surgery: OME videos

Question 1

what are the ultrasound findings for choledocholithiasis?

Answer 1

gallstones in GB/CBD; CBD distention >0.8cm (8mm)

Question 2

primary intervention for gallstones in cbd

Answer 2

ERCP (then cholesystectomy)

Question 3

what test should be performed prior to ERCP?

Answer 3

MRCP (except for ascending cholangitis)

Question 4

US findings for acute cholecystitis

Answer 4

pericholecystic fluid, GB wall inflammation/thickening, gallstones in cystic duct

Question 5

what patients are at the greatest risk for acute acalculous cholecystitis?

Answer 5

critically ill for a while, usually no enteric feeding (parenteral nutrition)

Question 6

major potential complication of ERCP that is quite common?

Answer 6

pancreatitis

Question 7

who gets black pigmented stones?

Answer 7

pts with hemolytic anemias (children or adults)

Question 8

risk factors for cholesterol gallstones

Answer 8

fat (hyperlipidemia, hypercholesterolemia)
fertile (multiparous - inc exposure to estrogen during pregnancy)
female (estrogen - fat and cholesterol metabolism)
40 yo+
foreign (hispanic, native american,black)

Question 9

what does biliary dyskinesia look like on US and HIDA scan?

Answer 9

US = normal
HIDA= fails to fully empty gall bladder

Question 10

what organisms should be covered in acute cholecystitis and ascending cholangitis?

Answer 10

gram negatives and anaerobes
(metronidazole? zosyn?)

Question 11

what does charcot’s triad (RUQ pain, fever, jaundice) suggest?

Answer 11

ascending cholangitis- obstruction of the CBD (jaundice + RUQ pain) with infection (fever)

Question 12

describe the abdominal pain associated with biliary colic

Answer 12

RUQ pain worse with fatty foods (intermittent)

Question 13

what is the difference between biliary colic and the pain of acute calculous cholecystitis

Answer 13

colic = intermittent, spontaneous resolution
cholecystitis = constant, does not resolve

Question 14

what is the primary intervention for cholelithiasis?

Answer 14

elective cholecystectomy

Question 15

how do you treat an abdominal wound evisceration?

Answer 15

saline gauze dressings –> surgical emergency

Question 16

how do you protect against intraoperative aspiration?

Answer 16

NPO 6-8 hours pre op +/- 4 hours no clear liquid
NGT w/ suction
avoid preoxygenation with ventilation

Question 17

who gets acute colonic pseudo-obstruction (oglivie)?

Answer 17

elderly esp after abdominal surgery

Question 18

how do you treat acute colonic pseudobstruction?

Answer 18

conservative measures for ileus, neostigmine, colonoscopy without insufflation and leave a rectal tube, hemicolectomy

Question 19

what does post-op ileus look like on imaging?

Answer 19

dilated loops of large AND small bowel

Question 20

cessation of smoking pre-op for wound healing

Answer 20

30 days before surgery

Question 21

post- op pt has reduced urine output overnight and a foley in place. what’s the likely cause?

Answer 21

volume depletion (foley kink ruled out, urinary retention can’t be the answer)

• high specific gravity
• pre-renal azotemia
• hx of diarrhea, vomiting, NPO, etc.

Question 22

what should you do if the pt has no urinary output for 6 hours and a distended suprapubic mass?

Answer 22

bladder scan –> in and out cath

Question 23

how to prevent and tx a post-op ileus

Answer 23

out of bed, ambulation, fluids, potassium correction (hypokalemia)

Question 24

who is at greatest risk for post-op urinary retention?

Answer 24

older men with BPH

Question 25

What is the difference between wound dehiscence and evisceration?

Answer 25

both are wound closure failure, evisceration is bowel protruding through the defect wound dehiscence typically occurs 5-8 hours post-op

Question 26

post-op pt has zero output overnight but has a foley in place; what is the next step?

Answer 26

flush and reposition the kinked catheter

Question 27

How long must DAPT be continued for a bare metal stent and for a drug- eluting stent?

Answer 27

1 month for bare metal stent 1 year for Drug-eluting stent, though can consider urgent surgery after 6 months.

Question 28

when do you perform stress testing in a preop work-up?

Answer 28

the patient has known CAD or risk factors and they cannot perform 4 METs of activity

Question 29

which patients with cirrhosis can undergo elective surgery?

Answer 29

childs-pugh A+ B or C-->B

Question 30

when is pulmonary function testing appropriate for preoperative clearance?

Answer 30

A previously undiagnosed obstructive lung disease that is apparent through history and physical (not routinely done).

Question 31

When should a patient stop smoking to optimize post-op wound healing?

Answer 31

30 days before surgery

Question 32

How long should smoking cessation occur prior to surgery pulmonary complications?

Answer 32

Any amount of time (not the erroneous 8 wk guideline, now revoked)

Question 33

describe the general rules for determining the risk of a procedure.

Answer 33

The deeper you go (skin/GI tract vs. into body cavity), the more you remove (resection worse than no resection), and the more you add (transplants highest risk), the higher the risk

Question 34

How do you perform stress testing in a pre-op work-up?

Answer 34

because they can't do 4 METs to qualify for stress testing, there must be pharmacologically induced stressing

Question 35

What is the cutoff for platelets to preclude elective general surgery (not neurosurgery)?

Answer 35

below 50,000 platelets

Question 36

what is the cutoff for INR that precludes elective surgery?

Answer 36

above 1.5

Question 37

What lab values should be used (and which should not be used) to assess the nutritional status of a patient?

Answer 37

albumin (not "prealbumin" aka transthyretin or CRP)

Question 38

what are the options for treating a peritoneal abscess following abdominal surgery

Answer 38

drain and antibiotics or open for washout and abx

Question 39

what are the options for treating an anastomotic leak following abdominal surgery

Answer 39

open to washout, then either fix anastomosis or create diverting ostomy

Question 40

what does rising end-tidal CO2 following administration of halothan or succinylcholine mean?

Answer 40

malignant hyperthemia

Question 41

what does UTI infection look like in a foley bag?

Answer 41

blood tinged, milky white, pus floaters

Question 42

fever after surgery but on post operative day zero is suspicious for what infections?

Answer 42

bacteremia or necrotizing fasciitis of the surgical incision site

Question 43

what is meant by early vs late post- op fever?

Answer 43

early <48 hrs; do not investigate late >48 hours - do fever work up (CBC, CMP, UA, CXR, inspection of surgical site, urine blood culture, etc.)

Question 44

what is the work-up for post op fever?

Answer 44

UA, urine blood culture, CXR, look at surgical site, (CBC w/ diff; CMP)

Question 45

In order from best to worst, what are the ways to prevent DVTs in post-op pts?

Answer 45

ambulation>LMWH> pneumatic compression (SCDs)

Question 46

how do you prevent post-op pneumonia?

Answer 46

out of bed (early ambulation) and probably incentive spirometry

Question 47

How do you prevent UTI in post-op pts?

Answer 47

get cath out as soon as no longer indicated

Question 48

how do you prevent surgical site infections by skin flora?

Answer 48

prophylactic antibiotics (1st/2nd gen cephalosporins, clindamycin?) Second-generation cephalosporins have coverage against Haemophilus influenzae (H. influenzae), Moraxella catarrhalis, and Bacteroides spp. The three antibiotics used in adult surgical prophylaxis, where weight-based dosing is recommended, are cefazolin, vancomycin, and gentamicin

Question 49

how do you treat a new, postop DVT?

Answer 49

SubQ LMWH then bridge to warfarin or NOAC

Question 50

what are NOACs and DOACs?

Answer 50

Direct oral anticoagulants (DOACs) are oral medications that specifically inhibit factors IIa or Xa. They are also known as new oral anticoagulants (NOACs) or target-specific oral anticoagulants (TSOACs). There are currently 4 NOACs available for healthcare providers to prescribe for patients with atrial fibrillation (see Table 1): dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), and edoxaban (Lixiana [Europe/Asia], Savaysa [Nth Am]).

Question 51

what is a heparin bridge

Answer 51

"Bridging” is a term that refers to the use of short-acting anticoagulants (heparin or LMWH) for a period of time during interruption of warfarin therapy when the INR is not within a therapeutic range. There is no established single bridging regimen. Usually low-molecular-weight heparin given by subcutaneous injection for 5- 10 to 12 days around the time of the surgery/procedure

Question 52

what medication treats malignant hyperthermia?

Answer 52

Dantrolene

Question 53

Name the symptoms of cellulitis

Answer 53

- systemic fever -warmth and erythema - not well circumscribed - most likely staph. aureus

Question 54

symptoms of an infected surgical wound

Answer 54

- same as cellulitis - staph aureus

Question 55

symptoms of a deep abscess associated with surgery?

Answer 55

pain, ileus that does not resolve

Question 56

symptoms of subphrenic abscess

Answer 56

- post splenectomy/gastrectomy -referred left shoulder pain

Question 57

how do you dx deep abscess or anastomotic leak?

Answer 57

abd CT