Surgery week quiz stuff

herbal medications prior to surgery

stop them

SSSI locations

superficial incision, deep incision, open space

ways to prevent intraoperative awareness by the patient

there are no (none of the above)

O2 dissociation curve description? T/F

true

prophylactic single same as 24 hours abx? T/F

true

rarely febrile 5 days post op? T/F

true

TPN, post op pts nutrition

vitamin requirements increase

drug not used for preoperative DVT prophylaxis

warfarin

5 w's

water, wind, walking, wound, wonder

PRBC inc Hgb and Hct by how much

1 g/dl and 3%

NS IV has how much Na

154 mEEq

necrotizing fasciitis mortality even w/ aggressive txt

20-50%

days post-op if no implant

30 days

pre-op smoking cessation

4 weeks

post op temp increase occurs in what %

40%

ventilator measurement

7 ml/kg of ideal body weight

oliguria definition

<0.5 ml

All of the following are true about necrotizing skin and skin structure infections (NSSSIs), except A NSSSIs are generally self-limited and non-threatening B Can be caused by single or polymicrobial infections C Small vessel thrombosis occurs along the infection progression pathway D Immunocompromised (eg, HIV, diabetes), intravenous drug abuse, and cancer patients are at a particularly higher risk of developing NSSSIs E Grayish discoloration of the underlying skin and pain beyond the affected skin area are especially suggestive of deeper underlying tissue involvement

A

All of the following are true about surgical site infection, except A Classified by the Centers for Disease Control into: (1) wound only, (2) organ space, and (3) involving organ parenchyma B Risk varies based upon degree of wound contamination by bacteria C Risk is modified by patient factors such as diabetes and ongoing immunosuppression D May have reduced risk by the use of appropriately chosen and timed antibiotics E Treatment emphasizes primary source control

A

All of the following are true of respiratory complications, except A They are common after chest procedures, but rare after abdominal operations B They are the most common single cause of morbidity after major surgical procedures C They occur more commonly in the elderly, smokers, and obese patients D Predisposing factors can be moderated by preoperative and postoperative activities E They include atelectasis, pneumonia, aspiration, and pulmonary emboli

A

All of the following are true of the Principles of Medical Ethics, except A Beneficence and nonmaleficence are synonyms B Justice addresses the distribution of medical care among patients and populations C Autonomy includes the concept that the patient has the right to choose or refuse their treatments. D Beneficence asserts that a practitioner should act in the best interest of the patient, without regard to physician's self-interest E Autonomy requires physicians to consult and obtain patient agreement before doing things to them

A

The American Society of Anesthesiologists (ASA) patient classification system A Is an approach to categorizing patients preoperatively to assess their risk for an operative procedure B Requires specific measures of certain laboratory values in order to complete the scoring system C Can be used to determine who not to operate on, for example, no ASA 5 patients should undergo operation D Includes categories ASA 1 through ASA 5 E Both A and C are true

A

The pulmonary failure of shock, trauma, and sepsis A Can be related to products of coagulation and inflammation that are washed out from the damaged tissues B Can be effectively treated with a combination of antibiotics and corticosteroids C Is always related to systemic infection D Is caused by a decrease in pulmonary vascular permeability E Both A and C

A

ASA classification

A and B classified 1-6 and categorize pre-op - risk for surgery

A 54-year-old alcoholic man is discovered to have a new gastric cancer. He reports 15 lb weight loss over the past month. Laboratory data includes an albumin of 2.4 g/dL, indicating significant longstanding malnutrition. Postoperatively, which of the following electrolyte derangements would be of initial concern, especially when he starts to eat or receive some other form of nutrition? A Hypophosphatemia B Hyperphosphatemia C Hypermagnesemia D Hyponatremia E Hyperkalemia

A. Hypophosphatemia. Refeeding syndrome occurs when a malnourished patient (eg, an elderly or alcohol-dependent patient, or a patient who has experienced recent weight loss) begins to consume calories or begins to receive intravenous glucose administration. Insulin levels rise, causing electrolytes which have shifted to the extracellular space during a period of starvation to shift back to the intracellular space for use in the construction of new proteins and cells. Refeeding also leads to increased intracellular requirements for PO43− and Mg2+ due to increased ATP production and glucose metabolism, decreasing serum levels of these electrolytes even further. This all leads to hypokalemia, hypomagnesemia, and hypophosphatemia, any one of which may be fatal. For these reasons, electrolytes must be closely monitored and aggressively repleted in patients at risk for refeeding syndrome.

stop which drugs if going to undergo anesthesia

ACEI (refractory hypotension)

All of the following are true about electrosurgery, except A In monopolar electrosurgery, the current flows through the patient from the active electrode to the return electrode B In bipolar electrosurgery, the current flows from the handpiece to the return electrode C The cutting mode of monopolar electrosurgery utilizes a continuous sine wave of current D The coagulation mode of monopolar electrosurgery relies on spikes of electric wave activity E The resistance of the tissue influences the effect of the electrosurgery

B

All of the following are true about pressure support ventilation, except A PSV is a pressure-limited ventilator mode B PSV includes a set inspiratory time C PSV breaths are patient-triggered D Inspiratory flow is adjusted to maintain airway pressure E PSV can be combined with IMV

B

Fire in the operating room A Is preventable by keeping the oxygen levels used for ventilation low B Depends upon the presence of an oxygen source, an ignition source, and fuel C Cannot be fed by alcohol from skin prep solutions because this is not flammable D Cannot be ignited by electrosurgical instruments E Has been eliminated by the abandonment of flammable anesthetic agents

B

Hypothermia in hemorrhagic shock A Is of limited risk in the initial 24 hours after injury B Can contribute to coagulopathy C Is unusual in the trauma population outside of cold-weather or water-immersion injuries D Is best treated by warming the ambient room temperature E Is a secondary concern that can be addressed after the care of injuries

B

Regarding the timing of the preoperative anesthesia workup for patients scheduled for a surgical procedure A The initial assessment can be done the day of surgery for healthy patients undergoing procedures of high surgical invasiveness. B The initial assessment should be done at a minimum the day before surgery for patients undergoing procedures of high surgical invasiveness. C The preoperative assessment for healthy patients by an anesthesiologist is not required. D A note from the patient's primary care physician stating that the patient is "cleared for anesthesia and surgery" will suffice as the preoperative assessment.

B

TcPO2 adversely affected by all except

B and D

Which phase of acute wound healing is prolonged during progression to a chronic wound? A Coagulation B Inflammation C Fibroplasia D Angiogenesis E Remodeling

B. Inflammation. An acute wound is defined by its ability to normally progress, in a predictable and timely manner, through all of the phases of wound healing; coagulation, inflammation, fibroplasia, angiogenesis, and remodeling. A protracted inflammatory phase is the usual mechanism for the formation of a chronic wound. All clinical efforts should be made to reduce chronic wound inflammation in an effort to support healing.

A 61-year-old woman undergoes a sigmoid colectomy for perforated sigmoid diverticulitis. Postoperatively she is transferred to the surgical intensive care unit, still intubated and mechanically ventilated. On postoperative day 3 she develops an ileus, and her orogastric tube is put to low wall suction. On postoperative day 8 she develops hypotension and tachycardia to 140 beats/min, and requires a norepinephrine infusion to maintain adequate mean arterial blood pressure. Laboratory data includes ABG 7.32/40/154/20 What is the most likely explanation for her acid-base disorder? A AG metabolic acidosis with adequate respiratory compensation B Mixed metabolic alkalosis and AG metabolic acidosis C Metabolic alkalosis with respiratory compensation D Mixed metabolic alkalosis and respiratory acidosis E Mixed AG metabolic acidosis and respiratory alkalosis

B. Mixed metabolic alkalosis and AG metabolic acidosis. The patient is acidotic, with a normal pCO2, low-normal HCO3−, and high anion gap. Therefore, this patient has an anion-gap metabolic acidosis. Given the clinical circumstances, the most likely etiology of her metabolic acidosis is lactic acidosis caused by septic shock. Note that the patient's pH is significantly below the lower limit of normal, despite the normal pCO2 and low-normal HCO3−. This should prompt concern for a mixed acid-base disorder. Her ΔΔ = 2, indicating a coexistent metabolic alkalosis. The several days of gastric suctioning provides a ready explanation for this component of her mixed acid-base disorder.

Regarding nutritional indices, which of the following is false? A PNI has been validated in patients undergoing either major cancer or gastrointestinal surgery and found to accurately identify a subset of patients at increased risk for complications. B The NRI is an excellent tool for tracking the adequacy of nutritional support. C The MNA is a rapid and reliable tool for evaluating the nutritional status of the elderly. D SGA is a reproducible clinical method that has been validated and encompasses the patient's history and physical examination.

B. The NRI is an excellent tool for tracking the adequacy of nutritional support. The NRI is an index that has been prospectively crossvalidated against other nutritional indices with good results, but is not a good tool for tracking the adequacy of nutritional support, since supplemental nutrition often fails to improve serum albumin levels. The index successfully stratifies perioperative morbidity and mortality using serum albumin and weight loss as predictors of malnutrition.

A 56-year-old woman is being prepared for an elective ventral hernia repair in the preoperative care unit. She is overweight, with a history of non-insulin-dependent diabetes, hypertension, and smoking. Her fingerstick glucose is 326, and you note that her most recent HgA1C is 8.4%. She wants to proceed with the operation and has traveled a long distance to see you and has taken the day off from work. The most appropriate choice of management is A Proceed with the operation and plan for an intraoperative insulin drip B Repeat the fingerstick after insulin administration and proceed with the operation if the glucose is improved with the plan for consultation of the diabetes team postoperatively for management C Cancel the operation with the plan for improved preoperative preparation D Admit the patient for preoperative glucose management and reschedule the operation for several days from now

C

A 64-year-old woman is 12 days after total abdominal hysterectomy for benign disease. She returns to the emergency room with nausea and vomiting, and has an abdominal examination that is distended, but not very tender, and her wound is clean. An abdominal series shows some dilated loops of small bowel but no free air. A She should return to the operating room as soon as is practical for lysis of adhesions. B The abdominal focus of her symptoms rules out chest problems such as pneumonia. C Her initial management can include intravenous hydration and nasogastric suction. D The presence of dilated loops of bowel on radiographs rules out the possibility of a benign ileus. E Both A and C are true.

C

A 82-year-old woman underwent a laparoscopic hand-assisted sigmoid colectomy with diverting loop ileostomy 5 days ago for a rectal cancer after neoadjuvant radiation therapy. She is tolerating a regular diet and her ileostomy is healthy and functional. The nurses report that she is somewhat somnolent, and has not urinated during the past two shifts. Which is the most likely cause of her anuria? A Acute renal failure B Inadequate fluid resuscitation in the operating room C High ileostomy output with inadequate postoperative replacement D Low cardiac output E Urinary retention

C

ACGME general competencies include all of the following except A Interpersonal and communication skills B Professionalism C Technical skills D Practice-based learning E Systems-based practice

C

Geriatric patients A Are a limited portion of a general surgery practice now and in the future B Can have their perioperative risk very closely estimated by their chronological age C Can have frailty measured by a variety of means that predict the risk of complications D Require limited special assessment other than modification of drug dosages E Both A and C are true

C

The efficacy of efforts to prevent SSI A Is not affected by the timing of antibiotic dosing as long delivery occurs by the time of skin closure B Is independent of the choice of antibiotic C Can be improved by the use of alcohol-containing skin preparation solutions D Is very similar at hospitals around the world E Is currently well-known, and best practices are no longer controversial

C

Venous thromboembolism (VTE) risk A Has no relationship to the family history B Is assessed using the RCRI score C Can be modified by risk-based interventions D Has few long-term consequences as long as a pulmonary embolus is not fatal E Frequently should be modified by placement of an inferior vena cava filter preoperatively

C

A 70-year-old man undergoes a laparoscopic cholecystectomy for acute cholecystitis. On postoperative day 1 he complains of light-headedness while attempting to transfer from his bed to a chair. His vital signs include T 99.1°F, P 82, BP 109/63 mm Hg, RR 14 breaths/min, O2 saturation 99% on room air. The nurse informs you that he has had poor enteral intake since the operation, and his urine output has diminished to 10 mL/h. She also informs you that his intravenous access was lost soon after his surgery and was never reestablished. His BUN and Cr preoperatively were 16 mg/dL and 0.8 mg/dL, respectively. Laboratory data include Urine Na 153 mmol/L Urine Cr 284 mg/dL You suspect the cause of his orthostasis and oliguria is hypovolemia. Which of the following findings would most strongly confirm your hypothesis? A BUN:Cr ratio < 20 B Fractional excretion of sodium (FENa) > 1% C FENa < 1% D Renal ultrasonography demonstrating normal kidney parenchyma and vasculature E Fractional excretion of urea nitrogen (FEUN) > 35%

C FENa < 1%. In oliguric patients, FENa < 1% is indicative of pre-renal azotemia and intravascular volume depletion. BUN:Cr ratio > 20 is indicative of hypovolemia. FENa > 1% is indicative of intrinsic renal causes of oliguria, and should prompt workup including microscopic urine analysis and renal ultrasonography. Post-renal obstruction should be investigated if clinically suspected (eg, caused by benign prostatic hypertrophy in this 70-year-old male).

Which cell is most important for signaling wound healing? A Platelet B PMN C Macrophage D Fibroblast E Endothelial cell

C Macrop14. The macrophage is the most important source of growth factor signals for wound healing. Experimental studies show that wound healing is most impaired in the absence of macrophages. Although fibroblasts are the main source of collagen synthesis and endothelial cells are required for revascularization, they are dependent on macrophage signaling to stimulate and direct tissue repair. A platelet is not a cell.

Which of the following is not a clinical impediment to wound healing? A Repeated trauma B Wound infection C A moist wound environment D Foreign bodies E Obesity

C. A moist wound environment. A moist or even wet wound environment is critical to normal wound healing. The cellular and molecular biological activity within a wound requires hydration to proceed. Clinical use of dry dressings to support wound debridement, for example, should be limited. Similarly, poor dressing resulting in repeated trauma and mechanical instability to the wound is often overlooked as a source for wound healing failure. Wound infection is the most clinically important, and expensive, impediment to surgical wound healing. Foreign bodies in the wound, such as synthetic surgical meshes, also delay normal wound healing. Finally, experimental and clinical data support that obesity contributes to abnormal wound healing, primarily through a metabolic pathway, and secondarily by increasing the risk of wound infection.

A 28-year-old man with history of depression is found down and brought to the emergency department. He responds to voice, moves his extremities spontaneously, and opens his eyes to pain only. Initial vital signs: T 98.0°F, P 72, BP 118/65 mm Hg, RR 28 breaths/min, O2 saturation 99% on a non-rebreather mask. Primary survey is within normal limits, secondary survey reveals only superficial abrasions. Initial laboratory data include ABG: pH 7.36, Pco2 38 mm Hg, Pao2 173 mm Hg, HCO3− 20 mmol/L CPK 125 Serum salicylate 824 mg/L (normal 30-300 mg/L) Based on this patient's history, examination findings and laboratory data, what is this patient's acid-base derangement? A No disorder B Respiratory acidosis with appropriate renal compensation C Anion gap metabolic acidosis with appropriate respiratory compensation D Nonanion gap metabolic acidosis with appropriate respiratory compensation E Mixed metabolic acidosis and metabolic alkalosis

C. Anion gap metabolic acidosis with appropriate respiratory compensation. As above, values from an arterial blood gas are typically reported in this order: pH, pCO2, paO2, HCO3−. This patient's pH is normal, but near-acidotic. HCO3− and pCO2 are both low. Decreased HCO3− will cause acidosis, while decreased pCO2 will cause alkalosis, thus the patient's primary disorder is metabolic. His calculated anion gap is 22. pCO2 is within the 36-40 mm Hg range of appropriate compensation predicted by1 Winter's formula, thus no concurrent respiratory disorder exists. Therefore, this patient has an anion gap metabolic acidosis with appropriate respiratory compensation. Respiratory compensation for metabolic disorders is rapid (note his hyperventilation), hence the normal pH. If respiratory compensation were inappropriate, one would need to consider another, simultaneous process, in addition to alkalosis, eg, the respiratory acidosis which occurs in the later stages of salicylate poisoning, when central respiratory drive has been suppressed. Note the patient's ΔΔ = 2.5. Considering this finding in isolation, one would conclude that the patient has a mixed anion-gap metabolic acidosis and metabolic alkalosis. This underscores the need to take into account all of the patient's data when making determinations of acid-base status. There is no additional evidence of a metabolic alkalosis, thus this additional disturbance is unlikely.

Which of the following is not a proposed mechanism by which enteral feeding decreases bacterial intestinal wall translocation when compared to IV nutrition? A Preserved local cytokine expression pattern B Increased villous height and over all mucosal mass C Bactericidal activity of enteral nutritioncomponents D Stimulation of intraluminal IgA transportation

C. Bactericidal activity of enteral nutrition components. Multiple mechanisms have been proposed for the morphological and functional differences observed in the intestinal epithelium with parenteral nutrition (PN) when compared to enteral nutrition. It has repeatedly been demonstrated that small bowel mucosal mass is lost with only PN. Yang and colleagues demonstrated that the administration of 25% enteral nutrition reversed the abnormal IL-10, IL-4, and IL-6 messenger RNA (mRNA) expression that had resulted from only PN support in animal models. This is of particular significance as these changes in cytokine expression were associated with epithelial leak and an increased rate of enterocyte apoptosis. It has also been shown that the type and route of nutrition affect pIgR expression in an organ-specific manner; pIgR represents the exclusive transport pathway for IgA to move from the lamina propria, through the epithelia, into the lumen of the gut where it acts as a key component in the gut's defense. Enteral nutrition components are not bactericidal and actually help preserve normal flora.

Which of the following is true? A Lactose intolerance is most prevalent in European Caucasians when compared to other populations. B Gastric residuals of 100 cc should prompt holding of tube feeds. C Gastric bypass patients are prone to deficiencies of the fat-soluble vitamins, calcium, iron, vitamin B12, and folate. D Enteral nutrition carries a technical complication rate of 10%.

C. Gastric bypass patients are prone to deficiencies of the fat-soluble vitamins, calcium, iron, vitamin B12, and folate. Gastric bypass procedures intentionally limit the amount of oral intake and decrease the amount of small bowel that takes part in absorption. This renders the population of patients prone to deficiencies of the fat-soluble vitamins (A, D, E, and K), calcium, iron, vitamin B12, and folate. Careful attention should be paid to ensuring that these deficiencies are countered with supplementation. Technical complications occur in about 5% of enterally fed patients and include clogging of the tube; esophageal, tracheal, bronchial, or duodenal perforation; and tracheobronchial intubation with tube feeding aspiration. Lactose intolerance is least common in European Caucasians, present within only 5%-10% of this population. Although recommendations differ depending on source, enteral feeds are not typically held until gastric residuals of greater than 200 cc are encountered.

The preoperative assessment by an anesthesiologist includes an assessment of a patient's risk for an intraoperative cardiac event. The RCRI factors include all of the following except A A history of ischemic heart disease B Diabetes mellitus C Obesity D Renal insufficiency E High-risk surgery F Heart failure

C. Obesity. The RCRI factors of (1) ischemic heart disease, (2) heart failure, (3) high-risk surgery, (4) diabetes mellitus, (5) renal insufficiency, and (6) cerebral vascular diseases are a validated set of independent predictors of cardiac risk for patients. There RCRIs were derived from a single-center prospective group of patients undergoing elective major noncardiac surgery. The anesthesiologist in a pre-op clinic will screen for these factors and recommend further studies based on the presence or absence of RCRIs. Patients with no RCRIs had a very low (0.4%) cardiac risk while patients with three or more risk factors have a 5.4% risk of an adverse cardiac event and warrant further testing or optimization of the factor(s).

Regarding centrally administered parenteral nutrition in the critically ill patient, which of the following is not true? A An initial formulation for nonamino acid calories is generally advised to consist of 70% dextrose and 30% fat emulsion. B TPN should be avoided if anticipated use is less than 6-7 days. C The recommended amino acid dose ranges from 0.8 to 1 g/kg. D The line-related complication rate from CVCs is greater than 15%.

C. The recommended amino acid dose ranges from 0.8 to 1 g/kg. The recommendation for the amino acid dose ranges from 1.2 to 1.5 g/kg/d for most patients with normal renal and hepatic function, although some sources recommend higher doses. TPN via a central line is indicated for patients who cannot obtain adequate nourishment via the gastrointestinal tract for a minimum duration of treatment of 7-10 days. The use of postoperative TPN for only 2 or 3 days is highly discouraged, as the risks outweigh the benefits incurred over this short period of time. A reasonable initial guideline is to provide 60%-70% of nonamino acid calories as dextrose and 30%-40% of nonamino acid calories as fat emulsion. The placement of central line catheters always carries risks; the overall complication rate related to this access is greater than 15%.Femoral vein access carries the highest risk of infection and should be avoided if possible.

A 43-year-old man with a distant history of intravenous drug use is now status post a right inguinal hernia repair and is complaining of severe groin pain on the side of the operation. All of the following are appropriate maneuvers except A Evaluate the patient for necrotizing fasciitis B Reassure the patient that his use of preoperative suboxone that morning may have blocked his postoperative response to narcotics C Allow the nurse to administer a postoperative parenteral nonopioid analgesic D Discharge the patient with a prescription for pain medication and a plan for follow-up in 2 weeks E Perform a nerve block with local anesthetics

D

A 72-year-old man underwent resection of hepatic segments 5/6 for a hepatoma in the setting of hepatocellular carcinoma 2 days ago and was recently discharged to the floor. Perioperatively, he required a large volume of fluid resuscitation. He now has bloody output from his two Jackson-Pratt drains that are seated in the liver bed, his hematocrit has fallen 7 points to 23 and his INR is 2.7, and he is febrile to 102.8°F and confused. Which of the following is the most appropriate order and choice of management? A Evaluation of the patient, transfer to higher level of care, transfusion with 2 units of unmatched packed RBCs, return to the operating room for surgical control of bleeding B Evaluation of the patient, transfusion with two packs of FFP and 2 units of matched packed RBCs, computed tomography with angiography for possible embolization C Evaluation of the patient, intubation for protection of airway, transfer to higher level of care, transfusion with cryoprecipitate, antibiotic administration, return to the operating room for surgical control of bleeding. D Evaluation of the patient, intubation forprotection of airway, transfer to a higher level of care, transfusion with 2 units of FFP and 2 units of matched packed RBCs, antibiotic administration, and computed tomography of the abdomen.

D

The American Board of Surgery and the American College of Surgeons A Are both part of the American Medical Association B Both report directly to the Surgery RRC of the ACGME C Work together to accredit individuals to practice general surgery D Are separate organizations that credential surgeons, and educate surgeons, respectively, as primary parts of their missions E A and C

D

The perioperative process, including the workup regarding safety for anesthetic, after the decision to operate has been made A Is the sole province of the anesthesiology specialists B Should not take into account the planned operation C Is best performed by specialists not directly invested in the planned operation D Should include a pain assessment to aid in the management of postoperative pain E Both A and C are true

D

A 19-year-old woman arrives in the trauma bay after a helmeted motorcycle crash. She is hemodynamically unstable, and immediately taken to the operating room. Exploratory laparotomy reveals 3 L of hemoperitoneum, a grade 5 splenic laceration, and a grade 3 liver laceration. A splenectomy is performed and the liver laceration is packed. Inspection of the rest of the abdomen reveals no additional injuries. Two hours into the case anesthesia alerts you that her temperature is 93°F and her pH is 7.2; thus you decide to suspend the operation, leave her abdomen open, and admit her to the surgical intensive care unit (SICU) for resuscitation before returning to the operating room. Despite aggressive resuscitation with packed red blood cells (PRBCs) and other blood products, she remains hemodynamically unstable. Pelvic angiography reveals a bleeding right inferior gluteal artery, which is embolized. She is returned to the SICU for further resuscitation. You take over her care at this point, and notice that she has received 21 units of PRBCs, 19 units of fresh frozen plasma, and 20 units of platelets, but has not had her serum electrolytes checked in 5 hours. Which of the following electrolyte disorders is she most at risk for? A Hypocalcemia B Hypomagnesemia C Hyperkalemia D All of the above E None of the above

D. All of the above. Stored blood products are anticoagulated with trisodium citrate, which chelates Ca2+ from stored blood, disrupting the clotting cascade. In the setting of massive transfusion, such as this patient has undergone, normal hepatic metabolism of trisodium citrate may be overwhelmed, and Ca2+ (along with Mg2+) may be chelated from the blood, leading to hypocoagulability, hypocalcemia, and hypomagnesemia. Furthermore, stored pRBCs contain high levels of K+, the result of lysis of red blood cells. This is especially true of the older pRBCs often utilized in massive transfusion situations. For these reasons, serum electrolytes must be closely monitored and controlled in the setting of massive transfusion.

A 30-year-old man is 16 hours s/p emergency laparotomy for blunt abdominal trauma from a motor vehicle accident. His spleen was removed, a liver laceration was managed with sutures and topical procoagulants, and a segment of damaged jejunum was resected. His operation took 3 hours, and he received 12 units of crystalloid, 6 units of blood, 4 units of fresh frozen plasma, and 5 units of platelets. His abdominal wall was closed primarily. He remains intubated and ventilated in the SICU. His urine output was 55 mL over the last 6 hours. Further steps in his management should include the following: A Early extubation is preferable to limit the risk of pneumonia, even if his mental status is not yet clear. B Aggressive early diuresis can promote continued renal function. C Further fluid resuscitation is rarely necessary after the bleeding is controlled. D Bladder pressure measurement may be useful to determine the likelihood of abdominal compartment syndrome. E A and C.

D. Bladder pressure measurement may be useful to determine the likelihood of abdominal compartment syndrome.

Which of the following stressors results in the greatest increase in energy expenditure above basal metabolic needs? A Sepsis B Trauma C Elective operations D Burns

D. Burns. Energy requirements above basal needs are approximately 10% for elective operations, 10%-30% for trauma, 50%-80% for sepsis, and 100%-200% for burns. Burns covering more than 40% total body surface area (TBSA) are typically followed by a period of severe stress, characterized by an exaggerated catabolic state. Increases in catecholamine, glucocorticoid, glucagon, and dopamine secretion are thought to initiate the cascade of events leading to the acute hypermetabolic response with its ensuing catabolic state. Appropriate nutrient delivery can be accomplished by feeding 1.2-1.4 times the measured resting energy expenditures (REEs).

The fundamental mechanism for incisional hernia formation is A Long-term fascial scar failure B Suture failure C Suture pulling through the fascia D Early fascial dehiscence and wound failure E Poor technique

D. Early fascial dehiscence and wound failure. Pollock and Evans showed in a classic clinical study that 94% of incisional hernias were the result of 1.2 cm fascial dehiscence before POD 30. The majority of the time, these were clinically occult wound closure failures, progressing to incisional hernias over the subsequent 3 years. It is no longer believed that many incisional hernias are the result of abnormal scar formation or suture breaking, stretching or even pulling through the fascia. Poor technique certainly will contribute to incisional hernia formation, but the fundamental mechanism is early fascial dehiscence.

Strategies to prevent intraoperative awareness include A Strict monitoring of intraoperative vital signs by the anesthesiologist will always detect intraoperative awareness B Informing patients during the preoperative workup of the possibility of awareness C Monitoring brain electrical activity with the BIS monitor D None of the above

D. None of the above. There is no way to be 100% of preventing intraoperative awareness. Anesthesiologists performing strict equipment check before beginning an anesthetic to ensure that vaporizers have sufficient agent levels, that there is an agent concentration monitor as part of the anesthesia monitoring system, and frequent observation that IV lines are patent and intact when intravenous medications are used is one way to eliminate the preventable components. Stable vital signs throughout a case are not always a reliable sign that a patient may not suffer from intraoperative awareness. Finally the processed EEG BIS monitor has been shown to be no more effective in preventing awareness than careful monitoring of end-tidal agent concentration.

Many patients take over-the-counter herbal remedies. In the perioperative period patients should be advised A To continue taking their usual herbal remedies B Stop only those remedies that have been approved by their physician C Continue taking only those remedies that have been approved by the FDA D Stop all over-the-counter herbal remedies

D. Stop all over-the-counter herbal remedies. Although the use of herbal medications has been around for many years, none have been approved by the FDA. Many times the pharmacology of these remedies is unknown and the remedies may not contain the correct amounts of active ingredients stated on the label. It is estimated that up to 12% of patients are using these herbal drugs.

Regarding patients who have had a recent drug-eluting stent placed and scheduled for an elective surgical procedure with a high risk of bleeding A Surgery may be performed within 4 weeks of stent placement as long as the patient continues taking aspirin and clopidogrel. B Surgery may be performed within 4 weeks of stent placement with the patient stopping the clopidogrel and continuing on low-dose aspirin. C Should have the surgical procedure delayed until the procedure can be performed with the patient only taking low-dose aspirin. D Surgery should be delayed for up to 1 year.

D. Surgery should be delayed for up to 1 year. The risk of stent thrombosis makes it necessary to place patients who have had a drug-eluting stent placed on antiplatelet agents such as clopidogrel and aspirin. Stopping these drugs prematurely to allow for the performance of an elective surgical procedure requires careful consideration of the risk of bleeding as well as the risk of stent thrombosis if the antiplatelet agents are both stopped. At a minimum aspirin should be continued. Emergent procedures that involve a high risk of bleeding require that the clopidogrel be stopped, but continuing the low-dose aspirin is recommended.

A 65-year-old woman undergoes a thyroid lobectomy for a follicular neoplasm. She has a history of coronary artery disease, hypertension, insulin-dependent diabetes, and stroke. The procedure lasted 2 hours during which the patient required occasional Neo-Synephrine for brief interoperative hypotension. Two hours after the procedure, the nurse calls from the PACU to report that the patient is agitated and hypertensive. Which of the following is unlikely to be the cause for her agitation? A Hypoxia B Stroke C "Unmasking" of cognitive dysfunction D Hyperglycemia E Hypocalcemia

E

Cardiac or great vessel compressive shock A Can be caused by pericardial tamponade B May accompany tension pneumothorax C Is worsened by the need for positive pressure ventilation D Cannot be caused by intra-abdominal injury E All of A, B, and C

E

Development of a SSI requires A A susceptible host B An infectious agent C As suitable medium or environment D Both A and C E All of A, B, and C

E

Effective communication with patients requires A Demonstrated respect for the patient as a person B Effective listening to the patient's message C Clarity in the physician's response to the patient D Family members who can reinforce the messages E A, B, and C

E

Shock can be caused by A Depletion of intravascular volume B Loss of autonomic control of the vasculature C Severe untreated systemic inflammation D Both A and C E All of A, B, and C

E

The Centers for Disease Control classification of SSIs includes A Infection at or near the surgical incision within 30 days of the procedure B Infection at or near the surgical site within 2 months if an implant is left in place C Subcategories of infection including deep incisional and organ/space D Excludes superficial infections that involve only the skin. E Both A and C are true

E

The LCME and the ACGME A Both accredit institutions to provide education or training B Provide diplomas and credentialing to individual practitioners C Conduct periodic reviews to ensure that institutions maintain their programs D Are units of the US Department of Commerce E Both A and C are true

E

The treatment of SSI includes A Opening the incision for superficial SSI B Antibiotics in every case C Debridement of necrotic tissue if present D Avoidance of wound cultures as this is expensive and unnecessary E Both A and C

E

Which of the following are routine components of the first 24-hour postoperative check in patients who have undergone colon resection? A Vital signs including heart rate, blood pressure, oxygen saturation B Wound evaluation including assessment of drain output and content C Assessment of the adequacy of pain management D Plan for removal of the nasogastric tube, Foley catheter, and advancement of diet E All of the above except for D

E

Patients with diabetes mellitus require more operations than their nonaffected counterparts, and if diabetes mellitus is not carefully controlled, they have increased risk of A Surgical site infection (SSI) B Perioperative adrenal insufficiency C Perioperative hypoglycemia D A, B, and C are all true E Both A and C are true

E. Both A and C are true

Which is the most predictive direct measure of impaired or delayed wound healing? A Vitamin C deficiency B Low serum albumin C Irradiated tissue D Smoking E TcO2 less than 30 mm Hg

E. TcO2 less than 30 mm Hg. Wounds will not heal when the tissue concentration of oxygen falls below 30 mm Hg. It is the most powerful predictive measure of delayed or impaired wound healing. Vitamin C deficiency may result in impaired collagen cross linking (scurvy) and weak scars. Low serum albumin predicts increased wound complications, like wound infection. The microangiopathy of radiated tissue indirectly reduces perfusion and therefore, TcO2 levels. Finally, smoking impairs wound healing through the vasoconstrictive effects of chronic nicotine and relative hypoxia as well.

DM increases what surgical risks

SSI preoperative hypoglycemia

MC HAI

UTI

what suggest ileus over bowel obstruction

absence of bowel sounds

Def of beneficence

act in best interest of patient regardless of your own opinions

Bovie - all except

active electrode is bipolar

effective communication

all of the above

ultrasound instruments

all of the above

hyperthermia

all of the above (inc O2 demand, coagulopathy....)

refeeding syndrome

all of the above (includes resp failure d/t dec ATP)

C-diff

all of the above are truee

dead space ventilation increases in all except which?

anemia

not in the NSQIP

anemia

why see major increase a little while after post op?

auto-diuresis

cost effective approach to prevent atelectasis

bedside incentive spirometry early ambulation

ideal prosethetic

biocompatible and material gets incorporated into tissue

TEE highest stress factor

burns

2 types of shock that --> JVD

cardiac compressive cardiogenic

MC prophylactic abx

cefazolin

types of wounds

clean, clean-contaminated, contaminated, dirty

ARDs

coagulation

coronary artery stent and surgery

delay surgery for 1 year

type of wound closure if not closed after surgery but wait for a couple of days

delayed primary closure

pre-op oral antihyperglycemic meds

dont take the morning of surgery

malignant hyperthermia, which is not true?

early clinical signs = hypercapnia, tachycardia, metabolic acidosis

complications of TPN

hepatic dysfunction/steatosis central venous catheter infection hyperglcyemia (answer is all of the above)

female w/ neck enlarged LNs, sort of like an STI clinical picture. what does she have?

hidradenitis suprativa

75 y/o female s/p sigmoid colectomy; MCC low urine output

high ileostomy output w/ inadequate IV and PO replacement

fire in OR

ignited by surgical instruments

enteral TPN complication

induces loose stools to mechanically clear bacterial overgrowth

byproduct of anaerobic glycolysis in metabolic acidosis

lactate

2-3 days port op, MCC fever is what two?

lungs and UTI

wound healing cells that release lactate

macrophages

Mallampati score

measurement of oropharynx structures to determine difficulty of intubation

not sure the ?

metabolic alkalosis, gastric loss, total K depletion

organisms seen w/ nec. fasciitis?

mixed anaerobes and aerobes

dont give vasopressors in shock except for which type?

neurogenic

pre-op required lab testing

none of the above, there is no one test that is absolutely required

HIT S/sx

platelets dec by 50%, VTE, MI

PEEP stands for what?

positive end expiratory pressure

hypothermia in hemorrhagic shock

profoundly.... (something, I didn't catch)

what to do for superficial phlebitis at IV site

remove IV, give PO anti-inflammatory meds for pain (DONT give abx)