Midterm Flashcards

Question

13.Surgical instruments

Answer 1

* Cutting instruments * Scalpels * Scissors -for tissues and sutures * Grasping instruments * Tissue forceps * Ratcheted tissue forceps * Needle-holders * Retracting instruments * Hand-held retractors * Self-retaining retractors

Answer 2

Surgical staplers * Skin stapler * Linear stapler * Gastrointestinal anastomosis stapler * Circular stapler

Answer 3

Energy applying instruments * Diathermy * Electrocoagulation * Monopolar- patient return electrode * Bipolar Other energy applying instruments * Mechanical energy (ultrasound scalpel) * Laser * Cyrotherapy * Radiofrequency needles

Answer 4

Sutures and Needles * Suture materials * Absorbable : polyglycolic acid,polydioxanone * Non absorbable : polypropylene,polyamide * Suture strand type * Monofilament * Multifilament * Twisted * Braided * Suture size : 10/0 - thinner than 1

Answer 5

Sutures and needles

Answer 6

* Inhibit electrical conduction along neurons * Transient blocking of Na⁺ transport channels in the cell membrane ⇒ blocks initial depolarization * sensory neurons are more sensitive than motor neurons * Lidocaine : 20mg/ml with or w/o adrenaline * Bupivacaine : 5mg/ml * Ropivacaine : 7.5 mg/ml * onset : 5-10 mins, duration 1-6 hrs

Answer 7

* Topical * Lipid soluble cream * Extent of action :skin and mucosa up to few mm deep * Local infiltration * injected into tissue * local nerves * Nerve block * Injected around a nerve or plexus * Distribution of nerve blocked * IV block * IV injection in arterial tourniqueted limb * Nerve tissue within limb * Centrineural block * Epidural or spinal injection * Multiple dermatomes * Cavity administration * intrapleural or intraperitoneal admin * local nerves in cavity

Answer 8

* Side effects * Mouth and tongue numbness * Anxiety * Tremor * Drowsiness * Tachypnea * Hypotension * Nausea & vomiting * Allergy

Answer 9

* Lidocaine * time to onset : 5-10 min * dilution : 2% lidocaine - max dose 300 mg for a 70 kg person * #23 blue or #25 orange needle * infiltration technique : inject around site of incision

Answer 10

* Suturing * simple interrupted sutures * running (continuous) sutures * Knot tying * Incisions & excisions * elliptical excision : to take out a lesion * incision * Wound debridement * Hemostasis * with electrocoagulation * with ligature * Dissection * blunt dissection * sharp dissection

Answer 11

* Sterile : all forms of microbial life destroyed * Aseptic : free from pathogens * Disinfection: process of destroying all pathogens * Clean : absence of gross contamination or dirt Principles 1. Reduction of env. contamination 2. Disinfection of procedural site 3. Isolation of procedural site 4. Sterilization of procedural tools

Answer 12

* Clean OR staff * clean clothing * hair and beard covered * OR shoes * face mask * Clean hands * hand washing (scrub or hydroalcoholic rub) * Clean air * closed OR * laminar airflow * Clean equipment * no touching

Answer 13

* Cleaning * washing to remove macroscoping contamination * hair removal * painting skin with antibacterial solution * chlorohexidine 0.5%, povidone iodine 10%

Answer 14

* Gowning and gloving * sterile gowns * sterile gloves - sometimes double gloving * no touch technique * Draping * exclusion of operative site w/ sterile towels or shet * two layers * raised sterile curtain btw anesthesist & surgeon

Answer 15

* Steam: * Sterilization of all metallic instruments * Sterilization in packs * 20 PSI / 126C / 10 min * Autoclave, flash sterilizes * Dry heat: * 160C/ 1h * Chemical: * Gas (ethylene oxide) * Liquid (glutaraldehyde) - 10h soaking * Plasma (ionized hydrogen peroxide gas) * Sensitive equipment (endoscopes) : soaked in disinfectant

Answer 16

Body fluids and substances * Risk of HBV,HCV,HIV * Avoidance of contact w/ mucosas and skin * Universal precautions Sharps and needles * Risk of injury from scalpels,needles * Handling,returning & handing over sharp instruments * Never recap needles * Never place sharps on pt * Protect needle point with needle holder Other hazards * Radiation exposure * Electrical shock from equipment * Toxic substances

Answer 17

Preparation for the procedure * Patient consent * Correct patient, correct operation,correct side - mark lesion * All lab and radiology tests available * Any pt allergies or important info known Positioning on operating table * No metal to skin contact * No pressure points * No abnormal traction or angulation of limbs * Mechanical DVT prophylaxis * Eyes taped shut to prevent drying * Stabilization of pt to avoid movement

Answer 18

Procedure * Injury from sharps * Injury from retractors * Electrocoagulation,lasers gauzes * Breach in sterile technique After procedure * Risk in transfer from the OR table (tube displacement, injury) * Post anesthetic observation

Answer 19

* Inflammatory response to injury * Two or more of the criteria: * T ≥ 38^oC or ≤ 36^oC * HR ≥ 90/min * RR ≥ 20/min * WBC ≥ 12000/mm³ or ≤4000mm³ * Balance⇒Recovery * Proinflamatory phase (SIRS) * Counter - regulatory anti inflammatory response syndrome (CARS) * Mixed antagonist response syndrome * Imbalance ⇒ Multi Organ Failure (MOF)

Answer 20

* Sepsis : Suspected documented infection + an acute increase of ≥ SOFA points * Septic shock : * Sepsis + persisting hypotension that requires vasopressors to maintain MAP of 65mmHg * Serum lactate level \> 2mmol/L (18mg/dL) despite adequate volume resussitation

Answer 21

* Non-specific proteins secreted in response to tissue injury * Produced by liver * Biomarkers of systemic inflammation * **CRP** - normal \< 1 mg/dL * **Procalcitonin** - normal \< 0.15 ng/mL * IL-6

Answer 22

Autonomic regulation of: * HR, BP,RR,GI motility * Body temp * Pro-inflammatory vs anti-infammatory response Afferent Signals * Inflammatory mediators * TNFa * Parasympathetic sensory input * Cytokines TNFa,IL-1 * Baroreceptors * Chemoreceptors * Thermoreceptors

Answer 23

Cholinergic anti-inflammatory response * Ach receptors on tissue macrophages : Ach reduces tissue macrophage release of proinflammatory mediators * Ach reduces macrophage activation * Effect of PS on HR, Gı motility, arteriole dilation

Answer 24

Pathways * Receptor kinases * G-protein receptors * Ligand gated ion channels ACTH- from anterior pituitary * glucocorticoid production Cortisol & Glucocorticoids - adrenal cortex * Hyperglycemia - release of FFA & TG from fat cells, immunosuppression, down-regulation of pro-inflammatory cytokines

Answer 25

* Cytokines * Heat shock proteins (protection from stress) * Oxygen radicals * Eicosanoids - endocrine,immune,vasomotor funct. * FA metabolites : attenuation of inflammatory resp. * Kallikrein-kinin sys : vasodilation, ↑ capillary permeability * Serotonin : vasoconstriction,bronchocons.,inotrope * Histamine : hypotension, ↑capillary permeability

Answer 26

* ↑ vascular permeability during inflammation * facilitate O₂ delivery * facilitate immunocyte migration * ischemia reperfusion injury * accumulation of neutrophils * unleashing O₂ metabolites,lysosomal enz * oxidation of basal membranes * microvascular thromboses * Endothelium hypoxia,endotoxins,injury and sheer stress produce * NO -smooth m relaxation * Prostacyclin - vasodilation & platelet activa. * Endothelins - most potent vasoconstrictor * Platelet-activ factor - activates neut,platelets - ↑ vascular permeability * Atrial Natriuretic Peptides -vasodilation,fluid & electrolyte secretion, aldosterone inhibitors

Answer 27

* Surgical trauma - sepsis * 3rd space fluid isolation * Peri-operative fasting * Vomiting * Diarrhea

Answer 28

* Total body water = 50-60% of total body weight * Tissue water concentration * Muscle-solid organs \> fat * New born\>adult\>elderly * Male\>female * Lean\>obese

Answer 29

* Intracellular fluid : 40% of total body weight * K⁺ : 150mM , Na⁺: 15mM, Mg²⁺: 40mM, Ca²⁺: minimal * Phosphates,sulfates:150mM,HCO₃^-: 10mM, proteins : 40mM * Extracellular fluid : 20% of total body weight * Interstitial fluid 15% * Plasma 5% * Na⁺ : 142mM, K⁺: 5mM,Ca²⁺: 5mM,Mg²⁺:2mM * Cl^-:103mM,HCO₃^-: 26 mM,Phosphates: 2mM,Sulfates :1mM, Proteins: 17 mM

Answer 30

* Total solute concentration : mOsm/kg * 290-310 mOsm/kg * water diffuses freely between compartments

Answer 31

* Sodium is confined to ECF * Sodium containing fluids * expansion of intravascular space - 5% * 3x expansion of interstitial space - 15%

Answer 32

* Oral intake : 2000 mL * Cell metabolism : 400 mL * Urinary excretion: 1500 mL * Stool: 200 mL * Skin,Lungs: 600 mL

Answer 33

* Baroreceptors * Pressure sensors in aortic arch & carotid sinuses * Osmoreceptors * Sensors that detect changes in osmolality,kidney * Hypothalamus⇒vasopressin ⇒renin-angiotensin-aldosterone⇒atrial natriuretic peptide⇒reduction in expanded ECF

Answer 34

* Volume disturbances * Volume deficit * Volume excess * Electrolyte concentration disturbances * Acid-base imbalance

Answer 35

Causes in surgical patients: * Inability to ingest water * Loss of GI fluids : * Nasogastric tube suction * vomiting * diarrhea * enterocutaneous fistula * Fluid isolation * soft tissue injuries * burns * peritonitis-sepsis * ileus-obstruction

Answer 36

Clinical observations * Weight loss 1kg/1L * ↓ skin turgor * Sunken eyes * Tachycardia * Hypotension * Oliguria * Confusion Lab exam: * ↑BUN,↓GFR * ↑BUN: Creatine ratio * ↑Hematocrite * ↑urine osmolality (higher than serum) * ↓urine sodium (20mEq/L)

Answer 37

Causes: * Iatrogenic * Renal dysfunction * Heart failure * Cirrhosis * Inappropriate secretion of antidiuretic hormone Clinical observations: * Weight gain * Peripheral edema- limb swelling * ↑central venous pressure * distended jugular veins * pulmonary edema - fine crackles * cardiac insufficiency - gallop rhythm Lab exams: * ↓ hematocrite * ↓ urine osmolality

Answer 38

* Na⁺ : predominant electrolyte of ECF * Na⁺concentration influences fluid osmolality * Changes in Na⁺ are inversely proportional to total body weight * Serum Na⁺: 135-145 mEq/L **Hypernatremia** * causes: * high volume * gain of Na⁺ in excess of water * hyperaldosteronism,cushing syndrome * normal or low volume * loss of free water (renal,GI tract,DI)

Answer 39

Clinical Observations of Hypernatremia * Thirst * If Na+ concentration \> 160mEq/L * Cellular dehydration - extracellular water shifting * CNS symptoms - restlessness,irritability,seizures,coma * Musculoskeletal - weakness * If hypovolemic hypernatremia * Tachycardia * Orthostatic hypotension Lab exams : serum Na+ \> 145 mEq/L severe if \> 160, urine specific gravity SG \> 1.030 if nonrenal water loss

Answer 40

**Hyponatremia** Causes: * Dilution * Iatrogenic * Polydipsia (psychogenic,DM, DI) * Severe hyperglucemia (glc osmosis) * Secretion of ADH (post trauma,surgery) * Drugs (ACEI,antipsychotics) * Depletion * Low Na⁺ diet * GI losses (vomiting,nasogastric suction) * Renal losses (diuretics,renal diseases)

Answer 41

Clinical observations of hyponatremia * If severe - \< 120 mEq/L * CNS - seizures, coma,↑intracranial pressure * Musculoskeletal - weakness,fatigue,cramps * Rapid correction of severe hyponatremia⇒ osmotic demyelination syndrome Lab exams: * Serum Na⁺ \< 135 mEq/L * Low urine Na⁺ concentration \< 20 mEq/L if extrarenal losses * High urine Na⁺ concentration \> 20 mEq/L if renal losses

Answer 42

* Predominant intracellular cation * Only 2% of total body K⁺ is extracellular while 98% is intracellular * Critical to cardiac and neuromuscular function * Serum K⁺ : 3.5-5 mEq/L **Hyperkalemia** : K⁺ \> 5mEq/L Causes: * Excesive K⁺ intake - supplements, blood transfuse * Cell destruction - hemolysis,crush injury * K⁺ extracellular shifting - acidosis * Impaired kidney K⁺ secretion -K sparing diuretics,renal insufficiency

Answer 43

Clinical Observations of hyperkalemia * GI - nausea,vomiting,colic * Neuromuscular - weakness,paralysis * Cardiovascular - arrythmia,arrest ECG alterations * Peaked T waves, flattened P wave * Prolonged PR interval * Widened QRS * V-fib

Answer 44

**Hypokalemia** : K⁺ \< 3.5 mEq/L Causes: * ↓ intake - inadequate oral or iv K⁺ * Intracellular K⁺ shifting - alkalosis * Excessive K⁺ renal excretion - diuretics,hyperaldosteronism * GI losses - diarrhea,vomiting,fistula

Answer 45

Clinical observations of hypokalemia * GI- ileus,constipation * Neuromuscular-↓reflexes,fatigue,weakness,paralysis * Cardiovascular-PEA,asystole ECG alterations * U waves * T-wave flattening * Arrythmias

Answer 46

* contained in bone matrix 99% * serum calcium - 50% ionized (free) and 50% bound (protein & phosphate complexes) * total serum Ca²⁺ is measured but the ionized is responsible for neuromuscular stability **Hypercalcemia** Causes: * primary hyperparathyroidism * malignancy - bone metastases,secretion of PTH related protein Clinical observations * GI - nausea,vomiting,abdominal pain * Neuromuscular - weakness,confusion,coma,pain * CV- hypertension,arrythmia,ECG alterations

Answer 47

**Hypocalcemia** : Ca²⁺\< 8.5 mEq/L Causes: * Hypoparathyroidism * Other - pancreatitis,renal failure Clinical observations: * In severe hypocalcemia * Neuromuscular - hypereflexia,tetany,Chvostek's sign (spasm of facial m. when facial n is tapped at lvl of jaw),Trousseau's sign (carpal spasm induced by BP cuff), bone pain * CV - heart failure, ECG alterations

Answer 48

* Predominantly intracellular * 1/3 serum Mg is albumin bound * Normal serum Mg²⁺ = 1.5-2.5 mg/dL **Hypermagnesemia** Causes: * Excess intake - Mg laxatives and antacids * Renal failure Clinical observations * GI - nausea,vomiting * Neuromuscular- weakness,vomiting, ↓reflexes * CV-hypotension,arrest,ECG alterations like hyper-K

Answer 49

**Hypomagnesemia** : Mg²⁺ \< 1.5 mg/dL Causes: * common in hospitalized patients * poor intake * ↑ renal excretion - alcohol, diuretics * GI losses - diarrhea * acidosis Clinical observations * Neuromuscular - hyperactive reflexes,tremors,tetany,seizures * CV - ECG alterations-torsade de pointes,arrest * can produce hypocalcemia * can cause persistent hypokalemia

Answer 50

* primarily a constituent of bone * predominant intracellular anion HPO₄^3- * abundant in metabolic active cells : high energy phosphate products (ATP) * controlled by urinary secretion * serum phosphorus : 2.5-4.5 mg/dL **Hyperphosphatemia** : P^-3 \> 4.5 mg/dL Causes * ↓ urinary excretion * ↑ intake - phosphorus rich laxatives * ↑ production- cell destruction Clinical observations * asymptomatic * high calcium-phosphate product⇒calcifications

Answer 51

**Hypophosphatemia** : P^-3 \< 2.5 mg/dL Causes: * poor dietary intake - alcoholism * antacid administration- binding of P in bowel * hyperparathyroidism Clinical observations: * When severe hypo-p \<1 mg/dL * Neuromuscular - fatigue,weakness,convulsions * CV- impaired heart contractibility * Osteomalakia-chronic depletion

Answer 52

* Daily metabolism produces 1 mEq/kg of H⁺ * Produced CO₂ is transformed to H₂CO₃ * Buffering systems * intracellular proteins- hemoglobin * extracellular bicarbonate/carbonic acid H⁺+HCO₃^- ⇔ H₂CO₄⇔H₂O +CO₂ pH = pK + log ( [HCO₃^-] / 003 x PCO₂ * PCO₂ ⇒ regulated by **pulmonary ventilation** * HCO₃^- is regulated by the **kidney** * HCO₃^- reabsorption * Secretion of H⁺ * Secretion of NH₄⁺

Answer 53

* pH is regulated at 7.35-7.45 * Acidemia ⇒ pH \< 7.35 * Alkalemia ⇒ pH \> 7.45 * HCO₃^- : 22-26 mmol/L * PCO₂ : 35-45 mmHg Anion gap * UA-UC = [Na⁺] - ( [HCO₃^-] +[Cl^-]) : 3-11 mEq/L

Answer 54

* PCO₂ \> 45 mmHg Acute respiratory acidosis * Acute respiratory failure - obstruction,aspiration * PCO₂ ↑ * HCO₃^- stable * pH↓ - acidemia Chronic respiratory acidosis * Chronic respiratory failure * PCO₂↑ * HCO₃^- ↑ - compensation - renal NH₄ excretion * pH normalized

Answer 55

* PCO₂ \< 35 mmHg Acute respiratory alkalosis * Acute hyperventilation - psychogenic,sepsis * PCO₂ ↓ * HCO₃^- stable * pH ↑ - alkalemia Chronic respiratory alkalosis * PCO₂↑ * HCO₃^- ↑ * pH normalized

Answer 56

* HCO₃^- \< 22 mmol/L * Excessive HCO₃^- - diarrhea, diuretics * HCO₃^- ↓ * Cl^-↑ * Anion gap is normal N = 3-11 mEq/L * hyperchloremic metabolic acidosis * Excessive lactate,acetoacetate,b-hydroxybutyrate * Addition of unmeasured anions * Anion gap is ↑ * HCO₃^- ↓ - consumption

Answer 57

* HCO₃^- \> 26 mmol/L * Causes * Loss of H⁺ ⇒ ↑ in HCO₃^- (vomiting,ng suction) * Impaireed renal exertion of HCO₃^- * Associated hyperchloremia * Volume depletion

Answer 58

* Surgical patients need fluids * None by mouth ⇒ IV * Maintenance of fluids * Volume replacement * Bleeding * Sepsis * GI losses * Evaluation of the fluid volume deficit * Calculation of ongoing fluid losses * Assessment of Na⁺,K⁺ requirements * Management of acid-base disturbances

Answer 59

**Crystaloids** * Solutions of water w/ electrolytes * Solutions of water w/ glucose **Colloids** * Solutions of high molecular weight macromolecules

Answer 60

* Maintenance fluids : 30-40 ml /kg/day * Replace all losses volume for volume * Isotonic vs hypotonic vs hypertonic * No K⁺ for the early post-operative period Infused fluids distribution * Glc solutions ⇒ 2/3 intracellular , 1/3 extracellular * Na⁺ solutions ⇒ 1/4 intravascular, 3/4 interstitial * Colloids⇒ intravascular space

Answer 61

Nutritional Assessment * Anticipated post-operative fasting * Dietary history * Weight loss \> 10% * Serum albumin \< 3 g/dL, transferrin \< 150 mg/dL Immune incompetence * Elderly patients, malnutrition,cancer,severe burns * Total lymphocyte count * Skin tests (anergy) Infectious risk * Drugs : corticosteroids, immunosuppressors,cytotoxic drugs, prolonged antibiotic therapy * Renal failure * Granulocytopenia * Hematologic diseases: lymphomas,leukemias,hypogammaglobulinemia * Uncontrolled diabetes

Answer 62

* Risk of post-operative complications : hypoxia,atelectasis,pneumonia History * Heavy smoking \>20 PY * Cough - character sputum,Wheezing * Exercise intolerance * Obesity * Old age * Known pulmonary disease Physical exam * Wheezing, prolonged expiration Lab tests * Chest x-ray, ECG * Arterial blood gases - CO₂ retention - respiratory acidosis, pulmonary function tests - FVC,FEV₁

Answer 63

Patient at risk * Hypoproteinemia * Vit C deficit * Volume disorders - edema/dehydration * Anemia * Diabetes * Smoking * Corticosteroids- in large doses * Cytotoxic chemotherapy * Irridation

Answer 64

Drug allergies * Penicillin/antibiotics * Morphine/opioids * Xylocaine-local anesthetics * Aspirin/NSAIDS * Tetanus antitoxin * Iodine-other antiseptics * Other drugs,Food,Adhesive tape Drug adaptation * Digitalis,insulin,corticosteroids⇒continuation * stress dose of corticosteroids- hydrocortisone 100 mg x3 * Oral anticoagulation drugs replaced w/heparin * Oral antidiabetics replaced w/ insulin during fasting * CNS depressants - barbiturates,opioids,alcohol,chlorpromazine * Antihypertensives

Answer 65

Patient risk factors * Cancer * Obesity * MI * Age \>45 * History of thromboembolic event Surgery * General,pelvic,orthopedic surgery DVT prevention * Early postoperative mobilisation * Mechanical : graduated compression stockings,intermittent pneumatic compression * Chemical : unfractioned heparin,low molecular weight heparin

Answer 66

Physiological vs chronological age * CV,renal,other systemic diseases Patients \> 60 * Arteriosclerosis * Cardiac reserve limitation * Renal reserve limitation * Occult cancer Avoid volume overload * fluid intake and output * body weight * CVP Adapted doses of drugs * Narcotics * Benzos can cause agitation

Answer 67

Metabolic Syndrome * ↑BP, ↑ blood sugar lvl, ↑↑↑ body fat around waist, abnormal cholesterol levels Risk of concominant disease * Heart disease * Stroke * Diabetes Wound complications

Answer 68

* Preoperative hyperalimentation (7-10d) * Pulmonary prep for \> 48h * Abstinence from smoking * Inhaled bronchodilators * Chest physical therapy x2 a day * Inspiratory effort exercise devices * Maintain blood volume and tissue perfusion * Avoid dehydration/volume deficit * Drug adaptation * Thromboembolic prophylaxis * Fasting for 6h (solids) & 2h (liquids) before major operations or general anesthesia

Answer 69

* Patient info * Surgeon * Diagnosis * Planned surgical procedure * Risks & possible complications * Need for blood transfusion * Postoperative recovery * Anesthesiologist * Type of anesthesia * Anesthesia related risks * Postanesthesia recovery * Signed informed consent * Signed by pt or legal guardian of minors * Emergency lifesaving operations

Answer 70

Initial prep- evening before operation * Washing w/ soap and water * No shaving - ↑ skin infection risk * Marking of operative site by surgeon In operating room * Hair clipping if required * Skin prep w/ 2% iodine in 90% alcohol - for \> 1 min, avoid using in perineum,genitelia,face,avoid spilling outside operative field * Universal precautions * Barrier protections * Avoid accidental injuries * Avoid contact of open wounds w/ pt * Check gloves for tears

Answer 71

Surgical infection control program * Target of \< 1% of clean wond infection rate * Cultures and antibiotic sensitivity on all infections * Isolation of pt w/ communicable infections * Aseptic technique * Isolation of OR * Dressing of open wounds * Hand washing * Antibioprophylaxis * For clean-contaminated & contaminated cases * For clean cases if implanted material * Give 1h to 30 min before incision * 2^nd gen cephalosporin,single dose. Repeat after 4h of surgery or major blood loss

Answer 72

Postanesthesia Care Unit * Monitoring for 1-3 hrs post-op * Discharge when cv,pulmonary & neurological functions normalized Discharge w/ written post-op orders to * Ward * ICU /High dependency unit

Answer 73

* Monitoring * Vitals * ECG monitor * CVP,PCWP * Fluid input/output * Respiratory care * Position in bed and mobilization * pt turned every 30 min til conscious * change position every 1h for first 8-12h * early mobilization * Diet,Fluids & electrolytes, * Medications : analgesics,dvt prophylaxis,gastric acid suppression etc * Lab & imaging exams

Answer 74

After complete recovery from anesthesia & transfer to ward * Wound care * Keep wound covered w/ sterile dressings for 2-3d post-op * Soaked dressings replaced * Dressing replacement on first 24h should be done w/ aseptic technique * By 48h after closure, the skin wounds is sealed off from external env

Answer 75

* Management of drains * Prevent contamination of drain tract * Handling of the drain w/ asceptic technique * Early drain removal * Post-op care of GI tract * GI tract peristalsis return to normal after laparatomy : * Small bowel w/in 24h * Right colon after 48h * Left colon after 72h * Early normal feeding/enteral feeding

Answer 76

Post-op pain control * Parenteral opioids * ↓ risk of addiction * side effects : respiratory depression, nausea, vomiting, paralytic ileus * NSAIDs * side effects : GI ulcers, impaired coagulation, reduced renal function * Paracetamol * Patient controlled analgesia * Continuous epidural analgesia * Nerve blocks

Answer 77

* Every complication that appears after operation * May result from 1^o disease, the operation, comorbidities, or unrelated factors * Early detection * Pre-op identification or risks & pt optimization

Answer 78

* Grade I : * any deviation from normal post-op course w/out need for pharma treatment, or surgical endoscopic and radiological interventions * Grade II: * Requiring treatment w/ drugs other than such allowed for grade I complications. * Grade III: * Requires surgical,endoscopic or radiological intervention * Grade IV: * Life threatening complications (including CNS) requiring ICU-management * Grade V: * Death of patient

Answer 79

Seroma * Fluid collection other than pus or blood * After lymphatic transection * Delay healing, infection risk * Treatment: watchful wait, needle aspiration, compression dressing Hematoma * Collection of blood & clot * Imperfect hemostasis * Discomfort, compression effect, infection risk * Risk factors: anticoagulants, aspirin, marked HT * Treatment: evacuation of blood clot under sterile conditions & hemostasis

Answer 80

Surgical site infection * Bacterial infection w/ inflammation and/or purulent collection * Breach of aseptic conditions or operative contamination * Risk factors: pt factors vs operation related factors * Treatment: wound exploration/drainage, cultures, antibiotics Pain * Controlled by analgesics * Pain ↓ on first 4-6 post-op days * Persistent pain needs exploration - abcess, granuloma, incisional hernia

Answer 81

Ascitic leak * Risk of wound infection and peritonitis * Treatment: wound exploration (OR) & fascia closure Wound dehiscence * Partial & total disruption of any or all layers of wound * Systemic vs. local factors * Between 5-8 post-op days * Discharge of serosanguineous fluid * Dehiscence of laparatomy ⇒ evisceration * Treatment: wound covered w/ moist towels, abdominal closure in OR

Answer 82

Atelectasis * Bronchiole closure &/or obstruction from secretions * Risk factors: old age, smoking, obesity, abdominal operations * Diagnosis: fever, tachypnea, tachycardia, chest x-ray * Atelectatic segments - risk of infection (pneumonia) * Prevention: early mobilization, frequent changes in position, coughing, incentive spirometer * Treatment: chest percussion,nasotracheal suction,bronchodilators,mucolytics

Answer 83

Pulmonary Aspiration * Risk factors: NG tube, CNS depression, gastroesophageal reflux, intestinal obstruction, pregnancy, trauma patients * Diagnosis: tachypnea, rales, hypoxia, cyanosis, wheezing * Causes chemical pneumonitis & is a major risk of pneumonia * Treatment: endotracheal suction, bronchoscopy, fluid resuscitation, antibiotics

Answer 84

Post-op pneumonia * Risk factors: intubation, atelectasis, aspiration, bronchial secretions * Microbes: g (-) bacilli, pseudomonas aeruginosa, klebsiella * Mortality : 20-40% * Treatment : Clearing of secretions, sputum cultures, antibiotics

Answer 85

Pleural effusion * After upper abdominal operations, cardiac failure, pulmonary lesion, subdiaphragmatic inflammation * Treatment: watchful wait, aspiration,drainage Pneumothorax * After pleural injury or positive pressure ventilation * Treatment: thoracostomy tube

Answer 86

Cardiac complications * Cardiac arrythmias * due to reversible factors (hypo-K, hypoxia, acidosis, stress, drug toxicity) * Pt w/ preexisting arrythmias * Post-op MI * 1/2 post-op MI are asymptomatic * Postponing elective operations for 6 mo after MI * Predisposing factors: hypoxia, hypotension, stress * Post-op cardiac failure * Left ventricular failure & acute pulmonary edema * Predisposing factors: cardiac arrythmia, MI, volume overload, sepsis

Answer 87

Hemoperitoneum * W/in 24h of the operation * Tachycardia, hypotension, peripheral vasoconstriction, oliguria * Changes in Hct and Hg seen after 4-6h * Radiological imaging - US, CT * Patient stabilization, surgical treatment

Answer 88

* Risk of drain tract infection * Drain displacement * Bleeding from drain tract * Pain

Answer 89

Prolonged paralytic ileus * Return of GI motility w/in 24h after non-abdominal surgery * After laparotomy return of GI motility w/in 48h * Paralytic ileus can last up to 5 post-op days * No specific therapy Bowel Obstruction * From post-op adhesions or internal hernia * Surgical treatment

Answer 90

Gastric Dilation/Gastroparesis * Massive distention of the stomach by fluid & gas * Abdominal pain, distention and hiccups * Risk of inhalation * Gastric decompression w/ ng tube Fecal Impaction * Aggravating factors: opioids, anticholinergics, paralytic ileus * Digital extraction, enemas

Answer 91

* Healing failure of an intestinal anastomosis * Usually 3-8d after surgery - up to 1 month * Peritonitis: acute abdominal pain w/ rigid abdomen, tachycardia, high fevers & often hemodynamic instability * Abscess: insidious presentation : low grade fever, prolonged ileus or failure to thrive * Treatment options: surgical treatment, percutaneous drainage

Answer 92

Hepatic dysfunction * Prehepatic jaundice * Hemolysis * Reabsorption of hematomas * Hepatocellular insufficiency * Hepatic cell necrosis (drugs, hypotension, hypoxia, sepsis) * Massive liver resection * After prolonged total parenteral nutrition * Posthepatic obstruction * Injury to the CBD * Retained CBD stones

Answer 93

Postoperative cholecystitis * Acalculous cholecystitis⇒risk of necrosis * After ERCP-Endoscopic Retrograde Cholangiopancreatography * After embolization of the right hepatic artery Postoperative pancreatitis * After operations in the vicinity of pancreas * Mechanical trauma to the pancreas or its blood supply * Drug induced pancreatitis (theiaazides, azathioprin, valproic acid)

Answer 94

* Post-op diarrhea - pseudomembranous colitis * From mild diarrhea to severe toxic colitis * Diagnosis by IDing the toxin in the stool, bacteriology, endoscopy * Prevention: hygiene, minimizing antibiotic use * Treatment: metronidazole, vancomycin, fecal transplantation

Answer 95

Urinary retention * Interference w/ neural mechanism of micturition * Bladder overdistention \< 500ml * Catheterization for operations longer than 3h, pelvic operations * Encourage preoperative urination & soon after UTIs * Most frequent nosocomial infection * Risk factors: catheter, urinary retention * Cystitis, pyelonephritis * Treatment: hydration, antibiotics

Answer 96

Air embolism * Accidental insertion of air in a central venous catheter * Acute dyspnea, tachypnea, continuous cough, gasp reflex, neurological symptoms * Position pt head down, right side up to trap air in right ventricle- supportive measures Ischemic necrosis of fingers * Ischemia due to indwelling radial artery catheter * Patency of ulnar artery (Allen's test) * Early removal of arterial catheter

Answer 97

Thrombophlebitis * Common cause of fever * Induration, edema, tenderness * Prevention: aseptic technique, change of tubing, rotation of insertion site

Answer 98

Postoperative stroke * Due to poor cerebral perfusion-abrupt hypotension * After carotid endarterectomy, open heart surgery w/ extracorporeal circulation Delirium tremens * Due to abrupt alcohol withdrawal w/in 2 weeks * Personality changes, restlessness, confusion, overactivity, seizures * Treatment: small amounts of alcohol, benzos

Answer 99

Postoperative psychosis * Elderly pt, severe systematic disease * Present mood disturbances, confusion, fear, disorientation, delirium * May be drug related: cimetidine, corticosteroids, benzos * Eliminate metabolic derangements and early sepsis ICU syndrome * Due to pain, fear, sleep deprivation from bright lights * Impaired cognitive ability, confusion, halucinations, delirium

Answer 100

* Post-op temperature elevation in 40% of pt * w/in 48h * After 2nd day : thrombophlebitis, pneumonia, UTI * After 5d: Surgical site infection, anastomotic leak * After 1w: Allergy, transfusion, sepsis, intraabdominal abscess

Answer 101

* Presence of tissue hypoperfusion that is insufficient to maintain normal aerobic metabolism * Provokes sympathetic/paras & neuroendocrine stress response * Leads to tissue hypoxia & end-organ dysfunction * ↑ cardiac contractility & peripheral vascular tone * hormonal response to preserve salt & intravascular fluid * changes in microcirculation to regulate blood flow * Persistent hypoperfusion w/ ↓ CO induce CV decompensation⇒ irreversible phase of shock, irreversible tissue injury and cell death

Answer 102

Afferent signals to CNS * Pain, infection, temp, hypoglycemia, emotional stress * Volume receptors : heart atria * Baroreceptors: aortic arch, carotid bodies * Chemoreceptors: aorta, carotid bodies Efferent signals to CNS * CV response: ↑HR(B1),↑H.contractility(B1),Arterial vasoconstriction(a1) * Hormone response: * ACTH⇒cortisol * Renin-angiotensin⇒aldosterone * ADH

Answer 103

Microcirculation * Vasoconstriction of arteries & larger arterioles (a1) * Vasodilation of distal arterioles (local factors) * Diminished capillary hydrostatic pressure * Shifting of fluid from EC space inside capillaries * Capillary occlusion from endothelium cell swelling & neutrophil sludging * Changes of microcirculation blood flow btw & w/in systems

Answer 104

Oxygen tissue lvl ↓ * Mitochondrial dysoxia * Anaerobic cell meetabolism (lactate production) * Lactic acidosis * Intracellular acidosis Cellular ATP depletion * Na⁺,K⁺, ATPase activity ↓ * Intracellular Na⁺ accumulation * Cellular edema * ↓ of cell membrane resting potential Apoptosis

Answer 105

Pro-inflammatory components * TNFa * By monocytes, macrophages, T-cells * Induction of septic shock * Peripheral vasodilation, pr breakdown, procoagulation * IL-1B * Half life of 6min * Febrile response, anorexia * IL-2 * By activated T-cells * Activates lymphocytes * Shock induced tissue injury

Answer 106

* IL-6 * Causes lung, liver & gut injury after hemorrhagic shock * Enhances activity of CRP, fibrogen, complement, neutrophil activation * IL-10 * Immunosuppressive properties * By T-cells, monocytes, macrophages * Depression of cytocine production, oxygen radical production, adhesion * IL-4

Answer 107

* Loss of circulating volume from hemorrhage * Sym activation⇒ vasoconstriction * Renin-angiotensin-aldosterone activation⇒urinary Na⁺ and fluid retention * ADH secretion⇒cerebral & coronary vessel autoregulation Diagnosis: * Capillary refill time \>2sec * Weak peripheral pulse * Cold & clammy extremities Treatment : * secure airway & ventilation * Hemorrhage control * Fluid resuscitation

Answer 108

* Circulatory pump failure ⇒tissue hypoxia in setting of adequate intravascular volume * Hemodynamic criteria * SBP \< 90 mHg for more than 30 min * Cardiac index \< 2.2L/min/m² * PCWP \> 15mmHg * Causes: * Acute MI * End-stage cardiomyopathy * Myocarditis * Valvular disease - aortic stenosis, mitral stenosis * Mortality : 50-80%

Answer 109

Diagnosis * Signs of shock * Physical exam * cardiac murmur/sounds * arrythmia * acute pulmonary edema * ECG * Chest x-ray * Heart ultrasound * Invasive heart monitoring * CVP * PCWP

Answer 110

Treatment * Secure airway & ventilation * Exclude hypovolemia * Correction of electrolyte imbalance * Inotropic support * Dobutamine * Dopamine * Epinephrine * Intra-aortic balloon pump * Treatment of underlying disease * PTCA +/- stent for acute MI * Heart transplantation

Answer 111

Vasodilatatory shock = failure of vascular smooth muscles to contract * septic shock * hypoxic lactic acidosis * carbon monoxide poisoning * terminal stage shock of any cause Pathophysiology * Derailment of SIRS ⇒vasodilation & hypotension⇒ ↑catecholamines,↑CO⇒R-A-Al activation ⇒ upregulation of iNOS in vessel wall

Answer 112

Diagnostic criteria * SIRS * T \> 38^oC or \< 36^oC * HR \> 90/min * RR \> 20/min or PCO₂ \< 32 mmHg * WBC \> 12000/mm³ or \< 4000/mm³ or bands \> 10% * Sepsis : SIRS + infection * Septic shock : sepsis + tissue hypoperfusion * SAP \< 90 mmHg * MAP \< 65 mmHg * SAP ↓ \> 40 mmHg from baseline * Lactate \> 4 mmol/L

Answer 113

Treatment * Secure airway & ventilation * Early hemodynamic optimization -6h * Fluid resuscitation * Vasopressors * Infection control * cultures * antibiotics * surgical source control * Glycaemia control * Immune modulation * Activated protein C * Cortisol

Answer 114

* Shock due to loss of vasomotor tone to peripheral arterial beds * Cause: spinal corn injury or ischemia Diagnosis * ↓BP, bradycardia * warm extremities * motor and sensory deficit * Radiographic evidence of spinal cord fracture Treatment * Secure airway & ventilation * Fluid resuscitation * Vasopressors : dopamine and phenylephrine (a-agonist)

Answer 115

* Due to mechanical obstruction of venous return * ↓ filling of right atrium (tension pneumothorax) ⇒ ↓ preload (cardiac temponade) Diagnosis : * Respiratory distress * Hypotension * Ipsilateral ↓ breath sounds * Hyperresonance to percussion * Tracheal deviation * Distended jugular veins Treatment : needle paracentesis, tube thoracostomy

Answer 116

Cardiac temponade Diagnosis * High index of suspicion - injury mechanism * Dyspnea * Tachycardia & hypotension * Chest pain * Muffled heart sounds * Distended jugular veins/ ↑ CVP * Chest x-ray * Echocardiography Treatment: needle pericardiocentesis, left thoracotomy &pericardial window

Answer 117

Systemic response after trauma * Mechanism * Soft tissue injury * Long bone fracture * Blood loss * Pathophysiology * Pro-inflammatory activation * High incidence of ARDS * Treatment * Hemorrhage control * Volume resuscitation * Stabilization of fractures & treatment of soft tissue injuries

Answer 118

* Goal in treatment of shock : restoration of adequate organ perfusion & tissue oxygenation * Endpoints for resuscitation * O₂ transport * Lactate * Base deficit * Gastric tonometry * Near infrared spectroscopy * Tissue pH, O₂,CO₂ * Right ventricular and diastolic index

Answer 119

Crystalloids vs Colloids * Crystaloids more used, cheaper, better results in trauma patients Albumin infusion : detrimental * ↑mortality in hypovolemia, burns, hypoalbuminemia Hypertonic saline (NaCl 7.5%) * Outcomes of hemorrhagic shock : immunomodulation, intracellular liquid shifting Blood transfusion trigger * Hg 7-9 g/dL , Hg 10-12 g/dL for pt w/ cardiac disease Hypotensive resuscitation * Penetrating injury : SBP 80-90 mmHg * Blunt trauma: SBP 110 mmHg

Answer 120

* Factors predisposing to malnutrition * Absorption disorders (celiac sprue) * AIDS * Alcoholism * Chronic renal insufficiency * Cirrhosis * DM * Enteric obstruction * IBS * Malignancy * Prolonged starvation * Psychiatric disorders * Recent major surgery,trauma or burn * Surgical operations of GI tract * Severe cardiopulmonary disease

Answer 121

Basal Energy Expenditure BEE(male) = 66.4 + [13.7 x weight in kg] + [5xheight in cm] - [6.8 x age] BEE(female)= 655 + [9.6 x weight in kg] + [1.7xheight in cm] - [4.7 x age] TEE = BEE x stress factor (1-1.8) kcal/day

Answer 122

* Basal Metabolic Rate - 60% of TEE * 50% ion pumping * 30% pr metabolism * 20% aa,glc,lactate &pyruvate metabolism * Physical activity - 30% of TEE * 10-50% for normal subjects * 10-20% for hospitalized pts * Thermic Effect of Food - 10% of TEE * Energy expanded for digestion,absorption & metabolism of nutrients

Answer 123

* 1^oenergy source * 30-40% of total caloric intake * 4 kcal/g * Digestion: * salivary & pancreatic amylase * absorption by first 1-1.5m of small bowel * Min. intake of 400 kcal of CHOs / day minimizes pr takedown * Glc necessary for hemopoietic system & CNS

Answer 124

* Composed of 20aas * 4 kcal/g of pr * Digestion * gastric peptin * pancreatic proteases * absorption at duodenum - 50% and mid-jejenum * Protein turnover * Total body pr 10-11 kg in a 70 kg person * Daily pr turnover 250-300g * Requirements : 0.8/kg body weight/day * Nitrogen balance * enteral + parenteral intake - urine losses-feces losses- other losses * 6.23 g of pr = 1 g of N * Urine nitrogen losses from 24h urine collection * Index of pr synthesis & breakdown

Answer 125

* 24-45% of caloric intake * 9 kcal/g of lipid * Digestion * Bile salts⇒emulsification * Pancreatic lipase,cholesterol esterase, phospholipase A2 * Lipolysis stimulated by steroids, catecholamines, glucagon. Inhibited by insulin * Body can synthesize most lipids * linoleic & linolenic LCFA are essential * Minimum of 3% caloric intake as essential FA

Answer 126

* Nucleotides * Fat soluble vitamins : A,D,E,K * Water soluble vitamins : B1, B2, B6, B12, niacin, folate, biotin, pantothenic acid * Trace elements : Fe, Zn, Cu, Cr, Se, Mn, I

Answer 127

Effects of fasting * Overnight fast⇒ depletion of liver glycogen * 24h fast⇒depletion of CHO stores * First days⇒degredation of pr & fat * depression of insulin * breakdown of muscle pr * liver gluconeogenesis from aas * TG hydrolysis⇒FFA⇒energy for gluconeogenesis

Answer 128

* Gluconeogenesis from aas * Urinary nitrogen secretion of 8-12g/day (urea) * Loss of 340g/day of lean tissue * Loss of 35% lean body mass in 1 month ⇒death * However : if sufficient water intake ⇒ starvation can be survived for 2-3 months * adaptation of metabolism to conserve energy by recycling metabolic intermediates

Answer 129

* Metabolic adaptations to chronic starvation * After 10 days of starvation, brain starts using ketones as 1^o fuel * ↓ in basic metabolism * ↓HR * ↓ of voluntary activity * ↑ in blood ketone levels * ↓ in gluconeogenesis * Urinary nitrogen excretion falls to 2-3g/day

Answer 130

* Neurohormonal activation * Epinephrine,cortisol - adrenals * Norepinephrine - sympathetic nerves * ADH- post pituitary * ACTH,TSH,GH - anterior pituitary * Glucagon * Peripheral lipolysis (glucagon,epinephrine,T3) * Accelerated catabolism-proteolysis (cortisol) * ↓peripheral glc uptake (GH,insulin) * glc intolerance * Water & Na urinary excretion * 15-20g/day * lean tissue loss of 750g/day - severe trauma * W/out nutrients the median survival is 15 days

Answer 131

* Inflammatory cytokines * TNFa, IL-1,IL-6 * Marked muscle catabolism * Plasma glc, aas, FFA ↑ * Glc intolerance * Urinary nitrogen excretion 20-30g/day * Without nutrients the median survival is 10 days

Answer 132

Surgical pt can't eat : * up to 6h before anesthesia * under sedation * before upper GI endoscopy * after major upper GI procedures * bowel obstruction * paralytic ileus Optimal diet: * CHO 55-60% (230-275g/day) * Fat 30% (70-75g/day) * Protein 10-15% (95-100g/day) * Cholesterol 300 mg/day - 1 egg yolk * Salt 3g/day * Fibers 25g/day * Vitamins * Total calories 2000-2500kcal/day - 30kcal/kg/day

Answer 133

Benefits: * Most physiological * Metabolic benefits * Production of gut immunoglobulins * Easily accepted by patient * Reduces post-op complications * Safer * Low cost Problems: * Cannot be used for paralytic ileus or bowel obstruction * Risk of vomiting & inhalation * Patient anorexia⇒inadequate caloric intake

Answer 134

* Food directly into the gut * Blenderized food or special formulas * Can be given with syrienge * a pump controls the mixture administration rate Benefits: * Preferred method of nutritional support for pt unable or unwilling to eat * Preserves gut functionality * Blenderized foot may be given * Lower cost than parenteral nutrition Problems * Cannot be used in pt needing bowel rest * Delivery method requires a tube placement, dietary formulas, monitoring of feeding * Technical problems (5%) - tube clogging or displacement * Metabolic problems (25%) - nausea, vomiting, diarrhea, distension, hypernatremia, hyperglucemia

Answer 135

* Nutrients given directly in blood * Requires specialized sterile nutritional slns * Circumvents digestive tube completely ⇒ bowel rest * Route of administration : peripheral parenteral nutrition, total parenteral nutrition Indications * short bowel syndrome \<100cm w/out colon, \<50cm w/ colon * ↑output enteric fistulas (\>500ml/d) * surgical pt w : prolonged paralytic ileus, multiple injuries or severe abdominal trauma * severe intestinal malabsorption syndromes * failure to maintain caloric needs w/ enteral nutrition

Answer 136

Formulas * 3-in-1 mixtures * Dextrose 20-50% * Aas 10% * Fat emulsion 20% * Electrolytes * vitamins * oligo-elements * Benefits * only method for pt w non functional digestive tube * bowel rest * Problems : * requires sterile conditions, catheter, close monitoring * technical problems : catheter clogging, displacement (embolism risk), infection(sepsis) * metabolic problems : hyper-hypoglucemia, electrolyte disorders, liver steatosis, gut mucosal atrophy

Answer 137

* Given through a peripheral vein catheter * Patients requiring nutritional support \< 14 days * To avoid phlebitis the solution osmolarity \< 1000 mosm/L * Great volumes of slns (\>2.5-3L/day) are needed to fulfill caloric needs

Answer 138

* Given through a central venous catheter (subclavian, internal jugular, femoral) or a peripheral inserted central catheter * More concentrated slns - ↑osmolarity *

Answer 139

* Self-sufficiency in growth signals * Insensitivity to anti-growth signals * Evading programmed cell death * Limitless replicative potential * Sustained angiogenesis * Tissue invasion & metastasis * Deregulated metabolism * Evading the immune system * Genome instability * Inflammation

Answer 140

* Fine needle aspiration biopsy * cytological examination- no architecture * breast lumps, lung nodules, thyroid tumours * Core needle biopsy * sliver of tissue for pathological exam * radiological guidance * Excisional biopsy * removal of entire gross tumors * Sampling of a representative area of a lesion

Answer 141

* Tumor grade is a histological determination of the degree of cellular differentiation * ↑tumor grade ⇒ tumor is more biologically agressive * tumor grade factors : nuclear pleomorphism, cellularity, necrosis, cellular invasion, # of mitoses * Tumor grade is important for sarcomas, astrocytomas, Hodgkin & non-Hodgkin lymphomas, prostate cancer

Answer 142

* Denotes the extent of disease * Most imprtant prognostic & therapeutic strategy deliminating factor * Staging * Clinical * Pathological * Staging systems * TNM * Stage I-IV

Answer 143

* Tumor - T * 1^o tumor extension * T1-4 * Lymph Nodes - N * Regional lymph node involvement * N0-3 * Metastases - M * Presence of distant metastases * M0-1

Answer 144

* Curative surgery * resection of 1^o tumor : R0,1 microscopic residual, R2 gross residual * Lymphadenectomy * Regional control * Sampling - staging * Sentinel lymph node - selective lymphadenopathy * Resection of isolated metastases * Adjuvant & neoadjuvant treatments

Answer 145

Control of pain, bleeding, obstruction, malnutrition, infection in unresectable advanced cancer Surgical palliation * malnutrition: vascular access, gastrostomy, jejunostomy * Pain * Oncological emergencies : hemorrhage, obstruction, perforation

Answer 146

Removal of an organ that is at high risk of developing cancer due to a present mutation * ulcerative colitis ⇒ total coloproctectomy * familial adenomatous polyposis coli ⇒ total colectomy * multiple endocrine neoplasia (MEN2a&MEN2b)⇒total thyroidectomy * BRCA1&2 ⇒ bilateral mastectomy

Answer 147

* Curative : for hematologic, anal, testicular cancer * Adjuvant : to improve survival after surgery * Neoadjuvant : to facilitate surgical resection by shrinking 1^o tumor, to convert an initially unresectable tumor to a resectable one, to test a tumor sensitivity to chemotherapy * Palliative: to prolong survival &/or improve quality of life * systemic vs regional administration * Alkylating agents, platinum analogues, antimetabolites, antimicrotubule agents, topoisomerase inhibitors, antibiotics

Answer 148

Blocking effects of hormones that stimulate proliferation * Estrogen & androgen inhibitors * Tamoxifen for estrogen sensitive breast c. * Flutamide for prostate cancer * GRH anologues : leuprolide ⇒ pharma castration for breast & prostate cancer * Aromatase inhibitors : Anastroxol for metastatic breast c in postmenapause woman * Somatostatin anagolues octreotide for neuroendocrine tumors of gut etc

Answer 149

* Locoregional control * Alone or in combination w/ surgery * pre or post operative * Mode of delivery * teletherapyi brachytherapy * Effect of radiation * Electrons or ↑E photons, exposure : roentgens, absorbed dose : gray, ionization ⇒ creation of free radicals

Answer 150

Molecular therapeutics exploit the molecular differences btw normal & cancer cells - targeted * Monoclonal antibodies w/ specificity to tumor antigens * Rituximab : anti CD20- non-hodgkin's * Cancer preventative vaccines * HPV,HBV * Immunostimulants & vaccines * BCG infusion for superficial urinary bladder carcinoma * Experiental biological therapy * oncolytic virus therapy, gene therapy, adoptive T-cell cancer therapy

Answer 151

* Survival & disease free survival * Tumor grade * Tumor stage * Optimized & customized treatment strategy * Response to systemic treatment

Answer 152

* Cushing syndrome - ACTH-like * Syndrome of inappropriate ADH-secretion * Hypercalcemia- osteolysis- pthlike * Venous thrombosis * DIC

Answer 153

Substances that can be deteted in ↑ than normal amounts in serum or body fluids of pts * Prostate-specific antigen * Carcinoembryonic antigen - colorectal cancer * Alpha Fetopr-hepatocellular carcinoma * Cancer Antigen 15-3,27-29-recurrence of breast c * Chromogranin A-prognosis and monitoring of neuroendocrine tumors

Answer 154

* Allograft : an organ or tissue transplanted from one individual to another * HLA : human leukocyte antigen, the main trigger to graft rejection * Xenograft : a graft performed btw different species * Orthotopic graft : a graft placed in its normal anatomical site * Heterotopic graft : a graft placed in a site different from that where the organ is normally located

Answer 155

* Allorecognition : IDing of antigen * APCs + Alloantigen +MHC * Bcells & antibodies * Tcells * Other cells : NK cells, monocytes/macrophages

Answer 156

* Hyperacute rejection : antibodies bind to ABO blood group antigens * Acute rejection : T-cells cellular, Bcells hormonal rejection * Chronic rejection : fibrosis of small vessels Diagnosis * Clinical & biochemical impaired organ function * Mild systemic immune symptoms : low grade fever, malaise, lymphocytosis * Biopsy * Immunosuppression masks symptoms

Answer 157

* Corticosteroids,cancineurein inhibitors * Mammalian target of rapamycin inhibitors * Mycophenolic acid, anti-thymocyte globulin Side effects * Opportunistic infection : Cytomegalovirus, Pneumocytosis jiiroveci * Malignancy : Post transplant lymphoproliferative disorders

Answer 158

* Living donors * Relatives or emotionally connected people * Organs : kidney,liver lobe * Minimal risk for donor * Deceased donation : heart- beating, brainstem death, non-heart beating donors after circulatory death 1. Registration as organ donor- agreement of next of kin 2. Confirmation of brainstem death-irreversible structural brain damage 3. Surgery for organ procurement 4. Organ preservation 5. Transplantation to receiver

Answer 159

* Indication : end-stage heart disease * Matching donor recipient * ABO compatibility * Size match * Technique : orthotopic heart * Survival 5-year 65%

Answer 160

* Indication : end-stage lung disease * Matching donor to recipient * ABO compatibility * Size match * Technique : orthotopic single lung, double lung, heart lung transplantation * Survival : 5 year 40%

Answer 161

* Indication : end stage renal failure * Matching donor to recipient * ABO compatibility * HLA typing * Technique : extraperitoneal placement into iliac fossa * Survival : 5-year survival 84%

Answer 162

* Indication: insulin-dependent diabetes - w/kidney transplantation * Technique * Pancreas transplantation: whole organ implanted intraperitoneally or right iliac fossa * Islet cell transplantation: islet cells isolated & embolized into the donor liver through portal venous catheter

Answer 163

* Indication: end-stage liver disease, hepatocellular carcinoma * Child-Pugh score C⇒ indication * High MELD score - ↑er priority * Technique: * Orthotopic liver transplant * Living donor- lobe-transplant * Survival : 5 year graft survival 60%

Answer 164

* Indication : intestinal failure w/ life threatening TPN complication * Short bowel syndrome \<50cm * High risk of acute rejection- gut immune cells

Midterm Flashcards

(197 cards)