General Surgery

Contraindications to surgery

  • –Absolute: Diabetic Coma, DKA
  • –Poor nutrition: albumin <3, transferrin <200,weight loss <20%
  • –Severe liver failure: bili >2, PT >16, ammonia > 150 or encephalopathy
  • –Smoker: stop smoking 8wks prior to surgery
  • If a CO2 retainer, go easy on the O2 in the post-op period. Can suppress respiratory drive.
Goldman’s Index
  • Tells you who is at greatest risk for surgery
  • –#1 = CHF
    • Check EF. If <35%, no surgery
  • –#2 = MI w/in 6mo
    • Check EKG -> stress test -> cardiac cath -> revascularization
  • –#3 =arrhythmia
  • –#4 =Old (age >70)
  • –#5 =Surgery is emergent
  • –#6 =Aortic Stenosis, poor medical condition, surg in chest/abd
    • Listen for murmur of AS
      • Late systolic, crescendo-decrescendo murmur that radiates to carotids.
      • ↑ with squatting, ↓ with decrease preload

Pre-operative Eval

CardiacHeart Failure, EF < 35%
MI within 6 mos.
1. ECG
2. Echo
3. Cath
Stenting + Plavix
BB, Ace-I, ASA, Statin
Interstitial lung disease (ILD)
Ventilation issue rather than oxygenPFTs
– low O2 = bad
– high CO2 = worse
Smoking cessation for 8 weeks before surgery
Quitting closer to surgery is worse
LiverChild-Pugh (class A, B, or C)
low albumin
high PT/PTT
high Bilirubin
MELD score
MELD = 3.78×ln[serum bilirubin (mg/dL)] + 11.2×ln[INR] + 9.57×ln[serum creatinine (mg/dL)] + 6.43

Contraindication: most surgeries
Liver Transplant
Diabetic KetoacidosisDiabetic with elevated blood glucoseCheck sugarDONT DO surgery!!!

IVF + Insulin
NutritionAt risk:
– lost 20% of body weight in 3 mos
– albumin < 3
– or failed skin anergy test
Need adequate nutrition for healingCRP, prealbumin to ensure low ablumin is from nutrition
Skin anergy test
10 days > 5 days
Preoperative evaluation checklist
  • Meds to Stop:
    • Aspirin
    • NSAIDs
    • vit E (2wks)
    • Warfarin (5 days) –drop INR to <1.5 (can use vit K)
    • Take ½ the morning dose of insulin, if diabetic
  • If CKD on dialysis: Dialyze 24 hours pre-op
  • Check the BUN and Creatinine:
    • –if BUN > 100
      • There is an increased risk of post-op bleeding 2/2 uremic platelet dysfunction
    • Expect on coagulation panel: Normal platelets but prolonged bleeding time

Vent Settings

  • Assist-control -> set TV and rate but if pt takes a breath, vent gives the volume.
  • Pressure support (Important for weaning) -> pt rules rate but a boost of pressure is given (8-20).
  • CPAP -> pt must breathe on own but + pressure given all the time.
  • PEEP  (Used in ARDS or CHF) -> pressure given at the end of cycle to keep alveoli open (5-20).

If a patient on a vent
  • Best test to evaluate management: ABG
  • If PaO2 is low: increase FiO2
  • If PaO2 is high: decrease FiO2
  • If PaCO2 is low (pH is high): Decrease rate of Tidal Volume
  • If PaCO2 is high (pH is low): Increase rate or TV
  • Tidal Volume is more efficient to change.
  • *Remember minute ventilation equation & dead space*

During Surgery

Malignant HTN
(wonder drugs)
During surgeryFamily hx
Bad reaction to anesthesia

Post-operative Fever

Day 0Bacteremia (wound)Blood cxAb
Day 1Atelectasis (wind) Neg CXRIncentive spirometerSpirometer
Day 2Pneumonia (wind)Abx
Vancomycin + Pip/Tazo for HAP
Day 3UTI (water)Urinalysis
(leuk esterase +, nitrites +, no epithelial cells)
WBC cast
AbxRemove Catheter early
Day 5DVT (walking)Bilateral Lower Extremity USHeparin -> WarfarinAmbulation
Day 7Wound (walking)Cellulitis is visible
US (r/o abscess)
Day 10 – 14Abscess (wound)CT scan
Fever on POD #1
  • –Most common cause, low fever (<101) and non-productive cough: Atelectasis
    • Dx: CXR-see bilateral lower lobe fluffy infiltrates
    • Tx: Mobilization and incentive spirometry.
  • –High fever (to 104!!), very ill-appearing: Nec Fasciitis
    • Pattern of spread: In subQ along Scarpa’s fascia.
    • Common bugs: GABHS or clostridium perfringens
    • Tx: IV PCN, Go to OR and debride skin until it bleeds
  • –High fever (>104!!) muscle rigidity: Malignant Hyperthermia
    • Caused by: Succinate or Halothane
    • Genetic defect: Ryanodine receptor gene defect
    • Treatment: Dantrolene Na (blocks RYR and decrease intracellular calcium.
Fever on POD #3-5
  • –Fever, productive cough, diaphoresis: Pneumonia
    • Tx: Check sputum sample for culture, cover w/ moxi etc to cover strep pneumo in the mean time.
  • –Fever, dysuria, frequency, urgency, particularly in a patient w/ a foley: UTI
  • Next best test: UA (nitritie and LE) and culture.
  • Tx: Change foley and treat w/ wide-spec abx until culture returns.
Fever > POD 7
  • –Pain & tenderness at IV site: Central line infection
    • Tx: Do blood cx from the line. Pull it. Abx to cover staph.
  • –Pain @ incision site, edema, induration but no drainage: Cellulitis
    • Tx: Do blood cx and start antibiotics
  • –Pain @ incision site, induration WITH drainage: Simple Wound Infection
    • Tx: Open wound and repack. No abx necessary
  • –Pain w/ salmon colored fluid from incision: Dehiscence
    • Tx: Surgical emergency! Go to OR, IV abx, primary closure of fascia
  • –Unexplained fever: Abdominal Abscess
    • Dx: CT w/ oral, IV and rectal contrast to find it. Diagnostic lap.
    • Tx: Drain it! Percutaneously, IR-guided, or surgically.
  • –Random -> thyrotoxicosis, thrombophlebitis, adrenal insufficiency, lymphangitis, sepsis.

Post Operative Problems

Altered Mental Status
ARDSloud and confusedNoncardiogenic PECXR – white outPEEP
Delirium Tremens48-72 hours after admission
Alcohol WithdrawalTx: Benzodiazepines

ppx: long acting benzo
ElectrolytesAMSIntake in:
BMPNa and/or Ca replacement
HypoxiaAMS + Low SatAtelectasis
pain from post-op
Pulse oximetry
Incentive spirometry
Acid-Base Disorders
  • Check pH -> if <7.4 = acidotic.
  • Next Check HCO3 and pCO2:
    • –If HCO2 is high and pCO2 is high: Respiratory Acidosis
    • –If HCO2 is low and pCO2 is low: Metabolic Acidosis
  • Next Check anion gap (Na –[Cl+ HCO3]), normal: 8-12
  • Gap acidosis = MUDPILES
  • Non-gap acidosis = diarrhea, diuretic, RTAs (I< II, IV)
  • Check pH if >7.4 = alkalotic.
  • Next Check HCO3 and pCO2:
    • –If HCO3 is low and pCO2 is low -> Respiratory Alkalosis
    • –If HCO3 is high and pCO2 is high -> Metabolic Alkalosis
      • Next Check urine [Cl]
      • If [Cl] < 20: Vomiting/NG, antacids, diuretics
      • If [Cl] > 20: Conn’s, Bartter’s Gittleman’s.

Breast Cancer
Asymptomatic: Screen
Breast Lump
Breast Mass
Early Menarche
Late Menopause

BRCA 1/2
< 30 = reassurance x 2-3 cycles
< 30 + persists = US
< 30 + cyst on US = FNA
< 30 + cyst resolves = reassurance

Mammogram & Core needle biopsy if:
> 30 yo
US shows mass
Bloody Aspirate
Cyst recurs after aspiration
Local Disease: Surgical Therapy
Lumpectomy + radiation or Mastectomy
Sentinel LN biopsy and then
Axillary LN Dissection if +

Spread Disease: Systemic Therapy
doxorubicin, paclitaxel
Her 2 Neu+: Trastuzumab
-Tamoxifen (pre-menopausal)
-Anastrozole (post-menopausal)
USPTF: start at 50 q 2 years
ACS: start at 40 q 1 year

Breast MRI: BRCA
Chest Pain
DVT/PEPleuritic chest pain– Post-op and bedridden
– Highest risk in ortho pts
US bilateral LE
CT spiral chest or
V/Q scan
Heparin drip -> Warfarin
IVC filter only – if no anticoagulation needed
Myocardial InfarctionSilent MI– Post-op
– Atherosclerosis

Murmur Buzzwords

Aortic Stenosis
  • SEM cresc/decresc, louder w/ squatting, softer w/ valsalva. + parvuset tardus
  • SEM louder w/ valsalva, softer w/ squatting or handgrip.
Mitral Valve Prolapse
  • Late systolic murmur w/ click louder w/ valsalva and handgrip, softer w/ squatting
Mitral Regurgitation
  • Holosystolic Murmur radiates to axilla w/ LAE
  • Holosystolic murmur w/ late diastolic rumble in kiddos
  • Continuous machine like murmur-
  • Wide fixed and split S2-
Mitral Stenosis
  • Rumbling diastolic murmur with an opening snap, LAE and A-fib
Aortic Regurgitation
  • Blowing diastolic murmur with widened pulse pressure and eponym parade.


Pleural Effusions
  • see fluid >1cm on lateral decubitus -> thoracentesis!
  • –If transudative, likely CHF, nephrotic, cirrhotic
    • If low pleural glucose: 0.5Rheumatoid Arthritis
    • If high lymphocytes: Tuberculosis
    • If bloody: Malignant or Pulmonary Embolus
  • –If exudative, likely parapneumonic, cancer, etc.
  • –If complicated (+ gram or cx, pH < 7.2, glc< 60):
    • Insert a chest tube for drainage.
  • –Light’s Criteria -> transudative if:
    • LDH < 200
    • LDH eff/serum < 0.6
    • Protein eff/serum < 0.5

Spontaneous Pneumothorax
  • Spontaneous Pneumothorax -> subpleuralbleb ruptures ->lung collapse.
  • –Suspect in tall, thin young men w/ sudden dyspnea (or asthma or COPD-emphysema)
  • –Dxw/ CXR, Txw/ chest tube placement
  • –Indications for surgery = ipsior contra recurrence, bilateral, incomplete lung expansion, pilot, scuba, live in remote area VATS, pleurodesis(bleo, iodine or talc)

Lung Abscess
  • Lung Abscess -> usually 2/2 aspiration (drunk, elderly, enteral feeds)
    • –Most often in post upper or sup lower lobes
    • –Tx initially w/ abx -> IV PCN or clindamycin
    • –Indications for surgery = abx fail, abscess >6cm, or if empyema is present.

Solitary Lung Nodule
  • 1st step = Find an old CXR to compare!
  • Characteristics of benign nodules:
    • –Popcorn calcification = hamartoma(most common)
    • –Concentric calcification = old granuloma
    • –Pt< 40, <3cm, well-circumscribed
    • –Tx: CXR or CT scans q2mo to look for growth
  • Characteristics of malignant nodules:
    • –If pt has risk factors (smoker, old), If >3cm, if eccentric calcification
    • –Tx: Remove the nodule (w/ bronc if central, open lung biopsy if peripheral.

  • Pathophys:
    • inflammation -> impaired gas exchange, inflammation mediator release, hypoxemia
  • Causes:
    • –Sepsis, gastric aspiration, trauma, low perfusion, pancreatitis.
  • Diagnosis:
    • 1.) PaO2/FiO2 < 200 (<300 means acute lung injury)
    • 2.) Bilateral alveolar infiltrates on CXR
    • 3.) PCWP is <18 (means pulmonary edema is non-cardio
  • Treatment:
    • Mechanical ventilation w/ PEEP


A patient presents with weight loss, cough, dyspnea, hemoptysis, repeated pneumonia or lung collapse.

  • MC cancer in non-smokers:
    •  Adenocarcinoma. Occurs in scars of old pneumonia
  • Location and mets:
    • Peripheral cancer. Mets to liver, bone, brain and adrenals
  • Characteristics of effusion:
    • Exudative with high hyaluronidase
  • Patient with kidney stones, constipation and malaise low PTH + central lung mass:
    • Squamous cell carcinoma. Paraneoplastic syndrome 2/2 secretion of PTH-rP. Low PO4, High Ca
  • Patient with shoulder pain, ptosis, constricted pupil, and facial edema:
    • Superior Sulcus Syndrome from Small cell carcinoma. Also a central cancer.
  • Patient with ptosis better after 1 minute of upward gaze:
    • Lambert Eaton Syndrome from small cell carcinoma. Ab to pre-syn Ca chan
  • Old smoker presenting w/ Na = 125, moist mucus membranes, no JVD:
    • SIADH from small cell carcinoma. Produces Euvolemic hyponatremia. Fluid restrict +/-3% saline in <112
  • CXR showing peripheral cavitation and CT showing distant mets:
    • Large Cell Carcinoma

Gastrointestinal Disorders

Esophageal Disorders
Achalasiafood gets stuck in the esophagusLES fails to relaxBarium swallow – bird’s beak esophagus
Manometry – tight LES
Dilation, Botox (inferior to Myotomy)
Mediastinitis: fever and leukocytosis
Transmural tear
air in the mediastinum
1st: Gastrografin
2nd: Barium swallow
Best: EGD if others are negative
Mallory WeissSelf-limiting UGIB
Weekend warriors with severe vomiting
superficial tearSelf-limiting

Cont bleed:
NG tube
2 large-bore IVs
Type and Cross
transfuse prn
GERDEsophageal burning
worse with laying flat and spicy foods
better with sitting upright and with antiacids
Nocturnal asthma
lower esophageal sphincter fails
acid reflux
Alarm sxs: EGD with BxNo alarm sxs: Lifestyle + PPI
Metaplasia Increase PPI + Increase Surveillance
Dysplasia Cryoablation
Adenocarcinoma Esophagectomy, Nissen Fundoplication
Esophageal CancerDysphagia
Weight loss
upper 1/3: SCC – hot drinks, smoking

lower 1/3: Adeno – GERD
Barium Swallow (localizes cancer)
EGD with Bx
Resection – Esophagectomy

  • Dysphagia to liquids & solids
  • Tx w/ CCB, nitrates, botox, or heller myotomy
  • Assoc w/ Chagas dz and esophageal cancer.

Boerhaave’s Esophageal Rupture
  • If hematemesis (blood occurs after vomiting, w/ subQ emphysema). Can see pleural effusion w/ ↑amylase
  • Next best test:
  • CXR, gastrograffin esophagram. NO endoscopy
  • Tx: surgical repair if full thickness

Diffuse esophageal spasm
  • Dysphagia worse w/ hot & cold liquids + chest pain that feels like MI w/ NO regurgitating symptoms.
  • Tx w/ CCB or nitrates

Esophageal Carcinoma
  • If progressive dysphagia/weight loss
  • Carcinoma Squamous cell in smoker/drinkers in the middle 1/3. Adeno in ppl with long-standing GERD in the distal 1/3.
  • Best 1sttest: barium swallow, then endoscopy w/ biopsy, then staging CT.

Gastric Cancer
  • Adeno most common. Especially in Japan
  • – Krukenberg: Gastric Ca -> Ovaries
  • – Virchow’s node: L supraclavicular fossa
  • – Lymphoma: HIV
  • – Blummer’s Shelf: METS felt on DRE
  • – Sister Mary Joseph: Umbilical node
  • – MALT-lymphoma: H-pylori

Other GI disorders
  • –Mentriers = protein losing enteropathy, enlarged rugae.
  • –Gastric Varices = splenic vein thrombosis.
  • –Dieulafoy’s = massive hematemesis -> mucosal artery erodes into stomach

Gastric Ulcers
  • MEG pain worse w/ eating. H.pylori, NSAIDs, ‘roids
  • –Work up = Double-contrast barium swallow-punched out lesion w/ reg margins. EGD w/ bx can tell H. pylori, malign, benign.
  • –Surgery if – Lesion persists after 12wks of treatment.

Gastric Varices
  • If gross hematemesis unprovoked in a cirrhotic w/ pulmonary HTN.
  • If in hypovolemic shock:
    • do ABCs, NG lavage, medical tx w/ octreotide or SS. B
    • balloon tamponade only if you need to stabilize for transport
  • Tx of choice:
    • Endoscopic sclerotherapy or banding
    • *Don’t prophylactically band asymptomatic varices. Give BB.

  • Epigastric pain worse after eating or when laying down, cough, wheeze, hoarse.
  • Most sensitive test is 24-hr pH monitoring.
  • Do endoscopy if “danger signs” present.
  • Tx w/ behavior mod 1st, then antacids, H2 block, PPI.

Hiatal Hernia
  • Acid reflux pain after eating, when laying down
  • –Type 1 = Hernia Sliding. GE jxn herniates into thorax. Worse for GERD. Tx sxs
  • –Type 2 = Paraesophageal. Abd pain, obstruction, strangulation -> needs surgery.

Zenker’s diverticulum
  • Bad breath & snacks in the AM.
  • Only contains mucosa
  • Tx w/ surgery

Indications for surgery
  • bleeding, stricture, Barrett’s, incompetent LES, max dose PPI w/ still sxs, or no want meds.

Distended Abdomen
Obstruction Distended Abdomen– Adhesion (previous surgery)
– Hernias (no previous surgery)
KUB (Xray)
– dilation/air-fluid levels proximal to the obstruction
– collapsed bowel distal to that

NG tube decompression
Ogilvie Elderly pt
Distended Abdomen
MC nursing home

Nontender but very distended
KUB (Xray)
– dilation of ENTIRE large bowel
– small bowel normal
Colonoscopy r/o cancer
Rectal Tube
Paralytic IleusDays after surgery
Distended Abdomen
No gas
No stool
Metabolic, K KUB (Xray)
– small bowel and large bowel both distended
Food intake
Fix K
Foreign body
Distal Obstruction
LIFT procedure – Remove the fistula

Duodenal Ulcers
  • -MEG pain better w/ eating
  • –95% associated w/ H. pylori
  • –Healthy pts< 45y/o can do a trial of H2 block or PPI
  • –Dx: blood, stool, or breath test for H. pylori but endoscopy w/ biopsy (CLO test) is best b/c it can also exclude cancer.
  • –Tx: PPI, clarithromycin & amoxicillin for 2wks. Breath or stool test can be test of cure.

ZE Syndrome
  • If MEG pain/ulcers don’t resolve
  • –Best test: Syndrome Secretin Stim Test (find inapprop high gastrin)
  • –Tx: Surgical resection of pancreatic/duodenal tumor
  • –What else to look for: Pituitary and Parathyroid problems.

SMA Syndrome
  • A patient has bilious vomiting and post-prandial pain. 
  • –Pathophys: 3rd part of duodenum compressed by AA and SMA
  • –Tx: SMA by restoring weight/nutrition. Can do Roux-en-Y

Abdominal Disorders
Small Bowel Obstruction Colicky abdominal pain
flatus and BM
Borborygmi – Absent
Adhesions (If prev GI surgery)
Hernias (if NO prev GI surgery)
1: Upright KUB (Xray) – air-fluid levels
2: CT scan gastrografin po contrast
Complete obstruction: Go to surgery
Incomplete: NG Tube decompression….wait 3 days…go to surgery if no change
Peritoneal signs: surgery
Hernias Abdominal bulge Direct Hernias: Adults, transversalis, Inguinal hernias males
Indirect Hernia: babies, patent processus vaginalis, inguinal ring, inguinal hernia
Femoral Hernia: women, under the inguinal ligament
Ventral Hernia: post-op, iatrogenic, failure of fascial plane
Physical Exam Reducible: Elective repair
Incarcerated: Urgent repair
Strangulated: Emergent repair
Appendicitis Umbilical pain that radiates to the RLQ (McBurney’s point)
Transmural necrosis
Surgery – laparoscopic appendectomy
Carcinoid Flushing
R sided fibrosis of the tricuspid valve
produces serotonin
metastasize to liver to produce sxs
5-HIAA in the urine
Octreotide scan
CT scan
Octreotide injections
Acute Pancreatitisepigastric pain that radiates to the back
positional chest pain
Increase lipase 3xNPO

No improvement: do CT scan
Necrotizing PancreatitisPoor Ranson’s criteria
falling Hgb
deteriorating pt
severe pancreatitisCT scan
Serial CTs
Surgical drainage & Debridement
Pancreatic Abscessdays after pancreatitis
leukocytosis that fails to resolve
pancreatic infectionCT scanAbx
IR drainage
Pseudocystsweeks after pancreatitis
early satiety
fluid-filled vesicle
not lined by endothelium
CT scan< 6cm, < 6 weeks: observe and wait

6cm or > or > 6 weeks:
Percutaneous drain or
gastric/duodenum drain
Chronic Pancreatitis
Anal Canceranal receptive sex
men with men
Anal pap
SCC secondary to HPVbiopsy
Assess HIV status
Chemo and radiation (Nigro Protocol)
Usually, resection is not needed

Anal FissuresPain on defecation
lasts for hours
fear of defecation
tight sphinctervisual inspectionsitz bath
nitroglycerin paste
CCB paste
botox injection
lateral internal sphincterotomy
Colon CancerPost-menopausal female or any male with iron deficiency anemia
alternating bowel habits with changes in the caliber of the stool
R sided bleed, but do not obstruct
L sided do NOT bleed, but do obstruct
ColonoscopyCT scan to stage

Screening: Colonoscopy
Familial Adenomatous Polyposis1000s of polyps by 20 yo
cancer by 30 yo
death by 40 yo
geneticcolonoscopyprophylactic colonoscopy
FistulaFecal Soiling
Foreign body
Inflammation/Infection Epithelization
Distal Obstruction
crohn’s disease
transmural inflammation
local radiation
endothelial lined connection from any two organs
GI tract to anything (vagina, skin, bladder)
probingLIFT = Fistulotomy
HemorrhoidsDark blood on the toilet paper after BM
rectal pain
Internal: BLEED, but DONT hurt
External: DONT bleed, but HURT
Visual InspectionHigh fiber diet
Sitz baths
preparation H
Internal – Banded
External – Resection
Pilonidal CystCongenital Defect
Hairy Butt
Abscessed Hair follicleclinicalincision and drainage
resection of the cyst
Polypasymptomatic: screening colonoscopyBenign:

colonoscopy with biopsyNo polyp = 10 years
Benign polyp = 5-7 years
Ulcerative Colitisbloody bowel movement plus weight loss
associated with PSC, seronegative arthritis
AI – Ashkenazi Jews
superficial colitis
colonoscopy = continuous lesions
biopsy = superficial inflammation
resection (before cancer)
can try monoclonal Ab anti-TNF

> 8 years from dx
mandatory annual colonoscopy
recommended ppx colectomy


Arterial Insufficiency Ulcerperipheral vascular disease
– hairless leg
– decreased pulses
– scaly legs
ulcers at tips of toes…dry gangrene
no blood circulatingankle-brachial index
Doppler US
Smoking cessation
Compression Ulcerbed-ridden patients who didn’t move
occur at:
out of bed
Diabetic Ulcerdiabetic
ulcers occur on heels and toes
clinicalcontrol blood glucose
wound clean
Marjolin’s Ulcerwound repeatedly healing and breaking down with a continuous draining tract

Ulcer: ugly, deep, heaped margins
punch biopsywide resection
Venous Stasis Ulceredema
medial malleolus
no blood circulatingclinicalcontrol disease: CHF/Nephrotic/Cirrhosis

Compression stockings
Unna Boots
Elevate legs

Pressure Ulcers

  • Caused by impaired blood flow -> ischemia
    • –Don’t culture will just get skin flora. Check CBC and blood cultures. Can mean bacteremia or osteomyelitis.
    • –Can do tissue biopsy to rule out Marjolin’sulcer
    • –Best prevention is turning q2hrs
    • –Stage 1 = skin intact but red. Blanches w/ pressure
    • –Stage 2 = blister or break in the dermis
    • –Stage 3 = SubQdestruction into the muscle
    • –Stage 4 = involvement of joint or bone.
  • Management:
    • Stage 1-2: get special mattress, barrier protection
    • Stage 3-4: get flap reconstruction surgery
      • –Before surgery, albumen must be >3.5 and bacterial load must be <100K

Metabolic Disorders

Sodium Abnormalities
  • ↓Na = Gain of water
    • –Check osm, then check volume status.
    • –↑volume ↓Na: CHF, nephrotic, cirrhotic
    • –↑volume ↓ Na: diuretics or vomiting + free water
    • –Normal volume ↓Na: SIADH, Addisons, hypothyroidism
    • –Treatment: Fluid restriction & diruetics
    • –If hypovolemic: Normal Saline
    • –When to use 3% saline: SalineSymptomatic (Seizures), < 110
    • –What would you worry about: 110Central Pontine Myolinolysis
  • ↑Na =Loss of water
    • –Treatment: Replace w/ D5W or hypotonic fluid
    • –What would you worry about: cerebral edema

Other Electrolyte Abnormalities
  • ↓Ca = Numbness, Chvostek or Trousseau, prolonged QT interval.
  • ↑Ca = Bones, stones, groans, psycho. Shortened QT interval.
  • ↓K = Paralysis, ileus, ST depression, U waves.
    • Treatment: give K (kidneys!), max 40mEq/hr↑K
  • ↑K = Peaked T waves, prolonged PR and QRS, sine waves.
    • –Treatment: Give Ca-gluconate then insulin + glucose, kayexalate, albuterol, and sodium bicarb. Last resort = dialysis

Urinary Disorders

Urinary RetentionDecreased urinary output
Urge to void
urethral obstruction
In and Out cath
(post-void residual)
Foley Cath
No Urine Outputno urine outputKinked foley
Unkink and flush foley
Acute Renal Injury-Reduced fluid intake (Nausea)
-Increased fluid losses (vomiting and diarrhea)
-Urinary tract symptoms (BPH -prostatic disease obstruction
-Recent drug ingestion (Paracetamol overdose)
1) Rise in serum creatinine of 23micromol/L/48hours
2) Urine output <0.5ml/kg/hour for 6 hours
Pre-Renal AKI-Dehydration
-Heart failure
-Vomiting and diarrhea-Over diuresis with diuretics
-Burns (Excessive fluid loss through skin)
-Renal artery stenosis
inadequate blood flow to perfuse the kidney (decreased renal perfusion)
Intra-Renal AKI-Vasculitis (inflammation of blood vessels
-Tubulointerstitial nephritis
-Acute tubular necrosis
Post-Renal AKI-Retroperitoneal fibrosis
-renal stone disease
-bladder carcinoma
-prostatic enlargement (BPH – benign prostatic hyperplasia)
-cervical carcinoma
Obstruction to the renal tract (anywhere from the renal pelvis to the urethra)

Fluid and Nutrition

  • Maintenance IVFs: D51/2NS + 20KCl (if peeing)
  • –Up to 10kg: 100mL/kg/day
  • –Next 10 kgs: 50mL/kg/day
  • –All above 20: 20mL/kg/day
  • Enteral Feeds: best to keep gut mucosa intact and prevent bacterial translocation.
  • TPN: indicated if gut can’t absorb nutrients 2/2 physical or functional loss.
  • –Risks = acalculus cholecystitis, hyperglycemia, liver dysfunction, zinc deficiency, other ‘lyte probs