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Medicine > Year 3 surgery > Flashcards

Year 3 surgery Flashcards

1
Q

Define severe inflammatory response syndrome?

A

Cluster of 2 features:

  • Temperature <36deg C or >38 deg C
  • HR >90BPM
  • RR >20
  • WBC <4 or >12 x10^9/L
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2
Q

What makes sepsis different from severe inflammatory response syndrome?

A

All the features of SIRS are found in Sepsis PLUS - culture-documented infection.

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3
Q

What features take sepsis to severe sepsis?

A

Features of organ dysfunction, hypotension or hypoperfusion

This includes reduced GCS, oliguria or raised lactate

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4
Q

What features take severe sepsis to septic shock?

A

Features of severe sepsis PLUS ongoing hypotension/ hypoperfusion despite fluid resuscitation

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5
Q

What are the red flags for sepsis?

A

1- objective measured altered GCS
2- SBP = 90mmHg (or drop of >40 from normal)
3- HR >/= 130bpm
4- RR >/= 25. Min
5- Needs O2 to maintain SpO2 >/= 92% (88% in COPD)
6- Non-blanching rash/ mottled/ ashen/ cyanotic
7- Lactate >/= 2mmol/L
8- Recent chemotherapy
9- Not passed urine in 18 hours (<0.5ml/kg/hr if catheterised)

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6
Q

What are potential sources of infection leading to seps?

A 
Resp
Brain
Urine
Surgical
Skin/joint/wound
In dwelling device
Other
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7
Q

What are risk factors for sepsis?

A

> 75yrs old
Impaired immunity (e.g. diabetes, steroids, chemo)
Recent trauma/ surgery/ invasive procedure
In dwelling lines/ IVDU/ broken skin

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8
Q

What is the sepsis 6?

A

Give- fluids, antibiotics, oxygen

Take- urine output, lactate, blood cultures

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9
Q

How is neutropenic sepsis treated?

A

Broad spectrum antibiotics administered within 1 hour

Take blood cultures prior to giving antibiotics but not delayed treatment of antibiotics

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10
Q

Name 2 bacteria that are commonly found in the upper respiratory tract

A

Staphylococcus sp
Streptococcus sp (Strep pneumoniae, viridans streptococcus)
Haemophilus sp
Anaerobes

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11
Q

Name 2 bacteria that are commonly found on the skin

A

Staphylococcus sp
Coryneform bacteria or diptheroids
Propionibacterium sp

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12
Q

Name 2 bacteria that are commonly found in the GIT

A

Anaerobes
Enterococcus sp
Enterobacteriaceae (Escherichea coli, Klebsiella sp)
Streptococcus sp (Streptococcus anginosus group)
Lactobacillus sp
Candida sp

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13
Q

Name 2 bacteria that are commonly found in the genital tract

A 
Lactobacillus sp
Streptococcus sp (Streptococcus agalactiae)
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14
Q

What criterion is used for helping diagnosing infective endocarditis?

A

Duke’s criteria

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15
Q

What constitutes Duke’s criteria for infective endocarditis?

A

-2 major + 1 minor/ 1 major + 3 minor/ 5 minor
-Major criteria= 1- Typical micro-organism from 2 or more sets of blood cultures, ideally more than 12 hours apart
2- Positive echocardiogram showing vegetation, abcess, dehiscence of prosthetic valve or new valve regurgitation
-Minor criteria=
1- predisposing heart condition or IVDU
2- Fever >38deg C
3- Vascular phenomena- emboli, my optic aneurysm, haemorrhage, Janeway lesions
4- Immunological phenomena- GN, Osler’s nodes, Roth’s spots, rheumatoid factor
5- Microbiological evidence- positive blood cultures but falls short of major criteria i.e. atypical micro-organism
6- Echo findings- consistent with endocarditis but not a major criteria e.g. thickened valve leaflets, transmural thrombus

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16
Q

What fibres carry sensory information relating to touch?

A

A-beta fibres

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17
Q

What fibres carry pain and temperature information?

A

A-delta and C fibres

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18
Q

What is the difference between A-delta and C -fibres?

A

A-delta - myelinated and quick signals

C - unmyelinated and slow signals

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19
Q

Name 4 inflammatory and chemical signals that cause peripheral sensitisation

A

Bradykinin
Histamine
Potassium
Hydrogen ions

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20
Q

What is the difference between direct or secondary activation of nerve fibres causing peripheral sensitisation?

A

Direct is where there is direct damage to the neurones causing hyperalgesia
Secondary is the damage/ change seen in the CNS

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21
Q

What is Peripheral sensitisation?

A

Injury to area/ cell damage -> flare response of nociceptors -> production of excessive amounts of neuropeptides -> increased sensitivity to heat and touch.

The sensitivity is much more pronounced after the damage and the stimulus may only be of a low intensity

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22
Q

What are 2 common causes of primary hyperalgesia?

A

Surgery

Trauma

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23
Q

What is central sensitisation?

A

Sustained activation of receptors in post-synaptic dorsal horn leads to long-term “wind-up” of the receptors (in particular NMDA receptors) and increased sensitivity

Produces secondary areas of hyperalgesia in areas of normal tissue surrounding the injury

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24
Q

What is gate theory?

A

Non-painful stimuli can override painful stimuli and reduce painful sensation

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25
What is allodynia?
Pain resulting from non-painful stimulus
26
What is hyperalgesia?
Increased response to a painful stimulus
27
What is paraesthesia?
Altered sensation including pins and needles sensation, typically related to nerve damage
28
What is visceral pain?
Pain arising from internal organs Afferent innervation is predominantly through small unmyelinated fibres Relatively few afferent fibres compared to somatic sensation and spinal afferents are stimulated bilaterally Poorly localised dull pain, often felt in the midline Often associated with autonomic features
29
What is referred pain?
Convergence of somatic and visceral afferent signals
30
Define neuropathic pain
Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system Arising due to abnormal activation of pain pathways
31
What character of pain is felt in neuropathic pain?
Burning, tingling, itching, pins and needles, shooting pains or sensation of an electric shock
32
What mnemonic is used to assess pain?
``` SOCRATES Site Onset - fast/ slow Character - dull/ sharp/ aching/ burning etc Radiation Associated symptoms Timing - related temporally to activities etc Exacerbating symptoms/ relieving factors Severity ```
33
What receptors do opioid analgesics work on?
Mew, Kappa, Delta receptors in the CNS Mew1 receptors act by increased the modulators action of the descending pathway to inhibit the painful stimuli Mew2 receptors produce the unfortunate side effecting (constipation, nausea, drowsiness and respiratory depression)
34
How does ketamine work?
Produces a dissociative analgesia | Acts on NMDA-receptor gated calcium channels and can prevent “wind up” and central sensitisation
35
How does capsaicin work?
Depletion of substance P and nerve fibre density
36
What are the fluid compartments and how much of it is water?
``` Total body water= 60% of body weight 70Kg man = 42L of water total ICF and ECF ICF = 2/3 = 28L ECF = 1/3 = 14L ``` Of the ECF 75% is interstitial fluid and 25% is plasma Interstitial fluid = 10.5L Plasma = 3.5L
37
Name a few areas where ECF fluid can be found
``` Peritoneal fluid CSF Pericardial fluid Synovial fluid Aqueous humour of the eye Pleural fluid Around cells Blood ```
38
What is the main difference between interstitial fluid and plasma of the extra cellular compartment of fluid?
Interstitial fluid has much less proteins than plasma | Both contain lots of sodium, chloride and bicarbonate
39
What are indications for IV fluid replacement?
``` NBM Vomiting Diarrhoea Hypovolaemia Sepsis ```
40
What are the 5 R’s of prescribing IV fluids?
``` Resuscitation Routine maintenance Replacement Redistribution Reassess ```
41
What are the 2 main types of IV fluid groups?
Crystalloid | Colloids
42
Name the 6 main crystalloid IV fluids
``` 0.9% sodium chloride Hartmann’s solution 5/10/20% dextrose Plasma-lyte Fluids with potassium ```
43
Name the 4 main colloid IV fluids
Human albumin solution Gelofusin Starch Blood
44
What fluids would be given in resuscitation?
Initial 250-500ml of isotonic fluid bolus Assess the response Can give a further 250ml bolus if fluid responsive Max 30ml/Kg Caution in elderly or co-morbid patient groups
45
What amount of fluids/ electrolytes should be given for maintenance/day?
Daily requirements: Water: 30ml/kg/day Sodium/potassium/chloride = 1mmol/kg/day Glucose - 50-100g/day
46
What is the normal cortisol production per day?
15-30mg/day | Pulsation with circadian rhythm
47
When going for surgery (major and minor) what is the amount of cortisol produced approximately?
Minor surgery - 50mg/day | Major surgery - 75-150mg/ day which is up to 72hours post cardiac surgery for example
48
Where in the HPA axis would primary adrenal insufficiency be causing the problem?
Adrenal gland
49
Where in the HPA axis would secondary adrenal insufficiency be causing the problem?
Pituitary /hypothalamus
50
What are the long term effects of exposure to high amounts of cortisol?
Cushing’s disease ``` Moon face, central obesity, buffalo hump Purple striae on abdomen and thighs Proximal muscle wasting Osteoporosis Skin thinning that bruises easily ``` HTN, LVH, T2DM, Hypokalaemia
51
How can HPA suppression be measured?
IV synacthen test 250mcg of synacthen Cortisol measured at 0, 30, 60minutes Peak at 420-700nmol/L is normal
52
What are some signs or symptoms of Addison’s disease?
``` Orthostatic Hypotension Lethargy Headache, confusion, Coma Dehydration, dizziness Abdo/ flank pain Fatigue, weakness, fever, N&V, anorexia Tachycardia, inc RR, sweating, CVS collapse ```
53
How is adrenal crisis treated?
100mg stat of IV hydrocortisone
54
How much steroids are given as steroid cover when going for surgery?
Hydrocortisone 100mg IV on induction followed by IV infusion of 200mg/24hours OR 50mg IM 6hourly For adrenal suppression patients only - give 6-8mg IV dexamethasone which will last 24hours Double usual steroid for 24-48hours
55
What are the 3 sick day rules for steroids?
Rule 1- moderate intercurrent illness: fever, infection requiring ABx, surgical procedure under local anaesthetic - double usual daily glucocorticoid dose Rule 2 - severe intercurrent illness: Hydrcortisone 100mg IV at onset + IVI of 200mg/ 24hours Rule 3- Hydrocortisone emergency injection kit - 100mg hydrocortisone sodium succinct for injection
56
What CBG would be aimed for in diabetics pre-op?
6-10mmol/L acceptable is 4-12mmol/L
57
If a patients HbA1c pre-op is >69mmol/mol what would be the correct procedure for managing their diabetes?
Peri-operative VRIII
58
If a patient’s HbA1c is <69mmol/mol what is the correct peri-operative procedure for managing their diabetes?
Plan VRIII on the following patients: 1- T1DM and potentially missing a meal/ not receiving background insulin 2- T2DM missing a meal and develops hyperglycaemia (CBG >12mmol/L)
59
If a patient is going for surgery in the morning and usually takes their insulin in the morning what should be done to the dose of insulin?
Decrease by 20% and check blood glucose on admission Reduce the previous day’s insulin by 20%
60
If a patient is going for surgery in the evening and usually takes their insulin in the morning what should be done to the dose of insulin?
Reduce dose by 20% and check CBG on admission Reduce the previous day’s insulin by 20%
61
If a patient is going for surgery in the morning and usually takes their insulin evening what should be done to the dose of insulin?
Check CBG on admission Reduce the previous day’s insulin by 20%
62
If a patient is going for surgery in the evening and usually takes their insulin in the evening what should be done to the dose of insulin?
Check CBG on admission Reduce the previous day’s insulin by 20%
63
If a patient is going for surgery in the morning and usually takes their insulin twice a day what should be done to the dose of insulin?
Halve the usual morning dose and check the CBG on admission Leave evening meal dose unchanged No change to previous days’ insulin doses
64
If a patient is going for surgery in the evening and usually takes their insulin twice a day what should be done to the dose of insulin?
Halve the usual morning dose and check CBG on admission | Leave the evening meal dose unchanged
65
If a patient is going for surgery in the morning/ evening and usually takes their short acting and intermediate acting insulin twice a day what should be done to the dose of insulin?
Calculate total dose of both morning insulins and give half as intermediate acting only in the morning Check CBG on admission Leave the evening meal dose unchanged No change to insulin on previous day
66
What are the 5 main cautions with VRIII in all patients?
1 - don’t infuse insulin without substrate i.e. sodium chloride. Or glucose if CBG’s are lower than 4.1mmol/L 2- measure CBG hourly 3- ensure administration of long acting basal insulin to prevent hyperglycaemia and ketosis on cessation 4- type 1 patients - never take down VRIII until alternative s/c insulin has been given in previous 30mins 5- measure sodium and potassium daily
67
How is DKA diagnosed?
Ketonaemia >/= 3.0mmol/L or ++ ketones on urine dip CBG >11mmol/L or known DM Bicarbonate <15mmol/L and/or venous pH <7.3
68
What are metabolic changes seen in response to trauma?
Protein - overall negative nitrogen balance, mostly from skeletal muscle Carbohydrate - reduced peripheral utilisation, increased endogenous production Fat - lips lysis
69
When would parenteral feeding be commenced?
Non-functioning GIT Inaccessible GIT High-output enteric fistulae Nutritional requirements outstrip absorptive capacity - short bowel segment, malabsorption, severe burns, major trauma
70
Define cauda equina syndrome
Patient presenting with acute back pain and/or leg pain - with a suggestion of a disturbance in their bladder or bowel function and/or saddle sensory disturbance
71
What usually causes cauda equina syndrome?
Paracentral vertebral disc herniation Central vertebral disc herniation Lateral vertebral disc herniation Lumbar spinal stenosis Inflammatory conditions - ankylosing spondylitis Infections of vertebra - osteomyelitis Tumours/ neoplasms/ mets - spinal cord compression Trauma to lumbar spine Post-operative complications - epidural abcess, spinal epidural haematoma, diskitis
72
What are the 4 stages of vertebral disc herniation?
1 - bulging - extension of the disc beyond margins of adjacent vertebral endplates 2 - protrusion - posterior longitudinal ligament remains intact but the nucleus purposes impinges on the annulus fibrosis 3 - extrusion - nuclear material emerges through the annular fibres but the posterior longitudinal ligament remains intact 4 - sequestration - nuclear material emerges through the annular fibres and the posterior longitudinal ligament is disrupted. A portion of the nucleus pulposus has protruded into the epidural space
73
What are the clinical symptoms of cauda equina syndrome?
Neurological - weakness, numbness, tingling/ paraesthesia, difficulty in walking/ gait problems Saddle anaesthesia Bladder/ bowel incontinence or retention
74
What are red flag symptoms of cauda equina syndrome?
``` Saddle anaesthesia Bladder disturbance Bowel disturbance Sexual problems Nerve root pain/ BIL radiculopathy ```

Medicine (15 decks)

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