peri OP

Question 1

Baby is born w/ respiratory distress,scaphoid abdomen & this CXR (bowel in the lung).

Answer 1

Diaphragmatic hernia

Question 2

Biggest concern for Diaphragmatic hernia?

Best treatment?

Answer 2

Pulmonary hypoplasia

If dx prenatally, plandelivery at @ place w/ECMO. Let lungs mature 3-4 days then do surg

Question 3

Baby is born w/ respiratory distress w/ excess drooling.

Best diagnostic test?

Answer 3

TE- Fistula

Place feeding tube, take xray, see it coiled in thorax

Question 4

Defect lateral (usually R) of the midline, no sac. *will see high maternal AFP

Answer 4

Gastroschisis

Question 5

Complications for Gastroschisis

Answer 5

May be atretic or necrotic req removal. Short gut syndrome

Question 6

Defect in the midline.Covered by sac.

Answer 6

Omphalocele

Question 7

Defect in the midline. No bowel present.

Assoc w/ other disorders?

Treatment?

Answer 7

Umbilical Hernia

Assoc w/ congenital hypothyroidism (also big tongue)

Repair not needed unless persists past age 2 or 3.

Question 8

4wk old infant w/ non-bileous vomiting and palpable “olive”?
-Metabolic complications?
–Tx?

Answer 8

Pyloric Stenosis

Hypochloremic, metabolic alkalosis

Immediate surg referral for myotomy

Question 9

2wk old infant w/ bileous vomiting. The pregnancy was complicated by poly-hydramnios.
–Assoc w/?

Answer 9

Intestinal Atresia Or Annular Pancreas

Down Syndrome (esp duodenal)

Question 10

1 wk old baby w/ bileous vomiting, draws up his legs, has abd distension.–Pathophys?

Answer 10

Malrotation and volvulus

*Ladd’s bands can kink the duodenum

Doesn’t rotate 270 ccw around SMA

Question 11

A 3 day old newborn has still not passed meconium.–DDX? (name 2)

Answer 11

Meconium ileus- consider CF if +FH (*gastrograffin enema is dx & tx)

Hirschsprung’s- DRE-> explosion of poo. bx showing no ganglia is gold standard

Question 12

A 5 day old former 33 weeker develops bloody diarrhea
–What do you see on xray?
–Treatment?
–Risk factors?

Answer 12

Necrotizing Enterocolitis

Pneumocystis intestinalis (air in the wall)

NPO, TPN (if nec), antibiotics and resection of necrotic bowel

Premature gut, introduction of feeds, formula.

Question 13

A 2mo old baby has colicky abd pain and current jelly stool w/ a sausage shapend mass in the RUQ.

Answer 13

Intussusception*Barium enema is dx and tx

Question 14

Contraindications to surgery

Answer 14

–Absolute?Diabetic Coma, DKA

–Poor nutrition?albumin <3, transferrin <200,weight loss <20%.

–Severe liver failure?bili >2, PT >16, ammonia > 150or encephalopathy

–Smoker?stop smoking 8wks prior to surgery

If a CO2 retainer, go easy on the O2 in the post op period. Can suppress respiratory drive.

Question 15

Goldman’s Index

Answer 15

Tells you who is atgreatest risk for surgery

–#1 =CHF* EF. If <35%, no surg.

–#2 =MI w/in 6mo *What should you check?(EKGstress testcardiac cathrevasc)
–#3 =arrhythmia

–#4 =Old (age >70)

–#5 =Surgery is emergent

–#6 =AS, poor medical condition, surg in chest/abd

Question 16

how do you check AS?

Answer 16

Listen for murmur of AS-Late systolic, crescendo-decrescendo murmur that radiatesto carotids. ↑ with squatting, ↓ with decr preload

Question 17

Meds to stop

Answer 17

Aspirin, NSAIDs, vit E (2wks)

Warfarin (5 days)–drop INR to<1.5 (can use vit K)

Take ½ the morning dose of insulin, if diabetic

Question 18

If CKD on dialysis

Answer 18

Dialyze 24 hours pre-op

Question 19

Why do we check the BUN and Creatinine?

Answer 19

–What is the worry if BUN > 100?
There is an increased risk of post-op bleeding 2/2uremic platelet dysfunction.

Question 20

–What would you expect on coag pannel for uremic platelet dysfunction.?

Answer 20

Normal platelets but prolonged bleeding time

Question 21

Vent Settings

Answer 21

Assist-controlset TV and rate but if pt takes abreath, vent gives the volume.

*Pressure support Important for weaning.pt rules rate but a boost of pressure is given (8-20).

*CPAPpt must breathe on own but + pressure given all the time.

PEEPpressure given at the end ofUsed in ARDS or CHF*cycle to keep alveoli open(5-20).

Question 22

you have a patient on a vent…*Best test to evaluate managemen

Answer 22

ABG

Question 23

If PaO2 is low?If PaO2 is high?

Answer 23

increase FiO2, decrease FiO2

Question 24

If PaCO2 is low (pH is high)?

If PaCO2 is high (pH is low?

Answer 24

Decr rate or TV

Incr rate or TV

Question 25

Which is more efficient?

Answer 25

TV is more efficient to change.Remember minute ventilation equation & dead space

Question 26

Non-gap acidosis

Answer 26

diarrhea, diuretic, RTAs (I< II, IV)

Question 27

What after determining resp/met alkalosis?

Answer 27

*NextCheck urine [Cl]

*If [Cl] < 20Vomiting/NG, antactids, diuretics

*If [Cl] > 20Conn’s, Bartter’s Gittleman’s

Question 28

↓Na workup?

Answer 28

↓Na =Gain of water
–Check osm, then check volume status.
–↑volume ↓Na:CHF, nephrotic, cirrotic–

decreased volume ↓ Na:diuretics or vomiting + free water

–Nlvolume ↓Na:SIADH, Addisons, hypothyroidism.

Question 29

↓Na workup?

Answer 29

↓Na =Gain of water
–Check osm, then check volume status.
–↑volume ↓Na:CHF, nephrotic, cirrotic–

decreased volume ↓ Na:diuretics or vomiting + free water

–Nlvolume ↓Na:SIADH, Addisons, hypothyroidism.

Question 30

↓Na workup?

Answer 30

↓Na =Gain of water
–Check osm, then check volume status.
–↑volume ↓Na:CHF, nephrotic, cirrotic–

decreased volume ↓ Na:diuretics or vomiting + free water

–Nlvolume ↓Na:SIADH, Addisons, hypothyroidism.

Question 31

treatment for hyponatremia?

Answer 31

Fluid restriction & diruetics

–If hypovolemic?Normal Saline

–When to use 3% saline?Symptomatic (Seizures), < 110

–What would you worry about?Central Pontine Myolinolysis

Question 32

↑Na Treatment?

What would you worry about?

Answer 32

↑Na =Loss of water–Treatment?

Replace w/ D5W or hypotonic fluid–What would you worry about?cerebraledema.

Question 33

↓Ca

Answer 33

Numbness, Chvostek or Troussaeu, prolongedQT interval.

Question 34

↑Ca

Answer 34

Bones, stones, groans, psycho. Shortened QTinterval.

Question 35

↓K, tx?

Answer 35

Paralysis, ileus, ST depression, U waves.

give K (kidneys!), max 40mEq/hr

Question 36

↑K, tx?

Answer 36

Peaked T waves, prolonged PR and QRS, sinewaves.

Give Ca-gluconate then insulin + glc,kayexalate, albuterol and sodium bicarb. Last resort = dialysis

Question 37

Fluid?

Answer 37

Maintenance IVFsD51/2NS + 20KCl (if peeing)
–Up to 10kgs100mL/kg/day
–Next 10 kgs50mL/kg/day
–All above 2020mL/kg/day

Question 38

Nutrition?

Answer 38

Enteral Feeds are bestkeep gut mucosa intact and prevent bacterial translocation.

*TPN is indicated if gut can’t absorb nutrients 2/2physical or fxnal loss.

Question 39

risk for TPN?

Answer 39

–Risks = acalculus cholecystitis, hyperglycemia, liverdysfxn, zinc deficiency, other ‘lyte probs