Surgery and peri/post operative care Flashcards
what are the big 5 reasons for fever in a post-op patient
surgical site
IV sites
UTI
pneumonia
DVT
what are the guidelines regarding insulin use (in a T1DM) prior to surgery
take half the dose of long acting insulin on the morning of the surgery only
which tendons of the hand flex the DIP and PIP
DIP flexion = FDP
PIP flexion = FDS
what is the most likely diagnosis of a breast lump in a young woman
fibroadenoma
benefits of split skin graft vs full thickenss skin graft
large area possible
easier take
suture duration for face, trunk, legs, back
face - 5d
trunk- 7d
legs/back - 10d
what is the most effective way of reducing the bacterial load of a wound
debridement
commonest diagnosis of sudden onset breast lump
fibrocystic change
3 major general causes of hypotension post surgery
hypovolaemia
MI/CCF
epidural - peripheral vasodilation
epitheliazation of wounds occurs within
24-48 hours (why we don’t take the dressing off to take a look within the first 2 days- leave to heal)
benefit of negative pressure wound therapy
promotes angiogenesis
which proximal arteries predominantly make the deep and superficial arteries of the hand
deep - radial
superficial - ulnar
4 main past medical history areas you want to ask about when doing pre-op workup for anaesthesia
cardiovascular
respiratory
diabetes
GORD
difference between graft and flap
- graft = transferred tissue dependent on RECIPIENT SITE
- flap = transferred tissue INDEPENDENT of recipient site
which thyroid cancer shows “Annie Eyes” histologically
papillary thyroid carcinoma
explain the ASA classification
1 - healthy patient
2 - mild systemic disease
3 - significant or severe systemic disease
4 - severe systemic disease that is a constant threat to life
5 - moribund patient not expected to survive 24 hours with or without surgery
6 - brain dead organ donor
sign of deep dehiscence
leakage of pink serosanginous fluid
which IV access devices are used for chemotherapy
infusaport/portocath
Hickman catheter
what are the main investigations for breast lumps
mammography (>35)
US (less than 35)
when do we do a sentinal node biopsy vs an axillary clearance
axillary clearance only done now if the patient who is positive for nodes in the axilla (by sentinal node biopsy)
what are the % oxygen that can be delivered through the different prongs/masks etc
nasal prongs - 25%
hudson mask - 50%
Hudson mask + tusks = 60%
rebreathing bag - 70%
a sentinal node is
any node that is blue, hot or palpable
3 major outcomes of FOOSH
scaphoid #
Colles # - radius + ulnar #
Radial head #
what causes pressure sores
weight of patient impairing the blood supply to an area of tissue due to occlusion of vessels
what should you ask in a pre-operative assessment in regards to diabetes
- Type of diabetes - DMCC
- current management of DM
- Check adequacy of control
- diagnose complications
- evaluate other risk factors for CVD (HTN, FHx, high cholesterol)
difference between follicular adenoma and follicular carcinoma
adenoma - intact, well formed capsule surrounding the tumour
carcinoma - capsular invasion
specific complications of radial head fracture
myositis ossificans
recurrent instability
indications for drains
prevent accumulation of fluid
prevent accumulation of air
characterize fluid
4 initial steps to do when faced with a patient with low urine output
- check for IDC blockage
- assess patient for hypovolaemia
- ensure patient not bleeding
- give fluid challenge - 500ml-1L stat
what causes hypertrophic and keloid scars
exagerrated normal remodelling response to a skin wound
what is a split skin graft
harvest epidermis and part of the dermis like a shave of skin
what is the most common thyroid cancer
papillary thyroid cancer
what are the causes of an acute fever (first week) post surgery
hospital acquired pneumonia/aspiration pneumonia
IV site infection with bacteraemia
UTI
surgical site infection
why should you strive to achieve glycaemic control in diabetic patients pre-operatively
- hyperglycaemia increases wound infection
- hyperglycaemia impairs wound healing and worsens outcome post neruological damage/MI
- hyperglycaemia induces an osmotic diuresis –> dehyrdation and electrolyte damage
- T1DM may develop DKA
- hypoglycamia may induce coma, arrhythmias and cognitive deficit
AB of choice for prophylaxis for a surgery that will have a contaminated or clean/contaminated wound
single shot IV first generation cephalosporin (to get rid of skin flora)
explain the body’s metabolic stress response to surgery/acute medical illness
- elevation in catecholamines, growth hormone, glucagon, cortisol and ACTH
- depression of insulin levels and insulin resistnace
–> leads to catabolic state (raised glucose levels, protein catabolism, lipolysis, FFA production and ketone body production)
explain the withholding of DM medications for surgery
- all oral hypoglycaemics (except metformin and long acting sulphonylureas) - withhold for the morning of surgery
- metformin - with-hold 48 hours prior to surgery
- long acting sulphonylurea - withhold >12 hours prior to surgery
- basal bolus insulin - give basal insulin (normal or 2/3) and then give bolus with breakfast if afternoon surgery. Also give IV 5% dextrose
what is the relevance of a cold or hot thyroid nodule
cold - more likely to be cancer
difference between a hypertrophic and a keloid scar
hypertrophic - stays within margins of original wound, can improve over time, and can respond to steroid injection
keloid - extends beyond wound, progresses over time, less responsive to steroids and silicone
What are the causes of an immedate fever post surgery
transfusion reaction
medication reaction
infection prior to surgery
trauma
malignant hyperthermia
intraductal papilloma most likely presents as
bloody nipple discharge
where are PICC lines/CVC/Vascath/Permcath/Portocath catheters placed
PICC - basilic vein
CVC - IJV or subclavian vein with tip in SVC
Vascath - IJV or femoral vein (NOT subclavian)
Permcath - IJV or EJV
Portocath - into SVC
what are the clinical signs of ventilation
chest movement
breath sounds
expired air
mask fogging
capnography
pulse oximetry
why would you do a flap instead of a graft
- bed doesn’t have a sufficient vascular supply to support a graft
- need to cover prosthetic material
- better appearance
- can contain muscle, bone, nerve etc
what are the suspicious features on ultrasound for malignancy of a thyroid nodule
hypoechoic
microcalcification
increased vascularity
infiltrative margins
absent halo
taller than wide
what does a fibroadenoma look like on US
well demarcated edges
lobulated
uniformly hypoechoic
what are the contraindications for using a nasopharyngeal airway
base of skull fractures and transphenoidal surgery
lifetime risk of breast cancer in women
1 in 9
benefits of full-thickenss skin graft vs split skin graft
less contraction of skin
better cosmetic outcome
what does the persistent fever vs the spiking fever mean
persistent - suggest drug reaction or neurosurgical
spiking - suggests abscess
explain the maintenance fluid rule
4,2,1 rule
- Give 4ml/hour/kg for the first 10kg of body weight
- Give 2ml/hour/kg for the second 10kg of body weight
- Remaining weight give 1ml/hour/kg
Which IV access devices are used for haemodialysis
vascath
permacath
clinical features of a fibroadenoma
smooth, rubbery, discrete, well-circumscribed, non-tender, mobile HORMONE DEPENDENT
what are the stages of ventilation (from least invasive to most invasive)
bag and mask
bag, mask and guedel
LMA and bag
ETT and ventilator
3 major complications of thyroid surgery
nerve injury (RLN and ESLN)
hypoparathyrodisim
bleeding
what are the predictors of difficult ventilation of a patient
previous difficult ventilation
obesity
short, thick neck
OSA
beard
edentulous
jaw pathology
what does the “sniffing the morning air position” do to the joints of the neck
cervical spine flexion
atlanto-occipital joint extension
what are the guidelines regarding metformin use prior to surgery
stop 48 hours prior to surgery
fasting guidelines for adults and infants
adults: 6 hours for solids 2 hours for clear fluids
infants: 3 hours for breast milk 4 hours for formula
management of DCIS
surgery - can progress to breast cancer
what is the fasting blood glucose target for dibetics for surgery
5-10mmol/L
reversible causes of pulseless electrical activity
5 Hs and 5 Ts
Hypoxia, Hydrogen ions (acidosis), hypovolaemia, hypothermia, hypo/hyperkalaemia
Tamponade (cardiac), thrombosis (cardiac), thrombosis (pulmonary), toxins, tension pneumothorax
what are the predictors of difficult intubation
history of difficult intubation
acquired conditions: RA, ankylosing sponylitis, TMJ problems, airway/neck pathology, radiation
examination findings: High Mallampati score, small inter-incisor gap, small thyromental distance, limited neck flexion, teeth, jaw protrusion or receeding jaw
what do you do to examine the airway in regards to pre-op workup for anaesthesia
Mallampati score
thyromental distance
tongue size
neck circumference
range of motion of head and neck
ability to protrude mandible forwards
classification of surgical wounds
clean
clean/contaminated
contaminated dirty - pus, preop infection
medullary carcinoma is associated with which condition
MEN 2A or 2B
what are the US findings of fibrocystic changes
thin outer membrane hypoechoic
how do you reverse warfarin
prothrombinex +/- Vit K and FFP
what is the major different between an LMA and an ETT
LMA - no protection against aspiration!
what are the difference between a continuous, passive expiration and forced expiration air leak in a drain
continuous - leak present during both insp and exp
passive exp - leak only present in exp
forced exp - leak only present during forced exp
treatment options for a toxic thyroid nodule
medication - carbimazole, PTU
surgery
radioactive iodine treatment
what is the normal punching injury of the hand
Boxers #
- fracture of the distal 5th metacarpal
