cumulative cms 3 review

agent that prevents bacteria from multiplying = bacterioSTATIC

agent that kills bacteria = bacteriCIDAL

what is the prion-causing neurodegenerative disease that patients can get from contaminated endoscopes?

what do we use to clean endoscopes?

creutzfeldt-jakob disease

gas sterilization

KNOW

what is the purpose of the surgical hand scrub? (2)

a. to make our skin sterile

b. to kill all of the microbes present

c. to decrease bacterial skin flora

d. to remove the pathogenic organisms

c. to decrease bacterial skin flora

d. to remove the pathogenic organisms

how long of a contact time do scrub solutions need to contact the skin to be effective?

3 minutes

what should you do if the BRUSH becomes contaminated during surgical scrub?

what should you do if your ARM becomes contaminated during surgical scrub?

start over

add 1 minute to the contaminated arm

when scrubbing in we use betadine. what can be used if someone has an anaphylactic allergy?

do you scrub in before or after mechanically cleansing the patient's skin?

plain chlorhexidine scrub (pink bar)

after! you don't want to scrub in and then get urself dirty/exposed to bacteria again

instant surgical hand sanitizers for scrubbing in

**remember: these are non-mechanical, do not require a scrub brush, and you should start at fingers & go 2 inches above elbow, and you do not need to towel before gowning & gloving

- sterillium rub

- avagard

- triseptin

how long of a drying time does chloraprep need on the patient's skin before we drape them?

when should we NOT use chloraprep (or any other alcohol-based prep, such as duraprep)?

3 min

on mucous membranes, vaginal orifices, or eyes --> use betadine instead!!

circulating nurse: goes b/w sterile & non-sterile areas, and is NOT sterile or scrubbed in!! they will tie your gown, prep the pt and supplies, collect specimens, and are responsible for legal documentation.

KNOW

scrub tech: collects needles, sponges, etc. at the end of surgery

positioning pt for surgery

- pillows under knees to prevent back strain

- pad bony prominences

- do NOT let sacrum hang off table

- avoid excessive flexion/extension n

- avoid pressure on common peroneal nerve

- avoid skin touching metal surfaces

pt cannot dorsiflex, raise foot at ankle, invert/evert ankle, foot appears floppy, sensation is lost over the area, and pt has a "steppage"/"foot drop" gait with high-step walk.

which nerve was likely injured during surgery d/t pressure from drapes, mayo stands, stirrups?

COMMON PERONEAL NERVE

branch of sciatic nerve

dorsal recumbent = supine = most basic position

ventral decubitus = prone

what is the preferred position for colonoscopy?

a. lateral kidney

b. prone

c. semi-prone (sims)

d. dorsal lithotomy

e. reverse trendelenburg

c. semi-prone (sims)

know

max time of tourniquet use

2 hours --> risk of ischemia to limb

remember pre-ob abx BEFORE starting the pressure

we need to give antibiotics within 1 hour of making the incision, ideally. when will we consider re-dosing?

at 4 hours

kocher = RUQ scar representing cholecystectomy

pfannenstiel = C-sections

midline incision = most common abdominal incision & usually spares the umbilicus

lanz = modified mcburney in the RLQ that runs more transverse

mcevedy = runs from femoral canal to inguinal region

muscle splitting loin = used for kidney transplants

stages of anesthesia

1. analgesia --> loss of pain + pt is conscious

2. excitement --> want to avoid

3. surgical anesthesia

4. medullary paralysis --> must not go into this stage

all of the following are reasons we would use benzos as a pre-anesthetic agent EXCEPT....

a. amnesia

b. analgesia

c. sedation

d. anxiety-relief

b. analgesia

benzos do not work for pain relief

diazepam = most used outpatient

midazolam = most used inpt

which opioid is used for post op shivers?

meperidine (demerol)

**high abuse risk

which halogenated agent has the LEAST degree of bronchospasm?

sevoflurane

KNOW

agents that can cause malignant hyperthermia

halogenated agents (isoflurane, desflurane, halothane, etc.)

succinylcholine

PROPOFOL is the most commonly used IV anesthetic agent, but who should we AVOID using this in d/t its SEs?

who is etomidate CI in?

who is ketamine CI in?

kids --> risk of severe acidosis in kids who has resp infx

cardiac instability / shock / emergency surgery -->

b/c propofol SE is severe hypotension

seizure patients

adrenocortical suppression

neurosurgery pts

increased ICP or HTN

relative CI = healthy adults (can reduce post op psych effects with a benzo)

post-op causes of fever:

first 24 hours: resp problems (atelectasis)

48-72 hrs: urinary tract complications

>72 hrs (3-5 days): wound infections, thrombophlebitis, DVT, PE

#1 MCC of surgical site infection

staph aureus

go thru types of wounds (clean ---> contaminated)

what level of post op fever is considered concerning & warrants an investigation?

>100.4 F / 38 C

what is the drug of choice for IV anesthesia when CV instability & cardiac contractile dysfunction is a concern?

etomidate!!

no effect on BP/HR/pulm pressure and only a mild effect on CO

tx for delirium tremens

librium or valium

which of of the following has a SE of myoclonus during induction?

a. propofol

b. etomidate

c. ketamine

b. etomidate

KNOW

IV induction agents of choice for asthmatics

propofol or ketamine

____________________ is a combo of IV sedation & local anesthesia.

TIVA (total IV anesthesia)

succinylcholine we would use for ET intubation & quick cases requiring fast intubation.

rocuronium & vecuronium are used for procedures > 30 minutes (aka in the OR).

what is the REVERSAL AGENT for roc/vec? (**does not work for succ**)

neostigmine or sugammadex

SEs of local anesthetics

seizures

cardiac arrest

metallic taste

HTN

tinnitus

lightheadedness

longest acting local anesthetic

bupivacaine

what can be added to local anesthetic to help decrease the burning caused by the acidity of the local anesthetic agent?

bicarb in a 1:10 ratio

reversal agents for anticoags

warfarin: vit K, FFP, PCC

unfractionated heparin: protamine

pradaxa: praxbind

eliquis, xarelto, lixiana: andexanet alfa

most common cause of post-op morbidity?

pulm complications --> #1 = ATELECTASIS

know

**remember that serum albumin < 3 is one of the strongest predictors of post-op pulm complications too

how long after drug-eluting stent placement do we need to wait?

how long after a MI do we need to wait to consider elective surgery?

how long after balloon angioplasty do we need to wait?

12 months (KNOW!!)

6 months

14 days

who to give BBs to perioperatively

already taking them

vascular operations

high cardiac risk (3 RCRI risk factors)

CAD/ischemia on pre-op testing

**start within 1 week of surgery

conditions requiring IE prophylaxis

heart transplant

prosthetic heart valve

prior rheumatic heart disease

CHD (unrepaired, prosthetic)

REMEMBER: prophylaxis is NOT needed for GU or GI procedures (so like a cystoscopy or hysterectomy you don't give prophylaxis for)

blood sugar goal in surgery for diabetics

how do we manage insulin?

how do we manage oral hypoglycemics?

100-180

insulin: decrease dose by 1/2 the morning of surgery

oral hypoglycemics: HOLD dose on day of surgery

**restart these when pt starts eating again post-op, unless it is METFORMIN then you need to wait until their renal function is stabilized d/t risk of fatal lactic acidosis!!!!!

child pugh class mortality risks

A: <10%

B: 40%

C: >80%

adrenal suppression in surgery:

patients who have taken >____mg of prednisone for > ______ weeks within the last year are considered at risk for adrenal suppression.

what do they require during surgery?

5 mg; 3 weeks

IV hydrocortisone

how long are type and cross units held for?

72 hours (3 days)

know

we should advise our patients to stop all narcotics before surgery EXCEPT for which one?

methadone

meds HELD on day of surgery

oral hypoglycemics

loop diuretics

ACEIs --> prils

ARBs --> sartans

how long is it recommended to fast solid & non-human milk (formula) prior to surgery?

how long is it recommended to human milk (breastfeeding) prior to surgery?

> 6 hours

> 4 hours

patient is undergoing surgery in which they were given succinylcholine for ET intubation, and halothane for inhaled anesthesia induction.

during surgery, they have a rapid rise in body temperature, muscle rigidity/stiffness (sustained tetany), increased HR, and dark brown urine (indicating rhabdomyolysis).

what is this condition called and how will you treat?

malignant hyperthermia

d/c the causative medication

DANTROLENE via rapid IVP

ice for cooling

**can do an in vitro contracture test prior to surgery to see if they're at risk

diabetic patient is 2 days post-op after ACL repair. you are suspicious of a soft tissue infection. the wound is inflamed, hot, red, and there is ***crepitus*** present. WBC >14,000, BUN > 15, and the patient is hyponatremic. you obtain a gram stain + culture, and it comes back with strep and clostridium.

what will you rx?

a. 1st gen cephalosporin only

b. fluoroquinolone

c. PCN G

d. PCN G + clindamycin

d. PCN G + clindamycin

**this is NECROTIZING SOFT TISSUE INFX.

the crepitus makes us think CLOSTRIDIUM and the culture confirms it

**if it was only strep present, we could do just a 1st gen ceph

what imaging should we get if we suspect an intra-abdominal post-op infection?

what will we rx?

CT scan --> to look for abscess

ampicillin + clindamycin + gentamicin

minimum urine output for an adult patient on maintenance IV fluids

minimum urine output for an adult trauma patient

30 ml/hr

50 ml/hr

**URINARY OUTPUT IS THE BEST WAY TO ASSESS FLUID STATUS

best indication of traumatic injury to the urinary system?

hematuria

risk of spontaneous bleeding in surgery if platelet count is less than what?

10,000 to 20,000

why is glucose/dextrose CI with bolus fluids?

why do we give it with maintenance fluids?

because body will not use sugar in times of acute stress, so we will become hyperglycemic and --> osmotic diuresis

it is given with maintenance fluids, in the absence of shock, to stimulate basal insulin secretion & prevent muscle breakdown

which of the following functions as a grasper, dissector, coagulator and cutter, and does so via ultrasonic vibration?

**there is no thermal spread, limiting injury to tissue, and is better suited for bowel and OBGYN cases.

a. laser

b. ligasure

c. enseal

d. harmonic scalpel

d. harmonic scalpel

electrothermal bipolar devices

ligasure + enseal

** don't need pad

vicryl rapide is well-suited for _____________ procedures.

dental

a wound becomes chronic if it doesn't heal in how many months?

3

which med is used as an antiemetic and decreases gastric volume, and is commonly given to diabetes or patients with gastric hypomotility prior to surgery?

metoclopramide (reglan)

*gastric motility stimulant

most common of breast cancer

#1 = DCIS

#2 = LCIS

MCC of mastitis

staph aureus

s/s of breast malignancy

unilateral spontaneous discharge

firm, fixed mass

non-cyclic (aka constant) pain

peau d'orange

complex findings on imaging

what is the gold standard for diagnosis of breast cancer?

what is the imaging of choice for a breast implant rupture?

mammo

MRI

how often should a patient receive bilateral mammograms after a lumpectomy + radiation?

how often should a patient receive a contralateral mammogram after a modified radical mastectomy?

how often should all pts after breast cx treatment have a PE of the breasts?

6 months after, and then annually

annually

every 3-6 months x 3 years, then annually

TRAM flap can be used for breast reconstruction when the pt desires a more "natural" breast reconstruction. what does this involve?

transverse rectus abdominal flap from the CONTRALATERAL side

which nerves, found in the tracheoesophageal grooves behind the cricothyroid muscle, must we be careful of during a thyroidectomy because they control our vocal cords and airway control?

RECURRENT LARYNGEAL NERVES

unilateral --> hoarseness + weak/breathy voice + dysphagia

bilateral --> loss of speech + airway control + stridor (REQUIRES TRACHEOSTOMY)

superior laryngeal --> loss of voice quality (deep/quiet)

gold standard for dx a thyroid nodule? definitive way to characterize the nodule?

gold standard = US (<1cm = we don't rly do anything)

definitive = FNA

tx for papillary thyroid cancer

MC thyroid cancer

total thyroidectomy

papillary

type of thyroid cancer that is associated with Men 2A/2B, has early cervical mets, and is tx with a total thyroidectomy?

medullary

what does hyperparathyroidism most commonly occur secondary to?

a single hyperfunctioning adenoma

MC visual defect seen in pituitary adenoma

bitemporal hemianopsia

s/s of prolactinoma

women:

galactorrhea

oligomenorrhea

amenorrhea

infertility

men:

gynecomastia

dec libido

erectile dysfunction

infertility

medication treatment of choice for a prolactinoma?

if this doesn't work, what surgery will we do?

BROMOCRIPTINE (know)

transsphenoidal pituitary surgery

PHEPO for pheochromocytoma

palpitations

headache

excessive sweating

pallor

orthostasis

**rapidly rising HTN**

triggers --> SUCCINYLCHOLINE, tyramine foods, physical exertion, propranolol

tx for pheochromocytoma is surgical excision, but what must be do before surgery to prevent a hypertensive crisis?

1. alpha blockade --> phenoxybenzamine

2. beta blockade --> phentolamine

tx for testicular torsion

surgical de-torsion + bilateral orchidopexy WITHIN 6 HOURS

post-void residual volume that indicates need for surgical intervention for BPH

>100

gold standard for diagnosis of prostate cancer

biopsy

radical prostatectomy

removes the prostate gland, seminal vesicles, and part of the urethrah

pantaloon hernia

indirect + direct hernias at the same time

INDIRECT V. DIRECT INGUINAL HERNIAS

INDIRECT: **OVERALL MOST COMMON**

- inguinal hernia protrudes through the deep and superficial inguinal rings into the inguinal canal.

- this commonly occurs congenitally d/t a patent process vaginalis

DIRECT:

- inguinal hernia protrudes through Hesselbach's triangle into the inguinal canal.

**this commonly occurs due to weakness in the abdominal wall with age

males = SI --> follows spermatic cord (vas deferens)

females = ovary/fallopian tubes --> follows round ligament

when can we do a laparoscopic approach (TAPP or TEP) for hernia repair?

what are the types of open repairs?

if it is reducible

lichtenstein --> mesh sutured around sperm cord

proline hernia system --> overlay mesh & underlay portion that is inserted thru the internal ring

incomplete rim sign think of what type of hernia?

ventral/umbilical hernia

#1 most common surgery among women

C-section

#2 = hysterectomy

partial/subtotal/supracervical hysterectomy: removes just the upper part of the uterus, and the cervix is left in place.

total hysterectomy: removes the uterus + the cervix.

radical hysterectomy: removes the uterus + the cervix + the upper part of the vagina + lymph nodes

**often done with uterine cancer

hysterectomy + BSO: removes the uterus, ovaries, and fallopian tube

fibroids removed from the uterus to promote fertility or reduce bleeding =

myomectomy

what is the 1st thing we come into contact with once we enter the peritoneal cavity?

thick layer of omentum

charcot's sign

choledocholithiasis

1. RUQ pain

2. fever

3. jaundice

jaundice + a palpable, non-tender GB =

what does it indicate?

courvoisier's sign

periampullary tumor (pancreatic cancer)

referred pain to the LEFT shoulder when the pt is lying down with legs up significies a possible splenic hemoperitoneum.

what is this sign called?

kehr's

MC site of bleeding in gastric ulcer = left gastric + splenic vessels

MC site of bleeding in duodenal ulcer = gastroduodenal artery

billroth procedure is done for peptic ulcers > _______ cm.

3

**billroth 1 = more likely for a stricture to occur

MC cause of pneumoperitoneum

how to dx?

perforated ulcer

CT = standard of care

3 reasons for spleen surgery

hemorrhage 2/2 trauma

ITP

sickle cell disease

**splenorrhaphy = tx of choice

**splenectomy = if pt is hypotensive & has lots of abd injuries

MC bacterial causes of overwhelming post splenectomy sepsis

strep pneumo

h flu (HIB)

n meningitidis

need to vaccinate against these before splenectomy!!

pancreatic cancer

MC type = ductal adenocarcinoma

courvoisier's = 95% specific to pancreas HEAD carcinoma

CT = diagnostic

things removed in whipple procedure

tumor/head of pancreas

duodenum

GB

portion of common bile duct

gallstones have a SHADOW on US (polyps will not).

MC congenital abnormality of the SI, and the most common cause of GI bleeding in kids

meckel's diverticulum --> get an abdominal CT

2% of population

2" in length

2 yo

2 types of mucosa

tx if kid has s/s of bleeding = laparoscopic ileal resection