Surgery

Question 1

How many ruptured AAAs make it to hospital?

Answer 1

Approx 50%

Of these approx 50% die before surgery and 50% do not survive the surgery

Question 2

Who is most at risk of AAA?

Answer 2

Male
> 65 years
Smokers
Hypertensives
Previous CVD
Connective tissue disorders e.g. Marfans and Ehlers Danlos

Question 3

What are the signs/symptoms of a ruptured AAA?

Answer 3

Back pain
 - may radiate to the legs or mimic renal colic
Circulatory collapse
Pulsatile abdominal mass
Lower limb paralysis

Question 4

How is a patient with ruptured AAA managed?

Answer 4

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

Question 5

How can you image a AAA?

Answer 5

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

Question 6

What complications occur after AAA surgery?

Answer 6

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

Question 7

What scoring systems can be used to predict outcome following a AAA repair?

Answer 7

Hardman index (predicts immediate outcome following surgery for AAA rupture)
Glasgow aneurysm score - cna also be used following elective AAA repair

Question 8

Describe the Hardman index

Answer 8

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

Question 9

Describe the Glasgow aneurysm score

Answer 9

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

Question 10

When do AAA’s normally get repaired electively?

Answer 10

Men >5.5cm
Women > 5 cm
Or > 1cm growth / year

Question 11

What are the indications for spinal drain insertion in AAA repair?

Answer 11

Reduce CSF pressure following complex EVARs where the patient is considered high risk for spinal cord ischaemia
Rescue therapy for delayed paraplegia postoperatively

Question 12

How do spinal drains work following AAA repair?

Answer 12

Cord perfusion pressure = MAP - CSF pressure

Therefore draining CSF will increase spinal cord perfusion

Question 13

What causes pancreatitis?

Answer 13

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

Question 14

What are the two types of pancreatitis?

Answer 14

Interstitial oedematous

Necrotising

Question 15

What scoring systems are there to identify severe acute pancreatitis?

Answer 15

1. Ranson criteria > 3 at 48 hours indicates severe acute pancreatitis
2. Glasgow criteria >2 predicts SAP
3. Apache II >8 defines acute severe pancreatitis
4. Balthazar CT grading

Question 16

Describe the Glasgow scoring system for pancreatitis

Answer 16

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

Question 17

What is the role of imaging in acute pancreatitis?

Answer 17

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

Question 18

When should patients with acute pancretitia be managed in ICU?

Answer 18

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

Question 19

What general principles govern the management of acute pancreatitis?

Answer 19

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

Question 20

What local complications does pancreatitis cause?

Answer 20

1. Pseudocyst

2. Pancreatic necrosis

Question 21

What is the role of surgery in SAP?

Answer 21

1. Pseudocyst - no intervention, perc aspiration, endoscopic or surgical techniques
2. Pancreatic duct disruption - image guided drain insertion to drain collection. Many need Whipples or distal pancreatectomy if refractory
3. Pancreatic abscess
4. 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

Question 22

How should patients with pancreatitis be fed?

Answer 22

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