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General Surgery > Principles of surgical care > Flashcards

Principles of surgical care Flashcards

1
Q

System used to classify surgical risk

A

ASA risk classification

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2
Q

Categories of ASA risk

A 
l - healthy
ll - minor disease (mild HPT)
lll- Sever non-incapacitating disease
lV - Incapacitating systemic disease (heart failure)
V - Moribund
E - Emergency surgery
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3
Q

Only routine test required for GA

A

Hb

Urine - glucose and protein.

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4
Q

Pathophysiological response to surgery

A
  1. Increased sympathetic innervation (tachy and vasoconstiction)
  2. Increase glucagon and cortisol (gluconeogenesis)
  3. Aldosterone + ADH + RAAS = sodium and water retention
  4. Decreased insulin
  5. Increased metabolic rate and acute phase proteins
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5
Q

Mendelson’s syndrome

A

Chemical pneumonitis caused by aspiration during anaesthesia

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6
Q

Average maintenance fluid requirements

A

30ml/kg/24hrs

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7
Q

Name the four stages of shock

A
  1. Initial
  2. Compensatory
  3. Progressive
  4. Refractory
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8
Q

Types of shock

A
  1. Hypovolaemic
    · Most common type
    · Due to insufficient circulating volume, most commonly blood loss
  2. Cardiogenic
    · Failure of the heart to pump effectively
    · Massive myocardial infarction, arrhythmias, cardiomyopathy, cardiac valve problems are
    common causes
3. Distributive
‘Relative hypovolaemia’ as a result of dilation of blood vessels which diminishes the systemic vascular
resistance
· Septic shock — caused by
overwhelming systemic infection
· Anaphylactic shock ~ anaphylactic
reaction to an allergen, antigen,
drug
· Neurogenic shock — trauma to
spinal cord with loss of autonomic
and motor reflexes
4. Obstructive 
The flow of blood is obstructed which impedes circulation
· Cardiac tamponade
· Tension pneumothorax
· Massive pulmonary embolism
· Aortic stenosis
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9
Q

Causes of cardiogenic shock

A

Massive myocardial infarction, arrhythmias, cardiomyopathy, cardiac valve problems

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10
Q

Causes of distributive shock

A

· Septic shock — caused by overwhelming systemic infection
· Anaphylactic shock - anaphylactic reaction to an allergen, antigen, drug
· Neurogenic shock — trauma to spinal cord with loss of autonomic and motor reflexes

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11
Q

Causes of obstructive shock

A

· Cardiac tamponade
· Tension pneumothorax
· Massive pulmonary embolism
· Aortic stenosis

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12
Q

What two major criteria must be met to diagnose septic shock?

A

Evidence of infection

Refractory hypotension

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13
Q

Which minor criteria must be met for diagnosis of septic shock

A

Two of the following:
Tachpnoea (>20) or pCO2 12
HR > 90
Temp 38

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14
Q

Most common cause of septic shock

A

endotoxin-producing gram-negative bacilli

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15
Q

Resus in septic shock must begin immediately when..

A

Hypotensive or metabolic acidosis or serum lactate >4 mmol/L

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16
Q

Treatment plan for septic shock

A 
Oxygen administration/ airway support
Volume resus
Early antibiotics
Rapid source identification
Support major organs
17
Q

Targets for volume resus in septic shock

A 
CVP 8 - 12 mmHg
MAP > 65 mmHg (adrenalin)
Urine output > 0.5ml/kg/hr
Haematocrit > 30%
CV or mixed venous > 70% and 64% respectively
18
Q

What connects the greater and lesser sacs of the peritoneal cavity?

A

Foramen of Winslow

19
Q

Nerve supply of:

  1. Parietal peritoneum
  2. Visceral peritoneum
A
  1. Afferent somatic (localised sharp pain)

2. Afferent autonomic (poorly localised and dull) NB sensitive to distension/ischaemia but not temp and pain

20
Q

Two clinical categories of peritonitis

A

1) Primary peritonitis is an infection of the peritoneum occurring de novo without obvious intra-abdominal
pathology.

2) Secondary bacterial peritonitis is a purulent inflammation of the peritoneum due to contamination following a complication of a preexisting primary intra-abdominal process such as perforated peptic
ulcer, ruptured appendix, a disrupted anastomotic suture line or as consequence of bacterial contamination from external sources (eg. penetrating injury).

21
Q

In whom does spontaneous bacterial peritonitis occur?

A

Alcoholic cirrhosis with ascites (prognosis poor due to poor baseline)

22
Q

Most common organisms in SBP?

A

E coli

pneumococci

23
Q

Most common cause of secondary peritonitis

A

ruptured appendix / direrticuli

24
Q

What can cause 2ndry peritonitis?

A 
Primary abdo disease
Trauma
Obstruction
Malignancy
Perforated ulcer/appendix/diverticulus
Bowel ischaemia
PID
Surgery (current or previous)
25
Q

Most commonly cultured orgs in 2ndry bacterial peritonitis

A

E coli

B fragilis

26
Q

What is the pathophysiology of bacterial peritonitis?

A

Fluid shift - from intravascular space to peritoneal space
Ileus
Endocrine - RAAS and Adrenal stimulation
CVS - Marked vasoconstiction -> lactic acid in peripheries -> metabolic acidosis which kidneys struggle to clear as prerenal failure
Resp - Increased demand and less space due to distension
Kidney - pre-renal plus sodium and water retention

27
Q

Essential management steps in peritonitis

A

Fluid resus
Antibiotics
Decompensation of GIT
Exploratory laparotomy if required.

NB respiratory function must be monitored

28
Q

Which antibiotics are used in peritonitis

A

Empiric triple therapy
Aminoglycosides - Gram negs (cleared renally {give third gen cefs} + ototoxicity)
Metronidazole - Anaerobes
Ampicillin - Enterococci

29
Q

Intra-abdominal abscess formation is

due to either:

A 
1. effective localization of the primary
pathology such as an appendiceal
or diverticular abscess
2. a sequel or complication following
generalized peritonitis or
3. intraperitoneal contamination
secondary to external trauma or
complicating previous surgery
30
Q

The major intraperitoneal anatomic spaces in which abscesses commonly localise are:

A
  1. Subphrenic space
  2. Subhepatic space (Morrison’s pouch)
    3/4. Paracolic gutters
  3. Interloop
  4. Appendiceal
  5. Pelvic
31
Q

Most useful investigation to identify intraperitoneal abscess

A

U/S or CT

General Surgery (20 decks)

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