Surgery. Flashcards
(116 cards)
1
Q
Which Surgerys are high, medium, and low risk for perioperative cardiac complications?
A
2
Q
What percentage of perioperative deaths are due to cardiac events?
A
⅓-½
DMs have a 50% increased risk of perioperative morbidity and mortality
Pulmonary = second most common cause of morbidity and mortality
3
Q
ASA classifications
A
4
Q
Types of Anesthesia
A
5
Q
Epidural vs Spinal Anesthesia
A
6
Q
Electrolyte composition of different body fluids and electrolyte abnormalities of surgery
A
7
Q
Nutritional Status of the Surgical Patient: Ebb & Flow
A
8
Q
Ebb Phase of Starvation & Stress
A
- Immediate
- Tissue hypoperfusion
- decreased metabolism
- catecholamine release
- norepi
9
Q
Flow Phase of Starvation/Physiologic Stress
A
- Catabolic & Anabolic
- increased cardiac output
- Peaks 3-5 days
- hypermetabolic
- hyperglycemia
-
Anabolic
- corticoid withdrawal
- repletion
10
Q
Lab Indicators of Illness and Perioperative Morbidity
A
11
Q
Nutritional Support for Surgery Pts
A
12
Q
Phases of Wound Healing & Care
A
13
Q
Factors that Affect Wound Healing
A
14
Q
Types of Wounds
A
15
Q
Classifications of Surgical Wounds and infx risk
A
16
Q
Primary Intention vs Secondary Intention Wound Healing
A
17
Q
Postoperative Complications
A
18
Q
Outpt Surgery vs Short Stay Inpatient
A
19
Q
Inpatient Surgeries & Pediatric Surgerys
A
20
Q
Acute Abd Pain Red Flags
A
21
Q
Peritonitis (Overview)
A
- Pt looks sick
- lie still → minimizes discomfort
- rebound tenderness & tenderness to percussion
- pain with light palpation and bumps
- diminished bowel sounds
22
Q
Causes of Abd Pain by Location
A
23
Q
What is an acute Abdomen?
A
requires a stat surgical consult/ to OR
sxs of obstruction or peritonitis
24
Q
Initial Diagnostics in Abd pain
A
- CBC with diff
- BMP/CMP
- AST/ALT, Alk phos, total bili
- Lipase
- UA
- Urine hcG in women
- abd imaging
- plain film
- CT U/S
25
How do you rule in/out peritonitis?
US or CT
but be careful with use of CT in children (1 CT may increase a child's risk of CA, 1/1000)
26
Acute Abd Pain Tx while you wait for surgical intervention
* IV, give fluids → this is a top priority!
* Pain control
* NPO (until they have been ruled out for surgery)
* Abx when indication
* Monitor for sxs of sepsis & shock
27
Abx prophylaxis before GI surgery
28
Acute Cholecystitis Tx
29
Steps of the Laparoscopic Cholecystectomy
30
Choledocholithiasis
31
Management of Pancreatitis
32
Best abx for pancreatic abscess?
Imipenem
33
Gastric Cancer Overview
34
Dx and Tx of Splenic Abscess vs Infarct
35
Acute Abd Pain Helpful Hints
36
Meckel's Diverticulum
37
Mesenteric Ischemia Management
38
Appendicitis Management
* Perioperative Abx
* Lower infectious complications
* Recommend 3-5 days in pts with confirmed perforated appendicitis
* (ceftriaxone + metronidazole)
* Appendectomy
* Open
* Laparoscopically
39
Steps of an Appendectomy
40
Complications Associated with Appendicitis
41
Diverticulitis Tx
42
Terminology of bowel Surgery
* _Ostomy_:
* new passageway for stool or urine → create an opening in abd wall
* _Stoma_:
* portion o fthe intestine outside the abdomen
* _Ileostomy_:
* small bowel divided
* _Colostomy_:
* colon divided → proximal end brought through the abd wall
* _Hartmann's Procedure_:
* colostomy with distal end oversewn and placed in peritoneal cavity as blind limb
43
Colostomy vs Loop Colostomy
44
Ileostomy
45
Stoma
46
Types of Colon Resections
47
Which arteries to clip during an extended right colectomy vs a colectomy for proximal transverse colon cancer
48
Small Bowel Obstruction: % of Acute Surgical Admissions and Major Causes
49
Red Flags Associated with SBO
* Pneumoperitoneum
* Retroperitoneal air
* Peritoneal Signs
* Shock
50
What etiology should you think of when approaching SBO with no hx of surgery or IBD and no hernia on exam?
TUMOR
51
Paralytic Ileus
* Obstipation (no stool or flatulence) and intolerance of oral intake
* **Due to non-mechanical factors**
* decreased motility (absent or hypoactive bowel sounds)
* certain degree is normal following abd and non-abd surgery
* more common with *larger incisions, lower abd operations*
* _Diagnostics_:
* same as SBO → since you are trying to rule SBO
* plain film will show bowel dilation involving ***_small and large bowel_***
* _Tx_:
* fluids & electrolytes
* pain management → not narcotics
* NGT in some, not most
* PPN, TPN
* Ambulation
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Physiologic vs Pathologic Ileus
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Partial vs Complete LBO Tx
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Sigmoid Volvulus Causes
55
Sigmoid Volvulus: Presentation, PE, Imaging, DDx, Tx
56
Cecal Volvulus
57
What is the MCC of rectal bleeding?
Internal Hemorrhoids
58
Internal vs External Hemorrhoids
59
Diagnostic Eval of Hemorrhoids
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Degrees of Hemorrhoids
61
Tx of Hemorrhoids
62
Perianal Infections and Anorectal Abscess Overview
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Anorectal Abscess Tx & Perianal Infx Tx
* _Anorectal Abscess Tx_:
* Surgical drainage
* broad spectrum abx
* wound care
* _Perianal Infx management:_
* shallow peri-anal abscess can be drained in office
* incision & drainage under anesthesia
* *some require drain placement*
* Abx based on cx
* not all need abx, but ***all require I&D***
* Commonly associated with fistulas
64
% chance of getting a anal fistula after anal abscess?
50%
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Fistulas (Overview)
66
Anal Fissures
67
Rectal Foreign Body Management
68
Rectal Prolapse
69
Atherosclerotic Aneurysms
70
Thoracic Aortic Aneurysm: S/sxs & Repair
71
Aortic Dissection: Sxs, workup, Imaging, & Initial management
* _S/xs_:
* CP, back pain (esp between shoulder blades), HTN in ⅔ of patients
* neurologic changes, distal ischemia, Acute cardiac failure ( Aortic Regurg, Coronary Ischemia)
* Hypotension & shock → Rupture
* **15-20% mortality initially → then 1% per hour for 1st 48 hours**
* _Signs_:
* HTN, different blood pressures
* Widened mediastinum
* pleural capping (d/t blood in pleural space in the apex), pleural effusion, hoarse voice
* _Imaging_:
* Spiral CT = gold standard
* MRI
* TEE: transesophageal echo, but may miss distal tears, good for eval of aortic valve proximal root
* _Initial Management_:
* Reduce systolic BP (\<100-120mmHg)
* Decrease LV dP/dT
* Pain Control
* **Beta-blockers 1st = ESMOLOL** then add vasodilators like nipride
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Type A vs Type B Aortic Dissection Management
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Triad of Aortic Dissection
1. Tearing abd pain that radiates to the back
2. mediastinal and/or aortic widening on CXR
3. HTN +/- Discrepant BP or pulse (absence of a proximal extremity)
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Tx or Ruptured or Symptomatic AAA
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Thoracic Aortic Transection
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Blunt Cardiac Injury: Myocardial Contusion
77
Hypovolemic Shock: Definition, Etiologies, Pathophys, S/sxs
* _Definition_:
* **reduction in intravascular volume/preload** → decreased CO → insufficient perfusion
* _Etiologies_:
* **hemorrhagic**: trauma, GI bleed, ruptured aneurysm, post-operative, open central line
* **non-blood fluid loss**: vomiting, diarrhea, 3rd spacing, burns, dehydration, DKA, over-diuresis
* _Pathophys_:
* loss of blood/fluid volume → increased HR & vasoconstriction, increased epi, vasopressin, & angiotensin
* _S/sxs_:
* **tachycardia/tachypnea**
* **narrowed pulse pressure (d/t vasoconstriction)**
* **oliguria (d/t decreased CO)**
* hypotension
* pale, cool dry skin and extremities
* cap refill \>3 sec
* decreased skin turgor
* dry mucous membranes
* AMS
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Features of Hypovolemic Shock
* _Preload_: decreased (volume depletion)
* _Cardiac Output_: decreased
* _Afterload_: increased (vasoconstriction)
* _BP_: low
* _Organ perfusion_: decreased
* _AVO2 Difference_: high (b/c heart is delivering less blood so tissues are using more O2 from the available blood)
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Phases of Hypovolemic Shock
* **_Compensated_**: **0-24.9% blood loss** (500-1250cc)
* normal SBP/pulse pressure/ pulse, alert
* **_Uncompensated_**: **25-40%** (1250-2000cc)
* decreased SBP/ pulse pressure, tachycardic, anxious
* **_Irreversible_**: **\>40%** **blood loss**
* decreased SBP/ pulse pressure, very tachycardic, lethargic
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Tx of Hypovolemic Shock
* ABCs
* **Volume resuscitation: Crystalloids (LR or NS)**
* usually 3-4 liters:
* initially **1-2 NS boluses** to restore tissue perfusion and continued at rapid rate until clinical signs of hypovolemia improve
* control the source of hemorrhage +/- packed RBCs if severe
* **maintain body temp** (prevent hypothermia)
81
Distributive Shock: Definition, Pathophys, & Etiologies
* _Definition_: **excessive vasodilation in small vessels** & altered distribution of blood flow with shunting from vital organs to non-vital tissues
* _Pathophys_:
* dilation of all blood vessels so the “tank” becomes too big
* _Etiologies_:
* **Septic**: overwhelming infx → systemic inflammatory response → systemic vasodilation
* **Anaphylactic**: severe rxn to allergen → systemic histamine release → widespread vasodilation
* **Neurogenic**: acute spinal injury that results in loss of sympathetic tone that normally keeps vessels constricted → vessel walls veno/vasodilate
* **Endocrine**: adrenal insufficiency
82
Distributive Shock: S/sxs of Sepsis, Anaphylaxis, and Neurogenic Shock
* _Sepsis_: “Warm shock" “warm shock”
* **warm, flushed extremities** (d/t systemic vasodilation of capillaries)
* **wide pulse pressure**
* bounding pulses
* hypotension
* _Anaphylactic Shock_:
* pruritus, urticaria
* angioedema
* hoarseness
* _Neurogenic_:
* warm skin
* bradycardia or normal HR
* wide pulse pressure
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Features of Septic Shock
Type of Distributive Shock
* _Preload_: decreased
* _Afterload_: decreased
* _Cardiac Output_: decreased
* _BP_: low
* _Organ perfusion_: decreased
* **Mixed venous O2: HIGH** (oxygen is not reaching tissues and is not getting used due to loss of vascular tone)
* **AVO2 difference**: **LOW** (oxygen is not reaching tissues and is not getting used due to loss of vascular tone)
* so mixed venous o2 is high and arterial o2 is also high
84
Features of Neurogenic Shock
Type of Distributive Shock
* _Preload_: decreased
* _Afterload_: decreased
* _Cardiac Output_: **increased**
* _BP_: low
* _Organ Perfusion_: normal (b/c of good cardiac output so normal organ perfusion)
* _AVO2 difference_: normal
85
Tx of Distributive Shocks
* **_Septic Shock_**:
* broad spectrum IV abx
* IV fluid resuscitation, then a vasopressor (vasoconstrictor: **epinephrine, norepi/phenylephrine)**
* **_Anaphylactic Shock_**:
* -Epi
* -Airway management
* -antihistamines
* **_Neurogenic Shock_**:
* IV fluid resuscitation
* vasopressors +/- corticosteroids
* **_Endocrine Shock_**:
* hydrocortisone
86
Obstructive Shock: Definition, Etiology & Tx
* _Definition_: **mechanical block to heart's outflow or inflow**
* _Etiology_:
* very large PE
* pericardial tamponade
* tension pneumo
* aortic dissection
* _Tx_: **Tx the underlying cause**
* PE: heparin, thrombolytics (TPA, TKI)
* Tamponade: pericardiocentesis
* Tension Pneumo: needle decompression
* oxygen, isotonic fluids, inotropic support (**dobutamine, epi, milrinone)**
87
Cardiogenic Shock: Definition, Etiology, & S/sxs
* _Definition_: **primary myocardial dysfunction** (pump failure) → low cardiac output → inadequate tissue perfusion
* _Etiology_:
* **Pump Failure**:
* ischemia (CAD), acute MI, myocarditis, valve dysfunction (mitral regurg secondary to papillary rupture), cardiomyopathy, post-operative, myocardial contusion, acute ventricular septal or L ventricular rupture
* Arrhythmia, toxic/metabolic
* _S/sxs_:
* **Acute hypotension** (you can only compensate with increasing afterload [vasoconstriction) **BP \<90/60**
* tachycardia, tachypnea
* weak pulses
* mottled skin
* diaphoretic
* AMS
* anxiety/restlessness
* **Elevated JVP**
* oliguria
88
Features of Cardiogenic Shock
* _Preload_: **increased** (due to decreased stroke volume)
* _Afterload_: increased
* _Cardiac Output_: decreased
* _BP_: low
* _Organ Perfusion_: decreased
* _AVO2 difference_: **high** (b/c heart is delivering less blood, so tissues are using more O2 from the blood available)
89
Tx of Cardiogenic Shock
**Tx the underlying cause**
* if acute MI: revascularize
* **i****notropic Support****(****dobutamine, epinephrine, milrinone****)**
* can use a vasodilator if BP is okay (**dobutamine, milrinone**)
* if hypotensive then use vasopressor (**Epi, norepi/phenylephrine**)
* intra-aortic balloon counterpulsation
* oxygen
* isotonic fluids: AVOID large amounts of fluid
* if you use fluids, will eventually need to diurese (**Lasix [furosemide])**
90
Cardiac Tamponade: Definition, Etiology, S/sxs, & PE
* _Definition_:
* **pericardial effusion causing significant pressure on the heart, impeding cardiac filling, leading to decreased cardiac output and shock.** The **Rate of accumulation of fluid is more critical than volume.** (slow accumulation of large volume is OKAY if pericardium is compliant)
* _Etiology_:
* **Malignancy**, idiopathic pericarditis, & uremia (renal failure) are the most common causes
* _S/sxs_:
* Dyspnea
* Fatigue
* peripheral Edema
* **BECK's Triad**:
* distant (muffled) heart sounds
* increased JVP
* systemic hypotension
* _PE_:
* EKG:
* **Electrical Alternans** (alternating amplitudes of the QRS complexes)
* **low QRS voltage**
* Echo:
* pericardial effusion & diastolic collapse of teh cardiac champers
* CXR:
* “water bottle” appearance
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Cardiac Tamponade: Tx
* immediate: oxygen, IV fluids, type & culture
* **Don’t give pain meds**, **sedate, or intubate** (causes vasodilation which will lower BP even further)
* **Pericardiocentesis**
92
“water bottle” appearance
associated with pericardial effusion/ cardiac tamponade
93
Beck's Triad
Associated with Cardiac Tamponade
1. elevated JVP
2. muffled heart sounds
3. systemic hypotension
94
Mnemonic to Remember Medical Tx of STEMI
**MOAN & BASH**
**Morphine**, **oxygen** if O2 \<90%, **Aspirin** 162 mg, **Nitro** q 5 min (don't give to pts with systolic \<90, or to inferior MI with R ventricular involvement → dependent on preload and nitro decreases preload)
**Beta blockers** (Decrease remodeling, decrease oxygen demand of heart, decreases HR, improve L ventricular hemodynamic funx, reduce incidence of ventricular arrhythmias; *Contraindication in Heart block, high risk for cardiogenic shock*) **, ACE-I/ARB** (more for long term use → improve L ventricular EF, mortality rate)**, Statin, Heparin** (antithrombotic therapy → impede progression of thrombus in coronary artery)
**TPA** if pt cannot have reperfusion from cath lab in \<90minutes from door to lab
95
Peri-Myocardial Infarction Emergencies
96
Bypass Surgery Common Post Op Complications
97
Traumatic Diaphragmatic Hernia
98
Pulmonary Contusion
99
Esophageal Perforation
100
Acute Mesenteric Ischemia: Causes, Dx, Workup & Management
101
Tx of Mesenteric Arterial Occlusion, arterial Thrombosis, and Venous Thrombosis
102
Diverticulitis Management
103
Features of Shock
104
Bariatric Surgery: Indications and candidates
105
Types of Bariatric Procedures Including description of Roux En Y
106
Vertical Banded Gastroplasty, Gastric Banding, Sleeve Gastrectomy, Mini-Gastric Bypass
107
Pre-Operative Assessment for Bariatric Surgery Includes:
108
Inguinal Hernia
109
At what point does hypotension occur in hemorrhagic shock in pediatrics?
25-30% blood volume loss → so should look at HR and tachycardia as a better indicator for circulation
bolus warm fluids 20ml/kg, may repeat x 2, 10ml/kg of blood (PRBCs)
110
Negative Effects of Hospitalization in Elderly and Common Complications
111
PeriOperative Considerations in Pts with recent or current steroid use
112
Who needs perioperative steroid coverage, does not need coverage and how to evaluate
113
Anesthetic Inductions: types of Anesthetics and Inductions
114
Risks of Post-Operative Nausea and Vomiting
* Gas anesthetics and opioids \> IV anesthetics
* Volatile Anesthetics \> IV \> Regional
115
Types of Fluids and which Compartment they end up in
116
Typical Complications of Appendectomy, Cholecystectomy, Nissen Fundoplication, Colon Resection, Thyroid surgery, Breast Surgery
