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Pete FFICM SOE/OSCE > Surgery > Flashcards

Surgery Flashcards

1
Q

Incidence of an emergency laparotomy

A

1:1000

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2
Q

30 day mortality of a laparotomy if over 80

A

25%

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3
Q

30 day mortality of a laparotomy if liver disease

A

75%

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4
Q

Components of the SORT score

A 
ASA
Age
Urgency of Op
Presence of malignancy
Severity of op
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5
Q

Components of P-Possum

A

12 physiological
6 operative

problem is these operative ones are estimates pre op

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6
Q

does p-possum over or under predict mortality

A

over predict, though correlates well up to mortality of 15%

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7
Q

What has P-possum been replaced by for NELA

A

The NELA Risk Prediction Model

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8
Q

Does P-possum predict at population or individual level

A

population

should not be used alone for deciding to operative

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9
Q

What is the percentage cut off in p-possum that means the case needs consultant anaesthetic/surgical involvement

A

5%

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10
Q

What percentage cut off in p possum means the case needs direct consultant supervision

A

10% (also admit to ITU as routine above this level)

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11
Q

What does ASA I mean and its associated mortality

A

Normal healthy patient

0.1%

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12
Q

ASA2 definition and mortaity

A

Mild systemic disease without substantial functional limitation
0.7%

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13
Q

ASA3 definition and mortality

A

Severe systemic disease with substantial functional limits (poorly controlled COPD, DM etc)

3.5%

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14
Q

ASA 4 definition and mortality

A

Severe systemic disease which is a constant threat to life (recent MI<3/12, sepsis

18.3%

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15
Q

ASA 5 definition and mortality

A

Moribund patient who is not expected to survive wihtout the op

93.%

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16
Q

ASA 6 definition

A

BSD patient for organ retrieval

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17
Q

What is the anaerobic threshold that is associated with adverse outcomes

A

11ml/kg/min

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18
Q

Does anaeoribc threshold vary with patient effort

A

No

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19
Q

RCoS criteria of major GI surgery that has a predicted mortality of >5%

A

Age of 50 and:

Emergency or re-do surgery
AKI or CKD, creatinine >130
DM
CVD

OR

Over 65

Or

Shock of any cause

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20
Q

HES procedure groups that have mortality of greater than 10%

A 
Laparotomy and peritonitis
Bowel/rectal resection
Therapeutic upper GI endoscopy
Gastrectomy
Ulcer surgery
Splenectomy
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21
Q

NICE recommendations on EGDT

A

Use an oesophageal doppler to guide fluid therapy

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22
Q

What was the OPITIMISE study

A

Multi centre study
RCT
Protocolised cardiac output guided fluid and inotropes versus usual care

No reduction in complications or 30 day

BUT added to a meta analysis the rate of complications reduced

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23
Q

Pre Op enhanced recovery

A 
Optimise condition and co-morbidities
Correct anaemia after Ix
Plan data of discharge and set criteria
Carb loading
Avoidance of bowel prep
Admit on the day of surgery
Hydrate and carb drinks
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24
Q

Intra op enhanced recov

A

Fluid and haemodynamic therapy guided by doppler

Balanced crystalloids, ringers hartmanns

Minimally invasive surgery

Avoid Hypothermia

Regional and epidural if possible

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25
Q

Post op enhanced recov

A 
Avoid iv fluids
Oral fluid and nutrition early
avoid ng tube and drains
avoid systemic opiates for simple analgesia
early mobilisation
remove catheter
rehab
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26
Q

Risks of blood going through bypass circuit

A

Activates clotting
Precipation of inflammatory response
Fluid shifts
Risk of emboli

Anticoag risk

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27
Q

General rules of thumb for drain bleeding post cardiac surgery

A

400ml 1st hour

OR

200mls/hr for first 2 hours

OR

100mls/hr for first 4 hours

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28
Q

Coag features of heparinisation

A

Prolonged activated clotting time ACT

Prolonged APTT

Prolonged R time on teg

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29
Q

What causes thrombocytopenia in CPB

A

Process consumes platelets so expect a drop in absolute count

Previous antiplatelet agent use

Fluid shifts dilute clotting factors

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30
Q

How to minimise impact of ischaemia reperfusion

A

Cardioplegic solutions (high K, conserves ADP whilst asystolic)

Hypothermia Reduces metabolic demand

Hyperosmotic buffer cardioplegic solutions to minimise myocardial oedema and acidosis

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31
Q

Problems after bypass

A

SIRS
Arrhythmia (usually AF, use amiodarone and B blockers)
Tampanade
Hypothermia - shivering increases O2 demand and impairs coag
Pericarditis - global concave ST elevation

Atelectasis, ARDS, AKI, Delerium, CVA

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32
Q

Usual time to extubation in cardiac cases

A

6 hours

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33
Q

Features of a tampanade

A

Low BP, low CO, rising filling pressure (CVP and PAOP)

But conisder in any unstable patient

Transoesophageal echo is best way

Have a low threshold for sternotomy

34
Q

Hb target for CPB

A

90

35
Q

Causes of medical bleeding post CPB

A

Incomplete reversal of heparin
Thromobcytopenia
Peri op platelet drugs
Coag from liver

36
Q

Features of medical/surgical bleeding

A

HR up
CVP/PAOP down
Cardiac index down
Blood in drains (surgical bleeding is more brisk)

37
Q

Investigaton of bleeding after CPB

A

Activated clotting time
TEG
FBC
Coag

Surgical exploration

38
Q

Causes of myocardial dysfunction after CPB

A

Post cariotomy stunning
Graft failure
Valve dysfunction
Pre existing dysfunction

39
Q

Features of myocardial dysfunction

A

HR up
CVP PAOP up
CI down
Not much blood in draing

40
Q

Ix of myocardial dysfunction

A

ECG
Echo both to look for regional ischaemia

Calcium level

41
Q

Treatment of myocardia dysfunction

A

Electrolytes
Inotropes - milrinone
IABP
Correc the graft or valve

42
Q

Complications of open AAA repair

A 
AKI
Spinal cord ischaemia - neuro defecit
Bleeding and coagulaopathy
Stroke
MI
43
Q

Mortality of emergency and elective AAA repair

A

36%

6%

44
Q

Commplications of EVAR

A 
Endoleak
Covert to open
Bleedind and coagulopathy
Embolic event
Rupture
AKI - flow or contrast
SIRS response - post implantation syndrome
45
Q

Why does aortic surgery needs a spinal drain

A

drain CSF
decrease pressure on cord
maintain blood flow

46
Q

Complications of intracranial surgery

A 
Bleeding
Haematoma
Raised ICP
Seizures
Cerebral oedema
Pneumocephalus
CSF leak --> infection
Neurogenic pulmonary oedema
DI
47
Q

Hypertension strategy

A

B blockers first line - do not affect ICP

Avoid GTN they increase flow

48
Q

Is negative fluid balance good for traumatic brain injury

A

NO

This group should avoid negative balance

49
Q

Why does free flap surgery fail

A

Thrombosis
Ischaemia/hypoperfusion - sedation, fluid loss, SIRS, vasoconstiction

Oedema - too much fluid, haemodilution, ischeamia

50
Q

What is the optimal difference between peripheral ad core temperature in flap surgery

A

<1C

51
Q

Hct target for flap surgery

A

30%

52
Q

Mortality of pneumonectomy surgery

A

11%

53
Q

Which side of pneumonectomy has higher mortality

A

Right (unclear why)

54
Q

What is the immediate anatomical change after a pneumonectomy

A

Space fills with air

55
Q

Is it routine to use drains in pneumonectomy

A

No

56
Q

If you use a drain what would happen if you put in on suction

A

Air removed, mediastinal shift and haemodynamic compromise

57
Q

What are the late anatomical changes after pneumonectomy

A

Raised hemi diaphragm
Mediastinal shift to the post pneumonectomy space
Other lung hyperinflates
CXR –> opacification of affected hemithorax at 4/12

58
Q

How does lung function change after pneumonectomy

A

Volumes, FVC and TLCO all reduce by half

59
Q

Complications of pneumonectomy

A

Pulm oedema of other lung - suddenly the entire CO goes through one lung

Haemothorax

Chylothorax

Bronchopleural fistula

Post pneumonectomy syndrome - breathlessness, infections and stridor (caused by compression of trachea and main stem bronchus)

Contralateral Ptx

Empyema in the pps

Cardiac herniation

Scoliosis

AKI

60
Q

Who is at risk for problems after pneumonectomy

A

BMI>30
COPD
Current smoker
Co-morbid status

61
Q

Normal time course for cardiac surgery post op

A 
3 hours - warm to 36.5
6 hours - extubate
overnight - wean pressors, ensure analgesia
Next day - MDT, drains out, art line out
Afternoon - ward or HDU
62
Q

Optimal heart rate post op, and when are epicardial pacing wires removed

A

80 BPMM

day 4 - if not, PPM

63
Q

BIggest risk to watch for after removing epicardial pacing wires

A

Tampanade

64
Q

Is there evidence for whish inotrope to use post op

A

No

65
Q

Inotropes to improve RV dysfunction

A

Inodilators - enoximone, milrinone, dobutamine
Improve RV perfusion pressure, reduce PVR

Improve RV afterload - avoid hypoxia, acidosis, hypercapnoea

66
Q

Triad of tamponade

A

BP fall, CO fall, rising CVP

67
Q

What to do in a cardiac arrest after bypass

A

Re-open the sternotomy

Consider epicardial wires

68
Q

IABP - where does it go

A

Descnding aorta distal to left subclavian and proximal to renal arteries

69
Q

How is the IABP balloon triggered

A

ECG or by BP

NOT time

70
Q

Inflation of the ballon does what?

A

Increases diastolic pressure and improves coronary flow
Decreases LV afterload

Increases SV by 40ml

71
Q

Indications for IABP

A 
Cardiogenic shock (pap muscle rupture, mitral regurg)
Post MI VSD
Unstabel angina
High risk cardiac surgery
Difficult weaning from bypass
72
Q

Contraindications to IABP

A

Moderate to severe AR
Aneurysm and dissection
PDA

Relative:
Bilatera peripheral arterial disease
Bleeding disorder
HOCM with LVOT

73
Q

Complications of IABP

A 
Stroke
Bleeding
Thrombocytopenia
Pseudoaneurysm
Renal hit 
Balloon rupture
74
Q

When is the predictable peak of creatinine

A

day 3

75
Q

Is there a risk of pancreatitis after cardiac surgery

A

Uncommon, but transient increases in amylase due to low CO, hypothermia and too much calcium

76
Q

Is RRT usually needed after cardiac surgery

A

Not in the first 24 hours

77
Q

Describe the 3 2 1 approach to acceptable bleeding in cardiac surgery

A

Hour 1 - 3ml/kg/hour
Hours 2 -4 2 mls/kg/hr
Hours 4-12 1ml/kg/hr

78
Q

Causative organisms of sternal wound infections

A

S.aureus
S. epidermmidis
Coliforms

79
Q

Drug re-introduction after cardiac surgery

A

Beta blockers on day 1 at half dose for rate control

Calcium channel blockers - rapid withdrawel can cause coronary artery spasm.

Digoxin on day 1

ACEi , A2 and spironolactone - delayed until inotropes off

80
Q

What is Lee’s Revised Risk Index and what is it made up of

A

Risk of cardiac complications after NON cardiac surgery

High risk surgery
IHD
CCF
U&amp;Es (Cr>176)
Previous Insulin for DM
Stroke

0 - 0.4%
1 0.9%
2 6.6
>3 11%

Pete FFICM SOE/OSCE (199 decks)

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