Surgery Workbook Flashcards
How is the water in 5% dextrose v normal saline distributed throughout the body?
dextrose - into total body water
normal saline - into extracellular water
What factors can increase fluid losses?
high urine output
D+V
stoma output
sweating
burns
haemorrhage
What should you do before prescribing IV fluids to any patient?
- check notes to understand clinical setting
- look at recent bloods
- inspect patients fluid charts and BP charts
- decide if pt is high risk (renal compromise/HF)
- are they in balance or deficit or surplus?
Why does urea increase relative to creatinine during dehydration?
decreased perfusion of kidneys = decreased excretion of urea
Consequences of starvation prior to surgery?
decreased wound healing
inc infection and skin breakdown
Why does surgery place additional demands on nutritional status of the body?
creates a catabolic state
Average daily calorie requirements for adult patients?
M = 2900
F = 2200
Complications of parenteral feeding?
thrombosis
infection
liver failure
micronutrient deficiencies
Commonest cause of preventable death in surgical patients?
P.E
Where do surgical patients often develop DVTs?
soleal and gastrocnemius venous sinuses
What pre-op, intra-op and post-op factors increase risk of DVT ?
Pre:
poor hydration, obesity, malignancy, prothrombotic drugs e.g. COCP
Intra-op:
longer procedure, under GA
Post:
prolonged immobility
How long must have elapsed since insertion of epidural before administering LMWH? Why?
4 hours
risk of epidural haematoma which can cause spinal cord compression
Which surgical pts should receive Dalteparin for up to 35 days post surgery?
Hip fracture and THR
Malignancy
target range of intra-op blood glucose?
below what value = ‘rescue tx’?
6-12
<4
Why is there risk of aspiration at induction of anaesthesia? Why is it so dangerous?
loss of LOS tone and protective laryngeal reflexes due to paralysis
can causes asphyxiation and aspiration pneumonia
Half life of IV insulin?
5 mins
How many calories does a litre of 5% dextrose contain?
700
What normally happens to serum ACTH after a major trauma such as surgery? Benefit?
It increases
prevent adrenal crisis because surgery increases demand on cortisol as your body is under physiological stress
Why is Addisonian crisis often difficult to detect operatively and operatively?
mimics other surgical complications
How long before surgery should EPO be given to increase Hb?
6 weeks
What 3 requirements must be met for consent to be legally valid?
given voluntarily
patient has capacity to consent
patient understands nature of tx
How should you present a CXR?
- Give the type of radiograph and projection
- Give the patients name
- Give the date the X-ray was taken
- Briefly assess the film quality to ensure it is adequate
- Run through the ABC of chest radiology
- Give a short Summary at the end.
What are you looking for in a CXR?
Airway - trachea, bronchi
Breathing - lung expansion, lung outlines, lung fields
Circulation - cardiac size, great vessels, mediastinum
Dem bones - ribs and shoulder girdle
Everything else - air under diaphragm, surgical emphysema, foreign bodies
What are you looking for in an abdo XR?
Air in the wrong place - pneumoperitoneum, air in biliary tree, Rigler’s sign
Bowel - dilated bowel, volvulus, hernias, thickened walls
Calcification - calcified gallstones, pancreatic calcification, AAA, foetus
Disability - fractures and solid organ enlargement
Everything else - evidence of surgery, lung bases, foreign bodies
Indications for AXR?
Suspected bowel obstruction - To look for dilated loops of small or large bowel or a dilated stomach
Suspected perforation - To look for evidence of pneumoperitoneum. An erect CXR should always be requested at the same time to look for free gas under the diaphragm
Moderate-to-severe undifferentiated abdominal pain - May be useful if the provisional diagnosis includes any of the following: toxic megacolon, bowel obstruction and perforation
Suspected foreign body
Renal tract calculi follow-up - To look for the presence or movement of known renal tract calculi.
Differentials for acute epigastric pain?
acute pancreatitis
perforated gastric / duodenal ulcer
GORD
gastritis
ruptured AAA
Boerhaave’s
MI
trauma
By what mechanisms can gallstones cause acute pancreatitis?
duct obstruction (pancreatic duct or bile duct) by migrated gallstones
increasing duct pressure and subsequent unregulated activation of pancreatic digestive enzymes
Which organs most commonly perforate?
appendix
duodenum
sigmoid colon
define peritonitis
inflammation of the peritoneum
What is the natural hx of untreated hernias?
incarcerated > strangulated > obstructed / infarcted
most common complications of appendicectomy?
peritonitis, peritoneal abscess
How long should patients refrain from driving after an uncomplicated appendicectomy?
1-3 weeks
indications for surgery in gallstones?
symptomatic
acute cholecystitis
gallbladder trauma / cancer
How would a patient with generalised peritonitis present?
lying very still, taking shallow breaths, pale
What factors increase risk of developing IBD?
fam hx
abx use
diet
smoking
Indications for surgery in IBD?
toxic megacolon
bowel perf
severe strictures/fistulae
Are diverticula in diverticular disease ‘true’?
yes - contain contents of mucosa and submucosa
Complications / indications for surgery in diverticular disease?
perf with faecal peritonitis
overwhelming sepsis
bowel obstruction
persistent vomiting
PR bleeding
What causes of SBO and LBO can be managed operatively? (if no signs of peritonitis)
SBO - intussusception
LBO - foreign body
Give 3 reasons for forming a stoma
perforation
ischaemia
cancer
Complications of stoma formation?
bleeding
local skin irritation
loss of bowel length = dehydration and malnutrition
obstruction
prolapse / retraction
psycho-social
