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General Surgery
| Question | Answer |
|---|---|
| Which types of medications should be stopped preoperatively? | 1) Anticoagulants 2) Antiplatelets 3) Diabetic medications 4) ACEIs and statins |
| When do we perform CBCs preoperatively? | As baseline If the estimated blood loss is >500mL In patients with chronic illness or anemia |
| When do we perform urine analysis preoperatively? | Urological symptoms present Instruments in UT Possible surgical placement of prosthesis |
| When do we check serum electrolytes preoperatively? | If the patient is >50 Chronic diarrhea Major procedures Renal, liver, cardiac disease HTN, DM Diuretic use, digoxin use, ACEI use |
| When do we perform coagulation studies preoperatively? | Anticoagulant use Family history of bleeding disorders History of abnormal bleeding Liver disease, malnutrition, and alcohol use |
| When do we test Beta-hCG preoperatively? | In any patient within the childbearing age |
| When do we test LFTs preoperatively? | Major procedure History of liver or biliary disease Albumin is a strong predictor for preoperative morbidity |
| When do cross-match blood preoperatively? | If estimated blood loss is >500 mL |
| When do we perform a chest x-ray preoperatively? | Acute cardiac or pulmonary symptoms Smokers |
| When do you perform ECGs preoperatively? | All patients >50 Patients with known heart disease Diabetic patients |
| What are the cardiovascular risks which increase morbidity in surgery? | Age >70 DM Unstable angina Recent MI (within 6 months) CHF Valvular heart disease Arrhythmias Peripheral vascular disease |
| Which drugs reduce peri-operative risk of cardiac events and MI? | Beta blockers |
| What are the pulmonary risks which increase morbidity in surgery? | COPD Smoking Advanced age Obesity Acute RTI |
| Which tests should be performed preoperatively in patients with a history of lung disease or smoking? | ABGs |
| What test should be done in a patient >30 years of age with breathlessness? | ECG |
| What are the renal risks which increase morbidity in surgery? | DM HTN CAD Hyperkalemia IV volume overload Infectious complications |
| What questions do you want to ask in the history of a patient with CKD? | Is it due to HT or DM? When was your first dialysis? How much fluid was removed? What is your preoperative weight? |
| How do you assess volume status in physical examination? | JVP and lung crackles |
| What investigations do we perform in patients with renal risk? | CBC, electrolytes, creatinine, BUN Urine analysis and culture |
| How do you manage patients with CKD? | Dialysis within 24 hours of surgery Intravascular volume status monitoring |
| What is the risk of AKI in patients without preexisting CKD for cardiac surgery and patients undergoing AAA repair? | 1.5-2.5% |
| What are the indications for dialysis? | Intavascular volume overload Hyperkalemia Severe metabolic acidosis Complications of uremia (encephalopathy, pericarditis) |
| What are the risk factors for AKI? | Increased BUN/ increased Creatinine CHD/introperative hypotension Advanced age Sepsis Administration of nephrotoxic substances |
| What post-operative events increase the chance of CVA? | A-fib Hypotensions |
| What are the types of wounds, according to the surgical procedure? | Clean Clean, contaminated Contaminated Dirty |
| What is the definition of a clean wound? | Non-traumatic No entry of GI, biliary, tracheobronchial, respiratory, or gut |
| What are some examples of clean wounds? | Wide, local excision of mass Hernia repair Thyroid surgeries |
| What is the definition of clean-contaminated wounds? | Respiratory, GU, GI entry with minimal contamination |
| What are some examples of clean-contaminated wounds? | Gastrectomy Hysterectomy Cholecystectomy |
| What is the definition of contaminated wounds? | Open, fresh traumatic wounds Uncontrolled spillage from poorly prepared hollow viscus Minor breaks in sterile techniques |
| What are some examples of contaminated wounds? | Ruptured Appendix Resection of unprepared bowel |
| What is the definition of dirty wounds? | Open, traumatic, dirty wounds Traumatic perforated viscus Pus in the operative field |
| What are some examples of dirty wounds? | Intestinal fistula resection Hartman’s for diverticular perforation |
| What are the risks of contamination in the different types of wounds? | Clean --> 2% Clean-contaminated --> <10 % Contaminated --> 20% Dirty --> 30-70% |
| What are the methods of prophylaxis of of preventing infections? | Strict sterile techniques Maintaining normal body temperature, blood glucose levels, and hyperoxygenation Pre-operative skin antisepsis by chlorhexidine-alcohol (better) or using Povidone-iodine scrub Antibiotic prophylaxis |
| What are the likely pathogens in cardiac operations? | Staphylococci Corynebacteria Enteric gram negative bacilli |
| What are the recommended antibiotics in cardiac surgery? | Vancomycin, cefazolin, and aztreonam |
| What are the likely pathogens in thoracic surgery? | Staphylococci |
| What are the recommended antibiotics in thoracic surgery? | Cefazolin Vancomycin |
| What are the likely pathogens in vascular surgery? | Staphylococci Streptococci Enteric grame negative bacilli Clostridia |
| What are the recommended antibiotics in vascular surgery? | Cefazolin Vancomycin and Aztreonam |
| What are the likely pathogens in orthopedics surgery? | Staphylococci |
| What are the recommended antibiotics in orthopedics surgery? | Cefazolin Vancomycin |
| What are the likely pathogens in Upper GI and hepato-biliary surgery? | Enteric gram negative bacilli Enterococci Clostridia |
| What are the recommended antibiotics in upper GI and hepatobiliary surgery? | Cefazolin Cefatetran Cefoxitin Clindamycin + Gentamycin (if allergic) Ciprofloxacin + metronidazole |
| What are the likely pathogens in appendectomy and colorectal surgery? | Gram-negative bacilli Enterococci Anaerobes |
| What are the recommended antibiotics in appendectomy and colorectal surgery? | Cefoxiting Cefotetan Ciprofloxacin and Metronidazole |
| What are the likely pathogens in OBGYN surgery? | Gram negative bacilli Anaerobes Group B steptococci Enterococci |
| What are the recommend antibiotics in OBGYN surgery? | Cefatetan Cefoxitin Cefazolin Clindamycin + Gentamycin |
| When undergoing and elective surgery, blood glucose levels should be controlled between | 100-250 |
| Patients on oral hypoglycemic agents should discontinue their medications | The night before the surgery |
| Patients on insulin undergoing major surgeries should receive: | ½ their insulin dose and 5% dextrose IV at 100-125 mL/hour |
| It is considered safe to perform surgery when INR is | <1.5 |
| If the INR is high before an emergency procedure, you should give: | you can either give factor VIII (immediately effective) or vitamin K (effective within 8 hours) |
| Most common indications for warfarin treatment: | Atrial fibrillation Venous thromboembolism Mechanical heart valve |
| How do you activate the pulmonary toiler postoperatively? | Early mobilization Incentive spirometry Cough Deep breathing exercises |
| What are the consequences of inadequate pulmonary toilet? | Fever, hypoxemia, pneumonia, and atelactasis |
| What medications are generally given to a patient post-op? | Antiemetics Ulcer prophylaxis (sucralfate) Morphine Antibiotics |
| What lab investigations are performed in a post operative patient? | CBC and coagulation (in significant blood loss) KFT (in insufficiency, large IV fluid volumes, TPN, tranfusion, NPO) Daily EGH and 3 troponin 3 levels (in cardiac risk factor patients) Chest X-ray (if thoracic cavity involved/cardiopulmonary risk) |
| What are the intraoperative causes of fever? | Malignant hyperthermia Transfusion reaction Pre-existing infection |
| What are the postoperative causes of fever? | Wind/Atelactasis (first 2 days) Water/UTI (3rd day) Wound (5th day) Walking/DVT (7-10 days) Wonder drug |
| Which bacteria can cause fever in the first 2 days after an operation? | Beta hemolytic strep or clostridium |
| Clostridium infections appear as | Painful bronze/brown weeping wounds |
| What is the treatment of malignant hyperthermia? | Dantrolene (antidote) 100% oxygen Correct acidosis and cooling blankets Water for developing myoglobinurea |
| What is the clinical presentation of post-op MI? | Often without chest pain New onset congestive heart failure New onset cardiac arrhythmias Abnormal vital signs: hypotension, tachypnea, tachycardia, or bradycardia |
| Treatment of post-op MI: | MONAH-B Morphine Oxygen Nitrates Aspirin Heparin Beta blockers |
| What are the risk factors for atelactasis post-op? | COPD/smoking Abdominal/thoracic surgery Poor pain control: patient cannot breathe in deeply secondary to pain on inspiration Oversedation |
| What are the signs of atelactasis? | Fever, tachypnea, and tachycardia Decreased breath sounds with crackles Increased density on chest X-ray |
| What is the treatment for post-op atelactasis? | Postoperative incentive spirometry Deep breathing exercises Coughing Early ambulation Chest and physiotherapy along with NT suction |
| What are the risk factors for aspiration pneumonia? | Intubation/extubation Chest pain Increased Impaired level of consciousness (drugs/ethanol overdose) NG tube Tendelburg position Emergent intubation on full stomach Gastric dilation |
| What are the common sites of aspiration pneumonia? | Supine: right upper lobe Sitting/semi-recumbent: right lower lobe |
| What are the common causes of urine retention post-op? | Enlarged urinary bladder resulting from medications or spinal anesthesia |
| What is the treatment of post-op urine retention? | Urinary catheter (Foleys) |
| How do you drain a massive urinary bladder? | Don’t drain all urine immediately to avoid a vasovagal reaction. Clamp after draining 1 liter of urine, then drain the rest slowly |
| The classic symptom of urinary retention in elderly is | Confusion |
| What are the differential diagnoses in postoperative renal failure? | Prerenal: inadequate perfusion Renal: kidney parynchemal dysfunction Postrenal: obstruction to outflow of urine |
| How do you interpret the work up to differentiate between Pre-renal and renal failure? | BUN: Cr >20:1 pre-renal <20:1 renal Specific gravity: >1.02 Pre-renal <1.02 renal Urine Na: <20 pre renal >40 renal Urine osmolality >500 pre renal <350 renal FENa <1% pre-renal >1% renal |
| What are the indications for dialysis? | Fluid overload Refractory hypotension Severe metabolic acidosis BUN >130 Uremic complications |
| What are the post-op neurological complications? | Delirium tremans Postop CVA |
| How do you treat delirium tremans? | IV benzodiazepenes |
| How do you treat post-op CVA? | Aspirin and Heparin |
| What are the possible complications of NG tube insertion? | Aspiration pneumonia Atelactasis if the tube is clogged Sinusitis Minor upper GI bleeding |
| What are the postop causes of paralytic ileus? | Lapotomy Hypokalemia Narcotics Intraperitoneal infection |
| What is short bowel syndrome? | malabsorption and diarrhea resulting from extensive bowel resection (<120 cm of small intestines remaining) |
| How is short bowel syndrome treated? | With TPN followed by many small meals chronically |
| What is Blind loop syndrome? | Bacterial overgrowth in the small intestines |
| What are the causes of post-op B12 deficiency? | Gastrectomy (decreased secretion of intrinsic factor) Excision of terminal ileum (site of B12 absorption) |
| What is Dumping syndrome? | Delivery of hyperosmotic chyme to the small intestine causing massive fluid shifts into the bowel |
| What are the signs and symptoms of Dumping syndrome? | Post prandial diaphoresis Tachycardia Emesis Dizziness, weakness Increased flatus Abdominal pain and distention |
| What are the causes of prehepatic jaundice? | Hemolysis Resolving hematoma Transfusion reaction Post-cardiopulmonary bypass |
| What are the causes of hepatic jaundice? | Drugs Hypotension/hypoxia Sepsis Pre-existing cirrhosis Right sided heart failure Gilbert/ Criglar-Najjar syndrome |
| What are the causes of posthepatic jaundice? | Choledocholithiasis Stricture Cholangitis |
| What are the post-op infectious complications? | Catheter related infection Prosthetic device related Facial muscle infection Intra-abdominal abscess/peritonitis Respiratory/GI/GU infection Wound infection Patients requiring mechanical ventilation for longer than 48 hours |
| When are potassium supplements contraindicated? | ECG changes or when potassium >6 |
| What are the potassium supplement doses recommended at different potassium levels? | <3: 30-40 mg/hour 3-4: 20-30 mg/hour >4 10-20 mg/hour 5 |
| When do you give bicarbonate to a DKA patient? | If the pH is <7.1 |
Created by:
Ulaisl
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