Stimulation of bowel movement after major surgery
Chewing gum accelerates bowel recovery
Drugs: Alvimopan and mosapride improve ileus
Factors reducing post-op resp Cx
Adequate analgesia
Reversal of neuromuscular blockade
Normothermia
Extubation at the end of surgery
Chest physio
Early mobilisation
KDIGO Criteria
RIGLE Criteria
Pathogenesis of tubular injury after major surgery
4 mechanisms
- baseline pre-disposition
- haemodynamic disturbances
- nephrotoxic insults
- inflammatory responses
Inflammatory mechanisms play a central role, causing both direct cellular injury and inflammation-induced microcirculatory dysfunction
Mechanims in Cardiac surgery associated AKI
- ischaemia–reperfusion injury
- exogenous and endogenous toxin
- inflammation
- oxidative stress
- vasodilation
CPB» systemic inflammatory mediators
Haemolysis leds to haem induced oxidative injury
Complications of liver resection
Infection
Bile leak
Coagulopathy
Biliary fistula
Post hepatectomy liver failure
Post hepatectomy hemorrhage
Post op anaemia
Hypophosphatemia
Hyperlactataemia
What is safe Future Liver Remnant (FLR) vol?
● 20% in those with normal LFTs
● 30-40% if severe steatohepatitis or received hepatotoxulic chemotherapy
● 50% in those with cirrhosis
Estimating hepatic functional reserve
◇ CT and MRI to estimate FLR
◇ FLR correlates with pist op liver function and risk of PHLF
◇ Dynamic function assessed by degree of retention of indocyanine green dye
°If >15% of dye remains in plasma 15min after injection, it suggests impaired hepatic clearance
Complications of bariatric surgery
Thyroid replacement in hypothyroidism
Thyroid hormone replacement
* IV liothyronine (T3) e.g. 0.2μg/kg QDS
* IV levothyroxine (T4) e.g. 200-500μg IV over 5-10mins followed by 50-100μg daily
Steroid cover due to impaired ACTH response e.g. 100mg hydrocortisone IV stat then 25mg QDS
Scoring systems to aid diagnosis of thyroid storm
Burch and Wartofsky Point Scale (1993)
Akamizu Criteria (2012)
Medical management of hyperparathyroidism
Rehydration; may require several litres of crystalloid to replace deficit and dilute calcium
Decrease skeletal release of calcium
* Bisphosphonates e.g. pamidronate 60mg/500ml 0.9% NaCl over 4hrs
* Calcitonin 3 - 4U/kg IV, followed by 4U/kg SC BD
Other methods for reducing calcium
* Phosphate 500ml of 0.1M solution over 6 - 8hrs
* Furosemide diuresis e.g. 40mg IV every 4hrs
* Haemodialysis
