Surgery Cheat Sheet

Here are some things that your surgery rotation cheat sheet should contain. I suggest making a cheat sheet for every rotation with pertinent information that 1) you will need daily or 2) you can study during down time when you don't have a book with you.

Blood Products:

RBC - 1 unit of PRBCs increases Hct about 3-4 pts
When to give it? symptomatic anemia, hemorrhage, continuing blood loss, low Hct (< about 21-30 this differs at different institution, but the literature say 21)

Plts - 1 unit of plts increases plts about 5-10K (often given in "6 packs" - 6 units)
When to give this? Plt count of less than 20K because it can result in spontaneous bleeding or plt count of <50 with active bleeding or if pt is prepping for the OR.

Layers of the Abdominal Wall (8) *favorite pimping question

1. skin
2. subcut tissue
3. scarpa's fascia
4. external oblique
5. internal oblique
6. transversus abdominus
7. tranversalis fascia
8. peritoneum

Post-Op Fever Workup (The W's)

Wind = pneumonia, atelectasis (esp 1-2 days post-op)
Water = UTI (esp if pt has foley)
Wound = Abscess or infx (5-7 days)
Walk = DVT, PE (get your pts out of bed [OOB])
Wonder drugs = Drug fevers (esp if on antibx for long time or new meds)
Whole blood = transfusion rxn

Causes of Fistulas *another favorite pimping question

"FRIENDS"
Foreign body
Radiation
Inflammation
Epithelialization
Neoplasm
Distal obstruction

IV to PO Antibx Changes When D/Cing Patients

Unison IV --> Augmentin PO
Levoquin IV --> Cipro PO
Kefzol, Ancef, Rocephin IV --> Keflex PO

Essential Meds for Surgery = 6Ps

PRNs
Tylenol 650 PO/PR q4-6hrs PRN (do not exceed 4g in 24hrs)
Reglan 10mg PO/IV with meals (30min prior)
Zofran 8mg PO/IV q8hrs PRN
Ambien 5-10mg PO before bed
Benadryl 25-50mg PO/IV q4-6hrs PRN

PAIN
Morphine 2.5-5 mg IV q2-3 hrs PRN
Demerol 25-50 mg IV q3-4 hrs PRN
Dilaudid 1-4 mg IV q4-6hrs PRN
Percocet 325/5mg 1-2 PO q4-6hrs PRN (Tylenol + Oxycodone HCl)
*Remember to take into account that Percocet contains Tylenol - esp if your pt is on a standing dose of Tylenol daily
 Vicodin 500/5 1-2 tabs PO q4-6hrs PRN

PROPHYLAXIS
Protonix 40mg PO/IV daily
Heparin 5000 U SQ q8-12hrs

POOP
Docusate 100-200 mg PO twice a day

PARASITES (Antibx) 
*These are only prophylactic doses
Ancef (Kefzol) 1g IV q6hrs
Unasyn 1.5-3g IV q6hrs
Zosyn 3.375 IV q6hrs
Metronidazole 500mg PO QID
Cefoxitin 1-2g IV q6-6 hrs

PRE-OP MEDS
Don't forget to start pt back on home meds when appropriate!

*NOTE: Drug dosages listed are *general* you must obviously take into account your pt's comorbidities and current condition. This list is meant only to be a reference for you while you are on your surgery rotation to help you think systematically about post-op patients. Be aware of medication SE and complications prior to giving them!

Levothyroxine vs Brand-Name

I vaguely remembered a comment from our endocrine teacher about not putting our patients on generic levothyroxine for hypothyroidism and that we should always opt for a brand name if the patient could afford it -- but the exact reason why had escaped me. I was recently presented with a situation in which I needed to make the call - generic vs brand - so I did some research and spoke to an endocrinologist. These are the main points that I came up with...

1. For tight control of TSH, use a brand name (which brand isn't important)
2. Tight control is particularly important in pregnant women, those looking to get pregnant, and those with h/o goiter or thyroid cancer
3. Once you pick a brand, try to stick to the same brand-name each month
4. The problem with generic levothyroxine is that the manufacturers producing the drug are variable and there are many companies moving in and out of the market so it is difficult to get the SAME generic pill each month from the pharmacy
5. If your pt can only afford generic, encourage them to take a photo of the pills that they get from the pharmacy - if they ever pick up their Rx and the pills look different then they should contact you to schedule thyroid blood work check in 5-6 weeks since the new generic could vary as much as 12.5%. If they are receiving the same generic pill each month, you should schedule normal follow ups. The bottom line is that each time they get a new generic pill from a new manufacturer, they should be re-tested.

This becomes important because many primary care providers Rx the generic because they believe that it isn't any different from brand names - and in most cases they are completely right. Ibuprofen vs Advil - no real noticeable clinical difference. The thyroid, however, is extremely sensitive and even the slightest variation from generic #1 to generic #2 can make someone's TSH impossible to tightly control and may even make them thyroid toxic.

When I presented this to several PCPs, it was received with a lot of skepticism. The first question they all asked was "Who did the study, the drug companies?" A great question to ask. The answer is... in addition to drug company studies... there have been independent studies and results have been examined by the FDA, Endocrinologist Societies (world-wide), and the Thyroid Association - all are in agreement about the results. There is a ppt available describing the results of these studies. They show the bioequivalence of generic vs brand, but also demonstrate the vast variability between generic manufacturers.

If you are looking for a quick 1 page break down of this subject - check out the following: Hennessey JV. Levothyroxine dosage and the limitations of current bioequivalence standards