Complete Surgery Objectives

Describe the depths of a burn

*1st degree* -Epidermis only (think sunburn) -Not counted in TBSA *Superficial 2nd Degree* -Burn through epidermis and papillary dermis -(MOST PAINFUL BURN) -Red/wet appearing/ blistering -Can regenerate in 7-14 days thanks to hair follicles and sweat glands (below this line you need to have grafts) ___________________________________ *Deep 2nd Degree* -Burns into reticular dermis -Less sensation more pale and dry in appearance. *3rd Degree* -Full thickness (dermis+epidermis) -Painless -Hard with leathery eschar *4th Degree* -Burn into muscle and bone

General pre op lab guidlines for a pt over 50, 65 and with cancer

*50*-CBC, BMP, Mg, PO4 *65*- add a CXR and an EKG (looking for an undiagnosed heart condition) (book says get pre-op EKG for men at 40 and women at 50) *Cancer* (any age) CXR- you are looking for masses that might interfere with ventilation or anesthesia.

Compare and contrast the different *types of hernias*, including treatment strategies, patient risk factors, discuss complications and patient education Note: You will not be responsible for the individual surgeries as listed in your text.

*A hernia is an abnormal weakness or hole in an anatomical structure which allows something inside to protrude through.* -It is commonly used to describe a weakness in the abdominal wall. Important Terminology: *Reducible*: Hernia able to be manually reduced back into the peritoneum *Incarcerated*: Hernia unable to be manually pushed back in ----> Surgical emergency because it can evolve into..... *Strangulated*: Blood flow to hernia has been cut off *Big time surgical emergency* the organ is not being perfused---> ischemia! INGUINAL Inguinal hernia: Makes up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women. Two types of inguinal hernias: *Indirect inguinal hernia* -follows pathway that testicles made during prebirth development. -This pathway normally closes before birth but remains a possible place for a hernia. - Hernial sac may protrude into scrotum. Follows the spermatic cord pathway, goes through deep and superficial iguanas rings. --) more often younger pt *Direct inguinal hernia* - This occurs slightly to the inside of the indirect hernia, in a place where the abdominal wall is naturally slightly thinner. - It rarely will protrude into the scrotum. (Often bilateral ) - The direct hernia almost always occurs in the middle-aged and elderly because their abdominal walls weaken as they age. *RISK FACTORS:* Male, Caucasian, chronic cough, chronic constipation, smoking, pregnancy, weak abdominal wall If you want more hernias surgery book page 215!

5. Understand the role of initial burn assessment, acute burn management

*A*irway -assess their airway, look for signs of soot, inhalation, edema, etc. -Suspect injury if there are facial burns, wheezing, black sputum, tachypnea, or singed nasal hairs -Give Pt 02 and Pulsox *B*reathing -Look for breath sounds and chest rise -Perform an escharotomy if needed -Dont be afraid to intubate *C*irculation -Check vitals -Establish 2 LARGE bore IV sites preferably in unburned skin -Start LR -Place Pt on EKG -Monitor extremities for compartment syndrome *D*isability -Assess patient -GCS < 8 INTUBATE!!! *E*xposure -Remove all clothing to assess extent of burn

Understand the ABCDE's of primary trauma assessment and their application.

*A*irway *B*reathing *C*irculation *D*isability *E*xposure Repeat frequently to assess for deterioration or need for additional intervention

1. Illustrate the anatomy and physiology of the breast.

*ANATOMY:* - Alveoli secretory units -> lobules -> Lobe -> collecting (lactiferous) duct -> collecting (lactiferous) sinus - Lobules and ducts give rise to most breast CA - Upper outer quadrant with most glandular tissue - Clavicle to 6th rib, sternum to mid axillary line - Under the superficial fascia of the anterior thoracic wall but rests on top of deep posterior fascia covering muscles (Pecs) - *Cooper's ligament* are fibrous bands that connect the 2 fascia which provide "suspensory function" to the breast. Aka bouncy bouncy. - Also sensory nerves, sebaceous and apocrine sweat glands *LYMPH (large amount):* superficial lymphatics -> deep subcutaneous -> axilla (small amount to internal mammary chain) *Axilla = primary site of lymphatic drainage, 1st spread of breast CA* 3 Levels. 1. Level 1- in axillary fat pad, lateral to pec major 2. Level 2- beneath the pec major 3. Level 3- superomedial to pec minor *PHYSIOLOGY:* - Modified apocrine sweat gland - Tanner phases 1-5 - Monthly, estrogen builds up proliferation of the ductal system, then after ovulation low progesterone and estrogen stops it. That's why in pregnancy it just keeps growing... - Menopause then could cause breast atrophy... sad face.

4. Understand the wound complications of dehiscence and evisceration, possible contributing causes, and the management of each.

*Abdominal Dehiscence*: *Separation of facial layers in the early post-op course* due to inproper suturing (to far apart, to much tension, etc) combined with an intra abdominal infection, malnutrition, corticosteroids, or any increased abdominal pressure (ascities, coughing) Sign- salmon colored fluid draining from abdomen that isn't healing post op. Requires emergency Surgery to correct or it progresses into *Evisceration*. If evisceration occurs, Keep it moist with a sterile object (he said cut open an IV bag) and keep clean till surgery

Airway

*Airway* First: ask the patient to speak - Normal: protecting airway - Unresponsive: not protecting airway Assess for airway compromise - Hoarse/grating voice - Shortness of breath/agitation Determine the need for a definitive airway *Definitive Airway* - Tube placed in the trachea with a cuff inflated below the vocal cords - Connected to a mechanical ventilator - Secured in place with tape *Predicting a difficult airway (LEMON)* *L*ook for face trauma *E*valuate: distance between incisors, chin-hyoid, hyoid-thyroid *M*alampati classification I-IV *O*bstruction caused by swelling, foreign body *N*eck mobility - more is better but protect the cervical spine *Airway Confirmation* - Chest rise - Auscultation - Tube condensation - Pulse oximetry - X-ray - *CO2 detector* / *End-tidal CO2 on monitor*

3. Discuss the principles of perioperative antibiotic use and be able to apply these to patient scenarios.

*Antibiotic Prophylaxis*: eradicate/retard growth of endogenous organisms. Must be given w/i 1hr window prior to incision time. (Most clean procedures do not require it, but long surgeries, CABG, prosthesis, laminectomies do) Redose every t1/2 for major surgeries >4hr or major blood loss. D/C w/i 24hr (or 48hr for CT surgery) Most clean procedures: Cefazolin 1g IV (2g persons >80kg) Thoracic or orthopedic: Cefuroxime 1.5g IV Bowel: Cefazolin/metronidazole OR cefotetan Appendectomy, Biliary tract: Timentin 3.1g IV Penicillin allergy: Clindamycin 800mg OR Levofloxacin 750mg Vancomycin: prevent MRSA when high prevalence, prosthetic valves and vascular grafts, hx broad spec abx therapy, pre-op stay longer than 1wk. Colorectal: pre-op IV abx -Bowel prep: oral neomycin + erythromycin/metronidazole -Mechanical prep: golytely, Mg+ citrate, phospho-soda

Outline the mechanisms of blunt and penetrating injury and define interventions for patients with these types of abdominal injuries.

*Blunt Trauma* - Multiple organs - Avulsion injuries - Assess for crush injury Penetrating Trauma - Linear distribution - Laceration injuries - Assess velocity

2. Given a patient scenario, create a differential diagnosis, treatment and educational plans for a patient presenting with breast pain, nipple discharge, fibrocystic breast tissue, fibroadenoma, breast abscess and mastitis.

*Breast Pain - mastalgia* i. Cause: Very common, Mostly due to fibrocystic changes, cysts, infection ii. Work-up: Look for associations with menstruation, masses, skin change, trauma iii. Treatment: minimize caffeine, diet change, NSAIDs, vitamin B6, primrose oil, OCP, tamoxifen iv. Mammogram for women >35yo and US *Nipple Discharge* - 10% of pts will have underlying CA (inc with age) i. Physiological - Nonspontaneous, bilateral, expressed from multiple ducts ii. Pathologic - spontaneous, unilateral, single duct. iii. If spontaneous from a single duct- Image to find source and duct excision. iv. Nonspontaneous discharge in young women is frequently benign. v. Make sure to note: Color, bloody, unilateral or b/l, single or multi pore *Cysts* - fluid-filled cavities, vary w/ menstrual cycle i. Simple - reassurance/observation ii. Complex - aspiration, mass, D/C *Fibroadenoma* - i. Most common tumor in women <30 yrs ii. mobile, encapsulated, painless iii. OBS in younger women, core bx or FNA if woman >30 *Infections* i. Mastitis - mostly w/ breast feeding - S. aureus most common ii. Abscess - breastfeeding, trauma, piercing iii. Treat - drain if abscess and antibiotics

Breathing

*Breathing* - Oxygenation and ventilation - Assess for pneumothorax and hemothorax

Be able to categorize a patient's *ASA (American Society of Anesthesiologist) class* given a clinical scenario.

*CLASS 1 AND 2 ARE OPTIMAL* *Grade 1* *Normal/healthy* → complete functional capability, no physiologic or psychiatric disturbances *Grade 2* *Mild systemic dx* → no functional limitations; well-controlled disease of only one body system; controlled disease without systemic effects; pregnancy *Grade 3* *Severe systemic dx* → some functional limitation, no immediate danger of death. Has to stop in middle of functional capability test due to distress, poorly controlled systemic disease *Grade 4* *Severe systemic dx that is a constant threat to life* → unable to do functional capability test, incapacitating disease; has at least one severe disease that is poorly controlled, possible risk of death. *Grade 5* *Dying patient who is not expected to survive without operation* → dying, end stage disease; not expected to survive > 24 hrs w/o surgery; multiorgan failure *Grade 6* *Declared brain-dead* patient whose organs are being removed for donor purposes

4. Know definitions for the following terms: cellulitis, gangrene, abscess, bacteremia, and sepsis, and discuss the management for each.

*Cellulitis*: A diffuse inflammation of connective tissue with severe inflammation of dermal and SQ layers of the skin. Body's reaction to bacteria, spreading bacterial skin infection. Tx: abx or debride if necessary *Gangrene*: A serious and potentially life-threatening condition that arises when a considerable mass of body tissue dies after an injury, infection or ischemia. Wet: dead, active infection (always emergent) Dry: dead, dry, uninfected *Empyema*: A collection of pus within a naturally existing anatomical cavity, such as the *lung pleura*. *Abscess*: a collection of pus in a newly formed cavity in any part of the body that is accompanied by swelling and inflammation. Tx: drainage *Bacteremia*: The presence of viable bacteria in the circulating blood that may or may not have any clinical significance. Tx: Remove source of infection and give abx. *Sepsis*: SIRS (any 2: <36F or >38F, >20 RR, >90BMP, >12K or <2K WBCs) PLUS infection (local or systemic) Tx: broad abx until cx results obtained *Septicemia*: bacteria in the blood that often occurs with severe infections and may be life-threatening. *Dehiscence*: A surgical complication in which a wound breaks open a surgical suture. Risk factors are age, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to wound after surgery. Emergent. *Evisceration*: wound and fascia opens, leading to herniation of organs through wound, emergent

Circulation

*Circulation* - Shock pathophysiology - Hemorrhagic shock pathophysiology (SEE CHART) *Stop the bleeding* - Direct pressure - Tourniquet - Surgery

Define the *most common complications* of anesthesia and surgery, and discuss treatment plans for each.

*Complications during surgery* Malignant hyperthermia (see next objective) GERD/full stomach - Causes: hx of GERD, hx of ESLD and Ascites, any trauma, pregnancy, diabetes of long duration - Solutions: Rapid sequence induction, cricoid pressure, awake fiber optic intubation Unstable neck - Causes: trauma, cervical spine fracture, atlanto-occiptal instability, spinal cord stenosis - Solutions: Awake fiberoptic intubation, awake positioning, inline stabilization *Post-Operative Complications* - *Post Operative Nausea and Vomiting (PONV)* (the most common) → use antiemetics - Pain → use short-acting meds early on, have naloxone nearby, watch respiratory depression - Hypothermia →Warm blankets, forced-air warming devices, water-jacket devices. - Respiratory depression → ensure patient is actually breathing, SpO2 monitoring - MI → stress on heart from surgery, take all chest pain seriously - Bleeding → call surgery service ASAP, watch HR and BPs - Altered Mental Status/Disorientation → Evaluation stroke vs. meds. Look for any focal signs (Suggestive of stroke)

Know the objectives, indications and major contraindications for the uses of each type of *sedation*

*Continuum of Sedation* 1. Minimal sedation (anxiolysis (anti anxiety)) → normal response to verbal commands, normal CV and respiraory status 2. Moderate sedation (conscious sedation) → purposeful response to verbal commands, maintained airway/ventilation/CV-status 3. Deep sedation (be thinking secure airway) → pt cannot be easily aroused, purposeful response to repeat or painful stimulation, airway and ventilation may be impaired, CV status maintained 4. General Anesthesia (loss of consciousness) → airway and ventilation may need to be secured, CV status may be impaired ii. Sedatives 1. benzodiazepines, barbiturates, ketamine, etomidate, propofol

Compare and contrast *Crohn's disease* and *Ulcerative Colitis*. Formulate a plan for distinguishing between the two diseases, treating your patient, as well as educating your patient regarding the prognosis of each.

*Crohn's Disease* -*May affect mouth to anus, but usually spares rectum* (whole GI tract ca be affected ) - Commonly affects the *terminal ileum* (where B12/Intrinsic Factor is absorbed) Presents with diarrhea, usually not bloody *Transmural inflammatory disease with cobblestoning, ulcers, fistula. Strictures. - skip lesions, patchy spread -RLQ pain, possible mass - extra intestinal sx are common Diagnosis via colonoscopy with biopsy CT: narrowing of terminal ileum - string sign Eccentric involvement Increased risk for cancer Management is *MEDICAL*: *- Anti-inflammatory medications, steroids for acute exacerbations* - Surgical management reserved for bowel obstruction unresponsive to medical management or perforation

4. Discuss the differential diagnosis of a breast mass as it varies over a patient's lifetime.

*Diagnostic problems* most often occur with intermediate group (30-50) may be benign or malignant. *Abnormalities* occurring in postmenopausal women such as pain, nipple discharge, mass are more likely to be related to malignancies *-Fibroadenoma* - late teens to early 30s *-Breast cyst* - 40s-50s *-Nipple discharge* - 40s-50s *-Mastitis* - breast feeding mothers *-Breast cancer chances:* See photo

Disability

*Disability* Determine the degree of neurologic disability. *Glasgow Coma Scale (GCS)* (SEE CHART) High score = Good Low score = Bad - Early GCS determination is important because treatments and medications can cloud the subsequent neurologic exam. - Depressed mental status is an indication for a definitive airway in order to protect the patient from aspirating gastric contents into the lungs.

What is the Management of electrical, and chemical burns?

*Electrical Burns:* -Look for entrance/ exit wounds (Damage will occur in between these points) -Monitor ECG/ Cardio status -Watch out for Rhabdomyolysis and Compartment syndrome -Monitor CPK and Urine Myoglobin to watch for Rhabdo *Chemical Burns:* -If powder, wipe away then irrigate with water -IRRIGATE with Significant water

Know the objectives, indications and major contraindications for the uses of each type of *Regional anesthesia - Epidural*

*Epidural Anesthesia* - Blocks sensation to affected dermatomes *Injected into the epidural space* (above dura mater) - blocks sympathetic response - blocks vagal response - Some neuromuscular blockage *Advantages* - allows patient to stay awake - no depression of baby, - postoperative analgesia - no respiratory depression - less risk of thrombosis - earlier intestinal motility - no intubation needed *Negatives* - Possible failures of block - headaches (from passing into the subdural space) - urine retention (not necessary to cath) - bleeding (esp into spinal canal) - Possible infection (once you're in that space it can travel up or down the cord) - wet tap (CSF from getting into the wrong area) - bradycardia - hypotension *Contraindications* - Pt unable to comprehend the procedure - Anatomical changes (spina bifida, some back surgeries) - Fixed cardiac output states (AS) - because pt cannot compensate with vasodilation and bradycardia - Skin infection, Sepsis - anticoagulation - increased ICP (herniation of brain)

Define *malignant hyperthermia*, the risk factors involved, and outline a treatment plan and patient educational plan.

*Etiology*: - AD variable inheritance (ryanodine receptor) - general anesthetics (esp. succinylcholine) result in Ca release and excitation-contraction syndrome *Signs*: - Increased temp, HR, resp rate, CO2 production - Acidosis - rigid muscles - rhabdomyolysis *Treatment*: - Discontinue anesthetic (Dantrolene) - Hyperventilate - Sodium bicarbonate - Cool patient - Watch hyper K and ABG closely. *Prognosis*:5% mortality now

5. Discuss the different modalities used for early detection of breast cancer.

*Exam* i. Inspect - Asymmetry, deformity, skin changes, edema. *Ex: peau d'orange* ii. Mass - Size, shape, texture, tenderness, location, fixation iii. Discharge - Color, quality, pressure iv. Nodes - Axillary, supra clavicular *Imaging* i. Mammogram (digital better) ii. *B*reast *I*maging *R*eporting and *D*ata *S*ystsm (See photo) iii. *Needle biopsy is gold standard,* U/S guided, only 5-10% need open surgical bx iv. *MRI* - Improves early detection and surgical management

Exposure

*Exposure* - Remove all clothing - Cover with a warm blanket - Head to toe examination

4. Compare and contrast the special drains a postoperative patient may have, their uses, and care. Closed Open Pleur-evac Vacuum

*General Info on Drains* i. Used to prevent or treat an unwanted accumulation of fluid ii. Prophylactic drains are placed in a sterile area iii. External portion of the drain must be handled with aseptic technique *Closed* (preferable) i. connected to suction devices ii. EX: Jackson-Pratt (JP) Drain *Open * i. open to air ii. EX: Penrose drain (genital area), ward catheter (pen-rose not really used any more) *Pleur-Evac* i. used to maintain negative pressures, used in chest wounds to maintain inflation of lung for example *Vacuum Drain* i. chronically-draining wounds, i.e. bedsores that are BAD

Know the objectives, indications and major contraindications for the uses of each type of *Regional anesthesia*

*Great for procedures that require no general anesthetic.* Examples include almost any procedure done: - below the waist - lower abdomen, - upper extremities. Types of Regional Anesthesia: - Spinal - Epidural - Peripheral Nerve Block Useful because - avoid airway manipulation - allows the patient to be conscious. - decreased blood loss during orthopedic procedures - fewer thrombotic complications - less pulmonary compromise - earlier hospital discharge - avoidance of immune response compromise.

Given a patient scenario, identify patient comorbidities and assemble a plan to reduce the risk for anesthetic complications.

*High Cardiac Risk Predictors:* - CAD (8x risk, wait 60 days after MI if possible) - Heart failure, especially decompensated - Valvular heart disease (TTE within 1 year) - Reduced functional status (METs) - Significant arrhythmias - High risk surgery (aortic cases, etc) *Intermediate* - mild angina pectoris - previous MI by history - pathological Q waves - compensated or prior heart failure - DM - renal insufficiency *Minor*: - Advanced age - abnormal ECG (rhythm other than sinus) - low functional capacity - history of stroke - uncontrolled systemic hypertension

Compare and contrast electrolyte abnormalities including symptoms, causes, management, complications, and patient education. *Calcium*

*Hypercalcemia (>10.5)* Often due to Hyperparathyroidism ● Lethargy, hyporeflexia, kidney stones, bone pain, AMS, pancreatitis ● Treatment: NS, lasix, dialysis, calcitonin/bisphosphonates *Hypocalcemia (<8)* ● Hyperreflexia, Chvostek's/Trousseau's sign, prolonged QT, hypoalbuminemia ● Treatment: IV calcium gluconate or chloride

List preoperative *screening tests* and assess *when to use them* in selected patients.

*Indication in a Asymptomatic Patients* - EKG: Age > 40, Diabetes, Hypertension - Creatinine: Age > 65 - Glucose: Age > 65 - Serum Electrolytes: Not routinely indicated - Hemoglobin or Hematocrit: Age > 65, History of Anemia - Urine HCG: Childbearing age - Prothrombin time (PT): Not routinely indicated - Liver function tests (LFTs): Not routinely indicated - Chest X-ray: Age > 65 and never performed *Indication in Symptomatic Patients or those with Chronic Disease* - EKG: Chest Pain, CAD, Dysrhythmia - Creatinine: Diuretic use, ACE Inhibitors, CKD, HTN - Glucose: Steroid use, DM - Serum Electrolytes: Diuretics, ACE Inhibitors, CKD, HTN - Hemoglobin or Hematocrit: Warfarin use, NSAIDs, Blood loss > 500 mL, menstruating - Urine HCG: Uncertain menstrual history - Prothrombin time (PT): Warfarin, CKD, Metastatic cancer, Alcoholism, Neurosurgical history - Liver function tests (LFTs): Warfarin use, CKD, Metastatic Cancer, Alcoholism - Chest X-ray: Dyspnea, cough, fever

3. Compare and contrast the phases and elements of wound healing.

*Inflammation* (0-6 days) -Neutrophils clear bacteria and debris -Macrophages eat dead tissue and release GF's -*Macrophages are the most important cell during this process* *Proliferation* (4-14 days) -Tissue continuity re-established -Fibroblasts (produce collagen) -Endothelial (angiogenesis in response to VEGF) *Maturation/Remodeling* (14 days-1 year) -Wound gets stronger -Collagen is remodeled into Fibrils and cross-linked

7. Understand and be able to discuss potential burn complications, including identification of patients at risk for inhalation injury, and treatment plans.

*Inhalation injury:* -carbon monoxide poisoning -Give 100% O2 -evaluate with bronchoscopy if uncertain as to thermal burn status -Progressive hoarseness is a sign of impending airway obstruction -progressive hoarseness -Anyone with over 50% burn, will need intubation Pain meds to be used: -If intubated-Fentanyl/ versed (midazolam) -If Awake-oxycodone/percocet, Dilaudid, morphine

Formulate differential diagnoses for patients presenting with pain in the *Left Lower Quadrant (LLQ)*

*Left Lower Quadrant (LLQ)* DDX: - *Diverticulitis* - Colitis - Appendicitis - Inguinal Hernia - Urinary Tract Infection - Pyelonephritis - Ureteral Calculus - Pelvic Inflammatory Disease - Ectopic Pregnancy

Formulate differential diagnoses for patients presenting with pain in the *Left Upper Quadrant (LUQ)*

*Left Upper Quadrant (LUQ)* Usually involving the *spleen or transverse/splenic flexure of the colon* - Splenic Trauma - Colon Cancer - Irritable Bowel Syndrome - Splenic infarct (as in Sickle Cell) - Left lung Pneumonia

Know the objectives, indications and major contraindications for the uses of each type of *Local anesthesia*

*Local Anesthestics* - reversible loss of sensation at the affected site *Topical or injected* - blocks Na-gated ion channels prevents depolarization - differ by onset of action, duration, etc. Lidocaine most commonly used (with or without epi) Epinephrine - prolongs duration of action - keeps the drug local - minimizes systemic effects - decreases bleeding Local anesthetics with epi cannot be given: ears, nose, fingers, penis because they will cause ischemia (book answer) Lidocaine toxicity: - reaction to PABA (breakdown product) - oral numbness, ,facial tingling, tinnitus, slurred speech, seizures, anaphylaxis, arrhythmias; Treatment: Intralipid (lipid emulsions) Prevention: - Drawing back on the needle - Use as little as possible

7. List the symptoms and physical findings related to dehydration.

*Mild dehydration* (4% total body weight loss) Dry skin, urine osm 500-700 *Moderate Dehydration* (6% total body weight loss) Dry skin, dry tongue, dry axilla, dry groin, urine osm 700-900 *Severe dehydration* (8%) Above plus weakness, hypotension, lethargy, ileus Urine Osm 900-1240 Shock (>8%) *General Sx* ■ Dry mucous membranes ■ Decreased skin turgor ■ Extreme thirst ■ Low urine output ■ Climbing BUN, possible creatinine - Rising BUN:Cr ratio ■ Low blood pressure ■ Low CVP ■ Tachycardia ■ FENA < 1% (Fractional excretion of sodium) ■ Altered mental status

4. Be able to calculate a patient's sodium and normal saline (NS: 0.9% NaCl) required to compensate for the deficiency.

*Na+ deficit = TBW x (140- actual [Na+])* *TBW* =60% X weight in men = 55% X weight in women = 40% X weight in elderly pts Give *no more than half* of deficit in first *12-18 hours*, then ther rest over *24 to 48 hours* Do not correct more than 0.5mEq/L/hr due to risk of central pontine myelinolysis (CPM) Unless the Sx are life threatening neurological Sx you give Normal saline (.9%)

Understand the indications for *operative and nonoperative management* of abdominal injuries.

*Non-operative management* *Stable patients only* - Physical exam - Serial assessments - Labs - Interventional radiology (Embolization) *Operative Management (OR)* - *Unstable Patients* - Gunshot wounds - Hypotensive Blunt Abdominal trauma (intra-abdominal bleeding until proven otherwise, most often the spleen or liver)

1. Discuss the factors that contribute to infection after a surgical procedure.

*PATIENT RELATED*: Pre-op admission, concomitant infection, DM, obesity, age, immune response, abdominal surgery, malnutrition (albumin <2.5, prealbumin), smoking, ischemia, nasal carrier, chemo/radiation, steroids/immunosuppresive *PERIOPERATIVE*: Abx prophylaxis, GI preparation, surgical time, OR ventilation/personnel traffic, hair removal, foreign material, patient scrubbing, sterilization techniques, drains, antisepsis, blood transfusion, surgical scrubbing, surgical technique (burn, hemostasis, trauma) Pneumonia: inhibition of normal cough reflex (anesthesia, narcotics, pain, ET intubation UTI: foley, elderly, debilitated, pregnancy, urological abnormalities IV Cath: duration, # of manipulations, multi-lumen, gauze vs sterile occlusive dressings MECHANICAL PREP to decrease risk Hyperglycemia: maintain tight glucose control below 150mg/dl, continuous IV insulin will decrease SSI better than SQ, each 50mg/dl above normal = increased length of stay Normothermia should be maintained: -vasoconstrictive response -> skin ischemia. -Temp > 36.5 decreases SSI risk Also good surgical technique, skin preparations (providone-iodine or chloro-hexidine), hemostasis and lavage of blood clots, reduction of wound physiologic dead space using layered closures all decrease risk.

List the characteristics of a patient with *acute peritonitis.* Discuss risk factors, treatment and the differential diagnosis.

*PERITONITIS* Inflammation of the lining of the abdominal cavity, often cause by defect in the viscera RISK FCTORS: Appendicitis, diverticulitis, perforated ulcers, Crohn's disease PRESENTATION: Hard abdomen, diffused pain with minimal stimulation, fever, guarding Management: surgical intervention

Coags: How it is written and normal Levels

*PTT* = partial thromboplastin time → intrinsic clotting cascade; increased by heparin (goes IN an IV so it is INtrisic) *PT*= prothrombin time → extrinsic clotting cascade; increased by coumadin Effects Clotting factors II, VII, IX, and X That rely on Vit K. *INR* = international ratio → checks coumadin; is the same internationally so you can get your levels checked anywhere and they will be consistent More important than any of this can be a *bleeding Hx.*DO they bleed like crazy if they get cut?

5. Discuss patient analgesia, comparing and contrasting the benefits vs detriments of: ♣ Parenteral Opioids ♣ Non-Opioid Parenteral Analgesics ♣ Oral Analgesics ♣ Patient-Controlled Analgesia

*Parenteral Opioids* (not via mouth) i. direct effect on opioid receptors ii. stimulation of descending brain stem system that contributes to pain inhibition iii. The *mainstay of therapy* for post-operative pain *Non-Opioid Parenteral Analgesics* i. NSAIDS → ketorolac potent analgesic and moderate anti-inflammatory (drawback: can lead to PUD) *Oral Analgesics* i. usually used several days post operatively (depending on severity of surgery) *Patient-Controlled Analgesia* → ideal option, typically narcotics i. patient controls boluses ii. sometimes also has a basal rate iii. has a "timeout" to prevent overdose iv. patient must be awake to push button

2. Create a model of a surgical team and compare the roles and responsibilities of each.

*Physician/Surgeon* - on right side of table with main part of surgery *Physician Assistant* - *First Assist* - Provide adequate exposure for the surgeon, keep the field dry, anticipate the steps in the procedure, anticipate the cutting of sutures *Scrub tech or scrub nurse* - elbow of the surgeon, overlooking the operative site and handling equipment to surgeon. To maintain sterility of operative field, they do not leave side of OR table until procedure is completed or another nurse has scrubbed in. RESPONSIBLE FOR INSTRUMENT COUNT. *Circulating Nurse(s)* - circulate' around OR and between OR and outside, seeing to any equipment and other needs of operating team. Assists scrub nurse with instrument count. No one leaves until all instruments, needles, lap pads and anything used during the procedure is accounted for. *Anesthesiologist/Anesthetist* - controls and monitors anesthesia and vitals *Resident* - help surgeon or anesthetist. 5t h yr residents perform most or all of surgery but always under supervision of attending. 1s t yr interns help surgeon by suctioning blood *Med or PA Student* -. Shut up and learn.

2. Identify complications associated with heparin use.

*Post-op bleeding*, Hyperkalemia, elevated AST/ALT, *Heparin induced thrombocytopenia/HIT* indicated by Hx of heparin, Clotting, and *FALLING PLATELT COUNT* The blood thinner is making you clot up - your antibodies cause *PLT aggregation*; treat by sending HIT antibody, stop heparin, use atrixtra or argatroban (DONT GIVE COUMADIN, IT LEADS TO TISSUE NECROSIS IN A HIT PT) For large emboli, need emergent surgical embolectomy by thoracic surgery Antidote for heparin overdose -- protamine

Be able to complete a pre-anesthesia H&P.

*Pre-Op Evaluation* Goals - Optimize patient condition - Understand and control comorbidities and drug therapy - Ensure patient's questions are answered Timing - High surgical invasiveness: at least 1 day prior - Medium invasiveness: day before or day of surgery - Low invasiveness: day of surgery *Pre-Op H&P* Review medical records prior to meeting with the patient Surgical History: - Previous operations - Anesthetic type - Any complications (allergic reactions, abnormal bleeding, delayed emergence, prolonged paralysis, difficult airway management, awareness, or jaundice) Medical History - Any serious cardiac conditions (unstable coronary syndromes, angina, myocardial infarctions, decompensated CHF, arrhythmias, or severe valvular disease) - Diabetes - Renal disease - Cerebrovascular disease symptoms (Stroke) - Thyroid disease - METS/functional status → best indicator of how someone will do under anesthesia Family Surgical History - Any family history of adverse responses to anesthetics (malignant hyperthermia) and Social history - Smoking - Drug use - Alcohol consumption Comprehensive Medications (May affect anesthetic choice and dosage): - Antihypertensives - Insulin - Bronchodilators - Any other medications that can interact with anesthetic agents. Physical Exam: - Cardiac Exam (Heart function) - Pulmonary Exam (Lungs function) - Upper Airway Exam (SEE NEXT CARD) - Potential intravenous catheter sites - Potential sites for regional anesthesia - Range of motion of limbs (may affect positioning in the operating room) - Any neurologic abnormalities

Obtain the essential elements of a patient's medical history in routine and emergency surgical circumstances.

*Pre-op assessment is a focused patient encounter*. Doesn't solely focus on the need for surgery HPI becomes a discussion of the illnesses that impact the peri-op period Elements Include: - *AMPLE*: (Allergies, Medications, Past Medical History, Last meal, Events preceding the surgery) - Assessment of co-morbidities - Determine baseline functioning - *Detailed cardiopulmonary ROS* (Consider breathing, Airway, Palpable pulses, Heart beat Abnormal bleeding) - Gastointestinal ROS (vomiting, change in bowel habits, hematemesis, hematochezia) - Adverse reactions to anesthesia - Pain - Family History

6. Classify wound closure by level of intention. Justify the use of each closure type based on patient scenarios

*Primary intention*: -Wound close by approximation of wound edges -Sutures, Staples, gluing, steri-strips are all examples *Secondary intention*: -Wound heals via spontaneous closure -Wound is left open -Used for wounds that are infected or are too large to close primarily -Wound vacs are useful -Look for "proud flesh" bright red easily bleeding tissue is a sign of good healing *Tertiary intention*: -The wound is left open for a time and then sutured at a later date or skin grafted -Skin grafts are considered tertiary intentions

Know the objectives, indications and major contraindications for the uses of each type of *Regional anesthesia - Peripheral nerve block*

*Regional anesthesia - Peripheral nerve block* - To block sensation to one particular region, identify the nerve for that area and inject the anesthesia at the nerve - Better for when you need to anesthetize a large area (the whole arm, etc)

Resuscitation Vs Maintenence

*Resuscitation or Replacement Therapy*: Goal is to correct existing deficits in volume and/or electrolytes *Maintenance Therapy*: Goal is to maintain water and electrolyte balance in a patient who cannot eat/drink Accounting for insensible losses

Formulate differential diagnoses for patients presenting with pain in the *Right Lower Quadrant (RLQ)*

*Right Lower Quadrant (RLQ)* DDX: - *Appendicitis* - Colitis - Diverticulitis - Inguinal Hernia - Urinary Tract Infection - Pyelonephritis - Ureteral Calculus - Pelvic Inflammatory Disease - Ectopic Pregnancy - Mesenteric Adenitis

Formulate differential diagnoses for patients presenting with pain in the *Right Upper Quadrant (RUQ)*

*Right Upper Quadrant Pain (RUQ)* Usually associated with the *liver, gallbladder, and hepatic flexure of the colon* - *Cholecystitis*/Cholangitis - Liver hemangioma/cyst - Liver Laceration following trauma - Crohn's disease - Colon Cancer - Kidney disorders (nephrolithiasis or pyelonephritis) - Diaphragmatic irritation following laparoscopic surgery or RLL - Pneumonia

Urinalysis includes

*Specific gravity* (estimate of Urine osm, High means dehydration) *Leukocyte Esterase (LE)* enzyme made by WBC. If it's in the urine it means you have a UTI *Nitrites* Created by bacteria... also means you have a UTI *WBC*- Infection, obstruction, inflammation in kidney, ureter, bladder ETC *Bacteria*- You have an infection *Casts*-Go look at the Kidney quizlets... different ones mean different things. Casts wont show up on a dipstick as they have to be identified visually. *RBC*- ummmm blood... its blood in your urine can be "gross" or "trace" but either way it's pretty gross.

2. Compare and contrast pressure ulcers by stage and treatment.

*Stage I:* -non-blanchable erythema -darkly pigmented skin -Early sign *Stage II:* -Partial loss involving epidermis or dermis -Shallow open ulcer with a red pink wound bed May also present as a serum-filled blister *Stage III:* Full thickness skin loss (epidermis and dermis) -No deeper than Sub Q fat -Stick your finger in for tunneling *Stage IV:* Full thickness tissue loss -exposed bone, tendon or muscle *Unstageable:* -Could be stage 3 or 4 but unknown because there is an eschar on top. -Cut out the eschar

Understand unique issues related to trauma in the pregnant patients

*Still ABCDE* Physiologic changes - Blood volume expands by 145% (More blood volume but not necessarily more RBCs) - Hypercoagulability - Intrathoracic lower esophageal sphincter Anatomic changes - Gravid uterus compresses IVC - Gravid uterus pushes diaphragm cephalad by 4 cm *Protect the baby* - Give Rho (D) Ig to all Rh- women - Avoid ionizing radiation (NO CT, avoid X-ray) - Assess fetal maturity ---> Estimate by fundal height (SEE PHOTO) ---> C-section for viable baby during trauma laparotomy or within 4 minutes of maternal death

Understand unique issues related to trauma in the children

*Still ABCDE* Physiologic changes - Small circulating blood volume (More abrupt drop in BP with increased blood lose SEE PHOTO) - Impaired thermoregulation - Age-specific vital signs (SEE PHOTO) Anatomy changes - Small mouth, large tongue, tonsils, adenoids, and epiglottis, anterior larynx, short trachea - Flexible cervical spinal ligaments (Spinal card injury is possible WITHOUT radiologic finding. PHYSICAL EXAM) - Lack collateral ventilation via pores of Kohn - Triradiate cartilage (Cartilage connecting the three pelvic bones) may be mistaken for a fracture - Bones are soft and pliable (Greenstick fractures SEE PHOTO) - Fractures may occur at growth plates (Salter- Harris Fractures SEE PHOTO)

3. Compare and contrast the following common surgical positions: a. Supine b. Prone c. Right and Left Lateral d. Lithotomy e. Sitting f. Jackknife

*Supine* - on back, arms out to either side w/ support at pressure points Ex: most surgeries *Prone* - on abdomen, head supported with pressure off face, abdomen is free, no pressure on axilla, elbow padded Ex: ortho, spinal *Right and Left Lateral* - named for the side that is down Ex: renal, spinal *Lithotomy* - head above the hip level, stirrups, knees up and hip flexed, expose the perineum at the edge of the table, may cause nerve compression if surgery is extensive Ex: Gynecological, urologic, anotrectal *Sitting* - patient is sitting up, secured in several locations, legs out straight, requires careful attention to airway monitoring Ex: ortho, neurosurgery *Jackknife* - my personal favorite, patient lying prone on bed bent at the hips, airway can be problematic in this position Ex: anorectal, colorectal surgeries..

Know specifically what constitutes the informed consent process, and be able to apply the elements to a hypothetical patient and surgical procedure.

*To obtain Informed consent the provider* should describe to the patient and close family in *understandable terms*: - The nature and purpose of the treatment - The planned surgical procedure - Any Risks with a probability > 1% - Severe or feared complications - Alternatives and consequences - Risk of doing nothing - Potential need for blood transfusion - What happens prior to anesthesia - What happens in the recovery room *Discussion should be documented in chart* If it isn't written, it didn't happen Tips - The provider should have sufficient training and information - Avoid jargon - Avoid pressure - Avoid misleading - Chose appropriate timing (better to day before or at least a few hours if possible)

ULCERATIVE COLITIS

*ULCERATIVE COLITIS* Colonic Inflammation, *involves rectum*, continuous spread MUCOSAL INVOLVEMENT *Presents with diarrhea/red blood per rectum* -extra GI involvement less comment *pseudopolyps* and possible loss of hausta Diagnosis via colonoscopy with biopsy Increased risk of cancer Management may be SURGICAL: *Total Proctocolectomy with end ileostomy or ileal J-pouch* (Proctocolectomy is the surgical removal of the rectum and all or part of the colon. It is a most widely accepted surgical method for ulcerative colitis and Familial adenoma)

Discuss the key features to an *upper airway examination*, including the *Mallampati airway classification.*

*Upper Airway Exam* Ability to control the airway is mandatory while the patient is under general anesthesia. The examination is to assess those factors that would make airway control (eg, endotracheal intubation) difficult or impossible. *Seven keys to the upper airway examination* should be documented: 1. Range of motion of the cervical spine: (Patients should be asked to extend and flex their neck to the full range of possible motion so the anesthesiologist may look for any limitations) 2. Thyroid cartilage to mentum (chin) distance (ideal is greater than 6 cm) 3. Mouth opening (ideal is greater than 3 cm) 4. Dentition (dentures, loose teeth, poor conservation) 5. Jaw protrusion (ability to protrude the lower incisors past the upper incisors) 6. Presence of a beard 7. Examination and classification of the *upper airway* based on the size of patient's tongue and the pharyngeal structures visible on mouth opening with the patient sitting looking forward. This visual description of the airway structures is known as the *Mallampati score* (SEE PHOTO) - *Mallampati classification* → tell patient to open mouth, and look in I. Full uvula and tonsillar pillars (suggests easy airway intubation) II. Partial uvula and tonsillar pillars III. Soft palate IV. Hard palate (suggests challenging airway) *Confirming Airway Placement* - use multiple methods to confirm - direct visualization - chest auscultation - epigastric auscultation - ETCO2 - Condensation on tube - bulb suction, - chest wall rise *DANGER ZONE: a lot of patients die from intubation into esophagus * - Use back-up devices to assist intubation if necessary

3. Be able to describe special monitoring needs in the postoperative setting.

*Vital Signs* Temp, BP, HR, RR, O2 SAt You also need to write an order for *telemetry* (which means they are hooked up to a moniter and recorded) and *pulse Ox* (if you don't order this then the nurse or CNA only checks it once in a while. *Central Venous Pressure*- pressure in vena cava next to right atrium. Tells you how much blood the pt gets back to the heart and therefore can pump out. If there is a big shift you should do something about it. *Intraventricular catheters*- ICU level monitor if they had brain surgery

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Diabetes

*What* 20% of surgical patients will be diabetic This leads to increased risk of: -CVA events -Infection -Poor wound healing -More hospitilizations -Longer length of stay -Higher morbidity and mortality *Goal* -Glycemic control (120-180 BG) Difficulties: -Disrupted administration insulin or oral hypoglycemics -altered metabolic needs, nutritional intake -Increased catecholamines, glucocorticoids, glucagon, GH (stress response) (patient blood sugar may rise) *Work up* -Assess risk of CV, Renal, HTN, and glycemic control at home -*Check Glucose, HbA1c, U/A, Electrolytes, EKG* *Management*: -Stop oral hypoglycemics -Stop short acting insulins -Decrease long acting insulin to 1/2 dose -Check BG frequently!!! -During surgery keep glucose between 120-180

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Cardiac Disease

*What* After the age of 40: -risk of major postop cardiac event is 5.8% -5-10% are MIs w/ 32-69% mortality -2.5% risk of MI perioperatively 2. Higher incidence if pre-existing cardiac disease a. Physiological stress related to surgery: fluid shifts, hypovolemia, hypotension, increased cardiac O2 demand, altered coagulation d/t anesthesiology, fasting 3. Risk of another cardiac event or death is 30% in the 1st 3 months if elective surgery is performed immed after an MI: -aim to postpone for 6 months -DM DOES increase risk for cardiac event -Stable angina does NOT ii. Major cardiac events 1. Myocardial Infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, complete heart block iv. Workup (Ideally 1 week in advance) 1. H&P a. screen for: CAD, angina, HTN, CHF, PVD, a fib, valvular disease, DM, functional capacity, meds (how many anti-HTNs are they on? any anti-arrhythmics?) b. BMI, BP/HR, heart, lung, abd, LEs *Labs*: *CBC, BMP* ii. EKG: screen for arrhythmia, Q waves, ST changes, BBB iii. CXR iv. Consider: Echo, stress test, angiography d. Physical exam: peripheral pulses, bruits (especially unilaterally)

6. Recognize breast tumor staging, implications, and *general treatment options according to TMN and axillary node staging described in slides.*

*~~Treatment~~* 1. *Surgery*- *primary treatment in early stage breast cancer* (see photo) -When patient risk is low for mets disease (tumor <5cm and no palpable lymphadenopathy) only need CXR and CBC before surgery. Rest need abdominal/chest CT and bone scans before surgery. -*Skin or Nipple sparing mastectomy* for early or preventative cases, helps with reconstruction *NOTE:* farther the women live from care, more likely to get mastectomy 2. *Sentinal Lymph node biopsy*, standard in early breast cancer. Inject radioactive colloid or blue dye -SLN first node of drainage -If negative assume entire basin is negative -If positive may need up to complete axillary dissection. (Edema in future :( ) 3. *Radiation* -After lumpectomy, reduces recurrence from 30% to 10% -Reconsider if >70, single cancer <2cm, completely excised, negative lymph nodes, tumor is hormone receptor positive 4. *Chemotherapy* -Indicated in Node positive disease or tumors >1cm -Multiple gene assays can predict recurrence and help decide which patients need chemo -Optimal chemo regimen not currently determined -Chemo may be used as first treatment to reduce or downstage tumor and axillary involvement to make surgery easier 5. *Follow up* -Physical exam 3-6 months for first 5 years, then yearly -Mammogram q 12 months -Annual GYN exam if pt has uterus or was on tamoxifen (chemo drug) -Bone density scan if was on aromatase inhibitor (chemo drug)

Describe a *Subcostal and bilateral subcostal incisions*

- *Chevron/subcostal*- bilateral subcostal incision in the abdomen, in the shape of an inverted "V"; used in upper abdominal procedures

Describe a *McBurney's incisions*

- *McBurney Incision*-Over McBurney's point, parallel with direction of external oblique, allows for separation of muscle fibers in their direction, decreasing healing time

Given a patient scenario, order the appropriate radiologic test(s) associated with the diagnosis of the various abdominal disorders.

- Cholelithiasis -> ultrasound ○ Biliary Colic - ultrasound → oral cholecystogram (if US is inconclusive, if the pt is a candidate for lithotripsy or ursodiol therapy, or if symptoms are highly suggestive) ■ Colic may aggravate cardiac problems, in that case, get an EKG or CXR ○ Cholecystitis - X-ray → Ultrasound ■ HIDA scan may be used if US equivocal or negative. ○ Gallstone Ileus - X-ray (upper GI series) ○ Choledocholithiasis - X-rays or CT scans, ultrasound, ERCP in patient with cholecystectomy, cholangiography if no cholecystectomy ○ Ascending Cholangitis - ultrasound

Recognize *common incisions* names/descriptions and their usefulness.

- Exposure - essential to good surgery - Location of Pathology dictates incision - *Midline laparotomy* (incision of indecision) ex: trauma you are not sure what you're looking for/ how bad the damage is. -*Kocher Incision*-RUQ over gallbladder (Can be extended to a Transverse incision) - *Pfannelstiel* (Transverse, just above pubic symphysis) - OBG, C section - *Chevron/subcostal*- bilateral subcostal incision in the abdomen, in the shape of an inverted "V"; used in upper abdominal procedures. - *McBurney Incision*-Over McBurney's point, parallel with direction of external oblique, allows for separation of muscle fibers in their direction, decreasing healing time -*Rocky Davis incision*-in RLQ same as -McBurney's incision, but directly transverse and splits the muscle.

Know the objectives, indications and major contraindications for the uses of each type of *Regional anesthesia regional - Spinal*

- Onset is fast - can give lower dose than epidural - does cause some more neuromuscular block - can only be given at specific point along backbone to avoid damage to cord *Contraindications* - *Same as epidural (See Card Above)* - beware high spinal block (C3, C4, C5) because that will stop the diaphragm - Caution with muscle relaxant administration (impairs assessment

Describe a *Rocky Davis Incision*

-*Rocky Davis incision*-in RLQ same as -McBurney's incision, but directly transverse and splits the muscle.

1. Compare and contrast wound types by classification, treatment, and types of injuries associated with each: *Laceration*

-A wound cause by BLUNT object -May cause jagged, dirty edges -Wash wound -Close via primary intention (suture)

1. Compare and contrast wound types by classification, treatment, and types of injuries associated with each: *Crush*

-Body part is subjected to HIGH pressure -Often leads to Compartment syndrome (> 30mmHg) -Watch for Rhabdomyolysis -Clean the wound -Control pain -Hydrate -Monitor for compartment syndrome and treat accordingly -CK and myoglobin are markers for rhabdo -Look out for pain with Passive movement (sign of compartment syndrome)

6. Discuss post-resuscitation burn management and wound care. Know types and side effects of topicals.

-Clean/ Debride the eschar -Cover the burns with topical antimicrobials -Later you will begin to skin graft -Keep the burns covered to prevent pseudomonas from infecting. -Oral/IV Antibiotics are not needed, only Topical! *Sulfamylon*- Used for Ears (or anything with cartilage) -good eschar penetration -AE: metabolic acidosis, Sulfa allergies *Bacitracin* -Used on Face -few side effects *Silvadene* -Use for everything else -Does not penetrate Eschar -AE: neutropenia/ Thrombocytopenia, Sulfa Allergies

1. Outline general steps in the diagnosis and management of burns.

-Determine history (how were they burned, how bad, how hot. etc) -Start with ABC's -Calculate TBSA -Use parkland formula to administer proper IV fluids -Control pain -Debride the eschar -apply antimicrobials -skin grafts (3-7 days later) -Follow up

1. Compare and contrast wound types by classification, treatment, and types of injuries associated with each: *Puncture*

-HOLE in skin into deeper tissue -Bullet, Stick, Shrapnel etc. -Inspect for FB's and extent of injury -Wash wound -Leave open to heal (via secondary intention)

4. Recognize barriers to wound healing and be able to correlate risk factors for delayed healing given clinical scenarios.

-Hematoma -Bacterial contamination -Vascular Disease -Diabetes -Steroids -Radiation -Nutritional Status (albumin and pre-albumin are good markers of nutritional status) -Age not sure if age or comorbidities associated with age.

3. Identify a patient's risk factors associated with breast cancer.

-Lifetime risk - 1/8 for women *Yearly mammogram* -@ age 40 *Clinical exam* every 3 years 20-39yrs old, yearly >40 *Positive family history* -5-10% of breast CA are genetic mutations - mammogram 10 years earlier than age of youngest affected - Prophylactic mastectomy is assoc with 90% risk reduction - Prophylactic mastectomy/oophorectomy - 95% risk reduction - Prophylactic oophorectomy alone - 50% risk reduction *High Risk- PACAN* *-P* pregnancy first >30 yrs *-A* age at menarche (earlier is longer hormone exposure) *-C* cancer of breast (self or family) -BRCA 1, ovarian (1% 30%) -BRCA 2, male associated risks *-A* age at menopause (later is worse, longer exposure) *-N* nulliparity (OCP also) *OTHER:* age, hormone replacement therapy, prior breast biopsy *NOTE: MANY WOMEN WHO DEVELOP BREAST CA HAVE NO RISK FACTORS*

8. Discuss timing and process of the rehabilitation phase.

-Skin grafts begin 3-7 days post-burn *Superficial 2nd Degree* -Will heal within 3 weeks without functional impairment or scaring!! *Deep 2nd Degree* -Xenograft can be used in short term (pig skin) -Takes 3-9 weeks to heal -*Need to Skin graft* -Will have permanent changes in function -Will see hypertrophic scarring *3rd Degree* -Need to graft -If no graft it will take over 6 months to heal from epithelialization from wound margin *4th Degree* -Need to do reconstructive surgery -Need tissue flaps -Grafting alone will not be sufficient. -Allografts (cadaver) can be used in serious burns but will need to be replaced in 2 Weeks with an Autograft.

5. Understand the rationale and use of debridement, vacuum assisted closure (VAC dressings), and hyperbaric oxygen in wound care.

-Use negative pressure to heal wound -can improve healing by 40% -Decreased Wound edema -Increased local tissue perfusion -Continual removal of wound exudates and reduction of wound bacterial burden -Accelerates wound contraction -The microdeformation placed in cells in the wound bed is thought to upregulate growth factor production -Hyperbaric 02 helps increase amount of 02 that reaches the damaged tissue -Used in crush injury -Infections that are not healing as expected

What is Compartment syndrome what are the signs of it, what is the prevention and treatment?

-When there are circumferential burns in the extremity it can compromise circulation -Compartment syndrome is when the pressure measured via striker needle is greater than *30 mmHG* *Signs: (6 P's)* -Pain -Pallor -Pulselessness -Parathesias (burning/ prickling) -Paralysis -Poikilothermia (Inability to regulate temperature) *Prevention*- Escharotomy *Treatment*- Fasciotomy

10. Know the common pulmonary post-op complications, treatments, and patient risk factors for the following respiratory conditions: aspiration, atelectasis, pneumonia, empyema, pleural effusion, pulmonary embolism.

1. *Atelectactasis*- most common source of fever in *first 24 hours*; collapse of parts of lung because of artificial ventilation during anesthesia; fever from cytokine release by alveolar macrophages, most resolve with*incentive spirometry/nebulizer*. Can be complicated by pneumonia 2. *Pneumothorax* - often caused by central line placement Tx: needle aspiration or chest tube to treat 3. *Aspiration* - can't protect airway, at risk if head of bed flat, leads to day 3 fever Tx: Abx 4. *Pneumonia* - community acquired vs. hospital acquired. Higher risk with prolonged mechanical ventilation. Dx: based on fever, leukocytosis, sputum gram stain, and CXR, Tx: treat with empiric antibiotics until culture complete 5. *Empyema* - a collection of pus within a naturally existing anatomical cavity, such as the lung pleura Dx with CT scan Tx: surgical drainage required, antibiotics 6. *Pleural Effusion* - exudative vs. transudative. Dx: Xray, paracentesis Tx: Drain with paracentesis 7. Pulmonary Embolism (once again) See card on PE

Post-Op Management Basic Principles (Review slide)

1. *Early Mobilization* → OOB on day 1 to prevent muscle wasting, risk of DVT, and return bowel function 2. *Pulmonary therapy* → incentive spirometry to prevent/correct atelectasis and prevent pneumonia 3. *Early nutrition* → Enteral > Parenteral; nutrition is SO IMPORTANT! Look at albumin for level of nutrition 4. *Adequate fluid & electrolyte* administration → must be individualized, admin fluid to keep up UOP > 30mL/hr 5. *Manage cardiac risk factors* → continue BB, statin 6. *Control blood sugar* → use sliding scale short-acting insulin; restart intermediate or long-acting insulin when eating

9. Discuss postoperative risk factors and treatment for the following abdominal complications: small bowel obstruction (SBO), paralytic ileus, Clostridium difficile enterocolitis.

1. *Small Bowel Obstruction* - due to adhesions from surgery, can occur years after abdominal surgery. Tx- surgical 2. *Paralytic Ileus*, "post op ileus" (poi) stunned intestine due to the stress of surgery. Sx: pain,anorexia,polyuria,nauseaandvomiting Dx: Plain films show dilation of intestines TO prevent, avoid NG tubes Tx: minimize narcotics, correct elecrolytes (potassium important), *early ambulation*, Wait for their intestines to wake up. (AROBF, awaiting return of bowel function) 3. *Clostridium difficile enterocolitis* - can be common for patients on any ABX (especially CLinda or flouroquinolones) Mucusy green diarrhea. can result in toxic mega colon which will need colectomy; high WBC (can be as high as 50,000), Positive antigen treat with IV Flagyl, PO (PR if ileus as well) Vancomycin, stop current Abx follow contact precautions on wards to prevent spread

8. Outline the various complications that can arise from treatment of breast cancer.

1. *Surgery* - Lymphedema - 5-8% after SN, 20-25% after axillary dissection 2. *Chemo* - Osteoporosis, DVTs, Endometrial cancer 3. *Radiation* - adequate dose needed to target, but don't want to irradiate surrounding normal organs because it could cause: - Cardiac ischemia, lung cancer, esophageal cancer, contra-lateral breast cancer, radiation induced sarcoma 4. *Contraindications for BCT surgery* - 1st and 2nd trimester of pregnancy, multicentricity, diffuse suspicious microcalcifications, prior therapeutic RT to breast, persistent positive margins. ALSO, scleroderma, large tumor in small breast BCT = breast conservation therapy, less radical forms than mastectomy

3. Evaluate the causes of postoperative fever and create a treatment plan. (5 W's are specifically on review PPt)

1. 38.5C or above after surgery 2. Associated with *cytokines released* by inflammatory cells responding to either tissue trauma or infection (monocyte, macrophage, neutrophils, IL1, IL6, TNF-a, interferon-gamma) *common causes* 3. *5 W's* - Day: Cause → work-up and treatment 1. POD 1: *Wind* - atelectasis → incentive spirometry, nebulizer 2. POD 3: *Water* - UTI → UA & Culture, Bactrim vs Cefepime 3. POD 5: *Walking* - DVT → upper and lower extremity venous duplex u/s & anticoagulation 4. POD 7: *Wound* - Surgical site infection → open wound, wet to dry dressings 5. POD 7+: *Weird* Drugs - B-Lactam abx, procainamide, INH, alpha-methyldopa → d/c the drugs *Other causes* 4. *Immediate fever* - onset in OR or in immediate post-OP period is due to *medication reactions* (AB, blood products, malignant hyperthermia-treat with dantroline) 5. *Acute fever* - first week after surgery; necrotizing infection (within 48 hours), anastomotic leak, PE, MI, pneumonia, aspiration, UTI, SSI, ETOH withdrawal, gout, pancreatitis 6. *Subacute fever* - over 1 week after surgery; site infection, UTI, line infection, AB-associated diarrhea, febrile drug reactions, thrombophlebitis, sinusitis 7. *Delayed* ; secondary to infectious cause Evaluation and Tx: *depends on the time and the pt's Sx* 8. Fever evaluation: ABCs, resuscitate, HPI (anesthesia record, op note, nurse report, flowchart), PE (wounds, drains, ulcers, tubes, etc.) 9. Post-op fever labs/studies - infection (CBC w diff, sputum Cx, UCx, Blood Cx X2, lumbar puncture if AMS/neck pain, C. diff toxin assay) 10. Imaging - CXR, LE venous duplex for DVT, CT scan for, abscess/leak/pancreatitis/PE, RUQ US for cholecystitis

Cardiac Disease management

1. Discontinue cardiac meds except: -B-blockers -Statins - *Clonidine* (worry about rebound hypertension) 2. Restart other meds gradually 3. Restart anticoagulation ASAP postop 4. hemodynamic control, fluid management 5. regional vs general anesthesia, pain control 6. blood transfusions only when STRICTLY necessary 7. Be prompt to recognize & treat acute coronary events 8. Control arrhythmias (rate > rhythm)

Describe a typical OR case for an Anesthesiologist

1st - Preoxygenatation - Using an nasal cannula or mask - 100% Oxygen (3mins) replaces nitrogen - Higher reserve for apnea / airway instrumentation 2nd - Administration of an opiate - Drugs: *fentanyl*, morphine, dilaudid - In a dose that reduces the amount of induction agent. (not intended to induce an anesthetic) 3rd - Induction (Multiple Options) Large amount, all at once - Intravenous Anesthetic Drugs: *propofol*, thiopental. In patients with cardiovascular complication : *etomidate* or ketamine - Inhalation anesthetic (Commonly used in kids) Drugs: isoflurane, sevoflurane, desflurane Administered with NO2, can cause immobility and amnesia Use the MAC (Minimal Alveolar Concentration required to suppress movement to a surgical incision in 50% of patients) 4th - Muscle relaxant (Neuromuscular Blocking Agents) - Drugs: *Succinylcholine* (Irreversible), Pancuronium, Rocuronium, Mivacurium (All reversible) - To facilitate endotracheal intubation. 5th - Intubation of the trachea - Once an adequate depth of anesthesia and muscle relaxation is attained - If the airway cannot be secured after multiple attempts, patients can be awakened to proceed with an awake, fiberoptic intubation or to cancel the anesthetic until further workup can be performed. 6th - Proper patient positioning - To avoid physical or physiologic complications. - Nerve damage from malpositioning during surgery is the second most common anesthetic complication 7th - Maintenance of "balanced anesthetic" 8th - Completion of Surgery - Reversed muscle relaxation - Decreased anesthetic depth (allows return to consciousness) - Removal of endotracheal (observed to ensure adequate ventilation) - Transfer to a stretcher and transport to the PACU

7. Compare and contrast the different types of breast cancer, including predominance, treatment, prognosis, typical course and patient outcomes.

25% new diagnosis are in situ *Ductal Carcinoma in situ- DCIS* i. Pre invasive form of ductal cancer ii. If not treated may develop invasive cancer in 30-50% of patients over 10 years iii. Typical appearance involves microcalcifications, rarely a mass on exam In conclusion: DCIS - Hasn't spread. Treated invasive. Operate and excise *Lobular carcinoma in situ- LCIS*, invasive lobular, NOT CANCER i. Considered a marker for increased risk of developing ductal or lobular carcinoma ii. Increased risk of cancer for both breasts *Angiosarcoma* - radiation induced, vascular malignancy *Phyllodes* - mixed connective tissue and epithelium, hematogenous metastases *Dimpling* - invaded suspensory ligamment *Skin of orange* - cancer invaded skin lymphatic, inflammatory *Hormone receptive* - to progesterone or estrogen, can block hormones and stop growth if positive

what fluids/electrolytes does a 70 KG pt require on day 1 then after 24 hours

70kg patient's requirements: Maintenance IVF: 110mL/hr = 2.6L/day Sodium (Na+): Needs 140-210 mEq/day Potassium (K+) : Needs 35-70 mEq/day After 24 hours: D5 ½NS + 20 mEq K+

Know the objectives, indications and major contraindications for the uses of each type of *General anesthesia*

A drug-induced loss of consciousness during which patients are not arousable even by noxious stimulus and often require a controlled airway Utilized in major surgeries

1. Compare and contrast wound types by classification, treatment, and types of injuries associated with each: *Abrasion*

AKA a Scrape -Loss of epidermis and possibly part of dermis -Clean and use wound care -Use topical antimicrobials -Use fluids if needed

Develop a plan for the identification and treatment of *acute and chronic pancreatitis*

Acute Pancreatitis - inflammation of pancreas ■ Most common causes: EtOH, gallstone disease, post-ERCP, trauma --> injury leads to blockage of pancreas and all the enzymes are activated inside pancreas instead of intestines. SX: Mild jaundice if obstruction, abdominal pain, *left upper quad pain radiating to back* (worse when walking or laying supine) N/v LABS: - elevated creatinine and hematocrit bc necrosis - elevated amylase and lipase U/s may show gallstone if obstructed ■ *Ranson's criteria * ● On admission: age >55 WBC >16,000 blood glucose >200 mg/dL AST >250 IU/L ● At 48 hours: serum calcium <8.0, Hct fall >10% hypoxia (PaO2<60) BUN increased by 5+ after fluid administration, base deficit >4 sequestration of fluids >6L ● If score ≥ 3, severe pancreatitis is likely ● If score < 3, severe pancreatitis is unlikely ○ 0-2: 2% mortality 3-4: 15% mortality 5-6: 40% mortality 7-8: 100% mortality ■ Newer criteria (Atlanta 2012 and DBC) focus on predicting the severity of disease based on the presence of the following and the time course that they happen over ● Organ failure (persistent >48 hours or not) ● Local effects (peripancreatic fluid collection, pancreatic necrosis, pseudocyst, abscess) ● Systemic severity scores such as Ranson's >3, APACHE II > 8 Treatment: Fluid Pain control Early post pyloric feeding (NOT NPO) Early ERCP if signs it is caused by stone Prophylactic antibiotics

BMP (basic metabolic panel):How it is written and normal Levels

BUN means blood urea nitrogen, a waste product of the liver your kidney should be getting rid of. Increase means kidney failure. Also the Co2 can also be written as Hco3, but either way it *is measuring the co2 in the blood*.

Not specifically an objective but Name these tumor markers! CEA CA 19-9 AFP PSA

CEA *(colon)* carcinoembryonic antigen CA 19-9 *(pancreatic)* cancer antigen 19-9 AFP *(testicular and hepatocellular)* alpha fetal protein PSA *(prostate)* Prostate specific antigen Remember that these *evaluate treatment effectiveness only*, and can't be trusted to diagnose or rule out cancer as they are thrown of by things like HCG. But if you see this and there is no Dx of CA you should *investigate further. *

6. Compare and contrast various causes of excessive surgical bleeding including appropriate diagnostic studies and treatment.

Causes of excessive surgical bleeding: ○ Surgical bleeding requires a return to the operating room - presents in the early postoperative period with tachycardia, hypotension and after volume resuscitation, a falling hematocrit ○ Bleeding is more likely in the *renal transplant patient* because of decreased platelet adhesiveness secondary to uremia 1. Signs/symptoms - vital signs, lab values, drain output 2. Location? Thorax, pelvis, abdomen, extremities, floor 3. Inadequate hemostasis is #1 reason! 4. Coagulopathy - plavix, Coumadin, heparin, blood transfusion, hypothermia 5. Stopping the bleeding - direct manual pressure, correct coagulopathy (FFP, fibrinogen, PLTs, vit. K), labs (Hgb/Hct, PT/INR, PTT, iSTAT, rapid TEG, type and cross), resuscitate,OR

Understand the concept of abdominal compartment syndrome and treatment.

Causes: - Aggressive IV fluid volume resuscitation - severe hemorrhagic shock - pelvic fracture - retroperitoneal hemorrhage Untreated = multiple organ dysfunction syndrome (MODS) FATEL The clinical triad: - increased airway pressures - decreased urine output - elevated abdominal pressure (SEE PHOTO) As well as: - Impaired venous return - Increased cardiac afterload - Increased intracranial pressure Diagnosis = measuring the pressure within the decompressed urinary bladder (Dome of the bladder acts as a passive diaphragm and transmits the pressure within the peritoneal cavity) Treatment: Decompressive Laparotomy Best treatment is prevention --> Early hemorrhage control --> Balanced hemostatic resuscitation --> Temporary abdominal closure

CHOLEDOCHOLITHIASIS

Choledocholithiasis- *gallstone obstructing the common bile duct* Obstructive jaundice - GGT, Alk Phos, total/direct bilirubin elevation (elevated LFTs) Intermittent RUQ Pain U/s shows dilated bile duct May resolve spontaneously, may require stone removal via *ERCP (endoscopically) or surgery* Patient should undergo elective *cholecystectomy* during same hospitalization

2. Given a clinical scenario, evaluate volume and/or electrolyte disorders and be able to assess the type and rate of replacement fluids. *Volume overload*

Clinical findings: pitting edema, diffuse swelling, crackles on chest auscultation, Body weight,High urine output( > .5ml/kg/hr) After a surgery volume overload is usually due to *too much fluid/improper IV fluid* Tx- *Mild= Fluid restrictions* *Severe= Diureses, Potassium replacement if needed.*

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Adrenal Insufficiency

Consider perioperative stress dose of steroids for: -anyone on exogenous corticosteroids (ie primary or secondary Cushing's) -critically ill patient -pregnant patient ii. Management - assess level of surgical stress to the pt 1. Minor surgery/local anesthesia: Rx NONE 2. Moderate and Major surgical stress: Rx 50-100 mg hydrocortisone IV before induction, then 25-50 mg q8h x 24h, then taper vs resume prior dose

Your patient is a 150 lb man who has a serum Na+ 114 mEq and he has become neurologically unstable. Calculate what volume of 3% saline should be used to correct the initial half of his sodium deficit and what length of time it would require

Correct ½ of the deficit over 24 hours (at a rate of no more than 0.5 mEq/L/hr) Factors: 2.2 lbs = 1 kg; 3% Saline has 513 mEq Na+ and TBW for a male is 0.65. Calculation: 1) 150 lb = 150/2.2= 68 kg; TBW = 0.65 x 68 kg = *44L* 2)Na+ deficit = 44Lx (140 - 114) = 1,144 mEq x1/2 = *572 mEq Na+* (3) mEq rate to increase Na+ titer by ~ 0.5 mEq/L/hr: 44L x 0.5 mEq/L/hr = *22 mEq Na+/hr* (4) Rate of infusion: 3% NaCl has *513 mEq* Na+ per liter, so 22 mEq Na+/hr x 1L/513 mEq Na+ x 1000 mL/1L = *43 mL/hr* (5) Length of infusion: 572 mEq Na+ ÷ 22 mEq Na+/hr = *26 hours*

6. Discuss the potential complications of IVF/electrolyte therapy, and detail effective therapies directed at these complications.

Correcting *hyponatremia* to quickly- *Central pontine demylenation* Do not correct more than 0.5mEq/L/hr Correcting *Hypernatremia* too quickly- *cerebral edema* Do NOT correct more than 10mEq/day or 0.5 mEq/L/hr Overcorrecting any of the other electrolytes leads to the problems of the opposite condition Ex Hypokalemia into hyperkalemia "Hi to low Brain Blows" "Low to Hi Pontine dies"

Revised Cardiac risk index

Each risk factor assigned 1 point 1. High-risk surgical procedures: abd, thoracic, major vascular 2. Hx ischemic HD 3. Hx CHF 4. Hx CVD 5. Preop use of insulin 6. Preop Scr > 2.0 Risk for a Cardiac event: Class I: 0 points 0.4% Class II: 1 point 0.9% Class III: 2 points 6.6% Class IV: ≥3 points 11%

CHOLELITHIASIS

Gallstones Present in 12% of Americans "5-Fs" ( female, fat, Forty, fertile, flatulent) Most are asymptomatic 70-80% gallstones are cholesterol stones Alone asymptomatic not an indication for surgery!

CHOLANGITIS

Gallstones -Ascending Cholangitis *Obstruction with bacterial stasis and inflammation* - there is an obstruction of the biliary tree--> stasis--> which lead to infection *Charcot Triad -* *1-Fever* *2- jaundice* *3- Right Upper Quadrant Pain* *Reynold's Pentad* - Above symptoms with: *Shock, Mental Status Change* ( this happens if the infection lead to fribrosis and stricture of the duct) SCLEROSING CHOLANGITIS TX: monitor for sepsis and hypotension! *- GENUINE MEDICAL/SURGICAL EMERGENCY!!!!!!* *Emergent fluids*, foley catheter, *antibiotics*, intensive care unit admission Endoscopic decompression-ERCP Should this fail, surgical extraction of stone, t-tube drainage of biliary system

BILIARY COLIC

Gallstones -Biliary Colic Symptomatic Gallstones - obstruction *Impaction of gallstone at GB neck* Intermittent RUQ pain-post prandially +/- nausea, vomitting Indication for elective cholecystectomy (removal of gallblader)

CHOLECYSTITIS

Gallstones -Cholecystitis *Gallstone obstruct cystic duct-> wall distention, inflammation of gallbladder * *Persistent RUQ pain*, N/V, loss of appetite *Gallstone on US, Murphy's Sign, wall thickening, pericholecystic fluid +/- fever/WBC/elevated LFTs* Indication for cholecystectomy during same hospitalization Or cholecystostomy (removal of stone but risk of recurrence)

IVF Chart from syllabus

Here is a chart of the composition of IVs. It's not an objective, but it is an "assigned reading" ..... so look at it.

What to do in a Hyperkalemia event

Hyper Kalemia above 5.4 is an EMERGENCY (Nml 3.5-5.0) -May see EKG changes, weakness, malaise, cardiac arrest. *C*alcium Gluconate *B*icarb/ Beta agonist *I*nsulin *G*lucose *K*ayexelate *D*ialysis I E Check EKG for abnormalities Don't forget about pseudohyperkalemia from bad sticks

2. Given a clinical scenario, evaluate volume and/or electrolyte disorders and be able to assess the type and rate of replacement fluids. *Volume depletion*

If their clinical presentation and labwork indicate that they are volume depleted, give them isotonic crystalloids like normal saline IV! You would see *elevated HR and decreased BP* See Chart to See what labs change and when they change with volume depletion. If you see these indications bolus IVF: 20mL/kg in peds, 1-2L in adults *Assess response and re-bolus until response has improved.* *-i.e. improved tachycardia, hypotension, urine, mentation* Use clinical judgment (if history of renal or cardiac failure, will give smaller boluses; if septic shock in a previously healthy individual, will provide larger boluses) Blood loss-LR (if HGB <7, transfuse) GI- Normal saline or LR Isotonic losses- Normal saline *How much to give if you know exactly how much they have lost* NS *3-to-1 rule* 3L NS to replace 1L of plasma Albumin/blood *1:1 replacement* 1L of 5% albumin or 3 Units (1 L)of PRBC to replace 1 L of plasma. Free water is 9:1 (and inefficient, don't give them water to drink if they are volume depeted)

7. Compare and contrast hypercoagulable states that affect the perioperative patient. Given a patient scenario create a treatment plan for a hypercoagulable patient.

If they are at risk for any of these give *Low molecular weight heparin* Watch out for HIT If they have or are developing any of this stuff give Heparin, coumadin, or both If they develop HIT give argatroban (DTI), lepirudin (DTI), or danaparoid (Anti Xa)

1. Compare and contrast IV fluids and their applicability in different patient scenarios. *Isotonic fluids*

If you are also giving *blood products*, only give *Normal saline*. D5w hemolyzes and LR cause clotting Only *20-30%* of the normal saline you give remains intravascular. Use LR to replace GI losses, acute blood loss (if not transfusing), and *burn or trauma Pt's*

5. Understand the potential causes of postoperative fever, including the meaning of nosocomial infections, and appropriate diagnostic steps when evaluating fever

Immediate post-op fevers (day 1 or 2): 1) *Atelectasis* (90% of pt under general anesthesia): consolidation from lack of negative pressure ventilation, typically in bases (decreased breath sounds). Tx: incentive spirometry, no abx needed 2) *Necrotizing Fasciitis*: surgical emergency, travels through fascia plane, sick appearing, causative agents: C. perfringens, streptococcus Tx: Surgery + PCN or Clinda The 5 W's of Post-op fever (38.3F) 1) *Wind* -> POD 1-2 -> Pneumonia 2) *Water* -> POD 2-3 -> UTI (usually due to Foley) -> UA, culture, WBCs -> Bactrim and Cefepime *in absence of functional/anatomic obstruction to urine flow, a post-op fever should not be attributed to the UT even with pos cultures. 3) *Wound* -> POD 3-5 -> SSI -> open wound -> wet to dry dressing (tachy may be 1st sign, followed by fever) 4) *Walking* -> POD 5-7 -> DVT -> up/low extremity venous duplex US & anticoag- Virchow's triad: stasis, endothelial injury to vessel wall, hypercoag state. (watch out for PE) 5) *Wonder/weird drugs* -> dx of exclusion -> drug fever- chemotherapeutic agents, abx, invasive lines/blood products -> D/C drugs "W" abscess: POD 7-10 (from book) *Nonsocomial infections*: hospital-acquired. All infections that occur after surgical procedure. SSI is 2nd MC nonsocomial infection (14-16%)* , SSI are related in >75% post-op deaths. Ex: Ventilator associated pneumonia, UTI, MRSA, C. diff, SSI *book says 2-5% of surgical pt

1. Compare and contrast IV fluids and their applicability in different patient scenarios. *Hypotonic fluids*

In D5W the dextrose (aka glucose) is broken down in the body, so what starts as isotonic in the bag ends up making the veins hypotonic. Don't give someone D5W if they are hyperglycemic Don't use D5W right after surgery due to complications from DI.

Understand the concept of 'damage control' surgery in the trauma setting.

In serious injury with *shock and hypotension*, it may not be possible or advantageous to attempt to repair all wounds at initial operation. Damage control surgery fundamentals: - - Control of massive hemorrhage - Control of enteric contamination of the peritoneal cavity - Minimize "lethal triad" (hypothermia, acidosis, and coagulopathy) Damage control techniques: Life-threatening hemorrhage --> - pack the abdominal with laparotomy pads - direct ligation - repair of bleeding sites - organ removal (i.e., splenectomy). Injured bowel --> - Resected but not anastomosed (minimize operating time) *Temporary abdominal closure* Usually take 60 to 90 minutes, then the patient is transferred to the ICU for resuscitation, rewarming, and correction of coagulopathy. Once stabilized, the patient is returned to the operating room 12 to 36 hours after the initial abbreviated laparotomy.

1. Compare and contrast IV fluids and their applicability in different patient scenarios. *Hypertonic fluids*

It is rare to use 3% NaCl, and you pretty much never use 5% You can give hypertonic saline to help with *Severe hyponatremia* but correct SLOWLY or you will permanantly demilenate part of their brain. It can also be used to treat elevated intracranial pressures (because 3% NaCl is hypertonic, it will draw water out of brain cells)

Discuss the *role and functions of the anesthesiologist* during surgical procedures.

It is standard anesthesia practice to apply monitors to measure: 1) Circulation (Watching for hypotension, blood loss, MI risk,Pain (HTN & Tachycardia)) - Arterial blood pressure (a-line, blood pressure cuff) - Heart rate (EKG) 2) Oxygenation (pulse oximeter) 3) Ventilation (capnography) (Watching for respiratory depression) 4) Temperature

Compare and contrast *open* vs. *laparoscopic* surgical procedures

LAPAROSCOPY: -Abdominal access via small incisions -Intraperitoneal insufflation with carbon dioxide -Performance of surgery utilizing camera and specialized laparoscopic instruments ADVANTAGES: Minimal Access (Less Scarring) Decreased Pain/ faster healing Shorter Hospitalizations Better Anatomic Visualization (going right where you need to be + don't have huge hands and instruments taking up space and blocking your visualization) DISADVANTAGES: Carries same risks as open surgery, with the addition of: Gas Embolism Pneumothorax May require conversion to open surgery Poor visualization No tactile sense Harder to control bleeding CONTRAINDICATIONS TO LAPROSCOPY: -Inability to withstand general anesthesia -Hypovolemic Shock -Heart Failure, Severe COPD-cannot tolerate pneumoperitoneum -Intractable bleeding disorders -End-stage liver disease (cannot coagulate well, will be even harder to control bleeding.)

Discuss procedure and strategy for *closing the abdomen*

LAYERS of Abdomen: Skin Subcutaneous Fat Campers Fascia Scarpa's Fascia Abdominal Wall Fascia Highest Tensile strength Pre-peritoneal Fat Peritoneum *Facial Closure* Running suture Interrupted suture *Retention Sutures* A heavy reinforcing suture placed deeply within the muscles and fasciae of the abdominal wall to relieve tension on the primary suture line and avoid postsurgical wound disruption. Internal External Skin closure ("its a luxury) None Stapled Suture Interrupted Running Subcuticular Other Secure Drains Ostomy appliance Abdominal Binder

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Liver Disease

Liver has a HUGE role in drug metabolism, coagulation, visceral-portal hemodynamics, albumin production *Work-Up*: H&P: EtOH, IVDU, blood transfusions, sexual promiscuity, fam hx, wt changes, fatigue, variceal bleeding, active infection, anemia, encephalopathy, hypoxemia, malnutrition, Jaundice, increased abdominal girth, mental status, hepatomegaly, gynecomastia, loss of body hair, etc. *Labs*: -CBC -Coag studies -albumin -total protein -CMP -Drug screen *Management* 1. Have to think about their coagulopathy and how you'll deal with it 2. Correct coagulopathy: vit K, FFP, factor VII, cryoprecipitate, avoid fluid overload 3. Correct electrolyte abnormalities 4. Aggressively treat ascites: diuretics, diuretics at time of surgery, drainage, admin albumin 5. Nutritional support: adequate protein intake minimize Na 6. Treat encephalopathy: lactulose, prevent precipitating events such as GI bleed, infection, excess protein

Describe a *Midline laparotomy* incision

Midline laparotomy (incision of indecision)

Describe the course of *acute appendicitis*. Create a plan for the identification, treatment, complications and patient education of *acute appendicitis*

Nausea/Vomiting/Anorexia Pain starting centrally, moving to RLQ Localizes to McBurney's Point (1/3rd the distance between R ASIS and Umbilicus) Fever, mildly increased WBCs DX: CBC, UA, Pelvic/Rectal Examinations (mak sure its not PID for example.) CT often performed, rarely necessary Patient to OR for appendectomy-usually performed laparoscopic TX: Appendectomy - usually laparoscopic Men usually just get the surgery with enough symptoms, dont need to investigate much. women may have a CT and other lab to make sure it is really the cause

Compare and contrast electrolyte abnormalities including symptoms, causes, management, complications, and patient education. *Phosphate*

Nml Phosphate 2.5-4.5 *Hyperphosphatemia* Cause:Decreased renal secretion (kidney failure), Increased vitamen D, tuberculosis, sarcoidosis, Acidotic states, tumor lysis, Rhabdo Sx:None Tx: Often unnecessary If you have to, give aluminum based antacids *Hypophosphatemia* Common in surgical Pt's Often accomanied by changes in Mg and K. Sx: anorexia, dizziness, osteomalacia, severe congestive cardiomyopathy, proximal muscle weakness, visual defects, ascending paralysis, Causes: Inadaquate uptake or absorbtion, Increased renal excretion (diuretics, hypervolemia), or shifts into the cells due to hormones/ DKA Tx, and alcohol Tx: Remove cause Severe = phosphate salts

1. List the common pre- and postoperative lab studies and interpret their significance in a surgical patient.

No absolute correct answer. Each pt and surgery are different. Try to find Dz that could affect/contraindicate the surgery *Do not* randomly order any and all tests. Only run what is pertinent to *your Pt* based on Hx and their surgery Common pre-op labs include. *CBC* *BMP, Mg, Phos* (Shows their electrolytes, more serious, not routine) *LFTs* (Liver function tests, not routine) *Urinalysis* (drug screen ordered seperately) *Coags* (especially if they are on blood thinners.) *Tumor Markers* These are used to follow progress of an older cancer, not to diagnose a new one due to false positives and negatives.

Compare and contrast electrolyte abnormalities including symptoms, causes, management, complications, and patient education. *Magnesium*

Normal range 2.0-2.7, Magnesium regulates movement of calcium into smooth muscle cells *Hypomagnesia* Causes: diuretics, *malabsorbtion* alcoholics, chronic malnutrition, diarrhea, diabetics, Sx-can cause arrhythmias (torsades de pointes) Tx- All Correct the cause Mild-Oral supplaments Moderate- IV Mag sulfate 50-100 meq/day Severe-Bolus IV 8-16 Meq Mag sulfate then IV Tx *Hypermagnesia* (rare) Causes- rhabdo, dehydration, renal failure Sx-hyporeflexia, weakness/lethargy, decreased DTR Treatment: Mild- hydration, control intake Severe- give calcium, may require dialysis

3. Calculate maintenance fluid requirements for adult patients if given body weight in lb or kg (lb=kg x2.2; kg = lb÷2.2).

Now the pt is euvolemic. How much do you give them to stay that way. A. use the *4:2:1 rule* 4:2:1 rule: 60 + (weight in kg - 20) ■ 4cc/kg/hr for the first 10 kg ■ 2cc/kg/hr for the second 10 kg ■ 1cc/kg/hr for each additional kg E.g. If 70 kg male, needs 4 x 10 (1st 10 kg) + 2 x 10 (2nd 10 kg) + 50 (additional kgs) = 110 ml/hr If weight is provided in lbs, must divide by 2.2 first to get weight in kg Or (much easier) B. *take the weight in kg and add 40 to find the number of cc/hour needed*

ACUTE BILIARY PANCREATITIS

Occurs primarily in acute obstruction Most often secondary to gallstones, but can be due to malignancy (stone in pancreatic duct causing inflammation) *Epigastric Pain radiating to back, vomiting, elevated amylase/lipase* Initial Medical Management (NPO, IVF, NGT, Pain Control) Stone Extraction-ERCP Cholecystectomy during same hospitalization once enzymes normalize *Courvoisier's Sign/Law: *An enlarged, *nontender gallbladder* in a patient with jaundice is unlikely to be due to gallstones ---> more likely to be a pancreatic head tumor or another biliary tumor. This kind of biliary obstruction evolves slowly. The gall bladder will be dilated, with a thin wall; it is not tender to the touch. By contrast, acute cholecystitis due to obstruction by stone(s) is a quick process that causes a dilated gall bladder that is tender to the touch (Murphy's sign). The inflammation of chronic cholelithiasis results in a shrunken, fibrotic gallbladder.

Identify a patient presenting with *diverticular disease*. Create a differential diagnosis, including an understanding of *colon and rectal carcinoma*, and propose appropriate treatment plans, evaluate your patient's risk factors, discuss complications and recommend appropriate patient education.

PRESENTATION: Abdominal pain (specially LLQ) - fever -WBC - *bright red blood per rectum* *Hinchey Classification* Hinchey I - localized abscess (para-colonic) Hinchey II - pelvic abscess Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity) Hinchey IV - feculent peritonitis Useful to guide management. Anything up to a Hinchey III can be treated with *laparoscopic washout and antibiotics*, avoiding the need for exploratory *laparotomy and ostomy*

3. Be able to calculate the extent of burn size as % total body surface area (TBSA) using the 'Rule of 9's' for adults and infants.

Palmar surface = 1% TBSA Head & Neck= 9% 1 Entire Arm= 9% 1 Entire Leg= 18% Anterior trunk= 18% Posterior Trunk= 18% Genitals= 1%

2. Understand burn pathophysiology, and be able to compare and contrast the clinical features, classifications of burn depth

Pathophysiology: 3 Burn zones *Zone of Coagulation:* inner most area of burn, total tissue loss *Zone of Stasis:* Reduced perfusion but may be salvaged with resuscitation *Zone of Hyperemia:* Inflammed area high perfusion but not damage. -When a burn crosses 30% of TBSA its inflammatory effects are systemic -Increased capillary permeability (ARDS) -Edema (burn and non burn skin) -Large fluid losses -Burn patients Ebb and Flow (HI metabolism--> Low metabolism) -Burn patients will require A LOT of nutrition. -an NG tube is often used

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Pulmonary Disease

People with lung disease have the *longest hospital stays* Pulmonary Complications: -*atelectasis* -infections (pneumonia, bronchitis) -respiratory failure -prolonged mechanical ventilation -bronchospasm -*exacerbation of chronic disease* -hypoventilation -loss of cough reflex -*decreased mucociliary clearance* -foreign bodies in airway *Work-Up* 1. H&P -Screen for: COPD, smoking, left-sided HF, obesity, sleep apnea, functional status, asthma, meds (ask re: inhaler use) -Heart & Lung exam, BMI *Labs* a. ABG → PaCO2 > 45 increases risk b. CXR → baseline, rarely changes management c. PFT, exercise testing -Canet Risk Index → 7 independent risk factors (not on exam) a. advanced age, decreased pre-op O2 sat, respiratory infection within a month of surgery, pre-op anemia, emergency surgery *Management* 1. smoking cessation! - affects tissue perfusion and healing time, ideal is 8 weeks 2. optimize chronic disease conditions: bronchodilators, steroids, antibiotics (if active infection), breathing exercises 3. Appropriate pain control → the stress of pain is going to perpetuate the issue 4. Judicious fluid administration 5. encourage breathing exercises, incentive spirometer 6. chest physiotherapy, positive pressure ventilation 7. prompt tx of infection 8. prevent aspiration

What makes a patient high risk for VTE? (DVT, PE) (review slide)

Preexisting hypercoagulable state, including but not limited to DVT, PE Cancer surgery Prolonged recovery: -Immobility -Prolonged intubation Ortho/trauma surgery Spinal cord injury

CHRONIC PANCREATITIS

Progressive and persistent inflammation of the pancreas --> permanent damage with endocrine and exocrine deficiency Risk Factors - alcohol (>70%) Tobacco Trauma Genetic (Cystic fibrosis) Idiopathic SX: May be asymptomatic until 90% of function is gone - abdom pain *Weight loss stearorrhea/ malabsorption* -- *onset of diabetes * *low serum trypsin* ERCP for diagnosis Treatment Medical: low fat diabetic diet with pancreatic enzyme replacement ERCP to remove stones Drainage or resectional surgeries (Frey or whipple)

CBC: How it is written and normal Levels

Reminder: *Hgb* The amount of hemoglobin in 100mL (a deciliter) of blood Provides an indication of the O2 transport capacity of the blood decrease means anemia *Hct* Packed cell volume, percentage volume of blood that is made up of erythrocytes Usually 3 times the value of Hgb decreased means in anemia

Pancreatic cancer

Risk Factors: The most firmly established risk factor of pancreatic cancer is cigarette smoking Nitrosamines have been found to be experimentally contributory Obesity Age >65 Gender (M>F) Race (AA>Caucasion) Presentation: No symptoms in the disease's early stages which contributes to the often too late diagnosis *Painless Jaundice is pancreatic cancer until proven otherwise* Unexplained weight loss Light colored stool Dark urine Loss of appetite DX: -CT scan chest abdomen, and pelvis looking for the mass as well as metastatic disease -LFTs may show elevated transaminases, total and direct bilirubinemia, and alk phos -CA19-9 frequently elevated in pancreatic cancer -EUS: Endoscopic ultrasound and Fine needle aspiration biopsy for tissue diagnosis Treatment: *Pancreaticoduodenectomy (Whipple)* Removes gallbladder, common bile dict, part of the duodenum, and the head of the pancreas Usually performed through midline laparotomy but can also be done through bilateral subcostal incision or laparoscopically -- 3 anestemosis Picture slide 35

1. Given a clinical scenario, identify a patient presenting with postoperative thromboembolic disease. Discuss risk factors, methods of prevention, and management of thromboembolic disease in the surgical patient.

Risks for DVT, or VTE (DVT to a PE) We're worried about a recent surgery putting them in virchows triad, causing a clot, and them throwing said clot into their lungs. Higher risk includes cancer, obesity, smoking, old age, pregnancy, estrogen (OCs, HRT), heart dx, immobilization, central line, surgery (orthopedic) Dx: with physical exam, patient stable, lung sounds, heart sounds, ABG, *CT angiogram looking for PE*, *U/S looking for DVT*, d-dimer not good for post op because already elevated; Prevention: Get them moving, Use a Sequential compression device (SCD) an inflatable sleeve to improve blood flow. Anticoagulate with heparin or use IVC filter Tx: Anticoagulants

Outline the *initial evaluation* and use of diagnostic tools for workup of *Penetrating abdominal trauma*.

SEE PHOTO *Abdominal stab wounds* - Anterior abdomen = local wound exploration - Subcostal space = diagnostic laparoscopy (very difficult to see on a CT or x-ray) - Back/flank = CT scan Additional Tips: - Consider CT scan if patient is morbidly obese (BMI > 30) or wound tract is long and tangential. - #FAST showing hemoperitoneum = Local Wound Exploration & complete blood count.

Outline the *initial evaluation* and use of diagnostic tools for workup of *blunt abdominal trauma*

See Diagram

5. Be able to create surgical notes and orders required of MDs/PAs on a surgical team.

Select the note you need, fill out accordingly *Pre-op Note* i. Date/Time: (of Preop note entry) ii. Diagnosis: (pertinent to surgery needed) iii. Plan: (surgical procedure planned) iv. Surgeon(s): v. Labs: (CBC, PT/PTT, BMP, LFTs, U/A) vi. CXR: (results) vii. EKG: (results) viii. Blood: (none, Type & Screen, or Type & Cross # units) ix. Consent (operative permit): 'Signed' *Operative Note* i. Date/Time: ii. Preop Diagnosis: iii. Postop Diagnosis: (may or may not be the same) iv. Procedure(s): v. Surgeon(s) & Assistant(s): vi. Anesthesia: (general, spinal, epidural, regional, local) vii. Estimated Blood Loss (EBL): viii. Fluids: (IVF/blood and volume) ix. U/O: x. Findings: xi. Specimen(s): xii. Drain(s): xiii. Complications: xiv. Condition: xv. Disposition: *Post-Op - POD 1* i. Assess level of pain, heart and lung status, gut activity ii. Examine for distention, bowel sounds, tenderness, wound drainage, bleeding iii. Convert IV meds to PO when tolerated iv. Out of bed activity as tolerated v. Consider stool softener vi. DVT prophylaxis *Post-Op - POD 2-7* i. Assess patient daily ii. Be alert for complications and treat accordingly iii. Daily laxative as needed until stooling iv. Advance diet as tolerated v. Discontinue tubes/drains as indicated vi. Change or remove surgical dressing vii. Check pathology report(s), cultures viii. Prepare for discharge *Post-Op - Daily SOAP Note* i. Date/time, HD#/POD#, abx day/Total # abx days planned ii. Subjective, how pt feels, observations re: pain relief, digestive tract, food/fluids iii. Objective, data collection, results iv. Assessment, summarize condition and enumerate pt issues v. Plan, detail plan of action *Post-Op - Discharge* i. Write orders, provide education, arrange for home care, discharge Rx, schedule f/u, write discharge summary, and cc info to referring dr ii. Admission Date: iii. Discharge Date: iv. Attending Surgeon: v. Primary Diagnosis: vi. Secondary Diagnoses: vii. Consults: viii. Procedures /Dates: ix. Reason for Admission (HPI): x. Hospital Course: xi. Discharge Labs: xii. Discharge Meds: xiii. Condition at time of discharge: xiv. Discharge Instructions: diet, bathing and activity restrictions, wound and dressing care, parameters for reporting concern xv. Followup appt(s):

Compare and contrast electrolyte abnormalities including symptoms, causes, management, complications, and patient education.*Hypokalemia*

Serum K < 3.5 Causes: diuretics, magnesium depletion, diarrhea, alkalosis Sx: Muscle weakness if severe (<2.5), and can be arrhythmogenic Treatment: *Remove cause* (if diuretic) *Give KCl* until pt is back to 3.5 *orally* if possible (do not exceed *40 mEq/hour orally*) or *IV if necessary* (Do not exceed 10 mEq/hour if IV)

Compare and contrast electrolyte abnormalities including symptoms, causes, management, complications, and patient education.*Hyponatremia*

Serum Na <135 Most common cause post op is *SIADH*, which you treat with *water restrictions* *Sx*: anorexia, nausea, lethargy, disorientation, agitation, neurological deficits, seizures, coma, death For neurologic symptoms then diuretic and 3% (hypertonic) saline. (Make them pee out the extra water while you add NA) TX: 1- determine *Na+ deficit = TBW x (140- actual [Na+])* *TBW* =60% X weight in men = 50% X weight in women = 40% X weight in elderly pts Give *no more than half* of deficit in first *12-18 hours*, then the rest over *24 to 48 hours* Do not correct more than 0.5mEq/L/hr due to risk of central pontine myelinolysis (CPM) Unless the Sx are life threatening neurological Sx you give Normal saline (.9%) If they are neuro Sx give 3% but be careful

Compare and contrast electrolyte abnormalities including symptoms, causes, management, complications, and patient education.*Hypernatremia*

Serum Na > 145mEq/L *Sx* restlessness, ataxia, seizures, lethargy, altered mental status *Hypovolemic Hypernatremia* They have lost both Na and water, but more water relatively, often seen after surgery *Sx* restlessness, ataxia, seizures, lethargy, altered mental status *Causes* *Loss of hypotonic fluid* Also, patients with large wounds/burns/Crush injuries can have massive *insensible losses* of hypotonic body fluids *Tx:* Correct their *volume deficit* with isotonic crystalloid solutions *(LR or NS)* then correct the *free water deficit no faster than 0.5 mEq/L/hr with D5W*

What factors predict pulmonary complications after surgery (Review Slide)

Smoking Lengthy surgery Surgery near diaphragm /Neuromusc blockade Site of surgery Current infection Preexist COPD OSA

6. *Recognize breast tumor staging*, implications, and general treatment options according to TMN and axillary node staging described in slides.

Stage 0,I,II is potentially curable meaning it may never reoccur. III or IV is possibly treatable. Regardless, surveillance for life. -Most common area of mets are bone, lung, liver, and lymph node

Outline the *initial evaluation* and use of diagnostic tools for workup of *abdominal trauma*

Step #1: Trauma history from paramedics Step #2: Primary Survey (ABCDE) - Visual Exam - Complete visualization of the exposed abdomen, flanks, & back and extremities - Documentation of old scars, bruising, puncture wounds, lacerations, asymmetry, and distension a Step #3: Palpation (May be unreliable) - The abdomen - Pelvis (Lateral and anteroposterior compression, looking instability) - *#FAST if necessary* (Focused assessment with sonography for trauma SEE PHOTO) Step #4: Follow workup diagram based on type of injury (Penetrating (next card) vs blunt (In 2 cards)) Step #5 :Repeat as needed - Secondary and tertiary abdominal exams should be performed to minimize the risk of missed injury.

2. Examine the four classes of surgical wounds and explore the frequency with which each type becomes infected, what type of infection typically ensues, and extrapolate this to examples of how these infections may occur.

Surgical Site Infection (SSI)= infection related to operative procedure that occurs @ or near surgical incision w/i 30 days or 1 year if an implant is left. *CLASSIFICATION OF SURGICAL WOUNDS*: based off level of potential bacterial contamination. 1. *Clean* - (Class 1, 1-3% risk of infection) most common category, include most elective surgeries: surgical procedure with prepped skin, not infected, no preexisting skin inflammation, no respiratory, GI or GU tract involved, primary closure Ex: inguinal hernia, thyroidectomy, mastectomy, vagotomy, neurosurgery, aortic graft MC agent: Gram positive organisms. S. aureus/epidermidis 3% infection frequency 2. *Clean-Contaminate* (Class 2, 2.4-7.7%): Respiratory, GI or GU tract, mechanical and antibacterial preparation, no evidence of an active infection, minor sterile technique errors Ex: cholecystectomy, appendectomy, elective colon resection, gastric resection, adenoidectomy, gastronomy tube, common bile duct exploration MC agent: Endogenous flora, polymicrobial 5-15% infection frequency 3. *Contaminated* (Class 3, 6.4-15.2%): Acute non-purulent inflammation, traumatic open wound, major failure in sterile technique, emergent wound massage, significant GI leak, secondary or delayed primary closure, gross spillage during operation Ex: Gangrenous, cholecystitis, enterotomy (incision of intestine), perforated ulcer MC agent: Endogenous flora, polymicrobial 15-40% infection frequency 4. *Dirty* (Class 4, 7.1-40%): Old traumatic wound (>6hr) aka established infection prior to surgical intervention, necrotic or infected wound, hallow organ perforation, active infection, delayed course Ex: Perforated apendicular abscess, perforated diverticulitis, infected mesh, resection of infarcted bowel, MC agent: Mixed - polymicrobial 40-50% infection frequency In addition, this was in ppt and study guide... *Types of Surgical Infections* 1. Incisional: deep and superficial -*Incisional Superficial*: (60-80%), infection involving skin & SQ tissues PLUS 1 of these: a. purulent discharge, b. wound opening by surgeon, c. positive culture, d. surgeon's diagnosis (Exclusion- wound environment): suture abscess, infected episiotomy, infected neonatal circumcision, infected burn) -*Incisional Deep*: Infection that involves soft tissue, fascia, and muscle of an incision PLUS 1 of these: a. purulent discharge, b. fever > 38, spontaneous or intentional wound opening, pain and tenderness c. Visual, radiological or histological evidence of abscess d. Surgeon's diagnosis 2. *Organ/Space*: more serious, may require operative/radiological drainage that involves any part of the anatomy that was manipulated PLUS 1 of these: a. purulent drainage from organ or space b. positive culture c. visual, reoperative, radiological or histopathological evidence of organ/space infection d. Surgeon's diagnosis

Describe the port placement of a *Laparoscopic Cholescystectomy*

Surgical removal of the gallbladder

Predict a patient's level of surgical risk based on history, physical exam, and lab results.

The *Dripps-American Surgical Classification* is used to quantify surgical risk. Categorizes patients into 5 groups - Class I = Healthy Patient: limited procedure - Class II = Mild to moderate systemic disturbance - Class III = Severe systemic disturbance - Class IV = Life-threatening disturbance - Class V = Not expected to survive, with or without surgery

Principles of Balanced Anesthesia

The goal of Balanced Anesthesia is to maintain the requirements of anesthesia, which are: 1. analgesia 2. amnesia (unconsciousness) 3. skeletal muscle relaxation 4. control of the hemodynamic responses to surgical stimulation. Anesthesia is maintained with a combination of: - An inhalation agent: Examples: isoflurane, sevoflurane, desflurane - nitrous oxide (NO2) - Opiate Examples: Fentanyl, Morphine, Dilaudid - Muscle Relaxant Examples: Succinylcholine (Irreversible), Pancuronium, Rocuronium, Mivacurium (All reversible) Analgesia = opiates and inhalational agents Amnesia = benzodiazepines, nitrous oxide, and inhalation agents Muscle relaxation = neuromuscular-blocking drugs, inhaled agents, or local anesthetics.

2. Construct appropriate postoperative orders for a given patient.

The pt's medical status has changed after surgery so this is basically a readmission. You have to re write their orders. Remember *ADCVANDIML* or if you are not a robot *After Deadlifting connor (im all) veiny And Numb Down In My Legs* It stands for: *Admit* *Diagnosis* *Condition* These three are always first and in this order *Vitals* (how often) *Activity* (stay in bed, walk around etc) *Nursing*- (ins and outs, drains, respiratory, monitors, dressings, accuchecks) *Diet* *IV fluids* (how much) *Meds* ( you have to re write their med list. do they still need old meds, is it still appropriate. Do they need more.) *Labs* (what and how frequent) don't forget "other" which includes anything pertinent to your specific pt

4. Be able to outline a plan for fluid replacement using the Parkland formula given body weight and % TBSA burned.

This helps determine amount of fluids needed within the 1st 24 hrs. *Parkland Formula= 4mL x %BSA x Wt in Kg* (4 x 30 x 75 kg)= 9,000 mL/ 24 hrs (4.5 L in the first 8) 1/2 of this should be given in the first 8 hours 1/2 over the next 16 -Lactated Ringers is the recommended fluid to administer

8. Given a patient with hemoperitoneum, create a differential diagnosis and treatment plan.

This is a *free intraabdominal hemorrhage* (in the peritoneal cavity) and can be *traumatic or nontraumatic in origin*. Causes: *anything that makes you bleed internally*. If untreated Internal bleeding can lead to hemorrhagic shock and death. The pt will have *Sx of blood loss*, *Thirsty, tachy, pallor, low HGB/HCT etc.* But injury might or might not be obvious. If you suspect it, get a *fast US, CT scan, or paracentesis* Tx: Requires *emergency Surgery* to stop the bleeding, the type of surgery depends on what is bleeding. Differential diagnosis will vary based on history. Don't memorize this list, they are just examples: Penetrating and deep abdominal trauma. Stabbing penetrating wound. Blunt trauma caused to the major abdominal organs like the liver or spleen. Spleen rupture. Spleen injury. Liver rupture. Bowel laceration. Aorta or any other vascular rupture like abdominal aortic aneurysym. Laceration of pancreas. Ectopic pregnancy and hemorrhage. Uterine rupture. Rupture of ovarian cyst. Perforated gastric ulcer

1. Compare and contrast wound types by classification, treatment, and types of injuries associated with each: *Avulsion*

Tissue is *torn* partially or fully away from insertion -Debride of necrotic tissue and suture in place -Allow wound drainage (loose suture) -Complete Avulsion= SAD face, no replacement

Fluid compartments

Total Body Water (TBW) in Liters = MALE 0.60 x Wt (kg) FEMALE 0.55 x Wt (kg) Intracellular Fluid (ICF) = 2/3 TBW Extracellular Fluid (ECF) = 1/3 TBW -Interstitial Fluid = 2/3 ECF -Plasma Fluid = 1/3 of ECF

When should you transition a burn patient to a burn Center?

Transition care when: -A *partial thickness* burn is greater than *10%* TBSA -A *full thickness* burn is greater than *5%* TBSA -The burn location is in a sensitive area -There are comorbidities (IE age, trauma, etc) -Children -Special needs that your facility cannot meet.

5. Be able to calculate a patient's free water deficit as well as volume of IVFs required to correct the deficiency.

a. Free water deficit (in L) = TBW x [serum sodium - 140]/140 givethis much over the next 24-48 hrs in either their tube feeds or d5w via IVF

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Renal Failure

i. Kidneys 1. 15% of the population has renal disease 2. A lot of drugs are metabolized by the kidneys 3. Fluid, electrolyte and acid-base balance 4. Erythropoietin production → when you have renal dz the kidneys don't stimulate epo production by the bone marrow, these pts are anemic ii. Renal Dysfunction 1. Causes: HTN, DM, polycystic kidney disease, nephrotic/nephritic syndromes 2. Leads to: HTN, CVD, anemia, osteodystrophy, coagulopathy, neuro impairment *Workup* -H&P a. Cause of ESRD and if associated systemic disease (HTN, CVD); other complications b. Daily urine output → if on HD, how often, what access, where done, how tolerated c. history of previous surgery, anesthetics, analgesics d. Overall appearance, signs of coagulopathy, complete cardiac exam e. Inspect AV fistulas, portacath, PD cath, other HD access sites -*Labs* a. *CBC, coagulation studies, CMP, U/A, HbA1c* b. EKG, Echo, CXR *Management* 1. Protect existing renal function! a. avoid nephrotoxins (contrast dye, NSAIDs, b-lactams, vanco) b. maintain euvolemia, NHCO3, time use of dialysis appropriately (usually just before surgery and PRN) 2. Adjust meds 3. Maintain fluid, electrolyte, and acid-base balance a. surgery, anesthesia, analgesia can worsen acidosis, hyperkalemia b. I/O balance; account for insensitive losses 4. Indications for Dialysis: *A*cidosis, *E*lectrolytes, *I*ntoxication, *O*verload, *U*remia

Extend your preoperative evaluation to encompass patients with the following conditions: ♣ Pregnancy

most common px: -appendicitis -biliary disease -trauma -breast/cervical dz -bowel obstruction *Avoid elective surgeries* Surgical issues: physiologic changes (anemia, thrombocytopenia, pro-coagulant state, relative hypotension); teratogenesis, miscarriage/preterm labor, aspiration Management: 1. *Delay* semi-elective procedures until *2nd trimester* 2. communication: surgeon, obstetrician, anesthesia, neonatologist 3. If 24-36 weeks, prophylactic glucocorticoids 4. Thrombophylaxis: Sub Q heparin, early ambulation 5. Meds: always look up teratogenic potential 6. Monitor fetal heart rate Intraoperative considerations: difficult airway, positioning, materno-fetal hemodynamics, be ready for emergent C-section

6. Compare and contrast Emergency, Urgent, and Elective surgeries apply what you know to decide urgency in a given clinical scenario.

o *Emergency Surgery* - Immediately life-threatening condition; surgery must be performed ASAP Ex: Ruptured appendix, open skull fracture, gunshot or stab wound, complete bowel obstruction o *Urgent Surgery* - Potentially life-threatening condition; surgery usually must be completed within 24-48 hours. Ex: Kidney stone, partial stomach or bowel obstruction, bleeding hemorrhoids, ectopic pregnancy o *Elective Surgery*- Timing of surgery subject to patient and/or physician choice. Surgery would be beneficial to the patient, but it doesn't need to be done at a particular time. Ex: Joint replacement skin biopsy, kidney transplant

Normal serum osmolality

ranges from 280-295 mOsm/kg Also, this is *not* *Osmolarity*, which is the actual number of molecules per L of solution.

8. Know the terms sterilization, antiseptics, and aseptic technique

■ *Sterilization* - process that eliminates or kills all forms of life and other biological agents from an object ■ *Antiseptics* - chemical agents that slow or stop the growth of micro-organisms on external surfaces of the body and help prevent infections. (antibiotics destroy organisms INSIDE the body and disinfectants destroy organisms on inanimate objects ■ *Aseptic technique* - Creating a sterile environment, in the operating room (scrubbing in) *Examples:* Handwashing, preop skin prep, gloving, sterile draping, isolations precautions/procedures, autoclaving of instruments (sterilization), sterility of operative field, proper waste disposal Antimicrobials applied to: inanimate objects = disinfection human tissue = antisepsis

7. Define the term 'Sentinel Event', types of sentinel events, and how to minimize error.

○ *Sentinel event* - "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." Serious injury specifically includes loss of limb or gross motor function and "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. ○ Events are called "sentinel" because they signal the need for immediate investigation and response ○ The terms "sentinel event" and "medical error" are not synonymous. Not all sentinel events occur because of an error, and not all errors result in a sentinel event ○ *Most common types of sentinel events:* delayed treatment, a fall, wrong patient, wrong procedure, etc... *Additional means to minimize medical error* *Preop verification process* → checklist confirms appropriate documentation completed and correct and includes patient, surgery, site *Surgical site marking* → Unambiguous marking, visible after prep and drape *Mandatory Time Out* → Pt on table, before first slice entire surgical team verifies patient, surgery, site