Surgical Intern Survival Guide

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Surgical Intern Survival Guide

• Brought to you by,
• The Chiefs

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Who do you want to be?
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Always remember...

• Dont worry, youre not alone!
• You are just an intern.
• Hierarchy exists for a reason.

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Outline

• I wrote the note - so the pre-ops done, right?

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Outline

• I wrote the note - so the pre-ops done, right?
• The operation is finished - do we still have to
  see the patient?

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Outline

• I wrote the note - so the pre-ops done, right?
• The operation is finished - do we still have to
  see the patient?
• Is now a good time to call the chief?

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Outline

• I wrote the note - so the pre-ops done, right?
• The operation is finished - do we still have to
  see the patient?
• Is now a good time to call the chief?
• What is that thing hanging out of the patient?

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Outline

• I wrote the note - so the pre-ops done, right?
• The operation is finished - do we still have to
  see the patient?
• Is now a good time to call the chief?
• What is that thing hanging out of the patient?
• What does D5 stand for anyway? (a.k.a Is it OK
  to replace Phos?)

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I wrote the note so the pre-ops done,
right?(a.k.a. How to do a pre-op)

• Plan ahead
• Check OR schedule frequently during the day
• Order the necessary labs and films early, so that
  they can be getting done as you work on other
  tasks during the day

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Pre-Op ingredients

• Labs
• Blood products
• Imaging
• Bowel prep
• Review of current medications
• Clearance
• Consent
• Note
• Orders

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Pre-op labs

• CBC
• How low can you go with Hct or Plts?
• Is the WBC count high for an elective case?
• Chem-7
• If any electrolytes need to be replaced, make
  sure you have a repeat chemistry afterwards
  showing the new normal value
• Chasing a low K can keep you up all night, so
  start early
• PT/PTT
• If INR is gt1.3 you might need Vit K or FFP, check
  w/ chief

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Blood products

• Type and screen
• Call the blood bank to confirm that its active
• Typically active for 48-72 hours after the draw
• Hold what you (and your chief) think is necessary
• 2U PRBC for typical abdominal case
• Is the patient on Coumadin or in liver failure?
• Will you need FFP or other products?

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Imaging

• CXR
• Any patient gt 60
• Anyone with a smoking history
• Any pulmonary pathology
• If any question, order it
• Have CTs, MRIs, angiograms available if requested
  by attendings or chiefs

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Bowel preparation

• Is it even necessary?
• Typically used for all colorectal cases
• Attending preference
• Bowel prep mechanical prep chemical prep

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Mechanical

• Sodium Phosphate (Fleets)
• Two doses of 45 ml given 3-6 hours apart
• May cause electrolyte abnormalities
• Avoid in renal failure, cirrhosis, ascites, CHF
• Polyethylene Glycol (GoLYTELY)
• 4L solution over 4-6 hours
• Large volume, salty taste, bloating / cramping
• Fewer water and electrolyte abnormalities
• Tap water enemas

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Chemical

• Neomycin 1 gm Erythromycin 1gm
• Each given for a total of three doses 3-4 hours
  apart
• Alternatives include Cipro Flagyl
• Intravenous antibiotics are also given in the OR

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Pre-Op medications

• Review all medications (home and hospital)
• Cardiac
• Anticoagulants
• Anti-platelet therapy
• Antibiotics
• Insulin

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Cardiac medications

• Continue all cardiac medications perioperatively
• Especially beta-blockers
• Post-op orders should include hold parameters
• Exception is diuretics
• Post-op patients tend to third space, dont want
  to further deplete intravascular volume with
  diuretics
• Hold AM dose on day of surgery
• Resume once taking adequate PO

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Chronic anticoagulation
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What to do?
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Antiplatelet therapy (Aspirin/Plavix)

• No increase in bleeding complications in patients
  taking aspirin preoperatively undergoing emergent
  surgical procedures (Ferraris et al. Surgery,
  Gynecology, and Obstetircs 1983)
• Cardiac surgery patients on aspirin have been
  noted to have increased transfusion requirements
  and rates of reoperation but no differences in
  mortality (Sethi et al. JACC 1990, Goldman et al.
  Circulation 1998)
• No consensus recommendations
• In practice, patients should have any
  anti-platelet therapy stopped 7-10 days prior to
  elective surgery

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DM medications

• Long-acting insulin (e.g., ultralente, glargine)
  should be discontinued 1-2 days before surgery
• Glucose levels should be stabilized with a
  regimen of intermediate insulin (e.g., NPH,
  lente) mixed with short-acting insulin (e.g.,
  regular, lispro, or aspart) twice daily or
  short-acting insulin before every meal
• Patients should receive 1/3 of their intermediate
  insulin dose the day of surgery
• Oral agents are discontinued before surgery
• Long-acting sulfonylureas (e.g., chlorpropamide)
  are stopped 2-3 days before surgery
• Short-acting sulfonylureas, other insulin
  secretagogues can be withheld the night before
  surgery

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DM medications

• Make sure every diabetic has a sliding scale
• Fingersticks should be performed q4 hr or before
  each meal and in the evening
• Patients should receive dextrose-containing
  solutions to avoid hypoglycemia

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Clearance

• Medicine, cardiology, neurology, nephrology,
  psychiatry, neurosurgery
• Need for clearance should be discussed with
  chief, attending, and anesthesia
• Prepare what is necessary for your consultants
  (most patients will require at least an EKG)

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Operative consent

• Think about this early!
• Does the patient have capacity?
• Who is the health care proxy?
• Discuss risks, benefits, alternatives (ask
  seniors or chiefs if unclear)
• Telephone consent requires the telephone operator
  to record the conversation - must record name of
  operator on the consent form

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Mount Sinai consent
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Elmhurst consent
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VA consent
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Pre-op Orders

• NPO after midnight
• includes tube feeds
• make sure the patient and the nurse know
• IVFs to start at midnight
• Medication changes
• Medications necessary on call to OR

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Pre-op Note

• More a formality, but it helps you and others
  review the status, should include
• Procedure
• Labs
• TS and blood availability
• EKG reading
• CXR reading
• NPO status / IVFs
• Consent status
• Medication changes

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Additional pre-operative concerns

• ESRD patient
• When did the patient last have dialysis?
• When do they need it next?
• Minimal IVFs when NPO
• Do they need blood before the OR?
• If a patient is on another service (including the
  SICU), always discuss pre-op status with the
  primary team

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The operation is finished, do we still have to
see the patient?Post-Op Checks

• Should be done 4-6 hrs after the end of surgery
• Check vitals look at trends
• Check urine output minimum of 0.5cc/kg/hr
• Check drain (JPs, NGT, G-tube, etc.) outputs
• Quantity/quality
• Can send fluid for hematocrit or creatinine if
  concerned
• Examine the patient
• Attention to the dressing

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Post-Op Checks

• Labs check post-op labs and order new ones if
  necessary
• Assure that the patient has venodynes and an
  incentive spirometer and an understanding of how
  to use both
• Note record all of the above with a legible,
  dated/timed note

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Is now a good time to call the chief?On-call
problems

• Most surgical emergencies evolve over hours, not
  minutes, take the time to think!
• Fever
• Chest pain
• Hypoxia
• Hypertension
• Hypotension
• Oliguria
• Pain
• Mental status changes
• The clogged/dislodged NG tube

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On-call problems Fever

• Fever T gt 38.2C
• Examine patient with attention to wound and lungs
  
• Fever work-up required if gt48 hours postop or
  clinical condition is not the expected
• CXR make sure it gets done, and f/u result
• CBC
• U/A, UCx, BCx w/ gram stain (both central and
  peripheral) order, draw if necessary, and f/u
• Tylenol
• ? Empiric antibiotics check with chief

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On-call problems Chest pain

• HP
• Is this cardiac? Pulmonary?
• Quality/duration of pain, previous episodes
• EKG
• Compare to old EKGs available in EDR
• Cardiac enzymes q8 x 3
• CK, CK-MB, Troponin (at Mt.Sinai, Troponin must
  be ordered separately)
• Pulse oximetry
• Chest x-ray

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On-call problems Hypoxia

• HP
• Repeat pulse oximetry
• Assure there is a good waveform
• Chest x-ray
• ABG
• Radial a., Femoral a., Dorsalis Pedis a.
• Avoid brachial a.
• CT angio
• Patient will need an 18-gauge or larger IV
  (central line too long for rapid flow)

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On-call problems Hypertension

• Examine patient
• Any associated symptoms, end-organ signs (blurry
  vision, headache, etc)?
• Repeat vitals
• Check BP on both arms using appropriately sized
  cuff
• Treat trends, not single values
• Review meds
• Did the pt skip his/her AM meds?
• Beta-blockers
• Best first-line agents if no contraindications
• e.g. Metoprolol 5mg IV q 6 hrs
• Avoid long-acting agents and diuretics

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On-call problems Hypotension/Oliguria

• Examine patient
• Check foley irrigate or replace if necessary
• Palpate bladder, assess skin turgor, mucous
  membranes
• Is the patient thirsty?
• Review fluid requirements and losses
• Review medication list, hold BP meds, hold
  epidural and narcotics
• This is surgery - think about bleeding!!
• Everyone can tolerate some fluid - start w/ a
  bolus
• Consider steroid withdrawal

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On-call problems Pain

• Examine patient
• Is the pain appropriate for the procedure
  performed?
• Review vitals tachycardia, hypertension
• Review preoperative narcotic use and OR
  requirements
• PCA
• Toradol
• Useful synergistic medication
• Avoid in patients with high bleeding risk or
  renal insufficiency
• Consider pain service consult

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On-call problems Mental status changes

• Think about why
• Hypoxia, sepsis, hypovolemia, hypoglycemia,
  medications, etc.
• Examine patient, get vitals O2 sat
• ABG
• Ask family, nurses re baseline
• Check a finger-stick glucose level
• Review medications
• Hold narcotics, H-2 blockers, psychotropic meds
• Is this narcotic overdose? Check pupils, give
  Narcan.
• Avoid sedatives
• Physical restraints
• Acceptable, especially if patient is at danger to
  self or others

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On-call problems The dislodged NGT

• Examine patient
• Why was it placed initially?
• If clogged, gentle flushing with NS often works
• Is there a danger in replacing the tube?
• Do not replace an NGT if placed intraoperatively
  during upper GI surgery
• Same for rectal tubes and lower GI surgery

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On-call problems Codes

• You MUST go to a code if your team has a patient
  on that floor
• Even if you have no idea what youre doing, you
  can start by
• Call for Team 7000
• Get the crash cart into the room
• Start with your ABCs
• Get the EKG monitor / defibrillator paddles on
  the patient to check the rhythm
• Help is on the way!

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Whats that thing hanging out of the
patient?Lines, drains, and tubes

• Post-op check
• CXR to check position and r/o pneumothorax
• Look at the site (esp. in a febrile pt)
• Record what date catheters are placed

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Triple lumen catheterShort-term central venous
catheter typically placed for TPN or Abx or
simply for access in patients with poor
peripheral veins
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Hickman/Broviac Long-term tunneled central
venous catheter typically placed for TPN or Abx
or simply for access in patients with poor
peripheral veins
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Shiley catheter

• Short-term large bore dialysis/apheresis catheter
  
• Needs to be flushed with heparin 1100 U solution
  using exact volume labeled on catheter

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Permcath

• Long-term tunneled dialysis / apheresis access
  catheter
• Needs to be flushed with heparin 1100 U solution
  using exact volume of catheter

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PICC Peripherally inserted central catheter

• Long-term catheter placed typically for TPN or
  Abx
• Really not for blood draws (clogs easily)
• Flush well if used

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PortacathCentral venous access with subcutaneous
reservoir typically placed for chemotherapy or in
patients with poor peripheral access who require
other IV medications or transfusions
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Dont forget about me.the external jugular vein
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.or methe arterial line

• Excellent source for blood draws in patients with
  poor venous access

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Other tubes / drains

• JP
• Penrose
• Hemovac
• NGT / Salem
• Gastrostomy and jejunostomy tubes
• Rectal tubes

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Jackson-Pratt drain

• Always check to make sure suction is working
• Strip on daily AM rounds

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Penrose drain
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Hemovac drain
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Nasogastric tube

• Salem sump should be placed to low continuous
  suction with the blue port open to air
• Clear port should be flushed q8 hr with 20 cc NS
  while the blue port should be flushed q 8 hr with
  air
• Single-lumen tubes should be placed on
  low-intermittent suction
• Never ever use an NGT for feeding unless youve
  checked an x-ray

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Gastrostomy and Jejunostomy tubes
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What does D5 stand for anyway? IVFs
Electrolytes

• Replacement Solutions isotonic solutions used
  to replace volume for pts who are hypovolemic
  from dehydration or bleeding
• Normal Saline (NS) just 0.9 NaCl
• Lactated Ringers (LR) glucose, Na, Cl, K, Ca,
  Lactate (converted to HCO3 by liver)
• Plasma-Lyte Na, K, Cl, Mg, Acetate

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IVFs Electrolytes

• Replacement solutions are typically given in 1L
  boluses
• Patients w/ sepsis, DKA, burns, trauma,
  pancreatitis may need many liters
• If patient w/ CHF can give 500cc over 1 hour and
  assess lung exam

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IVFs Electrolytes

• Maintenance Solutions
• hypotonic solutions used to replace normal fluid
  losses in an NPO patient
• Typically D5 ½ normal w/ 20 of K
• 5 Dextrose, 0.45 NaCl, and 20mEq of KCl

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IVFs Electrolytes

• Notes
• For ESRD patients, run fluids at 30-50cc/hr
• For pts w/ CRI or ESRD dont add K to
  maintenance fluids and dont replace K if mildly
  low (remember, its going to rise by itself until
  dialysis)
• Never bolus a patient w/ D5 or K
• If replacing GI losses, use a comparable fluid
• Diabetics need sugar too (OK to use D5 ½)

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IVFs Electrolytes

• Parenteral Nutrition
• TPN via central line or PICC
• PPN via peripheral line
• Should taper at ½ rate for an hour before
  stopping TPN
• If need to D/C, run D10

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IVFs Electrolytes

• Potassium
• If pt is taking PO, give oral replacement
• If Cr normal, can give lots PO safely
• Runs of IV if NPO
• Risk of arrhythmia - can only run 10 mEq of KCl
  per hour
• 20 mEq / hr in a monitored setting like ICU
• Actual deficit is larger than you might think
• eg. for K3.2 will likely need 10mEq IV x 4 or
  40mEq PO x 2

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IVFs Electrolytes

• Calcium
• If calcium is low, first adjust for albumin
• Can also check an ionized calcium instead
• If mild, give PO calcium carbonate (TUMS)
• If symptomatic, give calcium gluconate IV
• If head/neck surgery, may have inadvertently
  injured the parathyroids?

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IVFs Electrolytes

• Phosphate
• Often see drop in patients undergoing major
  hepatic resection
• Replace w/ PO NeutraPhos or IV K-Phos
• Magnesium
• Important to check Mg level if K is low
• Be cautious repleting electrolytes on ESRD pts

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IVFs Electrolytes

• Glucose
• If blood sugar is 50-80 can just give patient
  some juice and observe
• If lt50, or if patient is symptomatic (altered
  mental status, diaphoretic) push an ampule of D50
  x 1 stat

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Discharge planning

• Think about early and discuss with team
• Involve Social Work and Physical Therapy early
  when necessary
• Enter IDP (implement discharge plan) in TDS when
  discharge is planned in the next 24 hours
• Write prescriptions clearly and legibly in a
  timely fashion
• Complete discharge summaries before the chart
  disappears

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• ER 4-6639
• Blue slip 877.337.4624
• Main Pharmacy 4-7714
• ID drug approval p9407
• Main Labs 4-LABS
• Stat Lab 4-3895
• Blood Bank 4-6101
• Pathology 4-7373
• Main Radiology 4-7401
• Ultrasound 4-7431
• CT 4-7412
• Special Procedures 4-7409
• DAS 4-7778
• Bed Board 4-7461
• Main OR desk 4-1990
• PACU 4-1992
• Dictation line 8-9889
• Line service p1872

• 11W 4-5826
• 10E 4-3595
• 9E 4-7935
• 9C 4-7944
• 8E 4-7939
• 7W 4-7929
• SICU (6E) 4-5111
• MICU (5W) 4-5721
• Radiology on call p1490
• Surgical clinics 824-7606
• MEs Office 212-447-2030
• Sinai Surgery Office 4-5871
• Elmhurst Surgery Office
• 718-334-2475
• Englewood Surgery Office
• 201-894-3141
• Bronx VA Operator
• 718-584-9000

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Some last words of advice

• Always leave a dated / timed note for every
  encounter
• Trust no one! (always repeat the exam yourself,
  always re-check important labs, etc)
• Be meticulous you cannot remember everything,
  make detailed lists, cross off items as you go
• Never lie. The chief would much rather hear "I
  don't know for sure" rather than passing on
  incorrect information. You will find that
  admitting what you don't know is an very
  important part of "first do no harm".

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Some last words of advice

• and have fun!