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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
Q

What is allodynia?

A

Pain resulting from non-painful stimulus

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26
Q

What is hyperalgesia?

A

Increased response to a painful stimulus

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27
Q

What is paraesthesia?

A

Altered sensation including pins and needles sensation, typically related to nerve damage

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28
Q

What is visceral pain?

A

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

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29
Q

What is referred pain?

A

Convergence of somatic and visceral afferent signals

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30
Q

Define neuropathic pain

A

Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system
Arising due to abnormal activation of pain pathways

31
Q

What character of pain is felt in neuropathic pain?

A

Burning, tingling, itching, pins and needles, shooting pains or sensation of an electric shock

32
Q

What mnemonic is used to assess pain?

A 
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
Q

What receptors do opioid analgesics work on?

A

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
Q

How does ketamine work?

A

Produces a dissociative analgesia

Acts on NMDA-receptor gated calcium channels and can prevent “wind up” and central sensitisation

35
Q

How does capsaicin work?

A

Depletion of substance P and nerve fibre density

36
Q

What are the fluid compartments and how much of it is water?

A 
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
Q

Name a few areas where ECF fluid can be found

A 
Peritoneal fluid
CSF
Pericardial fluid
Synovial fluid
Aqueous humour of the eye
Pleural fluid
Around cells
Blood
38
Q

What is the main difference between interstitial fluid and plasma of the extra cellular compartment of fluid?

A

Interstitial fluid has much less proteins than plasma

Both contain lots of sodium, chloride and bicarbonate

39
Q

What are indications for IV fluid replacement?

A 
NBM
Vomiting
Diarrhoea
Hypovolaemia
Sepsis
40
Q

What are the 5 R’s of prescribing IV fluids?

A 
Resuscitation
Routine maintenance
Replacement
Redistribution
Reassess
41
Q

What are the 2 main types of IV fluid groups?

A

Crystalloid

Colloids

42
Q

Name the 6 main crystalloid IV fluids

A 
0.9% sodium chloride
Hartmann’s solution
5/10/20% dextrose
Plasma-lyte 
Fluids with potassium
43
Q

Name the 4 main colloid IV fluids

A

Human albumin solution
Gelofusin
Starch
Blood

44
Q

What fluids would be given in resuscitation?

A

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
Q

What amount of fluids/ electrolytes should be given for maintenance/day?

A

Daily requirements:
Water: 30ml/kg/day
Sodium/potassium/chloride = 1mmol/kg/day
Glucose - 50-100g/day

46
Q

What is the normal cortisol production per day?

A

15-30mg/day

Pulsation with circadian rhythm

47
Q

When going for surgery (major and minor) what is the amount of cortisol produced approximately?

A

Minor surgery - 50mg/day

Major surgery - 75-150mg/ day which is up to 72hours post cardiac surgery for example

48
Q

Where in the HPA axis would primary adrenal insufficiency be causing the problem?

A

Adrenal gland

49
Q

Where in the HPA axis would secondary adrenal insufficiency be causing the problem?

A

Pituitary /hypothalamus

50
Q

What are the long term effects of exposure to high amounts of cortisol?

A

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
Q

How can HPA suppression be measured?

A

IV synacthen test
250mcg of synacthen
Cortisol measured at 0, 30, 60minutes
Peak at 420-700nmol/L is normal

52
Q

What are some signs or symptoms of Addison’s disease?

A 
Orthostatic Hypotension
Lethargy
Headache, confusion, Coma
Dehydration, dizziness
Abdo/ flank pain
Fatigue, weakness, fever, N&V, anorexia
Tachycardia, inc RR, sweating, CVS collapse
53
Q

How is adrenal crisis treated?

A

100mg stat of IV hydrocortisone

54
Q

How much steroids are given as steroid cover when going for surgery?

A

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
Q

What are the 3 sick day rules for steroids?

A

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
Q

What CBG would be aimed for in diabetics pre-op?

A

6-10mmol/L acceptable is 4-12mmol/L

57
Q

If a patients HbA1c pre-op is >69mmol/mol what would be the correct procedure for managing their diabetes?

A

Peri-operative VRIII

58
Q

If a patient’s HbA1c is <69mmol/mol what is the correct peri-operative procedure for managing their diabetes?

A

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
Q

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?

A

Decrease by 20% and check blood glucose on admission

Reduce the previous day’s insulin by 20%

60
Q

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?

A

Reduce dose by 20% and check CBG on admission

Reduce the previous day’s insulin by 20%

61
Q

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?

A

Check CBG on admission

Reduce the previous day’s insulin by 20%

62
Q

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?

A

Check CBG on admission

Reduce the previous day’s insulin by 20%

63
Q

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?

A

Halve the usual morning dose and check the CBG on admission
Leave evening meal dose unchanged

No change to previous days’ insulin doses

64
Q

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?

A

Halve the usual morning dose and check CBG on admission

Leave the evening meal dose unchanged

65
Q

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?

A

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
Q

What are the 5 main cautions with VRIII in all patients?

A

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
Q

How is DKA diagnosed?

A

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
Q

What are metabolic changes seen in response to trauma?

A

Protein - overall negative nitrogen balance, mostly from skeletal muscle

Carbohydrate - reduced peripheral utilisation, increased endogenous production

Fat - lips lysis

69
Q

When would parenteral feeding be commenced?

A

Non-functioning GIT
Inaccessible GIT
High-output enteric fistulae
Nutritional requirements outstrip absorptive capacity - short bowel segment, malabsorption, severe burns, major trauma

70
Q

Define cauda equina syndrome

A

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
Q

What usually causes cauda equina syndrome?

A

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
Q

What are the 4 stages of vertebral disc herniation?

A

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
Q

What are the clinical symptoms of cauda equina syndrome?

A

Neurological - weakness, numbness, tingling/ paraesthesia, difficulty in walking/ gait problems

Saddle anaesthesia

Bladder/ bowel incontinence or retention

74
Q

What are red flag symptoms of cauda equina syndrome?

A 
Saddle anaesthesia
Bladder disturbance
Bowel disturbance
Sexual problems
Nerve root pain/ BIL radiculopathy

Medicine (15 decks)

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