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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What has P-possum been replaced by for NELA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
Post op enhanced recov
``` Avoid iv fluids Oral fluid and nutrition early avoid ng tube and drains avoid systemic opiates for simple analgesia early mobilisation remove catheter rehab ```
26
Risks of blood going through bypass circuit
Activates clotting Precipation of inflammatory response Fluid shifts Risk of emboli Anticoag risk
27
General rules of thumb for drain bleeding post cardiac surgery
400ml 1st hour OR 200mls/hr for first 2 hours OR 100mls/hr for first 4 hours
28
Coag features of heparinisation
Prolonged activated clotting time ACT Prolonged APTT Prolonged R time on teg
29
What causes thrombocytopenia in CPB
Process consumes platelets so expect a drop in absolute count Previous antiplatelet agent use Fluid shifts dilute clotting factors
30
How to minimise impact of ischaemia reperfusion
Cardioplegic solutions (high K, conserves ADP whilst asystolic) Hypothermia Reduces metabolic demand Hyperosmotic buffer cardioplegic solutions to minimise myocardial oedema and acidosis
31
Problems after bypass
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
32
Usual time to extubation in cardiac cases
6 hours
33
Features of a tampanade
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
Hb target for CPB
90
35
Causes of medical bleeding post CPB
Incomplete reversal of heparin Thromobcytopenia Peri op platelet drugs Coag from liver
36
Features of medical/surgical bleeding
HR up CVP/PAOP down Cardiac index down Blood in drains (surgical bleeding is more brisk)
37
Investigaton of bleeding after CPB
Activated clotting time TEG FBC Coag Surgical exploration
38
Causes of myocardial dysfunction after CPB
Post cariotomy stunning Graft failure Valve dysfunction Pre existing dysfunction
39
Features of myocardial dysfunction
HR up CVP PAOP up CI down Not much blood in draing
40
Ix of myocardial dysfunction
ECG Echo both to look for regional ischaemia Calcium level
41
Treatment of myocardia dysfunction
Electrolytes Inotropes - milrinone IABP Correc the graft or valve
42
Complications of open AAA repair
``` AKI Spinal cord ischaemia - neuro defecit Bleeding and coagulaopathy Stroke MI ```
43
Mortality of emergency and elective AAA repair
36% | 6%
44
Commplications of EVAR
``` Endoleak Covert to open Bleedind and coagulopathy Embolic event Rupture AKI - flow or contrast SIRS response - post implantation syndrome ```
45
Why does aortic surgery needs a spinal drain
drain CSF decrease pressure on cord maintain blood flow
46
Complications of intracranial surgery
``` Bleeding Haematoma Raised ICP Seizures Cerebral oedema Pneumocephalus CSF leak --> infection Neurogenic pulmonary oedema DI ```
47
Hypertension strategy
B blockers first line - do not affect ICP | Avoid GTN they increase flow
48
Is negative fluid balance good for traumatic brain injury
NO | This group should avoid negative balance
49
Why does free flap surgery fail
Thrombosis Ischaemia/hypoperfusion - sedation, fluid loss, SIRS, vasoconstiction Oedema - too much fluid, haemodilution, ischeamia
50
What is the optimal difference between peripheral ad core temperature in flap surgery
<1C
51
Hct target for flap surgery
30%
52
Mortality of pneumonectomy surgery
11%
53
Which side of pneumonectomy has higher mortality
Right (unclear why)
54
What is the immediate anatomical change after a pneumonectomy
Space fills with air
55
Is it routine to use drains in pneumonectomy
No
56
If you use a drain what would happen if you put in on suction
Air removed, mediastinal shift and haemodynamic compromise
57
What are the late anatomical changes after pneumonectomy
Raised hemi diaphragm Mediastinal shift to the post pneumonectomy space Other lung hyperinflates CXR --> opacification of affected hemithorax at 4/12
58
How does lung function change after pneumonectomy
Volumes, FVC and TLCO all reduce by half
59
Complications of pneumonectomy
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
Who is at risk for problems after pneumonectomy
BMI>30 COPD Current smoker Co-morbid status
61
Normal time course for cardiac surgery post op
``` 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
Optimal heart rate post op, and when are epicardial pacing wires removed
80 BPMM | day 4 - if not, PPM
63
BIggest risk to watch for after removing epicardial pacing wires
Tampanade
64
Is there evidence for whish inotrope to use post op
No
65
Inotropes to improve RV dysfunction
Inodilators - enoximone, milrinone, dobutamine Improve RV perfusion pressure, reduce PVR Improve RV afterload - avoid hypoxia, acidosis, hypercapnoea
66
Triad of tamponade
BP fall, CO fall, rising CVP
67
What to do in a cardiac arrest after bypass
Re-open the sternotomy | Consider epicardial wires
68
IABP - where does it go
Descnding aorta distal to left subclavian and proximal to renal arteries
69
How is the IABP balloon triggered
ECG or by BP NOT time
70
Inflation of the ballon does what?
Increases diastolic pressure and improves coronary flow Decreases LV afterload Increases SV by 40ml
71
Indications for IABP
``` Cardiogenic shock (pap muscle rupture, mitral regurg) Post MI VSD Unstabel angina High risk cardiac surgery Difficult weaning from bypass ```
72
Contraindications to IABP
Moderate to severe AR Aneurysm and dissection PDA Relative: Bilatera peripheral arterial disease Bleeding disorder HOCM with LVOT
73
Complications of IABP
``` Stroke Bleeding Thrombocytopenia Pseudoaneurysm Renal hit Balloon rupture ```
74
When is the predictable peak of creatinine
day 3
75
Is there a risk of pancreatitis after cardiac surgery
Uncommon, but transient increases in amylase due to low CO, hypothermia and too much calcium
76
Is RRT usually needed after cardiac surgery
Not in the first 24 hours
77
Describe the 3 2 1 approach to acceptable bleeding in cardiac surgery
Hour 1 - 3ml/kg/hour Hours 2 -4 2 mls/kg/hr Hours 4-12 1ml/kg/hr
78
Causative organisms of sternal wound infections
S.aureus S. epidermmidis Coliforms
79
Drug re-introduction after cardiac surgery
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
What is Lee's Revised Risk Index and what is it made up of
Risk of cardiac complications after NON cardiac surgery ``` High risk surgery IHD CCF U&Es (Cr>176) Previous Insulin for DM Stroke ``` 0 - 0.4% 1 0.9% 2 6.6 >3 11%

FFICM (57 decks)

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