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da3dl3us

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Hey All,

I got pimped by my surgery attending, and trying to find some definitive answers to give to him for tomorrow:

1. 4 Antibiotic prophylaxis before surgery - From what I gathered, I got 1st gen cephalosporin for gram + coverage (i.e. staph) and metro for anaerobe coverage. What are the other 2?

2. Fluid management immediately post op - The fluids are either LR or .9 NS, but what is the formula for the initial bolus? Is it the 4-2-1 rule for Adults as well?

3. Pain Management post op - What is the standard meds? PCA morphine, MS Contin, and anything else?

Thanks!
 

JkGrocerz

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im not a surgeon but i hope this helps

1. ancef....give at least 1 hour before incision is made. generally if its a dirty surgery they might clean out the bowel with some go lytely the night before
2. for the first 24 hours its LR. boluses are always 20cc per kg and in adults you with no cardiovascular issues you can give them 125cc an hour. if they are older, or with any sort of cardiac hx, 83 cc an hour is fine. maintenance is usually D5 half normal saline until they are eating and drinking. then you dc ivf
3. pca is common, sometimes prn morphine, it all depends on the surgery
 

dynx

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Hey All,

I got pimped by my surgery attending, and trying to find some definitive answers to give to him for tomorrow:

1. 4 Antibiotic prophylaxis before surgery - From what I gathered, I got 1st gen cephalosporin for gram + coverage (i.e. staph) and metro for anaerobe coverage. What are the other 2?

2. Fluid management immediately post op - The fluids are either LR or .9 NS, but what is the formula for the initial bolus? Is it the 4-2-1 rule for Adults as well?

3. Pain Management post op - What is the standard meds? PCA morphine, MS Contin, and anything else?

Thanks!

I've never seen anyone give 4 antibiotics before the procedure just for prophylaxis so Im not sure what you're asking in number one.
Ussually, they give Ancef for everything including the GI tract above the duodenum. If the procedure is below the Duodenum you'll need anarobic coverage so use (traditionally) a second generation cef but now they use a 3rd generation and Flagyl instead. For cardiac prophylaxis in the case of a valvular problem or Hx. of endocarditis you'll need amoxicillin or...if complicated (look it up) amp and gent or Vanco if Hx. of MRSA. So the only way possible I could see 4 antibiotics would be a colon surgery in the case of a person with valve disease where you would possibly give Amp, Gent, Ceftaz and Flagyl. If this is his answer tell him to get an ID consult to help him with his ABX managment because you dont need them all.

Fluid post op. A bolus in an adult is generally not that hard 500ml or 1L full open, if they don't have a heart condition.

Post op start with the big guns (PCA) and wean down from there, you don't want to get behind.
 
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in terms of fluid replacement post op you need to take several things into consideration
1. resuscitation: you need to give the following fluids over the next day, the first half over 8 hours and second half over next 16.
-replace all blood loss with 3 times as much crystalloid (look up 3:1 rule)
-replace urine output (i think- ive heard yes and no?)
-patients who have been open on the table for a while (large laparotomy) have insensible losses, these fluids need to be replaced as well.
-patients have likely been NPO for at least 8 hours. you need to calculate their maintenence fluids (for example say 100cc/hr, use 4-2-1 rule) and replace those fluids as a bolus as well. 100cc/hr for 8 hours would be an additional 800cc for resuscitation

2. maintenence
once the patient has been resuscitated, then you use the 4-2-1 rule to calculate their maintenence fluids for the rest of their hospital stay. use D51/2NS in adults and D51/4NS in children (less able to concentrate urine)

in terms of pain control- morphine or dilaudid pca to start with. may need a basal rate on the pca (continuous baseline infusion of narcotic if pt has a lot of pain). can switch to PO pain meds once thinking about sending patient home- percoset, dilaudid
 

SOUNDMAN

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Orally once they can start taking stuff you may need to use a long acting morphine or oxycontin with an additional, short acting, Lortab, etc) for break through pain for some things like orthopedic surgeries etc. The goal of course is to wean them off the long acting as soon as possible. Don't forget obvious bowel things of course that can happen with all these wonderful meds.
 
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