Surgery & Vascular Flashcards

Question

Mx and prevention of post-op wound infections

Answer 1

```  Regular wound dressing - clear for 48 hour after surgery - removed clips/ sutrues  Abx  Abscess drainage ``` Prevention - shower before surgery - electric clippers - abx? - sterile technique

Answer 2

``` 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

Answer 3

```  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 ```

Answer 4

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

Answer 5

``` Early  Haematoma / seroma formation: 10%  Intra-abdominal injury (lap)  Infection: 1%  Urinary retention ``` Late  Recurrence (<2%)  Ischaemic orchitis: 0l5%  Chronic groin pain / paraesthesia: 5%

Answer 6

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

Answer 7

``` Early  Ileus  AAC  Anastomotic leak  Enterocutaneous fistulae  Abdominal or pelvic abscess ``` Late  Adhesions → obstruction  Incisional hernia

Answer 8

 Anal incontinence  Stenosis  Anal fissure

Answer 9

Short gut syndrome

Answer 10

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

Answer 11

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) ```

Answer 12

``` 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 ```

Answer 13

 Anaesthesia → atelectasis  Pain → ↓ cough  Surgery → immunosuppression Rx  Chest physio: encouraging coughing  Good analgesia  Abx

Answer 14

```  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 ```

Answer 15

Acute infection of the subcutaneous connective tissue β-haemolytic Streps + staph. aureus

Answer 16

 Pain, swelling, erythema and warmth  Systemic upset  ± lymphadenopathy  ABx - fluclox

Answer 17

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

Answer 18

- Calf warmth/ tenderness/ swelling/ erythema - Mild fever - Pitting oedema

Answer 19

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)

Answer 20

- cellulitis | - Ruptured bakers cyst

Answer 21

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

Answer 22

 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

Answer 23

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 ```

Answer 24

``` 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 ```

Answer 25

- electrolyte imbalance - hypovolaemia - disrupt surgical site

Answer 26

- Medulla Oblongata | - involes histamine, Dopamine and acetylcholine

Answer 27

- metoclopramide (Da I) - Ondansetron (5HT I) - Hyoscine (Anti-Ach)

Answer 28

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

Answer 29

``` 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

Answer 30

 SIADH: pain, nausea, opioids, stress  Over administration of IV fluids  Correct slowly  Acute: 1mM/h  Chronic:15mM/d

Answer 31

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

Answer 32

```  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 ```

Answer 33

 Pain  Urinary retention  Previous HTN Mx - Rx cause  May use labetalol 50mg IV every 5min (200mg max)

Answer 34

```  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 ```

Answer 35

- Resuscitation - Routine Maintenance - Replacement (v&d&sweat) - Redistribution - Reassess every 24h

Answer 36

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)

Answer 37

``` 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 ```

Answer 38

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

Answer 39

+ve - less invasive - keeps gut bacteria working - ve - nasal trauma tube blockage - diarrhoea, electrolyte imbalance, aspiration, refeeding syndrome

Answer 40

```  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 ```

Answer 41

``` 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 ```

Answer 42

↓ 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

Answer 43

```  Malignancy  Anorexia nervosa  Alcoholism  GI surgery  Starvation ```

Answer 44

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

Answer 45

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

Answer 46

 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)

Answer 47

``` 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 ```

Answer 48

Atherosclerotic occlusion of abdominal aorta and iliacs  Buttock claudication and wasting  Erectile dysfunction  Absent femoral pulses

Answer 49

 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

Answer 50

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

Answer 51

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.

Answer 52

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

Answer 53

```  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 ```

Answer 54

```  Pale  Pulseless  Perishingly cold  Painful  Paraesthesia  Paralysis ```

Answer 55

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 ```

Answer 56

 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

Answer 57

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 ```

Answer 58

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.

Answer 59

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

Answer 60

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

Answer 61

 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

Answer 62

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

Answer 63

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

Answer 64

Abdo USS - screening and monitoring CT + contrast if >5.5cm

Answer 65

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

Answer 66

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

Answer 67

 ↑BP  Smoker  Female  Strong FH

Answer 68

- renal colic - diverticulitis - IBD/IBS - GI haemorrhage - appendicitis - ovarian torsion/rupture

Answer 69

``` Rupture retroperitoneal leak embolisation aortaduodenal fistrula infection ```

Answer 70

 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

Answer 71

```  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 ```

Answer 72

``` 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

Answer 73

MI PE Pericarditis MSK

Answer 74

- 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 ```

Answer 75

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

Answer 76

``` 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)

Answer 77

```  Cosmetic defect  Pain, cramping, heaviness  Tingling  Bleeding: may be severe  Swelling ```

Answer 78

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

Answer 79

Duplex ultrasonography  Anatomy  Presence of incompetence  Caused by obstruction or reflux ? trendelenburg for valvular incompetence using torniquet

Answer 80

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

Answer 81

```  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

Answer 82

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

Answer 83

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

Answer 84

 +/- 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

Answer 85

``` 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

Answer 86

``` 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

Answer 87

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

Answer 88

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)

Answer 89

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

Answer 90

Venous insufficiency DVT Infection or inflammation Lymphoedema

Answer 91

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

Answer 92

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 ```