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130 Cards in this Set
- Front
- Back
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First manifestation of sepsis?
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Hyperventilation with respiratory alkalosis
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Poiseuille's law
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Flow is proportional to radius^4 and pressure differential Inversely to viscosity and length
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Most common cause of hypercoagulable state
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Smoking
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Most common bacteria in SBP
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Gram-negative enteric (E coli, Klebsiella)
Tx with cefotaxime or similar 3rd generation cephalosporin |
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Empiric therapy of SBP, after ascitic cultures taken, if...
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Fever
Abdominal pain/tenderness Altered mental status Ascites fluid PMN cound >250 cells/mm3 |
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von willebrand factor is produced in
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endothelium, megakaryocytes/platelets
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function of von willebrand factor
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platelet adhesion, carrier for factor 8
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types of vWD?
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Type 1: mild, decreased vWF (75%) - nosebleeds
Type 2: qualitative defect (25%) Type 3: no vWF produced (rare) - severe bleeding |
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labs in vWD?
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increased PTT, decreased factor 8 (sometimes), platelet count normal
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manifestations of primary blast injury (from pressure wave itself)?
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Eardrum perforation (most common)
Lung injury (contusion to severe ARDS) Bowel injury |
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transplant types with highest risk of lymphoproliferative disease?
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highest: intestinal, multiorgan
lowest: HCT, renal, liver |
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pathogenesis of lymphoproliferative disease in most transplant patients?
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EBV-positive B cell proliferation in setting of chronic T cell suppression, though EBV-negative tumors can also occur
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major risk factors for lymphoproliferative disorder in transplant pt?
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Degree of overall immunosuppression
EBV status Time post-transplant |
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Majority of lymphoproliferative disorders post transplant?
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B cell lymphoma, non-Hodgkin's
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Neoadjuvant chemo/rads in rectal ca?
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For locally advanced T3/T4 rectal cancer
After neoadjuvant therapy you excise the cancer as per its initial staging, even if it appears to have disappeared entirely. Afterwards most patients get a 5FU based chemo regimen regardless of pathology. |
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Pretreatment staging of colon ca by
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Physical
CT Chest imaging Serum CEA levels Ideally, with full colonoscopy |
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Surgery for pts with metastatic colorectal ca?
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most are not candidates, get palliative chemo
in selected pts with limited mets to liver and/or lung, may try for cure with aggressive surgery/chemo |
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Most important indicator of outcome post resection of colon ca
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Pathologic stage
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Postresection surveillance for stage 1 colorecal ca?
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periodic H+P, colonoscopy
For stage 2/3, add CEA, annual CT |
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Low protein diet in renal failure?
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Not recommended!
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Calories for nutrition?
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25-30 kcal/kg per day in stable patient
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Protein for nutrition?
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Mild/moderate illness 0.8-1.2 g/kg per day
Critical illness 1.2-1.5 g/kg per day Severe burns 2 g/kg per day |
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Define intra-abdominal hypertension, abdominal compartment syndrome
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IAH = pressure >12 mmHg
ACS = pressure >20 mmHg with new organ dysfunction |
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Consequences of abdominal compartment syndrome?
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Impaired cardiac function with decreased venous return
Hypoxemia Hypercarbia Renal impairment Diminished gut perfusion Elevated ICP |
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Management of ACS?
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OR if pressure ~ >25mmHg
Drain fluid collections, NG, rectal tube Supine, no HOB elevation Adequate sedation/analgesia/paralysis PEEP, pressure limited ventilation No diuretics, limit fluids |
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time to onset of oral vitamin K? IV vitamin K?
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oral: 24-48 hours
IV: 12-24 hours (10-20mg dose will fully reverse but cause refractoriness) |
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Time to onset of action of FFP?
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onset almost immediate, but takes time to thaw and infuse. Need 3-5+ units, volume overload?
lasts 6-8 hours |
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what is octaplex?
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vitamin K dependent factors (2, 7, 9, 10)
contains heparin (don't use in HIT) works immediately, lasts 6-8 hours. |
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what level of activity of coagulation factors is required for hemostasis?
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25-30% of normal
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perioperative replacement in pts taking chronic steroids?
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if likely to have suppressed HPA axis (> 3 weeks tx of >5 mg a day prednisone)
Minor/local procedure: no change, usual dose Moderate stress: usual dose + 50 mg hydrocort IV before induction and 75 mg/day, divided for 24 hours Major stress: usual dose + 100 mg hydrocort IV before induction then 150 mg/day divided, tapering to maintenance level |
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how does UFH work, vs LMWH?
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UFH activates antithrombin and inactivates factor 10a
LMWH only inactivates factor 10a Much less HIT with LMWH |
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mechanism of action of warfarin?
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inhibits activation of vitamin-K dependent clotting factors, and proteins C and S
reduction of all vitamin-K dependent factors takes about a week after therapy is initiated |
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risk factors for surgical site infection?
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NOT age
Diabetes/hyperglycemia, obesity, cirrhosis, smoking, systemic immunsuppression, malnutrition, S aureus colonization, remote focus of infection, long hospitalization, severe illness, shaving, foreign body, long surgery time, tissue trauma, blood transfusion, use of electrocautery, inordinate personnel traffic during OR |
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Risk factors for C Diff diarrhea
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Increasing age
Renal/COPD/GI disease, NG tube Immunosuppressed, malignancy Preop bowel regimen ANtibiotic use SUrgery Prolonged hospitalization ICU Caregivers Longterm facilities NOT carrier status |
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biopsy for neck mass...
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FNA
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local anesthetics causing methemoglobinemia?
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benzocaine, prilocaine
rare with lidocaine (usually with congenital methemoglobinemia) |
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what is methemoglobin?
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hemoglobin with iron in oxidized state; shifts curve to left, can cause lack of tissue oxidation if level high
levels > 20% symptomatic, >40% high mortality |
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dx/tx of methemoglobinemia?
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both congenital and acquired forms (usually drugs)
blood dark-red/brownish, clinical cyanosis tx if >20%: d/c offending agent, if symptomatic give methylene blue or ascorbic acid |
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Induction dose of propofol? Time to effect? Duration of action?
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DOse 1.5-3 mg/kg, rapid onset, lasts 5-10 minutes.
No analgesia. Drops MAP by suppressing SNS, neuroinhibitory. Reduces airway resistance/bronchospasm. |
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Induction dose of ketamine? Time to effect? Duration of action?
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Dose 1-2 mg/kg, rapid onset, lasts 10-20 minutes.
Analgesic properties. Stimulates catecholamine release causing increase in HR, MAP. Prserves resp drive. Good in hypotension. |
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Problems with thiopental in induction?
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Can induce profound hypotension in doses needed for induction. Exacerbates bronchospasm, not for use in sepsis.
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Dose of midaz for RSI? Side effects?
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0.2 mg/kg - causes hypotension so not good in shock.
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signs of malignant hyperthermia?
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rise in EtCO2, increase in minute ventilation, rigidity, tachycardia, hyperthermia
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triggers for MH? inheritance?
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inheritance is autosomal dominant - tell family!
Triggered by inhalational agents (not nitrous), succinylcholine |
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tx of MH?
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Turn off triggering agents, give 100% O2, stop procedure, switch to propofol/midaz
Give dantrolene, bicarbonate Watch for hyperkalemia, arrhythmias Cool if temp >39 Transfer to ICU |
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Patients who survive clostridium septicum NF/gangrene should have....
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colonoscopy to r/o associated pathology of GI tract/GI cancer.
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substrates for gluconeogenesis?
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LGAG
lactate, glycerol, alanine, glutamine |
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TRALI?
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new-onset acute lung injury occurring during or within 6 hours of PRBC transfusion completion
Profound hypoxemia, bilateral pulmonary edema -> supportive tx. NO signs of circulatory overload (CVP, PCWP normal) Pathogenesis uncertain; usually resolves in 24-72 hours Risk per unit of blood is 1:10 000, leading cause of transfusion-related morbidity and mortality |
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tx to improve platelet function in uremic pts?
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Hemodialysis
DDAVP Correction of anemia Estrogen Cryoprecipitate Giving platelets will NOT Help |
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impact of uremia on coagulation?
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inhibits platelet function
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perioperative mgmt of warfarin anticoagulation in pts with mechanical valves?
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for any procedure with significant bleeding risk:
hold warfarin 5 days prior begin LMWH (stop 24 hours prior to procedure) or UFH (stop 4-6 hours prior to procedure) recommence anticoagulation as soon as possible, d/c heparin once INR in therapeutic range for 2 days |
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predictor of poor pulmonary function post lung resection?
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predicted post-operative FEV1/DLCO <40%
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hyperacute, acute, and chronic transplant rejection?
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hyperacute: minutes to days, mediated by preformed antibody (prevented by crossmatching)
acute: first weeks to months, or at any time, mediated by T cells and accompanied by acquired antibody response. only type that can be completely treated/reversed chronic: poorly understood, fibrosis and atherosclerosis of organ secondary partially to T and B cell processes |
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contraindications for liver transplant
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Cardiopulmonary disease that cannot be corrected and is a prohibitive risk for surgery.
Malignancy outside of the liver within five years of evaluation (not including superficial skin cancers) or not meeting oncologic criteria for cure. Active alcohol and drug use. Most programs require a minimum period of abstinence of at least six months with participation in a structured rehabilitation and abstinence program and adequate social support to help maintain sobriety. |
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effect of enteral or parenteral nutrition in severely malnourished preoperative patient
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decreases mortality
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enternal nutrition...
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decreases infectious complications in critically ill patients
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routine postoperative use of enteral and/or parenteral nutrition after cancer resection: effect on mortality?
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none
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electrolyte content of ringers lactate?
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130 mEq of sodium ion
109 mEq of chloride ion 28 mEq of lactate 4 mEq of potassium ion 3 mEq of calcium ion |
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role of steroids in icp mgmt?
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associated with worse outcome in head injury, cerebral infarction, intracranial hemorrhage
(only role to manage ICH in tumors and infections) |
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lower icp?
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sedate/paralyze/intubate
mannitol raise HOB prevent hypotension hyperventilate to pCO2 30 (brief periods only) EVD/shunt |
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greatest risk of death from a blood transfusion is due to...
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ABO incompatibility
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features of ATN on urinalysis?
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muddy/granular casts, uOSM <350, sodium >40, FENa >2%
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adrenal insufficiency - effect on BP, K, Na?
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hypotension
hyperkalemia hyponatremia |
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4 Ts for HIT?
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Thrombocytopenia (50% reduction)
Timing of fall (within 5-15 weeks of initiation) THrombosis (white clots, arterial or venous, skin necrosis) other causes for Thrombocytopenia |
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risk factors for HIT?
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longer duration of therapy
use of UFH surgical or female patient |
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triad of fat embolism syndrome
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resp/cardiac changes (hypoxia, tachycardia, tachypnea)
neurological abnormalities petechial rash 24-72 hours after initial insult |
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alternative to benzos in DTs
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propofol
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Genetics of lynch syndrome?
Cancers? |
autosomal dominant, mutations in DNA mismatch repair genes
Right-sided colon cancers, endometrium, ovary Dx by blood genetic test |
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familial adenomatous polyposis (FAP)?
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autosomal dominant, mutation in APC gene
thousands of colorectal adenomas by age 20-40, 100% risk of colon ca, also other GI cancers, thyroid ca annual colonoscopy, total colectomy by age 20 |
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Gardner's syndrome?
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FAP + extraintestinal lesions (sebaceous cysts, osteomas, desmoid tumors
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Turcot's syndrome?
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FAP + CNS tumor
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typical regimen for immunosuppression post kidney transplant?
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calcineurin inhibitor (cyclosporine or tacrolimus) +
antimetabolite (mycophenolate or azathioprine) + corticosteroid |
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use of PEEP affects paO2 or paCO2?
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paO2
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torsades des pointes?
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drugs, hypomagnesemia, hypokalemia
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factors controlling aldosterone secretion?
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plasma K, plasma Na, ACTH, angiotesin
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pretreatment for reducing risk of contrast induced nephropathy?
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hydration with IV sodium bicarbonate (better than saline)
PO acetylcysteine |
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5 year risk of rupture in 5.5cm AAA?
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25%
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Factors increasing central line infection
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Femoral placement
>3-6 days Non anti-microbial line |
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Content of chyle?
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Triglycerides
T cells, immunoglobulin Electrolytes, protein Fat soluble vitamins from intestine |
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Mgmt of postoperative chylothorax
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Initial observation with chest tube and TPN/high protein and low fat diet
If persists >14 days, thoracic duct ligation +/- pleurodesis |
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Rate of posterior urethral injury in pelvic #?
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5-10%
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risk factor for subglottic stenosis in trach?
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placement through 1st tracheal ring
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where is hydrocele
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tunica vaginalis
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best prognosticator of TBI recovery
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initial GCS
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contraindication to aminoglycosides
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neuromuscular blockade (potentiates)
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organisms in post splenectomy sepsis
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pneumococcus, H flu, meningococcus
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timing to stop/start LMWH in pt with neuraxial catheter
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stop 24 hours before
wait 6 hours after |
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four major predictors of cardiac risk in preoperative assessment
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MI in last 3-6 months
Recent PCI Decompensated CHF or severe valvular disease Significant arrhythmias (Vtach, uncontrolled SVA, high grade AV block) |
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what tissue is most immunogenic? least?
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most = bone marrow, skin
least = liver |
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mutation in MEN2
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RET oncogene
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extrahepatic manifestations of chronic hepatitis c?
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hematologic: cryoglobulinemia, lymphoma
renal: MPGN autoimmune: thyroiditis dermatologic: porphyria cutanea tarda, lichen planus endocrine: diabetes |
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major HLA antigens for kidney matching?
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DR > B > A
C not used |
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marker for recurrence of thryoid cancer
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thyroglobulin
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likelihood of NSAIDs causing GI bleed?
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ketorolac > naproxen > ibuprofen > coxibs
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tx of brain mets in recurrent breast ca
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surgical excision +/- whole brain irradiation
stereotactic rads if surcially inaccessible |
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cancers where link with smoking not proven
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breast, skin
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scarless fetal wound healing
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increased hyaluronic acid
fibroblasts produce more collagen, less degraded reduced immune response (less neutrophils, macrophages) lower levels of TGF-B, FGF-2, PDGF |
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what causes sickling in sickle cell?
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low pO2 -> polymerization of HbS
Aggravated by acidemia, increased CO2, increased 2,3-DPG, increased temperature and osmolality Decreased by presence of HbF (hydroxyurea) |
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prophylaxis for splenectomy
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for elective splenectomy: pneumococcal, meningococcal, Hib vaccines 14 days before surgery
asplenic children: daily prophylaxis with oral pen or amox until age 5 and at least 1 year following splenectomy |
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anticholinergic toxidrome
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blind as a bat, mad as a hatter, red as a beet, dry as a bone, hot as a hare, bowel and bladder lose tone
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cholinergic toxidrome
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SLUDGE (salivation, lacrimation, urination, diarrhea, GI distress, emesis)
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kilocalories in 20% lipid emulsion for TPN?
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about 2 kcal/mL (half that for 10%)
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when to use TPN?
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critically ill malnourished patient who cannot use enteral route for > 1 week
higher incidence of infectious complications with TPN overall |
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initial nutrition goal in critically ill patient?
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18 kcal/kg per day and 1.5 g of protein/kg per day
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dosing of fat in TPN?
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1-2.5 g/kg/day
should not exceed 60% of total calories |
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perioperative tx of new dx/uncontrolled hyperthyroidism
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delay surgery until controlled (3-8 weeks)
if emergent, give beta blocker +/- thionamide (PTU/methimazole - inhibits de novo synthesis of hormone so takes a few days to start working, give for postop control) +/- iodine (caution in toxic goiter, inhibits thyroid release) |
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tight glucose control in cardiac surgery...
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decreases deep sternal wound infection
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hx of CABG with fixed perfusion defect and no evidence of reversable ischemia, preop meds?
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beta blockers
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sx severe hypophosphatemia
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myocardial depression
muscle weakness with resp failure confusion, coma, seizures |
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causes of SIADH
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lung tumor
closed head injury alcohol withdrawal |
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RQ of carbs, protein, fat
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carbs 1.0
protein 0.8-0.9 fat/ketones 0.6-0.7 |
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most infectious of hep b, hep c, HIV?
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hep b - small inoculum, remains viable for days
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head trauma in anticoagulated patient
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if strong suspicion ICH and clear head injury, reverse without waiting for CT or INR
can also get delayed bleed |
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emergency surgery, took significant steroid in past year?
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could have HPA suppression - IV hydrocortisone
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hypocalcemia EKG?
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prolonged QT
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triggering of endocrine response after injury via
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afferent nerve stimuli from injured area
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what are acute phase proteins
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increase or decrease by >25% in inflammation
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major cytokine inducer of most acute phase reactants
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IL-6
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CRP and inflammation?
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sensitive but not specific (also up in metabolic malfunction)
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glucagon release stimulated by
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exercise
hypoglycemia epinephrine INHIBITEd by somatostatin |
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cells most responsible for il-1 production
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monocytes, macrophages
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effects of IL-1
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increase wound healing
fever vasodilation |
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VTE prophylaxis in pt with antithrombin-3 deficiency who cannot be given heparin?
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Antithrombin III concentrate to maintain levlels 80-120% of normal
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tx of non severe c diff
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Flagyl
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highest risk patients in which IE prophylaxis is probably a good idea
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Prosthetic heart valves, including bioprosthetic and homograft valves.
A prior history of IE. Unrepaired cyanotic congenital heart disease Completely repaired congenital heart defects with prosthetic material or device during the first six months after the procedure. Repaired congenital heart disease with residual defects Cardiac valvulopathy in a transplanted heart. |
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cell target of radiation damage
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nucleus
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best test for nutritional status
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clinical assessment (H+P)
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protein loss source in critical illness
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skeletal muscle
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FeNa in hemorrhagic shock
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<1-2%
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preop prep of pheochromocytoma
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alpha blocker (phenoxybenzamine)
then beta blocker |
