4- General Surgery Flashcards
When should tobacco be discontinued prior to surgery?
8 weeks
What meds should be continued in the perioperative period? (3)
Meds w/ significant withdrawal sxs not affecting anesthesia
CV meds
Statins
When should antiplatelet meds be d/c prior to surgery?
7-10 days prior
In low and mod risk patients, how does risk for operative mortality change for emergent procedures?
Doubles
What is the greatest RF/ predictor of DVT/ PE or bleeding risk?
Prior history
What nutrition state results in increased risk for surgical complications?
Severe malnutrition
Weight loss > 15% over prior 3-4 months
When is the body using carbohydrate vs fat stores?
Carbohydrate stores @ 24-72 hours
Fat stores @ 72hrs- 10 days (adaptive changes)
What is the nutritional status of a surgical pt hours after injury when pt exhibits sxs of shock and NE release?
Ebb phase
What is the nutritional status of a surgical pt days after injury when pt exhibits catabolic > anabolic processes (hypermetabolic, hyperglycemic, increased CO)?
Flow phase (peaks 3-5 days)
What is the nutritional status of a surgical pt weeks after injury when pt exhibits anabolic processes such as corticoid withdrawal and repletion?
Recovery phase
What lab test is used to indicate stress on the body if a pt has been in the hospital for a long time and has a half life of 21 days?
Serum albumin
< 3.5 g/dL
What lab test is used to indicate stress on the body, is highly sensitive, has a half life of 2-3 days and is used for trending purposes?
Prealbumin
< 5-17 g/dL
What lab test is used to indicate stress on the body by indicating if a pt is protein deficient and has a half life of 8 days?
Serum transferrin
< 200 mg/dL
What is the preferred nutrional support used for malnourished pts?
Enteral > parenteral
“if the gut works use it”
What is the nutritional caloric need for a “stressed” pt?
Stressed: 50 kcal/kgday, 2.5 protein/kg/day
What body temp should be maintained during immediate post op period for prevention of complications?
Core temp between 98.6- 100.4
What levels should glucose be maintained at through the surgical procedure?
150 mg/dL
When should hair removal be performed (clippers) for surgery?
Immediately prior to prep of surgical field
What skin antiseptics are preferred for prevention of surgical complications?
Chlorhexidine solutions (applied and air dry)
What oxygenation levels should be maintained intraoperatively?
80%
What is the most common method for prevention of VTE?
Mechanical (pneumatic compression)
+/- systemic anticoagulant
When should fluids and electrolytes be evaluated for POD 1 vs POD 2/ beyond?
POD 1- q 4-6 hrs
POD 2/ beyond- q 24 hrs
What is the preferred replacement IVF?
Crystalloids > colloids/ blood products
(colloids/ blood products more likely to stay in vascular compartment, colloids not used for rehydration/ bolus unless large amts of fluid loss)
What is the most common crystalloid used in the peri-operative period?
Isotonic > hyper/ hypotonic
What replacement IVF is used when cystalloids fail to sustain plasma volume due to low osmotic pressure (burns, peritonitis)?
Colloids
What Hg value is the common trigger for stable pts requiring a blood transfusion (1 unit = 1 g/dL increased in Hg)
7 g/dL
(earlier if sxs, underlying disease, transplant)
What type of transfusion therapy is used for active bleeding in thrombocytopenic pts?
Platelets (not packed cells)
What type of transfusion therapy is used for pts with deficiencies in clotting factors, active bleeding, or risk of bleeding from emergent procedure?
FFP
What is included in post op care of decreased functional residual capacity?
Periodic hyperinflation w/ incentive spirometry and early mobilization
When does peristaltic function begin to return post surgery?
Gastric- slowly
Small intestine- 24 hrs
R colon- 48 hrs
L colon- 72 hrs
What factors are the greatest contributors to post-op pain and what is the preferred tx?
Duration of surgery, degree of trauma
Opioids
Pt presents with fever, wound crepitence, and gray/ dusky coloration of the skin. What post-op complication are you concerned for and what is the tx?
Necrotizing fasciitis
Early/ aggressive surgical excision of affected tissue
What post-op wound complication is defined as partial/ total disruption of any or all layers of the operative wound and when is it most common?
Dehiscence
5-8 days post-op
What post-op wound complication is defined as rupture of all layers and extrusion of abdominal viscera?
Evisceration
Where is the most common location for Meckel’s diverticulum?
Antimesenteric border of the ileum
What is the rule of 2’s a/w Meckel’s diverticulum? (6)
2% of population
2:1 male: female
2 yo
2 ft from ileocecal valve
2 inches long
2 types of mucosa
Pt presents w/ abdominal pain, bleeding, intestinal obstruction, (or asx). What post- op complication are you concerned for and what can be used for dx?
Meckel’s diverticulum
Dx w/ Meckel’s scan, mesenteric arteriography, abd exploration
What is the tx for Meckel’s diverticulum?
Resection
What post-op complication is more common in older pts w/ disease causing embolic formation or cardiac disease and presents w/ post-prandial/ intestinal angina with POOP on PE?
Mesenteric ischemia
What is included in the management for mesenteric ischemia aside from aggressive fluid resuscitation and NG tube? (3)
Surgery- abd exploration (embolectomy, colon resection)
Abx
Systemic anticoagulation
What is considered a high-output enteric fistula?
> 500 mL/day
What is the most common cause of enterocutaneous fistulas?
Post-op complication
What is used for dx of enteric fistulas?
Imaging- CT
+/- endoscopy
What is the treatment for enteric fistula? (2)
Spontaneous closure vs operative tx
Control of drainage and skin protection
When is bariatric surgery indicated? (4)
BMI > 40
BMI > 35 w/ comorbidity
Failure of non-surgical weight loss efforts
Well-informed, compliant, motivated
What is the most common bariatric surgery performed in the US and what type is it (restrictive vs malabsorptive)?
Roux-en-y gastric bypass
Restrictive and malapsorptive
What bariatric surgery is a band connected to a subcutaneous reservoir and what type is it (restrictive vs malabsorptive)?
Gastric banding
Restrictive
Is a vertical banded gastroplasty a restrictive or malabsorptive bariatric surgery?
(rarely performed)
Restrictive
Is a sleeve gastrectomy bariatric surgery restrictive or malabsorptive?
Restrictive
What will a CT scan show for a pt with appendicitis?
Enlargement w/ wall thickening, fat stranding +/- fecalith
What is included in the management for appendicitis?
Perioperative abx (3-5 days if perforated)
Appendectomy
Pt who presents with diffiuse pain after localized tenderness and pain relief followed by peritonitis is concerning for what appendicitis complication?
Perforation
Pt who presents with high fever post appendicitis w/ perforation is concerning for what?
Peritonitis
Pt who presents with RLQ mass on PE with CT showing percutaneous drainage is concerning for what appendicitis complication and what is the tx?
Abscess
Tx w/ abx and appendectomy (if not already performed) +/- drain placement
Where is diverticulitis most common and what can result from an acute attack?
Sigmoid
Obstruction
What is included in the nonoperative management for diverticulitis?
Oral abx
Clear liquids
Low res diet (after sxs improve)
High fiber diet (once normal po intake)
When is surgical management of diverticulitis indicated? (3)
2+ attacks
Complications
Failure to improve w/ 3-4 days of conservative management
What surgical procedure involves the colon being divided with the proximal end being brought through the abdominal wall?
Colostomy
What type of colostomy involves the distal end of the colon oversewn and placed in the peritoneal cavity as a blind limb?
Hartmann’s procedure
What are the 2 types of colostomy?
Loop and ileostomy
What type of colon resection involves removal of the entire colon and rectum?
Proctocolectomy
What type of colon resection is performed for very low rectal cancers and involves removal of the lower sigmoid colon, entire rectum, and anus?
Abdominoperineal resection (APR)
What type of colon resection is performed for cancers of the middle and upper sections of the rectum and involves removal of the distal sigmoid colon and 1/2 of rectum with proximal sigmoid-distal rectum anastomosis?
Low anterior resection (LAR)
What is defined as a connection between 2 tubular organs?
Colonic anastomosis
How can you differentiate between an internal vs external hemorrhoid?
Internal- above dentate line, may bleed/ prolapse, non-painful
External- below dentate line, do not bleed, pain/itching/scarring
What is the most common cause of rectal bleeding?
Internal hemorrhoids
How are hemorrhoids classified and when is hemorrhoidectomy considered?
Grades I-IV
Consider hemorrhoidectomy for grades III-IV
(mixed internal/ external, extensive thrombosis/ pain, persistent bleeding)
What is the office tx for grade II and III internal hemorrhoid?
Rubber band ligation
Pt presents with severe, sharp anal pain and PE shows a palpable, tender, fluctuant mass. What are you concerned for?
Anorectal abscess
What is included in the tx for anorectal abscess aside from wound care?
Surgical drainage + abx
What is defined as an abnormal communication between the anal canal and perianal skin?
Fistula in ano
(50% chance after abscess)
How is fistula in ano diagnosed?
Cord like tract on DRE
Goodsall’s rule
What is the tx for fistula in ano?
Drainage/ curretage of fistula tract
Placement of Seton (loop of drainage tube)
Pt presents w/ palpable, soft abd mass +/- pain/ enlargement with straining. Pt examined upright/ supine confirms sxs. What are you concerned for?
Abd wall hernia
What is the management for an abd hernia?
Surgical repair
(can use laparoscopic if bilateral inguinal, recurrent, ventral/ epigastic)
Where will a direct inguinal hernia occur?
Through Hesselbach’s triangle
(inguinal ligament inferiorly, inferior epigastric vessels laterally, rectus muscle medially)
What kind of repair is used for an inguinal hernia?
Lichtenstein hernia repair
(uses mesh)
What post-op complications are a/w inguinal hernias?
Scrotal hematoma
Hemorrhage
Difficulty voiding
Pain
Neuroma/ neuritis
When is there a low vs high risk for hernia recurrence?
Low risk for indirect inguinal hernias/ Shouldice and Lichtenstein procedure
High risk for direct (if underlying process not corrected)
