SBAs in Surgery Flashcards
Other name for Hartmann’s?
Proctosigmoidectomy.
Resection of the rectosigmoid colon with closure of the rectal stump and formation of an end/terminal colostomy. Used to be common for diverticular disease and cancer.
Can be reversed in 60-70% cases
Chylothorax
A chylothorax (or chyle leak) is a type of pleural effusion. resulting from lymph formed in the digestive system (chyle) accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct, which transports up to 4 L of chyle per day, allowing a rapid and large accumulation of fluid in the chest.
50% malignant (60% lymphoma, esp NHL); 25% trauma (esp cardiothoracic surgery)
The best form of fluid therapy is to replace ____
Like with like
Initial first line fluid therapy for trauma patients according to ATLS?
2L warmed Hartmann’s solution
Colloids are useful as osmotically active and stay IV, but are used after initial crystalloid
Typical requirements of fluid and electrolytes in a healthy adult
1-2.5 L H2O
1-2 mmol/kg Na
0.5-1 mmol/kg K
30-40 kcal/kg/day
Third space losses in bowel obstruction (remember ITU pt laparotomy with Mr Tsochazis)
Patients with bowel obstruction sequester huge amounts of fluid within bowel (3rd space). This is salt rich fluid - approx 130 mmol/L Na, 110 Cl, and 10 K
Glasgow Scale Pancreatitis
PaO2 < 8kPa (60mmhg) Age > 55 years Neutrophils: (WBC >15 x109/l Calcium < 2mmol/l Renal function: (Urea > 16mmol/l) Enzymes: (AST/ALT > 200 iu/L or LDH > 600 iu/L) Albumin < 32g/l Sugar: (Glucose >10mmol/L)
3+ Indicate SEVERE disease
ALI in severe pancreatitis
Acute lung injury (ALI) is a complication of systemic inflammation where increased endothelial and epithelial barrier permeability results in leakage of a protein-rich exudate into the alveolar space and interstitial tissues, thus compromising oxygenation and gas exchange. Therefore lungs become susceptible to fluid overload. Presents similarly to acute heart failure.
Bilateral pulmonary oedema, normal cardiac filling pressures, and a ratio of arterial oxygen pressure and inspiratory oxygen concentration (PaO2/FiO2 < 300 mmHg for ALI and < 200 mmHg for ARDS.
CVP fluid challenge monitoring and what is normal?
No defined normal value for CVP. increased value in hypervolaemia and cardiac failure.
If after fluid challenge CVP doesn’t change pt is hypovolaemic. If it increases 2-4 mmH20 and goes back down within 30 min = euvolaemia. A sustained increase >5 mm H2O = overload/CF
Define massive blood transfusion
Replacement of individuals entire circulating volume within 24h
Complications of massive blood transfusion
Stored blood deficient in V and VII.
Additional plt and cryoprecipitate needed to avoid DIC and bleeding
Blood stored at low temp, therfore pt prone to hypothermia
Stored blood high in K, ++K can be a problem
Hypocalcaemia - stored blood anticoagulated with citrate, which Ca ions thus preventing coagulation. In massive transfusion citrate may overwhelm circulating Ca
Hartmanns Composition
Na 131 (all mmol/L) Cl 111 HCO3 29 K 5 Ca 2 Lactate 29
When is Hartmann’s useful, when is it not?
First choice resus fluid according to ATLS.
However lower Na than 0.9 saline (131 vs 150) and inability to add extra potassium (as in 0.9 saline) in pts experiencing salt losses makes its value more limited in medical patients.
SIADH
Hyponatreamia Inappropriately high urine osmolality (>200 mEq/L) Excessive urine Na losses (>30 mEq/L) Decreased osmolality Euvolaemic patient w/o signs of oedema
What should be measured daily in TPN patients?
Blood glucose Urea Creatinine K Na Mg PO4 - hypophosphate esp problematic in TPN pts FBC - prone to sepsis Daily weights and fluid balance charts
** LFTs twice weekly for cholestatic jaundice and fatty hepatitis
In TPN, of which is there more, fats or sugar?
Lipid > Carbohydrate (glucose converted to CO2 resulting in more resp work for the acute surgical pt)
Also 14 g Nitrogen as L-AA
Pneumothorax or Hemo/Chylo thorax?
With a very resonant percussion note - pneumo
With a dull percussion note - something solid must be filling that hole, either blood or chyle
How often should a central line be changed?
Every 5 days
Foramen of Winslow (Omental foramen)
Communication between greater and lesser sac of the abdomen. “Behind” CBD
Anterior: hepatoduodenal ligament (two layers containing CBD, HA and PV)
DAVE: Duct, Artery, Vein, Epiploic foramen.
Posterior: peritoneum covering IVC
Superior: peritoneum covering caudate lobe of liver
Inferior: the peritoneum covering the duodenum and the hepatic artery
Left lateral: gastrosplenic ligament and splenorenal ligament
As the portal vein is the most posterior structure in the hepatoduodenal ligament, and the inferior vena cava lies under the posterior wall, the epiploic foramen can be remembered as lying between the two great veins of the abdomen.
Where is portal triad contained anatomically?
Within hepatoduodenal ligament
Risk factors for gastric cancer
H pylori Pernicious Anaemia Previous gastrectomy Dried fish and cured meats Smoking and Drinking Blood group A (wierd) Atrophic Gastritis Low social status
What are the branched of the internal carotid before it reaches the cranial vault
Trick question - there are none
Oesophagus - structure and blood supply
Top 1/3 is stricated muscle supplied by inferior thyroid artery and drained by inferior thyroid veins and deep cervical lymph nodes
Middle 1/3 blend of striated and smooth muscle supplied by descending aorta, drains via azygous vein and posterior mediastinal LN
Bottom 1/3 smooth muscle, supplied by oesophageal branches of left gastric artery and drained via left gastric vein into portal circulation, and LN around ceoliac plexus.
Define achalasia
Degenration of the Auerbach plexus leads to aganglionosis and failure to relax of the lower oesophageal sphincter. Idiopathic, most likely between 25-50
Similar to trypanosma cruzi (Chagas disease)
Will present as progressive dysphagia to fluids before solids (opposite to cancer). Reason being is that fluids reach LOS quicker and therfore not enough time for relax. Slow eating of food makes more efficient use of LOS. Weight loss late presentation
