General Surgery – FMGE quick revision

1. Causes of post op fever

- POD 1- atelectasis
- POD 2-3 – UTI is the most common cause of hospital acquired infection; Superficial
thrombophlebitis is the most common complication after IV line insertion
- POD 4-5 – Surgical site infection (SSI) is the most common hospital acquired infection in
surgical patients
- POD 6 – burst abdomen can occur (salmon fluid sign)
- POD7 and beyond – intra-abdominal collections (most common site is pouch of douglas)

2. Prevention of wound infection

- Best way – Hand washing
- Prophylactic antibiotics – 30 mins to 1 hour before surgery; repeat dose after 4 hours in
prolonged surgery
- Clipping of hair is the best way to remove hair from an operative site
- Abdominal surgery – part should be cleaned from nipples to mid thigh

3. Types of wounds
Type Examples %SSI
Clean wounds Clean incised wound, <2%
Thyroid & breast surgery,
Knee replacement
Clean contaminated Abdominal or urological 2-10%
surgery when there is no
inflammation.
Elective cholecystectomy
and appendicectomy
Bowel surgery in a prepared
bowel
Contaminated Abdominal or urological 10-20%
procedure when there is non
purulent inflammation.
Emergency chole &
appendicectomy
Surgery in bowel obstruction
Dirty - Wounds with >20%
pus
- Peritonitis

4. Enteral nutrition is better than parenteral.

NG tube – length to be inserted is measured from tip of nose to ear lobule and from ear
lobule to xiphisternum
Most common complication of enteral nutrition – Tube related complications
Most common feeding regime complication – osmotic diarrhoea
5. Parenteral nutrition
- Best route – central lines
- Least preferred – peripheral IV line
- Most common tube related complication – catheter induced sepsis
- Most common overall complication – hyperglycemia
- Re-feeding syndrome – hypokalemia, hypophosphatemia, hypomagnesemia. Death is
due to CHF & arrythmias

6. Remember the colour coding of IV lines

7. Hypovolemic shock

Best indicator to determine amount of fluid required – PCWP > CVP

Best CLINICAL indicator for fluid resuscitation – urine output
New end point of resuscitation – MVOS (mixed venous oxygen saturation)

8. Massive blood transfusion – more than 10 units in 24 hours or if we replace entire blood
volume in 24 hours
Complications –
- Hypothermia
- Hypocalcemia
- Hyperkalemia followed by hypokalemia
- Coagulopathy (therefore ratio of PRBC:FFP: plt – 1:1:1)

9. Hemorrhage
- Primary – surgery
- Reactionary – within 24 hours; due to dislodgement of clot
- Secondary – after a few days; due to infection
- Venous bleeding is more difficult to manage

10. Neurogenic shock – Bradycardia and hypotension

Distributive shocks – neurogenic, anaphylactic and septic
Obstructive shock - cardiogenic