Surgery EOR Exam [PAEA Blueprint]

_______is the most important anesthetic complication. Anesthesia causes an uncontrolled increase in skeletal muscle oxidative metabolism, which overwhelms the body's capacity to supply oxygen, remove CO2, and regulative body temperature.

Malignant hyperthermia

If patient is hyperkalemic (normal range 3.8-5.0), how should you treat the patient?

treat with glucose/insulin, and calcium +/-bicarb

_______is the reversing agent for opiods.

Naloxone

_______is the reversing agent for benzodiazipines.

Flumazenil

What is the best indicator used to monitor nutritional status?

prealbumin - every 2-3 days

Intervention:

_________require central access and indicated when no enteral feeding for > 7 days.

TPN - total peripheral nutrition

The _________is the most important part of the history before surgery.

cardiac history -- history of MI, unstable angina, valvular disease

In patients with known cardiac disease, aggressive intraoperative lowering of myocardial oxygen demand with ____ has been shown in RCT's to improve outcomes and should be used.

beta blockers

When accessing cardiac disease prior to surgery, what is the most important thing to access?

aortic stenosis -- crescendo diastolic rumble at apex

Guidelines for the use of antibiotics include administration within _______ of surgery and redosing after 4 hours. What is the abx of choice?

1 hour

Abx of choice: cefazolin for all except colorectal then cefazolin/metronidazole

Pre-op -- Metabolic disease/syndrome -- what are the 5 criteria?

3/5 to diagnose:

1 - diabetes

2 - central obesity

3 - HTN

4 - high serum triglycerrides

5 - low HDL levels

______should be monitored before surgery bc it is a stimulant and vasoconstrictor -- can lead to severe tachycardia

Cocaine

Pre-Op -- What are the indications for EKG and CXR?

EKG - men >40, women>50, known CAD, DM, or HTN

CXR - age >50, known cardiac or pulmonary disease

What are the 5 classic "W's" of post operative fever?

W - wind (atelectasis)

W - water (UTI)

W - wound (wound infection)

W - walking (DVT/thrombophlebitis)

W - wonder drugs (drug fever)

If the post op fever occurs within the first 24 hours of surgery, what is the most likely cause?

wind/atelectasis

If the post op fever occurs within days 3-5 post op, what is the most likely cause?

water/UTI, catheter related phlebitis, pneumonia

If the post op fever occurs within days 5-10 post op, what is the most likely cause?

wound infection, pneumonia, abscess, infected hematoma, C diff colitis, anastomotic leak, DVT, peritoneal abscess, drug fever, PE, parotitis

_______is the most common pathogen in wound infections and around foreign bodies.

Staph aureus

_______invades the inner ear and enteric tissues as well as the lung.

Klebsiella

______organisms are often found together with anaerobes.

Enteric organisms ie. enterobacteriaceae and enterococci

Among the anaerobes, ___&___are often present in surgical infections and _____species are major pathogens in ischemic tissue.

Bacteroides & Peptostreptococci; Clostridium

___&___are usually nonpathogenic surface contaminants but may be opportunistic.

Some fungi and yeast cause abscesses in sinus tracts.

Pseudomonas & Serratia

History of recent surgery, trauma, cancer, prolonged immobilization, or oral contraceptive use increases the risk of ____.

DVT - deep vein thrombosis

What is Homan's sign?

pain on passive dorsiflexion of ankle

What is the test of choice for DVT?

doppler ultrasound

How is the D-dimer text useful?

It is good at ruling a DVT out (if the text is negative) but not rule it in

Tx of DVT --

1. Initiate use of ____or____to what dose?

2. Overlap with the use of ____to what therapeutic range?

3. Why overlap therapies?

DVT

1. Initiate Heparin to PTT of 0.3-0.7 U/mL or LMWH wo monitoring.

2. Overlap with warfarin to INR between 2-3.

3. Overlap therapies to decrease changes of hypercoagulable state.

The most common cause of SIRS (systemic inflammatory response syndrome) is sepsis. What are the criteria for dx of SIRS?

At least 2 of the following:

1. temp >38C or <36C

2. tachy >90

3. tachypnea > 20 breaths/minute

4. PCO2 <32mmHg

5. WBC > 12,000/uL or <4000/uL

After sepsis, what are the next two most common causes of SIRS?

pancreatitis and drugs

What is the difference between hypovolemia and dehydration?

hypovolemia is loss of both water and sodium while dehydration is loss of intracellular water or deficit with hypernatremia -- dehydration occurs when patient can not adjust water intake for water loss

What are the clinical signs of dehydration and hypovolemia?

tachycardia, hypotension, pale skin, increased capillary refill time, dizziness, faintness, nausea, thirst, decreased urine output -- in hypovolemia, urine will demonstrate low sodium concentration

What are 2 common conditions with dehydration?

diabetes insipidus (lack of ADH or unable to respond to ADH), fever with increased water loss

Hyponatremia Causes

_______ = cirrhosis, CHF, nephrotic syndrome, massive edema

_______=states of severe pain or nausea, trauma, brain damage, SIADH

_______=prolonged vomiting, decreased oral intake, severe diarrhea, diuretic use

Misc causes = factitious hyponatremia, hypothyroidism, adrenal insufficiency, malnourished states, primary polydipsia

Hypervolemic, Euvolemic, Hypovolemic

What are the two most common treatments for hyponatremia?

Other less common treatment?

salt tabs and fluid restriction; vasopressin receptor antagonist in SIADH, CHF, and cirrhosis

Hypernatremia is almost always due to _______. Therefore, what is the treatment?

dehydration; rehydrate!

What s/s can result in a hyperkalemic patient?

cardiac arrhythmias (tall peaked T waves) and weakness

If the potassium level is above 6meq/L or the patient has EKG changes, what treatments can lower K temporarily?

calcium gluconate, sodium bicarbonate, insulin and glucose, kayexalate (takes longer to be effective)

______&______ is extremely effective in decreasing potassium.

Dialysis and furosemide

Hypokalemia is usually due to ________, hypomagnesemia, alkalosis, high aldosterone levels. How is it treated?

potassium loss; replacement must be slow!!!

Mild loss: oral KCl supplements or K containing foods

Severe loss: IV supplementation - rate 10mEg/hr

Causes of ________are VITAMIN D METABOLIC DISORDERS, abnormal PTH function, primary hyperparathyroidism, Lithium, malignancy, disorders related to high bone turnover rates (hyperthyroidism, prolonged immobilization, thiazide use, vit A intoxication, Pagets dz of bone, multiple myeloma), renal failure

hypercalcemia

How should hypercalcemia be treated?

fluid and diuretics, bisphosphonates, and calcitonin

_______is usually caused by ineffective PTH (chronic renal failure, absent active vit D, ineffective active vit D, pseudohypoparathyroidism), deficient PTH.

Hypocalcemia

How should hypocalcemia be treated?

intravenous calcium gluconate, Tums

Increased CO2, hypoventilation, or decreased pH is aka ___.

respiratory acidosis

Decreased CO2, hyperventilation, or increased pH is aka ___.

respiratory alkalosis

Increased H+ or HCO3 loss, DKA, lactic acidosis is aka ___.

metabolic acidosis

Loss of H+ is aka ________.

metabolic alkalosis

The d/d of post op ___________can be MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection, pneumo/chyle/hemothorax, or gastritis.

chest pain

Who classically gets silent MI's?

diabetics

How should syncope be initially evaluated?

It is important to distinguish syncope from cardiac arrest from other nonsyncopal conditions causing LOC

Syncope d/d: Prodrome or aura usually associated with ____.

seizures (as is loss of continence)

Cardiac syncope's onset is usually ____without a prodrome. Monitor vitals regularly, EKG, orthostatic challenge, neuro exam etc.

sudden

In a surgery patient with dyspnea on exertion, what should be ruled out?

PE or pneumothorax

What are some chronic dyspnea on exertion causes?

asthma, COPD, interstitial lung disease, myocardial dysfunction, obesity

What are some acute dyspnea on exertion causes?

angioedema, anaphylaxis, foreign objects, airway trauma, pulmonary infection, pleural effusion, peritonitis/ruptured viscous, bowel obstruction

__________is pain, cramping, or both of the lower extremity (usually calf muscle) after walking a specific distance; then resolves for a specific amount of time while standing.

Claudication

What is claudication associated with?

peripheral vascular occlusion

D/D of lower extremity claudication?

neurogenic/nerve entrapment/discs, arthritis, coartation of the aorta, popliteal artery syndrome, neuromas, anemia, diabetic neuropathy pain

A _________is an abnormal dilation of an artery. Involve all layers of the arterial wall.

aneurysm

At what size is surgical repair of aneurysm recommended?

5.5 cm

95% of aneurysms are associated with ___________.

atheroschlerosis -- other causes are trauma, infection, syphilis, & Marfan's syndrome

What is the classic triad of s/s related to ruptured AAA?

abdominal pain, pulsatile abdominal mass, hypotension

Where does the aorta bifurcate?

At the level of umbilicus

Because the ________is often sacrificed during AAA repair, colonic ischemia can occur.

IMA - inferior mesenteric artery

_______is a separation of the walls of the aorta from an intimal tear and disease of the tunica media; a false lumen is formed and a "reentry" tear may occur, resulting in a "double barrel" aorta.

Aortic dissection

Explain the DeBakey classifications (Type 1,2, & 3) of aortic dissections.

DeBakey Type 1 - ascending & descending aorta

DeBakey Type 2 - ascending aorta

DeBakey Type 3 - descending aorta

Explain the Stanford classifications of aortic dissections.

Type A -- ascending +/- descending aorta

Type B - descending aorta

What is the most common cause of aortic dissection.

HTN!

What are the s/s of aortic dissection.

abrupt tearing pain/sensation

What are 3 other sequelae of aorta dissection?

cardiac tamponade, aortic insufficiency, aortic arterial branch occlusion/shearing

What is Beck's triad of cardiac tamponade?

muffled heart sounds, JVD, hypotension

What does CXR show with aortic dissection?

widened mediastinum

What is the gold standard but time consuming test of choice with aortic dissection/aneurysm?

aortagraphy

Which type of aortic dissection should be treated with surgical repair?

Involvement of ascending aorta -- Type A or Type I

Type III or B aortic dissections can be treated with what meds?

blood pressure meds

_______is a diffuse disease process in arteries; artheromas containing cholesterol and lipid form within the intima and inner media, often accompanied by ulcerations and smooth muscle hyperplasia. Risk factors: HTN, smoking, DM, FH, hypercholesterolemia, high LDL, obesity, & sedentary lifestyle.

Atherosclerosis

Common sites of arterial plaque formation?

branch points (carotid bifurcation) or tethered sites (superficial femoral artery in Hunter's canal of leg)

What is a major principle of safe vascular surgery?

get proximal and distal control of vessel so that if you put tension on the vessel loop it will occlude the vessel

What is Virchow's Triad (risk factors for thrombosis)?

stasis, abnormal endothelium, hypercoagulability

What are the 6 classic s/s of acute arterial occlusion?

pain, paralysis, pallor, paresthesia, poikilothermia, pulselessness

What is the immediate pre-op management of acute arterial occlusion?

anticoagulation with IV heparin -- angiogram

85% of emboli originate from where?

Heart -- a fib

What is the most common site of arterial occlusion by embolus?

SFA -- superficial femoral artery

What is the surgical treatment for acute arterial occlusion?

surgical embolectomy

Post op management of possible _________ie. tissue swelling from reperfusion can increase intracompartmental pressure, resulting in decreased capillary flow, ischemia, and myonecrosis.

compartment syndrome

What are the classic s/s of compartment syndrome?

pain, paralysis, parethesias, pallor

What is the tx for compartment syndrome?

fasciotomy

________is intermittent claudication. S/S are absent pulses, bruits, muscular atrophy, decreased hair growth, thick toenails, and tissue necrosis/ulcers/infection.

PVD - peripheral vascular disease

______is the gold standard for diagnosis of PVD.

arteriogram

Use Ankle to Brachial index to access PVD. What is the normal ABI.

ABI>1; Claudicator ABI<0.6; Rest Pain ABI<0.4

What are the indications for treatment of PVD? STIR

S - severe claudication that is refractory to conservative tx

T - tissue necrosis

I - infection

R - rest pain

What is the major post op concern after PVD operation?

cardiac status -- MI is the most common cause of post op death

The three treatment options for _______are surgical graft bypass, angioplasty, endarterectomy.

PAD

Arterial/venous ulcer disease is best treated with revascularization. An expensive alternative is ______ which stimulates angiogenesis. When revascularization is not possible, ______ is performed.

hyperbaric oxygen; amputation

__________most often occur in saphenous veins and are caused by incompetent valves from damage or venous dilation, AV fistula, congenital venous malformations.

Varicose veins

What are some treatment options for varicose veins?

compression stockings, leg elevation, venous ablation, sclerotherapy, great saphenous vein stripping

___________is obstruction of left subclavian artery. S/S: upper extremity claudication and upper extremity blood pressure discrepancy. Tx: surgical bypass or endovascular stent

Subclavian steal syndrome

_________is stenosis of renal artery which results in decreased perfusion of the juxtaglomerular apparatus and subsequent activation of the renin-angiotensin-aldosterone system. S/S - diastolic HTN, A-gram is diagnostic.

Renal artery stenosis

_________is a vasospasm of the digital arteries with color changes of the digits. Usually initiated by cold or emotion.

Raynaud's phenomenon

________is arteritis of the aorta and aortic branches resulting in stenosis/occlusion/aneurysms.

Takayasu's arteritis