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General Surgery

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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