3° Question 1 of 57 oe bp ° A.62 year old lawyer has a transurethral resection of the prostate which took 1 hour to perform. ‘The ST2 contacts you as the patient has become agitated. He has a HR’ 105 bpm and his blood pressure is 170/100 mmHg. He is fluid overloaded. His blood results reveal a Na of 120mmol/L What is the most likely cause? Over administration of 0.9% Normal Saline ‘Syndrome of inappropriate antidiuretic hormone secretion Congestive cardiac failure Acute renal failure Complications of Transurethral Resection: TURP Tur syndrome Urethral stricture/UTI Retrograde ejaculation Perforation of the prostate TUR syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are: 1. Hyponatraemia: dilutional 2. Fluid overload 3. Glycine toxicity Management involves fluid restriction and the treatment of the complications associated with the hyponatraemia | 9 | improve | Post prostatectomy syndromes * Transurethral prostatectomy is a common and popular treatment for benign prostatic hyperplasia. The procedure involves insertion of a resectoscope via the penile urethra. The bladder and prostate are irrigated and strips of prostatic tissue removed using diathermy. Indications for surgery in patients with BPH Refractory urinary retention Recurrent urinary tract infections due to prostatic hypertrophyComplications include haemorrhage, urosepsis, retrograde ejaculation and electrolyte disturbances from the irrigation fluids used during surgery. Bieaw-cs# Save my notes Search Search textbook Q Google search on "Post prostatectomy syndromes” ++ Suggest link “+ Suggest meta WSS S166 <6)3° Question 2 of 57 v Bb °o ‘A582 year old male presents with tearing central chest pain. On examination, he has an aortic regurgitation murmur. An ECG shows ST elevation in leads 1, Ill and aVF. What is the likely explanation? Distal aortic dissection eo Anterior myocardial infarct Inferior myocardial infarct Pulmonary embolism eo ‘An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Also the history is more suggestive of a dissection, Other features may include pericardial effusion, carotid dissection and absent subelavian pulse. "@ | Improve Chest pain Aortic dissection ‘+ This occurs when there is a flap or filling defect within the aortic intima. Blood tracks into the medial layer and splits the tissues with the subsequent creation of a false lumen. it most commonly occurs in the ascending aorta or just distal to the left subclavian artery (less common). It is most common in Afro-carribean males aged 50-70 years. + Patients usually present with a tearing intrascapular pain, which may be similar to the pain of a myocardial infarct, + The dissection may spread either proximally or distally with subsequent disruption to the arterial branches that are encountered. + Inthe Stanford classification system the disease is classified into lesions with a proximal origin (Type A) and those that commence distal to the left subclavian (Type B). + Diagnosis may be suggested by a chest x-ray showing a widened mediastinum. Confirmation of the diagnosis is usually made by use of CT angiography + Proximal (Type A) lesions are usually treated surgically, ype B lesions are usually managed non operatively. Pulmonary embolism + Typically sudden onset of chest pain, haemoptysis, hypoxia and small pleural effusions may be present. ‘+ Most patients will have an underlying deep vein thrombosis* Diagnosis may be suggested by various ECG findings including $ waves in lead |, Q waves in lead Ill and inverted T waves in lead Ill. Confirmation of the diagnosis is usually made through use of CT pulmonary angiography. + Treatment is with anticoagulation, in those patients who develop a cardiac arrest or severe ‘compromise from their PE, consideration may be given to thrombolysis. Myocardial infarction * Traditionally described as sudden onset of central, crushing chest pain. It may radiate into the neck and down the left arm. Signs of autonomic dysfunction may be present. The presenting features may be atypical in the elderly and those with diabetes. * Diagnosis is made through identification of new and usually dynamic ECG changes (and cardiac enzyme changes). Inferior and anterior infarcts may be distinguished by the presence of specific ECG changes (usually I, Il and aVF for inferior, leads V1-V5 for anterior). + Treatment is with oral antiplatelet agents, primary coronary angioplasty and/ or thrombolysis. Perforated peptic ulcer + Patients usually develop sudden onset of epigastric abdominal pain, it may be soon followed by generalised abdominal pain. ‘+ There may be features of antecendant abdominal discomfort, the pain of gastric ulcer is typically worse immediately after eating. + Diagnosis may be made by erect chest x-ray which may show a small amount of free intra- abdominal air (very large amounts of air are more typically associated with colonic perforation). ‘+ Treatment is usually with a laparotomy, small defects may be excised and overlaid with an omental patch, larger defects are best managed with a partial gastrectomy. Boerhaaves syndrome * Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting, + The rupture is usually distally sited and on the left side. * Patients usually give a history of sudden onset of severe chest pain that may complicate severe vorniting + Severe sepsis occurs secondary to mediastinitis. * Diagnosis is CT contrast swallow. * Treatment is with thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of aT tube to create a controlled fistula between oesophagus and skin * Delays beyond 24 hours are associated with a very high mortality rate. Bls@- ‘Save my notes<) Question 3 of 57 v Bp ©} ‘A53 year old man is due to undergo a right hemicolectomy for a caecal carcinoma. Which of the following would be usual practice prior to surgery? ‘Mechanical bowel preparation with oral sodium picosulphate Mechanical bowel preparation with oral mannitol Total gut cleansing with oral antibiotics 3 days pre-operatively lodine rectal washout pre-operatively Of the options presented here, only the oral carbohydrate drink would be standard practice prior toa right sided colonic resection. Whilst some surgeons may administer phosphate enemas before surgery, total gut clearance confers no benefit for right sided resections and delays recovery. In contrast, the carbohydrate loading drink is part of enhanced recovery protocols, ob | 9 | improve | Preparation for surgery * Elective and emergency patients require different preparation. Elective cases + Consider pre admission clinic to address medical issues. Blood tests including FBC, U+E, LFT's, Clotting, Group and Save Urine analysis Pregnancy test Sickle cell test ECG/ Chest xray Exact tests to be performed will depend upon the proposed procedure and patient fitness. Risk factors for development of deep vein thrombosis should be assessed and a plan for ‘thromboprophylaxis formulated Diabetes Diabetic patients have greater risk of complications. Poorly controlled diabetes carries high risk of wound infections. Patients with diet or tablet controlled diabetes may be managed using a policy of omitting medication and checking blood glucose levels regularly. Diabetics who are poorly controlled or who take insulin may require a intravenous sliding scale. Potassium supplementation should also be given.Diabetic cases should be operated on first, Emergency cases Stabilise and resuscitate where needed Consider whether antibiotics are needed and when and how they should be administered. Inform blood bank if major procedures planned particularly where coagulopathies are present at the outset or anticipated (e.g. Ruptured AA repair) Don't forget to consent and inform relatives. Special preparation ‘Some procedures require special preparation: ‘+ Thyroid surgery; vocal cord check. + Parathyroid surgery; consider methylene blue to identify gland. + Sentinel node biopsy; radioactive marker/ patent blue dye, + Surgery involving the thoracic duct; consider administration of cream. + Pheochtomocytoma surgery; will need alpha and beta blockade + Surgery for carcinoid tumours; will need covering with octreotide. * Colorectal cases; bowel preparation (especially left sided surgery) ‘+ Thyrotoxicosis; lugols lodine/ medical therapy. References Management of adults with diabetes undergoing surgery and elective procedures. NHS Diabetes. April 2011 Bere ge ‘Save my notes Search ‘Search textbook. ‘Q Google search on ‘Preparation for surgery" + Suggest ink + suggest media Dashboard<) Question 4 of 57 v Bb o ‘66 year old man is admitted with severe angina. There is a lesion of the proximal left anterior descending coronary artery. Which of the following would be the most suitable conduit for bypass? Long saphenous vein Short saphenous vein Cephalic vein Thoraco-acromial artery The internal mammary artery is an excellent conduit for coronary artery bypass. It has better long term patency rates than venous grafts. The thoraco-acromial artery is seldom used. ‘i Improve | Cardiopulmonary bypass * Indications for surgery * Left main stem stenosis or equivalent (proximal LAD and proximal circumflex) * Triple vessel disease * Diffuse disease unsuitable for PCI The guidelines state that CABG is the preferred treatment in high-risk patients with severe ventricular dysfunction or diabetes mellitus. Technique General anaesthesia Central and arterial lines Midline sternotomy or left sub mammary incision Aortic root and pericardium dissected Heart inspected Bypass grafting may be performed using a cardiopulmonary bypass circuit with cardiac arrest or Using a number of novel ‘off pump’ techniques. Procedure cardiopulmonary bypass + Aortic root cannulated + Right atrial cannula * Circuit primed and patient fully heparinised (30,000 Units unfractionated heparin) as the circuit is hiahlv thromboaenic+ Flow established through circuit, * Aortic cross clamp applied * Cardioplegia solution instilled into the aortic root below cross clamp * Heart now asystolic and ready for surgery Off pump techniques are evolving on a constant basis and details are beyond the scope of the MRcs. Conduits for bypass > Internal mammary artery is best. Use of both is associated with increased risk of sternal wound dehiscence. However, many surgeons will use both especially for redo surgery. > Radial artery harvested from forearm, Ensure ulnar collateral working first! > Reversed long saphenous vein grafts Typically anastamosed using 7/0-8/0 prolene sutures (distally) and 6/0 prolene for top end. Once flow established Anticoagulation reversed using protamine Patient is taken off bypass Inotropes given if needed Sternum closed using sternal closure device or stainless steel wire Complications + Post perfusion syndrome: transient cognitive impairment ‘+ Non union of the sternum; due to loss of the internal thoracic artery ‘+ Myocardial infarction + Late graft stenosis + Acute renal failure + Stroke + Gastrointestinal Perioperative risk is quantified using the Parsonnet and Euroscores and unit outcomes are audited using this data, Reference Eagle KA, Guyton RA, Davidoff R, et al: ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004; 110eo Question 5 of 57 v B © ‘A48 year old lady has a metallic heart valve and requires a paraumbilical hernia repair. Perioperatively she is receiving intra venous unfractionated heparin. To perform the surgery safely a normal coagulation state is required. Which of the following strategies is routine standard practice? Administration of 10 mg of vitamin K the night prior to surgery and stopping the heparin infusion 6 hours pre operatively Stop the heparin infusion on induction of anaesthesia Stopping the heparin infusion 6 hours pre operatively and administration of intravenous. protamine sulphate on commencing the operation None of the above Patients with metallic heart valves will generally stop unfractionated heparin 6 hours pre operatively. Unfractionated heparin is generally cleared from the circulation within 2 hours so this will allow plenty of time and is the method of choice in the elective setting. Protamine sulphate will reverse heparin but is associated with risks of anaphylaxis and is thus not generally used unless immediate reversal of anticoagulation is needed, e.g. coming off bypass. | | Improve Heparin » + Causes the formation of complexes between antithrombin and activated thrombin/factors 7.91011 & 12 Advantages of low molecular weight heparin + Better bioavailability + Lower risk of bleeding + Longer half life «+ Little effect on APTT at prophylactic dosages: * Less risk of HIT Complications Bleeding + Osteoporosis ‘+ Heparin induced thrombocytopenia (HIT): occurs 5-14 days after 1st exposure Anaphylaxis,In surgical patients that may need a rapid return to theatre, administration of unfractionated heparin is preferred; as low molecular weight heparins have a longer duration of action and are harder to reverse. ve my notes Search Search textbook Q Google search on Heparin’ + Suggest ink + Suggest media Dashboard " 12 13 14 15 16 7 18 22S 002 4444664644646 56° Question 6 of 57 v p S A 22 year old man presents with a perl anal abscess, which is managed by Incision and drainage. The perineal wound measures 3cm by 3em. Which of the following is best management option? Primary closure with interrupted mattress sutures oe Delayed primary closure with interrupted mattress sutures Insert a seton through the cavity into the rectum to allow a mature fistula track to develop @ Perform a V-Y flap 2 weeks later e Peri anal abscess are typically managed by secondary intention healing. Any attempt at early closure is at best futile and at worst dangerous. Insertion of a seton may be considered by an experienced colorectal surgeon, and only if the tract is clearly identifiable with minimal probing. There is seldom a need for flaps, ongoing discharge usually indicates a fistula (managed separately). [a [9 [impoe Wound healing * Surgical wounds are either incisional or excisional and elther clean, clean contaminated or dirty Although the stages of wound healing are broadly similar their contributions will vary according to the wound type The main stages of wound healing include: Haemostasis ‘+ Minutes to hours following injury + Vasospasm in adjacent vessels, platelet plug formation and generation of fibrin rich clot. Inflammation + Typically days 1-5 ‘+ Neutrophils migrate into wound (function impaired in diabetes). + Growth factors released, including basic fibroblast growth factor and vascular endothelial growth factor. + Fibroblasts replicate within the adjacent matrix and migrate into wound. ‘+ Macrophages and fibroblasts couple matrix regeneration and clot substitution Regeneration + Typically days 7 to 56+ Platelet derived growth factor and transformation growth factors stimulate fibroblasts and epithelial cells, * Fibroblasts produce a collagen network, + Angiogenesis occurs and wound resembles granulation tissue. Remodeling + From 6 weeks to 1 year + Longest phase of the healing process and may last up to one year (or longer), * During this phase fibroblasts become differentiated (myofibroblasts) and these facilitate wound contraction + Collagen fibres are remodeled. * Microvessels regress leaving a pale scar. The above description represents an idealised scenario. A number of diseases may distort this process. Neovascularisation Is an important early process. Endothelial cells may proliferate in the wound bed and recanalise to form a vessel. Vascular disease, shock and sepsis can all compromise microvascular flow and impair healing. Conditions such as jaundice will impair fibroblast synthetic function and Immunity with a detrimental effect in most parts of the healing process. Problems with scars: Hypertrophic scars Excessive amounts of collagen within a scar. Nodules may be present histologically containing randomly arranged fibrils within and parallel fibres on the surface. The tissue itself is confined to the extent of the wound itself and is usually the result of a full thickness dermal injury. They may go on to develop contractures. Image of hypertrophic scarring, Note that it remains confined to the boundaries of the original wound: Keloid scars Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the boundaries of the original injury. They do not contain nodules and may occur following even trivial injury. They do not regress over time and may recur following removal