Random facts 2 Flashcards
If a patient takes prednisolone, what does need to be prescribed before moderate-major surgery?
Hydrocortisone
* this is due to chronic Prednisolone Rx may suppress hypothalamic-pituitary-adrenal axis at the times of a stress e.g. surgery - may not respond appropriately
What’s Boas sign?
- Hyperaesthesia (altered sensation/sensitivity) below the R scapula
- maybe sign of acute cholecystitis
Treatment of rectal Ca that involves sphincter or lower part of the rectum
- abdomino-perineal excision of rectum (APER)
- radiotherapy (possible as rectum is a retroperitoneal structure)
How much of clearance margin is required in the rectum (in case of cancer)
at least distal 2 cm
Difference between external and internal haemorrhoids
External
- originate below the dentate line
- prone to thrombosis, may be painful
Internal
- originate above the dentate line
- do not generally cause pain
Grading of internal haemorrhoids
Grade I Do not prolapse out of the anal canal Grade II Prolapse on defecation but reduce spontaneously Grade III Can be manually reduced Grade IV Cannot be reduced
Management of haemorrhoids (routine - not acutely thrombosed)
Management
- soften stools: increase dietary fibre and fluid intake
- topical local anaesthetics and steroids may be used to help symptoms
- outpatient treatments: rubber band ligation is superior to injection sclerotherapy
- surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
- newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Common causes of small bowel obstruction (adults)
- incarcerated hernia
- Crohn’s
- internal malignancy
- adhesions (e.g. previous surgery)
Management of endometrial Ca
stage I and II (within the uterus)
stage III and IV (beyond the uterus)
Endometrial Ca
- Stage I and II: total hysterectomy with bi-laterral salpingo- oophorectomy + possible radiotherapy
- Stage III and IV: radiotherapy and high doseprogesterone (to shrink the tumour)
ASA classification criteria
ASA I
ASA II
- ASA I - healthy, non-smoker, minimal or no alcohol use
- ASA II - Including, but not limited to, well-controlled diabetes, hypertension. Social drinker. Smoker
ASA classification criteria
ASA III
ASA IV
ASA V
- ASA III - Including, but not limited to: poorly control diabetes, hypertension. BMI > 40. Previous MI > 6m ago.
- ASA IV - Including, but not limited to: recent MI (<3m), severe reduction in ejection fraction
- ASA V - Including, but not limited to: ruptured AAA, massive trauma
Parkland’s formula for the fluid resuscitation (required ml) in burns
Requirements for fluid resuscitation over hours:
SA of the body burnt % x weight (in kg) x 4ml
Fluid resuscitation in burns
- what’s used
- how much over 8 hours and then over 16 hours (24 hours in total)
- when to end
- when to start
Fluid resuscitation formula
Parkland formula
(Crystalloid only e.g. Hartman’s solution/Ringers’ lactate) Total fluid requirement in 24 hours =
4 ml x (total burn surface area (%)) x (body weight (kg))
* 50% given in first 8 hours
* 50% given in next 16 hours
Resuscitation endpoint:Urine output of 0.5-1.0 ml/kg/hour in adults (increase rate of fluid to achieve this) Points to note:
* Starting point of resuscitation is time of injury
* Deduct fluids already given
Why do we do fluid resuscitation in burns?
To prevent would deepening
- there is protein loss in burns
- fluid shifts from intravascular to interstitial compartment -> therefore circulatory volume may be compromised
Suxamethonium apnoea
- what happens
- causes
- management
Suxamethonium is a muscle relaxant (neuromuscular blocker) used in anaesthetics
What happens: Suxamethonium apnoea happens when there is little/ no respiratory effort after extubation following the surgery (+all other obs are normal)
Cause: a small proportion of the population has a mutation that causes defects in specific acetylcholinesterase enzymes that degrade suxamethonium -> therefore it takes longer for the effects to wear off
Management: ICU + mechanical ventilation
Can suxamethonium be prescribed in a patient with burns or trauma?
No, as it will increase the risk of hyperkalaemia
Surgical treatment of pancreatic pseudocyst
Cystogastrostomy
It is a fistule created between pseudocyst and a stomach -> so pancreatic juices can drain into it
TPN
- what’s that?
- route of administration
- rearrangement in what may be caused by TPN?
TPN = Total Paraenteral Nutrition
Bags contain: lipids, glucose, electrolytes
( depends on individual patient needs)
Administration: via central vein
Dearrangement in: liver funciton, possible cholestasis
(3) phases of WHO Surgical Safety checklist (time wise/when)?
The checklist identifies three phases of an operation:
1) Before the induction of anaesthesia (sign in)
2) Before the incision of the skin (time out)
3) Before the patient leaves the operating room (sign out).
Management of renal stones
- regarding size of stone
Disease Option Stone burden of less than 2cm in aggregate Lithotripsy Stone burden of less than 2cm in pregnant females Ureteroscopy Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy Ureteric calculi less than 5mm Manage expectantly
Investigations in acute urinary retention
- urine sample -> sent for urinalysis and culture. This might only be possible after urinary catheterisation.
- Serum U&Es and creatinine ->assess for any kidney injury
- FBC and CRP -> infection?
- PSA is not appropriate in acute urinary retention as it is typically elevated
Management of acute urinary retention
- bladder scan -> volume of >300 cc means retention, but even if less and consistent history, still consider the diagnosis as bladder scan is operator dependent
- catheterisation -> monitor the volume of urine drained in 15mins after insertion (volume of <200 cc means no acute urinary retention; volume of >400cc = catheter needs to be left in place)
- further evaluation of cause and referral to a specialist if needed -> e.g. BPH, neurological causes, treat UTI
*if no causes are found -> urologist evaluation needed for structural abnormalities and urodynamic studies
Initial investigations in a patient presenting with rectal bleeding (2)
- PR
- proctosigmoidoscopy
What’s transfusion-associated lung injury?
Pathophysiology
Symptoms and signs
Transfusion-associated lung injury
- complication of blood transfusion
Pathophysiology: microvascular injury to the lungs -> capillary leak -> acute onset of pulmonary oedema (thought to be immune-mediated; anti-bodies develop)
Symptoms and signs: sudden onset of dyspnoea, hypoxaemia <90%, hypotension and fever (within 6 hours following blood transfusion)
Management:
- supportive -> oxygen, sometimes aggressive airway support is needed
- vasopressors, IV fluids -> to maintain blood pressure
- corticosteroids and diuretics (if circulatory overload following transfusion)
What’s Courvoisier’s law?
The development of jaundice in association with a smooth right upper quadrant mass = distal biliary obstruction = secondary to pancreatic malignancy
Management of acute and chronic anal fissure
Management of an acute anal fissure (< 6 weeks)
- dietary advice: high-fibre diet with high fluid intake
- bulk-forming laxatives are first line - if not tolerated then lactulose should be tried
- lubricants such as petroleum jelly may be tried before defecation
- topical anaesthetics
-analgesia
* topical steroids do not provide significant relief
Management of a chronic anal fissure (> 6 weeks)
- the above techniques should be continued
- topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure
- if topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin
What’s paralytic ileus?
What conditions does it occur with?
Paralytic ileus
- a common complication after surgery involving the bowel, especially surgeries involving handling of the bowel
- no peristalsis resulting -> pseudo-obstruction
- association with chest infections, myocardial infarction, stroke and acute kidney injury.
Treatment options (drugs) for postoperative ileus
- Metoclopramide -> ptokinetic
- Erythromycin -> it increases GI motility
- Neostigmine -> acetycholinesterase inhibitor -> more ACh (PNS) activity -> GI contractions are induced
- Laxatives
Differentials for elevated amylase (hyperamylasaemia)
- Acute pancreatitis
- Pancreatic pseudocyst
- Mesenteric infarct
- Perforated viscus
- Acute cholecystitis
- Diabetic ketoacidosis
What’s Hartmann’s procedure?
Hartmann’s procedure
- resection of the relevant portion of bowel and formation of an end colostomy/ileostomy
- later on, patients can undergo a reversal of Hartmann’s procedure -> end colostomy is closed -> formation of a colorectal anastomosis-> restoring continuity of the bowels
- the ideal surgical procedure for emergency situations.
- this operation involves resection of the sigmoid colon
Possible causes of post-op fever re day time scale
- day 1-2
- day 3-5
- day 5-7
- day 5+
anytime
- Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
- Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
- Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
- Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
- Any time: Drugs, transfusion reactions, sepsis, line contamination.
What’s the difference between:
- Sign in
- Time out
- Sign out
- Sign in - before induction
- Time out - before the first incision
- Sign out - after last incision and before patient leaves the operating room
