mg 30 mins prior to surgery can decrease onset and severity of post-op pain

prevents hyperalgesia

Question 13

bone pain best treated with?

Answer 13

NSAIDs and steroids

Question 14

dosage and drugs for post-op /inpatient management

Answer 14

Ibuprofen - 600mg PO (3200 mg max)

*using two different analgesics (NSAIDS + opioids) leads to greater efficacy in pain control

Dilaudid (hydromorphone) (0.2-1mg q 2-3 hr) - pt. controlled analgesia

Question 15

tranexamic acid

Answer 15

antifibrinolytic
blocking plasminogen to plasmin
(plasmin used to break down clots)

Question 16

surgicel and bone wax

Answer 16

bone wax = paraffin and wax
oxidized cellulose (surgicel) are among the commonly used hemostatic agents for controlling hemorrhage from the surgical site. Bone wax is a sterile mixture of 85-90% white bees’ wax and 10-15% isopropyl palmitate,4 a palm oil-based emollient, moisturizer, thickening and antistatic agent.

The hemostatic action of surgicel is by formation of a gelatinous mass upon saturation with blood, which leads to formation of a stable clot.

Question 17

risk factors for nausea / vomitting

Answer 17

female
non smoker
hx of PONV or motion sickness
volatile anesthetics
nitrous oxide
opioid use
long anesthesia time

Question 18

prevention for nausea
include medications

Answer 18

prophylactic antiemetics (only moderate to high risk patients)
propofol induction
hydration
intra-op O2 use
Toradol
NG tube

scopolamine patch - evening prior or 4 hrs prior to conclusion of surgery

dexamethasone (induction) - steroid use
5-10 mg IV

ondansetron (closing) 5-HT seretonin inhibitor
4-8 mg IV

Question 19

post -op / inpatient managementfor N/V

Answer 19

rule out any local factors
if no prophylaxis was given (ondansetron) - give 4 mg q4hr

if prophy failed - give ondansetron or consider switching antiemetic classes -
promethazine - antihistamine (H1 antagonist)
compazine- dopamine receptor antagonist - also have anticholinergic and antihistaminic blocking effects
droperidol- D2 receptor antagonist in chemoreceptor trigger zone
metoclopramide - inhibits dopamine and serotonin 5-Ht3 receptors in chemo-receptor trigger zone

Question 20

caution with what when giving antiemetics?

Answer 20

QT interval prolonging
consult with attending before

Question 21

anxiety managment - medication and dosage

Answer 21

Ativan - Lorazopam
Benzo
lowers anxiety and potentiates effect of opiods
muscle relaxant at low doses
2mg q6-12 hrs (30mg max in 8 hrs)
Lorazepam binds to benzodiazepine receptors on the postsynaptic GABA-A ligand-gated chloride channel neuron at several sites within the central nervous system (CNS). It enhances the inhibitory effects of GABA, which increases the conductance of chloride ions in the cell.
caution with opioid use due to respiratory depression risk

Question 22

MOA of wound vacs
four principal components?

Answer 22

decreased pressure on wound allows for rapid healing
- pulls fluid from wound
- reduces swelling
- pulls wound edges together
- stimulates growth of new tissue
- reduces bacterial load

four principal components
1. macrodeformation
2. microdeformaion
3. stabilization
4. fluid removal

Question 23

indication for wound VAC use?

Answer 23

chronic non healing wounds
large wounds
skin grafts

Question 24

initial application of wound vac steps?

Answer 24

Window Paning: protects peri-wound surface, improves seal
Cut and Shape Foam
Place in Wound: height at top of wound, do not extend past wound margins
Cover with Drape: extend to peri-wound reach by half an inch circumferentially
Cut 2 cm Hole in Drape: must be placed above foam
Apply Vacuum Tubing
Connect Tubing to VAC Suction Canister
Activate Canister: perform leak check

Question 25

VAC changes occur?

Answer 25

every 24-72 hours
measure wound size and follow steps for initial application to re-apply

Question 26

cardiac electrolyte imbalances
hypo Mg?
hypo K?
Hypo Ca?
Hypo P?

seizures can occur with?

Answer 26

hypo Mg –> Torsades de pointes –> vFib
hypo K –> ST depression, T wave inversion, U waves
hypo Ca: QT prolongation
Hypo P: Hypertrophic cardiomyopathy - eventual CHF

Seizures with Na, Ca, Mg

Question 27

normal range for electrolytes:
potassium
phosphorus
magnesium
calcium
sodium

Answer 27

potassium : 3.6-5.5
sever hypo : below 2.5 sever hyper: 6.5-7 mmol/L

phosphorus: 3mg/dL
less than 2.5 , greater than 4.5

magnesium: 2 mEq
1.38-2.68

calcium : 8-10

sodium: 135-145 mmol/L

Question 28

how to replete following electrolyte imbalances
potassium
phosphorus
magnesium
calcium
provide target goal (this is the general card need to know)

Answer 28

potassium : 3-5 - want around 4 mEq –> 10 mEq over 1 hour each for 0.1 raise

phosphorus: target for 3 mg/dL –> 15 mmol potassium phosphate over 4 hours

magnesium: target 2
2mEq–> 2g mag sulfate over 1 hr.

calcium : target 8-10
2g Ca Gluconate over 1 hour

Question 29

potassium replacement protocol – IV*
in general at what value to start to replenish?

Answer 29

less than 3.6

goal is 10 mEq/ hour
maximum is 20 mEq/hr with continuous EKG monitoring

standard concentrations: 10mEg/50ml or 10/100ml 20 mEq/50ml or 20mEq.100ml
max concentration for CENTRL line is 20mEq/ 50mL
max concentration for PERIPHERAL line is 10mEq/50mL

Question 30

potassium replacement protocol for oral or enteral repletion

Answer 30

standard dosage forms: KCl 20mEQ tablet or KCl 10% solution (20mEq/15mL)m

Question 31

magnesium replacement protocol – IV*
in general at what value to start to replenish?

Answer 31

goal is 2 mEq/L
if less than 1.5
1gm of magnesium sulfate every 30 mins.
standard concentrations of 1gm/ 100mL and 2gm/50mL
*infusions should be no faster than

Question 32

calcium replacement protocol – IV* (clarify central vs peripheral)
in general at what value to start to replenish?
must specify what?

Answer 32

goal 8-10 mg/dL (1 deciliter is 100 ml)
specify the salt form ; calcium chloride or calcium gluconate
calcium chloride – must be administered via central line and reserved for level 1 areas only

target of: 2 g calcium gluconate over 1 hr.
standard concentrations: 1 gm / 50 mL
maximum rate of 3 gm IV over 10 mins

Question 33

phosphorus replacement protocol – IV*
in general at what value to start to replenish?

Answer 33

start infusion if lower than 2 and order must be placed in mmol of phosphorus
goal: 3 mg/dL–> 15 mmol potassium phosphate over 4 hours

recommended rate 3mmol/hr (4.4 mEq/h of K)

use SODIUM phosphate for patients with serum potassium over 4.5 mEq/L and serum sodium less than 145
(think about normal ranges of potassium and sodium we want for patients, 4 for K and 135-145 for sodium)