General Flashcards
What are the components of the WHO Checklist?
Three phases.
Sign in - led by anaesthetist, check the patient in, machine checks, anaesthetic concerns
Time out - led by surgeon, patient check, antibiotics, equipment check and sterility, VTE plan
Sign out - led by scrub team, procedure check, counts, specimens, equipment problems, postoperative plan
What is the audit cycle?
Identify issue
Define standards
Collect data
Analyse/interpret data
Implement change
Reaudit
How should patients with a pacemaker or ICD be managed intraoperatively?
Establish make and model
Ensure has had review by cardiac physiologist within 3 months and discuss case with them
Avoid diathermy, particularly monopolar, keep to short bursts or use ultrasonic dissectors
Some pacemakers can be deactivated by magnets, but not all.
How do cutting and coagulation diathermy work?
Passing high frequency AC to produce heat - 300kHz –> 10MHz
-Cutting = continuous low frequency
-Coag = intermittent high frequency
-Blend = continuous low frequency + intermittent high frequency
What is the difference between monopolar and bipolar diathermy?
Monopolar –> instrument –> patient –> plate (70cm2) (high power 400W)
Bipolar –> forceps ends (low power 50W)
How may groin hernias be classified?
European hernia society guidelines
1) Primary/recurrent
2) Size of defect
- 1 <1.5cm
- 2 1.5-3cm
- 3 >3cm
3) Site of defect (Lateral, medial, femoral)
What is the Shouldice technique?
Tissue repair of inguinal hernia
4 layers
- Deep upper TF –> lower TF (M–>L)
- Sup Upper TF –> Inguinal ligament (L –> M)
- Internal oblique/TA –> deep Inguinal ligament (L –> M)
- Internal oblique/TA –> sup Inguinal ligament (M –> L)
What are the risk factors for urinary retention after hernia repair?
Age
Laparoscopic approach
GA
What is the incidence and risk factors for chronic pain after hernia repair?
10-12% - bothersome in 0.5-6%
RF
- preop = young, female, preop pain, recurrence
- periop = less experienced, open, heavyweight mesh
- postop = complications, high post op pain
What are the management options for chronic pain after hernia repair?
–EHS guidelines
MDT
Consider LA/Steroid blocks
Consider triple neurectomy and mesh explantation after at least 1 year
RFA may be helpful
What would be an appropriate local anaesthetic choice for groin hernia repair?
Combination of lidocaine with adrenaline (7mg/kg) and bupivicaine (2.5mg/kg)
20mls 1% L+A
20mls 0.5% Bupivicaine
70kg.
What factors are important in the pharmacokinetics of LAs?
Protein binding - ability of drug to bind membrane proteins –> longer duration, less risk of toxicity
Lipid solubility - greater solubility == greater penetration of nerve membranes and increased rate of onset
-pKa - pH at which there is balance of ionised and non-ionised LA.
—Lower pKa, higher proportion in non-ionised form, more readily absorbed and more rapid onset
—Higher pKa, slower onset, more prolonged
What are the components of an enhanced recovery pathway?
Pre-admission - patient optimisation, comorbidities/anaemia addressed, patient education
Admission - day of surgery, carbohydrate loading, avoidance of bowel prep
Intra-op - minimally invasive, goal directed fluid management, individualised pain management, avoid tubes where possible
Post-op - early mobilisation, enteral nutrition and removal of tubes. Daily achievement goals
What are the criteria for discharge on ERAS?
1) Good pain control with oral analgesia
2) Eating and drinking without IVFs
3) Independently mobile
What structures drain lymph into the superficial inguinal nodes?
Skin and subcutaneous tissue of abdominal wall below umbilicus, perineum, buttocks, external genitalia and lower limbs
What is gynaecomastia and its common causes?
Benign proliferation of glandular male breast tissue. Consider pseudogynaecomastia
- Physiological (30% neonatal, puberty, old age)
- Drug (20%, protate cancer drugs, cardiac, retroviral - Spironolactone, steroids, cannabis)
- Pathological causes (25%, hyperthyroidism, alcohol, cirrhosis, testicular malignancy)
- Idiopathic (25%)
What endocrine tests should be sent for assessment of gynaecomastia?
B-HCG, LH, testosterone, oestrogen, prolactin and AFP
Also renal, liver, thyroid function
What are the classical stages of Hidradenitis supparativa?
Three stages described by Hurley
1 - single/multiple abscesses
2 - recurrent abscesses with tract formation
3 - multiple tracts and abscesses involving a whole area
What is a hydrocele and how may they be classified?
An accumulation of fluid around the testis in the tunica vaginalis
Communicating (associated with hernia)
Non-communicating
How may hydroceles be repaired surgically?
Inguinal approach
- high ligation of PPV in infants
Scrotal approach
- Jaboulay procedure - resection of most of sac leaving a cuff of tissue which is everted and sutured along the cord
What are the surgical concerns for patients with Sickle-cell anaemia?
Vaso-occlusive crises precipitated by infections acidosis, dehydration, hypoxia, surgical trauma.
Ensure Hb >10.
Acute chest syndrome - 2/3 days post surgery, pulmonary infiltrates on chest x-ray
What is the embryological origin of a thyroglossal cyst?
The foramen caecum develops at the base of the tongue at about 4 weeks
Forms the thyroid which migrates to the 5th Cervical vertebrae between 1st and 2nd branchial arches
Along this tract cysts or ectopic thyroid tissue can be found, most commonly at the level of the thyroid
What USS findings would suggest pyloric stenosis in infants?
Thickness of >3mm or length >15mm
What are the typical findings of dehydration in infants?
Mild 1-5% - <24 hours
Moderate 6-10% - loss of skin turgor, weight loss, sunken eyes/fontanelle, lethargy, dry membranes
Severe 11-15% - skin mottling, CV instability, neurological involvement
What clinical features might make you consider NOM of SBO to be failing?
WSES Bologna guidelines
- No passage of contrast into colon after 24 hours after WSCI
- >72 hours symptoms
- >500ml NG on D3
- Peritonitis or ischaemia
Why is splenectomy effective for ITP?
-Site of anti platelet antibody production and subsequent destruction
- NB spleen is normal sized in these patients
What are the common indications for elective splenectomy?
Immunological (ITP, Spherocytosis (aim for >6 years), AIHA)
Haematological malignancies/staging
Splenic tumours (haemangioma, giant cysts, abscesses)
Gastric varices secondary to splenic vein thrombosis
What are the risk factors for OPSI?
Age (younger)
Indication (elective, haematological)
Timing - within 2 years
What are the risk factors for DVT?
Patient
- BMI
- FH and inherited thrombophilia
- Age
- Drugs (COCP)
- Malignancy
Condition
- Acute inflamatory
- Immobility
- Pregnancy
Procedural
- Prolonged surgery
- Pelvic surgery
What is the operation of choice for Malrotation of the Gut?
Ladd’s procedure.
-Division of Ladds bands
-Place colon on left side, remove appendix
What is the most common type of Diaphragmatic hernia?
Bochdalek hernia (usually left sided)
How does Hirshprungs disease typically present?
With failure to pass meconium in 48 hours
Diagnose with suction rectal biopsy
Treat with serial washouts and pull through at 6 months
High incidence of NEC
How does Pyloric stenosis tend to present?
Non bile stained vomiting at 4-6 weeks
Ramstedt pyloromyotomy
5-10% FH
Where is the most frequent location of a thyroglossal cyst?
Just inferior to hyoid (65%)
Treat with Sistrunk procedure - excision of hyoid bone
Thin walled and anechoic
Where are branchial cysts most frequently located?
Usually located anterior to SCM near angle of mandible
75% from second branchial cleft
Usually anechoic and water like unless infected
Where is a cystic hygroma most commonly found?
Posterior to SCM
Usually present <2
Typically hypo echoic on USS
How do infantile haemangiomas present?
Rapidly growing neck mass that often spontaneously regresses
Contains calcified phleboliths on XR
What is the most common cause of PR bleeding in young children?
Probably Meckel’s or a polyp
IBD in older children
What is the best imaging test for a Meckel’s diverticulum?
Technetium 99
How do Meckel’s most frequently present if symptomatic?
Obstruction
Only 5% symptomatic
2% of population, 2 inches long , 2feet from IC valve
What is the incidence of Cryptorchidism?
Defined by failure to reach bottom of scrotum by 3 months, then 1-2%.
5% at birth
What congenital defects are associated with cryptorchidism?
PPV
Abnormal epididymis
Cerebral palsy
Learning difficulties
Wilms Tumour
Abdominal wall defects
What is the increased risk of testicular cancer with undescended testis?
40 times normal risk (seminoma)
50% of intra-abdominal will become malignant
When should an orchidopexy be performed for cryptorchidism?
6-18months of age.
If impalpable in the groin then laparoscopic exploration and 1/2 stage procedure
Above 2 the Sertoli cells degrade, and if presenting in teenage years, probably should just have orchidectomy
When does intestinal rotation occur in embryological development?
About the 4th week 270deg anticlockwise twist
What is the characteristic X-ray finding of duodenal atresia?
Double bubble sign on plain X-ray
40% have Down’s
8% of Downs have duodenal atresia
Treated with duodenoduodenostomy through transverse incision. Has good outcomes
How frequent is umbilical hernia in infants?
Up to 20%. Majority close spontaneously
What is the most common infective organism causing Omphalitis?
Staph Aureus
How does a persistent urachus present?
Urinary discharge from umbilicus
How does a persistent Vitello-intestinal duct present?
Umbilical discharge of small bowel content - often a Meckel’s diverticulum
How are paediatric inguinal hernias repaired?
High risk of strangulation <1 and should be repaired urgently. If >1, ?electively
Herniotomy is the treatment of choice
Females should have bilateral exploration ?lap
What are indications for circumcision?
Lichen sclerosus> BXO
Paraphimosis
Recurrent balanitis
Persistent phimosis - but only if pathological. 10% of 11 year olds non-retractile (does not matter)
When should a paediatric hydrocele be considered for treatment in children?
> 12 months and not decreasing in size –> referral
Ligation of PPV usually >2 years
How should microscopic haematuria be investigated in children?
If asymptomatic, may be benign and resolve. Consider repeating in 6 months
Red flag features include abnormal renal function, proteinuria, signs of fluid overload, hypertension or frank haematuria
Consider diagnosis of Alport syndrome or structural abnormalities
NB wilms (mass)
What is the peak incidence of Intussusception?
5-7 months, 70%<1 year
What proportion of thyroid nodules are cancerous?
<1%
Prevalence of nodules on USS c .50%
c.2,200 annual diagnoses of thyroid cancer
What are the effects of a GA on the liver in patients with cirrhosis?
Susceptibility to hyperaemia and hypotension due to hyper dynamic circulation
Risk of hepatic ischaemia, risk of halothane toxicity
How can patients with liver cirrhosis be risk stratified for surgery?
Childs-Pugh A/B/C
Mortality = 10/30/80%
Composite of:
1) encephalopathy
2) Ascites
3) Bilirubin
4) Albumin
5) INR
MELD/UK-ELD
How is an undescended testicle defined?
Failure to descend to normal position by 3 months of age
90% unilateral, 70% right
What are the phases of healing of an anastomosis?
Lag phase (0-4) - acute inflammatory response to clear wound debris
Proliferative (3-14) fibroblast proliferation and immature collagen
Remodelling/maturation (10+) collagen remodelling
What are the risk factors for anastomotic leak?
Technical:
- Blood supply
- Tension
- Contamination
Patient:
- Malnutrition
- Steroids
- DM
- Malignancy, radiation, chemotherapy
- Hypotension/shock
- Emergency
How do chemotherapy agents work?
- Anti-metabolites e.g. Methotrexate - inhibit DNA synthesis (folate), 5-FU (pyrimidines)
- Inhibition of microtubule assembly (Vinka Alkaloids)
- DNA Cross linking (prevents DNA repair, platinums)
- Inhibitor of topoisomerase (prevent DNA-coiling e.g. anthracyclines)
What are the side effects of chemotherapy?
General - N/V, BM toxicity, GI toxicity, alopecia, infertility
Specific
- Cardiomyopathy - doxorubicin
- Cyclophosphamide - haemorrhage cystitis
- Hepatic damage - methotrexate
- Skin pigmentation - 5-FU
- Peripheral neuropathy - Oxaliplatin
What is clinical governance?
A framework by which NHS organisations are accountable for improving their services and safeguarding standards of care. Ultimately the Chief executive is responsible
What are the 7 pillars of clinical governance?
SPARE-IT
Staffing and staff management
Patient involvement
Audit
Risk management
Effectiveness
Information use
Training and education
S
What is an audit?
A process used by clinicians to improve patient care by assessing practice, comparing it to accepted standards and making changes if necessary
How should patients with suspected C. Diff be managed?
- Isolated within 2 hours
- Gloves + Aprons and hand washing
- Stool sample –> micro
Who should receive a 2 week wait referral for bowel cancer?
FIT +ve
40 + with weight loss + abdominal pain
50 + with unexplained rectal bleeding
60 + with IDA or CIBH
Rectal/abdominal mass
What common gene mutations are seen in colorectal cancer?
APC
K-ras
p53
What are the risk factors for CRC?
Genetic - APC, HNPCC with various mutations
Lifestyle - obesity, low fibre, high processed meat, obesity, smoking, alcohol
PMH - IBD
What is the TNM staging of CRC?
T1 Invading mucosa/submucosa
T2 Invading muscularis propria
T3 Invading subserosa
T4 Invading visceral peritoneum/other organs
N1 1-3
N2 4+
How could you negotiate a tight stricture in colonoscopy?
Scope guide
Patient positioning
Buscopan
Paediatric endoscopy
Experience colleague
CT Colon….
What are the causes of Cushings syndrome?
ACTH dependent
- Cushings disease
- Ectopic secretion (SCLC, bronchial carcinoid)
ACTH independent
- Adrenal Adenoma/Adenocarcinoma
- Bilateral adrenal hyperplasia
- Iatrogenic (Steroids)
How can the difference causes of Cushings syndrome be differentiated?
1) Confirm syndrome - Low dose dexamethasone suppression test (should have suppressed cortisol in the morning)
2) Confirm source
–If ACTH high
—- High dose dexamethasone suppression test
—– Pituitary relatively suppressed, ectopic not suppressed
3) Image
-If High ACTH - CX and MRI pituitary
-If low ACTH - CT and MRI abdomen
How can patients with ectopic secretion of ACTH from cancers be managed?
Interruption of steroidogenesis using
- Ketoconazole
- Mitotane
- Metyrapone
What are possible complications of diathermy?
Inadvertent application
Heat transference
Plate burns
Spirit based burns
Explosion large bowel
What is the critical view of safety?
1)Hepatocystic triangle cleared for fat and fibrous tissue (c duct, CHD, inferior edge of liver)
2) Lower 1/3 of GB separated from cystic plate
3) two structures entering gallbladder
What is the cause of an in-growing toenail?
Lateral projection of nail growing into peri-ungal soft tissue, mostly great toe.
Nail fold penetrated, and colonised with bacteria/fungi
Oedema, erythema, pain abscess, granulation tissue
What is the anatomy of the nail?
Nail plate - body and root lie on nail bed
Germinal matrix runs form lunula to eponychium
Cuticle most distal portion of eponychium
How would you treat ingrowing nails?
Conservative management
Wedge excision
- Digital block with plain 1% bupivicaine
- Rubber tourniquet
- Lift lateral quarter of nail with haemostat
- Divide nail to underlying matrix and remove
- Debride bed
-Apply 80% phenol with cotton bud for 30-60s and irrigate
- Dress toe
What are the borders of the inguinal canal?
Superior - Muscles (IO, TA)
Anterior - Aponeurosis (EOA/IOA)
Inferior - Ligament (inguinal/lacunar)
Posterior - Tendon (Transversalis facia/conjoint)
MALT
What re the risk factors for Melanoma?
Fitzpatrick skin type 1
Sun exposure and sunburn in childhood
Other skin lesions esp melanomas, giant congenital pigmented hairy naevus
Immunosuppression
Xeroderma pigmentosa
What clinical features are suggestive of melanoma?
Asymmetry
Border irregularity
Colour variability
Diameter >6mm
Evolving/extra features (bleeding, itching, elevation)
Why is CO2 used for pneumoperitoneum?
Normal end product of metabolism and readily cleared by body
highly soluble in tissue
non-combustible
high diffusion coefficient
lowest risk of gas embolism
How is Botox administered for incisional hernia repair?
-3 sites on each side of lateral abdomen in EO,IO and TA
- total of 300 units
- increases stretch by about 30-50%
What is CEA?
Protein produced by some types of cancer including colon, breast, lung, liver, stomach
Can be raised incidentally from
Smoking, IBD and chronic liver disease
Normally less than 2.5ug/l
What are the complications of radiation induced bowel injury?
Obstruction
Malabsorption
Short gut syndrome
Fistula
Chronic inflammation
Sepsis
What factors increase the risk of radiation induced bowel injury?
CVS risk factors
Low BMI, old/young
Genetic predisposition - Ataxia telangiectasia
How does radiotherapy work?
Electron stream –> free radical mediated DNA damage
Normal cells more likely to be able to repair DNA damage
Oxygen dependent (nb necrotic cores)
When is a death reported to the coroner?
No doctor attended deceased during illness
Not seen within 14 days of death or after death
Cause of death unknown
Death occurred during an operation/before recovery from anaesthetic
Death due to industrial disease
Death sudden/unexpected/unnatural
What bias exists in a screening program?
Lead-time bias
Selection bias
Length bias
What are the cervical, AAA, breast and bowel screening programs?
Cervical - 25-64 every 3-5 years
AAA - USS at 65 in males
Breast - 50 every 3 years, 1:25 recall of whom 1:4 have cancer
Colorectal - 60-74 biennial FIT test
What are concerning causes of a new varicocele?
Left –> renal tumour
Right –> retroperitoneal tumour
What is the difference between split thickness and full thickness skin grafts?
SSG - epidermis and thin layer of papillary dermis, extracted with dermatome, often meshed (allows fluid escape, larger wound)
FTSG - epidermis and all of dermis - smaller defects. Harvested from neck, ear, groin, less contraction and better cosmesis
What antibiotics should be used for Gram +ve aerobes
Staphylococcus Aureus, Strep Pneumo, Enterococcus
Coamox, Gent, Teic, Vanc
What antibiotics should be used for Gram +ve anaerobes
C. Diff
Vanc, Met
What antibiotics should be used for Gram -ve aerobes
Bacteroides
Co-amoxiclav, Metronidazole
What antibiotics should be used for Gram -ve anaerobes?
E.Coli, Kelbisella, Pseudomonas
Co-amoxiclav, Gent
Where is an impalpable testis in an infant most likely found?
10% inguinal
40% intra-abdominal
50% absent
What comprises a major haemorrhage protocol?
20ml/kg Blood
20ml/kg FFP
10ml/kg Platelets
5ml/kg Cryo
Aim for Hb>80, Platelets >75, Fibrinogen >1.5g/l (Cryo), INR<1.5 (FFP)
Nb TXA
What are the components of the Glasgow Score for Pancreatitis?
PaO2<7.9
Age>55
WCC>15
Ca<2
Urea>16
LDH>600
Albumin<32
Glucose>10
Where do congenital diaphragmatic hernias most frequently occur?
Posterolateral Bochdalek hernia
Defect in pleuroperitoneal fold
78% Left
20% right
2%bilateral
Through which defect do Morgagni hernias occur?
Anterior space of Larrey
What are Kidney stones most frequently comprised of
40% Calcium oxalate
20% Calcium oxalate/phosphate
15% Calcium phosphate
15% Ammonium magnesium phosphate (Struvite)
10% Uric acid
What is a Meckel’s diverticulum embryological origin?
Remnant of Vitelli intestinal duct (can be attached to umbilicus - rarely discharging)
What is the incidence of a Meckels diverticulum?
2% (rule of 2s - 2inch/5cm long, 2feet (60cm) from IC valve - in ADULTS!, 2% incidence
What is the characteristic features of a contrast Xray for intestinal malrotation
Gasless abdomen, with corkscrew duodenum on contrast, with DJ flexure in RUQ
Usually isolated abnormality
Formation of LADDs band (caecum to RLQ retroperitoneum) and volving
1/500
How do Meckels diverticula most frequently present?
Obstruction (40-50%)
Peptic Ulceration (25%)
Acute Inflammation (20%)
What is the most common cause of intussusception?
Lymphoid hyperplasia in Peyer’s patches of gut. Most prominent in ileocolic segment
Other causes include Meckel’s diverticula, Duplication cysts, B cell lymphoma
Tend to present 2months to 2 years
What are the potential areas of portosystemic shunt in portal hypertension (4)
1) Rectum - Superior rectal (IMV) –> Middle/inferior rectal (Pudendal –> EIV)
2) Paraumbilical - recanalised vestigial umbilical vein –> Left portal vein
3) Oesophagus - left gastric vein –> azygous
4) Intrahepatic - portal vein and IVC
What is the most frequent cause of acute Lower GI Bleeding?
Diverticular disease (50%)
Angiodysplasia (40%)
Incidence of bleeding post polypectomy is 2%
85% resolve spontaneously
What degree of bleeding can be detected by a CT Angiogram
0.3ml/min
How is SIRS defined?
Any two of:
T<36 or >38
HR>90
WCC>12 or <4 with >10% immature bands
RR>20 or PaCO2<4.26
What is the definition of massive bleeding? (5)
-Blood loss of 1/2 circulating volume in 3 hours
-Blood loss of entire circulating volume in 24 hours
-Ongoing blood loss of >150ml/min
-Transfusion of 4 units PRC in 4 hours with ongoing bleeding
-Transfusion of 10 units PRC in 24 hours
What are the indications for thoracotomy (5)?
-Haemothorax - >1500ml immediately or >200ml/hs for 2-4 hours
-Diaphragmatic/oesophageal laceration
-Widening of mediastinum >8cm
-Cardiac tamponade
-Large unevaluated clotted haemothorax
What is Becks triad?
For Cardiac tamponade - muffled heart sounds, raised JVP and low BP
What fluid resuscitation should patients with burns receive?
Parkland formula - %burn x weight (kg) x 4
Give half in 8 hours then half in 16 hours
Rule of 9s for adults
Children similar but more for head and less for legs
In what proportion of cases does sigmoid volvulus recur?
50-90% (endoscopic resolution in 70-80% of patients)
Contrast enemas successful in 5%
Rarely resolves spontaneously
What are the characteristics of the Truelove and Witts criteria?
For acute severe colitis
Frequency of blood stools >6
Temperature >37.8
Heart rate >90
Haemoglobin <10.5
ESR >30 (can exchange for CRP>30)
If signs of systemic toxicity the rate of colectomy goes from 8.5% –> 30% –> 48%
What is the initial management of acute severe colitis?
100mg IV Hydrocortisone QDS
Stool culture x 3 for C.Diff
Consider Flexi and biopsy for CMV
Consider AXR (>5.5cm = megacolon)
If still severe on D3 consider rescue - Infliximab, Cyclosporin or surgery
What does Prothrombin Complex Concentrate (octaplex/berriplex) contain
II, VII, IX and X along with protein C/S
What is the required excision margin for a skin SCC?
<2cm well differentiated - 4mm
>2cm, poor or face - 6-10mm
What is the required skin margin for a BCC?
5mm (95% clearance - 85% at 3mm)
If recurrent - 5-10mm
What is the T staging of melanoma?
Tis
T0
T1 ≤1mm Breslow Thickness (to deepest point)
T2 1-2mm
T3 2-4mm
T4>4mm
Ta/b if ulcerated
When should a sentinel lymph node biopsy be offered for malignant melanoma?
Breslow thickness >1mm
Which patients with melanoma should receive staging imaging?
IIC without SLNB or suspected III/IV
Consider MRI for <24
What are the excision margins for melanoma (pTis, pT1, pT2, pT3, pT4)
Stage 0 - 0.5cm
Stage 1 - 1cm
Stage 2 - 2cm
pTis - 2-5mm
pT1 (0-1mm) 1cm
pT2 (1-2mm) 1-2cm
pT3 (2-4mm)/pT4 - 2cm
What is the typical threshold for radiological drainage of diverticular abscess?
4cm
What is the Hinchey classification of diverticulitis
1a) Pericolic inflammation
1b) Pericolic abscess
2a) Distant abscess amenable to drainage
2b) Complex abscess +/- fistula
3) Purulent peritonitis
4) Faecal peritonitis
What are the potential complications of diverticular disease?
Diverticulitis
Bleeding
Fistula
Perforation
Abscess
Phlegmon
When is oesophageal perforation most likely after ingesting Alkaline agents?
3 days. Perform OGD within 12-24 hours
What are the important determinants of a severe attack of pancreatitis?
1) Obesity
2) APACHE Score >8 in first 24 hours
3) After 48 hours any of:
CRP>150, Glasgow >3, persistent Organ failure
When should patients undergo radiologically guided drainage of pancreatic necrosis?
> 30% necrosis for culture
What treatments are appropriate for UGI ulcer bleeds at endoscopy?
Combination therapy including Adrenaline injection +
1) Thermal method (APC or heater)
2) Clip
3) Fibrin or thrombin injection
PPI infusion
Biopsy to exclude cancer
Even in cancer, attempt endoscopic approaches first
NICE Guidelines
What size of non-enhancing area of pancreas defines necrosis?
> 3cm
What is the initial inflation pressure of a Sengstaken Blakemore tube?
35-40mmHg, then deflated to 25mmHg when bleeding stops
what is the mechanism of action of TXA?
Prevents conversion of plasminogen to plasmin (and hence fibrin degradation)
What is the minimal amount of blood required to produce melaena?
60ml
What is the most common cause of upper GI bleeding (in patients who have an OGD)?
Peptic ulcer (26%)
Then oesophagitis (17%)/gastritis (16%)/duodenitis (9%)
Varices (9%)
Malignancy (3%)
MW-tear (3%)
12% no cause found
What is the best treatment for primary prophylaxis of variceal haemorrhage in Cirrhotic liver disease?
For Grade 2 or 3 varices - Non cardio selective beta blockers - propranolol>nadolol>carvedilol
For grade 1 varices without red signs, repeat OGD 1 year
2015 BSG Guidelines
What is the optimum treatment for gastric variceal bleeding?
Cyanoarcylate injection or thrombin
2015 BSG Guidelines
What is the inpatient mortality from variceal haemorrhage?
15%
What blood products should patients with variceal haemorrhage receive?
PRC target of 70-80g/l
Platelets if active bleeding and plt<50
FFP if fibrinogen <1g/L or PT/APTT>1.5
PCC for warfarinised patients
2015 BSG Guidelines
What management should be instituted in acute variceal haemorrhage
1) Resuscitation
2) Vasconstrictors - Terlipressin or somatostatin >octreotide
3) Antibiotics
4) OGD with Variceal Band Ligation
5) for patients with Childs B or Childs C <14 early covered TIPPS (<72hr)
2015 BSG Guidelines
What should be done for secondary prophylaxis of oesophageal varies?
Repeat VBL 2-4 weekly until eradicated
NSBB
TIPPS if rebelled (PTFE Covered stents)
2015 BSG Guidelines
What is the optimum treatment for diffuse gastric bleeding?
Argon plasma coagulation + PPI +/- proceed to surgery
What is the difference between a Sengstaken-Blakemore and Minnesota tube?
SSB has 3 ports (two balloons, one gastric aspiration channel)
Minnesota has 4 - extra oesophageal aspiration channel
How do you insert a Sengstaken Blakemore tube?
- Insert into stomach and inflate gastric balloon under IR and pull back to GOJ with traction
- Inflate balloon to compress oesophagus 35-45mmHg
- reduce pressure by 5mmHg every 3 hours and maintain for 24 hours, deflating every 6 hours
Risk factors for PUD?
1) NSAIDS (inhibit prostaglandin synthesis)
2) Smoking (inhibits HCO3- and nicotine increases H+)
3) H.pylori
4) Bariatric marginal ulcer
5)Fasting
6)Drugs
7)Zollinger-Ellison syndrome (consider if recurrent and multiple)
8)Alcohol
30d mortality of Haemorrhagic peptic ulcer?
8.6%
What risk scores exist for Perforated peptic Ulcer?
Boey, PULP, ASA
NELA
Simple albumin is strongly prognostic
If a non-operative approach is taken to perforated peptic ulcer, what treatments are required?
PPI
ABx
Anti-secretory (octreotide)
In unstable patients, what are the risks of laparoscopy?
Increases in:
1)SVR
2)MAP
3)afterload
4)HR
5)IVC pressure
6) RR
7)Peak airway pressure
8)PaCO2
Decreases in:
1)SV
2)venous return
3)Thoracic compliance
What is the best approach for repair of a small perforated peptic ulcer (<2cm)
No evidence of benefit to omental patch over suture closure
What are the management considerations of large perforated peptic ulcers (>4cm)?
1) raises suspicion of malignancy
2)10-16% of gastric perforations (1% of cancers)
3)For giant ulcers, resection and reconstruction recommended (may need damage control)
How long should antibiotics be given for in perforated peptic ulcer?
if not severely ill, consider 3-5 days - long course did not have any benefit in recent RCT
Antifungals should be given if immunocompromised, elderly, comorbid or prolonged ITU stay. First line would be fluconazole, upgraded to caspofungin if previously received fluconazole
What drains should be left after peptic ulcer repair?
Probably none, but could leave a suture site (WSES guidelines 2020)
When should patients with perforated gastric ulcers have a repeat endoscopy?
6 weeks
What is the Forrest classification of peptic ulcer bleeding?
Acute Haemorrage
1a) Active spurter
1b) Active oozing
Signs of recent haemorrhage
2a) Non-bleeding visible vessel
2b) Adherent clot
2c) Flat fomented haematin on ulcer base
Lesions without active bleeding
3) Clean -based ulcer
How should patients with UGI bleed be risk stratified?
Using the Glasgow-Blatchford score
0-1 - outpatient OGD
2-6 - I/P OGD
7+ - urgent I/P OGD
Which artery typically causes bleeding from duodenal ulcers?
Gastroduodenal artery (must be triple looped)
In patients with an UGI bleed, how should anticoagulants be managed?
Continue aspirin
Stop P2Y12 inhibitors until haemostasis UNLESS stents (40% risk of death/mi if stopped <1year), aiming to restart within 5-7 days
Stop warfarin and DOACs (nb idarucizumab and andexanet)
BSG guidelines 2020
What are the components of the Glasgow Blatchford Score? (4+4)
Urea
Hb
SBP
HR
Maelena
CLD
CHF
Syndope
What are the components of the Rockall score?
Age
Shock
Comorbidities (CLD/CRF/malig worse than IHD/others)
Diagnosis (MW/Cancer)
What are the greatest risk factors for rebreeding with UGI bleeds?
Active bleeding 100%
Visible vessel 50%
Non bleeding ulcer with clot 30-35%
Oozing ulcer 10-27%
Clean based ulcer <3%
Types of hernias
1) Bochdalek
2) Obturator
3) Lumbar hernia
4) Richters Hernia
5) Morgagni Hernia
6) Littres Hernia
1) Most common congenital, 85% Left M>F, associated with lung hypoplasia
2) Hernia through obturator canal, F>M, behind pectinous muscle
3) Lumbar triangle (crest of ilium inferiorly, EO laterally and LD medially)
4) Antimesenteric border of bowel
5) Rare, herniation through foramen of Morgagni, more on right
6) Inguinal hernia containing Meckel’s diverticulum
What is the most common place for inguinal hernias to recur?
47% Pubic tubercle
40% deep ring
13% entire back wall
Which type of renal stone is most radio dense?
Calcium phosphate
What is the mechanism of action of unfractionated heparin?
Activation of antithrombin 3
What is the reinfarct rate if a GA is performed within 1 month of a MI?
32%
Which clotting factors are consumed most rapidly in DIC?
V and VIII
What variables comprise the SOFA score (8)?
MAP
GCS
Creatinine
Urine output
Platelet count
Bilirubin
Inotrope use
PaO2/FiO2 ratio
What is the mechanism of action of Dabigatran?
Direct thrombin inhibition
What is the reversal agent for Dabigatran?
Idarucizumab
What is the reversal agent for Rivaroxaban?
Andexanet alfa
Which clotting factors does Heparin prevent activation of?
2, 9, 10 and 11
What kind of diathermy is used for ERCP?
Monopolar cutting (risk of bleeding)
What kind of diathermy is used for colonoscopy polypectomy?
Synergised diathermy using blend mode
Which blood group plasma products can be infused into any recipient?
Group AB (reverse of PRC transfusion)
Which type of renal stone is most radio dense on plain X-ray?
Calcium phosphate
What percentage of paediatric splenic injuries can be managed conservatively?
90%
What is the incidence of chronic pain after inguinal hernia repair?
10-15%
What is the maximum dosing of Bupivicaine?
2mg/kg - but based on IBW, so 150mg
= 30ml 0.5%
= 60ml 0.25%
Not affected by adrenaline as related to protein binding
How long after placing a bare metal stent (cardiac) should surgery be delayed?
At least 1 month - 6 months for DES
Risk of sudden occlusion with BMS is less
What is the most common cause of peritoneal catheter associated infections?
Coagulase negative Staphylococcus (Staph. epidermidis)
What is the most common cause of retroperitoneal abscess?
Renal infections (50%)
What is the most common pathological organism in SBP in adults?
E.Coli and Klebsiella.
Consider prophylaxis with fluoroquinolones in high risk.
From which muscle does the cremaster arise?
Internal oblique
What are the borders of a Petit hernia?
LD, Iliac crest and External oblique (inferior lumbar triangle)
What are the borders of a Grynfeltt hernia?
Quadratus lumborum, internal oblique muscle and 12th rib (Superior lumbar triangle)
What innervation does the genital branch of the genitofemoral nerve provide?
Cremaster muscle and side of scrotum/labia
What is Bowens disease?
SCC insitu of skin
Full thickness atypic of dermal keratinocytes over a broad zone
What are the types of BCC?
Nodular (commonest 60%, frequently on face)
Superficial (can use 5-FU)
Morpheaform (more aggressive, needs Mohs)
Cystic
Basosquamous (also more aggressive)
What excision margins should be achieved with a BCC/SCC?
4mm sufficient (98% excision)
High risk SCC, size >2cm and poor differentiation –> 6mm
What is the Neve supply to biceps femoris?
Tibial nerve (L5,S1,S2)
Which organ is most often injured in blunt abdominal trauma?
The spleen
From which AA are catecholamines primarily derived?
Tyrosine
What is the half life of albumin?
20 days
What is the most common cause of GORD?
Increased transit lower oesophageal sphincter relaxations
What is the most common cause of visceral ischaemia?
Embolism (50%)
Which portal vein does not follow normal pattern of biliary drainage?
Left portal vein (embryological conduit between umbilical vein and ductus venous)
In which situation are IgM Anti Heb B seen?
Acute infection
What proportion of inguinal hernias will present as an emergency?
about 5%
Where is most of dietary iron absorbed?
Duodenum
How is pancreatic necrosis defined on CT?
> 3cm area of no contrast uptake
What is the most common cause of vascular prosthetic infections?
Stap epidermis
How does botox exert its effects?
Inhibition of release of Acetyl Choline into neuronal synapse
Which type of breast cancer is characterised by a lymphocytic infiltrate?
Medullary
A Patey mastectomy requires division of which muscle?
Pectoralis minor
How does water appear in a T2 weighted MRI
T2 = Water White
What proportion of liver volume is right side?
60%
What is the rate of skip metastasis above the SLN in breast cancer?
3%
How long should Apixaban be discontinued prior to surgery
48 hours (half life is 12 hours)
For rivaroxaban and dabigatran probably 48-72 hours - variable half life
What is the pathological process in HIT?
Antibodies to Heparin-Platelet 4 complex (HP4)
What anticoagulant can be used for prevention of VTE in patients with HIT?
Fondaparinux (Synthetic Xa inhibitor)
What is the difference between lymphoedema praecox and lymphedema tarda?
Praecox presents in adolescence and tarda presents >35
What is the optimum skin preparation agent?
2% alcoholic chlorhexidine
What is the inheritance of Peutz Jeghers syndrome?
Autosomal dominant
What is the most appropriate feeding strategy for patients with newly diagnosed Crohns disease?
Elemental - can induce remission in up to 80%
What is the daily protein requirement?
0.8-1.5g/kg/day
What is the characteristic metabolic finding of pyloric stenosis?
Hypokalaemic, hypochloremic metabolic alkalosis
What are the immediate physiological effects of laparoscopy?
Stretching of peritoneum –> vagal stimulation
Sinus Brady/nodal rhythm
Hypercarbia/acidosis
What are the physiological effects seen with laparoscopy?
Increased - airway pressure, V/Q mismatch, SVR
Decreased - FRC, pulmonary compliance, venous return
Where in relation to the uterine artery does the ureter pass?
Posterior - ‘water under the bridge’
What is Bouveret’s syndrome?
Gastric outlet obstruction caused by gallstones
What is Meig’s syndrome?
Triad of benign ovarian tumour, ascites and pleural effusion that resolves after resection of tumour
What is Mackler’s triad?
Boerhaave’s syndrome
-Vomiting
-Pain
-SC emphysema
What is Whipple’s triad?
Insulinoma
-Hypoglycaemia during attacks
-Resolution of symptoms with correction of blood glucose
-Symptomatic at low blood sugars
What is Quicke’s triad?
Haemobilia
- Pain
- UGI Bleed
- Jaundice
What is Virchows triad
Risk of VTE
- Flow
- Vessel
- Coagulability
What is Beck’s triad?
Pericardial tamponade
- Raised JVP
- Muffled heart sounds
- Narrow pulse pressure
What is Cushings triad?
Raised ICP
-bradycardia
-hypertension/raised PP
-Irregular respirations
What is Riglers triad?
Gallstone ileus AXR
-SBO
-Gallstone
-Air in biliary tree
What is Dieulafoys triad?
Appendicitis
-hyperaesthesia
-tenderness
- guarding
over McBurney’s point
What is Borchardt’s triad?
Gastric volvulus
- sudden epigastric pain
- inability to vomit
- inability to pass NG tube
What is Bergmans triad?
Fat embolism
-Dyspnoea
-Petechiae of axilla or thorax
-Altered mental status
What is the MUST tool?
Assessment of malnutrition
BMI (if <18.5 = 2)+ Unplanned weight loss(0-5,5-10,10) + acute illness/no intake >5 days
Score of 2/more or at high risk
From which skin level is Breslow thickness measured?
top of stratum granulosum
What proportion of patients with asymptomatic hernias will present with increasing or pain or complications within 5 years?
25%
What is the minimum acceptable mesh pore size?
> 1mm
Which artery can be encountered and is at risk during Femoral hernia repair (medially)
Obturator artery
What is the eponymous name of a hernia and hydrocele combined?
Gibbon hernia
What is the eponymous name for a femoral hernia occurring anterior to the vessels?
Velpeau hernia
What is the eponymous name for a femoral hernia occurring behind the vessels?
Narath hernia
With normal renal function, how long before elective surgery should Rivaroxaban be stopped?
If low risk 24 hours
If high risk 48 hours
Restart 6-12 hours if low risk, if high risk then 48 hours
What type of thrombosis is APL associated with?
Both arterial and venous
In which setting should DOACs be avoided?
APL
In which Haematological condition are irradiated blood products required life long?
Hodgkins Lymphoma
At what threshold chance of identifying a mutation should BRCA screening be offered?
10% chance
What type of ovarian cancer is strongly associated with BRCA?
Serous ovarian cancer - 10-20% risk of BRCA
In which patients should VHL be screened for?
CNS haemangioblastomas
Which mutations are associated with Polymerase ‘proof reading’ polyposis syndrome (PPAP)
POLD1/POLE genes
Which infections can be associated with splenomegaly?
EBV
Malaria
Leishmainasis
Infective endocarditis
(Not listeria)
With what tumours are Bartonella infections associated?
Vascular tumours such as haemangiosarcomas
what type of bacteria is h.pylori?
Gram negative bacillus
In ABO incompatibility transfusion reactions in patients with blood type O what Ig is implicated?
IgG
In ABO incompatibility transfusion reactions in patients with blood type A/B what Ig is implicated?
IgM
What Ig crosses the placenta in RHD?
IgG
What are the antiseptic preps of choice?
0.5% chlorhex in 70%alcohol hydrex
2% chlorhex in 70%alcohol (chloraprep)
What is amifostine?
A chemotherapy adjunct which is used to:
-reduce nephrotoxicity of cisplatin
-reduce the proctitis with radiation
-reduce mucositis in head and neck cancers
What is MESNA?
A drug given to treat haemorrhagic cystic from cyclophosphamide
What is the characteristic side effect of Anthracyclines?
Cardiotoxicity
-Doxorubicin, epirubicin
What is the mechanism of action of gentamicin?
Inhibition of the 30s ribosome
How long before hernia repair should patients be advised to stop smoking?
4-6 weeks
What size mesh should be used for an umbilical hernia of size 1-4cm?
3cm overlap
What size overlap of mesh for laparoscopic ventral hernias?
5cm
How is T3 subdivided in rectal cancer?
T3a - <1mm from muscularis propria
T3b - 1-5mm from muscularis propria
T3c - >5mm from muscularis propria
Which familial condition is associated with papillary thyroid cancer?
FAP
What degree of tumour shrinkage is implied by a partial response?
At least 50%
Which type of renal tract stones are more likely to occur with short gut syndrome?
Calcium oxalate stones - increased colonic absorption of calcium oxalate
Where are ectopic pregnancies most likely to occur?
Ampulla of Fallopian tube
What is the most common USS finding in ectopic pregnancy?
Adnexal mass (50-60%)
Extrauterine gestational sac (35-50%)
20% can have intrauterine fluid collection - pseudosac
What is the recommended treatment course for PID?
1 x 500mg IM Ceftriaxone + 14days of Doxy 100mgBD + Metro 400mg BD
In premenopausal women which tumour markers are helpful for complex ovarian masses?
AFP, Beta-HCG, LDH
Which ovarian tumour subtype has the worst prognosis?
Clear cell carcinoma
Which ovarian tumour type is most frequently associated with torsion?
Teratoma
In whom do ovarian germ cell tumours tend to present?
Young patients <20 and AC/Asians
What is the difference between Lynch 1 and Lynch 2 syndromes?
Lynch 1 CRC only
Lynch 2 - others (inc ovarian, endometrial)
Within which ligament do the ovarian vessels run?
Suspensory ligament of ovary
May anastomose with uterine arteries in broad ligament
What is the most common cause of acute bacterial diarrhoea?
Campylobacter jejuni
Spiral/comma shaped Gram-ve rods
Usually affects TI >colon
Can mimic appendicitis
What is the most common organism in Shilgella infection?
Shigella soneii
Grame negative bacilli
Can give cipro if high risk
What are the different type of E.Coli infection?
Enteroinvasive - dysentery, large bowel necrosis/ulcers
Enterotoxigenic - SI, travellers diarrhoea
Enterohaermorrhagic - 0157, haemorrhage colitis, HUS and TTP
What are the different type of E.Coli infection?
Enteroinvasive - dysentery, large bowel necrosis/ulcers
Enterotoxigenic - SI, travellers diarrhoea
Enterohaermorrhagic - 0157, haemorrhage colitis, HUS and TTP
What intestinal parasitic infection can present with respiratory/wheezing symptoms?
Strongyloides stercoralis
What is the cause of pinworm?
Enterobiasis vermicularis
How is Giardiasis treated?
Metronidazole
What is the cause of hydatid cyst?
Echinococcus granulosus
Cestode with characterstic 3 segments
Rupture of mature cyst can cause reinfection or anaphylaxis
Two cyst walls - peri cyst (host) endocyst (organism)
Usually treat with mebendazole. Can use PAIR technique for multiple or deep seated if Type1/2
How can Hydatid cyst be classified?
Gharbi classification
Type 1 - Purely cystic
Type 2 - membrane partly detached
Type 3 - Multicystic lesion with septae
Type 4 - Degenerated with pseudo-solid appearances
Type 5 Calcified cyst
What is the most common type of hepatitis in children?
Hepatitis A
RNA Picornovirus
Usually resolves spontaneously
Hepatitis A IgM
How are Hepatitis C, D and E diagnosed?
Usually RNA PCR
What antibiotic prophylaxis is required for endoscopy?
Routine - none
CVS disease - none
Therapeutic procedures - ERCP, PEG, PEC, EUSFNA –> 1 x dose
What is the mechanism of penicillins/cephalosporins?
Inhibition of cell wall formation
What is the mechanism of action of quinolones and metronidazole?
Inhibit DNA synthesis
What is the mechanism of action of gentamicin and tetracyclines?
Inhibit protein synthesis by 30s subunit
What is the mechanism of action of linezolid and macrolides?
Inhibition of protein synthesis (50s subunit)
What cancers are associated with HPV 16/18?
Cervical cancer
Anal cancer
Penile cancer
Vulval cancer
Oropharyngeal cancer
What cancers are associated with EBV?
Burkitt’s lymphoma
Hodgkin’s lymphoma
Post transfusion lymphoma
Nasopharyngeal carcinoma
Gastric
What are the characteristics of antithrombin deficiency?
AD
Rare
Heparin ineffective
10 x risk
What is the most common genetic influence on DVT?
FVL (7% prevalence)
Activated protein C deficiency
What is the key plasma mediator of DIC?
Tissue factor - rich in lungs, brain and placenta, not normally exposed to blood
TF triggers extrinsic and then intrinsic clotting pathways
What is the abnormality in patients with hereditary spherocytosis?
Spectrin deficiency –> RBC deformation
Risk of gallstones. Splenectomy when haemolytic crises increase
What is the benefit of splenectomy in Beta Thalassaemia?
Can decrease transfusion requirement by 50%
What is the cure rate of splenectomy for ITP?
90%
How often is pneumococcal vaccine given post splenectomy?
5 yearly
In which inherited bleeding tendency is bleeding time increased?
von Willebrand’s disease (nb other platelet problems as well)
What factors does heparin administration affect?
2, 9, 10 and 11
What AntiA/B Ig is present in type O patients?
IgG (IgM for ABs)
What is the contents of cryoprecipitate (4)?
Factor 8
Factor 13
Fibrinogen
vWF
How is minor surgery managed in Haemophillia A?
Desmopressin immediately prior
Severe may require repeated infusions of product
Why are neat alcohols not used for skin sterilisation?
Not sporicidal
How does chlorhexidine work?
lysis of cell wall
What is the most common site of sarcoma?
Extremeties in 40%
What general margin is required for sarcoma excision?
2cm
how do sarcomas primary spread?
Haematogenous (often lung)
In which types of sarcoma is neoadjuvant treatment used?
Ewings and Rhabdomyosarcoma
How are type 4 hypersensitivity reactions primarily mediated?
T cells
What is the eponymous syndrome associated with adrenal haemorrhage?
Waterhouse-Friderichsen syndrome (fulminant meningoccemia)
In patients with significant cardiac instability which anaesthetic agents may be favoured?
Etomidate (nb adrenal suppression, ponv)
Ketamine
Propofol and thiopentone can produce more cardiac depression
How is Aortic stenosis graded?
Pressure gradient and aortic valve area
Mild <25mmHg and >1.5cm valve area
Moderate 25-40, 1.0-1.5
Severe >40 <1
What is the generic name for vicryl?
Polyglactin 910
Which botox is used clinically?
Botulinum toxin A
Inhibition of ACh release from NMJ
Which fingers tend to be affected most in Dupuytrens contracture?
Ring and little.
Middle may be affected in advanced cases. rarely index and thumb
What conditions are associated with Dupuytren’s contracture?
Idopathic
Liver cirrhosis
Alcoholism
TB (historically)
What is the risk of recurrent MI if surgery is conducted within 30 days of MI?
30%, 14% death
Decreases to:
18.7% at 2 months
8.4% at 3 months
5.9% at 6 months
What is the treatment of choice for TPN extravasation?
Hyaluronidase to periphery of extravasation site (within 60 minutes)
Promotes tissue permeability
How frequently does extravasation associated with chemotherapy occur?
6% of cases
Of which 30% result in ulceration
What is the treatment for chemotherapy extravasation?
Stop infusion, aspirate
Elevate limb
Warm compress with vinca alkaloids (vincristine)
Cold compresses with doxorubicin
Which nerve is at risk in a posterior approach to elbow?
Ulnar
Which nerve is at risk in an anterior approach to hip?
Femoral
Which nerve is at risk in a posterior approach to the hip?
Sciatic (and both inferior/superior gluteal nerves)
What is the failure rate for vasectomy?
1/2000
What is the reversal success rate after vasectomy?
55% if <10 years
Which antiretroviral is most classically associated with pancreatitis?
Didanosine
What is the most common cause of biliary disease in HIV?
(Secondary) Sclerosing cholangitis
from infections e.g. CMV, Crypto, Microsporidia
What class of agent is 5-FU?
Antimetabolite (also Methotrexate, 6-mercaptopurine)
-S-phase drug mimic of uracil incorporated into RNA
-Skin changes, neurotoxicity, neuropathy, marrow suppression
What class of agent is Doxorubicin?
Anthracycline (Adriamycin)
-inhibits DNA/RNA synthesis
-Risks - cardiac toxicity dose related, AML
What type of agent is Etoposide?
Topoisomerase 2 inhibitor
What type of agent is Cisplatin?
Alkylating agent (also cyclophosphamide)
Crosslinks DNA in G1 phase
Risks - myelosuppression, ototoxicity, nephrotoxicity
What type of agent is Vincristine?
Vinca alkaloid
M phase specific inhibition of microtubule formation
Main risk neurotoxicity
How does paclitaxel work?
Prevents microtubule breakdown in m phase
Main risk is neuropathy
What threshold HbA1c should be used to suggest referral for optimisation before elective surgery?
Above 8.5% or 69mmol/mol
(CPOC guidelines 2021)
How should metformin be managed in the preoperative period?
If taken 1-2 times per day – continue
If taken 3 times per day - omit lunchtime dose
If contrast used and eGFR<60, omit on day and for 48 hours
(CPOC guidelines 2021)
How should sulphonylureas be managed in the preoperative period?
Omit on morning of surgery
If AM operation and twice daily, can take PM
(CPOC guidelines 2021)
How should glitazones, DPP4 inhibitors (Gliptins) and GLP-1 receptor agonists (e.g. exenatide) be managed preoperatively?
Take as normal
Omit SGLT-2 inhibitors (e.g. dapagliflozin) on day of surgery
(CPOC guidelines 2021)
What glucose level defines hypoglycaemia?
<4mmol/l - ‘looming’ at 4-6
What treatment is required after drainage of uncomplicated paronychia?
No antibiotics
What are risk factors for paronychia?
Trauma
Artificial nails
manicures
Occupational
Oncychocryptosis
Onychophagia
What is the lymphatic drainage of the uterus?
Fundus runs with ovarian vessels mostly - so to para-aortic, however some may pass through round ligament to inguinal nodes
Lower body - broad ligament –> iliac nodes
What is the lymphatic drainage of the cervix?
3
-laterally through broad ligament –> EI nodes
- uterosacral fold –> presacral nodes
- posterolaterally –> iliac nodes
What is the diagnostic test for acute amoebic dysentery
Entamoeba histolytica stool ELISA
Which chemotherapeutic agent causes dose related lung damage?
Bleomycin
Which chemotherapeutic agent causes loss of deep tendon reflexes?
Vincristine
Also paralytic ileus, sensory motor neuropathy
Which chemotherapeutic agent causes conjunctivitis and cerebellar toxicity?
Cytosine arabinoside
Which chemotherapeutic agent causes dose related pancreatitis?
Asparginase
What are the myotomes associated with reflexes - Biceps, Triceps, Supinator, Knee and Ankle?
Biceps - C5/6
Triceps - C7/8
Supinator - C5/6
Knee - L3/4
Ankle - S1/2
Through which receptor does erythromycin exert its pro kinetic effects?
Motilin receptor
What are the types of Necrotising Fasciitis?
Type 1 - polymicrobial (dm, immuno)
Type 2 - usually strep
Type 3 marine
Type 4 fungal
How is sepsis defined in the SEPSIS 3 consensus?
Life-threatening organ dysfunction caused by a dysregulated host response to infection
What is the acceptable HbA1c threshold for elective surgery?
69mmol/l (8.5%)
What is a biological mesh?
Graft derived from human, bovine and porcine tissue, decellualrised to leave a collagen matrix
e.g. Permacol
What does of enoxaparin for VTE?
1mg/kg BD or 1.5mg/kg OD (low risk)
What is duty of candour?
Duty of candour is the GMC requirement for all healthcare professionals to be open and honest about any mistakes that have been made in the care of a patient.
You have to :
- Explain what happened to the patient
- Apologise on behalf of the trust
- Explain what the short term and long term consequences are
- Explain what you’re going to do to remedy the situation
At what NEWS scores should action be taken?
0 –> 12hourly
1-4 –> 4-6hourly obs and RN review
5-6 or 3+ in any parameter –> 1 hourly obs and Doctor review
7 + –> continuous monitoring, SR or Cons review
How is MRSA decolonisation undertaken?
3 days nasal mupirocin
5 days chlorhexidine body wash
What are the structures related to the pharyngeal pouches and arches?
Thyroid not related to any
Inferior parathyroid = 3
Superior parathyroid = 4
What findings are seen with a Horner’s syndrome?
Ptosis (small)
Miosis (constricted)
Anhidrosis
Ouclosympathetic paresis
What is Gilberts Syndrome?
AR
Mild elevation of uncojugated bilirubin
Precipitated by stress, surgery, dehydration, usually self-liiting
5-10% of Western European population
What surgical conditions are patients with Ehlers Danlos syndrome more at risk of presenting with?
Increased risk of:
Hernia
Rectal prolapse
GI Haemorrhage
Diverticulosis
What is Ehlers Danlos syndrome?
Spectrum of conditions associated with Collagen deficiencies
Various subtypes, classical (COL5a) vascular (COL3a), hyper-mobile (these are AD)
–Postoperative -
Risk of bleeding, poor wound healing, airway problems, avoid regional
– Type IV ED (Vascular Col3a1)
—retroperitoneal haemorrhage
— spontaneous GI perforation
What preoperative investigations should be performed before elective intermediate level surgery?
ASA 1-2 - Consider ECG, U&E, otherwise None
ASA3-4 - Consider FBC, Haemostasis, do U&E, ECG, ?lung function
What preoperative investigations should be performed before elective major level surgery?
ASA1-2 - FBC, U&E, ECG>65
ASA3-4 - FBC, U&E, ECG, ?Lung function ?Coag
What are the risk of Sistrunk procedure?
General
Scar (transverse)
Fistula
Recurrence (5%)
Hypoglossal nerve injury
What is the cumulative safe dose of ionising radiation?
Annual limit of <20mSv
For cancer 100-200mSv total?
What is the risk of malignancy with multiple CTs?
Probably Thyroid cancer, leukaemia and NHL
If study in childhood –> 9/100,000 person years Big Australian study
Some evidence that up to 100-200mSv does not increase risk in adulthood (10-20 scans), threshold model
3mSv annual background, CTAP = about 8-10mSv
Minimise use, low dose protocols, justification
What are risk factors for pyloric stenosis?
Male gender
First born
Bottle fed
Caesarian section
Can be an AD condition rarely
Can be inflammatory due to chronic ulceration in adults
When NAI is suspected how should you proceed?
Plausibility of injury, history of other injuries, bruises in multiple stages of healing, withdrawn child.
Consult hospital guidelines
Contact senior paediatrician and social worker
What is the differential diagnosis of vomiting in children?
Infants
– Medical - GORD, Reflux, Infection (GE, UTI, Meningitis), , inborn errors of metabolism
– Surgical - Pyloric stenosis, atresia, intussusception, malrotation, hernias, Hirschprungs
Preschool
–Medical - GE, Infection, Raised ICP, Coeliac disease, Renal failure
–Surgical - Appendicitis, intussusception, malrotation, volvulus
Adolescents
–Medical - GE, Infection (pyelonephritis), Migraines, Coeliac disease, Renal failure, Alcohol, DKA, pregnancy,
–Surgical - Appendicitis, torsion
What is the differential diagnosis of constipation in children?
In infants need to exclude neurologic/structural problems including anal/intestinal atresia and Hirschprungs, but often decreased fibre in diet.
Can present late occasionally, but usually fibre related when older. Can get into fissure cycle.
How is dehydration assessed in children?
What techniques can be used to help achieve visceral closure with loss of domain?
Progressive pneumoperitoneum over days (8-12 L)
Botulinum toxin A (3 sites on each side of lateral abdomen in EO,IO and TA 300u)
Occasionally colonic resection may be necessary
What complications are seen after incisional hernia repair?
About 5% overall
Lap - 1.5% risk of BO
Chronic surgical site infection 2% (0.1% Lap)
Mesh infection <1%
What are the rates of wound infection after lap chole, lap appendix, lap hernia, open hernia?
Lap Chole 2%
Lap Appendix 5%
Lap Hernia 2%
Open hernia 2-5%
What are risk factors for incisional hernia?
–Patient
Obesity, age, previous surgery, comorbidity, steroids, malnutrition, chronic cough, smoking, DM, obstructive jaundice
–Operative/Technical
AAA, emergency, wound infection, operative time, intra-operative contamination, re-laparotomy
What size of fluid in GB fossa is concerning soon post Lap Chole?
Early post op studies showed that up to 50-60ml is fairly common up to a week after surgery
How would you enter the abdomen in a patient who has a large intraperitoneal/incisional hernia mesh?
Veres insufflation/open cut down at Palmar’s point
What are the characteristics of intraperitoneal meshes?
In my practice I use Dynamesh IPOM which is polypropylene with a visceral side of PVDF like teflon material.
Intestinal obstruction may occur in 2-10% post operatively
Parietex composite may be better
What is sportsmen’s groin (Gilmore’s groin)
-Controversial
?entrapment of nerves due to imbalance between strong hip adductors and weaker lower abdominal muscles
- 60-80% success rate of surgery
What type of temporary abdominal closure should be used for the open abdomen?
Mesh mediated fascial traction with negative pressure therapy
e.g. Abthera with Prolene mesh on top
2% EAF rate
What are the components of enhanced recovery?
Preoperative - diet, exercise, stop smoking/alcohol, ?prehabilitation
Peri-operative - staying active, drinking fluids and preload carbo drinks up to 2 hours before operation, early mobilisation
Technical - minimally invasive approach, TIVA, minimising use of drains and tubes
NICE guidelines 2020 Perioperative care
How should patients be selected for day surgery?
British Association of Day surgery guidelines 2019
Social factors (presence of carer for 24hr)
Medical factors ( functional status not ASA, not BMI as such or OSA, not suitable if unstable)
Surgical factors (low risk of serious postoperative complications, controllable symptoms)
-Must be set up with good anaesthetist led/nurse-delivered assessment/prep
-Clinical lead developing process and guidelines
-Anaesthetists who can deliver appropriate anaesthetic
-Patient information and protocols
-Specialised unit
- Quality assurance
What are Never events?
Surgical - wrong site surgery, wrong implant, retained FB
Medical - misuse of strong K+, wrong med route, overdose of insulin, overdose of non-cancer methotrexate, miss election of high strength midzaolam
Mental health - collapsible shower and curtain rails
General - falls, entrapment in bed rails, ABO incompatible transfusion, misplaced NG tube, scalding, connection of air instead of oxygen
What should happen where patients lack capacity?
If a patient lacks MCA capacity and doesn’t have a power of attorney, decisions should be made in their best interests.
Should involve pt in decision if appropriate, obtain patients views and avoid discrimination. Also discuss with other carers, relatives, friends
Choose least restrictive option
IMCAS tend to act when decisions about accommodation or if DOLS
What types of gastroscopes?
Standard ≤10mm diameter and 2.8mm instrument channel
Large instrument channel 4mm
Dual channel
Paediatric 5mm scopes
High definition scopes
What guidelines exist for the use of sedation
What controls gastrointestinal motility?
Smooth muscle GI tract
Parasympathetic - excitatory via vagus and pelvic nerves
Sympathetic - inhibitory
Hormones - Ghrelin/Motilin (erythromycin)
Gastric emptying increased by Gastrin and motilin
Gastric emptying decreased by GIP, CCK, GLP-1, VIP, Somatostatin
What are the common causes of postoperative collapse?
–Hypoxia
PE, bronchopneumonia, aspiration
–Circulatory failure
Haemorrhage, MI, hypovolaemia
–Cerebral
epilepsy, stroke, drugs
What are the common aetiologies of retroperitoneal masses?
Secondary tumour
Lymphoma
Retroperitoneal fibrosis
Primary - sarcoma, lipoma/liposarcoma, leiomyoma/sarcoma
How Can a kidney be differentiated from a spleen clinically?
Spleen
– mobilises with respiration
– has a notch
–enlarges diagphramatically
–splenic rub
–Middeleton’s manoeuvre (left side lifted, face towards feet and wrap fingers over costal margin)
Kidney
–ballotable
–may be resonant due to overlying bowel
What does autosomal dominant mean?
Disorder carried on any of 22 autosomal chromosomes (not sex) and is present if either Maternal or Paternal gene affected
What are the common causes of Psoas abscess?
Primary or secondary
Secondary more common - Appendicitis, diverticulitis, Colon Ca, Crohns disease
Primary - DM, AIDS, RF, immunosuppression, IVDU
What is the value of an air leak test after anastomosis?
Systematic Review in Colorectal in 2016 by Wu
- ALR+ –> higher anastomotic leak rate, but repair may make no difference
Previous data suggested that can reduce the rate of leaks, but may be systems based effect
What are potential causes of postoperative confusion?
Immediate concern for sepsis, hypovolaemia or surgical complications
Otherwise postoperative delirium is multifactorial
- Preop (age, cognitive impairment, cormobidity, frailty)
- Intra-op (deep anaesthetic, increased surgical insult/duration, fluid/electrolyte disturbances)
- Post-op (inadequate pain control, sedation, benzos, drugs, sleep disturbance)
Where does a spigelian hernia arise?
In semilunar line, usually at arcuate line.
Through transversus aponeurosis behind IO/EO
What aspects of a Childs anatomy affect response to trauma?
Size and shape - greater force applied per unit body area, head larger, smaller stature
Skeleton - incompletely calcified, less likely to break but more internal injuries (# suggests v. high energy)
Surface area - higher BSA:Volume ratio
Psychological status, PTSD
What fluid resuscitation (crystalloid or blood) is given in trauma to children?
20ml/kg CSL (can repeat 1 - 2 times)
10ml/kg Blood
