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245 Cards in this Set

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standard preop surgery tests?
Depends on patient's previous condition:
ie
CBC, electrolytes, ECG, cxr ( if >40 m or >50 f or any sx of cardiac disease,
PT/PTT for any anticoag therapy or past hx of bleeding,
CXR for pulm disease,
LFT's for hepatobilary diseases or cancers,
etc
predictors of incraesed periop cardiac risk?
UNSTABLE ANGINA, DECOMP CHF
signif. arrhythmias
severe valv. disease
MAJOR Risk of cardiac events for what non-cardiac surg procedures?
major ops in elderly
aortic reconstruction.
major periph vasc procedures
procedures w/ major fluid shifts/ blood loss
Anasthesiologists classif of periop mortality?
1 = normal, healthy,
3= mod-severe systemic disease with fxnal limitation
5 = prob going to die in 24 hrs
6 = brain dead, surg for harvesting organs
How to decide whether local, spinal, or general anasthesia?
Most anasth' beleive it's not the type of surgery but HOW WELL the anasth is administered that determines its risk!
problem with local anasth?
pt may still experience severe px, which causes stress and High dosese of IV sedatives to offset, which increases the risk
which may cause fewer pulm complications, good spinal anasth or good general anasth?
good spinal
positives of general ansthesia?
maintains secure airway
Good analgesia and
anamnesia
good control
negatives of general anasth?
increased pulmonary complications and mild cardiodepression
time it takes for NSAID -induced platelet inhibition to reverse?
2 days;
time to wait after NSAID dose before surgery? after aspirin dose?
NSAIDS take 2 days to reverse; so discontinue for 2 days before surg.
Platelets are irrev; 7-10 days until new ones are made, so aspirin should be discontinued for 7-10 days
does previous MI increase risk for postop MI?
yes, just like it increases risk for any non-op MI..!
previous MI pt desiring electiv hernia. what do first?
do ECG, etc test, including possible stress test; and then possible cath (if ischemic signs present) to determine if revasc needed first
what give to diabetic pt going in for elective surgyer?
pt will be already given NPO after midnight, so should give IV dextrose + fluids and should NOT take any oral hypoglycemic agents he's already taking. If taking insulin, should check for hypo/hyper- g on morning of surg. slightly elev levels are preferred to reduced.
what if pt's gluc is >250 on morning of elective surg? if >100, <250?
give him 2/3 of his normal NPH and reg insulin.

give him 1/2 of normal mornign dose
m/c cause of anemia?
Colorectal cancer
hct of 35%, what do before elective surgery?
postpone; fix nemia first, check for GI blood loss or CRC cxr too
dehydration before elective surgery?
postpone until sufficient hydration is achieved.
causes of increased HCT?
DEHYDRATION,
PCV, COPD, EPO - secreting tumor ie RCC, HCC
prevention of DVT's in obese pt going into elective surgery? (2)
compression stockings
sub-Q heparin
poorly controlled DM causes what post-op?
higher risk of post - op wound infection!!
what else besides DM causes increased risk for post-op wound infection?
surgery in presence of other active infection (ie cellulitis)
in presence of other active but distant infections (ie toe infection) shoudl elective surg be postponed?
yes - especially in diabetics
should elective surg be postponed if UTI?
yes
diastolic bp > 110 is RF for what in elective surg?
rF for cv complics such as malignant htn, acute MI, chf
should continue hypertsnive pt on his htn drugs during elective surgery?
Yes, especially BBlockers, b/c if withheld may cause rebound htn
should postpone surgery for htn?
only for diast htn> 110
postop complication risk increase for smokers?
2-6x increased
how long must cigs be stopped pre-op in order ot improve postop resp morbidity?
8 WEEKS!
postpone surg for acute bronchitis (ie with green productive sputum in smoker) ?
yes, tx with oral ab's, then do surg
think what if blood-tinged sputum for 3 weeks? NSiM?
lung cxr! or active infection
do chest ct, xray, and possibly bscopy
what lab result signifies pulmonary htn? which is associated with increased perioperative morbidity?
PaO2 < 60mmHg
PCO2 >45 = increased morbidity
how to improve preop status ie in COPD pt before ie emergency cholecystectomy? how improve post-op status?
give bdilators, spirometry, ( and mobilization after surgery to prevent atelectasis)
pt with decompensating COPD, ie paO2 <60 and pcO2 >45 has risk for what during surgery?
acute pulm failure. do cxr to r/o underlying pneumonia before surg.
type of surg c/i'd in patient with cholecystitis and COPD w/ high risk of pulm failure
laparoscopy - leads to increased CO2 absorption in blood --> increased pulm work --> compromised pulm status. Should do either open surg or cholecytostomy = drains gb from outside to tx sepsis
earliest clinical sign of hypermagnesemia?
loss of deep tendon reflexes
predictors for risk of cardiac complication after vasc surgery? tests should be performed preop?
q waves
hx of vent ectopy that requires tx
hx of angina
dm requiring hypoglycemics or ins
age >70

do cardiologist evaluation and
stress test; if reversible ischemia do cath first
m/c cause of early post-op death after lower extremity revasc? risk of this?
MI
15%!
past acute MI within how many days of upcoming surgery is a MAJOR RF for cardiac complication?
7-30 days; if so, delay surgery
past CABG within 6mo-5years before surgery increases or decreases cardiac complic. risk?
decreases!
what's the incidence of restenosis at only 6 mo after PTCA?
25-35%!!
what if man had PTCA 2 weeks before upcoming surgery for lower leg revasc?
postpone surgery; thrombosis from PTCA increases during first month post-PTCA
do cath first for pt needing lower leg revasc surg but also has moderate angina on exertion?
YES = sx are of coronary disease.
what is the cardiac risk of arrhythmia most likely due to?
ventricular dysfunction, not necessarily underlying arrhythmias like excessive PVC's , etc
afib must be controlled with what before surgery
anticoagulation
cardioversion to normal sinus rhythm
B-blockers to control hr
risk of neurologic events due to non-cardia vascular surgery is high or low?
low
past stroke, what managmenet before revasc surgery to lower legs/. what do with findings?
do carotid duplex to assess any occlusion. if >70% occluded up to 99%, should do carotid endarterectomy
tx of abnormally high PT before surgyer?
give vit K
what does ulcer over hernia indicate?
pressure necrosis = up to 43% mortality!! EXPEDITE SURGERY!!
ascites may cause what type of infection? what test to do? for what?
spont bact ptitis = do tap and check if > 250wbc's in ptfluid
why must alcoholic stop drinking before surgery for liver failure and ascites causing umbilical hernia?
b/c post-surgical alcohol w/drawal is assoc with high mortality. must stop alcohol and undergo w/drawal before surgery
why does hemorrhoid surgery have high risk in ascitic pt?
b/c if due to portal htn, hemorrhage/bleed will cause massive blood loss due to increased blood pressure
what must do in CKD pt befoer taking to surgery for other condition?
1)must try to resolve any other correctable problems first. 2) DIALYSIS!! immediately before surgery is desirable. well-dialyzed pts have normalized pl fxn, hydraton state, bp control, and elyte status.
should continue steroids perioperatively for ie CKD pts?
YES
how recent should K+ levels in CKD pt be taken before surg?
K+ in CKD can change immediately. mut be taken in short periods before surg and surg only done if normalized
common cause of bleeding in CKD pt in surgery? does pl tfuision help?
due to PL dysfxn due to uremia of CKD. Pl transfusion does NOT help...DDAVP (desmopressin) does help, FFP does help, post-op hemodialysis does help
hypotension in CKD pt in OR may be due to?
CKD = tx with steroids; causing adrenal insuff due to GCSteroid deficiency in surgery => hypotension. tx with hydrocortisone intraoperatively and post-op
all pts with valvular heart disease should receive what during all surgical procedures? what specifically given for GI procedures? for dental, respi, or esoph procedures?
prophylactic AB's to prevent SBE
amp and gent for GI procedures to cover for enterococci.

amoxy (or clinda or ceph or clarithro for pen-allergic) for dental, respi, or esoph procedures
all pts that have valve abnorms, cmyopathy, acute mi hx, etc going in for any procedure needs what?
cardiology consultation
what's a cathartic?
ie Golitely = bowel prep
S/E's of Golitely?
not really many; no elyte or water balance changes;
only dehydratoin in older pts
C/I of Fleets Phospho-Soda?
don't give to DM pt bc has glucose in it!!
Is hypertonic so causes losses of HCO3 and K+(which are higher in fecal matter)...may cause MetAcidosis, hypokalemia, confusion, cramping, weaknes, fatigue, dehydration
MgCitrate S/E's?
is poorly absorbed into intestines, therefore draws liquid into lumen by osmosis = may cause diarrhea and e-lyte imbalance; mgemia ie hypotensions, decreased tendon reflexes, resp depression, etc.
tx for hypermagneseia?
ca gluconate (same for hyperkalemia)
how much iv fluid given in surgery is lost to EV space?
2/3!! so must replace 3 ml for every 1 ml lost
sample calculation
500ml blood loss
1000 ml IV fluids given
UO : 400ml
total amt to be given should be:
3X 500 = 1500
+ 400
= 1900, subtract amt already given (1000)
= give 900ml \isotonic (lactated Ringer's or NS)
estimated maintenance fluid req's?
1st 10kg = 100ml/kg/24hrs
2nd 10 = 50 "
beyond 20=20/kg "

ie 70 kg man = 1000+500+[(50x20) =1000] = 2500 total/24hrs
+ 20mEq KCl / L = 50mEq KCl
maintenance fluid to give
vs
replacement/intraop fluid req's?
maint = D5 0.5 NS plus KCl 20mEq/L
intraop = NS or Lactated ringers for first 24 hrs, then switch to above
normal input of water through ingestd fluids is?
1200 ml/day, from ingested foods 1000 ml/day and from metabolism 300 ml/day, totaling 2500 ml/day
normal output of water per day?
urine = 1500
feces 100
insensible loss (sweating, water evap) 800
vag secretions 50
= about 2500 to balance h20 input from drink, foods, metabolism
3 areas of post-op fluid replacement?
1) fluid lost during procedure
2) maintenance
3) fluid lost to drains, ng tubes, fistula (calc from chart)
normal urine output should be?
about 50ml/hr for 70kg adult (.5-1.0ml/kg)
conditions causing postsurgical increased diuresis (>>50ml/hr and resulting hypotension??
preexisting renal disease, DI, or postobstructive diuresis
severe oliguria postsurgical (<<<50ml/hr) algorithm?
M/C = mechanical problem with catheter: check catheter. If ok, consider
low volume = give fluids and recheck u/o
if still low, put CVP line to ***** CVP
things to assess if normal CVP but LOW urine output?
check for prerenal vs post-renal oliguria
pre = >500urine osm, <20 urine Na conc, <1% FeNa, and >20 BUN/Cr ratio
post = 250-300 urine osm, >40 urine Na, >3% FeNa, and <10 BUN/Cr ratio

if post, consider obstruction and rule out with US
#1, #2, etc causes of post-op fever?
M/C cause = ATELECTASIS = hear pulm crackles, cxray findings, etc)
#2 = UTI,
etc:
Pneumonia
DVT,
infected indwelling cath
drug-related fever
prevention of post-surg atelectasis?
pulm toilet ( blow bottles, suction)
incentive spirometry
NOT Ab's
Day that UTI usually shows up post-surg? tx?
day 3
tx with ciproflox or tmp-smx
tx for post-surg cellulitis?
ORAL Ab's
what is suppurative phlebitis?tx?
pus drainage at site of catheter; tx =remove cath, surgically excise vein, AB's for sepsis
any pt showing ptitis after surg requires what?
operative exploration or CT scan for intrabd collection of pus
tx of enterocutaneous fistula post-surg ?
NPO, TPN and measure fistula drainage...most will heal in several weeks. (except FRIENDS)
non-healing fistulas?
FRIEND
foreign body in wound
radiation damage to aria
infecton or inflamm bowel disease
epithelialization of fitulous tract
neoplasm
distal bowel obstr
SERIOUS wound infection causing very high fever, what suspect?
first r/o normal causes of post-op fever ie atelectasis, uti, etc...then check for gas-forming organism ie Clostridium which can cause necrotizing fasciitis, crepitus, brown bleb formation
gram +, spore producing rods found, dx of what in wound infection? tx?
clostridium infection
tx = penicillin, tetanus immunization, debridement, +/- hyperbaric O2
post-surgical acute hypotension and O2sat drop to 85%?
think PE!!! or MI!!
first r/o pthorax with bilateral ausc,
ECG, CXR,
IV heparin if PE
after how many weeks does scar collagen crosslinking and deposition reach its max amt ? after how many weeks is scar strength enough to allow exercise, heavy lifting, etc?
3 weeks
6 weeks
hard, knot-like structure beneath skin of wound?
suture knot = may go away with time/ if not, may be removed with local anasth
condition that may occur as result of wound infection, stuure failure, or fascial weakness? tx?
ventral hernia
tx = surgical repair
how long may complete wound healing require?
UP TO 6 MONTHS!
recurrence of hypertrophic scar common or uncommon after scar revision?
common unless tx'd with steroids, and local pressure dressings
what do most wound infections require?
debridement, drainage
NOT AB's (only severe infections ie spreading cellulitis)
post-drainage tx of wound infection?
daily moist gauze debridement to stimulate granulation tissue
option for wound infection that's healing with only healthy edges and granulation tissue?
split-thickness skin graft = epid and dermis graft from donor site = revascularization can occur and reepithelialization
must there be a low bacterial count for split thickness skin grat to take?
yes...<10^5 bact / gram tissue
split-thickness grafts reduce wound contraction by?
60%
must there be a low bact count for 3rd intention (wound surface sutured, inside with gran tissue left open) to work?
yes
peak of collagen production in wound healing?
5-7 days
what causes contractions and/or contractures in wound healing?
wounds by 2ndary intention contract due to myofibroblasts that contract with smooth muscle properties
vascular response in wound healing?
phases of wound healing?

cellular response in wound healing?
initial VC, later VD

inflammation--> proliferation --> remodeling

neutrophils-->macrophages-->lymphocytes-->fibroblasts
risk of infection in clean wound (ie for ventral hernia repair?)
<1%
if mesh inserted in surgery, what must give postop?
give AB's b/c of high morbidity assoc with infected mesh
clean-contaminated wound (ie colectomy, )risk of infection?
risk <10%
contaminated wound (ie perforated colon and colectomy and colostomy performed) ...tx?
PROBABLE gross contamination of wound with stool.
tx = leave wound open (for 2ndary intention healing) and tx with saline soaked gauze, +/- 3rd intention closure later after gran tissue sets in
infected wound (ie established infection before any incision is made, ie appendiceal abscess) risk for infection?
>50% risk for infected wound
what types of wounds should you give AB's single pre op dose 1hr before, and post op dose for?
clean-contaminated or worse, known exposure to bact, implantation of ANY prosthetic device,or IC host or poor blood supply
single 15 min episode of numbness and weakness in r arm alsting 15 mins in 60 y/o? MLD(most likely dx)
TIA caused by LEFT internal carotid plaque sending a t/embolism to brain
what % TIA left untreated will recurr or have later stroke? tests?
40%
US to carotids,
echo to heart for lesions, murmurs,
tx for 80% occlusion of carotid? what % stroke if tx'd?
1)aspirin= 26% stroke OR
2) endarterectomy = 9% stroke (if >70% + ipsilateral sx OR carotid bruit, endarterectomy indicated and shown to prevent stroke)
indications for carotid endarterectomy?
>70% occlusion PLUS
bruit OR
ipsilateral sx (TIA, single vision loss, stroke)
risk of stroke perioperatavely for endarterectomy?
1-3%
patient with TIA is most likely to die of?
MI...b/c is caused by the same disease: atherosclerosis
what is amaurosis fugax and what causes it? findings?
emboli from carotid bifurcation --> opthalmic artery --> retina -->transient blindness or "shade being pulled over the eye"
see Hollenhorst plaque on fundoscopy;
resolves in 15 mins
transient aphasia in right handed person?
in R handed, speech center is in Left hemisphere so TIA would be caused by Left carotid
do immediate endarterectomy for non-TIA stroke with sx that do NOT resolve?
NO---should wait 2-4 weeks after stroke to do endarterectomy
for asx carotid stenosis, do endarterectomy?
still controversial
what give immediately before op for leg pallor,plselessness, paralysis, poikilothermia and pain?
give HEPARIN, then do op for revasc. DONT need tlytics or preop angiography for good results . only intraop angiography for visualization of removal of all thrombi/emboli
m/c location of embolization to lower leg arts?
common femoral artery (45%)
op procedure of choice for leg artery emboli?
balloon catheter embolectomy
loss of motor ability and tenderness in calf of pt post-embolectomy despite good perfusion?
compartment syndrome
closure of fasciotomy for compartment syndrome uses what?
split-thickness skin graft
post - leg embolectomy long term tx?
warfarin (long term anticoag),
aortography/CT to search for emboli source
cramp in leg every time after walking 100 yards, then subsides with rest?
leg claudication
constant, sever, burning, forefoot pain?
rest pain
absent popliteal but present femoral art's. NSIM?
do ABI via doppler.
normally, what is ABI?
in mild, severe claudication?
>1.0
mild .6-.8
severe <.5
pts with symptomatic PAD have mortality rate of what in 10yers?
50%!! must tx CV risk factors!!!
most important rf modification impacting claudication and CV disease mortality?
SMOKING CESSATION!!
for most claudication pts, do surgery or not? what don't do?
most dont..give pentoxifylline or cilostazol a pde inhibitor; #1 tx = exercise management will iprove sx in 1/3 (1/3 will worsen!)
also attempt smoking cess.
don't give arteriogram unless surgery planned
for aortoiliac occlusive disease, do surgery? what type?
yes b/c is more progressive than claudication.
do balloon dilatation or stent placement
rest pain signifies ABI of what?
0.3-0.5
diff b/w tx of claudication and leg emboli?
leg emboli may be pulled out via balloon dilation, however, stenosis needs either balloon +stent placement or bypass with saph vn graft or if not successful, amputation
decision for tx of aoortoiliac occlusive disease:
depends on op risk, discomfort levelof pt, and whether or not he has rest px or ulceration. if severe enough, do PTA
what is trash foot?
post-aortofemoral bypass graft toe cyanosis caused by fibrin, platelets, or dislodged debris emboli to small pedal or dgiital arts during unclamping...significant healing commonly results, but give heparin and long-termantiplatelet therapy. amputation only if necrosis sets in; prophylactic AB's for any other procedures with risk of infection
in major vasc reconstruction ie aortoiliac graft, what % have periop MI, arrhythmia, or HF? cardiac mortality?
10%
3%
most useful procedures in testing pts with coronary risk that must undergo vascular surgery ie for aortoiliac bypass?
stress echo, Holter, and DTS (thallium scan)
DTS has good Neg predictive value or pos pred value?
Great Neg pred value (99%) but terrible PPV (1-20%).
Eagle's criteria to predict periop cardiac mortality risk?
Age >70
DM
Angina
Vent arrhythmias
Qwaves on ECG
DtS redistribution
if 1 or 2 = 15% risk of MI = do further tests ie DTS if haven't yet
if >3 = 50% risk of MI= DO PCI FIRST
pulsatile mass int he abdomen... what is it? what is dx criteria for surgery?
= abdominal aortic aneurysm AAA ; surg indicated if >5cm as long as life expect. is >2 yrs and pt can survive op
what other aneurysms that 50% them also have AAA?
popliteal
what char of AAA is related to rupture?
size/dilation
all pts who get AAA surgery also will have post op what?
large third spacing= extra fluid req's ; by third day it all remobilizes so may then require diuresis and IV restriction
ruptured AAA surgery must be careful not to injure what? causes what?
vagus plexus on ant surface of aorta near IMA = causes erectile dysfxn
syncope, hypotension, and pulsatile abd mass?
RUPTURED AAA
for ruptured AAA, do resusc first or straight to surg?
strait to surg
percent of 5 cm AAA's to ruptture in 5 yrs? of 7 cm?
20-33%
95%!!!
scan to r/o AAA in non-emergent (no hypotension, pulstile mass) pt?
do abd US or CT
periop mortality of ruptured AAA pt's?
80%!!!!
immediately do what to r/o post AAA reconstruction ischemic colitis in small amt of bloody diarrhea, fever pt?
sigmoidoscopy!!
what type of ischemic colitis requires what tx?
full-thickness = resection of non-viable bowel and end colostomy
partila thicknes ischemia = bowel rest, hydration, GI decompression, AB's frequent reexamination
6 mo hx of post-prandial abd px, 20lb wt loss, and intermittent diarrhea with multiple abd bruits
chronic mesenteric ischemia
cause of chronic mesenteric ischemia?
ath occlusion of celiac, sm. ..postprandial ischemia due to isch causes fear of food => wt loss
managmente for chronic mesenteric ischemic pt?
revasc with bypass from aorta to mes artery/ celiac art or end-end anast after resection of thrombi/plaque
tearing back pain, BP 200/140, sweating
ao dissection
complic's of ao dissection?
mesenteric ischemia,
stroke,
paraplegia, renal ischemia, periph vasc ischemia
therapy for ao dissection?
CONTROL HTN!!! (b-blocikers)surg if type II (ascending aorta)
most reliable clinical sign of DVT? most COMMON sx?
unilat leg SWELLING...m/c sx is unilat dull leg px. clin findings are only 50% reliable
def of DVT is b/w which vessels?
b/w IVC and bifurc of ant sup tibila vn and greater saph vn
dx confirmation of DVT? how sens and spec?
duplex ultrasound!! =over 90% sens and spec. for DVT
tx of DVT?
initial systemic anticoag with heparin IV., bedrest, and start warfarin in first few days to overlap and maintain to INR of 2.0-3.0
how monitor heparin tx'd pt?
with PTT to maintian 1.5-2.0 normal level; follow platelets for HITCP,
what % of pts on heparin get heparin induced TCP?
5%
warf inhibits what?
vit k dependent factors II, 7, 9, 10, and C and S
why must pts also stay on heparin a few days after warf begins?
warf can induce prot C deficiency = hypercoagulabiliy in first few days, so must overlap to prevent this
ways to lessen edema due to vasc valv insufficiency of DVT/post DVT?
compression stockings,
corhonic, marked edema, skin ulceration around ankles, and occasional claudication? mech?
post-thrombotic syndrome seen in post DVT due to chronic venous hypterension/pooling in lower leg....tx is compression stockings and tx to heal ulcers
what percent of general surgical procetures result in DVT? what percent of orthopedic surg's of leg?
20%!!!
70%!!
Virchow triad?
stasis of blood
state of hypercoagulability
endothelial /intimal injury
all these lead to DVT's
prophylactic for DVT during surgery?
position:legs above r atrium, feet above legs
post-surg early mobilization
post-surg compression stockings
*LOW DOSE* PROPHYLACTIC HEPARIN!!!
do intermittent pneumatic comression devices prevent DVT's?
YES...it has been proven...as well as low dose prophylactic heparin
mech of heparin?
upregulates antithrombin, which inhibits factor 2, 7, 9, 10, 11, and 12 and others so is ANTI coag
wells score?
clinically suspected DVT - 3.0 points
alternative diagnosis is less likely than PE - 3.0 points
tachycardia - 1.5 points
immobilization/surgery in previous four weeks - 1.5 points
history of DVT or PE - 1.5 points
hemoptysis - 1.0 points
malignancy (treatment for within 6 months, palliative) - 1.0 points
Traditional interpretation[3][4][9]

Score >6.0 - High (probability 59% based on pooled data[10])
Score 2.0 to 6.0 - Moderate (probability 29% based on pooled data[10])
Score <2.0 - Low (probability 15% based on pooled data[10])
Alternate interpretation[3][6]

Score > 4 - PE likely. Consider diagnostic imaging.
Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.
with wells' score of LOW probability, what is enough to then rule out DVT/PE?
In low/moderate suspicion of PE, a normal D-dimer level (shown in a blood test) is enough to exclude the possibility of thrombotic PE
mismatched V/Q scan and DVT on DVT makes dx of PE how likely?
95%
tx of PE?
identical to DVT =
IV heparin maintained at 2x norm, then warfarin to 2.0-3.0 INR
does normal CXR rule out PE?
no
Does normal perfusion scan rule out PE?
YES!! (with rare exceptions ie saddle embolus that has not yet affected small arteries)
is multiple subsegmental defects on perfusion scan dixanostic of PE?
no..should continue evaluation. MISMATCHED segmental perfusion/vent defect is HIGHLY suspicious fo PE
how suspicious is WEDGE-shaped perfusion defect for PE?
moderately
management of recurrent PE with failed anticoag therapy?
ICU, IVC greenfield filter, continued anti-coags
m/c indications for greenfield filter?
failed heparin anticoag;
heparin complics like bleeding
100ml vomited bright red blood post-heparin therapy for DVT? tx?
upper gi bleeding .tx with stopping anticoag immediately...use greenfield filter instead
hwat is phlegmasia cerulea dolens?tx?
"inflamm ..cyanotic...painful" = acute interruption of venous outflow from obstruction due to ie malgnancy...may lead to sensory and motor lsos and venous gangrene if not tx'd immediately. tx = anticoag and leg elevation...(then, only rarely needs thrombectomy)
ddx for upper epigastric pain?
ulcer, perforated ulcer, GERD, pancreatitis, cholecystitis/cholelithiasis, gastroenteritis
NSIM in dx for upper epigastric px?
labs, abd US to r/o gallstones, if negative, do EMPIRICAL H2/PPI for GERD
1st tx of GERD that may improve 65% of patients?
lifestyle: no caffeine, choco, alcohol that decrease LES tone, sleep upright in bed,
H2/PPI EMPIRICAL therapy
is sx persist after lifestyle mod for GERD?
Endoscopy for ulcer or hpylori gastritis
what % GERD refractive to maximal therapy? how tx?
10-15%; Nissen fundoscopy
what must do for all pt's going for surg for Nissen?
Manometry = to demonstrate intact esoph peristalsis, and
Biopsy
24-Hr probe to confirm dx of GERD (probably done already)
what % of pts with GERD have hiatal hernia?
80% (although most hiatal hernias don't have GERD)
lifestyle prevention of esophagitis 2ndary to GERD?
GERD modifications ie sleep not laying down, eat ok foods, also, eat frequent small meals, don't eat a late meal before bedtime,
what drug causes 85% remission of esophagitis 2ndary to GERD?
PPI's
chronic GERD esophagitis causes in 15% of pts ? tx for?
barret esophagus
tx = BIOPSY for adenocarc,
H2 blockers, PPI's, bed elevation; if severe, surveillance every 18-24 mo for progression to dysplasia
barrett's esophagus with progression to severe dysplasia tx?
esoph resection!!
type I hiatal hernia tx? type II?
type I = sliding = only give medical therapy w/o surgery.
type II = paraesophageal with stomach herniated and +/- other organs as well
what is hiatal hernia type II? tx?
when organs Ie stomach herniate into thorax. complication is necrosis of stomach!! very dangerous, so must be tx'd with surgery to prevent stomach necrosis!!
tx for H.pylori?
MOC, AMO or ACO
(Metro, Omeprazole, Ampicillin, Clarythro)
food increase or decrease pain of duod ulcer?
food decreases pain of duod ulcer, increases px of gastric ulcer.
surgery indications for duod ulcer?
Intratibility of px
Hemorrhage (massive)
Obstruction
Perforation
truncal vagotomy for decreasing acid secretion may also require what?
pyloroplasty to allow food to exit stomach otherwise pyloris won't open after vagotomy
tx for 1 duod bleed? 2 for duod ulcer? for 3 pyloric gastric ulcer 4 d and g ulcer?
1 oversew the bleeding vessel
2 meds -> prox gast vagotomy +/-pyloroplasty
3 meds -> distal gastric antrectomy w/ vagotomy
4 BI or BII and vagotomy
does duo ulcer ever lead to cancer?
never!! only gastric ulcers may...
which surgery for duod ulcer has lowest mortality rate? and is the operatio nof choice
PGV
cause of d ulcer vs g ulcer?
d : incrased gastric acid production
g: decreased cytoprotection or mucus secretion
when should gastric bx be done?
for ALL gastric ulcers!! to rule out g cancer
tx of gastric ulcer and duod ulcer?
PPI + 2 antibiotics
indications for surgery for gastric ulcer?
IHOP + C = cancer
tx for gastric ulcer causing HO or P?
gastrectomy (BI, BII, etc) without vagotomy (vagotomy to reduce acid secretion; gastric ulcer not due to acid increase) except if pyloric gastric ulcer = do vagotomy b/c pyloric ulcers are due to increased acid production
tx for perforated gastric ulcer?
Graham patch
Every gastric ulcer op must also include what?
BX to look for gastric cancer!!!
recurrence rate of gastric ulcer?
66%
sign of posterior duod erosion/perforation? anterior?
more common?
bleeding from gduod artery and/or acute pancreatitis

ant: free air under diaphragm
ant i s more common
cxray for air under diaphragm?
left lat decubitus and upright
initial tx of perforated ulcer?
NGT to derease peritoneal contamination from stomach/int
IV fluids/foley catheter
AB's
Surgery
#2 cause of ugi bleeding in adults ? in kids?
mallory weiss tears
kids - e varices
tx for mw tears?
room temp water lavage; 90% stop bleeding...i fnot, e cautery or surg after 6 PRBC's infused
give tamponade balloon for mw tears?
no, only for evarices
rule of 2/3rds?
2/3 of portal htn has evarices, 2/3 of evarices bleed,
dx of evarices and mw tears?
EGD
tx for evarices?
lower the portal htn with VASOPRESSIN/ SOMATOSTATIN, and also give nitro to heart pts to prevent coronary VC caused by these; S-B tamponade balloon if necessary;
then do sclerotherapy, band ligation, TIPS, +/- liver tplant
mw tears are mostly where?
in stomach
boerrhaave's syndrome?
post-emetic esoph rutpure due to violent retching and vomting, assoc with GERD
tx for UNCOMPLICATED peptic ulcer?
HSV = highly selective vagotomy
HSV has lower what but higher what?
lower mortality and dumping, but higher recurrence.
what must rule out with recurrent peptic ulcer disease?
measure serum gastrin levels to look for Z-E syndrome!! = 2% of all recurrent PUD's are Z-E's
if ZE syndrome, what must also rule out ; how?
MEN I ; do PTH and calcium to look for parathyroid tumor
duration of tx for gastric vs duod ulcer?
gastric = hpylori tx for 8-12 wks.
duo = hpylori tx for 2 weeks!
NON-healed gastric ulcer, NSIM?
should re-biopsy, and then resect to prevent unrecognized cancer.
No vagotomy
what must be done prior to gastrectomy for early gastric cxr?
STAGING! do abd exploration, CT or laparoscopy and check for L/N spread, etc.
5 yr survival of gastric cxr that is confined to mucosa and no mets?
90%
linitis plastica tx?
total g-ectomy with splenectomy....cure is RARE
first test to give pt with 4hrs epig px with fever, leukocytosis and rigid stomach?
uprigh CXR + left lat decubitus (obstructive series) to check for air under diaprhagm = perforation
type of peritonitis usually seen in perforation?
chemical peritonitis
tx of pt with acute perforation vs perforation clearly due to previous ulcer?
acute = just omental patch
previous ulcer = need to do HSV or vagotomy and pyloroplasty
If pt has signs of perforation and also signs of sepsis, or hypotension during op?
do graham patch QUICKLY, get out and give IV AB's/fluids in ICU, and only come back later to do definitive V &P etc surgery
coffee ground-like hematemesis...dx? tx?
dx = stress gastritis (ventilator dependence) / nsaids induced ulcer...or acid-induced bleeding...tx =h2 blocker and/or sucralfate = protects mucosal barrier... and misoprostol pge1 analog also protects mucosal barrier and prohibits gacid secretion.
upper endoscopy not needed with this type of bleeding
what if bright red blood appears in n/g tube of pt in ICU?
resuscitation! 2 lb iv needles, blood draw, cross match, fluids, LAVAGE until blood no longer returns, monitor bp...
ONLY AFTER STABILIZATION DO ENDOSCOPY
things to also tx before duo ulcer surgery in these pts:
1 pt with acute renal failure and elev CR?
2 pt with chronic alc cirrhosis
1 this pt probably has platelet dysfxn due to uremia; tx with dialysis and desmopressin, then do surg
2 pt has low coag fxors and TCP from splenomegaly...and is bleeding b/c of thess; give FFP before surg and pl tfusion
bleeding gastric ulcer tx?
excision, then return for biopsy later after bleeding subsides.
tx for gastritis?
keep ph above 5 with H2 blocker or PPI, give sucralfate to decrease bleeding,
do gastric varices respond to banding/sclerotherapy like esoph ones do?
not as much
which is better, banding or sclerotherapy?
banding
NSIM for alcoholic man in acute variceal bleeding?
if continues to bleed?
band the bleed
correct low plts and low coag fxors with pl tfusion and FFP
give somatostatin, vasopressin (+nitro if heart pt) for decreasing portal htn
+/- b blocker

if bleeding persists, consider porto systemic shunt ie TIPS (but has 50% mortality!!) or ballon tamponade( but bleeding recurrs as soon as its removed; only give on intubated pts)
all pts post variceal bleed, what medication may lessen chance of rebleed?
B-blockers!!!
staging and tx of gastric maltomas?
stage I = h pylori eradication and surgery alone +/- rad
stage II = total g-ectomy + l/n resection plus rad and chemo
stage III and IV = chemoradiation, no surgery