Pathophysiology Flashcards
Ideally, when would you want a pre-surgery evaluation?
2-4 weeks before procedure
T/F Informed consent is needed for a surgical procedure as well as anesthesia
TRUE
What medication should be D/C’d at least 1 week prior to surgery?
ASA
T/F All HTN medications should be discontinued well prior to the procedure
FALSE
T/F Smoking should be stopped at least 2 weeks prior to scheduled surgery
TRUE
What antibiotic therapy, if any, should be given prophylactically for any bowel surgery?
Neomycin and erythromycin are commonly used.
NPO rules prior to surgery usually means nothing by mouth within ____ hours of the procedure
6-8 hours
T/F A pt can take his/her medications with small sips of water up to 2 hours prior to surgery
TRUE
Virchow’s triad
1) Stasis 2) hypercoagulability 3) intimal damage
When should heparin be started in a pt who is at risk for DVT? How long should it continue?
Preoperatively and continue until the pt is ambulatory
T/F Blood type and cross screening should be done for ALL surgical patients
FALSE. Just those who are at increased risk of bleeding or needing blood
Who uses the Physical Status Classification?
The American Society of Anesthesiologists to determine a pts preoperative physical status
What benzo is commonly used for pt anxiety prior to procedure?
Midazolam
T/F Thorough explanation of the procedure, watching a video of it, and music therapy are all valuable ways of reducing pt anxiety prior to a procedure.
TRUE
The best pre-op prophylaxis to prevent postop wound infection is ____
1st generation ceph
Most common cause of postop wound infection?
Staph
A pt presents with fever, erythema, induration, pain, fluctuation, warmth, and discoloration around a wound site approx. 5 days post surgery
Postop wound infection
A pt has a hard, tender, red, folliculocentric nodule that has enlarged and becomes painful and fluctuant. It seems to be in a hair bearing region.
Furuncle. Deep necrotizing folliculitis with pus formation
T/F For a furuncle, you can use a warm compress and/or I/D it.
TRUE
A pt presents to clinic with multiple red, leaking pustules. They are EXTREMELY painful. The pt has a fever, and is malaise.
Carbuncle
T/F Carbuncles are particularly common among immunocompromised patients.
TRUE
Which requires abx - furuncle or carbuncle?
Carbuncle
Carbuncles are commonly caused by ____
MRSA, MSSA, pseudomonas, candida
A pt presents with a painful, erythematous, NON-WELL demarcated area on her lower leg. The pt has a mild fever.
Cellulitis
Treatment of cellulitis includes warm packs, elevation, and ____
An antibiotic (usually PCN or 1st generation ceph)
Most cellulitis is caused by ____
Staph or strep
A pt presents with a foul smelling wound with sloughing skin, discharge, and CREPITUS bubbles and blisters that appear to be bluish-maroon in color. He is in EXTREME pain. What is this most likely? What is the likely organism associated? How would you treat it?
Gas gangrene probably caused by clostridium perfringens. It is an EMERGENCY! Surgical debridement is necessary as well as amputation consideration. IV ABX that are broad spectrum should be administered ASAP
A pt presents with a purulent infection of the skeletal muscle. You note muscle edema, necrosis, and you worry about compartment syndrome. They have a fever and are complaining of muscle cramps. What might this be? What is the likely organism responsible? How would you treat it?
Pyomyositis caused by staph or GAS. You should give a broad spectrum ABX and consider surgical drainage.
A pt presents with what appears to be similar to cellulitis but it is EXTREMELY painful and you note crepitus and some bulla on the skin surface. What are you worried about? How would you treat it? What is the likely cause?
Necrotizing fasciitis caused by GAS, staph, or clostridium strains. Surgery is a MUST and you’d likely do a regimen of 3 ABX (1) PCN or Ceph 2) Aminoglycoside 3) Clindamycin.
Most common cause of abscesses?
Staph
15% of all hospital infections in patients?
Postop wound infection
Postop infections usually appear between the ____ and ____ days
5th and 10th
T/F Keflex is a good medication for ABX prophylaxis for postop wound infection prevention.
TRUE
Most common surgical infection?
Furuncle
What can you use to wash the sites of furuncle and carbuncle?
Hexachlorophene
“Brawny red”
Cellulitis
Crepitus myonecrosis
Gas gangrene
Incubation period for gas gangrene can be as short at ____ to about ____
6 hrs to 4 days
T/F Gas gangrene can progress several inches an hour
TRUE
Mortality for nec fasc is ____%
25-70%
Nec fasc is more common among what demographic?
DM, alcoholics, IV drug users
What is the most common pulmonary complication among patients who die after surgery?
Pneumonia
Incidence of UTI after 5 days of catheterization is near ____%
95%
When is a post op UTI likely to present?
48-72 hours postop
Risk factors for a postop hematoma include…
ASA, heparin, HTN…basically bleeding and vascular issues
What are indications for chest tube removal?
Less than 200mL drained per day or lung re-expansion noted on CXR
What test should be performed prior to inserting a radial arterial catheter?
Allen test to confirm adequate circulation
Fluid collection that is NOT blood or pus that is associated with surgeries involving lymph (mastectomy, groin, etc.)
Seroma
A partial or total tissue disruption that is common 5-8 days after procedure. Pt may hear or feel a “popping” and my see leakage from the wound. Many risk factors. Happens in 1-3% of surgery closures.
Dehiscence
What is it called when not only has a surgery site opened up…but all the insides are coming out?
Evisceration
Happening in 25% of pts who undergo abdominal surgery, this commonly causes an EARLY fever in pts as well as signs of respiratory struggle.
Atelectasis
T/F Atelectasis is more common in smokers, the elderly, obese, or those with preexisting lung problems.
TRUE
This accounts for up to 90% of all post op fevers
Atelectasis
T/F A person who commonly gets keloid scars will be likely to get them again after surgery.
TRUE. Duh.
T/F Keloid scars are most common among the whites and surgery to correct them is the best treatment.
FALSE and FALSE. More common in blacks and surgery will likely make it worse. Treat with triamcinolone topically.
A pt comes in with a broken femur and surgery to correct it is performed. 12-72 hours later, he is short of breath and is altered. What has likely happened?
Fat embolism
A pt presents with tachypnea, hypotension, and JVD. It is noted that a central line was just placed by an incompetent MD.
Air embolism
The death rate for a person who suffers this complication post surgery is as high as 15%. It is very common after colorectal surgery and is sometimes hard to catch.
Bowel obstruction
An elderly pt presents to clinic with anorexia and obstipation (initially it was watery diarrhea until it just stopped). They had surgery 10 days ago. What might this be? How would you know?
Fecal impaction. DRE
T/F 40% of pts have a fever after surgery
TRUE
Post surgery fevers - 48hrs, >3 days
Atelectasis 48hrs, wound infection >5 days
Surgery increases the risk of DVT by ____
21 x
What is the most common cause of PE?
DVT
A pt presents with mild fever, tachycardia, with mild edema and pain in her calf. What is it? What sign might you check for?
DVT. Homan’s sign
A pt goes into respiratory failure > 3 day postop. < 3 days postop.
PE > 3 days. Pneumonia/aspiration/atelectasis < 3 days.
A pt presents with glossitis, anorexia, diarrhea, paresthesias, dementia, balance problems. What type of anemia might this be? What type of surgeries are these commonly associated with?
B12 deficiency. Gastric operations.
A pt presents with fatigue, tachycardia, palpitations, tachypnea on exertion, SMOOTH TONGUE, BRITTLE NAILS, SPOONING OF THE NAILS, cheilosis, and pica. What type of post surgery anemia might this be?
Iron deficiency
A pt presents with LUQ pain that radiates to the neck and left shoulder. You note splenomegaly and the pt appears to be displaying signs of shock.
Ruptured spleen. CT it and then prepare for splenectomy
A pt presents to clinic with N/V and fever. They complain of sudden and severe mid/lower abdominal pain and you note abdominal rigidity. You decide to do an abdominal XR and you see air OUTSIDE the bowel.
Perforated bowel. You need to treat shock , provide ABX, and resect, repair, drain the area.
A pt presents with an ABRUPT fever, rebound tenderness and DECREASED BOWEL SOUNDS. You notice their walking strangely and cry out when you perform a heel jar test.
Peritonitis.
An older pt presents when COLICKY abdominal pain, distention, and vomiting. You note a KIDNEY BEAN appearance on XR and a BIRDS BEAK on barium enema. What might it be? What would you do?
Volvulus. Sigmoid decompression with colonoscopy.
T/F An umbilical hernia should be repaired quickly to avoid strangulation
TRUE
Which is more likely to strangulate…a direct or indirect inguinal hernia?
Indirect
T/F Abdominal pain lasting >6 hours is more likely to require surgical intervention
TRUE…duh…that perhaps was the dumbest flashcard I’ve ever written…um…no Corb…if it lasts 4 hours then suddenly feels better it’s REALLY bad. So…yes…if it lasts a long time…it’s likely worse.
T/F 2/3 of pts with abdominal pain DO NOT need surgery
TRUE
Foregut abdominal pain corresponds to pain where?
Upper abdominal area
Hindgut abdominal pain corresponds with pain where?
Lower abdominal area
T/F Midgut abdominal pain is in the periumbilical area
TRUE
Cramps are more associated with problems with hollow viscus organs or solid organs?
Hollow viscus organs
T/F Continuous pain is more often associated with solid organs
TRUE
List 3 useful diagnostic imaging studies that can be helpful when addressing a case of acute abdomen
Ultrasound, XR (chest, abdomen upright/flat), CT
Pain out of proportion with PE findings in an elderly person should have you thinking possible….
Intestinal ischemia
T/F Obese patients usually have less severe problems than indicated by the amount of pain they are in.
FALSE. Often more severe…so be suspicious of serious problems.
Upper diaphragmatic pain in an elderly person? You should ALWAYS consider this on you D/DX
Lower lobe pneumonia
T/F Spontaneous bacterial peritonitis (SBP) is NOT a surgical illness.
TRUE!!!
T/F It is best to correct DKA in an acute abdomen patient before initiating surgery because pain may resolve with DKA resolution
TRUE!!!
A pt presents with well-localized pain and tenderness and systemic hypoperfusion. Should you operate?
YES
What are the most common causes of acute abdomen in the elderly? List 5
Acute cholecystitis, appendicitis, bowel obstruction, cancer, and acute vascular conditions.
Appendicitis accounts for approximately ____ of all cases of acute abdomen in children
1/3
What are the two most common causes of acute abdomen most often mistaken as non surgical causes?
Appendicitis and intestinal obstruction
A kid presents with bizarre abdominal pain and has facial flushing…what could this be.
Appendicitis. Nearly 1/2 of kids with it present with facial flushing.
If abdominal pain has lasted longer than ____ days and there is no fever, it is less likely to be appendicitis
3 days
Intestinal obstruction in a female who HAS NOT had a recent surgery is likely caused by a ____
Femoral hernia
Elderly or cardiac patients with severe unrelenting diffuse abdominal pain but without commensurate peritoneal signs or abnormalities on plain abdominal films may have ____
Intestinal ischemia (think vascular issues!!!)
This NSAID has similar potency of morphine but does not have the same respiratory S/E
Ketorolac tromethamine
For a DM patient, BG should be below ____ on the day of surgery
250
If a DM patient has a marked increase in glucose and/or insulin requirement post surgery…what might it mean?
Occult infection
If a pt doesn’t awaken promptly from anesthesia and who manifests CO2 retention even to the point of CO2 narcosis, accompanied by hypothermia….this could be…
Myxedema coma. Watch for increased tissue friability, poor wound healing, wound dehiscence may also occur.
T/F Stress doses of cortisol prior, during, and after surgery should be considered for a patient with adrenal insufficiency
TRUE
T/F Wounds heal VERY fast with people with adrenal insufficiency
FALSE. Expect slow wound healing
Between ____% and ____% of hospitalized patients are malnourished.
30% and 50%
T/F PPN is safer than TPN
TRUE
A minimum of ____ days of adequate TPN is needed for preoperative nutritional repletion.
7-10 days
A clear liquid diet should NOT be used longer than ____ days without supplementation
3 days
Clear liquid diet is foods that are liquid at what temperature?
Body temperature
“No added salt” means < or = ____g/day
4g/day…YUCK!
What type of feeding tube is for SHORT term use?
NG tube
With this type of feeding tube, the tube is placed endoscopically…the pt does NOT need general anesthesia.
PEG
Bolus feeding is usually ok with a (G-tube/J-tube)
G-tube
PEG, G-tube, and J-tubes are indicated generally for nutritional support longer than ____
6 weeks
Why would you use a J-tube and not a G-tube?
If a pt has poor gastric emptying or there is a fear of aspiration via reflux
What is gold standard for confirming NG placement?
Radiography.
GI tract NOT entered. Irrigation and primary closure, no abx.
Clean wound
Trauma and communication with foreign materials from outside world or gross spillage of GI contents. What type of wound is it? What would you do?
Contaminated wound. Debridment and irrigation; secondary closure; abx ancef/cefotan/oflaxacin (floxin)
GI Tract entered, debris present. What type of wound is it? What would you do?
Clean-contaminated wound. Irrigate and primary closure; abx therapy with cefazolin (ancef)/cefotetan disodium (cefotan)
Pus Present due to active intracellular or intraorgan infection (bug has colonized), pus may flow or ooze from site, fascia commonly involved, tissue may appear necrotic. What type of wound is it? What would you do?
Dirty and infected wound. Debridement, irrigation and secondary closure, abx augmenting - human bites get pcn/clindamycin (goal is to cover a broad spectrum + anerobes)
Human and animal bite wounds (except those on the face for cosmetic reasons) would be allowed to close via what type of wound healing?
Secondary intention
Tertiary intention healing
AKA delayed primary closure. This is where a wound is allowed to stay open for awhile…and then it is closed later. This should be considered with all pts who are at greater risk of infection either due to the wound or due to immunocomromise.
T/F Epithelialization best happens when wounds are kept dry.
FALSE. Moist.
Fibroplasia and matrix deposition, angiogenesis, epithelialization.
Proliferative phase of healing
Collagen fiber maturation, lysis and contraction.
Remodeling phase
Staph and strep are aerobes
Not a question…just a fact
Peptostrepto and clostridium are anaerobes
Also a fact
What are the general requirements for a surgical infection to start?
1) Infectious agent 2) susceptible host 3) closed/unperfused space
What are 4 ways to help prevent post surgical infection?
O2, fluid, warming, pain management (gas em, drown em, burn em, or ignore em)
First gen ceph (keflex) is great prophylaxis to prevent infection.
Just a fact
Elevated WBC, elevated BUN, and hyponatremia. Triad of what?
Nec Fasc
Reasons to operate include…
Involuntary guarding or rigidity, especially if spreading, Increasing or severe localized tenderness, Tense or progressive distention, Tender abdominal or rectal mass with high fever or hypotension, Rectal bleeding with shock or acidosis, Septicemia findings, Bleeding (unexplained shock or acidosis, falling hematocrit), Suspected ischemia (acidosis, fever, tachycardia)
Approximately ____% of operations will result in an incisional hernia
10%
T/F “Acute abdomen” includes traumatic disorders of the abdominal area
FALSE
A pt presents with signs of shock, tenderness in the LUQ and 9th and 10th ribs and has an enlarged spleen. He has radiating pain to his neck and left shoulder (positive for Kehr’s sign).
Ruptured spleen
When would you use FAST technique?
Focused assessment with sonography for trauma - TRAUMA!!!
Air-fluid levels found outside the bowel
Perforated bowel
Pt presents with sudden onset of severe, agonizing mid/lower abdominal pain and symptoms of shock. She is N/V and has a fever and her abdomen is rigid and tender
Perforated bowel
A pt has acute cholecystitis…her pain may refer from the ____ to the ____
RUQ to the right thorax
A pt presents with RAPID ONSET OF SEVERE CONSTANT PAIN radiating from the middle upper epigastric region to her back.
Acute pancreatitis
A pt presents with an ABRUPT and EXCRUCIATING mid abdominal pain that radiates to her flank and back
Ruptured AAA
A pt presents with ABRUPT and EXCRUCIATING RLQ pain that radiates down to his grown area.
Ureteral colic
A pt presents with GRADUAL and STEADY pain in his RLQ and some more mild pain that shifts from there toward the mid-epigastric region
Appendicitis
List 2 causes of acute abdomen that present with INTERMITTENT, COLICKY, CRESCENDO pain with FREE INTERVALS
SBO, IBS (SBO Farting in a crescendo)
List 4 causes of acute abdomen that present with RAPID ONSET, SEVERE pain
Acute pancreatitis, mesenteric thrombosis, strangulated bowel, ECTOPIC PREGNANCY (A CUTE PA STRANGLED ECTOPIC PREGANCY)
List 5 causes of acute abdomen that present with ABRUPT, EXCRUCIATING pain
Biliary colic, ureteral colic, MI, ruptured AAA, rupturing (perforating) ulcer (BUMAAAR)
List 6 causes of acute abdomen that present with GRADUAL, STEADY pain
Acute cholecystitis, acute cholangitis, acute hepatitis, appendicitis, acute salpingitis, diverticulitis (ITIS’s)
T/F Inflammation of the gallbladder (cholecystitis) is almost always associated with gall stones (cholelithiasis)
TRUE
T/F N/V is common in up to 1/2 of cholecystitis/cholelithiasis cases
TRUE
What sign might be positive with cholecystitis/cholelithiasis
Murphy’s
Abrupt onset of fever, abdominal pain, distention, rebound tenderness, diminished bowel sounds, tachycardia, restlessness, dehydration, oliguria, disorientation, refractory shock.
Peritonitis
T/F ¼ of patients have minimal or no peritoneal signs with peritonitis
TRUE
Appendicitis is most common among what age?
5-14 yrs
T/F Barium should be given orally in the presence of a suspected colonic obstruction
FALSE
T/F 95% of malignant tumors of the colon and rectum are adenocarcinomas
TRUE
Pt presents with LLQ pain, mass, diarrhea or constipation, fever, anorexia, and leukocytosis and BLEEDING
DiverticulOSIS (“osis” = Oh Sis…you’re bleeding!)
Pt presents with LLQ pain, mass, diarrhea or constipation, fever, anorexia, and leukocytosis and NO BLEEDING
Diverticulitis (“ulitis” YOU LIED SIS…you’re NOT bleeding!)
An OLDER pt presents with colicky abdominal pain that persists between spasms, abdominal distention, occasional vomiting. You note distention, tympany, rushes, high pitched bowel sounds on exam.
Volvulus
Most common site of a volvulus is the ____ colon followed by the ____
Sigmoid (70%) followed by the cecum (30%)
What do white males age 15-40 have more than other groups?
Pilonidal cyst disease.
Sudden onset of severe perianal pain with BRBPR during and after dedication
Hemorrhoids
Removal of just the breast lump + radiation
Lumpectomy
Removal of entire breast with nipple
Simple (total) mastectomy
Removal of pretty much everything in the area of the affected breast
Modified radical mastectomy
Pt presents with pulmonary congestion and low cardiac output. He has experienced dyspnea, poor exercise tolerance, and fatigue.
You note a “blowing” systolic murmur over the cardiac apex and radiating to the axilla and an S3 gallop.
Mitral Regurgitation
On PE, you note a systolic crescendo/decrescendo murmur heard best over the base of the heart and radiating up the carotid arteries.
Aortic stenosis
You hear a high-pitched diastolic murmur immediately after the second heart sound
Aortic insufficiency
People with what syndrome are particularly at risk for aortic aneurysms?
Marfan syndrome
___cm AAAs are palpable as a pulsatile abdominal mass
5cm
T/F A pt who exhibits signs of shock, peritoneal irritation, or evisceration should get an immediate laparotomy
TRUE
What might you be mindful of if you are doing cautery on an elderly patient?
If they have a pacemaker, it could interfere with it.
T/F A pt who has suffered a recent MI within 3 months of surgery will likely have their surgery delayed.
TRUE. They prefer 6 months or more.
T/F A person with CHF with an ejection fraction <35% will NEVER have surgery
TRUE THAT!!! According to Paul Bolin
With regard to respiratory disease, what do you care most about with a pts history prior to surgery?
COPD or smoking. If they smoke, get a PFT, it it’s low (s, if PCO2 is above 45…hold the surgery and correct.
Any pt who becomes hypertensive during surgery…it is likely caused by ____ and the surgery should be ____
Stroke, stopped
Be cautious about EPI use with anesthesia in what patient population?
DM
LLQ pain with bleeding and “saw tooth” on barium
Diverticulosis
List 6 groups at higher risk for thromboembolism
Cancer, obesity, myocardial dysfunction, age over 45 years, and a prior history of thrombosis
Aged patients require (smaller/larger) doses of narcotics
Smaller
What should be given to a pt in myxedema coma post surgery?
Levothyroxine
