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200 Cards in this Set
- Front
- Back
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Rx for adrenal crisis
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IV steroids (dexamethasone), volume resuscitation
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When should transfusion with FFP be given?
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On call to the OR
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Factors that predispose to fistula formation and may prevent closure
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Foreign body
Radiation Inflammation Epithelialization of the tract Neoplasm Distal obstruction Steroids |
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Fever, chills, hypotension, oliguria, pain at IV site
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Hemolytic tranfusion reactions (due to reaction of recipient Abs against transfused antigens)
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Management of pt with hemophilia A who needs surgery
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If severe disease: e-aminocaproic acid (AMICAR; inhibits fibrinolysis) and desmopressin (DDAVP, increases VIII and vWF)
If mild: DDAVP alone |
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Why can FFP not be used successfully in hemophiliacs?
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Factor levels are too low; need cryo or recombinant factos
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NSAIDs can cause ___ dysfunction
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Platelet
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Potential vitamin deficiency syndromes from gastrectomy and Bilroth II procedure
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Megaloblastic anemia (decreased intrinsic factor)
Microcytic anemia (iron deficiency from decreased uptake in duodenum) Osteoporosis (decreased calcium absorption from duodenum/jejunum) Steatorrhea (fat malabsorpion) |
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Diagnostic test for suspected ureteral injury (intraop and postop)
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Intraop: methylene blue administration
Postop: CT to see hydronephrosis or fluid collection (urinoma), then IV pyelogram |
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Tingling sensation and muscle cramps after thyroid surgery
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Hypocalcemia, likely short-term due to transient ischemia of parathyroid gland
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Rx for symptomatic hypocalcemia
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IV calcium infusion (or oral if only mild symptoms); Vitamin D if persistent
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Massive transfusion is associated with what electrolyte abnormality?
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Hypocalcemia 2/2 chelation with citrate in banked blood
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Numbness, Chvostek's sign, and prolonged QT
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Hypocalcemia
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Best fluid replacement for enteric losses
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Ringer's lactate
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Rx for hyperkalemia
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Kayexalate (to bind it)
Sodium bicarb, dextrose, insulin (all to shift it intracellularly) Calcium gluconate (to counteract myocardial effects) |
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Best drainage system and location to minimize wound infections
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Closed drainage system that exits skin away from surgical incision
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When epithelialization is delayed beyond 3 wks, the incidence of ? increases
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Hypertrophic scarring
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Ex of epidermal burn
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Sunburn
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Why are superficial partial thickness burns painful?
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Exposed superficial nerves
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What leads to healing of superficial partial thickness burns?
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Regeneration of epidermis from keratinocytes w/in sweat glands and hair follicles (areas with more will heal more quickly)
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Rx for superficial partial thickness burns and why?
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Antimicrobial creams and occlusive dressings (epithelialization is faster in a moist environment)
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Rx for deep partial thickness wounds
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Excise to a viable depth and then skin graft, esp if in cosmetic location since healing is slow and associated with contraction
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Rx for full thickness injuries
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All should be excised and grafted unless <1cm and no compromise of function, b/c all regenerative elements have been destroyed
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When is the best time to graft burns?
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Within 5 days of injury to minimize blood loss
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Ideal skin covering choice?
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Split skin autograft from unburnt areas
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Alopecia, poor wound healing, night blindness, anosmia, neuritis, skin rashes
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Zinc deficiency
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Excessive diarrhea may lead to a ___ deficiency
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Zinc
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Cardiomyopathy may be due to a ___ deficiency
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Selenium
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Pts on long-term TPN may develop this deficiency w/ hyperglycemia, peripheral neuropathy, and encephalopathy
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Chromium
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Potential abnormality following administration of large volumes of normal saline
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Non anion-gap metabolic acidosis (due to increased chloride concentrations)
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Both LR and NS are both __ (acidic/alkalotic) w/ respect to plasma
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Acidic
pH of LR is 6.5 pH of NS is 4.5 |
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Two good situations for NS and for LR
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NS: vomiting or significant nasogastric suction losses (b/c pt will have tendency toward metabolic alkalosis)
LR: replacing GI losses and correcting ECF deficits |
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3 indications for a vena caval filter
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- Anticoagulation contraindication/ failure
- Free-floating venous clot - Chronic PE complicated by pulm HTN |
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Earliest signs of sepsis
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Altered mental status, flushed skin, tachypnea --> respiratory alkalosis
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Body's response to stress causes
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Increased CO
Hyperglycemia Peripheral vasodilation Decreased arteriovenous oxygen difference (from decreased peripheral use of O2) |
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Rx for hemolytic transfusion reaction
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- Fluid resuscitation
- Foley for diagnosis and monitoring of Rx - Mannitol to induce diuresis (so can clear hemolyzed red cell membranes and avoid renal damage) - Alkalinization of urine to prevent Hb clumping |
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Surgery for C. diff colitis
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Subtotal colectomy with end ileostomy
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Caloric requirements for 70kg man who is:
Nml Postop Septic Multiple trauma/ventilated Major burn |
Nml: 1450
Postop: 1500 Septic: 2000 Multiple trauma/ventilated: 2500 Major burn: 3000 |
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Bleeding from trach
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Bleeding from tracheoinnominate artery fistula
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Management of tracheoinnominate artery fistula
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If still bleeding: stop (inflate balloon or compress)
Once bleeding stopped: fiberoptic exploration in the OR |
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Criteria for extubation
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Negative inspiratory force >-20
Weaned to 5cm H2O PEEP Minute ventilation <10L/min RR <20/min Rapid shallow breathing index btwn 60 and 105 |
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What is the rapid shallow breathing index?
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Ratio of RR to tidal volume
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Anesthetic not to use in SBO operations and why
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Nitrous oxide, b/c is less dense than air so may cause distension of air-filled spaces
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Changes in ARDS
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Hypoxemia
Decreased compliance Decreased FRC Alveolar collapse from leakage of protein-rich fluid |
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Oxygen dissociation curve shifts (right/left) indicate?
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Right: increased tissue oxygen uptake
Left: decreased tissue oxygen uptake |
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Do the following conditions shift the oxygen dissociation curve R or L?
Acidosis Increased PaCO2 Increased temp Increased 2,3-DPG Chronic lung diseases Banked blood |
All right except banked blood (b/c low in 2,3-DPG)
Chronic lung diseases shift it right via an increase in 2,3-DPG due to chronic hypoxia |
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Dopamine at low doses
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Vasodilation of renal/mesenteric vessels and peripheral vasoconstriction, redirecting blood to kidneys/bowels
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Dopamine at high doses
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Increases HR, CO, BP and causes peripheral vasoconstriction
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Dopamine at all doses
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Increases diastolic BP and coronary blood flow
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Best pressor choice for cardiogenic shock
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Dobutamine (positive inotrope and vasodilates, but minimal chronotropic effect so only mild increase in O2 demand)
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Reversal of epidural opiates
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IV (not epidural) maloxone
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Cardiac index =
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CO/BSA
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Rx for acalculous cholecystitis
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Percutaneous drainage
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Hemodynamics in postop septic shock (early)
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Increased CO, decreased SVR, normal central pressures
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Rx for postop septic shock
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Fluids, pressors, Abx (against gram negative rods and anaerobes, esp after bowel surgery), laparotomy and drainage of intraabdominal abscess when identified/ if pt stable
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Indications for cholecystectomy in asymptomatic pts
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Immunocompromised
Porcelain gallbladder (calcified) Gallstones >3cm (associated w/ dev't of gallbladder carcinoma) |
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Why is an intraop cholangiogram often performed in cholecystectomies?
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To r/o common bile duct stones
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2 major complications of a cholecystectomy
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Injury to the common duct (--> chronic biliary strictures, infection, and cirrhosis)
Injury to hepatic artery (--> hepatic ischemia or bile duct ischemia and stricture) |
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Most common bacteria in cholecystitis
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E coli, enterobacter, klebsiella, enterococcus
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Antibiotics for cholecystitis
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2nd generation cephalosporin preop and for 24hrs postop
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When is lap chole indicated in cholecystitis?
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Within 48-72hrs
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Symptomatic cholelithiasis + elevated bili or elevated LFTs
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Suspect common bile duct obstruction
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When is removal of common duct stones not necessary?
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If they're smaller than 3mm
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Management of symptomatic cholelithiasis or gallstone pancreatitis in pregnancy
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Pain meds and hydration
If needed, cholecystectomy (ideally in 2nd trimester) or ERCP |
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Management of cholecystitis + elevated amylase
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Cholangiogram (and cholecystectomy) is mandatory with biliary pancreatitis
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Cholecystitis + severe symptomatic pancreatitis
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Delay cholecystectomy
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Ddx for very high fever, gallstones, and hypotensive
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Acute cholecystitis, cholangitis, empyema of gall bladder, or pericholecystic abscess
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Management of suppurative cholangitis
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Emergent ERCP with sphincterotomy, decompression of biliary tree, stone removal
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What causes a palpable gallbladder?
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Inflamed gallbladder with omentum attached
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Management of palpable gallbladder?
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Emergent cholecystectomy due to high rupture risk
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What is an emphysematous gallbladder?
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Air in the wall due to gas-forming organism that has invaded the tissues
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Management of emphysematous gallbladder
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Urgent surgery
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Jaundice, fever, and RUQ pain/tenderness
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Acute (or ascending) cholangitis
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Management of acute cholangitis
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Resuscitation, Abx, US of biliary tree
If obstruction or dilation of CBD seen, then ERCP and biliary decompression |
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Name for a common duct stone occurring w/in 2yrs of a cholecystectomy
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Retained stone
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Management of biliary stricture
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Surgical exploration and bypass of stricture usually w/ choledochojejunostomy
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What two tests should be done in a pt with fever or pain after a lap chole?
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Abdominal ultrasound and hepatobiliary nuclide scan (HIDA scan: hepatoiminodiacetic acid) looking for infection or biliary leak
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How does the gallbladder look on a HIDA scan in a pt with acute cholecystitis?
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Doesn't visualize
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Management of postop biliary leak identified on HIDA scan
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ERCP to define anatomy
If large collection: biliary drainage w/ temporary stent placed during ERCP |
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Tender lymph nodes in the groin
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Lymphadenitis (or, lower likelihood, malignancy)
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Tender testicle (acte vs. gradual)
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Acute: torsion of testis
Gradual: viral ochitis or epididymitis |
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Hernia pt with N/V/abdominal distention
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Incarcerated/ strangulated hernia
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Hernia pt w/ fever, leukocytosis, and acidosis
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Strangulated segment of bowel
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Most hernia repairs involve attaching which two structures?
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Transversalis fascia to either inguinal ligament or periosteum of pubic ramus
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Most common hernia repair type
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Lichtenstein repair (prosthetic mesh approximates superior abdominal wall structures to inguinal ligament)
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Advtg of mesh?
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Avoids creating tension on fascial structures, lessening postop pain and recurrence
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Nerves at risk of injury in hernia repair
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Genitofemoral, ilioinguinal, iliohypogastric, lateral femoral cutaneous
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Pediatric hernias represent a
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Persistent patent processus vaginalis, NOT an abdominal wall defect/ defect in floor of inguinal canal
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Sliding hernias may involve which other structures herniating?
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Bladder, cecum, or sigmoid colon
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When are ventral hernias difficult to repair?
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Inadequate tissue strength, insufficient tissue, infection, or poor nutrition
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Management of a perforated duodenal ulcer
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Emergent celiotomy and ulcer closure
If no Hx of PUD, can close ulcer w/ omental patch; if long-standing disease, antrectomy w/ truncal vagotom |
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Postop postprandial weakness, sweating, lightheadedness, crampy abdominal pain, diarrhea
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Dumping syndrome
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When should dumping syndrome symptoms abate?
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Within 3mo of surgery
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Mechanism of omeprazole
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Irreversabily inhibits H+/K+ ATPase in gastric parietal cells
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Management of ITP w/:
Plts >30,000 Plts <30,000 Active bleeding Refractory |
Observe
Prednisone (+/- IVIG) Plt transfusion Splenectomy |
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Management of appendical adenocarcinoma
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R hemicolectomy
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Management of achalasia
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Calcium channel blockers or long-acting nitrates; endoscopic dilation; Botox injection
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Pts with achalasia are at increased risk of
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Squamous cell carcinoma
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Which symptoms improve in UC pts after total proctocolectom?
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Peripheral arthritis, ankylosing spondylitis
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Indications for UC surgery
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Toxic megacolon, fulminant colitis, high grade dysplasia/carcinioma, definitive management of intractable disease (need end ileostom yas well)
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Pancreatic fluid collection 4-6wks after acute pancreatitis
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Pancreatic pseudocyst
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Rx for pancreatic pseudocyst or pancreatic abscess
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Percutaneous catheter drainage w/ Abx
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CEA and amylase levels in pancreatic malignancy
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High and low
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Conditions associated w/ familial autonomous polyposis
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Colon cancer
Fundic gland hyperplasia in stomach Premalignant polyps in duodenum and perampullary region Extraintestinal malignancies Retroperitoneal and abdominal wall desmoid tumors Benign osteomas |
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Most frequent serious complication of end colostomes
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Parastomal herniation
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Cause of parastomal herniation
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Stoma placed lateral to, rather than thru, rectus muscle
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Management of parastomal herniation
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If symptomatic, needs operative relocation
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Prolapse occurs most frequently w/ what type of colostomy?
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Transverse loop colostomy
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Management of transverse loop colostomy prolapse
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Restoration of intestinal continuity or converstion to end colostomy
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Contraindication for pancreatic cancer excision
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Involvement of superior mesenteric artery
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Management of variceal bleed
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Fluisd, octreotide or vasopressin to decrease splanchnic blood flow, beta-blockers for long term prevention
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Surgical option for recurrent bleeding varices
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TIPS (transjugular intrahepatic portosystemic shunt)
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2 classes and 4 types of ulcers
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Acid associated (II: body of stomach + duodenum; III: prepyloric)
Not acid associated (I: body or lesser curvature; IV: GE junction) |
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Surgical indications for ulcers
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Hemorrhage, perforation, refractory to medical Rx, inability to r/o malignancy
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What surgery is required for ulcers?
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Billroth I or II, + vagotomy if ulcer is a Type II or III (i.e. acid-associated)
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Billroth I reconstruction
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Distal gastrectomy w/ gastroduodenostomy
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Billroth II reconstruction
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Distal gastrectom w/ gastrojejunostomy
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What is a Klatskin tumor?
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Cholangiocarcinoma
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DDx of biliary obstruction (5)
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Pancreatic head cancer, periampullary carcinoma, cholangiocarcinoma, stricture of CBD, CBD stone impacted in ampulla
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2 types of pts who often get CBD strictures
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Chronic alcoholics w/ chronic pancreatitis
Pts w/ prior biliary surgery |
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What is a "double duct" sign?
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Dilated CBD and pancreatic duct due to narrowing of distal CBD
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Option for surgical palliation in pts w/ unresectable pancreatic cancer, and what it helps avoid
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Biliary and gastric bypass
Prevents gastric outlet or duodenal obstruction and bile duct obstruction |
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Dilated intrahepatic ducts (intrahepatic obstruction) but no dilation of the CBD (extrahepatic obstruction)
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Cholangiocarcinoma
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Where are cholangiocarcinomas located?
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At the bifurcation of the hepatic ducts
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ERCP or this alternative test can be used to identify the tumor especially if high in the bile duct
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Percutaneous transhepatic cholangiography
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Rx for cholangiocarcinoma
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If primary tumor only, excision (5 yr survival still only 15%)
If unresectable, palliative stenting (5% 5yr survival) No role for chemo/radiation |
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Biliary cancer with best cure rate
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Ampullary adenocarcinoma
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Resection method for ampullary adenocarcinoma
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Whipple
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Why is lap chole not a suitable option for malignant gallbladder adenocarcinoma?
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Need open to remove hepatic tissue (common direct spread to the liver)
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Management of calcified (porcelain) gallbladder and why
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Chole b/c of 50% association with adenocarcinoma
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What test is necessary to ensure not missing other potential diagnoses in a pt with suspected pancreatitis
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Obstructive abdominal series (rule out perforated ulcer w/ free air, etc.)
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Pancreatitis + severe deterioration and hypotension
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Severe necrotizing pancreatitis
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Two criteria systems for pancreatitis
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Ranson criteria or APACHE II
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Pt recovering from percutaneous pancreatic abscess drainage when suddenly becomes hypotensive and drainage becomes bloody
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Erosion of cathether or abscess into a major artery (diagnose w/ angiography; control w/ embolization)
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Management of elderly pt with suspected pancreatitis
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Abdominal CT b/c of concern for other pathologies (mesenteric ischemia and volvulus)
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Management of hepatic mets found during colectomy for colon cancer?
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Wedge resection
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Hernias are defects in what?
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Transversalis fascia
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Air in biliary tract of nonseptic pt?
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Biliary enteric fistula
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Complication of biliary enteric fistula
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Gallstone ileus (stone into duodenum causes SBO at distal ileum)
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Colonic syndrome w/o malignant potential and why not
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Peutz-Jeghers (intestinal polyposis and melanin spots on oral mucosa), b/c are hamartomas
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Management of gallstone ileus
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Ileotomy, removal of stone, cholecystectomy (or interval chole if too inflamed at time of op)
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Surgical indications for diverticular disease
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Hemorrhage, recurrent diverticulitis, intractable to medical Rx, complicated diverticulitis (perforated +/- abscess and fistula)
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Rx for diverticular abscess
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Percutaneous drainage then definitive resectional therapy
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Rx for perforated diverticulitis
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Hartmann's procedure (sigmoid resection w/ end colostomy and rectal stump) or sigmoid resection, anastomosis, and diverting loop ileostomy
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Rx for biliary dyskinesia
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Cholecystectomy
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Rx for gallbladder polyp
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<1cm: observe w/ serial US
Suspected carcionma: chole w/ intraop frozen section |
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Management of acalculous cholecystitis
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Abx and perc chole tubes until inflammation has resolved, then lap chole
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Appendicitis presentation in the elderly (+anticoag, trauma, or sudden muscular exertion) plus mass on CT
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Hematoma of rectus sheath: conservative management
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Acute pancreatitis that won't resolve
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Pancreatic pseudocyst
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Diagnostic test and management of pancreatic pseudocyst
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CT
NPO, TPN, observe; if not improved w/in 6wks, cystogastrostomy to drain fluid into GI tract (+biopsy to r/o cancer) |
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Management of simple hepatic cyst
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Observe; if persistently symptomatic, aspiration and then sclerosant or excision
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Multilocular cyst in liver w/ calcifications (and management)
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Suspect echinoccal cyst from GI parasite: need operative sterilization and excision
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Hepatic abscess
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IV antibiotics and CT-guided drainage
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Amebic hepatic abscess
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Metronidazole, no surgery
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DDx for solid liver lesion
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Hemangioma, focal nodular hyperplasia, hepatic adenoma, mets, HCC
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Pts with hepatic adenoma usually have a history of?
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OCP use
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How to diagnose a hemangioma?
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Labeled RBC scan
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Indications for surgical removal of benign liver mass
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Symptomatic, risk of spontaneous rupture, uncertainty of diagnosis
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Why is biopsy not performed when hemangioma or hepatadenoma are suspected but uncertain diagnoses?
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High risk of bleeding
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Management of hepatic adenoma?
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Stop OCPs
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Why must persistent or large hepatic adenomas be resected?
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Risk of rupture or of development into HCC
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When do hepatic adenomas have the highest risk of rupture?
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During pregnancy
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What is Bowen's disease?
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Squamous cell carcinoma in situ
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Melanoma location with worst prognosis
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Face or trunk
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Additional primary melanomas occur in what percentage of pts?
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5%
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Which melanoma pts need adjuvant therapy, and what does it consist of?
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Stage III and IV
Interferon or dacarbazine Possibly radiation |
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Management of large macular brown lesion on cheek
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Lentigo maligna (Hutchinson freckle): monitor closely, remove if changing b/c is a precursor to lentigo malignant melanoma
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Management of subungal melanoma
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Biopsy requires excision of portion of nail in continuity w/ lesion; reexcision following diagnosis involves amputation at DIP
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Prognosis for anal melanoma
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As with other mucosal melanomas, mortality is near 100% at 5 years
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Firm, painless mass that is larger than most benign tumors
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Sarcoma
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Fibrosarcoma and lymphangiosarcoma are associated w/ what two exposures?
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Fibrosarcoma: therapeutic radiation
Lymphangiosarcoma: axillary lympadenectomy |
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Management of suspected sarcoma
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Excision biopsy if <3cm
Incisional biopsy if >3cm NO FNA |
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Poor prognostic indicators in sarcoma
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Mitoses, degree of necrosis, >15cm, symptomatic
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Which pts need met workup, what does it consist of, and most common locations for mets
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All! (22% have mets at presentation)
CT, MRI, CXR Liver, lung, bone, brain |
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Surgical option for sarcoma
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Extensive: often total resection of tissue compartment or amputation of extremity
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Best adjuvant therapy for sarcoma
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Radiation
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Management of sarcoma recurrence in the lung
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Thoracic wedge resection (one of the whom tumors in which excision of pulmonary mets can result in long-term disease-free survival)
Same with liver mets |
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7 factors that slow wound healing
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Malnutrition
Diabetes Jaundice Uremia Steroids Chemo Smoking |
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Why can pts not do heavy lifting for 6wks postop?
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Collagen production and cross-linking are still occurring, so not yet at full tensile strength, prone to injury/disruption
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Hard knot-like structure underneath surgical wound
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Likely a suture knot: should resolve if was absorbable suture, otherwise can be removed under local anesthesia once wound is fully healed
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What is healing by third intention?
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Delayed primary closure
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Erythema and some pus drainage around wound 3mo postop
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Stitch abscess
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Management of a stitch abscess
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Explore opening w/ hemostat and remove suture under local anesthesia
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Management of postop ventral hernia thru wound
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Surgery
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How long should a wound be observed for before considering revision for its appearance?
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6mo
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Management of hypertrophic scar
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Steroid injections and local pressure dressings
Revision usually not appropriate as are likely to recur |
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Raised hypertrophic scar that is spreading outside immediate area of incision
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Keloid (same as treatment for hypertrophic)
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Management of wound infection
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Drainage and debridement; usually don't require Abx (only if cellulitis spreading despite drainage)
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2 types of wounds that heal by secondary intention
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Wounds that are intentionally left open
Wounds that become infected and require opening in immediate postop period |
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What is the process of a graft revascularizing from granulation tissue called?
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Inosculation
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What is the advantage of split thickness skin grafts for wounds?
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Reduce wound contraction by 60%
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Disadvantage of skin grafts
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More susceptible to trauma than normal skin
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What is required for the skin graft to attach successfully?
|
Bacterial count on granulation bed must be <10^5 bacteria/gram of tissue
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Four categories of wounds
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Clean, clean-contaminated, contaminated, infected
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Management of contaminated wound
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Leave open to heal by secondary infection, treat with saline-soaked gauze
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Definition of a clean wound
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No entry made into GI, respiratory, or GU tracts and no active infection
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Definition of clean-contaminated wound
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There is entry into GI, resp, or GU tract but it is prepared both mechanically and antibacterially (e.g. bowel prep before surgery)
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Need for prophylactic Abx for clean, clean-contaminated, and contaminated
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Clean: none
Clean-contaminated: single preop and postop dose |
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4 situations in which prophy Abx are indicated
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Exposure to bacteria
Prosthetic material Immunosuppression Poor bloody supply |
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When should prophy Abx be given?
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1 hr preop
Postop: multiply half-life of drug by 1-2.5 |
