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Surgery 2 > Sabiston Readings > Flashcards

Sabiston Readings Flashcards

1
Q

Did a retrospective study show that packed red blood cells (PRBC): fresh frozen plasma (FFP) ratio group of (1 : 1.4) had better survival rates in massive trauma?

A

YES

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2
Q

Should FFP be given EARLIER to patients requiring massive TRANSFUSION?

A

YES

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3
Q

Does increased use of FFP and PLATELETS improve survival after major TRAUMA when given EARLY?

A

YES

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4
Q

Is FFP associated with increased or decreased risk of multiple-organ failure and ARDS in BLUNT trauma patients?

A
  • INCREASED risk :(
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5
Q

What is a Massive Transfusion Protocol (MTP)?

A
  • recommendations that all trauma centers should have in place (ex. for severely injured patients, 2 units of O- blood should be available for immediate resuscitation).
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6
Q

Do most trauma patients require massive transfusion (more 10 units of PRBCs in 24 hours)?

A

NO

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7
Q

What happens if a patient requires more PRBCs due to massive transfusion requirements?

A
  • crossmatch blood ASAP and give 4 additional units PRBCs (on top of the initial 2). If patients require more than these 6 units, then give another 6 units of PRBCs with 6 units of FFP and 1 unit of PLATELETS.
  • give FFP and platelets first.
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8
Q

What is considered to be the reference COLLOID solution?

A

Human ALBUMIN (4-5%)

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9
Q

What is the main advantage of albumin (colloid) compared to crystalloids?

A
  • less inflammation, because it is natural and not artificial. Also less coagulopathy.
  • SAFE study showed this to be safe.
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10
Q

How does volume of 25% albumin (natural colloid) compare to artificial colloids?

A
  • 5 times LESS
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11
Q

What is the only bad thing about 25% albumin?

A

EXPENSIVE

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12
Q

What are the most commonly used ARTIFICIAL/SYNTHETIC colloids?

A
  • plasma, albumin, dextran, gelatin, and starch-based colloids
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13
Q

What is a problem with hetastarch (artificial/synthetic) colloid?

A
  • pro-inflammatory effects similar to crystalloids.
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14
Q

Can colloids do more harm in large volumes than crystalloids in some cases?

A

YES

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15
Q

Can ARTIFICIAL/SYNTHETIC colloids cause coagulopathy?

A

YES

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16
Q

What artificial/synthetic colloid is used to prevent clotting after vascular surgery?

A
  • dextrans
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17
Q

What is the maintenance IV fluid calculation?

A
  • 4 mL/kg/hr for first 10 kg
  • 2 mL/kg/hr for next 10 kg
  • 1 mL/kg/r for every kg over 20 kg.
  • so for any pt over 20 kg, give 60 mL/hr + the difference in weight over 20 kg.
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18
Q

What are the contents of maintenance solutions over 24 hrs?

A
  • water= 2760 mL
  • dextrose= 132 g
  • Na+= 11.8 g (203 mEq)
  • K+= 1.9 g (53 mEq)
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19
Q

What are the normal needs of a 70 kg man over 24 hours?

A
  • water= 2000 mL
  • urine= 1500 mL
  • Na+= 2-4 g
  • K+= 100 mEq
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20
Q

What is found at the inferior portion of the common bile duct?

A
  • the head of the pancreas
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21
Q

Into what is the cystic duct divided?

A
  • neck, infundibulum with Hartmann pouch, body, and fundus.
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22
Q

How much fluid does the gallbladder hold?

A
  • 30-60 mL of bile and up to 600 mL total.
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23
Q

What is the attachment of the gallbladder to the liver called?

A
  • gallbladder fossa (divides left and right lobes of liver) and the Glisson capsule of the liver does not form here, thus providing most of the venous drainage.
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24
Q

What are the sprial valves of Heister?

A
  • folds of mucosa oriented in a spiral pattern in the neck of the gallbladder, which act to keep gallstones form entering the common bile duct.
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25
Q

What is the hilar plate?

A
  • the confluence of the left and right hepatic ducts and is an extension of the Glisson capsule of the liver.
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26
Q

How many major hepatic veins drain into the IVC?

A
  • 3
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27
Q

What arteries supply the inferior bile duct?

A
  • tributaries of the posterosuperior pancreaticoduodenal and gastroduodenal arteries.
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28
Q

What arteries supply the superoduodenal common bile duct?

A
  • right hepatic artery and cystic artery (associated with Calot lymph node, which may be enlarged in gallbladder disease)
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29
Q

What is the smallest functional unit of the liver?

A
  • hepatic lobule (four to six portal triads), identified by its central terminal hepatic venule.
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30
Q

Do the bile salts themselves provide osmotic activity?

A

NO. Instead the cations that are secreted into the biliary tree along with the bile salt anion provide the osmotic load to draw water into the duct and to increase flow to keep bile electrochemically neutral.

31
Q

Is bile osmolality similar to that of plasma?

A

YES

32
Q

What induces bile secretion?

A
  • vagal activity
  • secretin
  • CCK (from intestinal mucosa)
33
Q

What is the space of Disse?

A

The perisinusoidal space between a hepatocyte and a sinusoid (blood plasma).

34
Q

What is the rate limiting step in bile salt excretion?

A
  • the transport of bile salts across the canalicular membrane (ATP dependent).
35
Q

What is the major lipid component of bile?

A
  • cholesterol
36
Q

What is a good example of bile toxin disposal?

A
  • bilirubin
37
Q

Is the gallbladder efficient at water reabsorption?

A
  • YES, thus concentrating bile (cholesterol and calcium mostly in the gallbladder lumen).
38
Q

What does CCK do to the sphincter of Oddi?

A
  • relaxes it
39
Q

What is Charcot triad?

A
  • RUQ pain
  • fever
  • jaundice
  • biliary disease
40
Q

What imaging studies are used for the biliary system?

A
  • Plain films (used only for exclusion of problems other than the biliary system).
  • US= sensitive, inexpensive, reliable, and reproducible.
  • HIDA SCAN (hepatic iminodiacetic acid test)/biliary scintigraphy= nuclear test used to evaluate the physiologic secretion of bile.
  • CT= superior anatomic information, used after US if needed.
41
Q

What is Renyolds pentad?

A
  • Charcots triad + hypotension and altered mental status= shock from biliary origin.
42
Q

What lab tests are used most often for the gallbladder?

A
  • BILIRUBIN (unconjugated vs. conjugated). Derangements up to and including conjugation, will manifest as elevated UNconjugated bilirubin.
  • ALK PHOS
43
Q

What imaging modality is the best for the initial evaluation of jaundice or symptoms of biliary disease?

A
  • ULTRASOUND
44
Q

What is ERCP?

A
  • invasive test using endoscopy and fluoroscopy to diagnose and treat choledocolithiasis.
45
Q

What is percutaneous transhepatic cholangiography (PTC)?

A
  • interventional radiology technique similar to ERCP, used to evaluate and treat biliary tree, but through the skin.
46
Q

Are most common bile duct stones secondary in the USA?

A

YES (aka retained after gallbladder removal).

47
Q

How do we diagnose choledocolithasis?

A
  • biliary ductal dilation via US.

- MRCP

48
Q

How do we treat choledocolithiasis?

A
  • ERCP
  • PTC (cheaper)
  • laparoscopic CBD exploration (don’t use if small friable cystic duct, more than 8 stones, or large stones).
  • open bile duct exploration (used when other methods are not feasible or when biliary drainage is required).
49
Q

What are the goals of therapy in iatrogenic bile duct injury?

A
  1. control infection and limit inflammation (parenteral antibiotics and percutaneous drainage).
  2. clear and through delineation of entire biliary anatomy (MRCP, PTC, or ERCP).
  3. reestablishment of biliary-enteric continuity (tension-free, mucosa-to mucosa anastomosis, Roux-en-Y hepaticojejunostomy, or long-term transanatomotic stents if bifurcation or higher is involved).
50
Q

What is gallstone ileus?

A
  • obstruction of the intestinal lumen by a gallstone. The stone in most dependent part (fundus) must FISTULIZE directly into the intestines.
  • most common in DISTAL ILEUM.
51
Q

Does gallstone ileus occur most often in older pts?

A

YES and may be casued by inflammation or pressure necrosis.

52
Q

How do you diagnose gallstone ileus?

A
  • CXR (air-fluid levels consistent with SBO (stone may not be identified).
  • CT= look for PNEUMOBILIA (presence of gas in biliary tree)
53
Q

How do you treat gallstone ileus?

A
  • exploration and enterotomy proximal to stone.

* site of impaction is at risk for ischemia (necrosis may lead to perforation so consider resection).

54
Q

Is biliary carcinoma aggressive?

A

YES and poor prognosis :(

*pts have no specific presenting symptoms

55
Q

When does biliary carcinoma manifest?

A
  • 6th or 7th decade of life

- more women from India, Pakistan, or native Americans.

56
Q

What is the primary risk factor for biliary carcinoma?

A
  • gallstones
  • 80% have cholelithiasis
  • porcelain GB
57
Q

What will US show in biliary carcinoma?

A
  • irregularly shaped lesion in subhepatic space, heterogenous mass in GB lumen, and asymmetrically thickened GB wall.
  • polyp greater than 10 mm should raise suspicion.
58
Q

How do you treat biliary carcinoma?

A
  • resection of cancer
59
Q

What should you include in your dDx of intermittent claudication?

A
  • nerve root compression
  • spinal stenosis (relieved by positional change)
  • arthritic inflammatory process
  • hip arthritis
  • symptomatic baker cyst
  • venous claudication
  • chronic compartment syndrome (tight bursting pain in heavily muscled athletes)
60
Q

** What is the Fontaine classification of peripheral arterial disease?

A
  • stage I= asymptomatic
  • stage IIa= mild claudicaton
  • stage IIb= moderate to severe claudication
  • stage III= ischemic rest pain
  • stage IV= ulceration or gangrene
61
Q

** What is the Rutherford classification of peripheral arterial disease?

A
  • 0= asymptomatic
  • 1= mild claudication
  • 2= moderate claudication
  • 3= severe claudication
  • 4= ischemic rest pain
  • 5= minor tissue loss
  • 6= major tissue loss
62
Q

What is the ankle brachial index (ABI)?

A
  • quick, noninvasive way to check your risk of peripheral artery disease (PAD), using each ankle.
63
Q

How do you calculate ABI?

A
  • take the higher pressure of the 2 ankle arteries, divided by the higher of the 2 brachial arterial systolic pressure.
  • normal= less than 10 mmHg
64
Q

What is critical limb ischemia?

A
  • severe obstruction of the arteries, which markedly reduces blood flow to the extremities and has progressed to the point of severe pain and sometimes skin ulcer/sores.
65
Q

How do you treat critical limb ischemia?

A
  • receive imaging (duplex, angiography, MRA, or CTA) and revascularization immediately.
66
Q

What if a pt is not a candidate for revascularization in critical limb ischemia?

A
  • if pain is stable, then medical treatment.

- if pain is not-tolerable, then amputation.

67
Q

What are the 6 P’s of acute limb ischemia?

A
  • Poikilothemia (inability to regulate core body temp).
  • Pain
  • Pallor
  • Pulselessness
  • Paresthesias (tingling/pricking from pressure on nerve)
  • Paralysis
68
Q

What is the most common cause of acute limb ischemia?

A
  • THROMBOEMBOLISM
69
Q

What are the categories and treatments of criticial limb ischemia?

A
  • I= limbs viable; Tx (thromboembolic therapy)
  • IIa= limbs threatened; Tx (thromboembolic therapy)
  • IIb= limbs are salvagable if treated as emergency; Tx (surgery)
  • III= amputation
70
Q

What is Reynauds phenomena?

A
  • recurrent episodic vasospasm of the digits precipitated by a stimulus such as environmental cold or emotional stress.
  • manifests as white, blue then red color changes.
  • may be associated with scleroderma (connective tissue disorders).
71
Q

How do you treat Reynauds?

A
  • avoid tobacco and add calcium channel blocker.
72
Q

What is carotid endarterectomy?

A
  • removal of the atherosclerotic plaque from the carotid bifurcation
73
Q

What are the indications for endarterectomy?

A
  • one or more TIAs in the last 6 months and carotid stenosis.
  • stroke with carotid stenosis greater than 70%
  • TIAs in the past 6 months and stenosis of 50-69%.
  • progressive stroke and stenosis greater than 70%.
  • mild or moderate stroke in the past 6 months and stenosis of 50-69%.
  • CEA ipsilateral to TIAs and stenosis greater than 70%, combined with required CABG.

Surgery 2 (13 decks)

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