surgery: OME videos Flashcards
- gallstone diseases
what are the ultrasound findings for choledocholithiasis?
gallstones in GB/CBD; CBD distention >0.8cm (8mm)
primary intervention for gallstones in cbd
ERCP (then cholesystectomy)
what test should be performed prior to ERCP?
MRCP (except for ascending cholangitis)
US findings for acute cholecystitis
pericholecystic fluid, GB wall inflammation/thickening, gallstones in cystic duct
what patients are at the greatest risk for acute acalculous cholecystitis?
critically ill for a while, usually no enteric feeding (parenteral nutrition)
major potential complication of ERCP that is quite common?
pancreatitis
who gets black pigmented stones?
pts with hemolytic anemias (children or adults)
risk factors for cholesterol gallstones
fat (hyperlipidemia, hypercholesterolemia)
fertile (multiparous - inc exposure to estrogen during pregnancy)
female (estrogen - fat and cholesterol metabolism)
40 yo+
foreign (hispanic, native american,black)
what does biliary dyskinesia look like on US and HIDA scan?
US = normal
HIDA= fails to fully empty gall bladder
what organisms should be covered in acute cholecystitis and ascending cholangitis?
gram negatives and anaerobes
(metronidazole? zosyn?)
what does charcot’s triad (RUQ pain, fever, jaundice) suggest?
ascending cholangitis- obstruction of the CBD (jaundice + RUQ pain) with infection (fever)
describe the abdominal pain associated with biliary colic
RUQ pain worse with fatty foods (intermittent)
what is the difference between biliary colic and the pain of acute calculous cholecystitis
colic = intermittent, spontaneous resolution
cholecystitis = constant, does not resolve
what is the primary intervention for cholelithiasis?
elective cholecystectomy
how do you treat an abdominal wound evisceration?
saline gauze dressings –> surgical emergency
how do you protect against intraoperative aspiration?
NPO 6-8 hours pre op +/- 4 hours no clear liquid
NGT w/ suction
avoid preoxygenation with ventilation
who gets acute colonic pseudo-obstruction (oglivie)?
elderly esp after abdominal surgery
how do you treat acute colonic pseudobstruction?
conservative measures for ileus, neostigmine, colonoscopy without insufflation and leave a rectal tube, hemicolectomy
what does post-op ileus look like on imaging?
dilated loops of large AND small bowel
cessation of smoking pre-op for wound healing
30 days before surgery
post- op pt has reduced urine output overnight and a foley in place. what’s the likely cause?
volume depletion (foley kink ruled out, urinary retention can’t be the answer)
- high specific gravity
- pre-renal azotemia
- hx of diarrhea, vomiting, NPO, etc.
what should you do if the pt has no urinary output for 6 hours and a distended suprapubic mass?
bladder scan –> in and out cath
how to prevent and tx a post-op ileus
out of bed, ambulation, fluids, potassium correction (hypokalemia)
who is at greatest risk for post-op urinary retention?
older men with BPH
What is the difference between wound dehiscence and evisceration?
both are wound closure failure, evisceration is bowel protruding through the defect
wound dehiscence typically occurs 5-8 hours post-op
post-op pt has zero output overnight but has a foley in place; what is the next step?
flush and reposition the kinked catheter
How long must DAPT be continued for a bare metal stent and for a drug- eluting stent?
1 month for bare metal stent
1 year for Drug-eluting stent, though can consider urgent surgery after 6 months.
when do you perform stress testing in a preop work-up?
the patient has known CAD or risk factors and they cannot perform 4 METs of activity
which patients with cirrhosis can undergo elective surgery?
childs-pugh A+ B or C–>B
when is pulmonary function testing appropriate for preoperative clearance?
A previously undiagnosed obstructive lung disease that is apparent through history and physical (not routinely done).
When should a patient stop smoking to optimize post-op wound healing?
30 days before surgery
How long should smoking cessation occur prior to surgery pulmonary complications?
Any amount of time (not the erroneous 8 wk guideline, now revoked)
describe the general rules for determining the risk of a procedure.
The deeper you go (skin/GI tract vs. into body cavity), the more you remove (resection worse than no resection), and the more you add (transplants highest risk), the higher the risk
How do you perform stress testing in a pre-op work-up?
because they can’t do 4 METs to qualify for stress testing, there must be pharmacologically induced stressing
What is the cutoff for platelets to preclude elective general surgery (not neurosurgery)?
below 50,000 platelets
what is the cutoff for INR that precludes elective surgery?
above 1.5
What lab values should be used (and which should not be used) to assess the nutritional status of a patient?
albumin (not “prealbumin” aka transthyretin or CRP)
what are the options for treating a peritoneal abscess following abdominal surgery
drain and antibiotics or open for washout and abx
what are the options for treating an anastomotic leak following abdominal surgery
open to washout, then either fix anastomosis or create diverting ostomy
what does rising end-tidal CO2 following administration of halothan or succinylcholine mean?
malignant hyperthemia
what does UTI infection look like in a foley bag?
blood tinged, milky white, pus floaters
fever after surgery but on post operative day zero is suspicious for what infections?
bacteremia or necrotizing fasciitis of the surgical incision site
what is meant by early vs late post- op fever?
early <48 hrs; do not investigate
late >48 hours - do fever work up (CBC, CMP, UA, CXR, inspection of surgical site, urine blood culture, etc.)
what is the work-up for post op fever?
UA, urine blood culture, CXR, look at surgical site, (CBC w/ diff; CMP)
In order from best to worst, what are the ways to prevent DVTs in post-op pts?
ambulation>LMWH> pneumatic compression (SCDs)
how do you prevent post-op pneumonia?
out of bed (early ambulation) and probably incentive spirometry
How do you prevent UTI in post-op pts?
get cath out as soon as no longer indicated
how do you prevent surgical site infections by skin flora?
prophylactic antibiotics (1st/2nd gen cephalosporins, clindamycin?)
Second-generation cephalosporins have coverage against Haemophilus influenzae (H. influenzae), Moraxella catarrhalis, and Bacteroides spp.
The three antibiotics used in adult surgical prophylaxis, where weight-based dosing is recommended, are cefazolin, vancomycin, and gentamicin
how do you treat a new, postop DVT?
SubQ LMWH then bridge to warfarin or NOAC
what are NOACs and DOACs?
Direct oral anticoagulants (DOACs) are oral medications that specifically inhibit factors IIa or Xa. They are also known as new oral anticoagulants (NOACs) or target-specific oral anticoagulants (TSOACs).
There are currently 4 NOACs available for healthcare providers to prescribe for patients with atrial fibrillation (see Table 1): dabigatran (Pradaxa®), rivaroxaban (Xarelto®), apixaban (Eliquis®), and edoxaban (Lixiana [Europe/Asia], Savaysa [Nth Am]).
what is a heparin bridge
“Bridging” is a term that refers to the use of short-acting anticoagulants (heparin or LMWH) for a period of time during interruption of warfarin therapy when the INR is not within a therapeutic range.
There is no established single bridging regimen.
Usually low-molecular-weight heparin given by subcutaneous injection for 5- 10 to 12 days around the time of the surgery/procedure
what medication treats malignant hyperthermia?
Dantrolene
Name the symptoms of cellulitis
- systemic fever
-warmth and erythema - not well circumscribed
- most likely staph. aureus
symptoms of an infected surgical wound
- same as cellulitis
- staph aureus
symptoms of a deep abscess associated with surgery?
pain, ileus that does not resolve
symptoms of subphrenic abscess
- post splenectomy/gastrectomy
-referred left shoulder pain
how do you dx deep abscess or anastomotic leak?
abd CT
