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Principles2 > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Pancreas:

  1. secretes how many liters per day of fluid into the duodenum?
  2. this aqueous solution is hi in what ot neutralize the acidic solution from the stomach?
  3. what other 3 ions does this solution contain?
  4. the arrival of what from the stomach stimulates the pancreas to produce the aqueous solution? (C)
  5. arrival of what stimulates enzyme production? (F)
A
  1. 1 L
  2. HCO3
  3. Na, K, Cl
  4. chyme (acidic solution)
  5. food
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2
Q

what are the 3 endocrine hormones the pancreas secretes? (IGS)

A

insulin, glucagon, somatostatin

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3
Q

do pancreatic enzymes require an acidic or basic solution to function?

A

basic

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4
Q

what 2 pancreatic enzymes are active enzymes? (A, L)

A

amylase, lipases

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5
Q

what pancreatic enzyme is secreted in an inactive form? (P)

A

proteases

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6
Q

what cells in the pancreas are responsible for releasing the enzymatic component? (AC)

A

acinar cells

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7
Q

what cells in the pancreas are responsible for the release aqueous component? (DC)

A

ductal cells

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8
Q

what is the most important enzymatic component that acinar cells produce? (C)

A

cholecystokinin (CCK)

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9
Q

what is the most important enzymatic component the ductal cells secrete? (S)

A

secretin

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10
Q

what compound potentiates the release of CCK? (A)

A

Ach

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11
Q

what 2 compounds potentiates the release of secretin? (C,A)

A

CCK, Ach

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12
Q

atropine and glyco cause a decreased response to what component? (S)

A

secretin

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13
Q

fasting results in a decreased secretion of what 2 enzymes? (A, L)

A

lipase, amylase

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14
Q

protein malnutrition results in a decreased amount of what secretion? (P)

A

peptidase

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15
Q

ETOH and gallstones account for what % range of all acute pancreatitis cases?

A

60-80%

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16
Q

can an acute pancreatitis be restored to normal function if the primary cause is resolved?

A

yes

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17
Q

what 2 position moves help pts decrease pain with acute pancreatitis? (S, LF)

A

sitting, leaning forward

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18
Q

what lab increase is the hallmark of acute pancreatitis? (SA)

A

serum amylase

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19
Q

what diagnostic procedure is the most useful in the setting of traumatic causes or gallstone?

A

ERCP

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20
Q

other than an ERCP, what is another diagnostic procedure to identify an acute pancreatitis?

A

CT with contrast

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21
Q

what % mortality with these ranges of Ranson Criteria:

  1. 1-2
  2. 3-4
  3. 5-6
  4. 7-8
A
  1. 5%
  2. 20%
  3. 40%
  4. 100%
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22
Q

Ranson Criteria for acute pancreatitis mortality:

  1. metabolic acidosis with base deficit >?
  2. fluid deficit >?
  3. corrected Ca
  4. drop in HCT >?
  5. BUN >?
  6. age >?
  7. PO2
  8. AST >?
  9. lactate dehydrogenase
  10. WBC >?
A
  1. 4
  2. 6
  3. 8
  4. 10
  5. 16
  6. 55
  7. 60
  8. 250
  9. 350
  10. 16,000
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23
Q

why does fluid leave IV space in acute pancreatitis?

A

lack of IV protein

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24
Q

what is the #1 C/V concern with acute pancreatitis? (IVVD)

A

IV volume depletion

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25
Q

acute pancreatitis can receive up to how many liters of crystalloids?

A

10 L

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26
Q

are attempts to decrease pancreatic production with an NGT or H2 blockers beneficial?

A

no

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27
Q

what is the abx of choice for surgical debridement of an acute pancreatitis? (C)

A

cefoxitin

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28
Q

what are 2 common complications with surgical debridement of an acute pancreatitis? (FF, DGE)

A

fistula formation, delayed gastric emptying

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29
Q

Pancreatic tumor:

  1. most often begins in the cells lining the what? (D)
  2. what 3 risk factors combine increases your risk more than any other factor alone? (S, PD, LSD)
A
  1. duct

2. smoking, poor diet, longstanding diabetes

30
Q

EBL mL range in these surgeries:

  1. distal pancreatectomy
  2. acute pancreatitis surgical debridement
  3. Whipple
A
  1. 300-500
  2. 300-750
  3. 500-750
31
Q

distal pancreatectomy:

  1. performed when tumor is at proximal or distal half of the pancreas?
  2. what are 3 common postop complications? (DM, I, PF)
A
  1. distal

2. DM, infection, pancreatic fistula

32
Q

whipple:

  1. performed when the tumor is located at what part of the pancreas? (H)
  2. what are 3 complications postop? (DGE, PF, S)
A
  1. head

2. delayed gastric emptying, pancreatic fistula, sepsis

33
Q

pancreatic tumor surgeries:

1. what are 3 parts of the anesthetic management? (GETA +/- TE, LDK, G)

A
  1. GETA +/- thoracic epidural, low dose ketamine, gabapentin
34
Q

pancreatic tumor surgeries:

  1. what is low dose ketamine mg/kg bolus on incision?
  2. what is infusion range during the procedure (mcg/kg/min)
  3. low dose ketamine decreased opioid requirement by weight % range?
  4. low dose ketamine also decrease what 2 things postop? (H, CPD)
  5. what is the mg range of gabapentin preop?
  6. is low dose ketamine often used in a setting with or without an epidural?
A
  1. 0.5 mg/kg
  2. 5-10 mcg/kg/min
  3. 30-50%
  4. hyperalgesia, chronic pain development
  5. 600-1200 mg
  6. without
35
Q

General surgery ERAS protocol:

  1. how many grams of mg into a bag of crystalloid?
  2. how many mg of dexamethasone?
  3. bolus bupivacaine 0.25% in what range of mLs up to how many mLs over how many minutes?
  4. then bolus how many mLs of bupivacaine 0.25% throughout the case via epidural?
  5. what is intraop plasmalyte range? (mL/kg/hr)
  6. what is phenylephrine gtt range? (mcg/min)
  7. what 3 meds with dose do you give at incision end? (Z, T, A)
  8. other management of epidural would be to start gtt at what fraction bupivacaine strength and use it continuously throughout the case?
A
  1. 2 grams of mg
  2. 8 mg
  3. 2-3 mL up to 10 mL over 20 minutes
  4. 2 mL
  5. 3-5 mL/kg/hr
  6. 10-50 mcg/min
  7. 4 mg zofran, 30 mg toradol, 1,000 mg of acetaminophen
  8. 1/2 strength (0.125%)
36
Q

Gallbladder:

  1. holds what range of mLs?
  2. what range of bile production is produced per day? (mL)
A
  1. 30-50 mL

2. 500-1500 mL

37
Q

Acute cholecystitis:

  1. what % result from cholethiasis?
  2. what are the 4 ways to diagnosis this? (AUS, HIDA, CT, MRI)
  3. what is the most specific way to diagnosis this?
  4. jaundice presentation is consistent with a stone where? (CBD)
A
  1. 95%
  2. abd ultrasound, hepatobiliary iminodiacetic acid, CT, MRI
  3. hepatobiliary iminodiacetic acid
  4. common bile duct
38
Q

Laparoscopic cholecystectomy:

  1. are the majority of them performed laparoscopically?
  2. EBL in one word? (M)
  3. pts with prior surgery where are at an increased risk for conversion to open procedure? (A)
  4. increased PIP from pneumoperitoneum is often offset by what 2 things? (P, MR)
  5. avoid what gas?
  6. place what to decompress the stomach?
  7. pain can be felt where from CO2 irritation on the diaphragm?
  8. what med can be given to help with this pain? (K)
  9. initially after insufflation, what 2 things increase even though what 2 things decrease?
  10. OG/NG placement can decrease the risk of what during initial trocar placement? (OD)
A
  1. yes
  2. minimal
  3. abdominal surgery
  4. positioning, muscle relaxant
  5. N2O
  6. OG/NG
  7. shoulder
  8. ketorolac
  9. SVR, BP; venous return and CO
  10. organ damage
39
Q

open cholecystectomy:

  1. larger risk of what type of complications from splinting/pain?
  2. what % of laparoscopic approaches are converted to open?
  3. are pts with an open technique at an increased risk of respiratory complications compared to laparoscopic technique?
A
  1. respiratory complications
  2. 5%
  3. yes
40
Q

anesthesia and esophageal disease:

  1. ensure pts take what meds? (HM)
  2. even if asymptomatic, what induction should be standard of care?
A
  1. home meds

2. RSI

41
Q

esophageal disease:

  1. what are the first 2 approaches of this disease before surgery? (ED, BI)
  2. chronic ETOH is associated with impaired what and hypotonia where? (EP, LES)
  3. mallory weiss tear typically occurs where as a result from persistent retching?
A
  1. esophageal dilation, botox injections
  2. esophageal peristalsis, lower esophageal sphincter
  3. gastroesophageal junction
42
Q

what moves into the chest for these hiatal hernias?

  1. type 1
  2. type 2
  3. type 3
  4. type 4
A
  1. GE junction
  2. just stomach
  3. GE junction and stomach
  4. other organs and stomach
43
Q

hiatal hernia:

  1. what % is type 1?
  2. what is the major symptom? (HB)
  3. typically managed what way? (M)
  4. what is indicated if pt has continued symptoms despite prophylaxis and especially if esophagus is inflamed or narrowed? (S)
A
  1. 95%
  2. heartburn
  3. medically
  4. surgery
44
Q

Nissen fundoplication:

  1. wrapping the fundus around what cm range segment fo the lower esophagus?
  2. EBL mL range for open?
  3. EBL mL for laparoscopic?
  4. 3 postop complications? (RH, GBS, TD)
  5. what is gas bloat syndrome?
A
  1. 3-4 cm
  2. 100-150 mL
  3. 50 mL
  4. recurrent hernia, gas-bloat syndrome, temporary dysphagia
  5. inability to release gas via belching
45
Q

esophageal diverticulum:

  1. what is the most common location? (PE/ZD)
  2. significant attention is paid to what for these pts? (A)
  3. extreme caution inserting what 3 things? (NG, OG, P)
A
  1. pharyngoesophageal/ Zenker’s diverticula
  2. aspiration
  3. NG, OG, probe
46
Q

esophageal cancer:

  1. pts typically present with a longstanding history of what resulting in what?
  2. what scan should be assessed preop to look for lymphadenopathy and tumors in the upper esophagus?
  3. radiation can cause tissue what? (F)
  4. bleomycin is associated with what? (PF)
  5. adriamycin is associated with what? (C)
A
  1. smoking, COPD
  2. chest CT
  3. friability
  4. pulmonary fibrosis
  5. cardiomyopathy
47
Q

esophagectomy:

  1. alway use what induction for pts getting this surgery?
  2. common when malignancy is where in the esophagus?
  3. end result of the surgery is what replacing the esophagus?
  4. what type of ETT is required for a thoracotomy approach?
  5. EBL mL range?
  6. what range of PRBC units should be on hold?
  7. what are the 3 types of lines? (LBIV, AL, +/-CL)
A
  1. RSI
  2. middle and lower third of the esophagus
  3. stomach
  4. double lumen tube
  5. 300-800 mLs
  6. 2-4 units
  7. large bore IV, art line, central line
48
Q

peptic ulcer disease:

  1. what are the 2 most common causes? (CNSAIDU, HPI)
  2. what 2 surgeries to treat? (V,A)
  3. what are the 3 complications of this? (B, P, O)
A
  1. chronic NSAID use, H. Pylori infection
  2. vagotomy, antrectomy
  3. bleeding, perforation, obstruction
49
Q

what % range of gastric cancers are adenocarcinoma?

50
Q

gastrectomy:

  1. EBL mL range for partial?
  2. EBL mL greater than what for total?
  3. what are 3 common complications? (DVT/PE, R, AL)
  4. post op pain is significant, so consider what when appropriate (R)
  5. DVT and PE are high therefore prophylaxis with SubQ what is recommended?
  6. tumors in the cardia of the stomach or GE junction are treated as what type of tumor?
A
  1. 100-500 mL
  2. > 500 mL
  3. DVT/PE, reoperation, anastomotic leak
  4. regional
  5. heparin
  6. esophageal tumor
51
Q

what is the difference between these 2 surgeries?

  1. Billroth 1
  2. Billroth 2
A
  1. partial gastrectomy, stomach is attached to duodenum

2. duodenum is closed off, stomach is attached to jejunum

52
Q

Gastrectomy:

  1. are these pts hyper or hypovolemic?
  2. fluid loss can cause abnormalities in what? (E)
  3. what type of induction?
  4. what is a good idea to achieve to prevent hemodynamic imbalances? (E)
A
  1. hypovolemic
  2. electrolytes
    3 RSI
  3. euvolemia
53
Q

post gastrectomy syndrome:

  1. occurs in what % range of pts after gastric surgery?
  2. if the pylorus is removed during surgery, the stomach is unable to retain food long enough for what to occur, so food travels to where too rapidly? (D, SI)
  3. what are 6 symptoms of this syndrome? (LMI, BGD, AC, D, L, IHR)
  4. “early” dumping syndrome occurs how many hours after eating?
  5. “late” dumping syndrome occurs what hour range after eating?
  6. what are 2 postop complications? (A, O)
  7. anemia occurs because of what 2 deficiencies?
A
  1. 25-50%
  2. digestion, small intestine
  3. large meal intolerance, blood glucose drop, abd cramping, diarrhea, lightheadedness, increase HR
  4. half hour
  5. 2-4 hours
  6. anemia, osteoporosis
  7. B12, iron
54
Q

post gastrectomy syndrome medical treatment:

  1. what type of diet? (HP, LC)
  2. what range of small meals a day?
  3. monthly injections of what?
  4. what 2 supplements? (I, C)
A
  1. high protein, low carb
  2. 5-6 meals
  3. B12
  4. iron, calcium
55
Q

Bariatric surgery:

  1. surgery can result in loss of what fraction range of excess body weight?
  2. what 4 pts are candidates for this surgery?
  3. consider TAP block with what LA?
  4. what 2 infusions for this surgery?
  5. do these pts get toradol?
  6. do these pts get a ketamine bolus at incision?
A
  1. 2/3 to 3/4
  2. BMI > 40, > 100 lbs over weight, BMI >35 with a comorbidity, inability to achieve healthy weight
  3. ropivacaine 0.5%
  4. propofol, remi
  5. no
  6. yes
56
Q

Obese pts:

  1. increased or decreased O2 consumption?
  2. increase or decreased CO2 production?
  3. increased or decreased FRC?
  4. increased or decreased WOB?
  5. increased or decreased CO?
  6. increased RBF and GFR may result in and increased or deceased drug clearance?
  7. obesity hypoventilation syndrome rely on what to drive ventilation?
A
  1. increased
  2. increased
  3. decreased
  4. increased
  5. increased
  6. increased
  7. oxygen
57
Q

gastrostomy is typically approached endoscopically with what technique? (P)

58
Q

SB lengths:

  1. typical length (meters, range)
  2. duodenum (cm)
  3. jejunum (meters)
  4. ileum (meters)
A
  1. 3-5 meters
  2. 25 cm
  3. 2.5 meters
  4. 3 meters
59
Q

Colon:

  1. is it essential for survival?
  2. what % of gut transit time?
  3. stores and controls what matter? (F)
  4. absorbs what 3 things? (W, E, RN)
A
  1. no
  2. 90%
  3. fecal
  4. water, electrolytes, residual nutrients
60
Q

Bowel surgery:

  1. significant bowel distention or ascites can result in decreased what lung measurement and increased what lung measurement?
  2. SB resection EBL mL range?
  3. Colon resection EBL mL range?
  4. what are 2 special considerations? (NGTP, SDS)
  5. what are 4 common complications after SB resection? (A, I, I, IL)
  6. what is the common complication after colon resection? (TITV)
A
  1. decreased FRC, increased V/Q mismatch
  2. 50-100 mL
  3. 300-1000 mL
  4. NG tube placement, stress dose steroids
  5. atelectasis, ileus, infection, intestinal leak
  6. transient inability to void
61
Q

ERAS Bowel surgery:

  1. what epidural spinal range?
  2. minimize fentanyl to what range mcg/kg?
  3. after initial bolus, epidural can be infused with what LA with what opioid amount? (%, mcg/mL)
  4. what epidural spinal range for lower rectal component?
A
  1. T10-L1
  2. 2-3 mcg/kg
  3. bupivacaine 0.1% with 5 mcg/mL
  4. T12-L2
62
Q

Inguinal hernia repair:

  1. standard induction and maintenance unless hernia is what? (I)
  2. goal of wake up is to prevent what 2 things against the fresh repair? (C, S)
A
  1. incarceration

2. coughing, straining

63
Q

Liver resection:

  1. EBL mL range
  2. what are 3 postop complications? (I, LF, BL)
  3. is pain score low, medium or high?
  4. giving what within 24 hours can help with coagulation abnormalities?
  5. what product is more useful for rapid coagulation correction preoperatively?
  6. consider what agent for induction if pt is hemodynamically unstable?
  7. consider what type of induction if there is significant ascites or trauma?
  8. if total vascular occlusion, increase CVP to what number and have what 2 meds ready?
  9. does the size of resection guide your fluid therapy and line planning?
A
  1. 50-800 mLs
  2. infection, liver failure, bile leak
  3. high
  4. vitamin K
  5. FFP
  6. ketamine
  7. RSI
  8. 12; phenylephrine and epinephrine
  9. yes
64
Q

splenectomy:

  1. what should pts receive one week prior to surgery? (V)
  2. what is a common initial complication postop? (ID)
  3. consider RBC transfusion when Hgb is in what range? (g/dL)
  4. plts should be given when what is low and with accompanied what?
  5. transfusions should be considered between what Hgb range if pt is symptomatic anemia, cardiac disease or with continued bleeding?
A
  1. vaccinations
  2. immune dysfunction
  3. 6-8 g/dL
  4. low plts with accompanied bleeding
  5. 8-10 g/dL
65
Q

Carcinoid tumor:

  1. most common in what 3 places? (B, J-I, C/R)
  2. can it occur in almost any GI tissue?
  3. this tumor releases a wide array of what? (BAS)
  4. carcinoid triad has what 2 symptoms and involves what system?
  5. left sided pulmonary lesion results in shunt in what direction?
  6. pulmonic stenosis results in open regurgitation of what valve?
  7. what hormone causes diarrhea? (S)
  8. what 2 hormones are responsible for wheezes? (S, H)
A
  1. bronchus, jejuno-ileum, colon/rectum
  2. yes
  3. biologically active substances
  4. flushing, diarrhea, C/V involvement
  5. right to left
    6 tricuspid
  6. serotonin
  7. serotonin, histamine
66
Q

Carcinoid tumor anesthesia:

  1. increased levels of what hormone is associated with delayed awakening?
  2. administration of what med preoperatively attenuates most adverse hemodynamics?
  3. what med is a useful choice for an antiemetic because it is a serotonin antagonist?
  4. is invasive BP monitoring recommended?
  5. is surgical management the only definitive cure for non-metastatic carcinoid tumors?
  6. what 8 meds can provoke mediator release? (SENDMIKE)
  7. what are other 3 meds that can provoke mediator release? (M,A,D)
A
  1. serotonin
  2. octreotide
  3. ondansetron
  4. yes
  5. yes
  6. succs, epi, NE, dopamine, morphine, isoproterenol, ketamine, ephedrine
  7. mivacurium, atracurium, d-tubocurarine
67
Q

Breast cancer:

  1. what are the 2 most important determinants of outcomes? (ALNI, TS)
  2. should you place IV in arm with less significant disease?
  3. should you avoid BP cuff on affected side?
  4. are these pts at a high risk of PONV even if no previous PONV?
  5. what patch is indicated?
A
  1. axillary lymph node invasion, tumor size
  2. yes
  3. yes
  4. yes
  5. scopolamine
68
Q

what anesthesia for these breast surgeries? (MAC, MAC with local, general with LMA, general with ETT):

  1. excisional breast biopsy/lumpectomy (1 option)
  2. sentinel node biopsy (2 options)
  3. axillary dissection (1 option)
A
  1. MAC with local
  2. MAC or general with LMA
  3. general with ETT
69
Q

Axillary dissection:

  1. do you use muscle relaxants?
  2. what is injected into nipple region and allowed to spread for lymph node mapping?
A
  1. no

2. methylene blue

70
Q

Breast surgery ERAS:

  1. avoid what drug for free flaps?
  2. what is fentanyl range? (mcg/kg)
A
  1. phenylephrine

2. 1-3 mc/kg

71
Q

what should range of epidural be for general surgery?

Principles2 (21 decks)

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