High-Yield Surgery Flashcards by Ben Aleckson

What to monitor with Toradol? Tylenol?

NSAID

SCr, Hgb
15mg IV q 6hr

Tylenol - LFTs

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Surgery progress note

24hr interval: fever, chills, SOB, CP, eating, NGT output, BMs, foley

Plan:

pain mgmt
I&Os
DVT ppx
pulm toilet
labs
functional status
PO status
diet

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Post Op Infection

PNA, UTI, wound infection (cellulitis, central line infection)

5-7d out –> abscess

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Causes of fever

Wind: atelectasis, PNA (POD 1-2)
Water: UTI, esp w/foley (POD 2-3)
Wound: incision site, cellulitis, abscess (after 72hr, POD 5-7)
Walking: DVT, PE, thrombophlebitis (after 72hr)
Wonder drug: drug reaction
Whole blood: transfusion reaction

Work up:

<48hr postop does not need workup
> 48hr postop: CXR, blood culture x2, urine culture
fever >1wk is a serious complication unless drug allergy

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Fluids

Resuscitative fluid (postop) = lactated ringer
Maintenance: D5 1/2NS + KCl
IV Fluids + TPN + Lipids = 100cc/hr

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Electrolyte goals for surgery

K+5

tablet KCl is C.I. w/SBO
if dumping, liquid >tablet

Phos 3
Mg 2
- if 1.5 give 2mg Mg sulfate; 1.2 give 4mg Mg sulfate

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Preop abx

Flagyl + Neomycin

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Pancreatitis Etiologies

I GET SMASHED

Idiopathic
Gallstones
EtOH
Trauma/Trigs
Steroids
Mumps
Autoimmune
Scorpion bite
Hyperlipidemia/HyperCa
ERCP
Drugs

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Voiding trial

Give 8hr to void after removing foley

Bladder scan if no void; if >600 = straight cath

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Diagnostic imaging first lines

Appendicitis: abd CT (US in kids, pregnancy) 
Chronic pancreatitis: ERCP
Gallbladder: US
Diverticulosis: barium enema
Diverticulitis: CT scan
Achalasia: barium swallow
Zenker's diverticulum: barium swallow
UGIB: endoscopy
PE: pulmonary angiogram

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Courvisier’s sign

palpable, nontender gallbladder

indicates compression or obstruction of distal CBD d/t mass = pancreatic cancer

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Trosseau’s sign

hypercoagulable state created by malignancy

migratory thrombophlebitis throughout body

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Whipple procedure

Pancreatic cancer

Pancreatoduodenectomy

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Most common kinds of cancer

Colon: Adenocarcinoma
Gallbladder: Adenocarcinoma
Pancreas: Adenocarcinoma (ductal) - CA 19-9
Prostate: Adenocarcinoma (MC cancer in men U.S.)
Liver HCC (AFP levels)
Renal: renal cell carcinoma
Small bowel: carcinoid tumors (ileum)
Esophageal: SCC
Anal: SCC
Vulvar: SCC (risk - lichen sclerosis)
Bladder cancer: transitional cell carcinoma (smoking)
Breast: IDC
Carcinoid tumors tend to be in appendix
Thyroid: papillary carcinoma (radiation = risk)

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Coagulation cascade

common pathway: II, V, X

PT: coumadin
- extrinsic, common pathways (VII)

PTT: heparin
- intrinsic pathway (VIII, IX, XI, XII)

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Bowel obstruction

1 = adhesions (western nations)

Worldwide - hernias

Other: malignancy

Ogilvie’s syndrome

Idiopathic pseudo-obstruction
Enormous dilation of right colon w/out obstruction

Mgmt:

bowel rest
IVF
rectal decompression tube via scope

MC Vascular procedure

CEA

Renal cell carcinoma triad

MC solid renal tumor

Flank pain
Hematuria
Palpable mass

Sutures

Vicryl: absorbable
Nylon: non-absorbable

Malignant hyperthermia

IV dantrolene

Gastric ulcers should…

undergo bx for risk of carcinoma

Ileus causes

laparotomy
hypoK
narcotics
intraperitonal infection

Virchow’s node

Left supraclavicular

Sister mary joseph node

Umbilical

Necrotizing fascitis

Renal impairment - hallmark - WBC > 14 - BUN > 15 - HypoNa < 135

Pressure ulcers

Stage I: intact skin w/blanching erythema Stage II: partial-thickness skin loss - breakdown of dermis from abrasion, blister, shallow ulcer crater Stage III: full thickness skin loss extending SubQ but not beyond fascia Stage IV: full thickness, SubQ loss, extending to muscle tendon, bones, joint

Factors affecting perioperative mortality (Goldman's index)

1. CHF (EF <35% - no surgery) 2. MI w/in 6mo (Check ECG, stress test, cath, reperfusion) 3. Arrhythmia 4. Age > 70 5. Emergent surgery 6. AS, poor medical condition, surgery in chest/abd - always check for AS murmur [late systolic, crescendo, decrescendo murmur radiating to carotids, increased w/squatting]

Meds to stop prior to surgery

Aspirin, NSAIDs, Vit E: 2wk Warfarin: 5d, drop INR to 1.5 (use Vit K if needed) 1/2 AM dose of insulin if diabetic [lactic acid risk w/metformin] CKD on dialysis: dialyze 24hr preop BUN>100: increased risk of postop bleed secondary to uremic platelet dysfunction

Ventilation Settings

Assist control: set tidal volume and rate but if pt takes a breath vent gives the volume Pressure support: pt rules rate but a boost of pressure is given; important for weaning CPAP: pt must breathe on own but positive pressure given at all times PEEP: pressure given at end of cycle to keep alveoli open; used w/ARDS and CHF

Ventilation - best tests to evaluate management

ABG PaO2 low: increase FiO2 PaO2 high: decrease FiO2 PaCO2 low (high pH): decrease rate or TV PaCO2 high (low pH): increase rate or TV TV is more efficient to change - more air goes into function space vs. increasing rate is getting more air into dead space

Fluids & Nutrition

Maintenance IVF: D5 1/2NS + 20KCl 4:2:1 rule when calculating cc/hr Daily requirements: 100mL/kg/d for first 10kg, 50mL/kg/d for next 10kg, 20mL/kg/d for all kg above 20 Enteral feeds are best: keep gut mucosa intact and prevent bacterial translocation TPN indication: - gut cannot absorb nutrients secondary to physical or functional loss - risks: acalculus cholecystitis, zinc deficiency, hyperglycemia, liver dysfunction, electrolyte problems

HIT

postop, decreased Plt, clots Tx: agatroban (synthetic heparin)

DIC

low Plt, increased PT/PTT, low fibrogen, high d-dimer, schistocytes

Lung Cancer

Low PTH --> hypercalcemia --> SCC [SIADH from small cell carcinoma] Peripheral: adenocarcinoma, large cell Central: squamous, small cell Small cell = no surgery -> chemo, radio-sensitive Non-small cell = surgery - adenocarcinoma, squamous, large cell

Right-sided murmurs get louder with

inspiration