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245 Cards in this Set
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standard preop surgery tests?
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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 |
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predictors of incraesed periop cardiac risk?
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UNSTABLE ANGINA, DECOMP CHF
signif. arrhythmias severe valv. disease |
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MAJOR Risk of cardiac events for what non-cardiac surg procedures?
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major ops in elderly
aortic reconstruction. major periph vasc procedures procedures w/ major fluid shifts/ blood loss |
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Anasthesiologists classif of periop mortality?
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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 |
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How to decide whether local, spinal, or general anasthesia?
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Most anasth' beleive it's not the type of surgery but HOW WELL the anasth is administered that determines its risk!
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problem with local anasth?
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pt may still experience severe px, which causes stress and High dosese of IV sedatives to offset, which increases the risk
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which may cause fewer pulm complications, good spinal anasth or good general anasth?
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good spinal
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positives of general ansthesia?
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maintains secure airway
Good analgesia and anamnesia good control |
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negatives of general anasth?
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increased pulmonary complications and mild cardiodepression
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time it takes for NSAID -induced platelet inhibition to reverse?
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2 days;
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time to wait after NSAID dose before surgery? after aspirin dose?
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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 |
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does previous MI increase risk for postop MI?
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yes, just like it increases risk for any non-op MI..!
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previous MI pt desiring electiv hernia. what do first?
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do ECG, etc test, including possible stress test; and then possible cath (if ischemic signs present) to determine if revasc needed first
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what give to diabetic pt going in for elective surgyer?
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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.
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what if pt's gluc is >250 on morning of elective surg? if >100, <250?
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give him 2/3 of his normal NPH and reg insulin.
give him 1/2 of normal mornign dose |
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m/c cause of anemia?
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Colorectal cancer
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hct of 35%, what do before elective surgery?
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postpone; fix nemia first, check for GI blood loss or CRC cxr too
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dehydration before elective surgery?
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postpone until sufficient hydration is achieved.
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causes of increased HCT?
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DEHYDRATION,
PCV, COPD, EPO - secreting tumor ie RCC, HCC |
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prevention of DVT's in obese pt going into elective surgery? (2)
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compression stockings
sub-Q heparin |
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poorly controlled DM causes what post-op?
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higher risk of post - op wound infection!!
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what else besides DM causes increased risk for post-op wound infection?
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surgery in presence of other active infection (ie cellulitis)
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in presence of other active but distant infections (ie toe infection) shoudl elective surg be postponed?
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yes - especially in diabetics
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should elective surg be postponed if UTI?
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yes
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diastolic bp > 110 is RF for what in elective surg?
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rF for cv complics such as malignant htn, acute MI, chf
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should continue hypertsnive pt on his htn drugs during elective surgery?
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Yes, especially BBlockers, b/c if withheld may cause rebound htn
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should postpone surgery for htn?
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only for diast htn> 110
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postop complication risk increase for smokers?
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2-6x increased
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how long must cigs be stopped pre-op in order ot improve postop resp morbidity?
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8 WEEKS!
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postpone surg for acute bronchitis (ie with green productive sputum in smoker) ?
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yes, tx with oral ab's, then do surg
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think what if blood-tinged sputum for 3 weeks? NSiM?
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lung cxr! or active infection
do chest ct, xray, and possibly bscopy |
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what lab result signifies pulmonary htn? which is associated with increased perioperative morbidity?
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PaO2 < 60mmHg
PCO2 >45 = increased morbidity |
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how to improve preop status ie in COPD pt before ie emergency cholecystectomy? how improve post-op status?
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give bdilators, spirometry, ( and mobilization after surgery to prevent atelectasis)
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pt with decompensating COPD, ie paO2 <60 and pcO2 >45 has risk for what during surgery?
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acute pulm failure. do cxr to r/o underlying pneumonia before surg.
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type of surg c/i'd in patient with cholecystitis and COPD w/ high risk of pulm failure
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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
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earliest clinical sign of hypermagnesemia?
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loss of deep tendon reflexes
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predictors for risk of cardiac complication after vasc surgery? tests should be performed preop?
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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 |
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m/c cause of early post-op death after lower extremity revasc? risk of this?
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MI
15%! |
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past acute MI within how many days of upcoming surgery is a MAJOR RF for cardiac complication?
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7-30 days; if so, delay surgery
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past CABG within 6mo-5years before surgery increases or decreases cardiac complic. risk?
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decreases!
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what's the incidence of restenosis at only 6 mo after PTCA?
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25-35%!!
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what if man had PTCA 2 weeks before upcoming surgery for lower leg revasc?
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postpone surgery; thrombosis from PTCA increases during first month post-PTCA
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do cath first for pt needing lower leg revasc surg but also has moderate angina on exertion?
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YES = sx are of coronary disease.
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what is the cardiac risk of arrhythmia most likely due to?
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ventricular dysfunction, not necessarily underlying arrhythmias like excessive PVC's , etc
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afib must be controlled with what before surgery
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anticoagulation
cardioversion to normal sinus rhythm B-blockers to control hr |
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risk of neurologic events due to non-cardia vascular surgery is high or low?
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low
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past stroke, what managmenet before revasc surgery to lower legs/. what do with findings?
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do carotid duplex to assess any occlusion. if >70% occluded up to 99%, should do carotid endarterectomy
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tx of abnormally high PT before surgyer?
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give vit K
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what does ulcer over hernia indicate?
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pressure necrosis = up to 43% mortality!! EXPEDITE SURGERY!!
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ascites may cause what type of infection? what test to do? for what?
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spont bact ptitis = do tap and check if > 250wbc's in ptfluid
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why must alcoholic stop drinking before surgery for liver failure and ascites causing umbilical hernia?
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b/c post-surgical alcohol w/drawal is assoc with high mortality. must stop alcohol and undergo w/drawal before surgery
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why does hemorrhoid surgery have high risk in ascitic pt?
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b/c if due to portal htn, hemorrhage/bleed will cause massive blood loss due to increased blood pressure
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what must do in CKD pt befoer taking to surgery for other condition?
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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.
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should continue steroids perioperatively for ie CKD pts?
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YES
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how recent should K+ levels in CKD pt be taken before surg?
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K+ in CKD can change immediately. mut be taken in short periods before surg and surg only done if normalized
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common cause of bleeding in CKD pt in surgery? does pl tfuision help?
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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
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hypotension in CKD pt in OR may be due to?
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CKD = tx with steroids; causing adrenal insuff due to GCSteroid deficiency in surgery => hypotension. tx with hydrocortisone intraoperatively and post-op
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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?
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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 |
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all pts that have valve abnorms, cmyopathy, acute mi hx, etc going in for any procedure needs what?
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cardiology consultation
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what's a cathartic?
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ie Golitely = bowel prep
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S/E's of Golitely?
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not really many; no elyte or water balance changes;
only dehydratoin in older pts |
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C/I of Fleets Phospho-Soda?
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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 |
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MgCitrate S/E's?
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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.
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tx for hypermagneseia?
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ca gluconate (same for hyperkalemia)
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how much iv fluid given in surgery is lost to EV space?
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2/3!! so must replace 3 ml for every 1 ml lost
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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) |
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estimated maintenance fluid req's?
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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 |
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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 |
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normal input of water through ingestd fluids is?
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1200 ml/day, from ingested foods 1000 ml/day and from metabolism 300 ml/day, totaling 2500 ml/day
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normal output of water per day?
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urine = 1500
feces 100 insensible loss (sweating, water evap) 800 vag secretions 50 = about 2500 to balance h20 input from drink, foods, metabolism |
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3 areas of post-op fluid replacement?
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1) fluid lost during procedure
2) maintenance 3) fluid lost to drains, ng tubes, fistula (calc from chart) |
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normal urine output should be?
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about 50ml/hr for 70kg adult (.5-1.0ml/kg)
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conditions causing postsurgical increased diuresis (>>50ml/hr and resulting hypotension??
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preexisting renal disease, DI, or postobstructive diuresis
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severe oliguria postsurgical (<<<50ml/hr) algorithm?
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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 |
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things to assess if normal CVP but LOW urine output?
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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 |
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#1, #2, etc causes of post-op fever?
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M/C cause = ATELECTASIS = hear pulm crackles, cxray findings, etc)
#2 = UTI, etc: Pneumonia DVT, infected indwelling cath drug-related fever |
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prevention of post-surg atelectasis?
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pulm toilet ( blow bottles, suction)
incentive spirometry NOT Ab's |
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Day that UTI usually shows up post-surg? tx?
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day 3
tx with ciproflox or tmp-smx |
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tx for post-surg cellulitis?
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ORAL Ab's
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what is suppurative phlebitis?tx?
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pus drainage at site of catheter; tx =remove cath, surgically excise vein, AB's for sepsis
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any pt showing ptitis after surg requires what?
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operative exploration or CT scan for intrabd collection of pus
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tx of enterocutaneous fistula post-surg ?
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NPO, TPN and measure fistula drainage...most will heal in several weeks. (except FRIENDS)
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non-healing fistulas?
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FRIEND
foreign body in wound radiation damage to aria infecton or inflamm bowel disease epithelialization of fitulous tract neoplasm distal bowel obstr |
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SERIOUS wound infection causing very high fever, what suspect?
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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
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gram +, spore producing rods found, dx of what in wound infection? tx?
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clostridium infection
tx = penicillin, tetanus immunization, debridement, +/- hyperbaric O2 |
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post-surgical acute hypotension and O2sat drop to 85%?
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think PE!!! or MI!!
first r/o pthorax with bilateral ausc, ECG, CXR, IV heparin if PE |
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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?
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3 weeks
6 weeks |
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hard, knot-like structure beneath skin of wound?
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suture knot = may go away with time/ if not, may be removed with local anasth
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condition that may occur as result of wound infection, stuure failure, or fascial weakness? tx?
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ventral hernia
tx = surgical repair |
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how long may complete wound healing require?
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UP TO 6 MONTHS!
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recurrence of hypertrophic scar common or uncommon after scar revision?
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common unless tx'd with steroids, and local pressure dressings
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what do most wound infections require?
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debridement, drainage
NOT AB's (only severe infections ie spreading cellulitis) |
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post-drainage tx of wound infection?
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daily moist gauze debridement to stimulate granulation tissue
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option for wound infection that's healing with only healthy edges and granulation tissue?
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split-thickness skin graft = epid and dermis graft from donor site = revascularization can occur and reepithelialization
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must there be a low bacterial count for split thickness skin grat to take?
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yes...<10^5 bact / gram tissue
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split-thickness grafts reduce wound contraction by?
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60%
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must there be a low bact count for 3rd intention (wound surface sutured, inside with gran tissue left open) to work?
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yes
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peak of collagen production in wound healing?
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5-7 days
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what causes contractions and/or contractures in wound healing?
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wounds by 2ndary intention contract due to myofibroblasts that contract with smooth muscle properties
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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 |
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risk of infection in clean wound (ie for ventral hernia repair?)
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<1%
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if mesh inserted in surgery, what must give postop?
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give AB's b/c of high morbidity assoc with infected mesh
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clean-contaminated wound (ie colectomy, )risk of infection?
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risk <10%
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contaminated wound (ie perforated colon and colectomy and colostomy performed) ...tx?
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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 |
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infected wound (ie established infection before any incision is made, ie appendiceal abscess) risk for infection?
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>50% risk for infected wound
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what types of wounds should you give AB's single pre op dose 1hr before, and post op dose for?
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clean-contaminated or worse, known exposure to bact, implantation of ANY prosthetic device,or IC host or poor blood supply
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single 15 min episode of numbness and weakness in r arm alsting 15 mins in 60 y/o? MLD(most likely dx)
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TIA caused by LEFT internal carotid plaque sending a t/embolism to brain
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what % TIA left untreated will recurr or have later stroke? tests?
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40%
US to carotids, echo to heart for lesions, murmurs, |
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tx for 80% occlusion of carotid? what % stroke if tx'd?
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1)aspirin= 26% stroke OR
2) endarterectomy = 9% stroke (if >70% + ipsilateral sx OR carotid bruit, endarterectomy indicated and shown to prevent stroke) |
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indications for carotid endarterectomy?
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>70% occlusion PLUS
bruit OR ipsilateral sx (TIA, single vision loss, stroke) |
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risk of stroke perioperatavely for endarterectomy?
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1-3%
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patient with TIA is most likely to die of?
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MI...b/c is caused by the same disease: atherosclerosis
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what is amaurosis fugax and what causes it? findings?
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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 |
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transient aphasia in right handed person?
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in R handed, speech center is in Left hemisphere so TIA would be caused by Left carotid
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do immediate endarterectomy for non-TIA stroke with sx that do NOT resolve?
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NO---should wait 2-4 weeks after stroke to do endarterectomy
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for asx carotid stenosis, do endarterectomy?
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still controversial
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what give immediately before op for leg pallor,plselessness, paralysis, poikilothermia and pain?
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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
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m/c location of embolization to lower leg arts?
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common femoral artery (45%)
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op procedure of choice for leg artery emboli?
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balloon catheter embolectomy
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loss of motor ability and tenderness in calf of pt post-embolectomy despite good perfusion?
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compartment syndrome
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closure of fasciotomy for compartment syndrome uses what?
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split-thickness skin graft
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post - leg embolectomy long term tx?
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warfarin (long term anticoag),
aortography/CT to search for emboli source |
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cramp in leg every time after walking 100 yards, then subsides with rest?
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leg claudication
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constant, sever, burning, forefoot pain?
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rest pain
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absent popliteal but present femoral art's. NSIM?
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do ABI via doppler.
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normally, what is ABI?
in mild, severe claudication? |
>1.0
mild .6-.8 severe <.5 |
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pts with symptomatic PAD have mortality rate of what in 10yers?
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50%!! must tx CV risk factors!!!
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most important rf modification impacting claudication and CV disease mortality?
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SMOKING CESSATION!!
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for most claudication pts, do surgery or not? what don't do?
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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 |
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for aortoiliac occlusive disease, do surgery? what type?
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yes b/c is more progressive than claudication.
do balloon dilatation or stent placement |
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rest pain signifies ABI of what?
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0.3-0.5
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diff b/w tx of claudication and leg emboli?
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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
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decision for tx of aoortoiliac occlusive disease:
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depends on op risk, discomfort levelof pt, and whether or not he has rest px or ulceration. if severe enough, do PTA
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what is trash foot?
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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
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in major vasc reconstruction ie aortoiliac graft, what % have periop MI, arrhythmia, or HF? cardiac mortality?
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10%
3% |
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most useful procedures in testing pts with coronary risk that must undergo vascular surgery ie for aortoiliac bypass?
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stress echo, Holter, and DTS (thallium scan)
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DTS has good Neg predictive value or pos pred value?
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Great Neg pred value (99%) but terrible PPV (1-20%).
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Eagle's criteria to predict periop cardiac mortality risk?
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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 |
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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
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what other aneurysms that 50% them also have AAA?
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popliteal
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what char of AAA is related to rupture?
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size/dilation
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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
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ruptured AAA surgery must be careful not to injure what? causes what?
|
vagus plexus on ant surface of aorta near IMA = causes erectile dysfxn
|
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syncope, hypotension, and pulsatile abd mass?
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RUPTURED AAA
|
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for ruptured AAA, do resusc first or straight to surg?
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strait to surg
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percent of 5 cm AAA's to ruptture in 5 yrs? of 7 cm?
|
20-33%
95%!!! |
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scan to r/o AAA in non-emergent (no hypotension, pulstile mass) pt?
|
do abd US or CT
|
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periop mortality of ruptured AAA pt's?
|
80%!!!!
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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
|
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cause of chronic mesenteric ischemia?
|
ath occlusion of celiac, sm. ..postprandial ischemia due to isch causes fear of food => wt loss
|
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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
|
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tearing back pain, BP 200/140, sweating
|
ao dissection
|
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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)
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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
|
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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
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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
|
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how monitor heparin tx'd pt?
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with PTT to maintian 1.5-2.0 normal level; follow platelets for HITCP,
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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
|
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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
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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?
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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. |
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with wells' score of LOW probability, what is enough to then rule out DVT/PE?
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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
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mismatched V/Q scan and DVT on DVT makes dx of PE how likely?
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95%
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tx of PE?
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identical to DVT =
IV heparin maintained at 2x norm, then warfarin to 2.0-3.0 INR |
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does normal CXR rule out PE?
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no
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Does normal perfusion scan rule out PE?
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YES!! (with rare exceptions ie saddle embolus that has not yet affected small arteries)
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is multiple subsegmental defects on perfusion scan dixanostic of PE?
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no..should continue evaluation. MISMATCHED segmental perfusion/vent defect is HIGHLY suspicious fo PE
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how suspicious is WEDGE-shaped perfusion defect for PE?
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moderately
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management of recurrent PE with failed anticoag therapy?
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ICU, IVC greenfield filter, continued anti-coags
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m/c indications for greenfield filter?
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failed heparin anticoag;
heparin complics like bleeding |
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100ml vomited bright red blood post-heparin therapy for DVT? tx?
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upper gi bleeding .tx with stopping anticoag immediately...use greenfield filter instead
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hwat is phlegmasia cerulea dolens?tx?
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"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)
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ddx for upper epigastric pain?
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ulcer, perforated ulcer, GERD, pancreatitis, cholecystitis/cholelithiasis, gastroenteritis
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NSIM in dx for upper epigastric px?
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labs, abd US to r/o gallstones, if negative, do EMPIRICAL H2/PPI for GERD
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1st tx of GERD that may improve 65% of patients?
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lifestyle: no caffeine, choco, alcohol that decrease LES tone, sleep upright in bed,
H2/PPI EMPIRICAL therapy |
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is sx persist after lifestyle mod for GERD?
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Endoscopy for ulcer or hpylori gastritis
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what % GERD refractive to maximal therapy? how tx?
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10-15%; Nissen fundoscopy
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what must do for all pt's going for surg for Nissen?
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Manometry = to demonstrate intact esoph peristalsis, and
Biopsy 24-Hr probe to confirm dx of GERD (probably done already) |
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what % of pts with GERD have hiatal hernia?
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80% (although most hiatal hernias don't have GERD)
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lifestyle prevention of esophagitis 2ndary to GERD?
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GERD modifications ie sleep not laying down, eat ok foods, also, eat frequent small meals, don't eat a late meal before bedtime,
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what drug causes 85% remission of esophagitis 2ndary to GERD?
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PPI's
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chronic GERD esophagitis causes in 15% of pts ? tx for?
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barret esophagus
tx = BIOPSY for adenocarc, H2 blockers, PPI's, bed elevation; if severe, surveillance every 18-24 mo for progression to dysplasia |
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barrett's esophagus with progression to severe dysplasia tx?
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esoph resection!!
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type I hiatal hernia tx? type II?
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type I = sliding = only give medical therapy w/o surgery.
type II = paraesophageal with stomach herniated and +/- other organs as well |
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what is hiatal hernia type II? tx?
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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!!
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tx for H.pylori?
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MOC, AMO or ACO
(Metro, Omeprazole, Ampicillin, Clarythro) |
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food increase or decrease pain of duod ulcer?
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food decreases pain of duod ulcer, increases px of gastric ulcer.
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surgery indications for duod ulcer?
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Intratibility of px
Hemorrhage (massive) Obstruction Perforation |
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truncal vagotomy for decreasing acid secretion may also require what?
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pyloroplasty to allow food to exit stomach otherwise pyloris won't open after vagotomy
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tx for 1 duod bleed? 2 for duod ulcer? for 3 pyloric gastric ulcer 4 d and g ulcer?
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1 oversew the bleeding vessel
2 meds -> prox gast vagotomy +/-pyloroplasty 3 meds -> distal gastric antrectomy w/ vagotomy 4 BI or BII and vagotomy |
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does duo ulcer ever lead to cancer?
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never!! only gastric ulcers may...
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which surgery for duod ulcer has lowest mortality rate? and is the operatio nof choice
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PGV
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cause of d ulcer vs g ulcer?
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d : incrased gastric acid production
g: decreased cytoprotection or mucus secretion |
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when should gastric bx be done?
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for ALL gastric ulcers!! to rule out g cancer
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tx of gastric ulcer and duod ulcer?
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PPI + 2 antibiotics
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indications for surgery for gastric ulcer?
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IHOP + C = cancer
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tx for gastric ulcer causing HO or P?
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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
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tx for perforated gastric ulcer?
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Graham patch
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Every gastric ulcer op must also include what?
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BX to look for gastric cancer!!!
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recurrence rate of gastric ulcer?
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66%
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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 |
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cxray for air under diaphragm?
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left lat decubitus and upright
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initial tx of perforated ulcer?
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NGT to derease peritoneal contamination from stomach/int
IV fluids/foley catheter AB's Surgery |
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#2 cause of ugi bleeding in adults ? in kids?
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mallory weiss tears
kids - e varices |
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tx for mw tears?
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room temp water lavage; 90% stop bleeding...i fnot, e cautery or surg after 6 PRBC's infused
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give tamponade balloon for mw tears?
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no, only for evarices
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rule of 2/3rds?
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2/3 of portal htn has evarices, 2/3 of evarices bleed,
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dx of evarices and mw tears?
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EGD
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tx for evarices?
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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 |
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mw tears are mostly where?
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in stomach
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boerrhaave's syndrome?
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post-emetic esoph rutpure due to violent retching and vomting, assoc with GERD
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tx for UNCOMPLICATED peptic ulcer?
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HSV = highly selective vagotomy
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HSV has lower what but higher what?
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lower mortality and dumping, but higher recurrence.
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what must rule out with recurrent peptic ulcer disease?
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measure serum gastrin levels to look for Z-E syndrome!! = 2% of all recurrent PUD's are Z-E's
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if ZE syndrome, what must also rule out ; how?
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MEN I ; do PTH and calcium to look for parathyroid tumor
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duration of tx for gastric vs duod ulcer?
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gastric = hpylori tx for 8-12 wks.
duo = hpylori tx for 2 weeks! |
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NON-healed gastric ulcer, NSIM?
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should re-biopsy, and then resect to prevent unrecognized cancer.
No vagotomy |
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what must be done prior to gastrectomy for early gastric cxr?
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STAGING! do abd exploration, CT or laparoscopy and check for L/N spread, etc.
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5 yr survival of gastric cxr that is confined to mucosa and no mets?
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90%
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linitis plastica tx?
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total g-ectomy with splenectomy....cure is RARE
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first test to give pt with 4hrs epig px with fever, leukocytosis and rigid stomach?
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uprigh CXR + left lat decubitus (obstructive series) to check for air under diaprhagm = perforation
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type of peritonitis usually seen in perforation?
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chemical peritonitis
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tx of pt with acute perforation vs perforation clearly due to previous ulcer?
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acute = just omental patch
previous ulcer = need to do HSV or vagotomy and pyloroplasty |
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If pt has signs of perforation and also signs of sepsis, or hypotension during op?
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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
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coffee ground-like hematemesis...dx? tx?
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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 |
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what if bright red blood appears in n/g tube of pt in ICU?
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resuscitation! 2 lb iv needles, blood draw, cross match, fluids, LAVAGE until blood no longer returns, monitor bp...
ONLY AFTER STABILIZATION DO ENDOSCOPY |
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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 |
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bleeding gastric ulcer tx?
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excision, then return for biopsy later after bleeding subsides.
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tx for gastritis?
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keep ph above 5 with H2 blocker or PPI, give sucralfate to decrease bleeding,
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do gastric varices respond to banding/sclerotherapy like esoph ones do?
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not as much
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which is better, banding or sclerotherapy?
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banding
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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) |
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all pts post variceal bleed, what medication may lessen chance of rebleed?
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B-blockers!!!
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staging and tx of gastric maltomas?
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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 |