General Surgery (Lauren 🌭) Flashcards
When you get a call from the ED that they need a surgical consult, what information are you going to get about the patient before you go see them?
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PMH
Vitals
Labs
Imaging
Notes from prior visits if available
Why is it important to know about someone’s previous knee replacement or dental procedures if you are consulted for a gallbladder surgery?
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Anesthesia tolerance
BLEEDING history
Prosthetic knee can affect where the grounding pad for the bovie is placed
If a patient says they only drink 2 beers a night and haven’t done meth in 2 years, what should you think about that?
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They are lying
What do we want to know about someone’s family history before taking them to the OR?
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Bleeding disorders
Clotting Disorders
History of malignant hyperthermia
Why do we need to ask about UTI symptoms before bringing someone into the OR?
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Surgeons don’t like to operate on people with UTIs because it messes up their postop infection stats
Why do we need to ask about someone’s acid reflux before taking them back to the OR?
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Anesthesia will need to know to look out for aspirations
Why do we need to test someone’s neck ROM before taking them to the OR?
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Can affect intubation if they cant move their neck
What is the “Natural history of a disease”
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The course of the disease if it were left untreated
Urgency (increases/decreases) risk
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Increases
Limits how much pre-op preparation you can do
Why does it matter if someone is a chronic alcoholic?
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They can have withdrawal symptoms if they need to be admitted to the hospital
Ideally, your patient should quit smoking ____ weeks prior to elective surgery
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8
Why do we care about someone’s musculoskeletal conditions before taking them to the OR?
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They could have decreased mobility and if you’re moving their arms/legs around during surgery you could really hurt them
Which medications should a patient continue to take before surgery?
Meds that have significant withdrawal symptoms that do NOT affect anesthesia
Should a patient keep taking all their cardiovascular meds before surgery?
Yes
EXCEPT for ACEs and ARBs 24 hrs before non-heart surgery***
Which really common medications NEED to be stopped 24 hours before a non-cardiac surgery?
ACEs and ARBs.
These will INCREASE mortality
Should you keep taking your statins before surgery?
YES**
Statins reduce peri-op mortality
When should a patient stop taking their antiplatelet meds before surgery?
7-10 days before
Should patients keep taking their herbal supplements and vitamins before surgery?
No, just discontinue them.
Some of them can increase bleeding risk
Do you we care about someone’s blood sugar before surgery?
Yes, tight glycemic control reduces mortality, infection and complications.
At Phoenix Indian Hospital, patient’s blood glucose must be less than _____ for elective surgery
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300
A patient should be NPO after __________ before surgery
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Midnight
Although now some places say clear liquids are ok up to 2 hours before
Procedures with a HIGH risk have a mortality of _____%
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Over 5
CABG, AAA repair, etc
Procedures with intermediate risk have mortality of _______
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1-5%
Procedures with Low risk have mortality of _____%
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Less than 1%
SURGERY=______
RISK
EVERY SURGERY.
Emergent nature _______risk for operative mortality in low-moderate risk patients
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Doubles
What is the ASA classification?
It indicates your degree of sickness prior to anesthesia.
Ties the OUTCOME to your health, not a predictor of operative risk
What is the range of ASA scores?
1-6
1= healthy, fit, nonsmoker
6= brain dead patient whose organs are being removed for transplant
What is the risk assessment tool used for someone with liver disease?
MELD score
What risk assessment tool is used to calculate someone’s risk for DVT?
CAPRINI
Tells you what to do for them in post-op
The most frequent cause of non surgical perioperative morbidity and mortality is _____
MI
💔
***
How do we assess the functional capacity of EVERY patient before surgery, so we know what other kinds of pre-op testing to do?
Exercise capacity
Ex:
1 MET= walking around house, using the toilet, feeding yourself
4 METs= climbing stairs, golf, heavy housework, run short distance
10 METs= strenuous sports like swimming, football, basketball, skiing ⛷
At age _____, perioperative mortality increases SIGNIFICANTLY
80
_______ is the best method of cardiac risk assessment
History
The most common SOURCE of perioperative morbidity and mortality are the _______
Lungs
what is the 3rd most common perioperative complication?
Pneumonia*******
He had this in RED
How can you prevent pneumonia intraoperatively?
Suction when extubating them
How can you avoid pneumonia post operatively?
Incentive spirometry. (Makes them inhale and prevents atelectasis)
When do you need to do PFTs before surgery?
To optimize asthma (?)
SOB with unknown cause
Lung resection surgery
Most cases of Obstructive Sleep Apnea are ___________
Undiagnosed
true or false:
Most patients who ARE diagnosed with sleep apnea are compliant with their CPAP
False
Why do we care if someone has sleep apnea?
Increases perioperative morbidity and mortality
What is the name of the scoring tool used to determine if someone has sleep apnea (even if they have never been diagnosed)
STOP BANG
Closer the surgery is to the _______, the higher the risk of pulmonary complications
Diaphragm
What is the best predictor of a patients bleeding risk?
Prior history of bleeding
Dental extractions, surgery, childbirth, family history
What did he find in that lady’s stomach that he is writing a paper about?
a BEZOAR
Big chunk of hair and clay. Lady was eating her hair, and then became iron deficient so she started eating clay too
The CAPRINI score stratifies a patient’s risk for VTE, and provides validated recommendations for:
Who should be discharged with continued prophylaxis
EVERY single surgical patient will have low ________
Albumin
**
Why is albumin low in every single surgical patient?
Albumin is a reverse acute phase reactant
Aka it goes DOWN in inflammation
Why would you do an intraoperative cholangiogram when you do a gallbladder removal?
It allows you to see if there’s a filling defect in the biliary tree aka if there’s a stone in the common bile duct that needs to come out
When you’re in the OR, don’t touch the _________
Mayo tray
In the OR, what is the name of the person who starts the foley, preps the skin, documents everything, etc
Circulating RN
In the OR, who is the person that hates you the most
Surgical tech/“scrub tech”
What is the FIRST thing you need to do when you walk into the OR?
Write your name and title on the whiteboard
When do you need to wear a mask into the OR room?
From the time equipment is opened to the closure of the incision
If you contaminate yourself, what should you do?
Call yourself out
Once you’re scrubbed in, is your back sterile?
No.
Must do weird roll around the other person if you want to switch places with them. (Back can not face the patient)
What happens during the “Surgical Timeout”
ALL OR team members pause!!
You do a checklist!
What things are on the checklist that is done during the surgical timeout?
- Correct patient
- Allergies
- Consent signed
- History and physical
- Procedure verification
- Site verification
- Required supplies
- Special equipment
- Antibiotics given
- Safety precautions
- Radiology exams, if applicable
What are the NEVER EVENTS that are serious, preventable, and a threat to public safety?
Wrong site surgery
Retention of foreign body after surgery
Surgery on the wrong patient
Wrong surgery performed
Intraopreative death on ASA 1 patient
When do you count all the sponges, tools, etc?
Before surgery
During surgery
After surgery
What gas is used to fill up the abdomen before a laparoscopic surgery
CO2
Whose job is it to insert the ports for a laparoscopic surgery?
Yours
What is the test of choice for gallstones?
Ultrasound
What is the diagnosis:
Thickened gallbladder wall
Pericholecystic fluid
Leukocytosis
RUQ tenderness
Fever
Acute cholecystitis
What is the diagnosis:
RUQ pain after a fatty meal
Gallstones on ultrasound
+/- Nausea/vomiting
Symptomatic cholelithiasis
How many episodes of Symptomatic cholelithiasis can a patient have before they are referred for surgery?
1
What procedure is recommended for all of these diagnoses:
Acute cholecystitis
Symptomatic cholelithiasis
Biliary pancreatitis
Gallbladder polyps
Cholecystectomy
What are the complications of cholecystectomy?
Bile leak
Retained CBD stone
Why would we do an open approach for simple procedures instead of a laparoscopic?
If they have adhesions, or a history of radiation therapy, etc
What are the complications of appendectomy?
Bleeding
Infection
Ileus
If you have acute appendicitis, can you just take antibiotyics and skip the surgery?
No it doesn’t work
What are the symptoms of diverticulitis?
LLQ pain
Fever
Rectal bleeding?
RLQ pain?
If complicated: abscess, fistula, obstruction, bleeding, perforation
What is the treatment for diverticulitis?
NPO
Antibiotics
Supportive care
Colonoscopy after acut epidosde to confirm diagnosis
Elective colectomy if repetitive episodes
If you know you have diverticulosis, should you avoid nuts and seeds?
NO
OLD WIVES TALE
NOT HELPFUL
What is the difference between neoadjuvant and adjuvant chemotherapy?
Neoadjuvant= before surgery
Adjuvant= after surgery
What are the 2 types of colon resections that can be done for colon cancer?
LAR (Lower Anterior Resection)
APR (AbdominoPelvic Resection)
APR or LAR:
Done to remove rectal cancers
Both
APR or LAR:
Used to remove cancers well above the anus⬆️
LAR
APR or LAR:
Used to remove cancers close to the anus
APR
APR or LAR:
Preserves the sphincter, colon is re-anastomosed
LAR
APR or LAR:
Sphincter is removed and a permananet colostomy is made
APR
APR or LAR:
Provides a better quality of life
LAR
LAuRen will improve the quality of your life :
When do prophylactic antibiotics need to be given before surgery?
Within 1 hour of incision time
Should you remove hair before doing surgery?
NO!
If it is removed, youre doing it with clippers in pre-op
(Although according to someone else who met with Ms. Sears, you ARE supposed to shave the hair with a razor)
(This person was Megan. I bet this will not be a question due to this discrepency -Shelby)
Also how many times can we add notes to this card as a group? 🧾
(I didn’t put Megan’s name in case she wanted to remain anonymous for some reason. Write back soon!
Your friend,
Lauren)
dear lauren, u r g8! hope you have a kickass summer! dont ever change. ILY -shelby
How should a patient prep their skin at home?
Shower with chlorhexidine soap the night before
Fluid (overload/depletion) is a big problem in post-op
Overload (iatrogenic because YOU gave them a shitload of fluids.)
If your surgical patient wakes up the next day with swollen legs and crackles in her lungs, what do you think is the problem
She is fluid overloaded because you gave too much fluid during surgery
How can a patient prevent hernias after surgery?
No heavy lifting
In what order do the parts of the GI tract come back to life after surgery?
24 hrs- small intestine
36 hrs- stomach
48 hrs- Right colon
72 hrs- left colon
“If the gut works, ________”
Use it.
Aka don’t do feeding tubes, enteral nutrtion, etc if they can eat normally
When you’re counseling your patient about pain, you need to tell them to have (unrealistic/realistic) goals
Realistic
Which day after surgery is usually the worst for pain
Day 3
What drugs are the mainstay of pain control after surgery
Opioids
What are your options for non-narcotic pain control after surgery?
Ketorolac (Toradol)
IV Tylenol
NSAIDs
Regional anesthesia (nerve blocks): TAP
Lidocaine patches (used a lot but are placebos)
Acupuncture/guided imagery (watching relaxing YouTube videos lol)
Cannabis
If the PACU nurse calls you and says your patient is having a lot of pain after surgery, you should:
A.) tell her to give him some more morphine and to stop bothering you on your lunch break’
B.) go see the patient because pain can be a sign of complication
B.
Pain can indicate:
Compartment syndrome (maybe due to all the FLUID you gave them)
Post-op bleed
Hematoma
DVT
MI
True or false:
Atelectasis causes post-op fever
TRUE
What can be done to prevent atelectasis after surgery?
Incentive spirometry
Do post op conditions satisfy Virchow’s triangle (and thus increase the risk for DVT)?
Yes
stasis, vessel injury, hypercoagulability
How do you treat postoperative ileus?
Early feeding
Ambulation
Avoid narcotics
(It will wake up with time)
What is this:
“An inherited hypermetabolism involving skeletal muscle after exposure to succinylcholine”
Malignant hyperthermia
Does malignant hyperthermia run in families?
Yes. Make sure you ask family hx
What is succinylcholine?
Anesthesia drug.
Can cause malignant hyperthermia
What’s the big deal if your patient gets malignant hyperthermia?
They get rhabdomyolysis, cerebral edema, DIC, and DEATH
What will be the first sign that something is going wrong when your patient develops malignant hyperthermia?
Increased CO2
What is the antidote for malignant hyperthermia?
Dantrolene
If you want to look at Stones, Bones, Gas, or Mass, you should use:
A) CT
B) X-ray
B) X ray
Becoming proficient at bedside ultrasound is an (MUST/option)
MUST
What is an ileostomy?
Connect ileum to abdominal wall
What is an End ileostomy?
Entire colon is removed and your GI tract ends at the hole in your stomach.
Permanent. (Obviously, since your entire COLON AND RECTUM WERE REMOVED)
What is a loop ileostomy?
A LOOP of your ileus is brought to the skin and they make a hole in your belly for your poop to come out of.
TEMPORARY
Which one is permanent:
A.) End Ileostomy
B.) Loop Ileostomy
A.) End ileostomy
What is a colostomy?
Connects colon to the abdominal wall.
Can be temporary OR permanent
What is Hartman’s Procedure?
- ) remove diseased rectosigmoid colon
- ) close the anorectal stump (tie off anus) lol
- ) End colostomy
What are the indications for Hartman’s procedure?
Ulcerative COlitis
REcto-sigmoid cancers
Sigmoid volvulus
Rectal injuries 🐹
most small bowel obstructions are managed:
A.) surgically
B.) Medically
B.) Medically.
NPO, fluids, NG tube, etc
What is the NON-OPERATIVE management for small bowel obstruction that is sufficient for like 82% of patients who have SBO
NG tube
NPO
IV Fluids/electrolyte replacement
Continuous reassessment
Ok he included Phoenix Indian Hospital’s SBO proticocol and he made some stuff red but he never talked about it in class. For completeness, I will list it here for you.
- Insert NG tube and place to low intermittent suction
- Keep head of bed to at least 30 degrees
- Flush NG tube q2h with 30mL of tap water. Flush blue sump port with 30 mL air q2h
- Foley catheter
- I/O’s
- 2 hrs after NG tube placement, give 90mL of UNDILUTED gastrograffin via NG tube. Clamp NG tube for 1 hr then return to low intermittent wall suction
- Obtain portable KUB 8hrs after gastrograffin administration
- KUB at 24 hrs after gastrograffin administration
- If contrast has reached the colon, start clear liquid diet
- Constant reassessment
- Dont say i never did anything nice for you
On your surgery rotation:
Dont examine the patient like a ________. Examine the patient like a ________.
Surgeon
Student
What kinds of things make diverticulitis “Complicated”
Abscess
Phlegmon
Fistula
Obstruction
Bleeding
Perforation
