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General Surgery > Midterm > Flashcards

Midterm Flashcards

1
Q

1.Approach to the Surgical Patient

A
  • Chief complaint
  • History of present illness
    • pain
    • vomiting
    • change in bowel habits
    • hematemesis,rectal bleeding
    • trauma
  • Past Medical history
    • drugs,ROS
  • Past surgical history
  • OB/GYN history
  • Social and family history
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2
Q

1.1.Approach to the Surgical Patient

A
  • Physical examination
    • Elective surgical examination
    • Examination of body orifices
  • <c>ABCDE
    <ul>
    <li>
    <strong>C</strong>atastrophic Haemorrhage control</li>
    <li>
    <b>A</b>irway (cervical spine control when appropriate)</li>
    <li>
    <strong>B</strong>reathing</li>
    <li>
    <b>C</b>irculation</li>
    <li>
    <strong>D</strong>isability</li>
    <li>
    <strong>E</strong>xtremity-environment-exposure</li>
    </ul>
    </c>
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3
Q

1.2.Approach to the Surgical Patient

A
  • Provisional diagnosis
    • most probable diagnosis so far
  • Differential diagnoses
    • list of probable diagnoses to rule out
  • Lab & other studies
    • blood tests
    • urine tests
    • functional studies : ECG etc
  • Imaging test
    • X-ray
    • ultrasound
    • CT,MRI
  • Special investigations
    • colonoscopy
    • angiography
    • cytoscopy
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4
Q

2.Types of Healing

A

Primary healing (first intention)

  • Tissue is clean
  • Reapproximation with sutures
  • Healing without complication, minimal scarring

Secondary Healing (second intention)

  • Infected wounds & burns
  • Open wound
  • Formation of granulation tissue

Delayed primary closure (third intention)

  • Secondary healing for 5 days
  • Then primary closure
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5
Q

3.Granulation Tissue

A
  • Red,moist,granular tissue
  • Appears during healing of open wounds
  • Microscopy : collagen, new blood vessels, fibroblasts, inflammatory cells
  • Healing achieved by creation of scar tissue
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6
Q

4.Wound Healing

Hemostasis & Inflammation

A
  • 0-5th day after injury
  • Platelet aggregation to exposed subendothelial collagen (IGF-1,TNFa,b, PDGF)
  • Coagulation cascade: fibrin clot⇒ coagulation &scaffolding
  • Chemotaxis : Damaged endothelial cells ⇒ activation of complement components
  • Inflammatory cells :
    • Neutrophils & monocytes 24-48h : rolling and adhesion
    • Macrophages 48-96h
    • T-lymphocyes peak at 7 days
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7
Q

4.1.Wound Healing

Proliferation

A
  • 4-14 days
  • Fibroblast replication
  • Platelets release PDGF,IGF-1,TGFb
  • Macrophages and fibroblasts release FGF,IGF-1,VEGF,IL-1,2,8, PDGF, TGFa,b
  • Fibroblasts produce collagen and proteoglycans
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8
Q

4.2.Wound Healing

Angiogenesis

A
  • 2nd to 4th day after injury
  • Response to chemoattractants from platelets and macrophages
  • PDGF,FGF,TNFa,b,VEGF
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9
Q

4.3.Wound Healing

Epithelization

A
  • starts from wound edges
  • Low PO2⇒TGFb from epithelial cells⇒blocks differentiation and promotes mitosis
  • Wound needs to be moist to promote epithelization
  • Exudate contains : growth factors and lactate
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10
Q

4.4.Wound Healing

Maturation & Remodeling

A
  • 8d-months
  • Fibroblasts replace fibrin ECM with collagen monomers⇒polymerization and cross-linking
  • ECM evolution : fibronectin, collagen III,glycosaminoglycans,proteoglycans,collagen I
  • Remodeling⇒collagen lysis and turnover (MPPs)
  • Collagen deposition>>collagen lysis
  • Fibroblasts attach to collagen fibres⇒wound contraction
  • Negative effect of contraction⇒deformation,stricture
  • Wound stretching if tension>>contraction
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11
Q

4.5.Wound Healing

Completion of Healing

A
  • Lactic acidosis and hypoxia normalization⇒stopping of healing
  • Keloids : hypertrophic scars due to local overgrowth of CT

Impaired healing

  • inadequate inflammatory response : corticosteroids,immunosuppressants,chemotherapeutic drugs
  • Excessive inflammation
  • Malnutrition (weight loss,hypoalbuminemia)
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12
Q

5.Healing of Specialized Tissues

Bone

A
  • Inflammation
  • Proliferation : specialized granulation tissue (fibrocartilaginous callus)
    • osteoclasts
    • osteoblasts
    • chondroblasts
  • Bone remodeling
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13
Q

5.1.Healing of Specialized Tissues

Nerve

A
  • Brain⇒CT scar
  • Peripheral nerves⇒sheath&axon regenerates from the nerve cell but reconnects randomly distally
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14
Q

5.2.Healing of Specialized Tissues

Intestine

A
  • 4-7th day : risk of anastomotic leakage
  • Strength regained in a week
  • Peritoneal adhesions
    *
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15
Q

6.Factors Affecting Wound Healing

A
  • Systemic
    • Age
    • Nutrition
    • Smoking
    • Metabolic diseases(DM,Metabolic syndrome)
    • Drugs: corticosteroids,immunosup,chemo
    • CT disorders - Ehler-danlos,marfan syndromes
  • Local
    • Hypoxia
    • Mechanical injury
    • Infection
    • Edema
    • Irradiation
    • Ischemia
    • Foreign bodies
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16
Q

7.Chronic Wounds &Ulcers

A

Decubitus ulcers

  • prolonged pressure⇒tissue ischemia
  • prolonged contact with moisture,urine,feces
  • malnutrition
  • in immobile,elderly,operated patients
  • Treatment:
    • drainage of infected space
    • excision of necrotic tissue
    • musculocutaneous flap
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17
Q

7.1.Chronic Wounds & Ulcers

A

Venous Ulcers

  • poor perfusion and perivascular leakage of plasma
  • lower leg
  • Treatment: compression stocking,surgical treatment of vein insufficiency

Ischemic Ulcers

  • Lateral ankle and foot
  • Treatment: revascularisation,hyperbaric oxygen
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18
Q

7.2.Chronic Wounds & Ulcers

A

Diabetic Ulcers

  • Neuropathy⇒trauma
  • Microangiopathy⇒ischemia
  • Treatment: protection of the ulcer,revascularisation

Treatment of wounds & ulcers

  • Control infection w/ antibiotics
  • Treat underlying circulatory disease
  • Keep wound moist
  • Debridement of unhealthy tissue
  • Reduce autonomic vasoconstriction
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19
Q

8.Excess Healing

A

Excess dermal scarring

  • Hypertrophic scar if epithelization takes longer than 3-4 wks
  • Keloid
    • 3 months after surgery
    • keloidal fibroblasts synthesize 20x
    • treat with local steroid injection

Peritoneal scarring(adhesions)

  • Fibrin,fibroblasts &collagen⇒filmy adhesions
  • Fibrinolysis w/in a week
  • Migration of capillaries,nerves,CT⇒solid adhesions
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20
Q

9.Wound Management

Classification

A
  • I.Clean:
    • uninfected,no inflammation
    • elective surgical wounds
    • e.g.hernia,breast surgery
    • management: primary closure
    • Infection rate : <2%
  • II.Clean-contaminated:
    • Minor and brief contamination,minor inflammation
    • Clean and sharp with local damage
    • e.g.gastric surgery
    • management: primary closure and wound cleaning
    • infection rate : 1-5%
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21
Q

9.1.Wound Management

Classification

A
  • III.Contaminated:
    • Contamination apparent and prolonged,major inflammation
    • Ragged and contused wounds w/ gross local damage
    • E.g. inflamed appendectomy,penetrating wounds
    • management: copious irrigation,debridement and primary closure
    • infection rate : 5-25%
  • IV.Dirty:
    • Gross contamination w/ infection
    • Old traumatic wounds >12h
    • Severe tissue damage and excessive ischemic tissue
    • e.g. abscess,perforated bowel
    • management healing by secondary intention
    • infection rate : 50%
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22
Q

10.Assessment of Wound Mechanism

A
  • Kinetic energy injury -closed -blunt
  • Kinetic energy injury-open-penetrating
    • low energy -knife
    • high energy - bullet
  • Thermal injury
    • Heat
    • Frost
  • Chemical injury
  • Electrical injury
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23
Q

11.Surgical Management of Wounds

A
  • Wound evaluation :
    • mechanism of injury
    • extent of injury and wound type
    • decision for wound closure
  • Patient consent
  • Antimicrobials : tetanus prophylaxis
  • Wound prep and sterile field
  • Anesthesia
  • Debridement-washing
  • Hemostasis
  • Closure
  • Dressing
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24
Q

12.Other skin closure options

A
  • Adhesive tapes
    • (+) rapid, simple, no risk of needle injury
    • (-) needs dry skin,poor adherence,poor hemostasis,accidental removal
  • Skin glue
    • (+) rapid,simple,reduced pain,good aethetic result
    • (-) poor approximation of deep layers,poor hemostasis
  • Surgical skin staples
    • (+) fast closure of large wounds,less rxn than sutures
    • (-) poor hemostasis
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25
Q

13.Surgical instruments

A
  • Cutting instruments
    • Scalpels
    • Scissors -for tissues and sutures
  • Grasping instruments
    • Tissue forceps
    • Ratcheted tissue forceps
    • Needle-holders
  • Retracting instruments
    • Hand-held retractors
    • Self-retaining retractors
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26
Q

13.1.Surgical instruments

A

Surgical staplers

  • Skin stapler
  • Linear stapler
  • Gastrointestinal anastomosis stapler
  • Circular stapler
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27
Q

13.2.Surgical Instruments

A

Energy applying instruments

  • Diathermy
  • Electrocoagulation
    • Monopolar- patient return electrode
    • Bipolar

Other energy applying instruments

  • Mechanical energy (ultrasound scalpel)
  • Laser
  • Cyrotherapy
  • Radiofrequency needles
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28
Q

13.3.Surgical Instruments

A

Sutures and Needles

  • Suture materials
    • Absorbable : polyglycolic acid,polydioxanone
    • Non absorbable : polypropylene,polyamide
  • Suture strand type
    • Monofilament
    • Multifilament
      • Twisted
      • Braided
  • Suture size : 10/0 - thinner than 1
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29
Q

13.4.Surgical Instruments

A

Sutures and needles

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30
Q

14.Local Anesthetics

A
  • Inhibit electrical conduction along neurons
  • Transient blocking of Na+ transport channels in the cell membrane ⇒ blocks initial depolarization
  • sensory neurons are more sensitive than motor neurons
  • Lidocaine : 20mg/ml with or w/o adrenaline
  • Bupivacaine : 5mg/ml
  • Ropivacaine : 7.5 mg/ml
  • onset : 5-10 mins, duration 1-6 hrs
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31
Q

14.Local Anesthetic Uses

A
  • Topical
    • Lipid soluble cream
    • Extent of action :skin and mucosa up to few mm deep
  • Local infiltration
    • injected into tissue
    • local nerves
  • Nerve block
    • Injected around a nerve or plexus
    • Distribution of nerve blocked
  • IV block
    • IV injection in arterial tourniqueted limb
    • Nerve tissue within limb
  • Centrineural block
    • Epidural or spinal injection
    • Multiple dermatomes
  • Cavity administration
    • intrapleural or intraperitoneal admin
    • local nerves in cavity
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32
Q

15.Local Anesthesia Toxicity

A
  • Side effects
    • Mouth and tongue numbness
    • Anxiety
    • Tremor
    • Drowsiness
    • Tachypnea
    • Hypotension
    • Nausea & vomiting
  • Allergy
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33
Q

16.Local infiltration anesthesia

A
  • Lidocaine
    • time to onset : 5-10 min
    • dilution : 2% lidocaine - max dose 300 mg for a 70 kg person
    • # 23 blue or #25 orange needle
    • infiltration technique : inject around site of incision
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34
Q

17.Basic Surgical Skills

A
  • Suturing
    • simple interrupted sutures
    • running (continuous) sutures
  • Knot tying
  • Incisions & excisions
    • elliptical excision : to take out a lesion
    • incision
  • Wound debridement
  • Hemostasis
    • with electrocoagulation
    • with ligature
  • Dissection
    • blunt dissection
    • sharp dissection
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35
Q

18.Sterile Technique

A
  • Sterile : all forms of microbial life destroyed
  • Aseptic : free from pathogens
  • Disinfection: process of destroying all pathogens
  • Clean : absence of gross contamination or dirt

Principles

  1. Reduction of env. contamination
  2. Disinfection of procedural site
  3. Isolation of procedural site
  4. Sterilization of procedural tools
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36
Q

19.Reduction of Environmental Contamination

A
  • Clean OR staff
    • clean clothing
    • hair and beard covered
    • OR shoes
    • face mask
  • Clean hands
    • hand washing (scrub or hydroalcoholic rub)
  • Clean air
    • closed OR
    • laminar airflow
  • Clean equipment
    • no touching
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37
Q

20.Disinfection of Procedural Site

A
  • Cleaning
    • washing to remove macroscoping contamination
    • hair removal
    • painting skin with antibacterial solution
      • chlorohexidine 0.5%, povidone iodine 10%
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38
Q

21.Isolation of Procedural Site

A
  • Gowning and gloving
    • sterile gowns
    • sterile gloves - sometimes double gloving
    • no touch technique
  • Draping
    • exclusion of operative site w/ sterile towels or shet
    • two layers
    • raised sterile curtain btw anesthesist & surgeon
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39
Q

22.Sterilization of procedural tools

A
  • Steam:
    • Sterilization of all metallic instruments
    • Sterilization in packs
    • 20 PSI / 126C / 10 min
    • Autoclave, flash sterilizes
  • Dry heat:
    • 160C/ 1h
  • Chemical:
    • Gas (ethylene oxide)
    • Liquid (glutaraldehyde) - 10h soaking
    • Plasma (ionized hydrogen peroxide gas)
  • Sensitive equipment (endoscopes) : soaked in disinfectant
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40
Q

23.Surgical Team Safety

A

Body fluids and substances

  • Risk of HBV,HCV,HIV
  • Avoidance of contact w/ mucosas and skin
  • Universal precautions

Sharps and needles

  • Risk of injury from scalpels,needles
  • Handling,returning & handing over sharp instruments
    • Never recap needles
    • Never place sharps on pt
    • Protect needle point with needle holder

Other hazards

  • Radiation exposure
  • Electrical shock from equipment
  • Toxic substances
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41
Q

24.Patient Safety

A

Preparation for the procedure

  • Patient consent
  • Correct patient, correct operation,correct side - mark lesion
  • All lab and radiology tests available
  • Any pt allergies or important info known

Positioning on operating table

  • No metal to skin contact
  • No pressure points
  • No abnormal traction or angulation of limbs
  • Mechanical DVT prophylaxis
  • Eyes taped shut to prevent drying
  • Stabilization of pt to avoid movement
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42
Q

24.1.Patient Safety

A

Procedure

  • Injury from sharps
  • Injury from retractors
  • Electrocoagulation,lasers gauzes
  • Breach in sterile technique

After procedure

  • Risk in transfer from the OR table (tube displacement, injury)
  • Post anesthetic observation
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43
Q

25.Systemic Inflammatory Response Syndrome

A
  • Inflammatory response to injury
  • Two or more of the criteria:
    • T ≥ 38oC or ≤ 36oC
    • HR ≥ 90/min
    • RR ≥ 20/min
    • WBC ≥ 12000/mm3 or ≤4000mm3
  • Balance⇒Recovery
    • Proinflamatory phase (SIRS)
    • Counter - regulatory anti inflammatory response syndrome (CARS)
  • Mixed antagonist response syndrome
    • Imbalance ⇒ Multi Organ Failure (MOF)
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44
Q

26.Sepsis and Septic shock

A
  • Sepsis : Suspected documented infection + an acute increase of ≥ SOFA points
  • Septic shock :
    • Sepsis + persisting hypotension that requires vasopressors to maintain MAP of 65mmHg
    • Serum lactate level > 2mmol/L (18mg/dL) despite adequate volume resussitation
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45
Q

27.Sequential Organ Failure Assesment Score

A
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46
Q

28.Acute Phase Proteins

A
  • Non-specific proteins secreted in response to tissue injury
  • Produced by liver
  • Biomarkers of systemic inflammation
    • CRP - normal < 1 mg/dL
    • Procalcitonin - normal < 0.15 ng/mL
    • IL-6
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47
Q
  1. CNS inflammatory regulation
A

Autonomic regulation of:

  • HR, BP,RR,GI motility
  • Body temp
  • Pro-inflammatory vs anti-infammatory response

Afferent Signals

  • Inflammatory mediators
    • TNFa
  • Parasympathetic sensory input
    • Cytokines TNFa,IL-1
    • Baroreceptors
    • Chemoreceptors
    • Thermoreceptors
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48
Q

29.1 CNS inflammatory regulation

A

Cholinergic anti-inflammatory response

  • Ach receptors on tissue macrophages : Ach reduces tissue macrophage release of proinflammatory mediators
  • Ach reduces macrophage activation
  • Effect of PS on HR, Gı motility, arteriole dilation
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49
Q

30.Hormonal Response to Injury

A

Pathways

  • Receptor kinases
  • G-protein receptors
  • Ligand gated ion channels

ACTH- from anterior pituitary

  • glucocorticoid production

Cortisol & Glucocorticoids - adrenal cortex

  • Hyperglycemia - release of FFA & TG from fat cells, immunosuppression, down-regulation of pro-inflammatory cytokines
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50
Q

31.Inflammatory Mediators

A
  • Cytokines
  • Heat shock proteins (protection from stress)
  • Oxygen radicals
  • Eicosanoids - endocrine,immune,vasomotor funct.
  • FA metabolites : attenuation of inflammatory resp.
  • Kallikrein-kinin sys : vasodilation, ↑ capillary permeability
  • Serotonin : vasoconstriction,bronchocons.,inotrope
  • Histamine : hypotension, ↑capillary permeability
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51
Q

32.Endothelium mediated injury

A
  • ↑ vascular permeability during inflammation
    • facilitate O2 delivery
    • facilitate immunocyte migration
  • ischemia reperfusion injury
    • accumulation of neutrophils
    • unleashing O2 metabolites,lysosomal enz
    • oxidation of basal membranes
    • microvascular thromboses
  • Endothelium hypoxia,endotoxins,injury and sheer stress produce
    • NO -smooth m relaxation
    • Prostacyclin - vasodilation & platelet activa.
    • Endothelins - most potent vasoconstrictor
    • Platelet-activ factor - activates neut,platelets - ↑ vascular permeability
    • Atrial Natriuretic Peptides -vasodilation,fluid & electrolyte secretion, aldosterone inhibitors
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52
Q
  1. Causes of Fluid and electrolyte imbalance
A
  • Surgical trauma - sepsis
  • 3rd space fluid isolation
  • Peri-operative fasting
  • Vomiting
  • Diarrhea
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53
Q

34.Body Water

A
  • Total body water = 50-60% of total body weight
  • Tissue water concentration
    • Muscle-solid organs > fat
    • New born>adult>elderly
    • Male>female
    • Lean>obese
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54
Q

35.Fluid Compartments

A
  • Intracellular fluid : 40% of total body weight
    • K+ : 150mM , Na+: 15mM, Mg2+: 40mM, Ca2+: minimal
    • Phosphates,sulfates:150mM,HCO3- : 10mM, proteins : 40mM
  • Extracellular fluid : 20% of total body weight
    • Interstitial fluid 15%
    • Plasma 5%
    • Na+ : 142mM, K+: 5mM,Ca2+: 5mM,Mg2+:2mM
    • Cl-:103mM,HCO3- : 26 mM,Phosphates: 2mM,Sulfates :1mM, Proteins: 17 mM
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55
Q

36.Body Fluid Osmolality

A
  • Total solute concentration : mOsm/kg
  • 290-310 mOsm/kg
  • water diffuses freely between compartments
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56
Q

37.Fluid Sodium

A
  • Sodium is confined to ECF
  • Sodium containing fluids
    • expansion of intravascular space - 5%
    • 3x expansion of interstitial space - 15%
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57
Q
  1. Daily solute balance
A
  • Oral intake : 2000 mL
  • Cell metabolism : 400 mL
  • Urinary excretion: 1500 mL
  • Stool: 200 mL
  • Skin,Lungs: 600 mL
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58
Q

39.Fluid Volume & Osmolality Control

A
  • Baroreceptors
    • Pressure sensors in aortic arch & carotid sinuses
  • Osmoreceptors
    • Sensors that detect changes in osmolality,kidney
  • Hypothalamus⇒vasopressin ⇒renin-angiotensin-aldosterone⇒atrial natriuretic peptide⇒reduction in expanded ECF
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59
Q

40.Body Fluid Disturbances

A
  • Volume disturbances
    • Volume deficit
    • Volume excess
  • Electrolyte concentration disturbances
  • Acid-base imbalance
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60
Q

41.Extracellular Volume Deficit

A

Causes in surgical patients:

  • Inability to ingest water
  • Loss of GI fluids :
    • Nasogastric tube suction
    • vomiting
    • diarrhea
    • enterocutaneous fistula
  • Fluid isolation
    • soft tissue injuries
    • burns
    • peritonitis-sepsis
    • ileus-obstruction
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61
Q

41.1.Extracellular Volume Deficit

A

Clinical observations

  • Weight loss 1kg/1L
  • ↓ skin turgor
  • Sunken eyes
  • Tachycardia
  • Hypotension
  • Oliguria
  • Confusion

Lab exam:

  • ↑BUN,↓GFR
  • ↑BUN: Creatine ratio
  • ↑Hematocrite
  • ↑urine osmolality (higher than serum)
  • ↓urine sodium (20mEq/L)
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62
Q

42.Extracellular Volume Excess

A

Causes:

  • Iatrogenic
  • Renal dysfunction
  • Heart failure
  • Cirrhosis
  • Inappropriate secretion of antidiuretic hormone

Clinical observations:

  • Weight gain
  • Peripheral edema- limb swelling
  • ↑central venous pressure
  • distended jugular veins
  • pulmonary edema - fine crackles
  • cardiac insufficiency - gallop rhythm

Lab exams:

  • ↓ hematocrite
  • ↓ urine osmolality
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63
Q

43.Electrolyte Disturbances

Sodium

A
  • Na+ : predominant electrolyte of ECF
  • Na+ concentration influences fluid osmolality
  • Changes in Na+ are inversely proportional to total body weight
  • Serum Na+ : 135-145 mEq/L

Hypernatremia

  • causes:
    • high volume
      • gain of Na+ in excess of water
      • hyperaldosteronism,cushing syndrome
    • normal or low volume
      • loss of free water (renal,GI tract,DI)
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64
Q

43.1.Electrolyte Disturbances

Sodium

A

Clinical Observations of Hypernatremia

  • Thirst
  • If Na+ concentration > 160mEq/L
    • Cellular dehydration - extracellular water shifting
    • CNS symptoms - restlessness,irritability,seizures,coma
    • Musculoskeletal - weakness
  • If hypovolemic hypernatremia
    • Tachycardia
    • Orthostatic hypotension

Lab exams : serum Na+ > 145 mEq/L severe if > 160, urine specific gravity SG > 1.030 if nonrenal water loss

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65
Q

43.2. Electrolyte Disturbances

Sodium

A

Hyponatremia

Causes:

  • Dilution
    • Iatrogenic
    • Polydipsia (psychogenic,DM, DI)
    • Severe hyperglucemia (glc osmosis)
    • Secretion of ADH (post trauma,surgery)
    • Drugs (ACEI,antipsychotics)
  • Depletion
    • Low Na+ diet
    • GI losses (vomiting,nasogastric suction)
    • Renal losses (diuretics,renal diseases)
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66
Q

43.3.Electrolyte Disturbances

Sodium

A

Clinical observations of hyponatremia

  • If severe - < 120 mEq/L
    • CNS - seizures, coma,↑intracranial pressure
    • Musculoskeletal - weakness,fatigue,cramps
  • Rapid correction of severe hyponatremia⇒ osmotic demyelination syndrome

Lab exams:

  • Serum Na+ < 135 mEq/L
  • Low urine Na+ concentration < 20 mEq/L if extrarenal losses
  • High urine Na+ concentration > 20 mEq/L if renal losses
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67
Q

44.Electrolyte Disturbances

Potassium

A
  • Predominant intracellular cation
  • Only 2% of total body K+ is extracellular while 98% is intracellular
  • Critical to cardiac and neuromuscular function
  • Serum K+ : 3.5-5 mEq/L

Hyperkalemia : K+ > 5mEq/L

Causes:

  • Excesive K+ intake - supplements, blood transfuse
  • Cell destruction - hemolysis,crush injury
  • K+ extracellular shifting - acidosis
  • Impaired kidney K+ secretion -K sparing diuretics,renal insufficiency
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68
Q

44.1.Electrolyte Disturbances

Potassium

A

Clinical Observations of hyperkalemia

  • GI - nausea,vomiting,colic
  • Neuromuscular - weakness,paralysis
  • Cardiovascular - arrythmia,arrest

ECG alterations

  • Peaked T waves, flattened P wave
  • Prolonged PR interval
  • Widened QRS
  • V-fib
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69
Q

44.2.Electrolyte Disturbances

Potassium

A

Hypokalemia : K+ < 3.5 mEq/L

Causes:

  • ↓ intake - inadequate oral or iv K+
  • Intracellular K+ shifting - alkalosis
  • Excessive K+ renal excretion - diuretics,hyperaldosteronism
  • GI losses - diarrhea,vomiting,fistula
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70
Q

44.3.Electrolyte Disturbances

Potassium

A

Clinical observations of hypokalemia

  • GI- ileus,constipation
  • Neuromuscular-↓reflexes,fatigue,weakness,paralysis
  • Cardiovascular-PEA,asystole

ECG alterations

  • U waves
  • T-wave flattening
  • Arrythmias
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71
Q

45.Electrolyte Disturbances

Calcium

A
  • contained in bone matrix 99%
  • serum calcium - 50% ionized (free) and 50% bound (protein & phosphate complexes)
  • total serum Ca2+ is measured but the ionized is responsible for neuromuscular stability

Hypercalcemia

Causes:

  • primary hyperparathyroidism
  • malignancy - bone metastases,secretion of PTH related protein

Clinical observations

  • GI - nausea,vomiting,abdominal pain
  • Neuromuscular - weakness,confusion,coma,pain
  • CV- hypertension,arrythmia,ECG alterations
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72
Q

45.1.Electrolyte Disturbances

Calcium

A

Hypocalcemia : Ca2+< 8.5 mEq/L

Causes:

  • Hypoparathyroidism
  • Other - pancreatitis,renal failure

Clinical observations:

  • In severe hypocalcemia
  • Neuromuscular - hypereflexia,tetany,Chvostek’s sign (spasm of facial m. when facial n is tapped at lvl of jaw),Trousseau’s sign (carpal spasm induced by BP cuff), bone pain
  • CV - heart failure, ECG alterations
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73
Q

46.Electrolyte Disturbances

Magnesium

A
  • Predominantly intracellular
  • 1/3 serum Mg is albumin bound
  • Normal serum Mg2+ = 1.5-2.5 mg/dL

Hypermagnesemia

Causes:

  • Excess intake - Mg laxatives and antacids
  • Renal failure

Clinical observations

  • GI - nausea,vomiting
  • Neuromuscular- weakness,vomiting, ↓reflexes
  • CV-hypotension,arrest,ECG alterations like hyper-K
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74
Q

46.1.Electrolyte Disturbances

Magnesium

A

Hypomagnesemia : Mg2+ < 1.5 mg/dL

Causes:

  • common in hospitalized patients
  • poor intake
  • ↑ renal excretion - alcohol, diuretics
  • GI losses - diarrhea
  • acidosis

Clinical observations

  • Neuromuscular - hyperactive reflexes,tremors,tetany,seizures
  • CV - ECG alterations-torsade de pointes,arrest
  • can produce hypocalcemia
  • can cause persistent hypokalemia
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75
Q

47.Electrolyte Disturbances

Phosphorus

A
  • primarily a constituent of bone
  • predominant intracellular anion HPO43-
  • abundant in metabolic active cells : high energy phosphate products (ATP)
  • controlled by urinary secretion
  • serum phosphorus : 2.5-4.5 mg/dL

Hyperphosphatemia : P-3 > 4.5 mg/dL

Causes

  • ↓ urinary excretion
  • ↑ intake - phosphorus rich laxatives
  • ↑ production- cell destruction

Clinical observations

  • asymptomatic
  • high calcium-phosphate product⇒calcifications
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76
Q

47.1.Electrolyte Disturbances

Phosphorus

A

Hypophosphatemia : P-3 < 2.5 mg/dL

Causes:

  • poor dietary intake - alcoholism
  • antacid administration- binding of P in bowel
  • hyperparathyroidism

Clinical observations:

  • When severe hypo-p <1 mg/dL
  • Neuromuscular - fatigue,weakness,convulsions
  • CV- impaired heart contractibility
  • Osteomalakia-chronic depletion
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77
Q

48.Acid Base Balance

A
  • Daily metabolism produces 1 mEq/kg of H+
  • Produced CO2 is transformed to H2CO3
  • Buffering systems
    • intracellular proteins- hemoglobin
    • extracellular bicarbonate/carbonic acid

H++HCO3- ⇔ H2CO4⇔H2O +CO2

pH = pK + log ( [HCO3- ] / 003 x PCO2

  • PCO2 ⇒ regulated by pulmonary ventilation
  • HCO3- is regulated by the kidney
    • HCO3- reabsorption
    • Secretion of H+
    • Secretion of NH4+
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78
Q

49.Normal Values

A
  • pH is regulated at 7.35-7.45
    • Acidemia ⇒ pH < 7.35
    • Alkalemia ⇒ pH > 7.45
  • HCO3- : 22-26 mmol/L
  • PCO2 : 35-45 mmHg

Anion gap

  • UA-UC = [Na+] - ( [HCO3-] +[Cl-]) : 3-11 mEq/L
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79
Q

50.Respiratory Acidosis

A
  • PCO2 > 45 mmHg

Acute respiratory acidosis

  • Acute respiratory failure - obstruction,aspiration
  • PCO2 ↑
  • HCO3- stable
  • pH↓ - acidemia

Chronic respiratory acidosis

  • Chronic respiratory failure
  • PCO2 ↑
  • HCO3- ↑ - compensation - renal NH4 excretion
  • pH normalized
80
Q

51.Respiratory Alkalosis

A
  • PCO2 < 35 mmHg

Acute respiratory alkalosis

  • Acute hyperventilation - psychogenic,sepsis
  • PCO2 ↓
  • HCO3- stable
  • pH ↑ - alkalemia

Chronic respiratory alkalosis

  • PCO2↑
  • HCO3- ↑
  • pH normalized
81
Q
  1. Metabolic Acidosis
A
  • HCO3- < 22 mmol/L
  • Excessive HCO3- - diarrhea, diuretics
    • HCO3- ↓
    • Cl- ↑
    • Anion gap is normal N = 3-11 mEq/L
    • hyperchloremic metabolic acidosis
  • Excessive lactate,acetoacetate,b-hydroxybutyrate
    • Addition of unmeasured anions
    • Anion gap is ↑
    • HCO3- ↓ - consumption
82
Q

53.Metabolic Alkalosis

A
  • HCO3- > 26 mmol/L
  • Causes
    • Loss of H+ ⇒ ↑ in HCO3- (vomiting,ng suction)
    • Impaireed renal exertion of HCO3-
    • Associated hyperchloremia
    • Volume depletion
83
Q

54.Respiratory & Metabolic Components of Acid-Base Disorders

A
84
Q

55.Principles of Fluid & Electrolyte Therapy

A
  • Surgical patients need fluids
    • None by mouth ⇒ IV
    • Maintenance of fluids
    • Volume replacement
      • Bleeding
      • Sepsis
      • GI losses
  • Evaluation of the fluid volume deficit
  • Calculation of ongoing fluid losses
  • Assessment of Na+,K+ requirements
  • Management of acid-base disturbances
85
Q

56.Volume and Electrolyte Content of GI Fluids

A
86
Q

57.Types of Replacement Fluids

A

Crystaloids

  • Solutions of water w/ electrolytes
  • Solutions of water w/ glucose

Colloids

  • Solutions of high molecular weight macromolecules
87
Q

58.Parenteral Electrolyte Solutions

Crystaloids

A
88
Q

59.Parenteral Electrolyte Solutions

Colloids

A
89
Q
  1. Replacement Fluid Guidelines
A
  • Maintenance fluids : 30-40 ml /kg/day
  • Replace all losses volume for volume
  • Isotonic vs hypotonic vs hypertonic
  • No K+ for the early post-operative period

Infused fluids distribution

  • Glc solutions ⇒ 2/3 intracellular , 1/3 extracellular
  • Na+ solutions ⇒ 1/4 intravascular, 3/4 interstitial
  • Colloids⇒ intravascular space
90
Q
  1. ASA Physical Status Classification
A
91
Q
  1. Altered State Patient
A

Nutritional Assessment

  • Anticipated post-operative fasting
  • Dietary history
  • Weight loss > 10%
  • Serum albumin < 3 g/dL, transferrin < 150 mg/dL

Immune incompetence

  • Elderly patients, malnutrition,cancer,severe burns
  • Total lymphocyte count
  • Skin tests (anergy)

Infectious risk

  • Drugs : corticosteroids, immunosuppressors,cytotoxic drugs, prolonged antibiotic therapy
  • Renal failure
  • Granulocytopenia
  • Hematologic diseases: lymphomas,leukemias,hypogammaglobulinemia
  • Uncontrolled diabetes
92
Q

63.Patient with Pulmonary Dysfunction

A
  • Risk of post-operative complications : hypoxia,atelectasis,pneumonia

History

  • Heavy smoking >20 PY
  • Cough - character sputum,Wheezing
  • Exercise intolerance
  • Obesity
  • Old age
  • Known pulmonary disease

Physical exam

  • Wheezing, prolonged expiration

Lab tests

  • Chest x-ray, ECG
  • Arterial blood gases - CO2 retention - respiratory acidosis, pulmonary function tests - FVC,FEV1
93
Q

64.Delayed wound healing

A

Patient at risk

  • Hypoproteinemia
  • Vit C deficit
  • Volume disorders - edema/dehydration
  • Anemia
  • Diabetes
  • Smoking
  • Corticosteroids- in large doses
  • Cytotoxic chemotherapy
  • Irridation
94
Q

65.Drug effect

A

Drug allergies

  • Penicillin/antibiotics
  • Morphine/opioids
  • Xylocaine-local anesthetics
  • Aspirin/NSAIDS
  • Tetanus antitoxin
  • Iodine-other antiseptics
  • Other drugs,Food,Adhesive tape

Drug adaptation

  • Digitalis,insulin,corticosteroids⇒continuation
    • stress dose of corticosteroids- hydrocortisone 100 mg x3
  • Oral anticoagulation drugs replaced w/heparin
  • Oral antidiabetics replaced w/ insulin during fasting
  • CNS depressants - barbiturates,opioids,alcohol,chlorpromazine
  • Antihypertensives
95
Q

66.Patient at Risk of Thromboembolism

A

Patient risk factors

  • Cancer
  • Obesity
  • MI
  • Age >45
  • History of thromboembolic event

Surgery

  • General,pelvic,orthopedic surgery

DVT prevention

  • Early postoperative mobilisation
  • Mechanical : graduated compression stockings,intermittent pneumatic compression
  • Chemical : unfractioned heparin,low molecular weight heparin
96
Q

67.Elderly Patients

A

Physiological vs chronological age

  • CV,renal,other systemic diseases

Patients > 60

  • Arteriosclerosis
  • Cardiac reserve limitation
  • Renal reserve limitation
  • Occult cancer

Avoid volume overload

  • fluid intake and output
  • body weight
  • CVP

Adapted doses of drugs

  • Narcotics
  • Benzos can cause agitation
97
Q

68.The Obese Patient

A

Metabolic Syndrome

  • ↑BP, ↑ blood sugar lvl, ↑↑↑ body fat around waist, abnormal cholesterol levels

Risk of concominant disease

  • Heart disease
  • Stroke
  • Diabetes

Wound complications

98
Q

69.Preoperative Patient Preparation

A
  • Preoperative hyperalimentation (7-10d)
  • Pulmonary prep for > 48h
    • Abstinence from smoking
    • Inhaled bronchodilators
    • Chest physical therapy x2 a day
    • Inspiratory effort exercise devices
  • Maintain blood volume and tissue perfusion
    • Avoid dehydration/volume deficit
  • Drug adaptation
  • Thromboembolic prophylaxis
  • Fasting for 6h (solids) & 2h (liquids) before major operations or general anesthesia
99
Q

70.Preoperative Formalities

A
  • Patient info
    • Surgeon
      • Diagnosis
      • Planned surgical procedure
      • Risks & possible complications
      • Need for blood transfusion
      • Postoperative recovery
    • Anesthesiologist
      • Type of anesthesia
      • Anesthesia related risks
      • Postanesthesia recovery
  • Signed informed consent
    • Signed by pt or legal guardian of minors
    • Emergency lifesaving operations
100
Q

71.Operative Field Preparation

A

Initial prep- evening before operation

  • Washing w/ soap and water
  • No shaving - ↑ skin infection risk
  • Marking of operative site by surgeon

In operating room

  • Hair clipping if required
  • Skin prep w/ 2% iodine in 90% alcohol - for > 1 min, avoid using in perineum,genitelia,face,avoid spilling outside operative field
  • Universal precautions
    • Barrier protections
    • Avoid accidental injuries
    • Avoid contact of open wounds w/ pt
    • Check gloves for tears
101
Q

72.Control of Hospital Cross-Infections

A

Surgical infection control program

  • Target of < 1% of clean wond infection rate
  • Cultures and antibiotic sensitivity on all infections
  • Isolation of pt w/ communicable infections
  • Aseptic technique
    • Isolation of OR
    • Dressing of open wounds
    • Hand washing
  • Antibioprophylaxis
    • For clean-contaminated & contaminated cases
    • For clean cases if implanted material
    • Give 1h to 30 min before incision
    • 2nd gen cephalosporin,single dose. Repeat after 4h of surgery or major blood loss
102
Q

73.Immediate Post-operative - Post-anesthetic Phase

A

Postanesthesia Care Unit

  • Monitoring for 1-3 hrs post-op
  • Discharge when cv,pulmonary & neurological functions normalized

Discharge w/ written post-op orders to

  • Ward
  • ICU /High dependency unit
103
Q

74.Post-operative orders

A
  • Monitoring
    • Vitals
    • ECG monitor
    • CVP,PCWP
    • Fluid input/output
  • Respiratory care
  • Position in bed and mobilization
    • pt turned every 30 min til conscious
    • change position every 1h for first 8-12h
    • early mobilization
  • Diet,Fluids & electrolytes,
  • Medications : analgesics,dvt prophylaxis,gastric acid suppression etc
  • Lab & imaging exams
104
Q

75.Intermediate Postoperative Period

A

After complete recovery from anesthesia & transfer to ward

  • Wound care
    • Keep wound covered w/ sterile dressings for 2-3d post-op
    • Soaked dressings replaced
    • Dressing replacement on first 24h should be done w/ aseptic technique
    • By 48h after closure, the skin wounds is sealed off from external env
105
Q

75.1.Intermediate Postoperative Period

A
  • Management of drains
    • Prevent contamination of drain tract
    • Handling of the drain w/ asceptic technique
    • Early drain removal
  • Post-op care of GI tract
    • GI tract peristalsis return to normal after laparatomy :
      • Small bowel w/in 24h
      • Right colon after 48h
      • Left colon after 72h
    • Early normal feeding/enteral feeding
106
Q

75.2.Intermediate Postoperative Period

A

Post-op pain control

  • Parenteral opioids
    • ↓ risk of addiction
    • side effects : respiratory depression, nausea, vomiting, paralytic ileus
  • NSAIDs
    • side effects : GI ulcers, impaired coagulation, reduced renal function
  • Paracetamol
  • Patient controlled analgesia
  • Continuous epidural analgesia
  • Nerve blocks
107
Q

76.Postoperative Complications

A
  • Every complication that appears after operation
  • May result from 1o disease, the operation, comorbidities, or unrelated factors
  • Early detection
  • Pre-op identification or risks & pt optimization
108
Q

76.1.1.Postoperative Complications

Classification Systems

A
  • Grade I :
    • any deviation from normal post-op course w/out need for pharma treatment, or surgical endoscopic and radiological interventions
  • Grade II:
    • Requiring treatment w/ drugs other than such allowed for grade I complications.
  • Grade III:
    • Requires surgical,endoscopic or radiological intervention
  • Grade IV:
    • Life threatening complications (including CNS) requiring ICU-management
  • Grade V:
    • Death of patient
109
Q

76.1.2.Postoperative Complications

Wound Complications

A

Seroma

  • Fluid collection other than pus or blood
  • After lymphatic transection
  • Delay healing, infection risk
  • Treatment: watchful wait, needle aspiration, compression dressing

Hematoma

  • Collection of blood & clot
  • Imperfect hemostasis
  • Discomfort, compression effect, infection risk
  • Risk factors: anticoagulants, aspirin, marked HT
  • Treatment: evacuation of blood clot under sterile conditions & hemostasis
110
Q

76.1.3.Postoperative Complications

Wound care

A

Surgical site infection

  • Bacterial infection w/ inflammation and/or purulent collection
  • Breach of aseptic conditions or operative contamination
  • Risk factors: pt factors vs operation related factors
  • Treatment: wound exploration/drainage, cultures, antibiotics

Pain

  • Controlled by analgesics
  • Pain ↓ on first 4-6 post-op days
  • Persistent pain needs exploration - abcess, granuloma, incisional hernia
111
Q

76.1.4.Postoperative Complications

Wound Complications

A

Ascitic leak

  • Risk of wound infection and peritonitis
  • Treatment: wound exploration (OR) & fascia closure

Wound dehiscence

  • Partial & total disruption of any or all layers of wound
  • Systemic vs. local factors
  • Between 5-8 post-op days
  • Discharge of serosanguineous fluid
  • Dehiscence of laparatomy ⇒ evisceration
  • Treatment: wound covered w/ moist towels, abdominal closure in OR
112
Q

76.1.5.Postoperative Complications

Respiratory Complications

A

Atelectasis

  • Bronchiole closure &/or obstruction from secretions
  • Risk factors: old age, smoking, obesity, abdominal operations
  • Diagnosis: fever, tachypnea, tachycardia, chest x-ray
  • Atelectatic segments - risk of infection (pneumonia)
  • Prevention: early mobilization, frequent changes in position, coughing, incentive spirometer
  • Treatment: chest percussion,nasotracheal suction,bronchodilators,mucolytics
113
Q

76.1.6.Postoperative Complications

Respiratory Complications

A

Pulmonary Aspiration

  • Risk factors: NG tube, CNS depression, gastroesophageal reflux, intestinal obstruction, pregnancy, trauma patients
  • Diagnosis: tachypnea, rales, hypoxia, cyanosis, wheezing
  • Causes chemical pneumonitis & is a major risk of pneumonia
  • Treatment: endotracheal suction, bronchoscopy, fluid resuscitation, antibiotics
114
Q

76.1.7.Postoperative Complications

Respiratory Complications

A

Post-op pneumonia

  • Risk factors: intubation, atelectasis, aspiration, bronchial secretions
  • Microbes: g (-) bacilli, pseudomonas aeruginosa, klebsiella
  • Mortality : 20-40%
  • Treatment : Clearing of secretions, sputum cultures, antibiotics
115
Q

76.1.8.Postoperative Complications

Respiratory Complications

A

Pleural effusion

  • After upper abdominal operations, cardiac failure, pulmonary lesion, subdiaphragmatic inflammation
  • Treatment: watchful wait, aspiration,drainage

Pneumothorax

  • After pleural injury or positive pressure ventilation
  • Treatment: thoracostomy tube
116
Q

76.1.9. Postoperative Complications

Respiratory Complications

A

Cardiac complications

  • Cardiac arrythmias
    • due to reversible factors (hypo-K, hypoxia, acidosis, stress, drug toxicity)
    • Pt w/ preexisting arrythmias
  • Post-op MI
    • 1/2 post-op MI are asymptomatic
    • Postponing elective operations for 6 mo after MI
    • Predisposing factors: hypoxia, hypotension, stress
  • Post-op cardiac failure
    • Left ventricular failure & acute pulmonary edema
    • Predisposing factors: cardiac arrythmia, MI, volume overload, sepsis
117
Q

76.2.Postoperative Complications

Peritoneal Complications

A

Hemoperitoneum

  • W/in 24h of the operation
  • Tachycardia, hypotension, peripheral vasoconstriction, oliguria
  • Changes in Hct and Hg seen after 4-6h
  • Radiological imaging - US, CT
  • Patient stabilization, surgical treatment
118
Q

76.2.1. Postoperative Complications

Complications of Drains

A
  • Risk of drain tract infection
  • Drain displacement
  • Bleeding from drain tract
  • Pain
119
Q

76.2.2.Postoperative Complications

GI Motility Complications

A

Prolonged paralytic ileus

  • Return of GI motility w/in 24h after non-abdominal surgery
  • After laparotomy return of GI motility w/in 48h
  • Paralytic ileus can last up to 5 post-op days
  • No specific therapy

Bowel Obstruction

  • From post-op adhesions or internal hernia
  • Surgical treatment
120
Q

76.2.3.Postoperatie Complications

GI Motility Complications

A

Gastric Dilation/Gastroparesis

  • Massive distention of the stomach by fluid & gas
  • Abdominal pain, distention and hiccups
  • Risk of inhalation
  • Gastric decompression w/ ng tube

Fecal Impaction

  • Aggravating factors: opioids, anticholinergics, paralytic ileus
  • Digital extraction, enemas
121
Q

76.2.4.Postoperative Complications

Anastomotic Leak

A
  • Healing failure of an intestinal anastomosis
  • Usually 3-8d after surgery - up to 1 month
  • Peritonitis: acute abdominal pain w/ rigid abdomen, tachycardia, high fevers & often hemodynamic instability
  • Abscess: insidious presentation : low grade fever, prolonged ileus or failure to thrive
  • Treatment options: surgical treatment, percutaneous drainage
122
Q

76.2.5.Postoperative Complications

Liver and Pancreas Complications

A

Hepatic dysfunction

  • Prehepatic jaundice
    • Hemolysis
    • Reabsorption of hematomas
  • Hepatocellular insufficiency
    • Hepatic cell necrosis (drugs, hypotension, hypoxia, sepsis)
    • Massive liver resection
    • After prolonged total parenteral nutrition
  • Posthepatic obstruction
    • Injury to the CBD
    • Retained CBD stones
123
Q

76.2.6.Postoperative Complications

Liver & Pancreas Complications

A

Postoperative cholecystitis

  • Acalculous cholecystitis⇒risk of necrosis
  • After ERCP-Endoscopic Retrograde Cholangiopancreatography
  • After embolization of the right hepatic artery

Postoperative pancreatitis

  • After operations in the vicinity of pancreas
  • Mechanical trauma to the pancreas or its blood supply
  • Drug induced pancreatitis (theiaazides, azathioprin, valproic acid)
124
Q

76.2.7.Postoperative Complications

Clostridium Difficile Colitis

A
  • Post-op diarrhea - pseudomembranous colitis
  • From mild diarrhea to severe toxic colitis
  • Diagnosis by IDing the toxin in the stool, bacteriology, endoscopy
  • Prevention: hygiene, minimizing antibiotic use
  • Treatment: metronidazole, vancomycin, fecal transplantation
125
Q

76.2.8.Postoperative Complications

Urinary Complications

A

Urinary retention

  • Interference w/ neural mechanism of micturition
  • Bladder overdistention < 500ml
  • Catheterization for operations longer than 3h, pelvic operations
  • Encourage preoperative urination & soon after

UTIs

  • Most frequent nosocomial infection
  • Risk factors: catheter, urinary retention
  • Cystitis, pyelonephritis
  • Treatment: hydration, antibiotics
126
Q

76.2.9.Postoperative Complications

IV and intraarterial catheters

A

Air embolism

  • Accidental insertion of air in a central venous catheter
  • Acute dyspnea, tachypnea, continuous cough, gasp reflex, neurological symptoms
  • Position pt head down, right side up to trap air in right ventricle- supportive measures

Ischemic necrosis of fingers

  • Ischemia due to indwelling radial artery catheter
  • Patency of ulnar artery (Allen’s test)
  • Early removal of arterial catheter
127
Q

76.3.Postoperative Complications

IV and intraarterial catheters

A

Thrombophlebitis

  • Common cause of fever
  • Induration, edema, tenderness
  • Prevention: aseptic technique, change of tubing, rotation of insertion site
128
Q

76.3.1.Postoperative Complications

CNS & Psychiatric Complications

A

Postoperative stroke

  • Due to poor cerebral perfusion-abrupt hypotension
  • After carotid endarterectomy, open heart surgery w/ extracorporeal circulation

Delirium tremens

  • Due to abrupt alcohol withdrawal w/in 2 weeks
  • Personality changes, restlessness, confusion, overactivity, seizures
  • Treatment: small amounts of alcohol, benzos
129
Q

76.3.2.Postoperative Complications

CNS & Psychiatric Complications

A

Postoperative psychosis

  • Elderly pt, severe systematic disease
  • Present mood disturbances, confusion, fear, disorientation, delirium
  • May be drug related: cimetidine, corticosteroids, benzos
  • Eliminate metabolic derangements and early sepsis

ICU syndrome

  • Due to pain, fear, sleep deprivation from bright lights
  • Impaired cognitive ability, confusion, halucinations, delirium
130
Q

76.3.3.Postoperative Complications

Postoperative Fever

A
  • Post-op temperature elevation in 40% of pt
  • w/in 48h
  • After 2nd day : thrombophlebitis, pneumonia, UTI
  • After 5d: Surgical site infection, anastomotic leak
  • After 1w: Allergy, transfusion, sepsis, intraabdominal abscess
131
Q

77.Shock

A
  • Presence of tissue hypoperfusion that is insufficient to maintain normal aerobic metabolism
  • Provokes sympathetic/paras & neuroendocrine stress response
  • Leads to tissue hypoxia & end-organ dysfunction
    • ↑ cardiac contractility & peripheral vascular tone
    • hormonal response to preserve salt & intravascular fluid
    • changes in microcirculation to regulate blood flow
  • Persistent hypoperfusion w/ ↓ CO induce CV decompensation⇒ irreversible phase of shock, irreversible tissue injury and cell death
132
Q

78.Neuroendocrine Response to Shock

A

Afferent signals to CNS

  • Pain, infection, temp, hypoglycemia, emotional stress
  • Volume receptors : heart atria
  • Baroreceptors: aortic arch, carotid bodies
  • Chemoreceptors: aorta, carotid bodies

Efferent signals to CNS

  • CV response: ↑HR(B1),↑H.contractility(B1),Arterial vasoconstriction(a1)
  • Hormone response:
    • ACTH⇒cortisol
    • Renin-angiotensin⇒aldosterone
    • ADH
133
Q

78.1.Neuroendocrine Response to Shock

A

Microcirculation

  • Vasoconstriction of arteries & larger arterioles (a1)
  • Vasodilation of distal arterioles (local factors)
    • Diminished capillary hydrostatic pressure
    • Shifting of fluid from EC space inside capillaries
  • Capillary occlusion from endothelium cell swelling & neutrophil sludging
  • Changes of microcirculation blood flow btw & w/in systems
134
Q

79.Cellular Response to Shock

A

Oxygen tissue lvl ↓

  • Mitochondrial dysoxia
  • Anaerobic cell meetabolism (lactate production)
  • Lactic acidosis
  • Intracellular acidosis

Cellular ATP depletion

  • Na+,K+, ATPase activity ↓
  • Intracellular Na+ accumulation
  • Cellular edema
  • ↓ of cell membrane resting potential

Apoptosis

135
Q

80.Immune & Inflammatory Response to Shock

A

Pro-inflammatory components

  • TNFa
    • By monocytes, macrophages, T-cells
    • Induction of septic shock
    • Peripheral vasodilation, pr breakdown, procoagulation
  • IL-1B
    • Half life of 6min
    • Febrile response, anorexia
  • IL-2
    • By activated T-cells
    • Activates lymphocytes
    • Shock induced tissue injury
136
Q

80.1.Immue & Inflammatory Response to Shock

A
  • IL-6
    • Causes lung, liver & gut injury after hemorrhagic shock
    • Enhances activity of CRP, fibrogen, complement, neutrophil activation
  • IL-10
    • Immunosuppressive properties
    • By T-cells, monocytes, macrophages
    • Depression of cytocine production, oxygen radical production, adhesion
  • IL-4
137
Q

81.Forms of Shock

Hemorrhagic Shock

(hypovolemic)

A
  • Loss of circulating volume from hemorrhage
    • Sym activation⇒ vasoconstriction
    • Renin-angiotensin-aldosterone activation⇒urinary Na+ and fluid retention
    • ADH secretion⇒cerebral & coronary vessel autoregulation

Diagnosis:

  • Capillary refill time >2sec
  • Weak peripheral pulse
  • Cold & clammy extremities

Treatment :

  • secure airway & ventilation
  • Hemorrhage control
  • Fluid resuscitation
138
Q

81.1.Forms of Shock

Cardiogenic Shock

A
  • Circulatory pump failure ⇒tissue hypoxia in setting of adequate intravascular volume
  • Hemodynamic criteria
    • SBP < 90 mHg for more than 30 min
    • Cardiac index < 2.2L/min/m2
    • PCWP > 15mmHg
  • Causes:
    • Acute MI
    • End-stage cardiomyopathy
    • Myocarditis
    • Valvular disease - aortic stenosis, mitral stenosis
  • Mortality : 50-80%
139
Q

81.1.2.Forms of Shock

Cardiogenic Shock

A

Diagnosis

  • Signs of shock
  • Physical exam
    • cardiac murmur/sounds
    • arrythmia
    • acute pulmonary edema
  • ECG
  • Chest x-ray
  • Heart ultrasound
  • Invasive heart monitoring
    • CVP
    • PCWP
140
Q

81.1.3.Forms of Shock

Cardiogenic Shock

A

Treatment

  • Secure airway & ventilation
  • Exclude hypovolemia
  • Correction of electrolyte imbalance
  • Inotropic support
    • Dobutamine
    • Dopamine
  • Epinephrine
  • Intra-aortic balloon pump
  • Treatment of underlying disease
    • PTCA +/- stent for acute MI
    • Heart transplantation
141
Q

81.1.4.Forms of Shock

Septic Shock

A

Vasodilatatory shock = failure of vascular smooth muscles to contract

  • septic shock
  • hypoxic lactic acidosis
  • carbon monoxide poisoning
  • terminal stage shock of any cause

Pathophysiology

  • Derailment of SIRS ⇒vasodilation & hypotension⇒ ↑catecholamines,↑CO⇒R-A-Al activation ⇒ upregulation of iNOS in vessel wall
142
Q

81.1.5.Forms of Shock

Septic Shock

A

Diagnostic criteria

  • SIRS
    • T > 38oC or < 36oC
    • HR > 90/min
    • RR > 20/min or PCO2 < 32 mmHg
    • WBC > 12000/mm3 or < 4000/mm3 or bands > 10%
  • Sepsis : SIRS + infection
  • Septic shock : sepsis + tissue hypoperfusion
    • SAP < 90 mmHg
    • MAP < 65 mmHg
    • SAP ↓ > 40 mmHg from baseline
    • Lactate > 4 mmol/L
143
Q

81.1.6.Forms of Shock

Septic Shock

A

Treatment

  • Secure airway & ventilation
  • Early hemodynamic optimization -6h
    • Fluid resuscitation
    • Vasopressors
  • Infection control
    • cultures
    • antibiotics
    • surgical source control
  • Glycaemia control
  • Immune modulation
    • Activated protein C
    • Cortisol
144
Q

81.1.7. Forms of Shock

Neurogenic Shock

A
  • Shock due to loss of vasomotor tone to peripheral arterial beds
  • Cause: spinal corn injury or ischemia

Diagnosis

  • ↓BP, bradycardia
  • warm extremities
  • motor and sensory deficit
  • Radiographic evidence of spinal cord fracture

Treatment

  • Secure airway & ventilation
  • Fluid resuscitation
  • Vasopressors : dopamine and phenylephrine (a-agonist)
145
Q

81.1.8.Forms of Shock

Obstructive Shock

A
  • Due to mechanical obstruction of venous return
  • ↓ filling of right atrium (tension pneumothorax) ⇒ ↓ preload (cardiac temponade)

Diagnosis :

  • Respiratory distress
  • Hypotension
  • Ipsilateral ↓ breath sounds
  • Hyperresonance to percussion
  • Tracheal deviation
  • Distended jugular veins

Treatment : needle paracentesis, tube thoracostomy

146
Q

81.1.9.Forms of Shock

Obstructive Shock

A

Cardiac temponade

Diagnosis

  • High index of suspicion - injury mechanism
  • Dyspnea
  • Tachycardia & hypotension
  • Chest pain
  • Muffled heart sounds
  • Distended jugular veins/ ↑ CVP
  • Chest x-ray
  • Echocardiography

Treatment: needle pericardiocentesis, left thoracotomy &pericardial window

147
Q

81.2.Forms of Shock

Traumatic Shock

A

Systemic response after trauma

  • Mechanism
    • Soft tissue injury
    • Long bone fracture
    • Blood loss
  • Pathophysiology
    • Pro-inflammatory activation
    • High incidence of ARDS
  • Treatment
    • Hemorrhage control
    • Volume resuscitation
    • Stabilization of fractures & treatment of soft tissue injuries
148
Q

82.Endpoints Resuscitation

A
  • Goal in treatment of shock : restoration of adequate organ perfusion & tissue oxygenation
  • Endpoints for resuscitation
    • O2 transport
    • Lactate
    • Base deficit
    • Gastric tonometry
    • Near infrared spectroscopy
    • Tissue pH, O2,CO2
    • Right ventricular and diastolic index
149
Q

83.Fluid Resuscitation

A

Crystalloids vs Colloids

  • Crystaloids more used, cheaper, better results in trauma patients

Albumin infusion : detrimental

  • ↑mortality in hypovolemia, burns, hypoalbuminemia

Hypertonic saline (NaCl 7.5%)

  • Outcomes of hemorrhagic shock : immunomodulation, intracellular liquid shifting

Blood transfusion trigger

  • Hg 7-9 g/dL , Hg 10-12 g/dL for pt w/ cardiac disease

Hypotensive resuscitation

  • Penetrating injury : SBP 80-90 mmHg
  • Blunt trauma: SBP 110 mmHg
150
Q

84.Nutritional Assessment

History

A
  • Factors predisposing to malnutrition
  • Absorption disorders (celiac sprue)
  • AIDS
  • Alcoholism
  • Chronic renal insufficiency
  • Cirrhosis
  • DM
  • Enteric obstruction
  • IBS
  • Malignancy
  • Prolonged starvation
  • Psychiatric disorders
  • Recent major surgery,trauma or burn
  • Surgical operations of GI tract
  • Severe cardiopulmonary disease
151
Q

84.1.Nutritional Assessment

Physical Examination

A
152
Q

84.2.Nutritional Assessment

Lab tests

A
153
Q

85.Nutritional Indices

A
154
Q

86.Calculating Daily Energy Requirements

A

Basal Energy Expenditure

BEE(male) = 66.4 + [13.7 x weight in kg] + [5xheight in cm] - [6.8 x age]

BEE(female)= 655 + [9.6 x weight in kg] + [1.7xheight in cm] - [4.7 x age]

TEE = BEE x stress factor (1-1.8) kcal/day

155
Q

87.Metabolism Energy Requirements

A
  • Basal Metabolic Rate - 60% of TEE
    • 50% ion pumping
    • 30% pr metabolism
    • 20% aa,glc,lactate &pyruvate metabolism
  • Physical activity - 30% of TEE
    • 10-50% for normal subjects
    • 10-20% for hospitalized pts
  • Thermic Effect of Food - 10% of TEE
    • Energy expanded for digestion,absorption & metabolism of nutrients
156
Q

88.Nutrient Requirements

Carbohydrates

A
  • 1o energy source
  • 30-40% of total caloric intake
  • 4 kcal/g
  • Digestion:
    • salivary & pancreatic amylase
    • absorption by first 1-1.5m of small bowel
  • Min. intake of 400 kcal of CHOs / day minimizes pr takedown
  • Glc necessary for hemopoietic system & CNS
157
Q

88.1.Nutrient Requirements

Proteins

A
  • Composed of 20aas
  • 4 kcal/g of pr
  • Digestion
    • gastric peptin
    • pancreatic proteases
    • absorption at duodenum - 50% and mid-jejenum
  • Protein turnover
    • Total body pr 10-11 kg in a 70 kg person
    • Daily pr turnover 250-300g
  • Requirements : 0.8/kg body weight/day
  • Nitrogen balance
    • enteral + parenteral intake - urine losses-feces losses- other losses
    • 6.23 g of pr = 1 g of N
    • Urine nitrogen losses from 24h urine collection
    • Index of pr synthesis & breakdown
158
Q

88.2.Nutrient Requirements

Lipids

A
  • 24-45% of caloric intake
  • 9 kcal/g of lipid
  • Digestion
    • Bile salts⇒emulsification
    • Pancreatic lipase,cholesterol esterase, phospholipase A2
    • Lipolysis stimulated by steroids, catecholamines, glucagon. Inhibited by insulin
  • Body can synthesize most lipids
    • linoleic & linolenic LCFA are essential
  • Minimum of 3% caloric intake as essential FA
159
Q

88.3. Nutrient Requirements

Nucleotides & Vitamins

A
  • Nucleotides
  • Fat soluble vitamins : A,D,E,K
  • Water soluble vitamins : B1, B2, B6, B12, niacin, folate, biotin, pantothenic acid
  • Trace elements : Fe, Zn, Cu, Cr, Se, Mn, I
160
Q

89.Starvation

A

Effects of fasting

  • Overnight fast⇒ depletion of liver glycogen
  • 24h fast⇒depletion of CHO stores
  • First days⇒degredation of pr & fat
    • depression of insulin
    • breakdown of muscle pr
    • liver gluconeogenesis from aas
    • TG hydrolysis⇒FFA⇒energy for gluconeogenesis
161
Q

89.1.Starvation

A
  • Gluconeogenesis from aas
    • Urinary nitrogen secretion of 8-12g/day (urea)
    • Loss of 340g/day of lean tissue
    • Loss of 35% lean body mass in 1 month ⇒death
  • However : if sufficient water intake ⇒ starvation can be survived for 2-3 months
    • adaptation of metabolism to conserve energy by recycling metabolic intermediates
162
Q

89.2.Starvation

A
  • Metabolic adaptations to chronic starvation
    • After 10 days of starvation, brain starts using ketones as 1o fuel
    • ↓ in basic metabolism
    • ↓HR
    • ↓ of voluntary activity
    • ↑ in blood ketone levels
    • ↓ in gluconeogenesis
    • Urinary nitrogen excretion falls to 2-3g/day
163
Q

90.Elective Operation or Trauma

A
  • Neurohormonal activation
    • Epinephrine,cortisol - adrenals
    • Norepinephrine - sympathetic nerves
    • ADH- post pituitary
    • ACTH,TSH,GH - anterior pituitary
    • Glucagon
  • Peripheral lipolysis (glucagon,epinephrine,T3)
  • Accelerated catabolism-proteolysis (cortisol)
  • ↓peripheral glc uptake (GH,insulin)
    • glc intolerance
  • Water & Na urinary excretion
    • 15-20g/day
    • lean tissue loss of 750g/day - severe trauma
  • W/out nutrients the median survival is 15 days
164
Q

91.Sepsis & Nutrition

A
  • Inflammatory cytokines
    • TNFa, IL-1,IL-6
  • Marked muscle catabolism
  • Plasma glc, aas, FFA ↑
  • Glc intolerance
  • Urinary nitrogen excretion 20-30g/day
  • Without nutrients the median survival is 10 days
165
Q

92.Surgical Patient Diet

A

Surgical pt can’t eat :

  • up to 6h before anesthesia
  • under sedation
  • before upper GI endoscopy
  • after major upper GI procedures
  • bowel obstruction
  • paralytic ileus

Optimal diet:

  • CHO 55-60% (230-275g/day)
  • Fat 30% (70-75g/day)
  • Protein 10-15% (95-100g/day)
  • Cholesterol 300 mg/day - 1 egg yolk
  • Salt 3g/day
  • Fibers 25g/day
  • Vitamins
  • Total calories 2000-2500kcal/day - 30kcal/kg/day
166
Q

93.Normal Diet

A

Benefits:

  • Most physiological
    • Metabolic benefits
    • Production of gut immunoglobulins
  • Easily accepted by patient
  • Reduces post-op complications
  • Safer
  • Low cost

Problems:

  • Cannot be used for paralytic ileus or bowel obstruction
  • Risk of vomiting & inhalation
  • Patient anorexia⇒inadequate caloric intake
167
Q

94.Enteral Nutrition

A
  • Food directly into the gut
  • Blenderized food or special formulas
  • Can be given with syrienge
  • a pump controls the mixture administration rate

Benefits:

  • Preferred method of nutritional support for pt unable or unwilling to eat
  • Preserves gut functionality
  • Blenderized foot may be given
  • Lower cost than parenteral nutrition

Problems

  • Cannot be used in pt needing bowel rest
  • Delivery method requires a tube placement, dietary formulas, monitoring of feeding
  • Technical problems (5%) - tube clogging or displacement
  • Metabolic problems (25%) - nausea, vomiting, diarrhea, distension, hypernatremia, hyperglucemia
168
Q

95.Parenteral Nutrition

A
  • Nutrients given directly in blood
  • Requires specialized sterile nutritional slns
  • Circumvents digestive tube completely ⇒ bowel rest
  • Route of administration : peripheral parenteral nutrition, total parenteral nutrition

Indications

  • short bowel syndrome <100cm w/out colon, <50cm w/ colon
  • ↑output enteric fistulas (>500ml/d)
  • surgical pt w : prolonged paralytic ileus, multiple injuries or severe abdominal trauma
  • severe intestinal malabsorption syndromes
  • failure to maintain caloric needs w/ enteral nutrition
169
Q

95.1.Parenteral Nutrition

A

Formulas

  • 3-in-1 mixtures
    • Dextrose 20-50%
    • Aas 10%
    • Fat emulsion 20%
    • Electrolytes
    • vitamins
    • oligo-elements
  • Benefits
    • only method for pt w non functional digestive tube
    • bowel rest
  • Problems :
    • requires sterile conditions, catheter, close monitoring
    • technical problems : catheter clogging, displacement (embolism risk), infection(sepsis)
    • metabolic problems : hyper-hypoglucemia, electrolyte disorders, liver steatosis, gut mucosal atrophy
170
Q

95.2. Peripheral Parenteral Nutrition

A
  • Given through a peripheral vein catheter
  • Patients requiring nutritional support < 14 days
  • To avoid phlebitis the solution osmolarity < 1000 mosm/L
  • Great volumes of slns (>2.5-3L/day) are needed to fulfill caloric needs
171
Q

95.3.Total Parenteral Nutrition

A
  • Given through a central venous catheter (subclavian, internal jugular, femoral) or a peripheral inserted central catheter
  • More concentrated slns - ↑osmolarity
    *
172
Q
  1. Hallmarks of Cancer
A
  • Self-sufficiency in growth signals
  • Insensitivity to anti-growth signals
  • Evading programmed cell death
  • Limitless replicative potential
  • Sustained angiogenesis
  • Tissue invasion & metastasis
  • Deregulated metabolism
  • Evading the immune system
  • Genome instability
  • Inflammation
173
Q

97.Diagnosis of Cancer

A
  • Fine needle aspiration biopsy
    • cytological examination- no architecture
    • breast lumps, lung nodules, thyroid tumours
  • Core needle biopsy
    • sliver of tissue for pathological exam
    • radiological guidance
  • Excisional biopsy
    • removal of entire gross tumors
  • Sampling of a representative area of a lesion
174
Q

98.Tumor Grade

A
  • Tumor grade is a histological determination of the degree of cellular differentiation
  • ↑tumor grade ⇒ tumor is more biologically agressive
  • tumor grade factors : nuclear pleomorphism, cellularity, necrosis, cellular invasion, # of mitoses
  • Tumor grade is important for sarcomas, astrocytomas, Hodgkin & non-Hodgkin lymphomas, prostate cancer
175
Q

99.Tumor Stage

A
  • Denotes the extent of disease
  • Most imprtant prognostic & therapeutic strategy deliminating factor
  • Staging
    • Clinical
    • Pathological
  • Staging systems
    • TNM
    • Stage I-IV
176
Q

100.TNM Staging System

A
  • Tumor - T
    • 1o tumor extension
    • T1-4
  • Lymph Nodes - N
    • Regional lymph node involvement
    • N0-3
  • Metastases - M
    • Presence of distant metastases
    • M0-1
177
Q

101.Treatment

A
  • Curative surgery
    • resection of 1o tumor : R0,1 microscopic residual, R2 gross residual
  • Lymphadenectomy
    • Regional control
    • Sampling - staging
    • Sentinel lymph node - selective lymphadenopathy
  • Resection of isolated metastases
  • Adjuvant & neoadjuvant treatments
178
Q
  1. Palliation
A

Control of pain, bleeding, obstruction, malnutrition, infection in unresectable advanced cancer

Surgical palliation

  • malnutrition: vascular access, gastrostomy, jejunostomy
  • Pain
  • Oncological emergencies : hemorrhage, obstruction, perforation
179
Q
  1. Indication for Prophylactic Surgery
A

Removal of an organ that is at high risk of developing cancer due to a present mutation

  • ulcerative colitis ⇒ total coloproctectomy
  • familial adenomatous polyposis coli ⇒ total colectomy
  • multiple endocrine neoplasia (MEN2a&MEN2b)⇒total thyroidectomy
  • BRCA1&2 ⇒ bilateral mastectomy
180
Q

104.Cytotoxic Chemotherapy

A
  • Curative : for hematologic, anal, testicular cancer
  • Adjuvant : to improve survival after surgery
  • Neoadjuvant : to facilitate surgical resection by shrinking 1o tumor, to convert an initially unresectable tumor to a resectable one, to test a tumor sensitivity to chemotherapy
  • Palliative: to prolong survival &/or improve quality of life
  • systemic vs regional administration
  • Alkylating agents, platinum analogues, antimetabolites, antimicrotubule agents, topoisomerase inhibitors, antibiotics
181
Q
  1. Hormonal Therapy
A

Blocking effects of hormones that stimulate proliferation

  • Estrogen & androgen inhibitors
    • Tamoxifen for estrogen sensitive breast c.
    • Flutamide for prostate cancer
  • GRH anologues : leuprolide ⇒ pharma castration for breast & prostate cancer
  • Aromatase inhibitors : Anastroxol for metastatic breast c in postmenapause woman
  • Somatostatin anagolues octreotide for neuroendocrine tumors of gut etc
182
Q

106.Radiation Therapy

A
  • Locoregional control
  • Alone or in combination w/ surgery
    • pre or post operative
  • Mode of delivery
    • teletherapyi brachytherapy
  • Effect of radiation
    • Electrons or ↑E photons, exposure : roentgens, absorbed dose : gray, ionization ⇒ creation of free radicals
183
Q

107.Biologic Therapy

A

Molecular therapeutics exploit the molecular differences btw normal & cancer cells - targeted

  • Monoclonal antibodies w/ specificity to tumor antigens
    • Rituximab : anti CD20- non-hodgkin’s
  • Cancer preventative vaccines
    • HPV,HBV
  • Immunostimulants & vaccines
    • BCG infusion for superficial urinary bladder carcinoma
  • Experiental biological therapy
    • oncolytic virus therapy, gene therapy, adoptive T-cell cancer therapy
184
Q

108.Prognosis

A
  • Survival & disease free survival
  • Tumor grade
  • Tumor stage
  • Optimized & customized treatment strategy
  • Response to systemic treatment
185
Q

109.Paraneoplastic Syndromes

A
  • Cushing syndrome - ACTH-like
  • Syndrome of inappropriate ADH-secretion
  • Hypercalcemia- osteolysis- pthlike
  • Venous thrombosis
  • DIC
186
Q
  1. Tumor Markers
A

Substances that can be deteted in ↑ than normal amounts in serum or body fluids of pts

  • Prostate-specific antigen
  • Carcinoembryonic antigen - colorectal cancer
  • Alpha Fetopr-hepatocellular carcinoma
  • Cancer Antigen 15-3,27-29-recurrence of breast c
  • Chromogranin A-prognosis and monitoring of neuroendocrine tumors
187
Q

111.Transplantation Definitions

A
  • Allograft : an organ or tissue transplanted from one individual to another
  • HLA : human leukocyte antigen, the main trigger to graft rejection
  • Xenograft : a graft performed btw different species
  • Orthotopic graft : a graft placed in its normal anatomical site
  • Heterotopic graft : a graft placed in a site different from that where the organ is normally located
188
Q

112.Transplant Immunology

A
  • Allorecognition : IDing of antigen
  • APCs + Alloantigen +MHC
  • Bcells & antibodies
  • Tcells
  • Other cells : NK cells, monocytes/macrophages
189
Q

113.Transplant Rejection

A
  • Hyperacute rejection : antibodies bind to ABO blood group antigens
  • Acute rejection : T-cells cellular, Bcells hormonal rejection
  • Chronic rejection : fibrosis of small vessels

Diagnosis

  • Clinical & biochemical impaired organ function
  • Mild systemic immune symptoms : low grade fever, malaise, lymphocytosis
  • Biopsy
  • Immunosuppression masks symptoms
190
Q

114.Immunosuppression & Side effects

A
  • Corticosteroids,cancineurein inhibitors
  • Mammalian target of rapamycin inhibitors
  • Mycophenolic acid, anti-thymocyte globulin

Side effects

  • Opportunistic infection : Cytomegalovirus, Pneumocytosis jiiroveci
  • Malignancy : Post transplant lymphoproliferative disorders
191
Q
  1. Transplant Donors
A
  • Living donors
    • Relatives or emotionally connected people
    • Organs : kidney,liver lobe
    • Minimal risk for donor
  • Deceased donation : heart- beating, brainstem death, non-heart beating donors after circulatory death
  1. Registration as organ donor- agreement of next of kin
  2. Confirmation of brainstem death-irreversible structural brain damage
  3. Surgery for organ procurement
  4. Organ preservation
  5. Transplantation to receiver
192
Q

116.Heart Transplant

A
  • Indication : end-stage heart disease
  • Matching donor recipient
    • ABO compatibility
    • Size match
  • Technique : orthotopic heart
  • Survival 5-year 65%
193
Q
  1. Lung Transplant
A
  • Indication : end-stage lung disease
  • Matching donor to recipient
    • ABO compatibility
    • Size match
  • Technique : orthotopic single lung, double lung, heart lung transplantation
  • Survival : 5 year 40%
194
Q
  1. Kidney Transplant
A
  • Indication : end stage renal failure
  • Matching donor to recipient
    • ABO compatibility
    • HLA typing
  • Technique : extraperitoneal placement into iliac fossa
  • Survival : 5-year survival 84%
195
Q
  1. Pancrease & Islets of Langerhan Transplantation
A
  • Indication: insulin-dependent diabetes - w/kidney transplantation
  • Technique
    • Pancreas transplantation: whole organ implanted intraperitoneally or right iliac fossa
    • Islet cell transplantation: islet cells isolated & embolized into the donor liver through portal venous catheter
196
Q
  1. Liver Transplantation
A
  • Indication: end-stage liver disease, hepatocellular carcinoma
  • Child-Pugh score C⇒ indication
  • High MELD score - ↑er priority
  • Technique:
    • Orthotopic liver transplant
    • Living donor- lobe-transplant
  • Survival : 5 year graft survival 60%
197
Q
  1. Small bowel transplant
A
  • Indication : intestinal failure w/ life threatening TPN complication
  • Short bowel syndrome <50cm
  • High risk of acute rejection- gut immune cells

General Surgery (1 decks)

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