Monday 9/5/16: Surgery exam 2 Flashcards
What is a common complication of a thyroidectomy for Grave’s disease?
Post-surgical hypoparathyroidism
What is a common complication from the removal of 3.5 parathyroid glands due to parathyroid hyperplasia?
Post-surgical hypoparathyroidism
What does post-surgical hypoparathyroidism cause in patient who has just had a thyroidectomy?
Hypocalcemia
How does hypocalcemia present?
- Fatigue
- Anxiety
- Depression
- Involuntary contractions involving the lips, face
- Seizures
How might an electrocardiogram look for someone with hypocalcemia?
May show a prolonged QT interval.
What is associated with hypercalcemia?
Vitamin D toxicity
Shortened QT interval
What can happen in persistent hypothyroidism?
Can cause hyponatremia if without thyroid supplementation.
How can you characterize hypoparathyroidism?
- Low calcium
- High phosphorus
All in the presence of normal renal function.
What are some causes of hypoparathyroidism?
- Post surgical
- Autoimmune parathyroid destruction
- Defective calcium-sensing receptor
How does a patient with a perforation of a hollow abdominal viscus present?
- Acute abdomen
- Rebound tenderness
- Subdiaphragmatic free (intraperitoneal air) on abdominal X-ray
What is the treatment of a perforated hollow abdominal viscus?
- Pre-operative NG decompression
- IV fluids and antibiotics
- Emergent laparotomy
If a patient in need of an ex lap has an INR of 2.1 which is therapeutic for atrial fib, what needs to happen before the surgery and why?
Warfarin-induced anticoagulation must be reversed because it will predispose the patient to intra-operative and post-operative bleeding complications.
What is the most rapid means of normalizing the prothrombin time?
Restoration of the vitamin-k dependent clotting factors through an infusion of fresh frozen plasma
When do patients receive packed red blood?
Usually when the tissue oxygen delivery does not become deficient until the hgb is below 7g/dL
What platelet lab values provide adequate hemostasis for most invasive procedures?
Above 50,000
What does vitamin k administration depend on to correct the coagulation time in warfarin treated patients?
Synthesis of new vitamin k dependent clotting factors (2,7,9,10) by the liver which takes time so should not be used in emergent situations,
When is desmopressin or DDAVP given pre-operatively?
Patients with mild hemophilia A in order to prevent excessive bleeding.
What does DDAVP do?
Indirectly increases factor 8 levels by causing vWF release from endothelial cells.
What can happen in a circumferential, full-thickness (3rd degree burn)
Eschar formation that restricts venous and lymphatic drainage leading to acute compartment syndrome.
What is acute compartment syndrome?
Occurs when excessive fluid accumulation in a confined compartment in the body causes an increase in compartment pressure to the point that blood flow is severely impaired.
What is the first presenting symptom of acute compartment syndrome?
Pain out of proportion to clinical findings
What are some other symptoms of acute compartment syndrome?
- Worsening pain on passive stretch
- Tissue tension
- Pallor
4 decreased sensation
What will happen if elevated compartment pressure is allowed to persist?
Tissue ischemia and eventual tissue death will occur.
How should acute compartment syndrome be managed?
- Serial compartment pressure monitoring to determine need for surgical intervention
- Surgical: compartment decompression by fasciotomy or in the case of circumferential burns, escharotomy.
How is cellulitis characterized?
Skin warmth
How is gas gangrene characterized?
Crepitus.
How does inflammatory arthritis present?
Pain and swelling often involving the bacterial metacarpal phalangeal joints.
What is the clinical presentation of a small bowel obstruction?
- Colicky abdominal pain
- Vomiting
- Inability to pass gas or stool
- Hyperactive bowel sounds
- Distended and tympanic abdomen
How do you diagnose a small bowel obstruction?
- Dilated loops of bowel with air fluid levels
- Partial: air in colon
- Complete: transition point (abrupt cutoff) no air in colon
What are some complications of small bowel obstruction?
- Ischemia/necrosis (strangulation)
2. Bowel perforation
How do you manage small bowel obstructions?
- Bowel rest, NG suction, IV fluids
2. Surgical exploration for signs of complications
What is an important risk factor for small bowel obstruction?
A history of prior abdominal surgery. SBO due to adhesion development
What is indicative of a complicated small bowel obstruction?
- Changes in the character of pain
- Fever
- Hemodynamic instability (hypotension, tachycardia)
- Significant metabolic acidosis (ex. Low bicarbonate)
Should antibiotics be given to patient with complicated SBO?
No, although it would be helpful in an uncomplicated SBO because they have increased risks of intestinal bacteria translocation with strangulation.
What does a small bowel follow through help diagnose?
Partial intestinal obstruction in clinically stable patients who do not respond completely to initial conservative management.
What is the preferred imaging choice for acute mesenteric ischemia
CT angiography
How would you know you have a colonic pseudo obstruction?
Imaging would instead show dilated colon.
When do you see acalculous cholecystitis?
In severely ill patients in the ICU with multiorgan failure, severe trauma, burns, sepsis, or prolonged parentral nutrition.
What causes acalculous cholecystitis?
Due to cholestasis and gallbladder ischemia leading to secondary infection by enteric organisms and resultant edema and necrosis of the gallbladder.
What are the signs of acalculous cholecystitis?
- Fever, leukocytosis
2. Usually no communicative due to their general medical condition.
What are some radiologic signs for acalculous cholecystitis?
- Gallbladder wall thickening
2. Presence of pericholecystic fluid
What is the immediate treatment in critically ill patients with acalculous cholecystitis?
Antibiotics
Percutaneous cholecystostomy under radiologic guidance.
What is the definitive therapy of acalculous cholecystitis?
Cholecystectomy with drainage of any associated abscesses when the patient stabilizes
How does ileus present?
Small and large bowel distinction
Hypoactive bowel sounds
How does pancreatitis present on CT?
Parenchymal enhancement with IV contrast( with no pancreatic necrosis)
Pseudocyst formation
Peripancreatic fluid collection
How does mesenteric ischemia present?
- Sudden periumbilical pain out of proportion to physical findings.
What are risk factors for mesenteric ischemia?
- Older age
- A. Fib.
- CHF
- Atherosclerotic vascular disease
How does the CT look for mesenteric ischemia?
- Focal or segmental bowel wall thickening
- Small bowel dilation
- Mesenteric stranding
How does duodenal perforation present?
- Sudden onset
- Diffuse abdominal pain
- Abdomen is rigid
- Signs of peritonitis
- Imaging shows free air under the diaphragm
