Misc Flashcards
Antibiotics to treat low-risk neutropenic fever…
Augmentin/Cipro
If PCN allergy, use clinda/cipro
How do we define neutropenic fever?
Temp > 38.0 for > 1 hour or isolated temp > 38.3 WITH ANC <=500
How do we treat high-risk neutropenic fever?
Zosyn or cefepime
If concern for line infection, add vanco
If concern for PNA, add gent or pulmonary fluroquinolone
BUN: Cr in pre-renal vs ATN
20:1 vs <20:1
Urine Osm in pre-renal vs ATN
> 500 vs <450
Urine specific gravity pre-renal vs ATN
> 1.020 vs <1.010
Urine sodium pre-renal vs ATN
<20 vs >40
FeNA in pre-renal vs ATN
<1% vs >2%
Casts seen in prerenal vs ATN
Hyaline vs muddy brown
Calculate energy expenditure
Harris-Benedict equation:
energy need = 655 + 9.6(wgt in kg) + 1.7(hgt in cm) + 4.7(age in yrs)
For normal person, multiple by 1.3 to get energy needs for TPN
Carbs = 50-60% Protein = 10-20% Lipids = 20-30%
How to calculate FeNa
(Serum Cr * urine Na)/(urine Cr * serum Na)
Causes of non-anion gap metabolic acidosis
RTA
Intestinal loss of bicarbonate (diarrhea/fistula)
Dilutional acidosis (rapid infusion of bicarbonate-free isotonic saline)
Ileostomy
Ureterosigmoidostomy
Drugs
Treatment of malignant hyperthermia
Dantrolene
Bladder innervation
Superior hypogastric plexus located over the sacral promontory
Hypogastric nerves contain sympathetic fibers and run below the ureter and lateral to the uterosacral - responsible for bladder compliance, urinary continence
Parasympathetic nerves come from pelvic splanchnic nerves and form the inferior hypogastric plexus which run along the parametria - responsible for detrusor contractability and rectal function
Type II vs type III radical hysterectomy
Type II is nerve sparing thus decreasing urology morbidity —> no difference in survival
What to do for ureteral injury
Above the pelvic brim: ureteroureterostomy or tranureteroureterostomy
Near bladder: Reimplantation
If much of pelvic ureter is removed, can perform a psoas hitch
If bladder is scarred preventing mobilization, a boari flap
Structures passing through the fossa ovalis
Fossa ovalis - opening in the fascia (covered by the cribiform)
Great saphenous vein, superficial epigastric artery, superficial external pudendal artery, femoral branch of the genitofemoral nerve
Most common fistula after radical hysterectomy; how do we diagnose and manage?
Ureterovaginal - 2-3%; present with watery vaginal discharge within 14 days of surgery
Diagnose with CT urogram or give pyridium and tampon test; Treat with stent or PCN
What bacteria cause vaginal cuff cellulitis? How do you treat it?
Polymicrobial - trx empirically with broad-spectrum penicillin with b-lactamase inhibitor (augmentin) or later-generation cephalosporin
Can also use flagyl and fluoroquinolone
What is the size threshold for draining an infection hematoma/abscess?
5 cm - can treat with gent/clinda or zosyn or cipro/flagyl
What are the bugs that cause hospital acquired PNA? What do you treat with?
HAP is no longer an entity defined by the ID society - but bugs are H influenza, Strep and Staph; less commonly E. coli, Enterobacter, Klebsiella, Proteus and Serratia
Treat with augment, levaquin, second or third generation cephalosporin
What are most common causes of community acquired PNA? How do you treat?
Strep pneumo, Klebsiellsa
Treat with respiratory quinolone or augmentin PLUS macrolide or doxy
How should we treat aspiration PNA?
Zosyn OR clinda + gent or cipro OR extended-spectrum cephalosporin + flagyl
Which type of hysterectomy has the highest risk of GU injury?
Laparoscopic
What to do with a ureteral crush injury…
Mild/minor - stent
Major/severe - resection of the injured portion with reanastomosis
Initial management of an anastomotic bowel leak…
Antibiotics and percutaneous drainage
What is blind loop syndrome?
Bacterial overgrowth in the small bowel —> chronic diarrhea and B12 deficiency
What increases risk for LE lymphedema following hysterectomy for uterine cancer?
Obesity, removal of more nodes, extent of surgery, post-operative infection, radiation therapy, postoperative DVT
Most common complication of a radical hysterectomy?
Bladder atony and urinary retention
How can we prevent wound infections in vulvar surgery?
Spare saphenous vein, optimize glucose control and use appropriate abx; we can also perform sentinel LN biopsy
What is incidence of lymphedema after inguinal LND? Risk factors?
Incidence = 14-48% RFs = obesity, # of nodes removes, extent of surgery, postoperative infection, RT to groin, postoperative DVT
Intrinsic vs extrinsic apoptosis pathway
Intrinsic = Mitochondrial mediated (get cytosolic cytochrome c —> activated by DNA damage, ER stress, oncogene activation; caspase 9 + cytochrome c = APAF1 Extrinsic = Death receptor mediated (TRAIL, TNFR); cascade 8
What is apoptosis?
Programmed cell death
What cascade is common executioner between intrinsic and extrinsic?
Caspase 3
Characteristics of apoptotic cells under microscope?
Chromatin condensation, nuclear fragmentation, membrane blabbing and cell shrinkage, formation of apoptotic bodies
What are gamma rays?
Emitted from unstable atomic nuclei during decay of radioactive material; used in brachytherapy
What are electrons used for and why?
Superficial lymph nodes or skin lesions —> deposit most of energy at or near the surface
Alpha particles
Positively charged emitted particles
Depth of 60Cobalt gamma rays? What is half life of cobalt?
1 cm (1.2 MeV); half life is 5 years
Tumor marker for breast cancer…
Ca 15-3
Germ Cell Tumor Markers
Dysgerminoma = LDH +/- bHCG Endodermal sinus = AFP Immature teratoma = +/- AFP Choriocarcinoma = bHCG Mixed germ cell = +/- AFP and bHCG Embryonal = bHCG +/- AFP Polyembryoma = bHCG +/- AFP
What does thumbprinting on an abdominal X-ray mean?
Sign of colonic inflammation - C diff, UC, ischemia colitis
In what germ cell tumor do we see multinucleated giant cells?
dysgerminoma (make bHCG)
What are Sedlis’ criteria?
High-intermediate risk factors for cervical cancer Treat with RT if... -deep stromal invasion (outer 1/3) -LVSI -tumor > 4cm
What tumor do you NOT want to radiate?
Verrucous carcinoma - can become more aggressive with RT
How to distinguish an endometrial stromal nodule from low-grade ESS
Tumor circumscription - LGESS shows irregular nodular growth pattern and worm-like plugs that fill and distend myometrial veins; with ESN there is no vascular invasion and a non-infiltrative border
Translocations associated with endometrial stromal sarcomas
LGESS = JAZF1/SUZ12 (t(7; 17)(p15;q21) HGESS = YWHAE/FAN22
Hemostatic agents
Fibrillation
Tisseal (can use in a patient with a defective clotting system ie DIC)
Floseal/Surgiflo
Gelfoam
How does hyperglycemia impair healing/increase infections?
Increased glucose levels impair phagocyte function and chemotaxis of granulocytes; also impairs fibroblast function
At what chronic steroid dose do we need to be concerned about adrenal insufficiency?
20 mg of prednisone daily for > 5 days
Definition of SIRS/sepsis
SIRS = two of more of the following in a setting of inflammation: temp > 38 or < 36, pulse > 90, RR > 20 or PaCO2 < 32, WBC > 12K or < 4K or > 10% band forms
Sepsis = SIRS due to known infection
Severe sepsis = sepsis with evidence of organ dysfxn, hypotension or hypoperfusion
What is Xgris?
Drotrecogen alpha - a recombinant form of human activate protein C which is frequently deficient in sepsis —> was previously used in sepsis but no longer
ASA classes
I: no chronic medical problems
II: Optimal control of mild chronic disease
III: Severe disease that limits activity without incapacitation
IV: Severe, incapacitating disease with constant threat to life
V: Moribund, death likely within 24 hours with or without surgery
MET as measure of functional capacity
1 MET = self care, walk around house, walk 1-2 blocks at 2-3mph
4 MET = can climb a flight of stairs, walk up a hill, walk on level ground at 4 mph, run a short distance, move furniture, play golf
10 MET = Strenuous activity, swimming, skiing
NY Heart Association Functional Classification of Heart Disease
I: Can carry 24 pound object up 8 steps, walk 5 mph, carry 80# object shovel snow
II: Can walk 4 mph, rake or weed garden, have sex, walk up 8 steps
III: Can make bed, push lawn mower, shower, walk 2.5 mph, dress
IV: None of the above
Equation for SVR
SVR = [(MAP-PAWP)/CO]*80
Normal 700-1600 dynes/sec/cm-5
What on PFTs predict high risk surgical candidate?
FEV1 < 1L, FEV1/FVC < 75%, MMV < 50%
How far prior to surgery should a patient stop smoking to decrease risk?
8 weeks
How to calculate anion gap?
AG = Na - (Cl + HCO3)
Normal = 12 +/- 4
How to calculate serum osmolality?
Osmolality = 2[Na + K] + urea/2.8 + glucose/18
