Sept 2023 Flashcards
What is the side effect of Atracurium?
Histamine Release
What is the major side effect of succinylcholine?
Malignant hyperthermia and hyperkalemia and increased intraocular pressure
What is the side effect of etomidate?
Adrenal suppression
What is the main adverse effect of pancuronium?
Tachycardia
How do you manage an insulin pump during major surgery?
Start an IV insulin infusion and titration every hour at least
What is the most common cause of mortality after a blood transfusion?
TRALI
How do you treat an undifferentiated spindle cell tumor of the bone?
Neoadjuvant chemo and wide local excision
Mucinous cystic neoplasm found in pancreas. What do you do?
Resect.
If benign, no surveillance needed.
If malignant, biannual CT/MRI surveillance for recurrence.
In the setting of severe pna, can you get a tracheal aspirate for culture?
No, likely upper airway contamination. Need bronch with BAL.
What is a beta error and how do you prevent it?
Failing to reject the null when it is false- increase sample size.
What factors make up the grade of a soft tissue sarcoma?
Tumor differentiation, tumor mitosis activity, cellular atypia, and necrosis
All affect prognosis. So does location to fascia, size, lymph node involvement
In an APR what structure guides the perineal part of the resection?
The coccyx
What is a grade 3 pancreatic injury?
Distal pancreatic injury with duct injury or transection
Needed liver remnant percentage?
40% if cirrhosis
30% if fibrosis or chemo liver injury
20% if otherwise healthy liver
What is the definition of respiratory quotient?
CO2 produced/O2 consumed
What resuscitation does a boy need who has pyloric stenosis?
1.5 times maintenance based on kg
New onset afib post op - what do you do? (Pt stable)
Rate control with beta blockers
What is the most common gas forming organism in a wound infection?
Clostridium
What do you do for an iatrogenic perforation in a lady with achalasia?
If stable, do primary repair, contralateral myotomy, and wrap to buttress repair
What lung function tests do you need prior to lung resection?
FEV1, DLCO, %postop FEV1, %postop total lung capacity via VQ scan
What if conservative measures fail for chylous ascites?
Intranodal lymphangiography with embolization
Triple negative breast cancer in a person who has BRCA 1 or 2. What additional therapy is needed?
PARP inhibitor
What is the order of fastest to slowest for restoration of motility after surgery?
Small bowel first then stomach then colon
Describe the anatomy of the vagus nerves in the abdomen.
Right becomes posterior giving criminal nerve of grassi and goes to celiac plexus
Left becomes anterior gives rise to hepatic branch and innervates the pylorus via nerve of Latarjet
How do you reduce gallstones in patients with short gut?
Any enteral feeding helps produce CCK to prevent gallstones
What FEV1 is needed for a lobectomy and a pneumonectomy?
What next if too low?
> 1.5 for lobectomy
2.0 for pneumonectomy
If too low, do a VQ scan
If you have less than desirable FEV1 for a lobectomy/pneumonectomy, what what post op predicted FEV1 on a VQ scan would take you to surgery?
Post op predicted FEV1 > 40% and predicted post op total lung capacity >40%
This is >800 mL
If still not adequate, what do you test next?
If you have inadequate FEV1 and post op predicted FEV1 and total lung capacity for a lobectomy/pneumonectomy, what VO2 max do you need on exercise testing to proceed with surgery?
> 15 mL/kg/min
How much protein should renal failure patients get in TPN?
Less bc they can’t clear excess nitrogen which is a neurotoxin.
1.2-1.5 g/kg/d
If conservative measures have failed and you have a persistent chyle leak what is the next step?
Intranodal lymphangiography with embolization
MRI if that fails to identify the leak
If BRCA positive and has triple negative cancer, what additional drug
A PARP called Olarib for 1 year
What dose of hydrocortisone is equivalent to 5mg of prednisone?
20 mg of hydrocortisone
When has a wound achieved it’s max tensile strength?
8 weeks
Most appropriate treatment of a parastatal hernia?
Lap sugarbaker.
Melanoma with clinically negative nodes and the sentinel lymph node is positive for cancer. Next step?
US of node basin every 3 months
You take out a testicle with a mass and get a stage 1 seminoma. What is the next step and treatment?
Next step is tumor markers, if positive needs chemo but if negative can do surveillance or radiation.
Where does iodine-131 iodobenztlguanidine accumulate and what disease process does it localize?
Adrenal, pheochromocytoma
Imaging test of choice for a colovesical fistula?
CT with oral or rectal contrast (no IV)
Do passive rewarding techniques transfer heat energy?
No
18yo with APC with colon polyps. When do you get an EGD?
20-25 yrs old or when colon polyps develop. So now.
What is a positive apnea test?
PCO2 rises to > 60 or >20 over baseline after 10 min off the vent.
If they desat or decompensate or it is aborted then to you need confirmatory testing.
Does luminal acid inhibit or promote gastrin secretion?
Inhibits.
High output cardiac failure from AV fistula - what do you do first if medical management fails?
Try banding it.
What percent of patients have resolution of pseudo tumor cerebri after Bariatric surgery?
> 90%
You diagnose paget disease of the anus. What do you need to make sure you look into?
Colonoscopy with CT CAP bc the risk of internal malignancy is 33-86%
Describe the action of dopamine at different levels?
Low: DA1/2
Med: alpha agonist
High: beta agonist
Hemophilia A. What should you give for bleeding?
Cryo which is rich in factor VIII
What compartment of the Lower leg is most susceptible to compartment syndrome?
Anterior bc of osseus boundaries
What kind of fluids do you give kids?
Isotonic with potassium and dextrose.
Abx for VAP?
Zosyn, only add vanc if high risk for MRSA
In HCC what is a T2 lesion?
T1?
<5cm with vascular invasion
T1 is any size with no vascular invasion
Most potent stimulator of pancreatic enzyme secretion?
What about bicarbonate secretion?
CCK
Secretin
Layers of the gallbladder wall?
When can you just take out the gallbladder and observe with gallbladder cancer?
Epithelium
Laminate propria
Muscle
Connective tissue
Serosa
Ok to invade the lamina propria (T1a) but not ok if it invaded the muscle (T1b)
Malnourished severe necrotizing pancreatitis. Start on TPN and they have some difficulty breathing.
What is happening and how do you treat?
Receding syndrome - difficulty breathing from low phos. Slow TPN rate.
Contraindications to living donor kidney donor?
BMI > 40
DM
Active cancer
Kidney disease GFR <70
Albuminuria
HTN on multiple meds
Pelvic/horseshoe kidney
Psych issues
Cystine/struvite kidney stones
Where do you poke a person for a spinal?
L2 since that’s below the conus medullaris
What does a person have if they are found to have a mutation in the PMS2 gene?
Lynch syndrome or hereditary nonpolyposis colorectal cancer
Cancers include colorectal, endometrial, stomach, ureter/renal pelvis
Endometrial is most common after colon cancer
Bern vs. Beger procedure. What are they and when do you do them?
Beger is more intense, is the true duodenum preserving pancreatic head resection. Requires 2 anastomoses, one to the pancreatic tail and one to the sliver of pancreatic head left on the duodenum.
Bern is a modified Beger that’s less intense, and no pancreatic transection at the portal vein. You just have 1 anastomosis to the coring out of the pancreatic head.
No difference in outcomes. You do them when you have no duct dilation and an inflammatory mass in the pancreatic head.
Complications of a brachial plexus block?
Vascular puncture
Pneumothorax
Nerve injury
Symptomatic diaphragmatic palsy from accidental infiltration of phrenic nerve
Facial papillary lesions, breast cancer, thyroid cancer. Name of condition and gene involved?
Cowden syndrome.
PTEN, autosomal dominant
How do you manage rectal intussusception without overt prolapse?
Conservative with diet modification and biofeedback
What are the signs of Class 1 hypovolemic shock?
When do you move to class 2 shock?
Nothing. Maybe slightly anxious. Everything else normal.
Class 2 has narrow pulse pressure and tachycardia <120 and normal UOP
If a somatostatinoma needs debulking, what do you need to debulk?
Liver Mets if present
What is the anti-inflammatory cytokine?
IL-10 - reduces inflammation unlike the rest of them
What is the optical magnification of standard endoscopy equipment?
30-35x optical magnification with additional 1.5-2x digital zoom.
What do you do if you can’t get past the sigmoid with a colonoscopy?
Try with a pediatric colonoscope
Midshaft humoral fracture with inability to extend wrist and dorsal hand numbness. Nerve injured?
Radial nerve
Pelvic bleeding unstable and inability to do angiography. What do you do?
Preperitoneal pelvic packing
On Coumadin with large recurs sheath hematoma with no active extrav. Tx?
Observation
Preferred abx for human bite?
Anoxicillin clavulanic acid
Post splenectomy infection suspected. What do you do?
Abx right away. High mortality so you don’t wait for cultures or anything.
What do you do with warfarin and lithium after you do a gastric bypass?
Decrease dose of warfarin and decrease lithium
What are leukotrienes and what do they mediate the release of?
They are the slow acting substances of anaphylaxis. Leukocyte chemoattraction and adhesion, bronchoconstriction, mucus production, capillary permeability
Mediate the release of platelet aggregating factor
What test offers best locoregional staging for esophageal cancer?
EUS
Pt with VHL what surveillance?
Eye/retinal exams age 1-4
Age 5-15 years audiology assessment
16 and up US abd/MRI to assess kidneys pancreas and adrenals and MRI nervous system
Annual metanephrines starting age 5
Most common kidney stone?
Calcium oxalate
What needle and suture do you use to control hepatic parenchyma bleeding?
0 chromic on a blunt needle
What tumor has positive staining for chromogranin and rare motor Iv features with bland cytologies features?
Well differentiated neuroendocrine tumor
Inheritance pattern of hereditary spherocytosis?
What do they need before splenectomy?
Autosomal dominant
Need US gallbladder when removing spleen to see if they need a chole at the same time
How do you treat a pleomorphic adenoma?
Superficial resection. It is benign.
What is a contraindication for resection for squamous cell cancer of the lung?
Contralateral lung lymph node involvement.
What is MUTYH associated polyploids syndrome?
They have 10-100 polyps and have an 80% lifetime risk of colon cancer. Can also get duodenal, bladder, ovarian, endometrial, and sebaceous cell cancer and gastric and duodenal polyps. Autosomal recessive.
When do you start screening in IBD?
8 years after diagnosis
When do you start screening for Lynch and FAP?
Lynch or HNPCC: 20-25 or 2-5 years before onset of cancer in relative
FAP 10-15years old
What is dantroline?
An IV muscle relaxant
In TBI what is the best predictor of long term outcomes?
Post resuscitation motor component of GCS
What decubitus ulcers can you use a vac on?
Stage 1 and 2. Higher you should use a local flap.
What is paget disease of the anus?
Intraepithelial adenocarcinoma of the dermal apocrine sweat glands
A Unix cell carcinoma of parotid not invading facial nerve. Tx?
Resection and then radiation.
What causes inability of a fistula to mature?
Deep venous outflow tract or venous branches
Stress induced gastritis causes what kind of ulceration in the stomach?
Linear ulcerations with oozing in the body and fundus
T2 esophageal cancer invades what level?
Muscularis propria
T1b esophageal cannier invades what structure?
Submucosa (T1a limited to muscularis mucosa)
Submucosa has lymph channels so more likely to spread
T1a esophageal cancer invades what structure?
Muscularis mucosa only
Type III choledochal cyst treatment?
ERCP and sphincterotomy
Someone with aortoiliac occlusion (occluded right common and left common internal and external with reconstituted femorals) has severe claudication after max medical/exercise therapy. Otherwise relatively healthy and 62.
Treatment and why?
End to side aortobifemoral bypass.
End to side so that you can perfuse the pelvis via the open R internal iliac
Aortobifemoral bc it has the best patency rates in this relatively healthy young guy
Stents can’t use if occluded, more for focal stenosis
Ax fem bypass low patency rates only for old comorbid man
What is the most common mesenteric cystic mass?
Cystic lymphangioma
Treatment for toxic multinodular goiter confined to the R lobe?
Total thyroidectomy - has lower recurrence rate than subtotal
What are the strongest predictors of operative mortality after coronary artery bypass grafting?
nonelective surgery, low ejection fraction, and prior heart surgery
