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Anesthesia / Peri-Op / Fluids / Electrolytes

• Ondansetron is the most efficacious method for post-op nausea because Serotonin receptor antagonists are the most efficacious

Intra-op complications

• Manage intra-op hyperthermia, rigidity, and difficulty ventilating with IV fluids, O2, and muscle relaxants
• Hyperkalemia is seen in malignant hyperthermia
• Succinylcholine is the most likely inciting agent for rigidity and hyperthermia post-intubation
• Diffuse rash, hypotension, and bronchospasm intra-op is treated by stopping muscle relaxants and giving IV epinephrine

Right heart strain and tachycardia

• Trans-esophageal ECHO is the best next test to identify Pulmonary Embolism causing right heart strain

Normal Saline

• Normal saline contains Na 154, Cl 154

Trauma and IV fluids

• Large volume normal saline resuscitation causes metabolic acidosis by dilution of bicarb

Maintenance fluid rate and solution for a 60kg lady who is NPO

• 5% DW, 0.45%NS and 20KCl at 100cc/hr is appropriate

Clinical Sign of Hypermagnesemia

• Loss of deep tendon reflexes is the first clinical sign

Mallampati score

• The Mallampati score can help predict a possible difficult airway

Beta-blocker

• Continue beta-blockers unless there are concerns with hypotension

Laparoscopic cholecystectomy

• Stop ASA and continue a beta-blocker as best management of medications peri-op

Peri-Op clinic

• Severe valvular heart disease increases the peri-op risk for a patient seen in pre-op clinic for inguinal hernia

Cardiac Risk Index

• Detsky Modified Multifactorial Index, points are scored for each cardiac risk index
• 20 points for class IV angina or suspected critical aortic stenosis
• 10 points for alveolar pulmonary edema within 1 week or Class III angina
• 5 points for MI >6 months ago or >5 PVCs any time before surgery

Patient Risk

• Severe valvular heart disease increases the patient's peri-operative risk the most
• A mitral regurgitation or aortic stenosis can cause a grade II/VI systolic murmur
• Age >80 is the highest risk for peri-operative pulmonary complications

Highest relative risk

• The highest relative risk in decreasing order is ASA class >II, CHF, age >60, functional dependence, COPD, smoking, and obesity

Elective blepharoplasty

• A lady who wants elective blepharoplasty for her eye but had a DES two months ago after ACS should wait 10 months for surgery

Colon Cancer

• Operate 30 days after a patient admitted to hospital with anemia has ACS and treated with BMS and is subsequently diagnosed with colon cancer

Stress Dose Steroids

• A patient requires a stress-dose of 25mg daily for 3 weeks

Lidocaine Allergy

• Manage a patient with known allergy to lidocaine, requiring excisional biopsy of skin lesion on the cheek, with Procaine

Surgical Needle

• Unexpected change in procedure has the highest chance of retained foreign body (surgical needle)

Retained sponge

• Multiple surgeons involved in the case in a patient with breast cancer and has oncologic resection is a risk factor for a retained sponge

Plasma Volume for 70kg male

• Plasma Volume = 40 cc/kg (*70 = 2800), around 3L

CAGE questionnaire

• The CAGE questionnaire is used to cut back, and identify if the person is annoyed or guilty, and their eye opening

ASA classification

• A patient with comorbidities but no functional limitations has an ASA classification of 2
• A patient with comorbidities and functional impairment has an ASA classification of 3

Anesthetic dose

• Hepatic failure decreases the anesthetic does that should be administered

Bupivacaine

• Bupivacaine has a longer duration of action than lidocaine and slower onset
• Bupivacaine has greater cardiotoxicity than lidocaine
• Perioral numbness is the earliest symptom of local anesthetic toxicity
• Ketamine is the most likely medication to cause hypertension and tachycardia immediately after induction of general anesthetic

Endoscopy

• During endoscopy with midazolam for sedation, patient has decreased LOC with bradycardia and hypotension, manage with Flumazenil

Active Rewarming

• Rewarming BairHugger is the active rewarming method

Risk of fire in the OR

• Using cautery in neck dissection with airway with flammable gases, increases the risk of fire in the OR

Electrocautery

• High heat, low frequency is the difference between coag and cut when resident begins case using coagulation function instead of cut on the electrocautery and is unable to cut through the epidermis

Hyponatremia

• Hyponatremia commonly manifests as ICP/headache

Electrolyte Abnormality

• Hypercalcemia is the most likely electrolyte abnormality in a patient with pancreatic cancer and bony metastases who has nausea, vomiting and ECG findings of flattened T waves, short QT, and AV nodal block

Pancreatic cancer

• Fluid restriction for a pancreatic cancer patient with euvolemia and hyponatremia, Ambulatory, and asymptomatic, admitted for pain control with Na 130, Urine Na 28, and U/O good

Chronic Pain

• Pain after surgery is considered chronic pain after 3 months

Cardiac Surgery

• Arterial is superior to venous bypass grafts used for Coronary Artery Bypass Graft

ENT

• Staph Aureus is the most common cause of parotitis
• The next best step for a man with 3cm mass anterior to his earlobe is a CT scan
• If a patient is admitted for elective endoscopic sinus surgery with image-guided navigation to improve patient safety and they realize the pre-operative CT at another institution is incompatible with the present equipment, wake up patient and ask them how they would like to proceed

Ethics

• 4 main ethical principles: autonomy, justice, beneficence, Non-maleficence
• A 16 year old patient is a contraindication to MAID, must be 18 years old

Ethical Principle

• Autonomy is an ethical principle violated if surgical foundations committee decides that every resident must suffer for 5 years so patients can benefit

MAID

• A patient with metastatic pancreatic cancer and intolerable pain qualifies for MAID if he has an intractable medical condition
• Attempting to make a follow-up plan is the best course of action for a man in ED with a hand tendon laceration who is angry about the wait times and decides to leave AMA

Beneficence

• Beneficence is doing good for others

Medical records

• Autonomy is the ethical principle that has the patient requesting his medical records with a recent diagnosis of glioblastoma with headaches for the past 6 months

Surgical complication

• Ethically responsible to disclose complication immediately

Surgeon litigation

• Poor communication is the most common cause for surgeon litigation

Small hospital

• High volume centers have better outcomes/decreased complications so a samll hospital's outcome measures/complication rates notes rate higher than average is true

General Surgery

• Invasive wound infection must be ruled out for a patient post laparotomy and small bowel resection develops a temperature 38.9 within 24 hours
• Vomiting with gastric loss of sodium is the most likely cause of electrolyte abnormalities for a 64 year old male with small bowel obstruction admitted for emergent surgery with Na 112, Cl 96, K 3.8, Glc 12
• Man with unknown history presents with massive hematemesis, ascites, splenomegaly, and spider angiomas gets Somatostatin (this is octreotide) while waiting for urgent endoscopy in addition to transfusion of red blood cells
• Decreased CVP occurs upon CO2 insufflation during laparoscopy
• Endoscopy is the most common cause of esophageal perforation
• Celecoxib is the least likely NSAID to cause a GI bleed
• BMI>40 is an indication for bariatric surgery
• Fascial dehiscence is the dx for POD#8 patient presents with 1cm defect in wound with persistent copious amounts of serosanguinous discharge

Abdominal Compartment Syndrome

• Low urine output, decreased preload, and increased intra-pulmonary pressure is seen in abdominal compartment syndrome
• However for ACS, CVP can be increased despite decreased preload

Cirrhosis

• Patients with cirrhosis are more sensitive to some general anesthetic medications

Post-op thyroidectomy/neck dissection patient

• Open wound at bedside and take back to OR when a Post-op thyroidectomy/neck dissection patient in the PACU develops stridor and pulsatile hematoma beneath surgical incision

Hematology/ Transfusion Medicine

• Von Willebrand Disease is the most common congenital bleeding disorder
• Hemophilia A is the most common indication for FFP going for emergency surgery

INR

• Factor VII is measured by INR
• Platelets has the highest rate of bacterial infection
• Factor VIII is required for platelets to adhere to collagen
• vWF binds to Factor VIII

Warfarin

• PCC is the best way to reverse it for a patient taking Warfarin who requires urgent laparotomy
• Do nothing for a patient with platelet count of 55, no abnormal bleeding, is undergoing wound debridement for burns, no need for pre-op management
• The liver creates Factor 1, fibrin
• Congenital afibrinogenemia -- missing factor 1, unable to make clots--, has increased risk of bleeding

Female Undergoing Thyroid Surgery

• LMWH is best DVT prophalaxis for female undergoing thyroid surgery who is healthy but has had prior DVT

MVC Trauma

• LWMH is modality in the literature that has the best evidence for DVT prophylaxis for patient in an MVC trauma with grade II liver laceration, open tibial fracture, and cerebral contusion

Bariatric surgery

• LMWH is the kind of DVT prophylaxis for a bariatric surgery patient with prior DVT

Dialysis patients

• Dysfunctional platelets despite normal coagulation testing is true about coagulation status in chronic dialysis patients
• Hold for 5 days, and then restart 2-3 days later if no bleeding concerns when patient is scheduled for a TURP perioperative Warfarin

Surgicel

• Surgicel can be placed directly on bleeding tissue

Patient Transfusion

• TRALI has the Post-op for cancer tx requiring 12 units of pRBC intraoperatively and is now hypoxic

Massive Transfusion Protocols

• 1 unit pRBC : 1 unit FFP : 1 unit Platelets is the 1:1:1 ratio

HIT

• If the Patient Developed HIT (Heparin-induced thrombocytopenia)

Dabigatran

• Stop dabigatran 2-4 days prior to operation, or if a major bleeding is anticipated
• Argatroban should be stopped and placed on for patients with HIT

ICU / Nutrition

• Does not improve perfusion at tissue and cellular level, why are vasopressors bad

Energy reserve

• Fat is the biggest energy reserve in a 70kg man

Severe Trauma

• Proteolysis is the difference between energy expenditure in severe trauma and chronic starvation

Critical Illness

• Lipids is the most important energy source in critical illness

Pareneteral nutrition

• Inability to gain access to GI tract, trauma and the patient have perforated small bowel

Urine output

• 500-800mL (0.5 x 60 kg = 30 x 24 hrs = 720 mL) daily minimum acceptable urine output for 60kg man

Air Embolism

• Insert venous catheter into the right atrium and aspirate air, how to manage air embolism

TTE

• Valvular disease is what the TTE best for

TPN

• Hepatic steatosis is a complication of TPN and high caloric diet, common in patients with a history of alcoholism

Long Term Enteral Feeds

• G-tube is best for a patient requiring severe brain injury, with long term enteral feeds in the ICU

Ng Enteral feeding

• Best suited for patients with normal mentation and intact laryngeal muscles who can protect their airway (wording slightly different), true regarding NG enteral feeding

Decreased Aspiration

• Raising head of bed 10 degrees decreases risk and has a lower risk than NG

Digested Carbohydrates

• Small intestine is where carbohydrates are digested
• Fever, increased pulse pressure, high WBC, tachycardiac, tachypnea, and warm, seen with septic shock
• Septic shock presents with warm extremities
• Increased bleeding, possible complication with Activated Protein C given in sepsis
• Tissue hypoperfusion and cell death represents the decompensation phase within the "vicious cycle" of shock
• Decreased chest wall compliance and expansion, why obese patients harder to ventilate

Refeeding Syndrome

• Increased feeding in severely malnourished alcoholics, Seen with
• Minimal cerebral flow on ancillary studies, is required to diagnose brain death

Start arginine Vaopressin infusion

• Start arginine Vaopressin infusion for a patient with neurologic death in the ICU is reasonably stable with plans for organ donation but then crashes with hypotension, tachycardia and U/O increases to 1500cc/hr from previously 50cc/hr, and Sodium increases from 140 to 158

Metabolic Acidosis

• Ketoacidosis, caused by high anion gap metabolic acidosis
• Respiratory acidosis and metabolic acidosis, with low ph, high pCO2, normal p02, low HCO3 in the case of a patient

Demonstrate Myocardial Ischemia

• Dobutamine is administered to demonstrate myocardial ischemia during ECHO
• Assessment of valvular disease, ECHO is used best for

Volume Overload

• Increased CO, supportive for volume overload

Best initial management

• Feed, because best management is to stop for ICU pt.
• Use enteral used in increased risk of bacteremia from CVC

Vasopressors and Dobutamine

• Vascular trauma, use as last measure

Low urine output

• Check kidney volume followed by arterial pressures

Hypoglycemia & Pre Existing Structural Brain lesion

• Risk factor for delirium

Antipsychotic Medication

• Give minimal dose of antispychotic medication to achieve effect elderly female Pt P.O agitated

large volume Paracentesis & Red Skin, O2 100%, Acidotic

• Indication for Albumin, as you go up pull out fluid will come back.
• Carbon monoxide poisoning, what is the presentation?

Oxygenation

• Fetal hemoglobin shifts the curve left Oxygenation dissociation curve

Infectious Diseases

• Vancomycin Used As A Periop Antibiotic:
• Documented MRSA Patient
• Appropriate Time Interval For Redosing Prophylactic Pre-Operative Antibiotics:
• Half-Life, Want To Keep Adequate Dose Through Operation
• When To Give Pre-Op:
• Within 1 Hour Of Incision
• Prophylactic Antibiotics:
• Need Time To Get Adequate Levels At Operative Site Prior To Contamination
• Pathogen Most Commonly Seen With Catheter Related Uti:
• E. Coli.
• Nosocomial Uti:
• Do Not Need To Treat If Asymptomatic
• Antibiotic Causes Tendon Rupture:
• Ciprofloxacin
• Raw Hamburger With Hematuria And Purpura With Epitasxis:
• Hemolytic Uremic Syndrome
• Pre-Op Supervised Nurse:
• Electric Clippers Use For Hair Removal
• SSI, A common source of the morbidity
• decrease SSI?
• loban, antibiotic rinse, frequent saline of open wounds does NOT dec.
• Which of the following increases your risk for SSI
• blood transfusion
• Following will dec risk of SSI
• quiting 30 days before surgery
• Pokes with hollow bore-needler
• What should you d a) Start Prophylaxis whiting a few hours
• 15. Which one is you most likey get form blood transfusion
• HBV
• Which test from pseudmermbrnrouos
• stool test
• Gram Negative which one is
• Enterobacter cloacae

Neurosurgery

• Extracellular has the highest sodium

Traumatic CSF Leak

• Appropriate management- observation

Trauma

• Traumatic injury zone 2, rapid expanding hematoma
• OR for ex

Vascular Problems

• Bicarb:
• Rhabdo
• Zone 2 penetrating neck Injured and need to call surgery to vascular

Wound Healing

• Absorbable Monofil Monofil sucks so

Complications of Bone

• Bone fracture
• Pulmonary issue

Research & Statistics

Chi square and case control

• Best test determne causaality between 2 VA
• Rare and best used when there were questions Were there any exposed

High Alpha and 1 2 Test

• Alpha 1 error reject null and type 2 fiailed
• NNT &
• 1/.05
• Treatment has a relative risk and absoltue .25 and .04
• What is import var in deciding to implment
• must implement improves outcome

Bias Problems

• bias problems

Transplant

• Preservation
• Hypo then wisc solution
• Chonic rejection
• ENDO AND Epithenlum

What are and abo typing

• Hyper acute reject

Trasplanta ab matching

PRE FORM AND ABO AND

what is tureof hLA

cd BY HA -2

• Antigen pro skin cell
• Marophages PTLD is with WHAT

EBV EB V

• Most common by
• Squammouls
• Aza will incerases
• Neprotxoicy with Cyclo spor

A TRANS plant called with Donor AND ANOTHER H

All otralnsplat .Zone AND PEN inj

C-spine fracture

• Neurogenic shock

Patient is stabbed in chest and hypotensive