Surgery EOR

What is the most common cause of early fever?

Atelectasis

What are the 5 W’s?

• Wind (atelectasis)

• Water (UTI)

• Walking (DVT)

• Wound (surgical site infection)

• Wonder drugs

What is used for infection risk for GI pre-op?

IV cefazolin and metronidazole 30-60 minutes before the first incision

What is an anastomotic leak?

• Most common post-op days 3-7

• Fever and tachycardia on POD 3-5 after bowel surgery → anastomotic leak until proven otherwise

• Diagnosis: CT with contrast

• Treatment

  • Unstable: emergent return to OR

  • Stable: NPO and broad spectrum IV antibiotics and drainage

What are the types of wound dehiscence and their treatments?

• Superficial (skin separation) → wound care daily with daily dressing changes

• Fascial dehiscence (separation of fascia) → emergent OR

• Evisceration (bowel protruding) → cover with moist gauze and emergent OR

What is gastric cancer?

• Most common histology: adenocarcinoma

• Diagnosis: EGD with biopsy

• Treatment: partial/total gastrectomy with lymph node dissection

What is the treatment for a Mallory Weiss tear?

PPI

What are the treatments for the different types of volvulus?

• Sigmoid (left side and more common) → try endoscopic decompression first than surgery

• Cecal (right sided) → surgery

What is the work up for a lower GI bleed?

• Stabilize first

• Colonoscopic therapy (clips, cautery, epinephrine) is first line after stabilization/bowel prep

• CTA for active bleed

• Tagged RBC scan if intermittent bleeding

What is ischemic colitis?

• One of the first areas injured when circulation drops → splenic flexure (sits at the edge of two major blood supplies and gets least reliable blood flow)

• S/S: crampy abdominal pain and bloody stools

• Diagnosis: CT or colonoscopy

• Treatment

  • Supportive: IV fluids, bowel rest, antibiotics

  • Surgery if gangrene/perforation

What are the types of hiatal hernia?

• Sliding → GE junction and fundus of stomach protrude through diaphragm

  • Presents like GERD

  • Treat medically like GERD (PPIs)

• Paraesophageal → GE junction remains but fundus of the stomach protrudes through diaphragm

  • Presents with post prandial fullness and chest pain

  • Higher risk for strangulation → surgical repair

• Diagnosis

  • Barium swallow is best initial study

  • EGD to assess mucosa

What should be administered in symptomatic hyperkalemia?

Calcium → helps to stabilize the cardiac membrane

What is Crohn’s disease?

Diagnosis

• Colonoscopy with abscess: skip lesions and granulomas

• Labs: elevated CRP and ESR, ANCA (+)

Treatment

• Immunomodulators

• Biologics

• Steroids for flares

• Supplements: vitamin B12 and vitamin D

What is UC?

• Diagnosis

  • Colonoscopy with biopsy: continuous inflammation, crypt abscesses (avoid in full flare due to perforation risk)

  • Labs: elevated CRP and ESR, pANCA (+)

• Treatment

  • 5-ASA

  • Mesalamine

  • Immunomodulators

  • Biologics

  • Steroids for flares

• Get colonoscopy every year 8-10 years after diagnosis

What is the most common histology of colon cancer?

Adenocarcinoma

What is a sentinel pile?

Skin tag associated with chronic anal fissure

What is a risk factor for post-op ileus?

Hypokalemia

What is the treatment for hemorrhoids?

• Fiber

• Sitz baths

• Steroids

• If internal → rubber band ligation or sclerotherapy

• If grade III-IV → hemorrhoidectomy

• If thrombosed: excise within 72 hours, if outside of this time period then wait for resolution on its own

What is the treatment for anal fissures?

• Fiber and stool softeners with sitz baths: should heal in 6 weeks

• Topical nitroglycerin and/or CCB to improve sphincter spasm and blood flow

• Refractory: lateral sphincterotomy

What is hepatocellular carcinoma?

• Risk factors

  • Cirrhosis (most common)

  • Viral hepatitis

  • Aspergillus

• Diagnosis

  • Multi-phasic helical CT and MRI with contrast

  • AFP

• Treatment

  • Confined to lobe and not associated with cirrhosis → removal

  • Advanced → atezolizumab and bevacizumab

• U/S every 6 months in high risk patients

Gallbladder blood flow

Calot’s Triangle (modern) → contains cystic artery

• Common hepatic duct

• Cystic duct

• Inferior surface of liver

Critical view of safety

• Clear Calot’s triangle

• Separate the lower 1/3 of the gallbladder from the liver

• Confirm there are only 2 structures entering the gallbladder (cystic duct and cystic artery)

What is toxic megacolon?

• Colon dilation > 6 cm

• Treatment

  • NPO

  • NG tube

  • IV fluids

  • Broad spectrum antibiotics

  • IV steroids if IBD related

  • Surgery if no response

What is parenteral nutrition?

• Complete nutrition delivered via central line (has high osmolarity)

• Indications → stomach or bowel not working

  • Bowel obstruction

  • Severe pancreatitis

  • Prolonged ileus

  • Short bowel syndrome

  • Severe malabsorption

• Can be short or long term

What is a PEG tube?

• Used for long-term feeding

  • Stroke, neurological disease, head/neck cancer

  • Stomach and bowels have to be working

• Contraindications

  • Severe ascites

  • Gastric outlet obstruction

  • Peritonitis

  • Hemodynamic instability

What is the number 1 cause of peri-operative cardiac morbidity?

CAD

What are the cardiac surgery risk classifications?

Low risk

• Breast

• Hernia

• Endocrine

Intermediate risk

• Bowel

• Orthopedic

• Intra-thoracic

High risk

• AAA repair

• Major vascular surgery

What is the cardiac risk index?

1 point each

• Ischemic heart disease

• CHF

• Stroke/TIA history

• Diabetes on insulin

• CKD

Meaning

• >=3 means very high risk

What is functional capacity for cardiac surgery (METS)?

< 4 METS → poor functional capacity

• Cannot walk 2 blocks without stopping

• Cannot climb1 flight of stairs

• Cannot perform light housework

4-10 METS → good functional capacity

• Climbs a flight of stairs or walks briskly

• Heavy housework and gardening

More than 10 METS → excellent capacity

• Vigorous sport

Who requires cardiac imaging pre-operatively?

EKG

• > 40 y/o

• Known cardiac disease

• Intermediate or high risk for surgery

Echo

• New CHF

• Known valvular disease

How should medications be handled for cardiac surgery?

• Continue BB

• Continue statins

• Hold ACEI/ARBS on day of surgery

• Stop anticoagulants

• Continue aspirin only in patients with recent stents/vascular surgery

What is the most common post-operative dysrhythmia?

Atrial fibrillation

• Cardioversion if hemodynamically unstable

• Treat with metoprolol or diltiazem if hemodynamically stable

• If > 48 hours → anticoagulation with heparin drip or apixaban

What is cardiogenic shock post-operatively?

• Severe pump failure due to MI or arrhythmia

• Diagnosis: echo showing low EF and elevated lactate

• Treatment

  • NE drip

  • Dobutamine for low output

  • PCI

What are IV drip medications for post-operative HTN?

• Nicardipine

• Labetolol

• Nitroprusside

How should AAA be treated and monitored?

• Elective repair for AAA >= 5.5 cm in men or 5 in women

• Surveillance schedule

  • 3.0-3.9 cm: every 3 years

  • 4.0-4.9 cm: every 1 year

  • 5.0-5.4 cm: every 6 months

What is aortic dissection?

• Intimal tear

• Diagnosis → CTA with contrast

• Treatment

  • Type A: emergent surgical repair

  • Type B: if uncomplicated, medical

  • Aggressive BP and HR control → IV labetolol or esmolol to HR < 60 and then add nicardipine

What is atherosclerotic RAS?

Presentation

• Refractory or accelerated HTN

• Worsening renal function after starting ACEI/ARB

Diagnosis

• Gold standard: renal arteriography

• Renal duplex U/S

What murmurs increase with squatting?

• Aortic stenosis

• Mitral regurgitation

• Aortic regurgitation

• Mitral stenosis

What is aortic regurgitation murmur?

• Decrescendo diastolic blowing murmur heard best at left lower sternal border,may have an S3 gallop and have wide pulse pressure

• Treatment: afterload reduction (ACEI/nifedipine)

What is mitral stenosis murmur?

• Decrescendo diastolic blowing murmur with an opening snap best heard at the apex and left upper sternal border

• Treatment: balloon valvotomy or valve replacement

What murmurs increase with inspiration?

Right sided

What is the approach to AV fistula placement?

• Indications

  • ESRD needing chronic hemodialysis

• Preferred sequence

  • Radiocephalic

  • Brachiocephalic

  • Brachial-basilic

• Must palpate a thrill at the end of surgery

• Late complication

  • Steal syndrome: ischemic hand pain, pallor, and cold

What is the approach for central line placement?

• Sites

  • IJ: safest (with U/S)

  • Subclavian: lowest infection risk but highest risk for pneumothorax

  • Femoral: highest infection risk

• Indications

  • Need for vasopressors

  • Rapid volume resuscitation

  • CVP monitoring

  • TPN administration

  • Long term IV medications/antibiotics

What is a chylothorax?

• Leakage of chyle into pleural space due to thoracic duct injury

• MCC: post-operative, trauma, non-Hodgkins lymphoma

• Diagnosis: pleural fluid triglycerides > 110 mg/dL and confirmed with chylomicrons present on lipoprotein analysis

• Treatment

  • NPO and TPN or very low fat or medium chain triglycerides diet to reduce chyle flow

  • Chest tube drainage

  • Octreotide to reduce lymphatic flow

  • Indications for surgery: output > 1 liter per day for 5 days, persistent leak > 2 weeks, clinical deterioration

What is the treatment for hemothorax?

• Large bore chest tube for drainage (tube thoracostomy)

• Surgical indications

  • Immediate drainage of > 1500 mL on chest tube insertion

  • Ongoing bleeding > 200-300 mL/hr for 3 hours

How is small cell lung cancer treated?

• Chemotherapy and radiation

• No surgery

What are the anterior mediastinal disorders?

The T’s

• Thymoma (may have myasthenia gravis) → surgical excision

• Teratoma/germ cell tumor (cystic mass) → surgical excision

• Thyroid → surgical excision if compressive

• Lymphoma (terrible) → chemotherapy ± radiation, surgery only for biopsy or decompression

What are the middle mediastinum disorders?

• Bronchogenic cyst (congenital) → surgical excision if symptomatic or enlarging

• Pericardial cyst → observation if small

• Lymphadenopathy → biopsy for diagnosis and manage underlying malignancy

• Vascular aneurysms → surgical repair if large or at risk if rupture

What are the posterior mediastinum disorders?

• Neurogenic tumors (may cause radicular pain) → surgical excision if symptomatic or enlarging

• Esophageal tumors → esophagectomy or large resection

• Enteric cysts → surgical excision

What is the most important risk factor for pleural effusion?

Heart failure

What is the Light’s Criteria

Transudate (CHF, ascites)

• Pleural:serum protein <= 0.5

• Pleural:serum LDH <= 0.6

• Pleural fluid LDH: <= 2/3 upper limit of normal serum LDH

Exudate (malignancy, pneumonia, TB, PE, pancreatitis)

• Pleural:serum protein > 0.5

• Pleural:serum LDH > 0.6

• Pleural fluid LDH: > 2/3 upper limit of normal serum LDH

• From pancreatitis: elevated amylase levels

What are indicators of unresectability of gastric cancer?

• Disease encasement of hepatic artery

• Distant metastases

• Invasion of major vascular structure

• Occlusion of proximal splenic artery

What GI structure is associated with the highest mortality if it perforates?

Esophagus

What should be used in the acute treatment of hypercalcemia?

IV fluids

What is the treatment for subcutaneous pacemaker pocket infection?

• IV antibiotics

• Specialist consultation

• Admission

What does the ascitic fluid look like with bacterial peritonitis?

• PMNs >= 250/uL

• If from dialysis: peritoneal fluid >= 100 WBCs/uL with 50% PMNs

What is incident to billing?

A way for a clinical to bill at the physician’s full compensation rate when a PA or NP is seeing the patient

• Patient must be an established patient

• Physician must be present in the office suite while the PA or NP sees the patient

• The physician must actively participate in the course of the patient’s treatment (must have originally diagnosed the patient and determined the treatment course: the PA or NP then sees the patient to continue the original treatment plan

• Must take place in a non-institutional setting

What is post-operative urinary retention?

• Inability to void after anesthesia despite having a full bladder

• Risk factors: male, advanced age, concurrent neurologic disease

• Associated with higher risk: anorectal surgery, joint arthroplasty, hernia repair

• S/S: lower abdominal or suprapubic pain and discomfort

• Diagnosis: bladder U/S (> 300 mL)

• Treatment: urethral catheterization

What are surgical indications for PUD?

• Bleeding ulcer refractory to repeated endoscopic intervention or causes the patient to become unstable (especially for ulcers > 2 cm)

• Perforated ulcer that has caused significant pneumoperitoneum

• Extra-luminal contrast extravasation or signs of peritonitis

• Gastric outlet obstruction

What medication has a boxed warning for use after CABG?

Meloxicam

• Increases risk for MI and stroke

What is Brown Sequard Syndrome?

• Hemi-transection of the spinal cord with unilateral damage to the corticospinal and spinothalamic tracts (usually from penetrating injuries)

• Ipsilateral loss of motor strength, vibratory sensation, and proprioception with contralateral loss of pain and temperature sensation below the level of the injury

What is the most common complication of thoracostomy tube placement?

Chest tube malposition

When should radioiodine therapy be used for thyroid cancer?

• After resection in treating differentiated thyroid cancer in high risk and certain intermediate risk patients

• Used in patients who do not have risk for subsequent thyroid cancer, leukemia, or other malignancies

What should be used for post-operative nausea and vomiting?

• Transdermal scopolamine

What is the most reliable indicator for assessing adequacy of fluid resuscitation?

Urine output

What is the Parkland formula?

4 mL x % of TBSA affected by 2nd and 3rd degree burns x weight in kg

What are ways to reverse anticoagulation?

• Warfarin → vitamin K and/or 4 factor PCC (K-centra) (can also use FFP)

• Unfractionated heparin: protamine

• Low molecular weight heparin: protamine

• Synthetic pentasaccharide factor Xa inhibitors: no specific reversal agents, need hemostatic measures (activated PCC and recombinant activated factor VII)

• Direct thrombin inhibitors: idarcizumab

• Direct factor Xa inhibitors: hemostatic measures (4 factor PCC or aPCC)

What is the second most common cause of a CNS mass in patients with AIDS?

Primary cerebral lymphoma

• Strongly associated with EBV

• HA, altered mental status, focal neurological deficits

• Solitary, weak ring enhancing lesion in peri-ventricular white matter

How to differentiate between near miss and no harm event?

• Near miss: a patient safety event that does not reach the patient

• No harm event: a patient safety event that reaches the patient but does not cause harm

What anticoagulation is preferred for pregnancy?

• Heparins: do not cross the placenta and do not result in fetal anticoagulation

• LMWH frequently preferred over UFH for all but the final weeks of pregnancy → LMWH produces a more predictable anticoagulant response and does not require routine monitoring

What test is most appropriate to diagnose lactose intolerance?

Lactose hydrogen breath test

• Will show a rise in breath hydrogen > 20 ppm within 90 minutes of ingesting 50 grams of lactose

What are contraindications of succinylcholine?

• Recent spinal cord injury (1 week to 3 months) → have risk of severe hyperkalemia (after spinal cord injury, up-regulation of ACh receptors outside of the neuromuscular junction, and these extra receptors can cause excessive release of K+ from muscle cells into the blood stream)

Succinylcholine is a depolarizing agent that exerts itself by binding non-competitively with ACh receptors on the motor endplate of myocytes and causing sustained depolarization

How should bridging when a patient is on warfarin be done?

Determine risk with CHA2DS2-VASc

• If score of 0-1 and duration of interruption < 1 week → bridging not needed

• If interruption > 1 week or patient has high short term risk (score >= 2), history of stroke, or mechanical or rheumatic mitral valve → bridge with either IV UFH or LMWH

What is used to diagnose GB syndrome?

• Lumbar puncture: elevated protein and mild pleocytosis

Where is needle decompression done for tension pneumothorax?

• 2nd ICS at midclavicular line

How to approach pulmonary nodules?

• > 3 cm: treated as cancer until proven otherwise

• CT is gold standard

  • Use PET scan for nodules > 8 mm

• Signs of benign nodule: central or popcorn calcification, smooth borders, stability for >= 2 years

• Suspicious features: spiculated borders, size > 8 mm, eccentric calcification, growth

• Treatment

  • < 6 mm: no follow up or optional CT

  • 6-8 mm: CT at 6-12 months

  • > 8 mm or high risk features: PET-CT, biopsy, surgical excision

What is the triangle of safety for chest tube placement?

• Lateral border of pectoralis major

• Anterior border of latissimus dorsi

• Mid-axillary line at 5th ICS above the rib

What is the most common complication after breast surgery?

Seroma

• Risk increases with large tissue removal or no drain placement

• Occurs days-weeks after

• Have non-tender swelling

• Management: aspiration, compression garment

What is mammary duct ectasia?

• Inflammatory duct dilation with periductal fibrosis

• Have unilateral green, yellow, or bloody discharge with nipple inversion, may feel subareolar mass or fullness

• U/S: dilated ducts and periductal calcifications

• Treatment: conservative, smoking cessation

Where is metastasis often with breast cancer?

The spine

How does treatment differ based on receptor status for breast cancer?

• ER/PR (+): hormonal therapy (tamoxifen)

• HER2 (+): use trastuzumab (Herceptin) (major and well known adverse effect is cardiotoxicity, which can manifest as an asymptomatic decline in LVEF, need baseline echocardiogram)

• Triple (-): aggressive, treated with chemotherapy only

What is the most common complication of the augmented breast?

Capsular contracture

• Fibrous scar capsule tightens around the implants

• More common with sub-glandular placement

How is the ingestion of cleaning products treated?

• ABCDE approach

  • Consider early intubation of signs of airway compromise

  • Avoid GI decontamination or inducing emesis

• Evaluate for GI mucosal injury, esophageal perforation, and gastric perforation

  • Obtain chest CT and abdomen with IV contrast to asses for indications for urgent surgery

  • Arrange for EGD within 12-24 hours

What is the pathophysiology behind parapneumonic pleural effusion?

• Is an exudative pleural effusion

• Inflammation of lung parenchyma adjacent to the pleura

  • Underlying pneumonia triggers release of inflammatory cytokines → increases permeability of capillaries in visceral pleura → allows protein rich fluid, neutrophils, and other inflammatory cells to leak from the microvasculature into the pleural space

What is the pathophysiology of transudative pleural effusion?

• Imbalances in hydrostatic or orthostatic pressures

  • Cirrhosis/nephrotic syndrome: decreased plasma oncotic pressure (due to hypoalbuminemia)

  • CHF: increased hydrostatic pressure

What is glucagonoma?

• Rare endocrine tumor of pancreatic alpha cells → secrete excessive amounts of glucagon

  • Stimulates hepatic glycogenolysis and gluconeogenesis

• Classic triad

  • Necrolytic migratory erythema

  • Weight loss

  • New onset DM

What is immediate for deep neck infections, like retropharyngeal abscess?

• Attempt intubation in a controlled setting, like the OR

How should the dose of long-acting opioids be increased?

• Calculate total daily dose of opioids and use this to determine the new long-acting dose

What is atrophic gastritis?

• Classically begins in the gastric antrum and progresses proximally

• Manifestations: iron deficiency anemia

• Endoscopic findings: pale mucosa, prominent vessels, flattened rugae

• Biopsies of antrum highest yield for confirming atrophy and detecting intestinal metaplasia

What is a risk factor for calcium oxalate stones?

• High doses of vitamin C: metabolized to oxalate → hyperoxaluria

• Terminal ileum resection: in fat malabsorption, unabsorbed fatty acids bind to intestinal calcium (saponification), leaving oxalate unbound and soluble, leading to increased reabsorption in the colon, causing increased urinary oxalate excretion and supersaturation of calcium oxalate in the urine

• Hypocitraturia (citrate normally binds to urinary calcium, preventing it from precipitating with oxalate): more commonly associated with metabolic acidosis

What is the standard of care for a patient who has most likely experienced thermal and chemical injury to the upper airway?

• Prophylactic airway protection with endotracheal intubation

  • Fiberoptic bronchoscopy is gold standard for evaluating the extent of airway damage, but it should be done after the necessary initial management steps have been done

What should be done if a patient has a DNR order and requires a surgical procedure?

Complete a procedure specific DNR order

What is the treatment for asymptomatic sliding hiatal hernia?

Reassurance and observation

What are empiric antibiotics for non-purulent and purulent soft tissue infections?

Mild

• Non-purulent:

  • Penicillin V

  • Cephalexin

  • Dicloxicillin

  • Clindamycin

• Purulent:

  • Consider topical (mupirocin)

Moderate

• Non-purulent:

  • Penicillin G

  • Ceftriaxone

  • Cefazolin

  • Clindamycin

• Purulent:

  • Bactrim

  • Doxycycline

Severe

• Non-purulent:

  • Vancomycin + pip-tazo or meropenem

• Purulent:

  • Vancomycin

  • Daptomycin

  • Linezolid

  • Ceftaroline

  • Telavancin

How should breast cysts be managed?

• Asymptomatic: short term imaging follow up

• Symptomatic: FNA

How should patients with asthma undergoing a procedure with endotracheal intubation be managed pre-operatively?

• Endotracheal intubation is a major risk factor for bronchospasm: administer short acting beta agonist 15-30 minutes before intubation for prophylaxis

How to manage other respiratory issues preoperatively?

• Acute respiratory infection

  • Increases risk for perioperative pulmonary and airway complications

  • Consider delaying surgery to treat the infection

• COPD

  • Stable pulmonary disease and adequate oxygenation: further testing typically not needed

  • Unstable pulmonary disease, impaired oxygenation or ventilation: consider delaying surgery to allow for further assessment and treatment

• Advanced COPD

  • Routine PFTs performed

  • Cardiopulmonary exercise testing may be considered if PFT is equivocal

What is the gold standard for evaluating hemodynamically stable patients with suspected renal trauma?

CT with IV contrast

• FAST has poor sensitivity for directly visualizing or grading solid organ injuries (especially those in the retroperitoneum)

How to manage opioid withdrawal?

• Buprenorphine (partial u opioid agonist) → first line (alleviates withdrawal symptoms and cravings)

• Naltrexone (opioid antagonist): should be initiated after a patient has completed detoxification and has been opioid free for 7-10 days

GCS Scale

What can be injured with a posteriorly displaced supracondylar humerus fracture?

• Brachial artery

• Median nerve