Surgery Flashcards
Pre-op Assessment
Cardioresp function: CXR, ECG/echo, PFT, exercise
bloods: FBC, UE, BM, XM/GS
MRSA/infection screen, current illness
DH and allergies, esp. steroids
PMH and comorbidities, pregnancy!
previous anaesthesia, intubation (neck, teeth)
special tests (e.g. bowel prep)
cannula, VTE PPx, drug chart, consent, marked, NBM
Vascular Imaging/Ix
Doppler: venous reflux, pulses (triple), ABPI
Duplex: doppler + flow direction
CT/MR angiography: non-fempop
ABPI: lying; highest arm + highest foor (each leg); 0.8/0.6/0.3
Beurger’s: reactive hyperaemia; 25 = CLI, 45 = severe
Allens: pre-ABG
Tourniquet/Trendelenburg: venous incompetence (from above)
SSI risk
Clean (hernia): not entering viscus/cavity; no ABx needed
Clean-contaminated (lap chole/appe): elective viscus/cavity; ?ABx
Contaminated (intestinal spillage/inflamm): contaminated but not infected; ?ABx
Dirty (abscess, peritonitis): active infection; ABx
Post-op review
End of the bed: well = read notes first
R/V notes: test results, fluids/tubes/drains, NEWS, meds
Hx: operation, symptoms, E+D, BO/wind, mobilise, ICE/Qs
Ex: AtoE, vitals, fluid status (incl. IV, catheter, drains), chest2, abdo, wound, legs
*wound: dressing (?leak), pain, ?infection, d/c
*drains: location, working, fluid type, volume
document: ID, summary (op, days), latest results, SOAP, sign
* plan: Ix, Tx, other (TTO, chase, d/w etc.)
Amputation
gangrene/CLI severe infection massive trauma malignancy intractable pain/malformation
toes/transmeta/transmall (Syme’s)/transtib/throughknee/transfem
HTN stages
stage I: >140/90 (135/85 ABPM)
stage II: >160/100 (150/95)
stage III: >180/110
isolated systolic:
grade I: 140-159 (DBP <90)
grade II: >160 (DBP <90)
Malignant/accel: >200/120 + retinal hge
*headache, SOB, palp, CP, PVD, LOC
Secondary HTN (5%)
renovascular disease: RAAS; surgery
Renal disease: PCKD, DM, GN, pyelo
Coarctation: proximal HTN; rad-fem delay, CXR
Endocrine: Phaeo, Conn’s, Cushing’s, hyperPTH, acro, thy
Neurogenic (ICP)
drugs: OCP, alc, CST, NSAID, ADD, MAOI
pregnancy/pre-eclampsia
HTN complications
CVS: CAD/IHD, PVD, AAA, dissection, HF
Brain: ICH, CVA, vasc. dementia
Renal: sclerosis, nephritic, nephrotic, CKD
eyes: silver-wiring, AV nipping, hge/CWS, papilloedema
HTN Ix
first line: diagnose, ?2nd, damage/risk
UA, MSU, FBC, U&E, LFT, Ca, lipids, glucose, CXR and ECG
second line (<45yo - ?2nd) abdo US, 24h catechole, renin, cortisol, aldosterone, echo, MRA (?coarctation)
HTN Mx
treat if stage III, high CV risk, vascular disease, organ damage
lifestyle + RF: incl. DM and lipids, antiplatelet
A/C rules: A/C, A+C, A+C+D, ACD +other
Primary Cardiac Prevention
lifestyle: weight, diet, exercise, alc, smoke
regular risk review for >40yo
QRISK: DM, HTN, BMI, demo, chole, PMH/FH, smoking
atorvastatin 20mg if >10% risk, or DMT1, or CKD
Secondary Cardiac Prevention (in PVD)
lifestyle and DM
anti-plt: aspirin
anti-lipids: statin (atorva 80)
anti-HTN: ACEI (caution in PVD)
*statin: LFTs (3x)/CK (5x) + Sx = stop + restart lower
Hyperlipidaemia
primary: apoproteins/enzymes
secondary: DM, obesity, alc, nephro/nephritic, hypothy
VLDL/TAG: atheroma risk
apolipoA: IHD/CVD
Statins (aim <4-5, LDL <3), fibrates (ppar-a; TAG), ezetimide (absorption)
Statins
anti-thrombo, anti-inflam
stabilise plaques
reduced cholesterol
take ON
SE: myalgia, abdo pain, LFTs, CK, rhabdo
Atherosclerotic Aneurysm
> 150% normal diameter (>4cm aorta)
RF: age, male, FHx, CTD, athero, mycotic, injury, Takayasu aortitis
sites: abdo, asc/arch, cerebral, mycotic wall (Any)
effect: mass effect (pain, Fx), rupture, thrombosis/emboli
True vs. false aneurysm
true: all wall layers; sacular/fusiform;
* aorta > iliac > popliteal > femoral > thoracic
false/pseudo: surrounding tissue; trauma + pulsing haematoma
*firm, enlarged, pulseless vessel
AAA presentation (always rule out if abdo pain)
infra > juxta or suprarenal
aSx until expanding/leaking/rupture epigastric/back/groin pain pulsatile expansile mass HD instability, anaemia, haematemesis trash feet: dusky toes (emboli) sudden death
Popliteal aneurysm
present in 40% of AAA; also check femoral
pulsatile fossa mass
acute ischaemia (T/E clot), chronic isch (thrombus),
‘DVT’/compression (swelling, cyanosis)
rupture (pain, swelling, ischaemia)
Mx: thrombolysis + surgery
thoracic aneurysm pathology
intimal tear; false lumen between media/intima
external rupture: lower aorta; fatal haemothorax
retrograde spread to heart: pericardial rupture - tamponade
internal rupture: double channelled aorta (rare)
RF: HTN, pregnancy, degeneration, atheroma, FHx, Marfan’s/ED
Thoracic aneurysm: presentation
severe central CP, ‘tearing’
radiates to back/arms
can mimic MI
shock, unequal arm pulse/BP
neurology: brain/SC e.g. CVA
AKI, MI, fistulae,
acute ischaemia: lower limb, visceral
Thoracic aneurysm management
CXR: wide m’stinum/knuckle
MRI: gold standard
TOE/CT: confirms Dx
ECG: rule out MI
XM 10U + urgent cardiothoracic consult permissive hypotension (100-110 SBP) - labetalol type A: surgery (stent/replace) type B: medical unless comlpications
EVAR vs. open
mortality: 1.7% vs. 5% shorter stay: 2-4 vs. 7-10 days ITU less likely more expensive anatomy important: 15cm normal infrarenal more f/u: CT and USS lifelong re-intervention likely: endo leak
*open F/u: d/c at 3/12, re-scan at 5-7y
PAD - Fontaine classification
1) aSx
2) intermittent claudication
3) rest pain:
a/b: ankle >/<50mmHg
c/d: DM, ankle >/<30mmHg
4) CLI: tissue damage (gangrene, ulceration)
PAD - Rutherford classification
0) aSx
1) mild IC
2) mod IC
3) severe IC
4) rest pain
5) ulceration (toes only)
6) severe ulceration/gangrene
Intermittent Claudication
common, progression unlikely
angina of the legs; consistent distance
Leriche: ileal aa; erectile dysfunction + thigh/buttock pain
calf = fempop; thigh = iliac
DDx: spinal claudication, OA, neuropathy, venous claudication, aneurysm, pop aa entrapment
pulses
Buerger’s disease
lifestyle/other RF (e.g. DM)
antiplatelets (all), ACEI (HTN), statins (all), ?iloprost
Percut Transluminal Angioplasty (PTA)
Bypass/reconstruction
Amputation (pain, gangrene, sepsis)
Rest pain (vs. neuropathic)
burning pain at night (lying down), gravity eases
forefoot; cold, pale, and pulseless
neuro: red, warm, pulses;
glove/stocking, paraesthesia
hyperalgesia, allodynia
PAD signs
+RF for progression
absent pulses, postural colour change
cold white legs, atrophic skin, hair loss
painful ‘punched-out’ ulcers
Buerger’s angle <20 + reactive hyperaemia
CRT >15s
6Ps if acute; may have bruit
RF: smoking, DM, HTN, lipids, FHx
Gangrene DM vs. non-DM
drys vs. wet vs. gas (clostridium)
sensation, contracture, hge, focal gangrene
DM: wet more likely; single toes/heels (smaller aa)
PAD - Mx
FBC, U&E, CRP/ESR, lipids, ECG, clotting + G&S (arteriography)
ABPI, arteriography (e.g. duplex)
lifestyle/other RF (e.g. DM)
antiplatelets (all), ACEI (HTN), statins (all), ?iloprost
Percut Transluminal Angioplasty (PTA)
Bypass/reconstruction
Amputation (pain, gangrene, sepsis)
Mesenteric ischaemia
arterial/venous/trauma/vasculitis/strangulation
ACUTE TRIAD: pain, shock, no abdo signs
chronic: atheroma + low flow
CHRONIC TRIAD: pain (post-prandial), weight loss, bruit/N&V
ischaemic colitis: chronic IMA; LIF pain +/- bloody dd; ‘thumb print’ enema
Ulcers
arterial: painfull, small and deep, dry, ABPI, pulseless
* toes, heel, foot, lateral, tibia
venous: painless, large and shallow, wet, pulses
* medial malleolus; NOT foot/leg
neuro: painless, pressure areas, pulses, wet, deep
* other: vasculitic, SCD, infection, cancer, pyoderma, trauma (pressure ulcers)
Acute PAD (6Ps)
RF: dehydration, hypoTN, posture, cancer, hypervisc, IVDU, thrombophilia
aetio: thrombo, embo, iatro (graft), trauma, dissection, pop aneurysm
thrombo: Virchow’s, acute-on-chronic, abn pulses, bruit, calcified
embo: AF/AAA thrombus; acute, normal pulses, no PMH
Acute PAD: Mx
non-viable: stained, blanches, rigor mortis
*amputate
threatened: anaesthesia, passive pain/calf squeeze
* revasc <6h: embolectomy, tPa, amputation
non-threatened: normal fx
*RF/meds + LMWH + semi-elective revasc
Raynauds Syndrome (secondary)
CTD: SSc, mixed, SLE, Sjogrens, myositis
CVD: atheroma, Buerger’s, thoracic outlet
occupational: vibration, chemical, cold, compression
drugs: cytotoxic, BB, ergotamine
other: Ca/paraneo; causalgia, livedo
3 phases (white, blue, red)
reperfusion pain/burn/numb
severe: infarction and emboli
Ix: FBC, U&E, PT/APTT, glucose, TFT, specials
Tx: warm, smoking, nifedipine, ARB/AB/SSRI/iloprost
thoracic outlet syndrome (TOO)
cervical rib, clav#, muscle, fibrous bands
neuro T1 root: hand mm + inner arm sensory
arterial: claudication, aneurysm, emboli/ischaemia
Ix: BP (lower), arteriography, CXR (rib), bruit
Varicose veins
1: DTSI (deep to superfical incompetence)
2: obstruction (DVT), inflam/destruction (AVF),
RF: standing, pregnancy, obesity, FHx, OCP
ache, worse on ex, pain, eczema, thrombophleb (‘cords’), ulcers
decreased capps, increased wcc trapping and fibrin
Venous disease - VVV LAPS
varicose veins: great/small saph venous stars/spider veins venous ulcers lipodermatosclerosis, eczema, atrophy blanches, haemosiderin pitting oedema and skin thickening scars/fibrosis - champagne legs
venous Ix
doppler: flow direction; DTSI at SFJ/Pop fossa
* compression = upflow, release stops (compentent valve)
duplex: direction + anatomy; blue forward, red reflux/back
trendelenburg/tourniquet: SLR to empty veins, tourniquet, test refilling
*fillinf from above = incompetent, below = problem lower down
venous ulcer Mx
nutrition and RF
compression bandages (ABPI >0.8)
- I: ‘tired legs’, mild VV/oedema
- II: severe VV/oedema, prevent ulcers
- III: ulcers, ‘itis’, lymphoedema
cellulitis: ABx, debride, soak, cressing
varicose veins Mx (pain, bleed, ulcer, thrombopleb, QoL)
education, weight, exercise, support/bandage
endovascular surgery: RFA, endovenous ablation/coag, injection sclerotherapy
open: ligation, avulsion, stripping
post-op: tight bandages + 24h elevation, then reg walking
Lymphoedema
swelling, non-pitting, cobblestone skin
primary: young, inherited
secondary: obstruction (Ca, post-op), tumour, RDT (fibrosis), injury/inflam
Mx: compression, massage, ABx (cellulitis), avoid surgery
Arterial Injury Sx
pulsatile bleed, bruit/thrill, distal ischaemia, haematoma
Ix: doppler, angio, ABPI, visualistion (theatre)
beware reperfusion injury/compartment syndrome
Arterial Injury types
dissection, aneurysm (T/F), transection, AVF
transection Mx: pressure + gauze; image + repair (may need graft)
AVF: trauma, erosion, or iatro (dialysis); heavy + pain
support stocking, sclerotherapy, surgery (embolise)
