NMS - Casebook Flashcards
What should blood glucose be in the immediate Preop period? What can be done to ensure this?
Between 100-250
Hold oral hypoglycemics, give 1/2 or 2/3 of NPH/insulin on day of surgery
What type of patient may not be a good candidate for laparoscopic surgery, and open surgery be preferred?
Patients with poor pulmonary function (specifically COPD with high pCO2), as CO2 from insufflation gas may be absorbed to blood stream in excess
Which five factors predict risk for cardiac complications after vascular surgery?
- Q waves on ecg
- History of ventricular ectopy requiring treatment
- Hx of angina
- DM requiring medical therapy
- Age > 70
When should aspirin and NSAIDs be stopped in the Preop period?
Aspiring 7-10 days before surgery, NSAIDs 2 days before, to ensure normal platelet function
What ECG finding is highly suggestive of underlying ischemic heart disease?
Left bundle branch block (never a normal variant)
What should be done for a patient who is found to have afib preoperatively?
- Find underlying cause
- Cardio version or beta blockers
- Oral anticoagulant
What is the main surgical risk in a cirrhotic patient?
Inability to tolerate even mild sedation
Check lab values and physical exam signs of cirrhosis
What factors need to be optimized in a patient with cirrhosis and as it’s to undergo surgery?
- Decrease ascites with K sparing diuretics and salt and water restriction
- Decrease Child risk classification
- Normalize PT with vitamin K
- Alcohol abstinence for 6-8 weeks
What should be done if ulceration is noted over a hernia?
Sign of pressure necrosis, thus increased risk of rupture
expedite surgery
What is the risk of hernia leaking ascitic fluid?
Risk of SBP, get cell count and culture of fluid and start IV Abx
Repair hernia urgently
What is the likely cause of capillary oozing in a chronic kidney failure patient and how can you treat this?
Platelet dysfunction due to uremia
- Desmopressin (ddAVP)
- FFP
- PostOp hemodialysis
What is the most likely cause of hypotension in a kidney transplant patient postop with no signs of hemorrhage? How can you treat?
Glucocorticoid deficiency, as patients are usually on steroids
Give hydrocortisone 25mg intraop and 100mg over 24 hrs
What should all patients with valvular abnormalities getting surgery receive?
Prophylactic Abx for prevention of subacute bacterial endocarditis
What is the equation for calculating intraop fluid requirements?
(EBL x 3 mL isotonic fluid / 1 mL blood loss) + UO - IVF given in OR = 700
What is the risk of continued IVF in the recovery period following surgery?
Fluid overload, edema, pulmonary edema (as 3rd spaced fluid goes back into IV space)
What is suppurative phlebitis and how do you treat it?
Infected thrombus in the vein and around indwelling catheter
Tx: remove catheter, surgical excision of infected vein
How do you treat enteric fistulas in patients without signs of peritonitis? Wha situations change this management plan?
NPO, TPN, replete electrolytes, close monitoring of fistula output: and in time fistula will close on its own
Will not close if FRIEND: foreign body, Radiation dmg, Infection or IBD, Epithelialization of fistulous tract, Neoplasm, Distal bowel obstruction
What is the cause of a very high fever (e.g. 105F) 12 hrs post op?
Major atelectasis (one whole lung or multiple lobes)
Or large abscess by gas forming bacteria (like after penetrating trauma)
How should wounds suspicious for gas gangrene (clostridium perfringens) be managed?
High dose penicillin G, wound debridement, hyperbaric O2, tetanus immunization
How do you treat hypertrophic scars and keloids?
Hypertrophic scars that are expanding and keloids should be revised and treated with steroid injection and pressure padding
What factors are involved in wound healing and how?
- Platelet derived GF - brings in macrophages, fibroblasts and PMNs
- TGF B - increases collagen synthesis
- FGF - hastens wound contraction
How can you differentiate malignant vs benign lesions on CXR?
Malignant - coin lesions in >50 yo, spiculated surface
Benign - calcification, bulls eye, popcorn shape
Besides size and stage of a tumor what is another important factor in determining the type of surgical resection for a lung cancer?
Location, if a main stem bronchus is affected Pneumonectomy may be required
What differentiates stage 2 vs 3 lung tumor? Treatment differences?
Stage2 affects hilar and peri bronchial LNs, can treat with surgical rsxn
Stage 3 - mediastinal LNs, requires chemo and RT, possible rsxn if tumor shrinks
What must be ruled out in older patients with pleural effusion? On DDX?
Cancer!
Ddx: CHF, infxn, empyema, TB
What is the only tx that is potentially curable for mesothelioma?
Extra pleural Pneumonectomy- rsxn of lung, all pleura, possibly diaphragm and pericardium
> 10% MM, 30% recovery
What should be done if the lung does not reexpand following chest tube placement for a PTX?
- Check for proper tube placement or leak at site of entry
- Check for leaks at tubing connections
- If all normal then cause is large leaks from lung parenchyma from large blebs –> do thorascopic excision of blebs and pleural abrasion
What is pleurodesis? When is it used?
Irritation (by abrasion) of visceral and parietal pleura causing adherence and future pneumothorax
Pts with recurrent spontaneous PTX, bilateral spontaneous PTX, and PTX that doesn’t improve with chest tube placement
Echocardiogram reveals severe AS in an elderly patient. what workup must be done following this finding if evaluating for surgery?
- Cardiac Cath to check for coronary artery disease, valve size and pressure gradient, and ventricular function.
- Carotid doppler studies to rule out internal carotid artery obstruction
What is the cause of most deaths following heart transplant?
Infection related to immunosuppressive drugs and accelerated coronary artery atherosclerosis, (chronic rejection??)
What is an epiphrenic diverticulum? How do you treat?
AKA pulsion diverticulum, at distal esophageal gastric junction -fills w/ undigest food, gets regurgitated and may be aspirated
Tx: Excision and esophageal myotomy at EG jct
How do you treat a pharyngeal diverticulum?
Cervical esophagomyotomy - Transection of cricopharyngeal muscle, to relax esophageal entrance and prevent uncontrolled contraction
-Removal of diverticulum if large size
What is a Heller myotomy?
Distal esophageal dilation to treat achalasia (incision through muscular layers of lower esophagus)
How do you stage an esophageal tumor?
- Endoscopic ultrasound examination to determine WALL PENETRATION and adjacent LN enlargement
- CT scan of upper abdomen and chest for celiac node enlargement
What is the primary treatment for cervical and upper third esophageal tumors? Middle third?
- IRRADIATION - chemo as well (resect only if obstruction persists)
- Irradiation and chemo to downstage, which may allow for surgical resection
What is the most likely anterior mediastinal tumor that will cause progressive weakness of upper and lower extremity and double vision?
What are the most common tumors of the middle mediastinum? posterior mediastinum?
Middle - Lymphatic tumors and various cysts
Post - Neurogenic tumors, adjacent to vertebral bodies (from nerves and nerve sheaths - e.g. neurilemoma)
What major risks must be discussed prior to endarterectomy?
1-3% stroke risk, injury to hypoglossal, vagus and marginal branches of facial nerve
Most likely cause of death after CEA procedure?
MI
What should be done for patients experiencing a small stroke?
Carotid duplex studies, aspirin, observe for improvement
Endarterectomy as early as 2-4 weeks depending on favorable recovery, regaining or stabilization of neurological fxn
What are the common sites of lower extremity arterial occlusion?
- Common femoral artery
- Aorta, common iliac, popliteal
- External iliac
- Posterior artery
What needs to be done for a patient with occlusion of a lower extremity artery?
Administer heparin and take to OR for a balloon catheter embolectomy
What is a common occurrence following revascularization of an acutely ischemic limb? What are the symptoms?
Compartment syndrome (ischemia-reperfusion injury)
Postop calf tenderness and inability to dorsiflex toes
Which artery is most likely affected in a patient with claudication?
Superficial femoral artery, at the adductor hiatus
What does claudication with absent femoral pulse(s) indicate? What would this patient require?
Aortoiliac occlusive disease
-Do ABI and Doppler as per usual; but may also require ballon dilation or stent placement
What should be done for patients with very low ABIs presenting with foot or toe ulcers?
Revascularization most likely to allow adequate tissue perfusion and healing of ulcer
Amputation in patients with severely limited mobility, severely limiting CV disease or short life span
What repair can be done for occlusion of superficial femoral artery with distal reconstitution?
Reversed or in situ saphenous vein graft from common femoral artery to popliteal artery
What increases the chances of graft failure in vascular surgery?
More distal and more diseases vessels
How do you treat bilateral occlusion of common and external iliac arteries?
If limited stenosis, PTA (angioplasty). If bad Aortobifemoral bypass (axillary bifemoral if high risk)
How do you manage patients following vascular bypass procedures?
Heparinization and long term anti platelet therapy
What must be done for all patients before revascularization procedures?
Thorough cardiac assessment, possibly including: carotid duplex study, stress test, dipyridamole-thallium scintigraphy (DTS scan) or cardiac cath, depending on risk factors
How does the management of a perforated ulcer change depending on the patients history of symptoms?
- perf requires immediate surgery
- if no prior history of PUD, close perf with a graham patch
- if patient on H2 blocker therapy for PUD symptoms for many months close the perf AND do HSV or a V&P for definitive cure (antrectomy or ST gastrectomy not usually done)
What is a likely cause of fever POD3 in a patient following AAA repair surgery (occurs in 2-3% of patients)? How does this arise and how should you manage it?
Ischemic colitis from compromised collateral flow from SMA and hypogastric arteries from clamping
-Do immediate sigmoidoscopy, bowel rest, NGT, Abx, frequent exams (if mucosal injury only), resection and end colostomy (for full thickness involvement)
