General surgery

Question 1

What is a ‘clean’ surgery? Give an example.

Answer 1

Does not enter a colonised viscus or lumen. Infection only from environment or surgeons.
e.g. thyroid removal 2% risk SSI

Question 2

What is a ‘potentially-contaminated’ surgery? Give an example.

Answer 2

Procedure enters into a viscus or cavity but under elective circumstances. 10% risk SSI
e.g. elective lap chole

Question 3

What is a ‘contaminated’ surgery? Give an example.

Answer 3

Contaminated area within viscus but without infection e.g. diverticulitis, rectal surgery
risk 20%

Question 4

What is a ‘dirty’ surgery? Give an example.

Answer 4

Active infection already present e.g. intra-abdo abscess and perforation, peritonitis

Question 5

Complications of stoma (early and late)

Answer 5

Early: Infarction, infection, high output causing dehydration
Late: parastomal hernia, stoma prolapse, stoma retraction, stenosis

Question 6

Indications for a chest drain

Answer 6

Pneumothorax, pleural effusion, post op (thoracotomy)

Question 7

Name two contraindications to urethral catheters

Answer 7

Urethral injury (pelvic fracture) or acute prostatitis

Question 8

When would you consider a suprapubic catheter

Answer 8

Pelvic trauma and suspected urethral injury

Question 9

Name some complications of catheterisation

Answer 9

Retrograde infection, paraphimosis, creation of false passage, urethral strictures, bleeding

Question 10

Describe the difference between active drain, passive drains, open drains, closed drain

Answer 10

Superficial = placed in skin wound
Active drains = suction from a vacuumed container (draws out collections)
Passive drains = uses gravity (risk of reverse of pressures and infection)

Open drains = always passive, leading into a dressing or stoma. Can be tubes or sheets
Closed drains = tubes into a container with or without suction (active or passive)

Question 11

Indications for central venous catheters

Answer 11

• Critically ill patients needing continuous CVP monitoring of fluid status
• Infusion of irritant substances
• Long term access: parenteral nutrition, chemo, antibiotics
• Haemdialysis

Question 12

Difference between a tidy wound and an untidy wound

Answer 12

Tidy: can be closed if <12h old e.g. lacerations
Untidy: marginal necrosis, crush injuries, tearing injuries. Need wound excision with removal of debris and dead tissue

Question 13

Describe primary and secondary healing

Answer 13

1y = Close apposition of wound edges. Healing without tissue loss. Fibrosis and epithelialisation leaves a smooth scar
2= Phagocytosis removes debris, granulation tissue forms to fill defect. Slower. Leaves a broader, hypertrophied and contracted scar. Need daily wound care.

Question 14

What triggers RAAS

Answer 14

• Unloading of high pressure on baroceptors in arterial system (left atrium, carotid body, aortic arch)
• Decreased flow to the juxta glomerular apparatus

Question 15

Name factors that can contribute to an infection following a surgical procedure

Answer 15

Patient factors: age, malnutrition, immunosuppression, malignancy, obesity, hypoxia, anaemia
Local factors: type of surgery, length of procedure, foreign body insertion, ischaemia
Microbiological factors: lack of antibiotic prophylaxis, virulence of organism

Question 16

Name some common causes of post-op fever

Answer 16

Pneumonia, PE, UTI, deep or superficial wound infection, abscess, DVT, drug reaction, infected line
Normal response to surgery

Wind, Wound, Walking, Wonder drugs, Water

Question 17

Symptoms of an intra-abdo abscess

Answer 17

Swinging fever, malaise, anorexia, tachycardia, +/- mass

Question 18

Treatment of an intra-abdo abscess

Answer 18

• CT to diagnose
• IV empirical Abx + CT/USS guided drainage if possible.
• Surgical drainage last line

Question 19

Parameters for SIRS

Answer 19

Need +2 of:
-Temp >38.3 or under 36
-RR >20
-HR >90
-WCC <4 or >12
(or glucose of >7.7 non diabetic)

Question 20

Difference between SIRS, sepsis, severe sepsis and septic shock

Answer 20

SIRS = presence of (temp, RR, HR, WCC) paramaters
Sepsis = SIRS and suspected site of infection
Severe sepsis = Sepsis + hypotension or end organ dysfunc (oliguria, confusion, lactate >2, O2 <94%)
Septic shock = severe sepsis with hypotension not responding to fluid resuscitation

Question 21

Classification of haemorrhagic shock + basic management of each

Answer 21

Class 1 750ml <15%
Class 2 <1500ml <30%
Class 3 <2000ml <40%
Class 4 >2000ml >40%

Give fluids class 1
Consider giving blood at class 2
Consider surgery at class 3
Needs surgery at class 4

Question 22

What is Gas gangrene

Answer 22

• Life threatening infection by Clostridium (most often perfringens).
• Usually following trauma or surgery, spontaneous infection is rare.
• Muscle necrosis, sepsis, gas production
• Associated with soil contact
• Also known an anaerobic gangrene

Question 23

What is the treatment of Gas gangrene

Answer 23

• Antibiotic combination
• Surgery - wound debridement
• Systemic support (O2, fluids, pain relief)