The SNU Manual of Surgical Care 5 Edition

By Department of Surgery, Seoul National University College of Medicine

This book serves as a concise surgical manual that quickly references the latest information essential for determining the policies of surgical patient care and pre-and post-operative treatment. It is a necessary guide not only for surgical residents and medical students but also for practicing surgeons.
Features of this book:
1. Provides information on surgical care through a systematic approach to surgery-related topics.
2. Reflects the latest research findings and recommendations on the rapid development and evolution of the surgical field.
3. Covers a wide range of topics and areas in surgical surgery, including patient management before and after surgery, basic techniques and procedures, management of complications, fluids, and nutrition.
4. Offers practical guidance that can help in real surgical situations and practice.
5. Available in a pocket size that can be easily referred to at any time.
6. An English edition that can be referenced by medical professionals both in the Korea and abroad.
Table of contents
Contributors
Preface to the 5th edition of SNU Manual of Surgical
Preface to the 1st edition
Preface to the 2nd edition
Preface to the 3rd edition
Preface to the 4th edition
I. Basic Considerations
01 Surgical Infections and Antibiotics
02 Fluids and Nutrition
03 Critical Care Medicine
04 Surgical Complications
05 Preoperative Evaluation and Management for Medical Disease
06 Basic Surgical Skills
07 Symptomatic Surgical Management
II. Specific Considerations
01 Liver
02 Bile Duct and Pancreas
03 Gastrointestinal Tract
04 Small Intestines
05 Colon, Rectum and Anus
06 Breast
07 Endocrine
08 Vascular 491
09 Kidney and Pancreas Transplantation
10 Pediatric Surgery
11 Trauma
12 Liver Transplantation
Index

• Language: English
• Publisher: PANMUN
• Release date: Mar 13, 2024
• ISBN: 9791159434235

Book preview

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THE SNU MANUAL OF SURGICAL CARE 5th Edition

Copyright © 2023 Department of Surgery Seoul National University College of Medicine, SNUH

All Rights Reserved. This book is protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publisher.

Used with the permission of the American College of Surgeons. Amin, M.B., Edge, S.B., Greene, F.L., et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017

Paper Back

ISBN: 979-11-5943-405-1 (93510)

eBook

ISBN: 979-11-5943-423-5 (95510)

First Printing : Jul. 15th. 2023

Book size : 127*188 mm

Publisher / Panmun Education Co., Ltd. Sung Kwon Liu 211,

                 Mokdongseo-ro, Yangcheon-gu, Seoul, 07995, Korea

www.medicalplus.co.kr, [e-mail]

Managing Editor /Jai Seon Lee

Editor /Jee in Yu

Marketing /Tae Wan Lim, Ho Chul Kim, Sung Gue Choi, Myoung Han Jung, Tae Su Han, Jin Hyung Kim, Mo Ran Kim, Ye ren Noh, So young Kim, Yun sook Lee

Printed in South Korea

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A

surgeon is a medical doctor who treats patients with surgery, which includes open surgical, interventional, and medical treatment. The word surgeon comes from the Greek kheirourgos, which means done by the hand. A surgeon literally means a doctor treating the patients with his/her hands. In old English proverb, a good surgeon should have an eagle’s eye, a lady’s hand, and a lion’s heart. Knowledge, skills, and a warm or unbreakable heart are essential components to be a successful surgeon.

This manual is designed to serve as a practical guide for surgeons in training, as well as a reference for practicing surgeons. As the faculty of the Department of Surgery, Seoul National University Hospital, one of the most leading academic center with excellence in Korea, we have published the manual for residents and medical students in a clear and concise manner. Since the first edition of the manual was published in 2010, we have revised the manual every few years to keep pace with the rapidly evolving field of surgery. And now, we publish the 5th edition in English to help doctors from other countries.

We are delighted to present the 5th edition of The SNU Manual of Surgical Care, which reflects the latest developments in surgical treatments and care. This edition has been meticulously revised and updated to provide a comprehensive and authoritative guide to surgical care. We are confident that this latest manual will be a valuable resource for surgical residents, practicing surgeons, and medical students alike. We extend our heartfelt thanks to all the contributors, editors, and staff who have worked tirelessly to produce this edition, and we hope that it will continue to serve as a trusted guide to surgical care for many years to come.

May 2023

Seung-Kee MIN,

Professor and Chairman,

Department of Surgery,

Seoul National University College of Medicine

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T

he manual was made for the residents at the front lines of surgical patient care, both before and after surgery to facilitate convenient decision-making and treatment direction. There are many surgical manuals, both domestic and foreign, that are useful for caring for surgical patients. In 1993, our hospital published a booklet titled ‘A Resident handbook’. However, many parts of the manual are not appropriate for our reality and deviated considerably from clinical principles and practices being implemented at Seoul National University College of Medicine. Additionally, surgical treatments have undergone significant changes and advancements over time, with an increase in surgical patients and diversified disease patterns.

As a result, we decided that a new manual should be created for the residents who are busy caring for a wide range of differentiated patients before and after surgery. The revised ‘The SNU Manual of Surgical Care’ is intended for our hospital’s residents, but we are confident that it will also serve as a valuable reference to the residents, fellow doctors and certified board doctors who are closely involved in patient care. The manual’s format was designed to be easy to carry and read. The details have been simplified in modified style rather than a descriptive pattern, and most of the figures have been newly created. The writing of the manual was primarily carried out by young doctors and fellow doctors in our hospital, with editing done by senior residents and mid-level professors.

I express my gratitude to everyone who contributed to and supported the creation of this manual. While there may be some deficiencies and emerging new guidelines following its completion, we assure you that these matters will be addressed and corrected in future revisions.

February 2010

Sun-Whe KIM,

Professor and Chairman,

Department of Surgery,

Seoul National University College of Medicine

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T

he 1st edition for the residents was published 2 years ago, and a new version has finally been published for working on it for 1 year. This decision was made by our department to release a revised version every two years, given the rapid changes and advancements in surgical treatments. Young professors played a major role in its creation, but follow doctors from every departments, who are certified board surgeons and have firsthand experience in clinical care, also contributed significantly.

Collaborating with fellow members provided a valuable opportunity to take responsibility for their respective parts and consolidate knowledge and expertise in general theories and other fields. I want emphasize that the content in each section has been enhanced in terms of trustworthiness and authority through verification by corresponding professors. It was unfortunate that the first edition could not meet the surprising demand from surgical residents, young board surgeons, and students due to insufficient printing. I hope that many doctors will purchase this new edition. Once again, I express my gratitude to the young professors, fellows, and hospital staffs who attended numerous meetings and participated in practical work for its publication.

January 2012

Sun-Whe KIM,

Professor and Chairman,

Department of Surgery,

Seoul National University College of Medicine

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I

n 2010, our department published the 1st edition of ‘The SNU Manual of Surgical Care’ which incorporated the latest knowledge in general surgery. The revised edition was published in 2012, and now, we present the 3rd edition. We made the decision to create a revised version to encompass the most recent clinical practices, as examination skills and treatments for surgical diseases are rapidly advancing. This edition reflects practical guidelines in clinics.

The revision was based on the practical work conducted by young professors and fellow members who are actively involved in the treatment and care of patients before and after surgery, taking into account the valuable opinions of surgical residents. We believe this manual will serve as a comprehensive guide for surgical treatments and postoperative care, especially for busy residents who are faced with a diverse and increasing number of surgical patients and varied disease patterns.

While ‘The SNU Manual of Surgical Care’ primarily caters to the residents in our hospital, we are confident that it will also serve as a valuable reference for residents, fellow doctors and certified board doctors who are closely involved in patient care. The writing of the manual was mainly done by young doctors and fellow doctors in our hospital, with editing performed by senior residents and experienced professors.

Although there may be some areas that require further improvement and new guidelines that have emerged since its completion, we assure you that these matters will be corrected and addressed in further revisions. I express my gratitude to young professors, fellows, and staff members of the hospital who dedicated their time to numerous meetings and practical work for the publication of this manual.

March 2015

Kyung-Suk SUH,

Professor and Chairman,

Department of Surgery,

Seoul National University College of Medicine

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T

he remarkable development in modern medical sciences can be attributed to the introduction of big data and artificial intelligence, as well as the advancement of new medical instruments. Consequently, there is a growing need to focus on specialized medical areas. However, it is essential to have a solid foundation of basic and general knowledge in order to effectively examine and treat patients in specified fields. In this regard, it is evident that being familiar with the latest theories on non-major parts can be a valuable tool for appropriate patient care.

In 2010, our department published ‘The SNU Manual of Surgical Care’, which provided a concise review of the latest theories in general surgery based on realities of Korea. Revised editions were subsequently published in 2012 and 2015. Initially, these manuals were created to aid residents in the treatment and care of surgical patients before and after surgery. However, the continuously updated manuals have proven to be of great assistance not only to residents and certified board surgeons in specific specialties but also to doctors in other departments and medical students.

Now, in the midst of a rapidly changing medical environment and the continuous development of new theories in the field of surgery, we are proud to publish ‘the 4th edition’. This edition incorporate the latest theories that are relevant to our reality and aligns with the medical treatment guidelines implemented by the Department of Surgery at Seoul National University College of Medicine. It was developed with the expertise of professors and fellow doctors specializing in specific fields. I am confident that it will be valuable not only to doctors outside the surgical realm but also medical student.

Lastly, I would like to express my deep gratitude to all members of the department who devoted their time to contribute to the creation of this manual, despite their demanding schedules filled with patient care, researches, and education.

April 2019

Kyu Joo PARK,

Professor and Chairman,

Department of Surgery,

Seoul National University College of Medicine

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Contributors iii

Preface to the 5th edition of SNU Manual of Surgical Care v

Preface to the 1st edition vii

Preface to the 2nd edition ix

Preface to the 3rd edition xi

Preface to the 4th edition xiii

I   Basic Considerations

01 Surgical Infections and Antibiotics

02 Fluids and Nutrition

03 Critical Care Medicine

04 Surgical Complications

05 Preoperative Evaluation and Management for Medical Disease

06 Basic Surgical Skills

07 Symptomatic Surgical Management

II Specific Considerations

01 Liver

02 Bile Duct and Pancreas

03 Gastrointestinal Tract

04 Small Intestines

05 Colon, Rectum and Anus

06 Breast

07 Endocrine

08 Vascular

09 Kidney and Pancreas Transplantation

10 Pediatric Surgery

11 Trauma

12 Liver Transplantation

Index

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1.1 Surgical Site Infection (SSI) 

1 Definition

• Infections occurring at the surgical site within 30 days after a procedure

• The most common and costly of all hospital-acquired infections

• Accounts for 20% of all hospital infections

2 Classification

Table 1-1 CDC/NHSN Classification of SSI

3 Risk Factors

4   Determining Factors for Infection Prevention

5   Surgical Wound Classification

1.2 Types of Surgical Site Infections

• Strains of surgical infections are often mixed aerobic and anaerobic, and most of them are induced from the patient’s endogenous flora.

• The basic principle of treatment should be controlling the source.

➊ Drainage of the abscess

➋ Debridement

➌ Closure of the perforation

➍ Relief of intestinal obstruction through diversion

1 Non - necrotizing Soft Tissue Infection

1) Subcutaneous Abscess: a semiliquid central portion (pus) without blood supply composed of marginal tissue debris, dead white blood cells, and bacteria, and showing symptoms such as local edema and tenderness. The pus must be drained or removed for the issue to be resolved.

2) Cellulitis: an acute inflammatory reaction with normal blood supply and living tissue, engorgement of small blood vessels, stasis, endothelial leakage, interstitial edema, etc. If it does not progress to tissue necrosis, it is usually treated with antibiotics.

3) Empyema: the collection of pus in a cavity in the body (ex. GB empyema, pleural empyema).

2   Necrotizing Soft Tissue Infection

1) Characteristics

(1) Rapidly progressing skin and soft tissue infections associated with necrosis of the dermis, subcutaneous tissue, superficial fascia, deep fascia, or muscle.

(2) Rapid progression, irreversible tissue necrosis, high rates of sepsis, and mortality rates (10-25%).

(3) Prognosis depends on early recognition and administration of appropriate treatment as soon as possible.

2) Clinical Features: erythema, warmth, pain, systemic illness.

3) Treatment

(1) Surgery: the affected tissue should be sharply excised leaving a rim of normal tissue of at least 1 cm.

(2) Antibiotics: broad-spectrum antibiotics should be initiated as soon as possible.

→ De-escalated to one or two agents, once the patient is clinically improving and culture results are available.

(3) Resuscitation: patients demonstrating sepsis and septic shock should be managed in an intensive care unit (ICU) using the standard guidelines for sepsis.

(4) Wound care and reconstruction: large soft tissue defects require extensive reconstructive procedures once the patient has recovered from the acute episode.

3 Operating Room Manual to Prevent Wound Infection

1) Clean the surgical site with an antiseptic (tincture of iodine; alcohol-containing iodine, povidone iodine, chlorhexidine, etc.) before surgery.

2) Hair removal: this is generally not required, but if it is performed, use clipping or hair removal agents rather than shaving and perform it only at the surgical site immediately before surgery.

3) After disinfection of the surgical site, put on a surgical drape and wear two pairs of sterile surgical gloves.

4) Disposable foam is recommended rather than re-sterilized foam.

5) Traffic rules: minimize movement in and out of the operating room.

6) The surgical team should scrub for 5 minutes for the first operation of the day and 3 minutes for subsequent operations.

7) Use of monofilaments to reduce the chance of bacterial growth in highly infected wounds.

8) For drainage, it is recommended to use a closed rather than an open drainage tube.

9) Avoid excessive tension during skin suturing and reduce dead space as much as possible.

10) Postoperative Oxygen Supply: increases the partial pressure of oxygen at the wound site to activate neovascularization.

11) Delayed Primary Closure

(1) Initially, only the fascia is sutured, and the wound is sutured later after it is confirmed there are no signs of infection.

(2) On the 5th day after surgery, phagocytic activity and capillary budding at the surgical site are the most active, so it can reduce the rate of wound infection.

12) Careful Observation of Wound Infection: erythema, swelling, pus

1.3 Principles and Indications for Antibiotics 

1 Prophylactic Antibiotic Administration

1) General principles

(1) Prophylactic antibiotics are not required for clean surgeries.

➊ Mastectomy, hernia surgery, etc.

(2) Colon surgery: use a combination of oral non-absorbable antibiotics and injection antibiotics.

(3) Inject antibiotics within one hour after starting the skin incision.

➊ Vancomycin or fluoroquinolone within two hours.

➋ Injection 1 hour before or after the formation of a fibrin film, after surgery, or after wound closure, has no effect.

(4) One injection is sufficient and one additional injection is given 4 hours after surgery or after the half-life or twice the half-life of the drug.

(5) Antibiotics to prevent infection of the central line, urinary catheter, drainage tube, chest tube, tracheostomy, and open wound are unnecessary.

2) Indications

(1) High-risk gastroduodenal surgery: gastric cancer, ulcer, intestinal obstruction, and bleeding

(2) High-risk biliary tract surgery: 60 years of age or older, acute infection, biliary stones, jaundice, history of biliary tract surgery, endoscopic biliary tract surgery

(3) Colon and small intestine resection anastomosis

(4) Vascular surgery: lower extremity arteriovenous surgery, and abdominal aortic surgery

(5) Surgery requiring artificial structure insertion

(6) Surgery on wounds with a bacterial infection

(7) Wounds with significant contamination and tissue damage

(8) Wounds susceptible to infection by Clostridium perfringens due to extensive muscle necrosis

2   Therapeutic Antibiotic Administration

• Used in most surgical infections except for minor infections; antibiotics are administered intravenously.

1) Matters to be considered when antibiotic administration is ineffective

(1) Inappropriate dose and drug interactions

(2) Presence of necrotic tissue or abscess

(3) Presence of resistant bacteria

(4) Drug fever

(5) Presenting complications

(6) Presenting superinfections

(7) Maintaining the proper concentration of antibiotics in the body.

(8) Incorrect choice of antibiotic

(9) The need to add new antibiotics.

2) Determining when to stop antibiotics

(1) Normal body temperature for more than 48 hours

(2) Normalization of the state of consciousness

(3) Normalization of intestinal motility

(4) Disappearance of tachycardia

(5) Spontaneous urination

3 Antibiotic r esistance

1) Type

(1) Intrinsic resistance: when genetically resistant to a specific antibiotic

• e.g., Gram-negative strain and vancomycin

(2) Acquired resistance: when the genetic composition of a strain is changed due to internal change or mass transfer from another strain.

• Molecular biological mechanisms for acquired resistance

➊ Reduction of intracellular antibiotic concentration: possibly occurs with most antibiotics (e.g., Pseudomonas/Enterobacteriaceae: b-lactam antibiotics).

➋ Neutralization by enzyme inactivation: the most common mechanism, most of which corresponds to b-lac-tam antibiotics (e.g., b-lactamase production from Gram-positive or Gram-negative strains).

➌ Changes in the target on which the antibiotic will act (e.g., Pneumococcus for penicillin, Methicillin Resistant Staphylococcus Aureus for b-lactam antibiotics, MRSA).

➍ Complete annihilation of the target that antibiotics will act on: in the case of removing the target of antibiotic action by creating a new metabolic pathway by the strain (e.g.., Vancomycin-resistant Enterococcus, VRE).

2) Risk factors

(1) The use of antibiotics

(2) Long stay period

(3) Broad-spectrum antibiotics

(4) ICU patients

(5) Use of invasive equipment: endotracheal intubation, central venous catheterization, foley catheterization

3) Multidrug-resistant bacteria

(1) Vancomycin-Resistant Enterococci (VRE)

➊ Propagation route and bacterial identification: propagated by forming colonies in the GI tract and excreted in the feces. Bacteria are identified by rectal or perirectal swab stool culture. In the case of surgical patients, it can also be detected from wounds or drainage tubes.

➋ Hand hygiene is important because there are many infections transmitted by the hands of medical staff.

➌ Prevalence of antibiotic use or working in a long-term care facility

➍ 8% of colonized patients progress to infection, and the infection rate is higher in critically ill or immunocompromised patients.

➎ Routine cultures are not recommended.

➏ Active surveillance cultures are required in high-risk patients.

➐ There is no need to decolonize the VRE carrier.

➑ Recognized as a negative carrier if a rectal swab yields a negative result 3 times in a week.

(2) Methicillin Resistant Staphylococcus Aureus (MRSA)

➊ MRSA is a cause of staphylococus that is difficult to treat because of its resistance to some antibiotics.

➋ Methicillin resistance is defined by the Clinical Laboratory Standards Institute as an oxacillin minimum inhibitory concentration (MIC) ≥ 4 mcg/mL.

➌ Methicillin resistance requires the presence of the mec gene.

➍ Patients with skin and soft tissue infections known or suspected to be due to MRSA may present with cellulitis, an abscess, or both.

➎ Principles of infection prevention for reducing spread of MRSA include paying attention to careful hand hygiene practices and adherence to contact precautions.

➏ Bacteremia management

a. 1st-line

- Vancomycin 500 mg IV q6hr or 1.0 g IV q12hr (do not exceed 2 g per day)

- Teicoplanin: 400 mg (about 6 mg/kg) IM or IV q12hr (x3) → 400 mg (about 6 mg/kg) q24hr

b. Alternative

- Linezolid 600 mg IV or PO q12hr

- Daptomycin 6 mg/kg IV q24hr

➐ Skin or soft tissue infection management

a. Injection prescription

• 1st-line

- Vancomycin 500 mg IV q6hr or 1.0 g IV q12hr (do not exceed 2 g per day)

• Alternative

- Linezolid 600 mg IV q12hr

- Tigecycline 100 mg IV (x1) → 50 mg IV q12hr

- Daptomycin 4 mg/kg IV q24hr

b. Oral prescription

• 1st-line

- TMP-SMX 2 T PO q12hr

- Doxycycline or minocycline 100 mg PO q12hr

- Clindamycin 300-450 mg PO q8hr or q6hr

• Alternative

- Linezolid 600 mg PO q12hr

(3) Extended-Spectrum Beta-Lactamases (ESBLs)

➊ ESBLs are enzymes that confer resistance to most beta-lactam antibiotics (penicillins, cephalosporins, and monobactam).

➋ The most common types of bacteria that produce ESBLs: Escherichia coli, Klebsiella pneumoniae

➌ The identification of E. coli or K. pneumoniae with overt resistance to any of the carbapenems: likely ESBLs

➍ Management

• Carbapenems: first-line therapy for severe infections

- Imipenem, meropenem, and doripenem

• Fosfomycin: an inhibitor of bacterial cell wall synthesis that has excellent bactericidal activity in the urinary tract.

• Beta-lactamase inhibitors

- Amoxicillin-clavulanate, ticarcillin-clavulanate, and peperacillin-tazobactam

• Colistin: when other medications have failed to stop the ESBL infection

4) Reserved and Restricted Antibiotics

(1) Reserved antibiotics

➊ Antibiotics with a high potential for resistance spread, or with serious toxicity or side effects, or expensive or newly developed antibiotics

• e.g.: cefuroxime, cefodizime, aztreonam, amikacin, ciprofloxacin, piperacillin, efotaxime, clindamycin, ampibactam, ceftazidime, ceftriaxone, cefotetan, levolinfloxacin, cefotiam, piperacillin/tazobactam, etc.

(2) Restricted antibiotics

➊ Antibiotics that need to be strictly restricted due to special antibacterial activity or there is no other drug to choose from when resistant bacteria emerge.

• e.g.: cefepime, vancomycin, imipenem/cilastatin, teicoplanin, meropenem, linezolid, ertapenem, etc.

1.4 Common Surgical Infections

1 Catheter - Related Urinary Tract Infections

1) Symptoms: abnormal urine color, hematuria, foul or strong urine odor, fever, chills, discomfort and pain in the lower abdomen

2) Diagnosis

(1) Urinalysis pyuria (WBC ≥ 5/HPF)

(2) Quantitative urine culture ＞ 10⁵ bacteria/mL

3) Causative Bacteria

(1) E. coli, P. aeruginosa, K. pneumoniae, P. mirabilis, S. epidermidis, Enterococcus and Candida

4) Treatment

(1) Asymptomatic bacteriuria is usually not treated.

(2) If there are symptoms, systemic antibiotics are administered because there is a high possibility of urinary tract infection-related bacteremia or pyelonephritis.

➊ ceftriaxone 1-2 g q24hr, ciprofloxacin 400 mg q12hr

2   Hospital Acquired Pneumonia ( HAP)

1) Symptoms: fever, respiratory symptoms (cough, sputum, shortness of breath, pleural pain), tachypnea, hearing crackles on auscultation

2) Diagnosis

(1) A newly discovered or progressive invasive lesion on a simple chest X-ray in conjunction with one of the following

➊ Body temperature ＞ 37.9˚C

➋ Purulent sputum

➌ Leucocytosis ＞ 10,000/mL

3) Test

(1) Gram staining and culture test of sputum and blood before antibiotic treatment

4) Causative bacteria

(1) S. aureus (MRSA), S. pneumoniae, P. aeruginosa, E. coli, K. pneumonia and Acinetobacter species

5) Treatment

(1) Ceftriaxone 1-2 g q24hr, levofloxacin 750 mg q24hr, moxifloxacin 400 mg q8hr or ciprofloxacin 400 mg q8hr, ampicillin/sulbactam 20 mg/kg/day

3   Vascular Catheter - Related Infections

1) Type

(1) Exit site infection: infection within 2 cm from the intubation site

(2) Tunnel infection: infection that spreads beyond 2 cm from the intubation site

(3) Catheter related blood stream infection (CRBSI): when a culture taken from the blood and catheter both show the same strain of bacteria

(4) Complicated CRBSI: infective endocarditis, septic thrombophlebitis, metastatic infection

2) Diagnosis

(1) Evidence of clinical infection (fever, chills)

(2) Identification of bacteria in at least one pair of peripheral blood cultures

(3) One or more of the following

➊ Removed catheter semi-quantitation ≥ 15 colony forming units (cfu)

➋ Quantitative culture of removed catheter ≥ 10²-10³ cfu/mL

➌ Number of catheter blood culture bacteria ＞ 3-5 × number of peripheral blood culture positive bacteria.

➍ The catheter blood culture positive reporting time is more than 2 hours earlier than the peripheral blood culture positive reporting time.

3) Treatment

(1) Catheter removal

➊ Cases with complications

➋ Sepsis of unknown cause, e.g., septic shock

➌ Tunnel infection

➍ Positive blood culture even 72 hours after administration of the appropriate drug

➎ If the causative microorganism is S. aureus, Candida, or Gram-negative bacilli

(2) Systemic antibiotic treatment

➊ Antibiotics are selected according to the type of bacteria identified and the result of antibiotic susceptibility.

➋ The duration depends on the type of infected bacteria, treatment response, and presence or absence of complications.

➌ A period of at least 2 weeks is required.

(3) Antibiotic lock therapy

➊ Indicated for patients with catheter-related blood stream infections involving long-term catheters.

➋ No signs of exit site or tunnel infection

➌ The optimal duration for antibiotic lock therapy is 7 to 14 days.

➍ Antibiotic lock solutions contain antimicrobial solution mixed with sodium chloride 0.9%, filling the catheter lumen.

- Examples are: vancomycin, cefazolin, ciprofloxacin, linezolid, teicoplanin, gentamicin or ampicillin

1.5 Classification of Antibiotics and Antifungals 

References

1. F. Charles Brunicardi et al. Schwartz’s Principles of Surgery, 11th ed. McGraw- Hill, 2019

2. Gilbert DN et al. The Stanford guide to antimicrobial therapy. 49th ed. 2020

3. Klingensmith ME et al. The Washington manual of Surgery, 8th ed. Lippincott 2019

4. Surviving Sepsis Campaign Guidelines, Critical Care Medicine, 202

5. Townsend CM et al. Sabiston Textbook of Surgery, 21th ed. Saunders Elsevier, 2021

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2.1 Fluid, Electrolyte and Acid-Base Disorders 

1 General Overview

1) Body Fluid Compartments

(1) Total body water (TBW)

• Accounts for about 60% of the body weight for males and about 55% of the body weight for females

• Lower percentage for obese and elderly patients (0.5 L/kg for males; 0.45 L/kg for females)

(2) 60% of TBW is intracellular water.

(3) 40% of TBW is extracellular water.

(about 80% is interstitial fluid; about 20% is plasma volume)

2) Estimating Daily Fluid Requirements

(1) 30-35 mL/kg

(2) 100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, and 20 mL/kg thereafter.

(3) Increased insensible losses with fever (around 10-15% for every degree Celsius greater than 37˚C).

3) Estimating Electrolyte Requirements

(1) Approximate electrolyte concentrations in extracellular and intracellular fluids (ECF and ICF)