SURGERY + HOSPITAL Flashcards
PreOp conditions that might make you cancel or defer a scheduled surgery
Focus on CV, Pulmonary, Neuro and CoMorbidities
AGE is itself a big risk
CARDIAC: looking for MI risk, JVD, 3rd or 4th
heart sounds, sufficient ejection fraction
CAROTID BRUITS (new ones) - you should order a doppler. If over 50% occluded no surgery. Pt could stroke on the table. If under 50% advise pt of risks, note it to surgeon but you can go forward.
PNEUMONIA just don’t do surgery until its over
DM - ensure BG is controlled and EKG is clear
HTN - End organ damage is the issue, review
cardiomegaly/ej fraction kidney, retina,
possibly ejection fraction assessment d/t
cardiomegaly
Tests you WILL do if asked to clear your Pt for elective Surgery:
EKG and CXR if over 40
EKG in ALL diabetics d/t silent MI silent d/t nerve damage so they don’t feel it.
CXR on ANY smoker regardless of age
Main causes of Morbidity in Pts undergoing Surgery:
MI + Heart Failure
Stroke (DON’T MISS a Carotid Bruit!!!)
You could use the Goldman, Lee or the American Association of Cardiologists PreOp Risk Assessment - that might be a good place to start
Mneumonic for Hospital Admission Note
Deb’s fav
ABC DAVIDS
A- Admit to (Dr. & Floor)
B- Because… Dx requiring Admission + others
C- Condition (stable, not stable + why not)
D- Diet + DVT prophylaxis orders
A - Allergies (any) + Activity level orders
V- Vitals (how often taken)
I - IV Fluids + Drugs (Medicines are usually IV)
D- Diagnostic Testing
S- Special Nursing Orders
Floors in a Hospital
MED-SURG (is general) SURGERY (OR Suites + pre/post op rooms) OB ICU ER PAC-U/ RECOVERY TELEMETRY ONCOLOGY ORTHO Mother/Baby/Nursery LABOR + DELIVERY
Even OTC Vitamin E can cause problems in a hospitalized patient, what does it do?
Slows Clotting
Nice for avoiding embolus but not so good if you’re having surgery…
How long is Pre-Op blood work good?
10-14 days depending on the doc
Personally, I would repeat the pregnancy test before surgery and the CBC…
How long is a Pre-Op CXR good?
6 Months
Is a pelvic necessary for a Pre-Admission H+P?
A DRE?
Pelvic is optional
DRE + Guiac are not optional. A (+) Guiac is cause to delay a surgery until the cause is found and neutralized.
Maintenance D5W NS for NPO patients
100-150 cc/hr
You might start high for an hour or two then lower it to maintenance if the pt has been N/V/D for more than 1 day to make up the fluid deficit
Specialty Nursing Directives include?
Anything out of the ordinary that you want the nurses to do/arrange:
PT q day Respiratory Therapy orders Restraints Assist to Toilet Bed by window, shades up during day... Notify if daily CBC shows changes to BUN/CR...
OOB means
Out of Bed
If a pt gets admitted from the ER, how long does the hospitalist MD/PA have to get the Admission H+P done + into the notes
24 hrs
but better in the first shift after admission, so the nurses and other providers know what’s going on.
What is the focus of the SURGICAL H+P, done to the extent possible on an 911 admission to surgery ?
Focus on conditions that will impact surgical outcome:
Comorbidities:
Cardiac
Renal
Bleeding Disorders
Pulmonary Disease
-Asthma/COPD/Smoking
CANCER OF ANY KIND - they will look for
mets whereas they wouldn’t if they didn’t
know of a prior/cured cancer
Past Surgeries: No Tonsils, No Appendix..
-Were there complications
- Is there Mesh inside?
- How about metal joints/replacements…
-Any problems with the anesthesia
SOCIAL HX:
-Who can we speak with after the surgery?
-End of life planning/ CPR Intubation
Heroic Measures Refusal
- Will you be able to recover at home
-Supervision
-Stairs
-Toilet on 1st Floor…
ADDICTIONS
ETOH/DRUGS get CIWA protocol
Why does COPD send up red flags for Surgery
They don’t come off vents well, neither do smokers. Some surgeons won’t operate on COPD or even on active Smokers until they’ve quit.
CIWA Protocol?
Frequent Vitals, Neuro Checks and Ativan for Addicts to prevent the DTs
The Four Ps for:
MEDICATION
Pain
Puke
Pus
Prophylaxis
Pain: Oral? Oxycodone/Tramadol/Percocet
IV - usually for break thru or if NPO
Toradol IV/IM is nice but watch the kidney
PCA - your doc will have a protocol
Epidural still in? you can use that
Puke: Don’t rip out those stitches heaving!
Put in an order of Zofran PRN for most
surgical patients. Try 4mg IV, may need
to increase for over 170 lbs
Pus: Avoid Infection!!!
PreOp, IntraOp and PostOp ABX!
Prophylaxis: Think DVT and Atelectasis
Use Heparin for DVT (and get them up and
walking ASAP
Order Spirometry q 4 hrs to prevent lung
collapse
Toradol Protocol
15-30 mg q 6 Hrs
Not more than 120 mg/day
Not more than 5 Days
Daily BUN/CR (daily CBC really)
As Toradol does a number on the kidneys
PCA
Patient Controlled IV Anesthesia
What is the concern with epidurals?
HypOtension
What’s the trouble with surgery pts on beta blockers?
They slow the heart and reduce contractility and that might not be desirable in a surgery patient but you can’t just stop them as you’ll likely get rebound tachycardia
Consider holding them the morning of surgery and then monitoring HR often, hourly and adding them back in if HR climbs out of your target range.
Zofran aka?
Odansetron
4mg IV or IM to start, may need to increase for pts over 175 lbs.
Its a serotonin (5HT3) blocker that works in about 30 minutes (orally) ASAP via IV/IM
Hepatically conjugated then renal cleared. Take care with Liver Dz as it will keep circulating in active form until the diseased liver gets around to deactivating it.
DON’T use with other serotonin blockers like SSRI, SNRI or MAO Inhibitors. May cause Serotonin Syndrome, watch out for:
gitation, ataxia, diaphoresis, diarrhea, hyperreflexia, mental status changes, myoclonus, shivering, tremor, or hyperthermia
Don’t Forget QT prolongation. If you’re giving it to your cardiac pts or someone on erythromycin or Amitriptyline or other QT lengtheners, keep them on an EKG or better yet, don’t give it. A little nausea is better than Torsades.
Serotonin Syndrome
Symptoms coincide temporally with the addition of a serotonergic agent to a patient’s regimen or with an increase in the dose of a previously prescribed serotonergic agent
At least 3 of the following physical findings are present:
agitation, ataxia, diaphoresis, diarrhea, hyperreflexia, mental status changes, myoclonus, shivering, tremor, or hyperthermia
A neuroleptic agent has not been recently added to the patient’s regimen or increased in dose, if previously prescribed
Other etiologies, such as infection, intoxication, metabolic derangements, substance abuse, and withdrawal, have been ruled out
Kefzol (Cephazolin)
1st Gen Cepahlosporin
often used before, during + after surgery
1-2 grams IV q 8 hrs
Clindamycin (Cleocin)
Lincosamide Abx
Good for G(-) Anaerobes + Protozoa which is why its often used in the gut.
THIS is the antibiotic most associated with promoting c. Dif (gram (+) gut bacilli)
Clostridium Dificile
Gram + Gut Bacillus
Causes severe diarrhea, painful + perhaps bloody when it displaces the normal flora of the colon, usually after a course of broad spectrum ABX aimed at Gram (-) anaerobes i the gut.
Best to use an antibiotic that also kills cdif too! That’s why we always add Flagyl to a gut regimen, specifically to kill the c Dif - though it has many other wonderful qualities. For severe C Dif infection, only oral Vanco will do. This is the only oral use for Vanco.
These guys are HIGHLY contagious and form spores in bad conditions and they do it when exposed to many “disinfectants” as well, thus surviving even a good cleaning. KILL C Dif with BLEACH, use bleach wipes, strong ones. You can disinfect a hospital room with a hydrogen peroxide vapor systems or ultraviolet light.
how to kill MRSA?
VANCO IV
Vanco orally for c Dif
Describe the presentation of a peritonitis patient
Patient should have diffuse abdominal pain, ascites, likely a fever, possibly chills and bloating. You may see air under the diaphragm on CXR and abdomen should be hyper resonant to percussion.
This pt is SICK SICK SICK and looks it
Peritonitis pts are not wiggly or in the fetal position, they just lie very very still and don’t want anyone to touch them.
Suspected peritonitis pts must have PARACENTESIS in the ER. You’re looking for Neutrophils over 500/microliter. This takes time right now but there is a leukocyte esterase dip-stick in the works that appears likely to replace the physical cell count and speed diagnosis.
Medscape says Cefoxatime is as good as the classic ampicillin/gentamycin regimen for empiric Rx of peritonitis (bacterial, of course)
Manipulation of the bowel is a set up for…
ILIUS!
Opening of the peritoneal cavity and handling of the intestines both precipitate a local inflammatory rxn which immediately induces smooth muscle relaxation and ilius. In Fact, the degree of bowel manipulation during surgery DIRECTLY CORRELATES to the duration of post op Ilius.
Post Op Ilius (POI) usually lasts 3-5 days
It appears to be lessened/shortened by epidural during the procedure and by post op NSAID therapy (controls local inflammation). The COX-2 Inhibitor CELECOXIB is favored for this d/t reduced peptic damage but carries the risk of increased vascular events by blocking COX-2 on blood vessel walls, preventing secretion of prostacyclin which both dilates vessels and prevents platelet aggregation - thus long term use of celecoxib increases risk of “vascular events” aka MI - not so welcome after surgery. But a single dose post op is not uncommon.
Opiates post op will also delay resumption of normal intestinal peristalsis.
TO REDUCE POST OP ILIUS
1) Consider Laproscopy vs Laparotomy access
2) Consider Epidural anesthesia, at the Thoracic level
3) Give a dose of Celecoxib post op
4) Initiate post op oral food as soon as possible, Gum chewing before hand if actual eating is not yet possible.
5) Up and out of bed - just for good measure
WHO changes surgical dressings in the 24-48 hrs immediately following surgery?
MD or PA… Nurses don’t. Don’t know why. They do seem to monitor them though.
Post Op failure to urinate plan
Always leave a plan for monitoring of urination post op in patients who do not get a foley in the or.
If no pee within 6-8 hrs post op, insert FOLEY. If you get over 500 ml out, leave the foley inserted. If you don’t get 500, you can assume there was no pee to urinate out and remove the foley. Always order a foley post op, cause you cannot leave a robin in if it turns out pt has urinary retention from surgery.
DON’T Strait Cath after surgery - if a lot of urine is evacuated because you have retention, you’ll just have to RECATH with a foley. It’s OK to treat a foley like a strait cath and NOT leave it in if you don’t evac much urine.
What is CIWA protocol?
Frequent Vitals + Neuro Checks for Addicts with standing orders for Ativan to prevent DTs
Laproscopy vs Laprarotomy
Laproscopy: Through small incisions with instruments. Reduces post op ilius when compared with laparotomy
Laparotomy: Open Air Abdominal incision
What are chemically impregnated dressings and when do you use them?
Bandages impregnated, usually with Vaseline but also with Silver.
Come in a foil packed, nice for:
-Skin Avulsions (bandaid has a product)
-Sometimes the vaseline occludes minimal
bleeding
Perfect dressing for early pressure sores
Foam Dressing : DUODERM
They’re self adherent and waterproof
They protect the wound and pad the ulcer and prevent further damage from sliding over sheets
REVIEW DEB’S DRESSINGS PWR PT
AND make slides - notes are not good on this
Tegaderm?
DRY wounds
Burns- AFTER they stop weeping
Dry Eschar on Elbows/Heels
NOT for Infected Wounds
Why use a drain post op?
When can you take out the drain?
Difference between Active + Passive Drains
How to remove drains?
To ensure neither fluid nor air build up beneath the suture site.
You can take it out when there is less than 25ml of fluid in a day.
Active drains are hooked to Low Wall Suction or they are end in a bulb from which the air is expressed creating a vacuum (Jackson Pratt Drain for mastectomy + Tummy tucks).
Passive Drains are just rubber or silicone tubes - DO inquire about latex allergy of every surgical patient!!!
Premedicate Pt before removing - it HURTS!!
- Remove 2cm/day so track heals from the inside out
- At the very end, cover remaining tubing with vaseline impregnated bandage SNIP THE STITCH - DON’T FORGET THIS!!! then yank the tube out in one swift motion + press down on the bandage - secure with tape.
Jackson Pratt Drains
Closed system drain that ends in a bulb from which air is removed, creating a low pressure vacuum. Mastectomies and Tummy Tucks typically use these.
What is Continuous Bladder Irrigation
Its a 2-Way Foley through which sterile saline is run INTO the bladder to prevent build up of clots or sediments typically after genitourinary surgeries (prostate, bladder, ureter)
A 3-way Stop Cock is attached to the special Foley: Urine comes out one tube, One tube is for inflating the balloon and sterine NS goes into the bladder through the third tube.
Post Op instructions need to state how often the catheter must be drained and irrigated and how often (at minimum) Nursing is to check the catheter to ensure it isn’t blocked. They will check frequently but an order for checking every 20 minutes for the first few hours post op is not out of line.
Pulmonary Wege
Balloon inserted thru SWAAN GANZ catheter to measure pulmonary pressures
This is not such a popular technique these days and is mainly seen in ICU
Normal Wedge Pressure is 2-15 mm Hg
PWP is the GOLD STANDARD for diagnosing the CAUSE OF PE, not really whether or not there IS a PE.
High PWP indicates impaired left ventricular function and may indicate Mitral Valve Stenois.
PE Diagnostic Tests
Thoracic Ultra Sonography (TUS) and Spiral CT or CT angiogram.
Sonogram is faster and very effective but a Negative soon doesn’t rule OUT PE. However a positive SONO can point you toward clot dissolution ages before you can get a CT Angiogram done and read.
CT Angiogram (aka Spiral CT) is the GOLD STD but sono is faster, reliable and worth the extra step if you can’t get your CT done and read right away.
Pulmonary Wedge Pressure (PWP) is the GOLD STANDARD for diagnosing the CAUSE OF PE, not really whether or not there IS a PE. High PWP indicates impaired left ventricular function and may indicate Mitral Valve Stenois.
Anasarca
Extreme
Generalized EDEMA
Usaually caused by liver or kidney failure but can be induced by Fluid Volume Excess caused by IV therapy.
Ex: Swollen face of child with Malaria caused Nephrosis and PEDIATRIC NEPHROTIC SYNDROME associated swelling is called Anascarca.
Fluid Volume Excess
Usually over hydration caused by IV Therapy
It means so much fluid onboard has deranged the electrolytes - namely SODIUM
If not caused by IV Therapy, it can be induced by release of BNP in response to right atrial distention. This will cause the kidneys to stop conserving sodium so as to decrease overall blood volume, but sometimes it backfires.
911 Rx for FVE is:
Loops Limit Fluids and GIVE SODIUM!! Dialysis if that doesn't work Continuously monitor paO2, EKG, Lytes Monitor Is + Os
How does morphine reduce pulmonary edema?
It seems MORPHINE causes VASODILATION and this increases drainage of fluid from the lungs into the venous system.
It also decreases after load in the cardiac patient, which is why it’s not a bad idea in the MI pt with High Blood Pressure.
It also reduces tachypnea, which may help with PE.
presurgical medication changes
Aspirin - stop 7 days prior
Coumadin - stop 3 days prior
Diabetic Meds - stop orals
- give 1/2 dose am INSULIN
the morning of surgery
HTN meds - try holding them. Anesthesia
BP. Monitor and add back in if
warranted by rising BP.
Where can you use IV Regional Anesthesia?
aka BIER METHOD
On arms/legs distal to elbow/knee
Blood is driven proximally by a pressure bandage then a double pneumatic cuff is applied to keep it out during the nerve block - the prevents the meds from going systemic in a huge bolus and causing trouble outside the extremity.
Then Lidocaine, the block agent, is suffused into the limb from as far distal as possible, usually the dorsal hand or foot. A 20- minute wait ensues then the pneumatic devices can be partially reduced.
Obviously surgery has to be quick (less than 1 hr) d/t the reduced blood flow.
Benzos and Fentanyl help prevent seizures though why this is a risk with this method I’m not sure.
AMPLE 911 Hx Pneumonic
A- Allergies !!! M- Medicines P- Past Medical Hx L- Last oral intake E- Events leading up to surgery
Life threat side effect to succynl choline?
Hyper Thermia - use cooling blankets!
Fluid Shift caused by:
Isotonic/ Hypotonic/ Hypertonic
Iso - no shift
Hypotonic in the ECF Shifts fluid INTO the cell
Why operate on Diabetics early in the day?
They need to be NPO for surgery but you don’t want to cause hypOglycemia. You will need to give them half their morning insulin though you can hold their oral and other injectables until they eat.
How does HypOnatremia cause cerebral edema?
q
How does hypOcalcemia cause tetany and prolonged QT interval and positive Chovsteck and Trousseau?
q
PreOp bleeding tests
PT PTT Platelet Count
Peaky T and U waves
Hyper K
C Big Kay Drop
Calcium Chloride or Gluconate to ensure
QT doesn't lengthen into Torsades
BiCarb AND Beta Block
Insulin
Glucose
Kay-exalate binds K+ in the gut
Drop - Dialysis or Diuretics to "Drop" K+
out into the pee
How long to Hold METFORMIN before surgery? Why?
Metformin clears in about 12 hrs, that’s why its a BID med. Regardless, if surgery is elective, stop Metformin at least 48 hrs before surgery and do not restart it until the patient is eating normally.
Remember, Metformin causes lactic acidosis in those who have GFR less than 60. Infection, Sepsis, Hypoxia and Ischemia all also cause acidosis and surgery can bring any of these conditions on, so don’t leave Metformin on board to complicate the acidosis situation further.
Also stop Metformin before CT with contrast as contrast will stress the kidney and you don’t need to stress it more with having Metformin on board.
Normal range for Potassium in serum
3.5-5.5
Hyper-Kalemia Signs/Symptoms
Hyper K+ Treatment
Peaky Ts on EKG
Fatigue + Weakness, possibly palpitations
Bouts of paralysis after exercise - this is a genetic familial disorder of humans and quarter horses
Scour Med list for K+ sparing diuretics (spironolactone, Aces + Arbs) and diets for K+ supplementation or eating lots of fruits, especially juices, also lots of energy drinks or rehydration drinks.
Rx: C Big Kay Drop
Calcium for heart
Bicarb for ?
Beta Block for palpitations
Insulin to shift K+ intracellular
Glucose to offset hypoglycemia of insulin
Kay-Exalate binds K+ in the gut
Drop - DropK+ into the urine with K+
wasting Loops, Thiazides or Dialysis
HypOkalemia signs, symptoms + Rx
Weakness + Fatigue (just like hyped K+) Constipation Abdominal Bloating Exercise Intolerance Muscle Cramps
Meds/conditions that cause it: Loops + Thiazides Insulin (shifts too much K+ intracellular) Albuterol + other beta agonists DIARRHEA
Rx:
Switch Loops/thiazides for ACE/ARB or spironolactone but don’t give both spironolactone AND and ACE/ARB
you can just give KCL orally but it is preferable to alleviate the loss rather than to replace as its so easy to overshoot into HYPER kalemia.
VIRCHOW’s TRIAD
Hypercoagulability
Endotheial Injury
Venous Stasis
A direct path to DVT!!!
Make sure your surgical and/or Immobile pts are on DVT protocol and are up and walking regularly. And if they’re obese, just put them on Heparin 5000 units sq.
Dehiscence, what is it and who’s at risk?
Dehiscence is a parting of the wound, a failure to stay closed.
It is common on abdominal/periumbillical incisions especially in obese individuals.
It is also a result of IN-Version of the edges of the wound instead of proper E-Version. Wound edges are ONLY INVERTED on colon resections.
What do 5-HT Receptor Antagonists DO?
they block serotonin receptors and reduce Nausea/Vomiting.
Zofran/Odansetron
Serious Side Effects: Ototoxicity & QT prolongation. Worstened in setting of compromised LIVER function.
Patients inherently at risk for nausea + vomiting post op and why that’s a problem and what to do about it?
Females and those with histories of Motion Sickness
It’s a post op problem because retching is so violent and can pull out stitches just about anywhere but the arms and legs
Zofran/Odansetron (5HT3 antagonist) is even given prophylactically to such patients. NG Tube may help
ER minimal History Pneumonic:
AMPLE
Allergies Meds Prior Surgeries + Past Medical Hx Last Oral Intake Events leading to the emergency
Most common cause of fever on Post Op days 1-2
Atelectasis
5 Ws of Post Op Fever
Wind - not moving air - Atelectasis
Water - UTI
Walking - or rather NOT WALKING - DVT
Wound - Surgical Infection
Wonder Drug - Serotonin Agonists some
Antibiotics, Sulfa Drugs
AntipsychoticsSplinting
Not taking in a deep breath because it hurts, this leads to Atelectasis then pneumonia
Fever Post Op day 3-5
Pneumonia cause by the atelectasis from days 1+2 caused by the splinting
Should have gotten sufficient pain relief on board to prevent the splinting and spirometery from day 1 post op!
Fever Post Op days 5-7
UTI
Get that FOLEY OUT!!
If you’d gotten it out earlier, perhaps the UTI wouldn’t have developed. Now you have to treat a nosicomia UTI which may require big guns like Levofloxacin or a third gen Cephalo IV
You’ll need to get a culture but start empiric RX as soon as you do. Switch to a less broad abx if culture indicates.
Drug Associated with Malignant HypERthermia
Succinyl Choline
only in genetically predisposed persons though
Of course, these persons don’t usually realize they are genetically predisposed and find out when they get trached and have massive temp increases.
Use the arctic cooling blanket for this or cold gastric lavage
Most common side effect of spinal anesthesia is?
Headache
You breached the CSF and pushed something into it… head is bound to hurt!
MOST common breast cancer
Invasive Ductal Carcinoma
Point at which it is advisable to remove a surgical drain
Drainage is less than 25ccs/day
Atypical Ductal Hyperplasia
d
Breast Cancer mets to
Bone, Liver, Lung, Brain
Conscious Sedation /MAC
k
Common for Knee surgery
Low Risk baseline Mamo age
35-40
Foods that exacerbate fibrocystic breast dz
fat and caffeine
Mastitis most common bugs
Abx and why this abc?
Staph + Strep are most common
Dicloxacillin is the Rx
It’s Safe for baby and will do the job
How does Aspirin protect against breast cancer?
overall inflammation reduction. try 81 mg 2X/week
Fibrosis, cysts + swollen mammary glands =
Fibrocystic breast dz
Familial Hx of Non-breast cancer that is a risk for breast cancer
Ovarian Cancer
Most common unavoidable breast cancer risk
Age over 70
Lifestyle choices that increase risk for breast cancer even in women with no family Hx
Smoking
Even Moderate Drinking
Sedentary
Obesity
Most common site for tumor detection in the breast
upper outer quadrant, including axillary nodes
Basic Differences between Benign and Malignant Lumps
Benign Malignant
-Multiple -Single
-Bilateral -One Side Only
-well circumscribed -hard to define
borders border
-Mobile -Fixed
-Rubbery -Hard
-smallish -large
-slow growing -rapidly growing
-goes away -doesn’t go away
-pain is cyclical -pain noncyclical
-Milky discharge -Bloody, clear, colored
Discharge
-Many ducts leak -Only one duct leaks
-Orange Peel skin
-Nipple inversion
Fibrocystic Breast Changes
Benign lumps, usually in both breasts that become tender cyclicly, before menstruation
Not consuming this will lessen pain of fibrocystic breast change but is unlikely to have effect on mallignancy
Caffeine
Takes 3 weeks to feel the change as it stays in your system that long
catchall word for breast pain
Mastalgia
Controversial medication for cyclical Mastalgia
Tamoxifen
Estrogen Receptor Modulator SERM
10mg daily for a 3 month pd was found to be effective though there may well be relapses. Longer treatments are deemed too risky. No information about applying Tamoxifen gel to the breast as transdermal is still experimental.
RISK OF ENDOMETRIAL CANCER!!!!!!!
Danazol
Synthetic Androgen used in Progesterone Positive breast cancer and simple mastalgia to bind up progesterone receptors
Not quite as effective as tamoxifen in mastalgia, also works better in cyclical mastalgia as does tamoxifen - this makes sense as it is progesterone that usually causes cyclical mastalgia. As with tamoxifen, it has a 50% relapse rate in mastalgia. Seems to work best when it is actively blocking progesterone receptors.
DEPRESSSION, HIRSUITISM, ACNE AND of course, it’s TERATOGENIC.
NOT WORTH THE RISKS, JUST STOP THE CAFFEINE
BROMOCRIPTINE
Dopaminergic Agonist which blocks PROLACTIN release from the posterior pituitary.
SERM
Selective Estrogen Receptor Modulators
SERMS agonize some estrogen receptors and antagonize others. They are selectively created to enhance estrogen’s activity at the bone (prevent osteoporosis) and to block it at the breast (prevent estrogen + breast cancers). With regard to the uterus, Blocking estrogen is protective against endometrial and ovarian cancers but increases risks of certain other cancers so that’s a hard place to know what to block.
All SERMS end in Fen or Fene
Tamoxifen - Antagonist @ breast,
Agonist @ Bone + Uterus
Treats Breast Cancer
Experimentally for Mastalgia
May increase risk of Uterine Canc
Raloxifene - Antagonist @ Breast + Uterus
Agonist @ Bone
Treats Breast Cancer and
Treats Osteoporosis
Does not increase Uterine Canc
risk
Clomifene - Antagonizes Estrogen Receptors
in the Hypothalamus thereby
keeping FSH Stimulating
Hormone flowing and ovarian
follicles maturing. Will cause
maturation of multiple follicles
enhancing fertilization potential
or just getting multiple eggs to
harvest for IVF
Ormeloxifene - Saheli Only legal in India
Antagonist in the uterus+breasts
Agonist in the bones
It prevents timely preparation of
the endometrium such that when
ovulation occurs, implantation is
unlikely. 1-2% failure rate when
taken weekly as directed, slightly
less effective than hormonal BCP
There are a few more. Most are agonists at the bone to protect against osteoporosis - though this seems to work better in post menopausal females than in pre.
BRCA1 + BRCA2
Genes encoding for DNA Repair which, if mutated, significantly predispose one to breast and ovarian cancer development. Moreso Breast (a strait 50% risk, in addition to any behavioral/lifestyle risks) but a BRCA1 mutation increases risk (40-60% risk)
Describe Breast Cancers
Most are carcinomas, meaning they begin in epithelial cells. More specifically, most are adenocarcinomas, meaning they are cancers that begin in the epithelial cells of glands.
The breast also hosts Sarcomas, which begin in connective, muscle or fat tissue but these are less common than the carcinomas.
DCIS (Ductal Carcinoma In Situ) is an abnormal proliferation of the cells lining the breast duct. These change the appearance of the duct and may break out of the duct, in which case they will become INVASIVE DUCTAL CARCINOMA (IDC). There isn’t a way yet to tell if DCIS will progress to IDC
DCIS vs IDC
DCIS (Ductal Carcinoma In Situ) is an abnormal proliferation of the cells lining the breast duct. These change the appearance of the duct and may break out of the duct and invade surrounding breast tissue, in which case they will become INVASIVE DUCTAL CARCINOMA (IDC). There isn’t a way yet to tell if DCIS will progress to IDC
IDC, invasive ductal carcinoma is the MOST COMMON Breast Cancer type.
Due to it’s potential to become invasive, we do remove DCIS and closely monitor women who’ve had an episode of DCIS as they are more likely to develop another.
LCIS vs ILC
Lobular Carcinoma In Situ is a proliferation of the epithelial cells that line the lobe of the breast. These cells may or may not invade tissue outside their original lobe, and in fact, it is thought less likely that lobular carcinoma in situ will invade than ductal carcinoma in situ.
If LCIS does break out of its lobe, it becomes INVASIVE LOBULAR CARCINOMA, the second most common invasive breast cancer.
As with DCIS, we do go ahead and remove LCIS to prevent any chance of development into ILC
Just how fast can Inflammatory Breast Cancer spread?
REALLY Fast, hours to days. Its the one that looks like a rash or a pimple or mastitis. With the orange peel skin.
ALWAYS RX Inflammatory Breast Cancer with Chemo BEFORE removing it!!!
HER2
Human Epidermal Growth Factor Receptor #2 (there is also a HER1)
The HER proteins cross the cell membrane and can initiate cell proliferation if “turned on” by Human Growth Factor. These signaling proteins are not usually present in great number on cell membranes. If there are too many of them, cell safeguards against over proliferation are overwhelmed and a tumor can result. The number present in the membrane is genetically encoded.
The more aggressive, deadly breast, ovarian, stomach and uterine cancer cells often over-exhibit HER2 protein receptors.
When a tumor tests + for HER2, we use the MAB designed to target HER2 to kill the tumor: TRAZTUZIMAB (Herceptin).
Traztuzimab targets only the HER2 receptor proteins and won’t work on cancers that don’t have it. Traztuzimab can cause congestive heart failure so tumors are tested for HER2 before Traztuzimab treatment is initiated. Since HER2 tumors are so aggressive, the risk of cardiac side effect is felt to be worth it.
Traztuzimab is used in conjunction with surgery and other chemotherapy and is improving survival rates and reducing relapse rates in aggressive tumor diagnoses.
The tumors adapt quickly to Traztuzimab with resistance developing in ALL patients. It is thought best to give it full force, with other chemo and then remove the tissue altogether.
Traztuzimab
HER2 Receptor Blocker creates a window within which Human Epithelial Growth Factor is prevented from stimulating tumor growth.
During that window, other therapies and surgery have a better chance to work
Costs $70,000 for a year’s course. 9 weeks may do the trick though and ROCHE is coming out with a cheaper version.
Simple Mastectomy/ Total Mastectomy
All breast tissue is removed but Axillary lymph nodes are not - though the Sentinal Node is
taken in the “Total Mastectomy”
This procedure is for DCIS or prophylactic mastectomy based on family or prior history.
Modified Radical/ Radical Mastectomy
Radical is removal of the breast, all associated lymph nodes AND the pectoral muscles. Rarely done now as most breast cancers don’t invade the pectoral muscle or chest wall and we can tell which ones do. Radical is reserved for those that DO invade the pectorals and/or chest wall
Modified Radical is the breast + Lymph Nodes sparing the pectoral muscle. As effective at stopping non-metastatic cancer as the radical.
Phyllodes Tumor
Looks like fibroadenoma
Rare tumor
it is a malignant tumor of the connective (stromal tissue)
Padget’s Dz of the Breast
Flaky Eczema
Padgets Dz of the Nipple
Malignant
Intraductal Papilloma
sub arealar intraductal mass
Unilateral bloody nipple discharge
Benign but you ‘ll have to prove it isn’t cancer with a biopsy
Internist’s Fluid
NS 0.9% NaCl
Careful, NS can cause Acidosis
These are isotonic as to sodium but NS doesn’t have buffers and can cause acidosis and hyperchloremia.
Surgeon’s Fluid
Lactated Ringers
Isotonic as to Na+ with buffers that address acidosis before it happens
HyperK+ could occur if you have a renal patient, esp one on spironolactone, Aces or Arbs (all K+ sparing) Otherwise, the K+ in Ringers isn’t of much concern.
Liver patients can’t metabolize the Lactate so give them NS
MAC
IV Benzos + IV Propofol
Local Anesthesia
Eye Surgury + Colonoscopy
IV Regional vs Regional
Double Cuff vs
Spinal/Epidural/ Nerve Block
Muscle Relaxants
Benzos, Succynl Choline, Curare
FRIENDS for Fistula Risk
FB Radiation Infection Epithelialization Neoplasm Distal Obstruction Steroids (block healing)
FINA Score for whether renal failure is pre or post renal
less than 1 = pre renal cause
greater than 1 = post renal
Pulmonary Wedge Pressure Normal:
2-15
Mitral Valve Stenosis
LV Failure
Cardiogenic Shock
Hypervolemia vs Over Hydration
Hypervolemia - think kidney dysfunction. Also high salt diet
Over-Hydration you are replacing water without sodium and electrolytes.
BNP less than 100 with Hypervolemia
source of your excess fluid is not cardiogenic, think kidneys
Crystalloids
D5W
Lactated Ringers
NS
Fluid Filled Cyst in the breast you can:
A) Aspirate if symptomatic (pain)
B) watch it
For fluid/solid mix, order a fine needle aspiration guided by ultrasound.
For solid mass, use core needle biopsy or excise it.
Use D5W
Hypernatremia
Dehydration
Fluid loss from burns
It’s just sugar in water - doesn’t have Na+ so monitor for hyponatremia if using lots.
Dextran
Volume Expander with Anticoagulation properties
Synthetic colloid (starch ) effects last 6-12 days
Microreimplantation surgical reattachment of severed limbs, fingers…
Hydroxyethyl Starch
Volume Expander with anti-inflammatory properties
Most used synthetic colloid
Effects last 8-12 hrs
Albumin effects last
16-24 hours
Given in Burns, Liver Disease
Gelatin Solution
effects last 5 hours
Extra-corporeal Circulation
Epidural side effect of most concern
HYPOtension
Hydro-Fiber Dressing
Absorbs exudate
Wound care for dry eschar and skin tears
TEGADERM
transparent film dressing
Hydrogel + Hydrocolloid
colloid risks anaerobic bacteria growth as it is occlusive. Stays in place up to 7 days
Hydrogel is changed every day.
How to know when your fluid resuscitation is sufficient?
Pt pees 30-35cc/hr
