Term
| What problems are associated with MEN2a? |
|
Definition
| medullary thyroid cancer, pheochromocytoma, hyperparathyrodism, lichen planus amyloidosis, Hirschsprungs |
|
|
Term
| What problems are associated with MEN2b? |
|
Definition
| medullary thyroid cancer, pheochromocytoma, marfanoidhabitus, mucosal neuromas, ganglioneuromatosis of the GI tract |
|
|
Term
| What is a follicular thyroid adenoma? |
|
Definition
| benign thyroid nodule noted to be fairly common in adults; usually takes up radioactive iodine |
|
|
Term
| What is the prevalence of thyroid nodules? |
|
Definition
detected by PE= 4-7%
detected by U/S or autopsy= 19%-67% |
|
|
Term
| At what size are thyroid nodules considered clinically significant and require further evaluation? |
|
Definition
|
|
Term
| What should you ask a pts with a thyroid nodule? |
|
Definition
| hyper/hypo thyroidism, compressive sy,mptoms, prior history of head/neck irradiation/thyroid cancer, family history of thyroid cancer, hyperparathyroidism, pheochromocytoma |
|
|
Term
| THyroid nodules commonly compress structures such as... |
|
Definition
| trachea, esophagus, recurrent laryngeal nerve |
|
|
Term
| If a pt with a solitary thyroid nodule says they have a history of neck/head irradiaiton, then you should think.... |
|
Definition
| they have a 40% chance of this nodule being cancer |
|
|
Term
| What percent of thyroid cancers are familial? |
|
Definition
| 5% of papillary cancers are familial; 20-30% of medullary thyroid cancers occur as part of a familial syndrome |
|
|
Term
| Adenopathy + thyroid nodule= |
|
Definition
| increased suspicion of cancer |
|
|
Term
| What is the initial and most important step in diagnostic evaluation of a dominant thyroid nodule? |
|
Definition
|
|
Term
| How reliable is FNAB of a thyroid nodule? |
|
Definition
| 1-2% false positive; 2-5% false negative |
|
|
Term
| What do you do if pt with solitary thyroid nodule ahs a benign FNAB and normal TSH? |
|
Definition
| yearly physical examination of the neck |
|
|
Term
| What is a cellular FNAB of a thyroid nodule? |
|
Definition
| specimen with cytologic features consistent with either a follicular or a Hurthle cell neoplasm but you can't tell if its an adenoma or adenocarcinoma using cytologic criteria alone; made on the presence of capsular or vascular invasion |
|
|
Term
| What percent of pts with a hyperfunctioning nodule have a low TSH? |
|
Definition
|
|
Term
| What percent of pts with hyperfunctioning nodules have cancer? hypofunctioning? |
|
Definition
|
|
Term
| PT with a solitary hypofunctioning nodule and a cellular FNAB have a ___ incidence of carcinoma? |
|
Definition
|
|
Term
| If a pt has a nondiagnosted FNAB of a thyroid nodule what is the next step? |
|
Definition
| repeat biopsy (50% chance of getting a good specimen) |
|
|
Term
| In a pt with a persistently nondiagnostic FNAB what is the next step? |
|
Definition
| if the serum TSH is normal or high, operate to remove it; if TSH is low, perform an iodine-123 scintigraphy |
|
|
Term
| T/F Surgery is recommended for patients with persistently nondiagnostic FNAB results of a hypofunctioning thyroid nodule. |
|
Definition
| true; can do a partial thyroidectomy |
|
|
Term
| What is the incidence of carcinoma in patients with a persistenlty nondiagnostic FNAB and a hypofunctioning thyroid nodule? |
|
Definition
|
|
Term
| What should you do if a pt has incidental finding of multiple subcentimeter thyroid nodules on U/S? |
|
Definition
| low probability of cancer so just observe with repeat ultrasound |
|
|
Term
| What is a primary spontaneous pneumothorax? |
|
Definition
| caused by rupture of subpleural blebs |
|
|
Term
| What are the causes of a secondary spontaneous pneumothorax? |
|
Definition
| bullous emphysematous disease, COPD, cystic fibrosis, primary and secondary cancers, and necrotizing infections with organisms such as Pneumocystis carinii, TB, catamenial, asthma |
|
|
Term
| What is an open pneumothorax? |
|
Definition
| injury to the full thickness of the chest wall such that the negative intrapleural pressure results in air being sucked directly through the chest wall defect, preventing air from being taken in through the trachea; it requires a mechanical covering over the chest wound |
|
|
Term
| What is the treatment for pneumothoraxes? |
|
Definition
| less than 15% the width of the hemithorax deflated without symptoms can be initially observed with serial CXRs; from 15-30% can use thoracentesis or pleural catheter drainage; over 30% can use tube thoracostomy; if complicated may require surgery |
|
|
Term
| What should you do if a patient's pneumothorax doesn't improve with observation or thoracentesis or the patient develops symptoms? |
|
Definition
|
|
Term
| What is the typical demographic of pts with primary pneumothorax? |
|
Definition
| male, tall, slender, 15-35 yoa; smoking increases risk |
|
|
Term
| What is the most common demographic of a pt with secondary spontaneous pneumothorax? |
|
Definition
|
|
Term
| What is a catamenial secondary spontaneous pneumothorax? |
|
Definition
| due to pulmonary endometriosis, occuring usually with menstruation |
|
|
Term
| What percent of spontaneous pneumothorax require surgical intervention? |
|
Definition
|
|
Term
| When is surgery indicated for correction of spontaneous pneumothorax? |
|
Definition
| first time spontaneous pneumothorax when there is persistent air leakage (3-5 days), when the lung fails to reexpand, in patients who are at high risk for recurrence (bilateral pneumothoraces, a previous history of contralateral pneumothorax, significant bullous disease on radiographs), in patients who have limited access to medical care (those living in remote areas), and in patients whose occupation produces an increased risk (SCUBA divers, pilots) |
|
|
Term
| What is the recurrence rate of spontaneous pneumothorax after the first occurence? second occurence? third occurence? |
|
Definition
| first= 30%; second= 50%; third= 80% |
|
|
Term
| What is done during surgical treatment of a spontaneous pneumothorax? |
|
Definition
| pleurodesis and resection of the blebs by either thorascopic approach or thoracotomy |
|
|
Term
| What are the physical exam findings associated with acute lung injury? |
|
Definition
| nonspecific; diminished breath sounds and scattered rhonchi |
|
|
Term
| What is the typical CXR with ALI? |
|
Definition
| bilateral nonsegmental infiltrates |
|
|
Term
| What does an ABG of a pt with ALI typically show? |
|
Definition
|
|
Term
| What is the typical chest x ray associated with PE? |
|
Definition
|
|
Term
| What is the strict definition of ALI? |
|
Definition
| acute onset respiratory insufficiency, PaO2: FiO2 of less than 300, bilateral infilatrates, PCWP of less than 18 mmHg |
|
|
Term
| What should be in the ddx of a pt with ALI? |
|
Definition
| aspiration pneumonitis, atypical pneumonia, atelectasis and PE |
|
|
Term
| What is the pathophys of aspiration? |
|
Definition
| spillage of gastric contents into the bronchial tree causing direct injury to the airways, which can progress to a chemical burn or pneumonitis (esp when pH <3) and predispose to bacterial pneumonia; when the aspirated gastric contents contain particulate matter, bronchoscopy may be helpful in clearing the airway |
|
|
Term
| Pts with aspiration pneumonitis have what chance of developing pneumonia if they are given empirical antibiotics? |
|
Definition
|
|
Term
| Why are post op pts at higher risk for pneumonia? |
|
Definition
| incisional pain frequently affects the patients ability to clear airway mucus, leading to small airway obstruction and ineffective bacteria clearance |
|
|
Term
| In high risk surgical patients, what is the risk of developing a clinically significant PE? fatal PE? |
|
Definition
|
|
Term
| What are the clinical hallmarks of PE? |
|
Definition
| acute onset hypoxia associated with anxiety leading to tachypnea and hypocarbia without significant CXR abnormalities |
|
|
Term
| What is the pathophys behind morbidity of lung contusions? |
|
Definition
| direct parenchymal injury and bronchoalveolar hemorrhage, causing VQ mismatch leading to hypoxia. This condition is worsened by chest wall injury pain leading to atelectasis in the uninvolved lung |
|
|
Term
| What is the most severe form of ALI? |
|
Definition
|
|
Term
|
Definition
| condition encompassing a spectrum of lung injuries characterized by increasing hypoxia and decreasing lung compliance while the PaO2:FIO2 is <200 |
|
|
Term
| What is the pathophys of ARDS? |
|
Definition
| injury to pulmonary endothelial cells leads to an intense inflammatory response; inhomogeneous involvement of the lung occurs with interstitial and alveolar edema, hyaline membrane deposition, and eventual fibrosis; These changes manifest clinically as severe hypoxia, decreased lung compliance and increased dead space ventilation |
|
|
Term
| What are the symptoms of atelectasis? |
|
Definition
| low grade fever and mild respiratory insufficiency |
|
|
Term
| What is the pathophys of cardiogenic pulmonary edema? |
|
Definition
| myocardial dysfunction causes pulmonary interstitial edema; the increase in the amount of interstitial water compresses the fragile bronchovascular structures, thereby increasing the B/Q mismatch and resulting in hypoxia |
|
|
Term
| Pts with respiratory insufficiency and lethargy/diminished mentation may benefit from what treatment? |
|
Definition
| intubation to protect against against aspiration |
|
|
Term
| When should a patient with respiratory insufficiency be intubated? |
|
Definition
| lethargy, inability to maintain a PaO2 of 60 mmHg or an oxygen saturation of more than 91% with a supplemental nonrebreathing O2 mask (both indicative of significant alveolar arterial A/a gradient) |
|
|
Term
| How is a pts adequacy of ventilation assesed? |
|
Definition
| observe pt's respiratory efforts, subjective symptoms, measurement of PaCO2 by ABG analysis |
|
|
Term
| Why is there a decrease in pulmonary compliance when there is a lung injury? |
|
Definition
| inflammatory cells and fluid are sequesterd in the lungs leading to a decrease in pulmonary compliance and an increase in the work of breathing |
|
|
Term
| What does the ALI prodrome look like? |
|
Definition
|
|
Term
| Pts with mild acute post op respiratory insufficiency can be treated with noninvasive tx such as ... |
|
Definition
| suplemental O2, CPAP (useful for atelectasis), chest physiotherapy, including bronchodilators and mucolytic agents (useful for atelectasis, pneumonia, and reactive airway disease) |
|
|
Term
| What are the pressures created by conventional ventillation? |
|
Definition
| supraatmospheric pressure creating positive transpulmonary pressure ensuring inflation of the lungs; exhalation is passive and occurs after release of positive pressure |
|
|
Term
| What are the major settings in conventional ventilation? |
|
Definition
| volume and pressure controlled, where the tidal volume delivery is based on either volume- or pressure- limiting settings |
|
|
Term
| What is high frequency ventilation? |
|
Definition
| very small tidal volumes (1 mL/kg) at a high rate (100-400 breaths per minute) |
|
|
Term
| Is high frequency ventilation useful? |
|
Definition
| important in treating respiratory insufficiency in neonates; but not hte same success with adults |
|
|
Term
| What is the theoretical advantage of liquid ventilation? |
|
Definition
| reduces the amount of energy necessary to overcome surface tension at the gas liquid interface of alveoli and because disease lungs have less surfactant, liquid ventilation can improve lung compliance |
|
|
Term
| Is liquid ventilation better for ARDS? |
|
Definition
| need more studies to determine |
|
|
Term
| What is extracorporeal life support? |
|
Definition
| a heart lung machine can take over pulmonary and/or cardiac function; if cardiac function is adequate, a venovenous circuit can be used to remove CO2 and oxygenate the blood |
|
|
Term
| What's another name for extracorporeal pulmonary bypass? |
|
Definition
|
|
Term
| What is negative pressure pulmonary edema? |
|
Definition
| ALI secondary to forced inspiration against a closed or narrow airway resulting in "negative-pressure pulmonary edema" |
|
|
Term
| What is the treatment for negative pressure pulmonary edema? |
|
Definition
| unusual variant of acute lung injury and is often self-limiting with supportive care that include mechanical ventilation and IV fluids |
|
|
Term
| What are the complications that can result from abdomenal fascia dehiscence? |
|
Definition
| abdominal evisceration, enterocutaneous fistulas, and incisional hernias |
|
|
Term
| What are the patient factors that predispose to abdominal fascia dehiscence after surgery? |
|
Definition
| age over 70, diabetes mellitus, malnutrition, perioperative pulmonary disease, corticosteroid use, smoking |
|
|
Term
| What two factors guide the management of fascia dehiscence fuond in the early postoperative period? |
|
Definition
| stability of the intraabdominal contents (based on appearance of the wound and whether it has occured after fibrous scar has formed) and teh presence of absence of ongoing infection |
|
|
Term
| For a patient with abdomenal fascia dehiscence when do you immediately take them back to the OR? |
|
Definition
| pts at risk for evisceration, enterocutaneous fistula, or uncontrolled sepsis |
|
|
Term
| What causes enterocutaneous fistulas? |
|
Definition
| can develop from wound dehiscence and direct trauma to the underlying bowel or can be the primary processleading to wound dehiscence |
|
|
Term
| What is the prognosis of enterocutaneous fistula? |
|
Definition
| can be a devastating complication leading to septic and metabolic derangements, long-term disability, and mortality |
|
|
Term
| T/F Incisional hernias are usually evident after the skin has healed and bandages are removed. |
|
Definition
| false; can remain undetectable for as long as 5 years after the operation |
|
|
Term
| What are the phases of wound healing? |
|
Definition
| inflammatory, proliferation, and remodeling phases |
|
|
Term
| What happens during the inflammatory phase of wound healing? |
|
Definition
| inflammatory cells function in sterilizing the wound and secreting growth factors stimulating fibroblasts and keratinocytes in the wound repair process |
|
|
Term
| What happens during the proliferation phase of wound healing? |
|
Definition
| deposition of fibrin-fibrinogen matrix and collagen, resulting in formation of the wound matrix and an increase in wound strength |
|
|
Term
| What happens during the remodeling phase of wound healing? |
|
Definition
| capillary regression leads to a less vascularized wound, and with collagen cross-linking there is a gradual increase in wound tensile strength |
|
|
Term
| How does infection delay wound healing? |
|
Definition
| leads to delays in fibroblast proliferation, wound matrix synthesis and deposition |
|
|
Term
| How does inadequate nutrition affect wound healing? |
|
Definition
| vitamin C deficiency leads to inadequate collagen production, vitamin A deficiency leads to impaired fibroplasias, collagen synthesis/crosslinking, and epithelialization, vitamin B6 deficiency causes impaired collagen cross-linking |
|
|
Term
| How does oxygenation affect wound healing? |
|
Definition
| collagen synthesis is augmented with oxygen supplementation |
|
|
Term
| How do corticosteroids affect wound healing? |
|
Definition
| reduce wound inflammation, collagen synthesis and contraction |
|
|
Term
| How does DM affect wound healing? |
|
Definition
| microvascular occlusive disease leads to poor wound perfusion; impair keratinocyte growth factor and platelet derived growth factor functions in the wound |
|
|
Term
| What percent of patients who undergo abdominal surgery develop fascial defects? |
|
Definition
|
|
Term
| By how much does having a wound infection increase your risk of abdominal fascial dehiscence? |
|
Definition
|
|
Term
| Excessive fluid drainage from an abdomenal wound should make you think about what complication? |
|
Definition
|
|
Term
| When does the inflammation stage of wound healing o ccur? |
|
Definition
|
|
Term
| When does the proliferation stage of wound healing occur? |
|
Definition
|
|
Term
| When does the remodeling phase of wound healing occur? |
|
Definition
|
|
Term
| When post op is the highest likelihood of evisceration with dehiscence? |
|
Definition
|
|
Term
| Why is it not recommended to immediately correct all abdominal wounds that have fascial dehiscence? |
|
Definition
| because vasodilation and fibrosis during weeks 2 and 3 contributes to increased technical difficulty in reoperation during this time |
|
|
Term
| What are the post op complications more common in incisional hernias vs inguinal hernias? |
|
Definition
| wound infection rate (7-20% for incisional) and recurrence rate (20-50%) |
|
|
Term
| What are the technical factors related toabdominal closure failure? |
|
Definition
| inadequate tissue incorporation, inappropriate sutures/inappropriate suture placement, inadequate patient relaxation, excessive tension |
|
|
Term
| What are the different types of mesh that can be used for hernia repair? |
|
Definition
| polypropylene, composite mesh (expanded polytetraflouroethylene, PTFE, on the inside with polypropylene on the outside), biosynthetic prostehsis containing collagen harvested from cadavers or porcine sources |
|
|
Term
| What is the danger of using polypropylene mesh? |
|
Definition
| increased risk of erosion into the hollow viscus and subsequent enterocutaneous fistula formation |
|
|
Term
| When might you use a biosynthetic mesh? |
|
Definition
| high-risk, contaminated wounds |
|
|
Term
| Which is better for incisional hernias? primary repair vs with mesh? open or laparoscopic? |
|
Definition
| primary repair is better; laparoscopic and open are the same |
|
|
Term
| When is the tensile strength of a wound back to normal fascia strength? |
|
Definition
| is at 75-80% strength at 8 weeks and thereafter continues to strengthen but never is a strong as uninjured tissue |
|
|
Term
| What type of suture material should be avoided in closing an infected abdomen? |
|
Definition
| braided, nonabsorbable suture material is associated with entrapment of infected debris within the suture material and may lead to an increased number of infections |
|
|
Term
| How much suture do you need for a given wound length? |
|
Definition
| 4x as much suture as the wound is long |
|
|
Term
| T/F Reclosure of a previously healed fascial incision is associated with lower strength of healing and increased wound breakdown |
|
Definition
|
|
Term
| Where are common places for a post op pt to get infections? |
|
Definition
| UTI, pneumonia, blood borne, incision, IV catheter infection, antibiotic associated colitis |
|
|
Term
| What can a CT scan show you if you suspect intraabdominal infection? |
|
Definition
| abcesses or inflammatory changes without abscesses that is suggestive of persistent secondary peritonitis |
|
|
Term
| What is the treatment for persistent secondary peritonitis? |
|
Definition
| may be caused by inappropriate or inadequate antimicrobial therapy; in tehse cases, treatment consists of extending the course of therapy or modifying the antimicrobial regimen |
|
|
Term
| At what point is a temp a fever? |
|
Definition
| higher than 38.0 to 38.5 C; 100.4 to 101.3 F |
|
|
Term
| What are teh different categories of surgical site infections? |
|
Definition
| superficial=above the fascia, and deep= involving the fascia |
|
|
Term
| How are superficial surgical site infections treated? |
|
Definition
| wound exploration and drainage of the infected material, although systemic antibiotic therapy may be needed when there is extensive surrounding cellulitis (>2cm from the incision margins) or if the patient is immunocompromised |
|
|
Term
| What is a deep surgical space infection? |
|
Definition
| also referrred to as intra-abdominal nifections in teh setting of post operative abdominal surgery, they include secondary peritonitis, tertiary peritonitis, and intra-abdominal abscesses |
|
|
Term
| What is secondary microbial peritonitis? |
|
Definition
| spillage of endogenous microbes into the peritoneal cavity following viscera perforation |
|
|
Term
| What determines the persistence of secondary microbial peritonitis? |
|
Definition
| microbial inoculum volume, the inhibitory and synergistic effects of the polymicrobial environment and host response |
|
|
Term
| What is tertiary microbial peritonitis? |
|
Definition
| occurs in ptswho fail to recover from intra-abdominal infections despite surgical and/or antimicrobial therapy because of diminished host peritoneal response; frequently due to low virulence or opportunistic pathogens such as staph epidermidis, enterococcus faecalis, and candida species |
|
|
Term
| How does the abdomen wall off infection? |
|
Definition
| fibrin deposition, omental containment, and ileus of the small bowel |
|
|
Term
| What types of bacteria are present in the gut? |
|
Definition
| anaerobes and gram negatives |
|
|
Term
| What are noninfectious etiologies that can cause fever in a hospitalized surgical patient? |
|
Definition
| systemic inflammatory response syndrome, endocrinopathies (adrenal insuffieceincy, thyrotoxicosis), drug reactions and transfusion reactions |
|
|
Term
| How many microbes are in the colon versus the stomach? |
|
Definition
stomach= 10^2 to 10^3
colon= 10^11 to 10^14 |
|
|
Term
| What is the body's reaction to infection in the peritoneum? |
|
Definition
| peritoneal macrophage and PMN recruitment, development of ileus and fibropurulent peritonitis to localize the spillage; translymphatic clearance of sequestered microbes and inflammatory cells, leading to the resolution of peritonitis |
|
|
Term
| What are the goals in management of secondary peritonitis directed at? |
|
Definition
| eliminating the source of microbial spillage and early initiation of preemptive antibiotic therapy |
|
|
Term
| What percent of people with secondary peritonitis continue to have complications such as recurrent 2ndary peritonitis, tertiary peritonitis, or intraabdominal abscesses? |
|
Definition
|
|
Term
| What is standard dual agent therapy for intraabdominal infections? |
|
Definition
| aminoglycoside plus metronidazole or clindamycin (this regimen should be used with extreme caution for older patients and those with renal insufficiency; aminoglycoside peak and trough levels should be monitored closely with prolonged use in most if not all patients) |
|
|
Term
| What is nonstandard dual agent therapy for intraabdominal infections? |
|
Definition
1) second or third generation cephalosporin (cefotetan, cefoxitin, ceftriaxone, cefotaxime, cefepime) plus metronidazole or clindamycin
2) flouroquinolone (cipro, levo, gati) plus metronidazole or clindamycin |
|
|
Term
| What is single agent therapy for intraabdominal infections? |
|
Definition
mild or moderate infection= cefoxitin, cefotetan, ceftriaxone, ampicilllin-sulbactam
Imipenem= cilastatin, meropenim, piperacillin-tazobactam, ticeracillin-clavulanate |
|
|
Term
| What are the major causes of persistent secondary peritonitis? |
|
Definition
| inappropriate selection of and insufficient duration of antimicrobial therapy |
|
|
