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IPE > Surgery & Vascular > Flashcards

Surgery & Vascular Flashcards

1
Q

Drugs to stop before surgery

A
  • Clopidogrel 7d before
  • Warfarin 5d before (if high risk - bridging LMWH and stop 12h preop) restart LMWH 6h post op and warfarin next day. If emergency -stop warfari, give IV VIt K +/- FFP
  • OCP/ HRT 4 weeks before and restart 2 weeks after
  • oral hypoglycaemia - stop from day of surgery until eat again ( if cant eat start sliding scale)
  • Insulin - sliding scale (up until eat again)
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2
Q

Pre-op investigations

A

Bloods - FBC; U+E; G+S; Clotting; Glucose ?LFT;TFT
- +/- crossmatch - 4u gastrectomy and 6u AAA
CXR if symptoms or > 65
ECG if HTN/Hx CVD >55
MRSA swabs

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3
Q

When should nutrition be stopped before surgery

A

> 2 hours for clear fluids

>6 hours for solid food

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4
Q

When should DVT prophylaxis be given

A
  • All - TED stockings

Low risk/ neck surgery - early mobilisation
Mod risk - + 20mg dalteparin
High risk + 40mg dalteparin + intermittent compressino boots peri-op

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5
Q

ASA grades

A
  1. Normally healthy
  2. Mild systemic disease
  3. Severe systemic disease that limits activity
  4. Systemic disease which is a constant threat to life
  5. Moribund: not expected to survive 24h even with op
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6
Q

Mallampati score

A

1) complete visualisation of soft palate
2) complete visualisation of uvula
3) visualisation of uvula base
4) Can’e see soft palate

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7
Q

Pre-medication for anaesthesia

A

 Anxiolytics and Amnesia: e.g. temazepam
 Analgesics: e.g. opioids, paracetamol, NSAIDs
 Anti-emetics: e.g. ondansetron 4mg / metoclop 10mg
 Antacids: e.g. lansoprazole
 Anti-sialogue e.g. glycopyrolate (↓ secretions)
 Antibiotics

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8
Q

3 principals of anaesthesia

A
  • Muscle relaxation
  • Hypnosis
  • Analgesia
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9
Q

Main drugs used in anaesthesia

A

Induction - propofol
Muscle relaxation - suxamethonium
Airway control - ET tube/LMA
Maintenance - N20/oxygen mix e.g. halothane
Reversal - neostigmine and glycopyrronium bromide

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10
Q

Complications of anaesthesia

A

Propofol - Cardiorespiratory depression
Intubation - Oro-pharyngeal injury/ Oesophageal intubation
Loss of pain sensation - Urinary retention/ Pressure necrosis/ Nerve palsies
Loss of muscle power - Corneal abrasion
 No cough → atelectasis + pneumonia
Malignant Hyperpyrexia - Rapid rise in temperature + masseter spasm
 Rx: dantrolene + cooling
Anaphylaxis

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11
Q

Analgesia pain ladder

A

1) Paracetamol and NSAIDS (SE - IGRAB - interact - warfarin, Gastric ulcer, Renal Impairement, Asthma, Bleeding)
2) Weak opiod + non-opiod
- dihydo/-codiene, tramadol
3) strong opiod + non-opiod
- morphone, oxycodone, fentayl
(SE sedation, confusion, prutitis, tolerance dependence, resp depression, constipation)

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12
Q

Positives and negatives of PCA

A

+ve

  • analgesia tailored to pt requirements
  • reduced risk of overdose
  • can record easily
  • reduce staff workloads
  • reduce need for IM injections
  • ve
  • can stop pt mobilising
  • not appropriate if low dexterity/ dementia
  • initial equipment expensive
  • pt has to understand
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13
Q

+ve and -ve of syringe drivers

A

+ve

  • avoid large swings in pain
  • reduce staff workload
  • good if pt ventilated
  • useful if low dexterity
  • ve
  • only get right rate after initial error
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14
Q

What is spinal anaesthesia and complications

A
  • anaesthesia into sub-arachnoid space, to affect the spinal roots passing through - L3/4 (or L2/3)
  • pass through supraspinatous–> ligamentum flavum –> extradural space –> dura mater–> arachnoid mater

There is free flow of CSF when in correct place

complications - total spinal block (low BP, Low HR, anxiety, LOC); headache; urinary retention; permanent neurological damage

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15
Q

What is epidural anaesthesia and its complications

A
  • Anaesthesia into extradural space (need firmly into ligamentum flavum - loss of resistance) - L3/4 (or L2/3)

complications
- headache; - vessel puncture; - apnoea; - LOC; - hypoventilation; - marked hypotension; - epidural haemotoma; - nerve- root damage; - patchy/ unilateral block; total spinal block (low BP, Low HR, anxiety, LOC)

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16
Q

CI for epidural anaesthesia

A

Anti-coagulated (P damage to cord from bleed)
local sepsis (may introduce infection to CSF)
shock/ hgypovolaemia/ APH
raised ICP
Uncooperate pt
MS/AS
Allergy

Relative CI - neurological disease, IHD, previous deformity of spins/surgery, bowel perforation

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17
Q

Pre operative optimisation

A 
Aggressive physiological optimisation
 Hydration
 BP (↑ / ↓)
 Anaemia
 DM
 Co-morbidities
 Smoking cessation: ≥4wks before surgery
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18
Q

Post operative enhanced recovery

A

 Aggressive Rx of pain and nausea
 Early mobilisation and physiotherapy
 Early resumption of oral intake (inc. carb drinks)
 Early discontinuation of IV fluids
 Remove drains and urinary catheters ASAP

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19
Q

Surgical complications

A

Immediate (<24h)
 Intubation → oropharyngeal trauma
 Surgical trauma to local structures
 Primary or reactive haemorrhage

Early (1d-1mo)
 Secondary haemorrhage (>24h post-op; usually due to infection)
 VTE/ MI
 Urinary retention
 Atelectasis and pneumonia
 Wound infection (5-7d post-op) and dehiscence (~10d)
 Antibiotic association colitis (AAC) - c.diff

Late (>1mo)
 Scarring
 Neuropathy
 Failure or recurrence

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20
Q

Causes and risk factors for post op urinary retention

A

Causes
 Drugs: opioids, epidural/spinal, anti-AChM
 Pain: sympathetic activation → sphincter contraction
 Psychogenic: hospital environment

Risk Factors
 Male
 ↑ age
 Neuropathy: e.g. DM, EtOH
 BPH
 Surgery type: hernia and anorectal
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21
Q

Signs and Treatment of post op urinary retention

A

Signs

  • reduced urine output
  • sensation of needing to void
  • suprapubic mass which is dull to percuess
  • bladder scan for residual volume

Mx
 Privacy  Ambulation
 Void to running taps or in hot bath  Analgesia

 Catheterise ± gent 2.5mg/kg IV stat
 TWOC = Trial w/o Catheter

 If failed, may be sent home c¯ silicone catheter
and urology outpt. f/up

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22
Q

Causes, presentation and mx of Pulmonary Atelectasis

A
  • after every nearly every GA
     Mucus plugging + absorption of distal air → collapse

Causes
 Pre-op smoking
 Anaesthetics ↑ mucus production ↓ mucociliary
clearance
 Pain inhibits respiratory excursion and cough

Presentation
 w/i first 48hrs
 Mild pyrexia
 Dyspnoea
 Dull bases c¯ ↓AE

Mx
 Good analgesia to aid coughing
 Chest physiotherapy

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23
Q

Operative classification of wounds

A

 Clean: incise uninfected skin w/o opening viscus
 Clean/Cont: intra-op breach of viscus (not colon)
 Contaminated: breach of viscus + spillage or opening of
colon
 Dirty: site already contaminated – faeces, pus, trauma

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24
Q

Risk factors for post-op wound infections

A 
Pre-operative
 ↑ Age
 Comorbidities: e.g. DM
 Pre-existing infection: e.g. appendix perforation
 Pt. colonisation: e.g. nasal MRSA
 Malnourished/ obese

Operative
 Op classification and wound infection risk
 Duration
 Technical: pre-op Abx, asepsis

Post-operative
 Contamination of wound from staff

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25
Q

Mx and prevention of post-op wound infections

A 
 Regular wound dressing
- clear for 48 hour after surgery
- removed clips/ sutrues
 Abx
 Abscess drainage

Prevention

  • shower before surgery
  • electric clippers
  • abx?
  • sterile technique
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26
Q

Risk factors for wound dehiscence

A 
Pre-Operative Factors
 ↑ age
 Smoking
 Obesity, malnutrition, cachexia
 Comorbs: e.g. BM, uraemia, chronic cough, Ca
 Drugs: steroids, chemo, radio

Operative Factors
 Length and orientation of incision
 Closure technique
 Suture material

Post-operative Factors
 ↑ IAP: e.g. prolonged ileus → distension
 Infection
 Haematoma / seroma formation

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27
Q

Mx of wound dehiscence

A 
 Replace abdo contents and cover c¯ sterile soaked gauze
 IV Abx: cef+met
 Opioid analgesia
 Call senior and arrange theatre
 Repair in theatre
- Wash bowel
- Debride wound edges
-Close c¯ deep non-absorbable sutures
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28
Q

Complications of cholecystectomys

A 
 Conversion to open: 5%
 CBD injury: 0.3%
 Bile leak
 Retained stones (needing ERCP)
 Fat intolerance / loose stools
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29
Q

Complications of inguinal hernia repairs

A 
Early
 Haematoma / seroma formation: 10%
 Intra-abdominal injury (lap)
 Infection: 1%
 Urinary retention

Late
 Recurrence (<2%)
 Ischaemic orchitis: 0l5%
 Chronic groin pain / paraesthesia: 5%

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30
Q

Complications of appendicectomy

A

 Abscess formation
 Fallopian tube trauma
 Right hemicolectomy (e.g. for carcinoid, caecal
necrosis)

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31
Q

Complications of colonic surgery

A 
Early
 Ileus
 AAC
 Anastomotic leak
 Enterocutaneous fistulae
 Abdominal or pelvic abscess

Late
 Adhesions → obstruction
 Incisional hernia

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32
Q

Complications of anorectal surgery

A

 Anal incontinence
 Stenosis
 Anal fissure

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33
Q

Complications of small bowel surgery

A

Short gut syndrome

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34
Q

Complications of splenectomy

A

Gastric dilatation (2O gastric ileus) - Prevent c¯ NGT
 Thrombocytosis → VTE
 Infection: encapsulated organisms

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35
Q

Complications or arterial and aortic surgery

A

Arterial Surgery
 Thrombosis and embolization
 Anastomotic leak
 Graft infection

Aortic Surgery
 Gut ischaemia
 Renal failure
 Aorto-enteric fistula
 Anterior spinal syndrome (paraplegia)
 Emboli → distal ischaemia (trash foot)
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36
Q

Causes of post-op pyrexia

A 
WIND - pulmonary atelectasis / pneumonia
WATER - UTI (3-5d)
WALK - VTE (5-10d)
WOUND - cellulitis (early) infection or anastomotic leak(5d +)  
WORRY ABOUT DRUGS (7d +)
- drug reaction
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37
Q

Causes of post-op pneumonia and management

A

 Anaesthesia → atelectasis
 Pain → ↓ cough
 Surgery → immunosuppression

Rx
 Chest physio: encouraging coughing
 Good analgesia
 Abx

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38
Q

Presentation, locations and Rx of a post-op collection

A 
 Malaise
 Swinging fever, rigors
 Localised peritonitis
 Shoulder tip pain (if subphrenic)
Locations
 Pelvic:  4-10d post-op
 Subphrenic: 7-21d post-op
 Paracolic gutters
 Lesser sac
 Hepatorenal recess
 Small bowel
Rx
 Abx
 Drainage / washout
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39
Q

Causative organisms of post-op cellulitis

A

Acute infection of the subcutaneous connective tissue

β-haemolytic Streps + staph. aureus

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40
Q

Presentation and Rx of post-op cellulitis

A

 Pain, swelling, erythema and warmth
 Systemic upset
 ± lymphadenopathy

 ABx - fluclox

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41
Q

Virchow’s triad

A 
Hypercoagulability
- Surgery → ↑ plats and ↑ fibrinogen + Dehydration
Stasis
- surgery/ immobility/ obesity 
Endothelial damage
- esp. pelvic veins/ Previous VTE
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42
Q

Signs of DVT

A
  • Calf warmth/ tenderness/ swelling/ erythema
  • Mild fever
  • Pitting oedema
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43
Q

Risk factors for DVT

A

THROMBOSIS
Thrombophilia e.g. antiphospholipid syndrome
Hx DVT/PE
Recent Travel
Obstetric - Late pregnancy; C-section; OCP
Malignancy - Abdominal/ Pelvic/ Metastatic
Broken lower limb/ varicose veins
Old age and obesity
Surgery - Abdominal/pelvic; Knee/ hip replacement
Immobility
Sex (female)

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44
Q

Differentials for DVT

A
  • cellulitis

- Ruptured bakers cyst

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45
Q

Dx of DVT

A

2-Level DVT Wells Score
Cancer, immobility, local tenderness, leg swollen, calf swelling >3cm, pitting oedema. Collateral superficial veins., previous DVT

≤ 1 – DVT unlikely
Perform D-Dimer.
- If -ve, DVT excluded
- If +ve, proceed to USS (if USS -ve, DVT excluded; if +ve treat as DVT)

≥ 2  DVT likely 
Do D-Dimer + USS. 
-	If both -ve DVT excluded. 
-	If USS +ve – treat DVT. 
-	If USS -ve and D-Dimer +ve – repeat USS in 1 week.

If unusual presentation do thrombophilia screen

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46
Q

Rx of DVT

A

 Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC
 Start warfarin
 Stop LMWH when INR 2.5

Duration - 3m if post-op; 6m if no cause/ Ca

Graduated Compression Stockings

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47
Q

Preventing DVTs

A

Pre-Op
 TED stockings
 Aggressive optimisation: esp. hydration
 Stop OCP 4wks pre-op

Intra-Op
 Minimise length of surgery
 Use minimal access surgery where possible
 Intermittent pneumatic compression boots

Post-Op
 LMWH
 Early mobilisation
 Good analgesia
 Physio
 Adequate hydration
48
Q

Factors which increase risk of post-op N+V

A 
Patient
- female
- non-smoker
- young
- hx motion sickness
- hx migraines
- anxiety 
Surgical 
- abdo/gynae procedure (obstruction/ileus)
- cholecystectomy
- thyroid
- ophthalmology
Anaesthetic
- NO
- Opioid pre-op
- Long duration
49
Q

Consequences of PONV

A
  • electrolyte imbalance
  • hypovolaemia
  • disrupt surgical site
50
Q

Where is the vomiting centre and what are the NT involved

A
  • Medulla Oblongata

- involes histamine, Dopamine and acetylcholine

51
Q

Treatment of PONV

A
  • metoclopramide (Da I)
  • Ondansetron (5HT I)
  • Hyoscine (Anti-Ach)
52
Q

Causes of post-op dyspnoae/ hypoxia

A 
 Previous lung disease
 Atelectasis, aspiration, pneumonia
 LVF
 PE
 Pneumothorax (e.g. due to CVP line insertion)
 Pain → hypoventilation
  • CXR and ECG
53
Q

Causes and Rx of reduced urine output post-op

A 
Post-renal
 Blocked / malsited catheter
 Acute urinary retention
Pre-renal: hypovolaemia
Renal: NSAIDs, gentamicin
  • Stop responsible drugs, Assess fluid status, Inspect drips, drains, stomas, CVP
     Flush - 50ml NS and aspirate back
     Fluid challenge
54
Q

Causes and Mx of post-op hyponatraemia

A

 SIADH: pain, nausea, opioids, stress
 Over administration of IV fluids

 Correct slowly
 Acute: 1mM/h
 Chronic:15mM/d

55
Q

Causes of post-op hypotension

A 
CHOD
Cardiogenic
 MI
 Fluid overload
Hypovolaemia
 Inadequate replacement of fluid losses
 Haemorrhage
Obstructive
 PE
Distributive
 Sepsis
 Neurogenic shock
56
Q

Mx of post-op hypotension

A 
 Tilt bed head down, give O2
 Assess fluid status
 Hypovolaemia → fluid challenge - 250-500ml colloid over 15-30min
 Haemorrhage → return to theatre
 Sepsis → fluid challenge, start Abx
 Overload → frusemide
 Neurogenic → NA infusion
57
Q

Causes and Mx of post-op hypertension

A

 Pain
 Urinary retention
 Previous HTN

Mx - Rx cause
 May use labetalol 50mg IV every 5min (200mg max)

58
Q

Causes of post-op confusional state

A 
 Drugs: opiates, sedatives, L-DOPA
 Eyes, ears and other sensory deficits
 Low O2 states: MI, stroke, PE
 Infection
 Retention: stool or urine
 Ictal
 Under- hydration / -nutrition
 Metabolic: Na, AKI, glucose, EtOH withdrawal
59
Q

Factors to consider when prescribing fluids

A
  • Resuscitation
  • Routine Maintenance
  • Replacement (v&d&sweat)
  • Redistribution
  • Reassess every 24h
60
Q

Different types of IV fluid

A

Crystalloid

  • 0.9% NaCl
  • 5% dextrose
  • Dextrose saline (0.18%NS and 4% dextrose)
  • Hartmann’s (Na, Cl, K, Ca, Lactate)

Colloid
- Blood (risk anaphylaxis)

61
Q

Examination of fluid status

A 
IV volume
 CRT
 HR
 BP lying and standing
 JVP
Tissue perfusion
 Skin turgor
 Oedema: ankle, pulmonary, ascites
 Mucus membranes
End-organ
 UO, ↑U+Cr
 Consciousness
 Lactate
62
Q

Feeding hierachy

A

Enteral
Oral nutritional supplements - If unable to eat sufficient calories (ONS)
NGT/NJ - ↓ calories orally or dysfunctional swallow
SE – gastric erosions
(NJ if risk of pul regurgitation)
PEG/RIG - oesophagus blocked/dysfunctional
- med-long term
Jejunostomy - stomach inaccessible/ outflow obstruction

Parental
- jejunum inaccessible or intestinal failure or obstructed gut
TPN IV – very thrombogenic

63
Q

Positives and negatives of enteral feeding

A

+ve

  • less invasive
  • keeps gut bacteria working
  • ve
  • nasal trauma tube blockage
  • diarrhoea, electrolyte imbalance, aspiration, refeeding syndrome
64
Q

Indications for TPN

A 
 Prolonged obstruction or ileus (>7d)
 High output fistula
 Short bowel syndrome
 Severe Crohn’s
 Severe malnutrition
 Severe pancreatitis
 Unable to swallow: e.g. oesophageal Ca
65
Q

Complications of TPN

A 
Line-related
 Pneumothorax /haemothorax
 Cardiac arrhythmia
 Line sepsis
 Central venous thrombosis → PE or SVCO
Feed-related
 Villous atrophy of GIT
 Electrolyte disturbances
 Refeeding syndrome
 Hypercapnoea from excessive CO2 production
 Hyperglycaemia and reactive hypoglycaemia
 Line sepsis: ↑ risk c¯ TPN
 Vitamin and mineral deficiencies
66
Q

What is refeeding syndrome, its complications, ix and mx

A

↓ carbs → catabolic state c¯ ↓insulin, fat and protein
catabolism and depletion of intracellular PO4

Refeeding → ↑ insulin in response to carbs and ↑
cellular PO4 uptake → hypophosphataemia
 Rhabdomyolysis
 Respiratory insufficiency
 Arrhythmias
 Shock
 Seizures

ix - low K, low mg, low P

Mx - parental and oral PO4 supplementation and manage complications

67
Q

Patients at risk of refeeding syndrome

A 
 Malignancy
 Anorexia nervosa
 Alcoholism
 GI surgery
 Starvation
68
Q

Pathogenesis of atherosclerosis

A

• Triggered by injury (HTN/ ↑ lipids)
• Lipoproteins oxidised - taken up by macrophages =
foam cells
• Release of cytokines → accumulation fat and smooth
muscle proliferation
• Plaque formation

69
Q

Risk factors for atherosclerosis

A 
Modifiable
 Smoking
 BP
 DM control
 Hyperlipidaemia
 ↓ exercise
Non-modifiable
 FH and PMH
 Male
 ↑ age
 Genetic
70
Q

Presentation of intermittent claudication

A

 Cramping pain after walking a fixed distance
 Pain rapidly relieved by rest
 Calf pain = superficial femoral disease (commonest)
 Buttock pain = iliac disease (internal or common)

71
Q

Presentation of critical limb ischaemia

A 
Rest pain for >2weeks
 Especially @ night
 Usually felt in the foot
 Pt. hangs foot out of bed
 Due to ↓ CO and loss of gravity help
Ulceration
Gangrene
72
Q

Leriche’s Syndrome presentation

A

Atherosclerotic occlusion of abdominal aorta and iliacs

 Buttock claudication and wasting
 Erectile dysfunction
 Absent femoral pulses

73
Q

Signs of chronic limb ischaemia

A

 Pulses: pulses and ↑ CRT (norm ≤2sec)
 Ulcers: painful, punched-out, on pressure points
 Nail dystrophy / Onycholysis
 Skin: cold, white, atrophy, absent hair
 Venous guttering
 Muscle atrophy
 ↓ Buerger’s Angle
- ≥90: normal
- 20-30: ischaemia
- <20: severe ischaemia
 +ve Buerger’s Sign
 Reactive hyperaemia due to accumulation of
deoxygenated blood in dilated capillaries

74
Q

Fontaine classification of chronic limb ischaemia

A
  1. Asympto (subclinical)
  2. Intermittent claudication
    a. >200m
    b. <200m
  3. Ischaemic rest pain
  4. Ulceration / gangrene
75
Q

Ix for chronic limb ischaemia

A

ABPI (ankle/brachial pressure index) - diagnosis + quantify severity.
 Normal > 1.1
Doppler USS - Assess the severity and anatomical location of any occlusion.

CT angiography or MR angiography (MRA).

CV risk assessment - BP, glucose, lipid profile and ECG.

< 50 yrs without significant risk factors - thrombophilia screen and homocysteine levels checked.

76
Q

Mx of chronic limb ischaemia

A

CV risk modification – 78%
• Lifestyle advice (smoking cessation, regular exercise, weight reduction)
o improve walking technique to optimise collateral blood distribution
• Statin
• Aspirin or clopidogrel
• Optimise diabetes control
- Analgesia

Surgical
- Indications
 V. short claudication distance (e.g. <100m)
 Symptoms greatly affecting QoL
 Development of rest pain
\+ Conservative failed

 Angioplasty with stenting – single occluded region
 Endarterectomy: core-out atheromatous plaque
 Bypass grafting – diffuse disease
 Amputation – unsuitable for revascularisation with ischaemia causing incurable symptoms or gangrene –> sepsis

77
Q

Causes of acute limb ischameia

A 
 Thrombosis in situ (60%)
 Embolism (30%) -  AF/ Valve disease
-  Iatrogenic from angioplasty / surgery
- Cholesterol in long bone #
-  Paradoxical (venous via PFO)
 Graft / stent occlusion
 Trauma
 Aortic dissection
78
Q

Presentation of acute limb ischaemia

A 
 Pale
 Pulseless
 Perishingly cold
 Painful
 Paraesthesia
 Paralysis
79
Q

Thrombosis v embolus presentation of acute limb ischaemia

A

Thrombosis
Hrs-days
Less severe ischaemia - (collaterals)
Claudication Hx
Contralat pulses Absent
Dx Angiography
Rx Thrombolysis or Bypass surgery

Embolus 
Suddenly
Profound ischaemia
Embolic source (AF)
Clinical Dx
Present contralat pulse
Rx - embolectomy  + Warfarin
80
Q

Mx of acute limb ischaemia

A

 NBM
 Rehydration: IV fluids and high flow oxygen
 Analgesia: morphine + metoclopramide
 Abx: e.g co-omox if signs of infection
 Unfractionated heparin IVI
 Complete occlusion?
- Yes: urgent surgery: embolectomy (using balloon catheter) or bypass
Thrombolysis if unsuccessful
- No: angiogram + observe for deterioration

Unsuccessful - emergency reconstruction/ amputation

81
Q

Rx before embloectomy and complications post- embolectomy

A

Rx
Anticoagulate: heparin IVI → warfarin
 ID embolic source: ECG, echo, US aorta, fem and pop

Complications
> Reperfusion injury
 Local swelling → compartment syndrome
 Acidosis and arrhythmia 2O to ↑K
 ARDS
 GI oedema → endotoxic shock
Chronic pain syndromes
82
Q

Classifications of anerysms

A

Abnormal dilatation of a blood vessel > 50% of its
normal diameter.

 True Aneurysm
involving all layers of
the wall and is >50% of its normal diameter

 False Aneurysm
Collection of blood around a vessel wall that
communicates c¯ the vessel lumen.
 Usually iatrogenic: puncture, cannulation

Dissection
 Vessel dilatation caused by blood splaying apart
the media to form a channel w/i the vessel wall.

83
Q

Causes of aneurysms

A 
Congenital
 ADPKD → Berry aneurysms
 Marfan’s, Ehlers-Danlos
Acquired
 Atherosclerosis
 Trauma: e.g. penetrating
 Inflammatory: Takayasu’s aortitis, HSP
 Infection - Tertiary syphilis
84
Q

Complications of aneurysms

A 
 Rupture
 Thrombosis
 Distal embolization
 Pressure: DVT, oesophagus, nutcracker syndrome
 Fistula (IVC, intestine)
85
Q

Presentation and Mx of a popliteal aneurysm

A

 Very easily palpable popliteal pulse
 50% bilateral
 Rupture is relatively rare
 Thrombosis and distal embolism is main complication → acute limb ischaemia

Mx
 Acute: embolectomy or fem-distal bypass
 Stable: elective grafting + tie off vessel

86
Q

Presentation of AAA

A

Dilatation of the abdominal aorta ≥3cm
 90% infrarenal; 30% involve the iliac arteries

 Usually asympto: discovered incidentally
 May → back pain or umbilical pain radiating to groin
 Acute limb ischaemia
 Blue toe syndrome: distal embolisation
 Acute rupture

87
Q

Examination features of AAA

A

 Expansile mass just above the umbilicus
 Bruits may be heard
 Tenderness + shock suggests rupture

88
Q

Ix of AAA

A

Abdo USS - screening and monitoring

CT + contrast if >5.5cm

89
Q

Mx of AAA

A

Manage CV risk factors: esp. BP
- 3.0-4.4cm: yearly Duplex USS & 5.0-5.4cm: 3-m Duplex USS

Surgical
- before it ruptures.
 Indications
 Symptomatic (back pain = imminent rupture)
 Diameter >5.5cm
 Rapidly expanding: >1cm/yr
 Causing complications: e.g. emboli
 Open or EVAR

Risks - EVAR - endovascular leak, graft infection
OPEN - AKI when clamp aorta

Screening - one off at 65

90
Q

Presentation of AAA rupture

A

 Sudden onset severe abdominal pain - Radiates to back or flanks (don’t dismiss as colic)
 Hypotension/; Collapse → shock
 Expansile abdominal mass

91
Q

Factors which increase risk of AAA rupture

A

 ↑BP
 Smoker
 Female
 Strong FH

92
Q

Differentials of AAA rupture

A
  • renal colic
  • diverticulitis
  • IBD/IBS
  • GI haemorrhage
  • appendicitis
  • ovarian torsion/rupture
93
Q

Complications of AAA

A 
Rupture
retroperitoneal leak
embolisation
aortaduodenal fistrula
infection
94
Q

Management of ruptured AAA

A

 High flow O2
 2 x large bore cannulae in each ACF
- Give fluid if shocked but keep SBP <100mmHg
- Give O- blood if desperate
 Blood: FBC, U+E, clotting, amylase, xmatch 10u
 Instigate the major haemorrhage protocol
 Call vascular surgeon, anaesthetist and warn theatre
 Analgesia
 Abx prophylaxis: cef + met
 Urinary catheter + CVP line
 If stable + Dx uncertain: US or CT may be feasible (to see if suitable for EVAR)
 Take to theatre: clamp neck, insert dacron graft

95
Q

Presentation of thoracic aortic dissection

A 
 Sudden onset, tearing chest pain
-Radiates through to the back
- Tachycardia and hypertension 
 Distal propagation → sequential occlusion of branches
- Left hemiplegia
- Unequal arm pulses and BP
- Paraplegia (anterior spinal A.)
- Anuria
 Proximal propagation
-  AR/ Tamponade
 Rupture into pericardial, pleural or peritoneal cavities
96
Q

Classification of aortic dissection

A 
Type A: Proximal
 70%
 Involves ascending aorta ± descending
 Higher mortality due to probable cardiac involvement
 Usually require surgery

Type B: Distal
 30%
 Involves descending aorta only: distal to L SC artery
 Usually best managed conservatively

97
Q

Differentials of aortic dissection

A

MI
PE
Pericarditis
MSK

98
Q

Mx of aortic dissection

A
  • Resuscitate
  • Investigate
     Bloods: x-match 10u, FBC, U+E, clotting, amylase
     ECG: 20% show ischaemia; exclude MI
     Imaging
     CXR
     CT/MRI: not if haemodynamically unstable
     TOE: can be used if haemodynamically unstable
Treat
 Analgesia
 ↓SBP
- Labetalol/ esmolol (short t½)
 Keep SBP 100-110mmHg
 Type A: open repair
 Type B: conservative initially
99
Q

Definition and pathophysiology of varicose veins

A

Tortuous, dilated veins of the superficial venous system

 One-way flow from sup → deep maintained by valves
 Valve failure → ↑ pressure in sup veins → varicosity
- SFJ: 3cm below and 3cm lateral to pubic tubercle
- SPJ: popliteal fossa

100
Q

Causes of varicose veins

A 
Primary
 Idiopathic (congenitally weak valves)
 Prolonged standing
 Pregnancy
 Obesity
 OCP
 FH

Secondary
 Valve destruction → reflux: DVT, thrombophlebitis
 Obstruction: DVT, foetus, pelvic mass (uterine/ovarian)
 Constipation
 AV malformation
 Overactive pumps (e.g. cyclists)

101
Q

Symptoms of varicose veins

A 
 Cosmetic defect
 Pain, cramping, heaviness
 Tingling
 Bleeding: may be severe
 Swelling
102
Q

Signs of varicose veins

A 
Skin changes
 Venous stars
 Haemosiderin deposition
 Venous eczema
 Lipodermatosclerosis (paniculitis)
 Atrophie blanche (scar tissue)
Ulcers: medial malleolus / gaiter area
Oedema
Thrombophlebitis
103
Q

Ix of varicose veins

A

Duplex ultrasonography
 Anatomy
 Presence of incompetence
 Caused by obstruction or reflux

? trendelenburg for valvular incompetence using torniquet

104
Q

Referral criteria for varicose veins

A 
 Bleeding
 Pain
 Ulceration
 Superficial thrombophlebitis/ lower limb skin changes e.g. eczema/ pigment
 Severe impact on QoL
105
Q

Mx of varicose veins

A 
 Lose weight
 Relieve constipation
 Avoid prolonged standing
 Regular walks
 Class II Graduated Compression Stockings
 Maintain hydration -  emollients
 Treat ulcers rapidly

Surgery

  • Injection sclerotherapy
  • radiofrequency ablation
  • SSV ligation
106
Q

Complications of varicose vein surgery

A 
 Haematoma (esp. groin)
 Wound sepsis
 Damage to cutaneous nerve (e.g. long saphenous)
 Superficial thrombophlebitis
 DVT
 Recurrence: may approach 50%
107
Q

Causes of leg ulcers

A 
 Venous: commonest
 Arterial: large or small vessel
 Neuropathic: EtOH, DM
 Traumatic: e.g. pressure
 Systemic disease: e.g. pyoderma gangrenosum
 Neoplastic: SCC
108
Q

Presentation of venous ulcers

A

 +/- Pain, sloping, shallow ulcers with irregular borders. Worse on standing
 Usually on medial malleolus: “gaiter area”
 Assoc. with haemosiderin deposits, lipodermatosclerosis, oedema and atrophie blanche
- warm skin, normal pulses
ABPI = 0.8-1
 RFs: venous insufficiency, varicosities, DVT, obesity

109
Q

Presentaion of arterial ulcers

A 
Arterial: 2%
 Hx of vasculopathy and risk factors
 Painful (esp at night), deep, punched out lesions on a necrotic base 
 Occur @ pressure points
 Heal
 Tips of. and between, toes
 Metatarsal heads (esp. 5th)
 Other signs of chronic leg ischaemia - cold, weak peripheral pulses, shiny pale skin, loss of hair
ABPI <0.8

Mx - Mx RF and CV RF
- angioplasty/ bypass grafting

110
Q

Features, ix and mx of neuropathic ulcers

A 
Painless/ insensate surrounding skin
- Warm foot c¯ good pulses
hx DM, Vit B def 
If ABPI <0/.8 then neuroischaemic
X-Ray to excluse osteomyelitis

Mx - wound debridement, regular repositioning, appropriate footwear and good nutrition

111
Q

Complications of ulcers

A

 Osteomyelitis

 Development of SCC in the ulcer (Marjolin’s ulcer)

112
Q

Mx of venous ulcers

A

Refer to leg ulcer community clinic
 Graduated compression stockings
 Venous surgery
 Optimise risk factors: nutrition, smoking

 Analgesia
 Bed Rest + Elevate leg
 4 layer graded compression bandage (if ABPI >0.8)

113
Q

Differentials of bilateral leg swelling

A 
↑ Venous Pressure
- RHF
- Venous insufficiency
- Drugs: e.g. nifedipine
↓ Oncotic Pressure
- Nephrotic syndrome
- Hepatic failure
- Protein losing enteropathy
Lymphoedema
Myxoedema
- Hyper- / hypo-thyroidism
114
Q

Differentials of unilateral leg swelling

A

Venous insufficiency
DVT
Infection or inflammation
Lymphoedema

115
Q

Causes of hepatomegaly, splenomegaly and hepatosplenomegaly

A

Hepatomegaly

  • cirrhosis
  • hepatitis
  • NAFLD
  • malignancy

Splenomegaly

  • Splenic/hepatic vein thrombosis
  • thalassaemia
  • malaria
  • CML/ Myelofibrosis
  • HIV
  • Cirrhosis

Hepatosplenomegaly

  • CLD and portal HTN
  • Hepatitis virus and CMV
  • Malaria
  • Sarcoidosis
  • Leukaemia
116
Q

Scoring system using to predict mortality and morbidity in surgery

A

POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity

Physiological Parameters (12)
•	Age
•	Cardiac and Respiratory disease/treatment
•	ECG, Heart Rate, Blood Pressure, GCS
•	Haemoglobin, WCC
•	Sodium, Potassium, Urea
Operative Parameters (6)
•	Operation Type, Urgency and Number of Procedures
•	Operative Blood Loss
•	Peritoneal Contamination
•	Malignancy Status

IPE (9 decks)

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