Surgery Flashcards
How many ruptured AAAs make it to hospital?
Approx 50%
Of these approx 50% die before surgery and 50% do not survive the surgery
Who is most at risk of AAA?
Male > 65 years Smokers Hypertensives Previous CVD Connective tissue disorders e.g. Marfans and Ehlers Danlos
What are the signs/symptoms of a ruptured AAA?
Back pain - may radiate to the legs or mimic renal colic Circulatory collapse Pulsatile abdominal mass Lower limb paralysis
How is a patient with ruptured AAA managed?
This is a surgical emergency Management should follow an ABCDE approach with minimum delay to definitive surgical management -2 large bore cannulae -massive transfusion protocol -rapid volume infusers -aim SBP 90 -analgesia -FBC, U+es, coag, gas, ECG
How can you image a AAA?
CT - useful of diagnosis not clear. Allows details of the aneurysm, could be used to assess suitability for EVAR
USS - will detect an aneurysm and free fluid
MRI - avoid contrast
What complications occur after AAA surgery?
Renal failure MI Spinal cord ischemia and paraplegia Hepatic dysfunction HAP/VAP ARDS Abdo compartment syndrome Ileus DVT/PE Bowel ischaemia TRALI Trash foot Infection Graft occlusion Aorto-enteric fistula Pseudoanyrysm Endoleak
What scoring systems can be used to predict outcome following a AAA repair?
Hardman index (predicts immediate outcome following surgery for AAA rupture) Glasgow aneurysm score - cna also be used following elective AAA repair
Describe the Hardman index
Predicts immediate outcome after repair of ruptured AAA
Age >76 = 1 point
Cr > 190 = 1 point
Hb < 90 = 1 point
Myocardial ischaemia on ECG = 1 point
Hx of loss of consciousness after arrival to hospital = 1 point - scores of 2 or more suggest an 80% predicted mortality
Describe the Glasgow aneurysm score
Predicts mortality for AAA A value of 84 predicts a 65% mortality Age = age in years Shock = 17 points Myocardial disease = 7 points Cerebrovascular disease = 10 Renal disease (ur > 20, Cr > 150) = 14 points
When do AAA’s normally get repaired electively?
Men >5.5cm
Women > 5 cm
Or > 1cm growth / year
What are the indications for spinal drain insertion in AAA repair?
Reduce CSF pressure following complex EVARs where the patient is considered high risk for spinal cord ischaemia
Rescue therapy for delayed paraplegia postoperatively
How do spinal drains work following AAA repair?
Cord perfusion pressure = MAP - CSF pressure
Therefore draining CSF will increase spinal cord perfusion
What causes pancreatitis?
Obstructive: Gallstones, tumour, cystic fibrosis, congenital anomalies.
Systemic: hypoxia/ischaemia, durgs e.g. steroids, hypothermia, hypercalcaemia, high TGs, viruses e.g. HIV, CMV, mumps, scorpion venom
Parenchymal: Alcohol, trauma incl ERCP, auroimmune e.g. primary sclerosing cholangitis
What are the two types of pancreatitis?
Interstitial oedematous
Necrotising
What scoring systems are there to identify severe acute pancreatitis?
- Ranson criteria > 3 at 48 hours indicates severe acute pancreatitis
- Glasgow criteria >2 predicts SAP
- Apache II >8 defines acute severe pancreatitis
- Balthazar CT grading
Describe the Glasgow scoring system for pancreatitis
P - PaO2 < 8 A - age > 55 N - WCC > 15 C - ca < 2 R - urea > 16 E - LDH > 600, ALT/AST > 200 A - albumin < 32 S - glucose > 10
What is the role of imaging in acute pancreatitis?
AXR - limited role, will detect free air, ileus, calcified gallstones/pancreas
CXR - pleural effusions - usually left
USS - detecting gallstones
EUS - detects periampullary lesions
CT - always indicated in SAP, used to detect necrosis, fluid collections, haemorrhage, pseudoaneurysms, guide interventions
ERCP - relieve biliary obstruction
MRI - MRCP is not as sensitive as ERCP but is safer and non-invasive, can delineate necrotic areas
When should patients with acute pancretitia be managed in ICU?
Strong indicators for admission include: Age > 70 BMI > 30 Ongoing volume resuscitation Indicators of more severe disease - substantial pancreatic necrosis, > 2 ranson criteria, pleural effusions, crp > 150 at 48 hours
What general principles govern the management of acute pancreatitis?
ABCDE
Fluid resus - inadequate fluid repletion is a/w high rates of pancreatic necrosis
Pain management
Organ support
Nutritional Support
Prevention and treatment of infection
Treatment of associated of causative conditions
General supportive measures - VTE, VAP bundles, physio
What local complications does pancreatitis cause?
- Pseudocyst
2. Pancreatic necrosis
What is the role of surgery in SAP?
- Pseudocyst - no intervention, perc aspiration, endoscopic or surgical techniques
- Pancreatic duct disruption - image guided drain insertion to drain collection. Many need Whipples or distal pancreatectomy if refractory
- Pancreatic abscess
- Infected pancreatic necrosis - aspiraiton or necrosectomy. About half of patients with necrosis develop infection by week 3-4. Timing of surgery is important - early surgery is a/w a very high mortality. Necrosectomy to remove infected tissue should be delayed until clear demarcation of infected tissue can be demonstrated
How should patients with pancreatitis be fed?
Enteral feeding to help maintain intestinal mucosal barrier and prevent translocation
NJ feeding may be required as gastric emptying is often impaired.
TPN if enteral feeding is not tolerated
