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Maintaining ICM knowledge > Surgery > Flashcards

Surgery Flashcards

1
Q

What are the risk factors for AAA?

A
  • male
  • age > 65
  • smoking
  • hypertension
  • myocardial and/or cerebrovascular disease
  • genetic / familial e.g. inherited CT disorders such as Marfans and Ehlers-Danlos
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2
Q

How does a ruptured AAA present?

A

Most rupture into the RP cavity resulting in classic triad of:
- pain -> severe and usually in the back
- circulatory compromise
- pulsatile abdominal mass
Also - back pain mimicking renal colic, pain radiating into legs, chronic severe back pain (contained rupture), transient lower limb paralysis

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3
Q

What is the management of a patient with ruptured AAA?

A

Resus - 2 x large IV access
Massive transfusion protocol
Aim SBP 90
Analgesia
Bloods - FBC/u+es/coag/venous gas
ECG
Emergent transfer to operating theatre

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4
Q

How might a AAA be imaged?

A
  1. CT - good in uncertain diagnosis, gives details analysis and localise morphology. Can delay surgery, nephrotoxic contrast.
  2. US - rapid bedside confirmation
  3. MRI - not appropriate in rupture
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5
Q

How can you prognosticate in ruptured AAA?

A
  1. Hardman index
  2. Glasgow aneurysm score
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6
Q

Describe the Hardman index

A

Predicts immediate outcome after ruptured AAA surgery
- age > 76 = 1 point
- Cr > 190 = 1 point
- Hb < 90 = 1 point
- MI on ECG = 1 point
- LOC after arrival in hospital = 1 point
Scores of 2+ predict a mortality of 80%

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7
Q

Describe the Glasgow aneurysm score

A

Age = age in years
Shock +17 points
Myocardial disease = 7 points
Cerebrovascular disease incl TIA = 10 points
Ur > 20 +/or Cr > 150 = 14 points
A value of 84 = predicted mortality of 65%

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8
Q

What are the complications following emergency surgery for ruptured AAA?

A

Graft-related: early
- massive transfusion
- Distal embolisation
- Aortic branch involement causing ischaemia e.g. pancreatitis, AKI
- Endoleak
Non-graft related: early
- AKI, MI, paraplegia, hepatic dysfunction, HAP/VAP, ARDS, ACS, ileus
Late complications
- infected graft, graft occlusion, aorto-enteric fistula, anastomotic pseudoaneurysm, prolonged resp wean, small bowel obstruction, sexual dysfunction, incisional herniae, DVT/PE

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9
Q

What are the indications for spinal drain insertion in AAA?

A
  1. Reducsed CSF pressure following complex abdo EVARS where patients are considered high risk of spinal cord ischaemia
  2. Rescue therapy for delayed paraplegia post-op
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10
Q

How do lumbar drains work?

A

Cord perfusion pressure = MAP - CSF pressure
Therefore cord perfusion can be increased by decreasing the CSF pressure

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11
Q

What are the CIs to spinal drain insertion?

A
  • Anticoagulation and coagulopathy
  • Active infection (systemic or local)
    Raised ICP
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12
Q

How to manage CSF drainage from a spinal drain

A

Most people produce 10-20mls/hour
- Target CSF pressure = 10
- Don’t drain too quickly - increases ICH - 5mls-10mls alloquots
- MAP target 85-90
- Aiming SCPP 75mmHg

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13
Q

What is normal IAP?

A

5-7mmHg

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14
Q

What is abdominal perfusion pressure?

A

MAP - IAP

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15
Q

What id intra-abdominal hypertension?

A

Sustained or repeated elevations in IAP > 12mmHg

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16
Q

What is abdominal compartment syndrome?

A

Sustain IAP > 20mmHg that is associated with new organ dysfunction

17
Q

What is the grading of intra-abdominal hypertension?

A

Grade 1 = 12-15mmHg
Grade 2 = 16-20mmHg
Grade 3 = 21-25mmHg
Grade 4 = 26+mmHg

18
Q

What are the risk factors for developing ACS?

A
  1. Reduced abdominal compliance
    - abdo surgery with tight closure
    - trauma, burns, obesity
    - prone positioning
  2. Increased abdo contents
    - ileus, gastroparesis, psuedo-obstruction, ascites, haemoperitoneum
  3. Capillary leak
    - severe sepsis, trauma, pancreatitis, burns
    -hypothermia
    - acidosis
    - massive transfusion
    - fluid resus,+ve FB
  4. Other / misc
    - MV
    - PEEP > 10cmH2O
    - Increased head of bed angle
    - Shock or hypotension
19
Q

How is intra-abdo pressure measured?

A
  1. Direct - via needle into abdomen e.g. during laparoscopy
  2. Indirect - transduction of an intra-abdo viscus e.g. bladder. Zero at symphysis pubis
20
Q

What are the pathological effects of ACS on the resp system?

A
  • Basal atelectasis and collapse due to diaphragm splinting and reduced chest wall and lung compliance
  • Increased V/A mismatch, hypoxia and hypercapnia
  • Application of PEEP worsens venous return and cardiac output
21
Q

What are the pathological effects of ACS on the CV system?

A
  1. Raised IAP is transmitted to the abdo vasculature
  2. Reduced CO due to reduced venous return and increased afterload
  3. Reduced CO further reduces APP
  4. Increased intra-thoracic pressure due to diaphragm splinting may compromise CO further
22
Q

What are the pathological effects of ACS on the neurological system?

A
  1. Increased ICP can occur due to impeded venous return due to raised intra-thoracic pressure
  2. ICP may be further elevated due to cerebral vasodilatation due to hypoxaemia and hypercapnia
23
Q

What are the pathological effects of ACS on the renal system?

A
  1. Reduced renal blood flow due to transmission of raised IAP to the renal vasculature
  2. The raised IAP is also transmitted to the renal outflow tract increasing pressure on the tubules and reducing filtration gradient
  3. Compensatory activation of the RAAS further worsens renal insult
24
Q

What are the pathological effects of ACS on the GI and hepatic system?

A
  1. Hypoperfusion caused by critical illness is exac by venous hypertension, which results in bowel wall oedema
  2. This may cause bowel ischaemia and bacterial translocation
  3. Reduced flow in the hepatic vessels contributing to liver dysfunction
  4. Biliary sepsis resuting from increased pressure within the biliary tree
25
Q

What are the principles of managing abdominal compartment syndrome?

A
  1. Medical management to reduce IAP - sedation, analgesia, muscle relaxant, avoid prone position
  2. Optimise fluid and correct +ve FB
  3. Evacuation of intraluminal contents - gastric decompression, prokinetics and laxatives
  4. Evacuation of abdo fluid collections - abscess drainage, paracentesis
  5. Organ support
  6. Surgical decompression
26
Q

What are the complications / issues with an open abdomen?

A
  1. Nursing issues - skin prone to damage, issues with turning, pain
  2. Fluid loss - can be litres/day, unreliable fluid balance
  3. Malnutrition - protein/nitrogen loss from the open abdomen
  4. Infection risk - sterilty is almost impossible
  5. Visceral injury and adhesions
  6. Ileus
  7. Abdominal wall-related - large ventral hernias following definitve closure, inability to definitvely close
  8. Significant risk of enterocutaneous fistulation

Maintaining ICM knowledge (11 decks)

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