Module B Flashcards
Fascia Iliaca Block
Performed using ultrasound-guided approach or a landmark
The fascia iliaca compartment is a potential space lying between the fascia ilaca anteriorly and the iliacus and psoas muscles (iliopsoas) posteriorly
Indications: analgesia for fractured neck of femur (safe, cheap and effective)
Works by affecting the femoral, obturator and the lateral cutaneous nerves with a local anesthetic
Urinary urge incontinence
Urine leaks due to intense urge to pass urine
1st line tx: antimuscarinic drugs e.g. oxybutynin, tolterodine, and solifenacin
2nd line tx: mirabegron (β3 agonist)
Urinary stress incontinence
Defined as: physical movement or activity e.g., coughing, laughing, sneezing, running or heavy lift which puts pressure/stress on bladder, causing urine leakage
Non-medical management: pelvic floor exercises, and caffeine intake reduction
Medical tx: duloxetine (serotonin/norepinephrine reuptake inhibitor)
Small bowel bacterial overgrowth syndrome
Excessive amounts of bacteria in the small bowel
RFs: scleroderma, neonates with GI abnormalities, DM
Symptoms: chronic diarrhoea, bloating, flatulence, abdominal pain (resemble IBS)
Dx: hydrogen breath test, small bowel aspiration and culture (not commonly used as invasive), abx trial
1st line tx: rifaximin (low systemic absorption, good intraluminal target)
2nd line tx: co-amoxiclav or metronidazole
Acute ascending cholangitis
Bacterial infection of biliary tree (typically E. coli)
RF: gallstones
Charcot’s triad: fever, jaundice, RUQ pain
Reynold’s pentad: fever, jaundice, RUQ pain, confusion, hypotension
Ix: raised inflammatory markers (WBC), bilirubin, and ALP
Mx: IV abx, and ERCP after 24-48 hours to relieve obstruction via biliary drainage
Reynolds’ pentad
Fever, jaundice, RUQ pain, confusion, hypotension
Use: diagnosis of obstructive ascending cholangitis
Charcot’s triad
Fever, jaundice, RUQ pain
Due to ascending cholangitis (an infection of the bile duct in the liver)
Alvarado score
Clinical scoring system used in the diagnosis of acute appendicitis: Migration of pain Anorexia Nausea Tenderness in RLQ Rebound tenderness Elevated temperature Leucocytosis Shift of WBC to the left (neutrophils >75%)
Acute appendicitis
Commonest acute abdomen presentation
Px: periumbilical pain migrating to RIF, N&V, mild pyrexia, anorexia, diarrhoea(rare)
Dx: Rovsing’s sign, rebound tenderness
Alvarado score used, raised WBC (neutrophils), raised inflammatory markers, negative pregnancy test, USS to confirm absence of alternative pelvic organ pathology (may observe free fluid - pathological in males)
Tx: appendicetomy with prophylactic IV abx given preoperatively
Rovsing’s sign
palpation in the LIF causes pain in the RIF
Murphy’s sign
Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.
Group & Save
Blood taken to determine patient’s blood group then serum is saved for rapid cross-matching if required
Rigler’s sign
AKA double wall sign seen on abdominal x-ray that identifies a pneumoperitoneum with gas outlining both sides of the bowel wall,i.e. gas within the bowel’s lumen and gas within the peritoneal cavity
Pancreatitis causes
I GET SMASHED
I - idiopathic
G - gallstones; genetic (cystic fibrosis)
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion
H - hyperlipidaemia/hypercalcaemia/hyperparathyroidism (metabolic disorders)
E - ERCP
D - drugs (tetracyclines, furosemide, azathioprine, thiazides and many others)
Anaesthesia definition
Drug induced reversible loss of consciousness which allows surgery and invasive procedures
Triad of anaesthesia
Hypnosis = unconsciousness
Analgesia = pain relief
Muscle relaxant = paralysis
Pre-operative assessment
Doctor or nurse meets pt
History, examination, appropriate tests
Discuss risks of surgery and anaesthesia
Advise regarding alternatives (including non-operative interventions) to encourage pt to be involved in shared decision making
Suggest modifiable risk factors e.g. smoking cessation, weight loss, dietary recommendations, stopping/starting new drugs
Regional anaesthesia
May be with/out GA
E.g. peripheral nerve block, spinal (subarachnoid), epidural, local anaesthetic field block, plexus nerve block
3 aims of WHO surgical checklist
Reduce risk of wrong sites surgery
Encourage communication between all team members
Ensure there are no preventative errors
Timeline of anaesthesia
Induction = transition from awake to anaesthetised Maintenance = keeping a patient unconscious & paralysed + perioperative care Emergence = reversal of unconsciousness and paralysis Recovery = monitor vital signs, pain, possible complications (e.g. airway control, eating, drinking, speaking)
Induction of anaesthesia
1st stage of anaesthesia timeline: IV or inhalational
IV = analgesia and hypnotic agent e.g. fentanyl and propofol
Inhalation = volatile agent e.g. sevoflurane with O2 and air or N2O
Muscle relaxant given if intubation required or surgery requires pt to be immobilised
Preoperative assessment on day of operation
Anaesthetic hx + past problems
FH of anaesthetic problems (rare)
PMH - CV, Resp, DM, fits/seizures, epilepsy
DH + allergies
Metal work - important for diathermy
SH - excessive alcohol intake ↑anaesthetic required
Airway assessment - loose teeth, caps, crowns, dentures; Mallampati score, flexion/extension of neck, number of fingers in mouth
Mallampati score
Class 1: soft palate, fauces, pillars, uvula visible
Class 2: soft palate, fauces, part of uvula visible
Class 3: base of uvula visible, soft palate visible
Class 4: hard palate only visible
Higher class results in more difficulty controlling airway during anaesthetic
MAC
Minimum alveolar concentration
Defined as the fraction of volume of the anesthetic present in the inspired air that provides sufficient analgesia in 50% of patients, meaning that patients will not respond to an extremely painful stimulus such as surgical skin incision
Determines potency of inhalational anaesthetics as the MAC is inversely related to the anaesthetic potency (1/MAC = potency)
EC50
Effective concentration required to produce 50% of the maximum possible response
Determines potency of drug
ED50
ED50 is the median effective dose that produces a desired beneficial effect in 50% of the population
Therapeutic index
A measurement of the safety of a drug
Malignant hyperthermia
A subclinical myopathy in which general anesthesia triggers an uncontrollable contraction of skeletal muscle that leads to a life-threatening hypercatabolic state and increase in body temperature
Autosomal dominant - mutation in ryanodine receptor type 1 on sarcoplasmic reticulum causing an accumulation of intracellular calcium in skeletal muscle that leads to its overactivation and hypermetabolism
Signs and symptoms: tachycardia, tachypnoea, cyanosis, rigidity, hyperthermia (up to 45ºC)
Tx: stop responsible agent, 100% oxygen and give Dantrolene (inhibits ryanodine receptors to prevent calcium release)
2:1 M:F
70% mortality rate if not rapidly treated, risk reduces to <10% with treatment
Airway management during induction
Head tilt, chin lift, jaw thrust manoeuvres
Adjuncts e.g. Guedel airway, nasopharyngeal airway
Supraglottic device - laryngeal mask airway, iGel
Endotracheal intubation
Maintenance of anaesthesia
Volatile agents delivered via anaesthetic machine with measured concentrations with oxygen and air
IV maintenance with propofol and opioid infusions
Intraoperative care
- Analgesia - to reduce sympathetic response + smooth emergence
- Positioning - adapt neutral position with padding to prevent nerve and pressure injury
- Warming - at risk of hypothermia
- Fluid balance - IV fluids and monitoring
- CVS manipulated to offset hypotensive effects of anaesthesia e.g. IV fluids, alpha and beta adrenoceptors agonist (ephedrine and metaraminol), antimuscarinic cholinergic drugs
- Blood and product transfusion
- Antibiotics
- Post-operative drugs e.g. DVT prophylaxis, analgesia, pt’s current drugs
Emergence from anaesthesia involves…
Analgesia and anti-emetics
Muscular function restored by reversing paralysis
Maintenance agents switched off once muscle control demonstrated
Extubation e.g. ET or LMA
Monitor for immediate post-operative complications
Recovery
Monitor pt: vital signs (HR, BP, RR, SpO2), pain scores, ABCDE approach to post-operative complications
Pain relief and anti-emetics
Transfer to ward, day care unit, ITU
Patient involved in enhanced recovery program
Train of 4 stimulation
A technique to assess neuromuscular blockade in patients receiving anesthesia. Four electric stimuli are administered along the ulnar nerve every 2 seconds; the number of twitches of the adductor pollicis muscle are counted
Zero twitches indicates profound block; 1–2 twitches indicate partial block.
Hydrogen breath test
SIBO
Lactose intolerance breath test
Use:
CT enterography with IV contrast
Use:
Nausea
Vague, disagreeable sensation of queasiness or feeling sick to the stomach, that may be followed by vomiting
Vomiting
Forceful expulsion of gastric contents, through a relaxed upper oesophageal sphincter and open mouth
Bloating
Considered the subjective sensation that is associated with abdominal distension i.e. the visible increase in abdominal girth
Succusion splash
Observed on auscultation
Why are calcium levels measured in patients reporting prolonged nausea and vomiting?
Hypercalcaemia typically presents with vomiting, abdominal pain, and constipation
Upper GI endoscopy
Use:
CT abdomen (indications)
Used for: abdominal pain abdominal sepsis bowel obstruction postoperative complications trauma vascular compromise, e.g. aortic aneurysm bowel perforation colon cancer
MRI abdomen
Use:
Gastric emptying scan
Use:
Diabetic gastroparesis
An autonomic neuropathy seen with poor blood glucose control (BM >15mmol/L) Typically affects the vagus nerve 27-58% of pts are T1DM May be seen in T2DM in first 10yrs Tx: prokinetics e.g. metoclopramide
GI stromal tumour
Use:
Anti-TTG
Use:
Faecal calprotectin
Use: differentiates between IBS and IBD
Small intestinal bacterial overgrowth
Seen in pts with reduced gastric acid, small bowel diverticulae, small bowel strictures, post-op adhesions, diabetes, scleroderma
Symptoms: bloating, chronic diarrhoea, malabsorption, weight loss
Tx: rifaximin (not licensed use), co-amoxiclav, ciprofloxacin, metronidazole, tetracyclins
Rome III diagnostic criteria for functional bloating
Used for IBS bloating
Pt must report both for 3months with symptom onset at least 6 months prior to diagnosis:
1. Recurrent bloating or visible distension at least 3 days a month in the last 3 months
2. Insufficient criteria for functional dyspepsia, IBS, or other functional GI disorders
Epigastric pain differential diagnosis
Gastritis Pancreatitis Peptic ulcer Perforated ulcer Biliary colic Cholecystitis Small bowel obstruction Mesenteric ischaemia Epigastric hernia
Right/Left loin/lumbar/flank pain differential diagnosis
Ureteric colic
Pyelonephritis
AAA
RIF Pain Differential Diagnosis
Appendicitis Mesenteric lymphadenitis Meckel's diverticulitis or perforation Terminal ileitis Perforated caecum Caecal diverticulitis Sigmoid diverticulitis Hernia Ruptured or torted ovarian cyst Salpingitis or PID Ectopic pregnancy Mittelschmerz Endometriosis Testicular torsion
Hypogastric/Suprapubic pain differential diagnosis
Cystitis Urinary retention Uterine fibroids Period pain Pregnancy Ovarian pathology Diverticulitis Appendicitis
LIF Pain differential diagnosis
Sigmoid diverticulitis Caecal diverticulitis Colitis Constipation Large bowel obstruction Perforated cancer Ruptured/torted ovarian cyst Salpingitis or PID Ectopic pregnancy Endometriosis Hernia Testicular torsion
RUQ pain differential diagnosis
Gastritis Peptic ulcer Perforated ulcer Pancreatitis Cholecystitis Biliary colic Cholangitis Hepatitis Ureteric colic Pyelonephritis RLL pneumonia
LUQ pain differential diagnosis
Painful splenomegaly Pancreatitis Diverticulitis Colitis Perforated transverse/left colon Epiploic appendagitis LLL pneumonia MI
Finkelstein’s test
Used to diagnose de Quervain’s tenosynovitis in people who have wrist pain
Trendelenburg’s test
Used to assess the strength of the hip abductors, specifically the gluteus medius and minimus
Performed when patient has a limp or hip pain
Phalen’s test
A provocative test used in the diagnosis of carpal tunnel syndrome
Pt flexes wrist at 90 degrees whilst resting on table for 30-60s and if CTS present, will elicit pain/tingling/paraesthesia associated with CTS along fingers innervated by the median nerve
Bulge sign test
Used to identify joint effusion in the knee
The examiner strokes upwards with the edge of the hand on the medial side of the knee to drain the fluid proximal to the patella. The examiner then proceeded to push the fluid inferiorly into the lateral aspect of the knee.
Schober’s test
Used to determine if there is a decrease in lumbar spine range of motion (flexion), most commonly as a result of ankylosing spondylitis
SLE
Associated with thymomas (less frequently than myasthenia gravis)
Positive glutamate dehydrogenase
Faecal test that indicates the large intestine is colonised by Clostridium difficile
Further test required to determine if toxins A and B are present indicating an infection rather than colonisation
C. difficile infection treated with metronidazole
Treatment for mild diverticulitis
Metronidazole
Disulfiram-like reaction with alcohol seen with…
Metronidazole
Cefoperazone
Symptoms include: headache, N&V, head and neck flushing, sweatiness, palpitations
Total parenteral nutrition
Used if enteral feeding is contraindicated, concerns about malnourishment following surgery/chemotherapy/radiation therapy/coma
Administered via a central vein (IV) as it is strongly phlebitic
Feeding bypasses GI tract; considered a last resort to resolve complete enteral starvation
Long term use effects: fatty liver and deranged LFT’s
Percutaneous endoscopic gastrostomy
Combined endoscopic and percutaneous tube insertion
Pt must be fit for endoscopy
Risks: aspiration and leakage at site of insertion
Feeding jejunostomy
Surgically sited feeding tube
Low aspiration risk, safe for long term use following upper GI surgery
SEs: tube displacement and peritubal leakage (immediately after insertion, associated with peritonitis risk)
Nasogastric feeding
Administered via fine bore nasogastric feeding tube
Complications associated with misplaced tube and aspiration
Safe for use with impaired swallowing
Contraindicated following head injury due to risks associated with tube insertion
Nasojejunal feeding
Insertion of feeding tube more technically complicated (easiest if done intra operatively)
Avoids problems of feed pooling in stomach (and risk of aspiration)
Safe following oesophagogastric surgery
Consequences of hypothermia intraoperatively
Anaesthetic drugs are metabolised more slowly
Platelet, coagulation factors and the immune system are less effective = increased bleeding risk
Muscle relaxants prevents shivering
Spinal/epidural anaesthesia prevents peripheral vasoconstriction via reduced sympathetic tone causing increased heat loss at the peripheries
Primary biliary cholangitis
Chronic autoimmune liver disease associated with Sjorgen’s syndrome, RA, systemic sclerosis and thyroid disease
Interlobular bile ducts damage by chronic inflammation causing cholestasis and cirrhosis
Px: middle aged woman with itching, asymptomatic, hyperpigmentation, xantholasma/mata, hepatosplenomegaly
Dx: anti-mitochondrial antibodies (>1:40), raised ALP & GGT
Tx: all pts PO ursodeoxycholic acid lifelong, fat soluble vitamin supplementation, cholestyramine for symptomatic mx of pruritus
Complications: cirrhosis, portal hypertension, ascites, variceal haemorrhage, osteomalacia, osteoporosis, 20x increased risk of hepatocellular carcinoma
Decompensated liver disease
Symptomatic cirrhosis where liver function is longer preserved
Px: fatigue, jaundice, pruritus, ascites, easy bleeding/bruising, peripheral oedema, N&V, abdo pain
Tx: liver transplant
Paralytic ileus
Complication after bowel surgery
No peristalsis (hence absent bowel sounds, distension, no wind passed or bowel opening) resulting in pseudo-obstruction
Seen with chest infections, MI, stroke, and AKI
U&Es performed immediately as may be caused by deranged electrolytes e.g. K+, Mg2+, or phosphate
Tx: IV electrolyte replacement
Spinal epidural complication
epidural haematoma
epidural abscess (slow progression of symptoms)
direct spinal cord injury (immediate symptoms after surgery)
local anaesthetic toxicity (numbness, restlessness, tinnitus, shivering, muscular twitching, convulsion, LOC, apnoea seen)
Carcinoid syndrome
Due to metastases to liver (or lung in some cases) resulting in bradykinin and serotonin release into circulation. May also stimulate ACTH or GHRH causing Cushings features (round face, weight gain)
Px: flushing, diarrhoea, bronchospasm, hypotension
Tx: octreotide (somatostatin analogue)
Septic arthritis
Aetiology: S. aureus, N. gonorrhoea (in sexually active young adults) via haematogenous spread (from distant bacterial infections)
Px: acute painful swollen joint with restricted movement, fever
Ix: synovial fluid sampling, blood cultures, joint imaging
Tx: IV flucloxacillin or clindamycin (if penicillin allergic) for 6-12weeks with needle aspiration to decompress the joint
Gastrostomy
used for gastric decompression or feeding
location = epigastrium
End ileostomy
following complete excision of colon or where ileocolic anastomosis is not planned
stoma location: right iliac fossa
End colostomy
performed when the colon is diverted or resected and anastomosis is not primarily achievable or desirable
involves bringing the distal part of the colon up to the skin
stoma location: L/R iliac fossa
Loop ileostomy
Used for defunctioning of colon e.g. following rectal cancer surgery
Stoma at right iliac fossa
Wilson’s disease
autosomal recessive disorder characterised by excessive copper deposition in the tissues
Defect in the ATP7B gene located on chromosome 13
Px aged 10-25yrs with:
- liver problems (young adults - hepatitis, cirrhosis)
- neurological problems (kids) - basal ganglia degeneration affecting globus pallidus or putamen, behavioural/speech/psychiatric problems, asterixis, chorea, dementia, parkinsonism
Signs: Kayser-Fleischer rings (green/brown rings in Descement membrane of eyes), blue nails, renal tubular acidosis (Fanconi syndrome), haemolysis
Ix: low serum caeruloplasmin, low serum copper, slit lamp examination of Kayser-Fleischer rings, increased 24hr urinary copper excretion
1st line tx: penicillamine OR trientine hydrochloride
Carpal tunnel syndrome
Compression of median nerve in the carpal tunnel
Causes: idiopathic, pregnancy, RA (bilateral), lunate fracture, oedema
Px: pain or pins and needles in thumb, index and middle finger, may ascend proximally, shaking hand to obtain relief typically at night
Ix: electrophysiology shows prolongation of action potential in motor and sensory axons
Findings: weakness of thumb abduction (abductor pollicis brevis), thenar eminence wasting, tinel and phalen’s signs
Tx: wrist splints at night, corticosteroid injection, surgical decompression (division of flexor retinaculum)
Tinel’s sign
Tapping on median nerve causes paraesthesia (tingling or pins and needles) along nerve
Used in carpal tunnel syndrome diagnosis
Also used in cubital tunnel syndrome (ulnar nerve entrapment)
Acute pancreatitis
Px: epigastric pain radiating to the back, N&V, fever, tachy Modified Glasgow (Glasgow-Imrie) Score used to determine severity of pancreatitis: P - Pa02 < 8kPa A - Age > 55 years N - Neutrophilia (WBC > 15x10^9) C - Calcium < 2mmol/L R - Renal function (Urea > 16mmol/L) E - Enzymes (LDH > 600; AST > 200) A - Albumin < 32g/L S - Sugar (Blood glucose > 10mmol/L) Mx: fluids and nutritional support Complications: peripancreatic fluid collections which resolves or forms a pseudocyst or abscess (transgastric or endoscopic drainage required), pancreatic necrosis (manage conservatively initially), ARDS, MOF
Pancreatic pseudocyst
Typically develops 4 weeks after acute pancreatitis due to peripancreatic fluid collection walled by fibrous or granulation tissue
mild elevation of amylase seen typically
Resolves spontaneously hence, only analgesia required for first 12weeks
After 12 weeks consider endoscopic or surgical cystogastrostomy or aspiration
Gout
Hyperuricaemia resulting in deposition of crystals in joint
Px: rapid onset hot, swollen, painful joint
RFs: male, obese, high purine intake, CVD, renal disease, diuretic use
Dx: clinical diagnosis typically; arthrocentesis (rule out septic arthritis) - needle-shaped monosodium urate crystals with negative birefringence under polarised light; X-ray - lytic lesions, punched out appearance, sclerotic borders, overhanging edges, normal joint space
Acute attacks tx: NSAIDs, Colchicine (if pt has heart disease), Steroids (if pt has renal failure)
Prophylaxis: allopurinol 100mg PO OD (started once attack has subsided, continue through attacks once started), weight loss, reduced uric acid intake, reduce alcohol, improve hydration
Pseudogout
Calcium pyrophosphate deposition, EULAR classification used to identify type
Px: hot, swollen, painful joint
Ix: joint aspiration - rhomboid-shaped calcium pyrophosphate crystals with positive birefringence of polarised light; x-ray - LOSS signs, chondrocalcinosis (line in middle of joint)
Tx: NSAIDs, Colchicine, IA steroids, joint washout (arthrocentesis in severe cases)
Bony sarcoma
Malignant tumour of mesenchymal origin
Osteosarcoma = mesenchymal cells with osteoblastic differentiation, common in males 25-30yo, tx: limb preserving surgery & chemotherapy
Ewing sarcoma = common in males 10-20yo in femoral diaphysis (shaft), associated with bloodborne mets, histo. shows small round tumour, tx: chemotherapy and surgery
Malignant fibrous histiocytoma (may be soft tissue origin) = large number of histiocytes (phagocytic cells in connective tissue)
Chondrosarcoma = tumour of cartilage cells, pt > 40yrs, commonly seen in upper arm/pelvis/femur
Soft tissue sarcoma
Malignant tumour of mesenchymal origin
Liposarcoma = adipocytes, deep location e.g. retroperitoneum, pt > 40yrs, pseudocapsule hence surgery not an option, tx: palliative radiotherapy
Rhabdomyosarcoma = striated muscle
Leiomyosarcoma = smooth muscle
Synovial sarcomas = close to joints
Malignant fibrous histiocytoma (can be bony as well) = large number of histiocytes (phagocytic cells in connective tissue), most common sarcoma in adults, tx: surgical resection and adjuvant radiotherapy to reduce local recurrence
Osteochondroma
Benign primary bone tumour
Common in M < 25yrs
Arises from Exostosin 1 and 2 gene (EXT1/2) mutations
Management of asthma and COPD in the perioperative period
Asthmatics should have a PEFR done and bronchodilators should be continued pre/post -operatively
COPD patients may need physiotherapy both pre- and post-operatively
