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Questions and Answers
Which of the following is NOT one of the 'Take 3' actions in the Sepsis Six protocol?
Which of the following is NOT one of the 'Take 3' actions in the Sepsis Six protocol?
The target central venous pressure (CVP) in managing sepsis is 12 mm Hg.
The target central venous pressure (CVP) in managing sepsis is 12 mm Hg.
False
What is the recommended volume of crystalloid fluids for a patient with hypotension or a lactate level ≥ 4 mmol/L?
What is the recommended volume of crystalloid fluids for a patient with hypotension or a lactate level ≥ 4 mmol/L?
30 ml/kg
The mnemonic to remember the actions of the Sepsis Six is _____
The mnemonic to remember the actions of the Sepsis Six is _____
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Match the Sepsis Six actions with their corresponding categories:
Match the Sepsis Six actions with their corresponding categories:
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What does a low mixed venous oxygen saturation (MVOS) indicate?
What does a low mixed venous oxygen saturation (MVOS) indicate?
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Neurogenic shock is characterized by an increase in pulmonary vascular resistance.
Neurogenic shock is characterized by an increase in pulmonary vascular resistance.
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Name one example of cardiogenic shock.
Name one example of cardiogenic shock.
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In neurogenic shock, patients typically exhibit ______ extremities.
In neurogenic shock, patients typically exhibit ______ extremities.
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Match the following types of shock with their characteristics:
Match the following types of shock with their characteristics:
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Which score indicates sepsis according to the new definition?
Which score indicates sepsis according to the new definition?
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The term 'severe sepsis' is still in use in the current definition of sepsis.
The term 'severe sepsis' is still in use in the current definition of sepsis.
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What are the three parameters used to calculate qSOFA?
What are the three parameters used to calculate qSOFA?
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Septic shock is defined as the need for _______ plus a lactate level greater than 2 mmol/L.
Septic shock is defined as the need for _______ plus a lactate level greater than 2 mmol/L.
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Match the following terms with their definitions:
Match the following terms with their definitions:
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Which condition is an example of obstructive shock?
Which condition is an example of obstructive shock?
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Warm extremities indicate distributive shock.
Warm extremities indicate distributive shock.
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Name two examples of endocrine shock.
Name two examples of endocrine shock.
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The body's response to inflammation is known as _____ (abbreviation).
The body's response to inflammation is known as _____ (abbreviation).
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Match the following types of shocks with their descriptions:
Match the following types of shocks with their descriptions:
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What percentage of lymphatic drainage in the breast is associated with the Axillary Lymph Nodes?
What percentage of lymphatic drainage in the breast is associated with the Axillary Lymph Nodes?
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The Terminal duct lobular unit (TDLU) is where most breast cancers originate.
The Terminal duct lobular unit (TDLU) is where most breast cancers originate.
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Name the first lymph node that drains lymph from cancer in the breast.
Name the first lymph node that drains lymph from cancer in the breast.
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The clinical examination utilizes the _____ clock method for breast examination.
The clinical examination utilizes the _____ clock method for breast examination.
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Match the types of lymph nodes with their respective percentage of lymphatic drainage:
Match the types of lymph nodes with their respective percentage of lymphatic drainage:
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At what hemoglobin level is red blood cell transfusion not indicated if risk factors are absent?
At what hemoglobin level is red blood cell transfusion not indicated if risk factors are absent?
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First generation blood substitutes include polyethylene glycol (PEG) hemoglobin.
First generation blood substitutes include polyethylene glycol (PEG) hemoglobin.
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What is the primary purpose of an anti-shock garment?
What is the primary purpose of an anti-shock garment?
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The second generation blood substitute is _____ hemoglobin.
The second generation blood substitute is _____ hemoglobin.
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Match the following blood substitutes with their generation:
Match the following blood substitutes with their generation:
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What effect does histamine release have in anaphylactic shock?
What effect does histamine release have in anaphylactic shock?
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Septic shock is characterized by a consistently low cardiac output regardless of the phase.
Septic shock is characterized by a consistently low cardiac output regardless of the phase.
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In anaphylactic shock, how does the body respond to decreased cardiac output?
In anaphylactic shock, how does the body respond to decreased cardiac output?
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In cold septic shock, cardiac output is __________ compared to warm septic shock.
In cold septic shock, cardiac output is __________ compared to warm septic shock.
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Match the type of shock with its associated characteristic:
Match the type of shock with its associated characteristic:
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What is the primary role of the suspensory ligaments of Cooper?
What is the primary role of the suspensory ligaments of Cooper?
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Dimpling of the breast is a sign of skin involvement in breast cancer.
Dimpling of the breast is a sign of skin involvement in breast cancer.
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What condition is characterized by the orange peel appearance of the breast?
What condition is characterized by the orange peel appearance of the breast?
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The _______ tail of Spence extends up to the axilla and can be mistaken for a lump.
The _______ tail of Spence extends up to the axilla and can be mistaken for a lump.
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Match the following clinical signs to their descriptions:
Match the following clinical signs to their descriptions:
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What is a potential complication of massive blood transfusion related to the anticoagulant used?
What is a potential complication of massive blood transfusion related to the anticoagulant used?
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Urine output is a common indicator of kidney perfusion.
Urine output is a common indicator of kidney perfusion.
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What is the best end point of resuscitation according to systemic perfusion monitoring?
What is the best end point of resuscitation according to systemic perfusion monitoring?
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Massive blood transfusion is defined as replacing the entire circulating volume in __________ hours.
Massive blood transfusion is defined as replacing the entire circulating volume in __________ hours.
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Match the organ with its corresponding clinical investigation for perfusion monitoring:
Match the organ with its corresponding clinical investigation for perfusion monitoring:
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Which of the following is a common cause of coagulopathy in surgery?
Which of the following is a common cause of coagulopathy in surgery?
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Transfusion-related acute lung injury (TRALI) is primarily caused by cardiac overload.
Transfusion-related acute lung injury (TRALI) is primarily caused by cardiac overload.
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What is the recommended ratio of PRBC, platelets, and FFP to prevent coagulopathy?
What is the recommended ratio of PRBC, platelets, and FFP to prevent coagulopathy?
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The clinical feature associated with transfusion-associated cardiac overload (TACO) includes __________.
The clinical feature associated with transfusion-associated cardiac overload (TACO) includes __________.
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Match the following reactions with their causes:
Match the following reactions with their causes:
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Study Notes
Sepsis Six
- Six key actions to be completed within one hour to treat sepsis, remembered by the mnemonic FABULOS
- Fluid resuscitation
- Antibiotics
- Blood cultures
- Urine output assessment
- Lactate measurement
- Oxygen administration
Surviving Sepsis Guidelines/Sepsis Bundle
- The first three hours of sepsis treatment require:
- Lactate measurement
- Blood cultures taken before administering antibiotics
- Administration of broad-spectrum antibiotics
- Fluid resuscitation with 30 ml/kg of crystalloid for patients with hypotension or a lactate level ≥ 4 mmol/L
- Within six hours:
- Vasopressors should be administered for refractory hypotension
- If continued hypotension or lactate ≥ 4 mmol/L, central venous pressure (CVP) and central venous oxygen saturation (ScvO2) should be measured
- Lactate levels should be re-measured if initially elevated
- Target CVP ≥ 8 mm Hg and ScvO2 ≥ 70%
Mixed Venous Oxygen Saturation (MVOS)
- Represents the unused oxygen returning to the heart
- Normal value: 50 – 70%
- Measured via a catheter in the right atrium
Types of Shock
-
Low MVOS:
- Indicates low cardiac output
- Reduced oxygen pump (Hypovolemic shock)
-
High MVOS:
- Suggests Distributive shock
Cardiogenic Shock
- Examples:
- Myocardial infarction
- Cardiac tamponade
- Arrhythmias
- Pathophysiology: The heart is not functioning properly
- Reduced cardiac output (CO)
- Decreased systolic blood pressure (SBP)
- Increased pulmonary vascular resistance (PVR)
- Elevated jugular venous pressure (JVP)
- Oxygen is not adequately pumped
- Lowered MVOS
- Cold extremities
Neurogenic Shock
- Example: Spinal cord injury above T6 level
- Pathophysiology: Loss of sympathetic nervous system drive
- Vasodilation
- Decreased PVR
- Decreased heart rate (HR)
- Warm extremities
Sepsis
- Old definition: SIRS (Systemic Inflammatory Response Syndrome) + Known foci of infection
- New definition: SOFA score ≥ 2 + Documented infection
SOFA (Sequential Organ Failure Assessment) Score
- Score ≥ 2 indicates sepsis
- Evaluates six organ systems: respiratory, cardiovascular, hepatic, renal, coagulation, and neurological
qSOFA (Quick SOFA) Score
- Parameters:
- Systolic Blood Pressure (SBP) < 100 mmHg
- Respiratory rate (RR) > 22/min (tachypnea)
- Altered mental state
- qSOFA score ≥ 2 indicates a poor outcome.
Septic Shock
- Sepsis accompanied by fluid unresponsive hypotension
- Multi-organ dysfunction syndrome (MODS): Failure of two or more organ systems
SEPSIS 3.0
- Sepsis: Life-threatening organ dysfunction resulting from a dysregulated host response to infection
- Septic Shock: Requires vasopressors or ionotropes and Lactate > 2 mmol/L
- The term severe sepsis is no longer used.
- SIRS is no longer a diagnostic criterion.
- qSOFA/SOFA scores are used for sepsis diagnosis.
General Surgery
OBSTRUCTIVE SHOCK
- Type of cardiogenic shock
- Decreased preload due to inadequate heart filling
- Examples:
- Cardiac tamponade
- Massive pulmonary embolism
DISTRIBUTIVE SHOCK
- Redistribution of blood to the periphery
- Examples:
- Decreased cardiac output
- Neurogenic shock
- Anaphylactic shock
- Warm septic shock
- Warm extremities
- Decreased cardiac output
ENDOCRINE SHOCK
- Combination of cardiac and distributive shock
- Examples:
- Hypo/hyperthyroidism
- Adrenal insufficiency
SIRS (Systemic Inflammatory Response Syndrome)
- The body's response to inflammation
- Etiology of inflammation
- Infective
- Non-Infective
- Mediators:
- IL-1
- IL-6
- TNF-alpha
SIRS Parameters :
- Temperature > 38°C or < 36°C
- Heart rate > 90 bpm
- Respiratory rate > 20/min or PaCO2 < 32 torr
- WBC > 12000/mm2 or < 4000/mm2 or > 10% band forms in peripheral smear.
- Any two parameters present indicate SIRS
Breast Lymphatic Drainage
- Lymphatic drainage pathways in the breast:
- 85-90% of lymphatic drainage occurs through the axillary lymph nodes (LN)
- 10-15% drains through the internal mammary LN
Clinical examination of lymph nodes in the breast:
- Anterior
- Central
- Apical
- Lateral
- Posterior
Surgical division of axillary lymph nodes:
-
Level I
-
Level II
-
Level III
-
Rotter's lymph nodes: between the pectoralis major and minor muscles
-
Sentinel lymph node: The first lymph node that drains lymph from the cancer
Functional Unit of the breast:
- Terminal duct lobular unit (TDLU): Where most breast cancers originate
- Stroma: the supporting tissue between TDLUs
- Fibroadenoma: Benign breast tumor
- Phyllodes tumor: Can be benign or malignant
Assessment of a Breast Lump
- Triple Assessment:
- Clinical examination
- Radiological investigation (e.g., mammogram, ultrasound)
- Histopathological investigation (biopsy)
Clinical Examination:
- Detailed history
- Breast examination (using the Dial clock method)
Perioperative Red Blood Cell Transfusion Criteria
- Hemoglobin level (g/dL) | Indications
- 8 | Not indicated if risk factors absent
Blood Substitutes
- First Generation: Perfluorocarbon
- Second Generation: Stroma-free hemoglobin
- Next Generation:
- Polyethylene glycol (PEG) hemoglobin
- Hemospan (AKA MP40x)
- Pyridoxylated hemoglobin polyoxyethylene conjugate (PHP)
Anaphylactic Shock
- Peripheral pooling of blood leads to decreased JVP, decreased CO, and decreased SBP
- Bradycardia and hypotension
- Example: Mismatched blood transfusion
- Pathophysiology: Histamine release causes vasodilation → blood pooling → decreased PVR (warm extremities), decreased JVP, decreased SBP, and decreased CO.
- Due to a normal sympathetic system, decreased CO leads to an increased HR and decreased stroke volume (SV)
Septic Shock
- Warm septic shock: - Hyperdynamic circulation - Increased CO, increased HR, and increased SBP - Elevated MVOS due to the inability of tissues to utilize O₂
- Cold septic shock: - Pathophysiology : Late phase of sepsis → Toxins inhibit myocardium → similar to cardiogenic shock
Rate over Pressure Evaluation (ROPE)
- Used to assess the severity of shock
- Uses:
- Heart rate (HR)
- Pulse pressure (PP)
Monitors for Organ/Systemic Perfusion
| Organ Perfusion | Clinical | Investigations |
|---|---|---|
| Systemic perfusion | Base deficit | |
| Lactate | ||
| Signs of acidosis | ||
| Mixed venous oxygen saturation (mVOS) | ||
| Best end point of resuscitation | ||
| Muscle | Near-infrared spectroscopy | |
| Gut | Tissue oxygen electrode | |
| Gut mucosa (most sensitive to hypovolemic insult; forms stress ulcers) | Sublingual capnometry | |
| Gut mucosal pH | ||
| Kidney | Urine output | Laser Doppler flowmetry |
| Brain | Consciousness level | Tissue Oxygen Electrode |
| Near-infrared spectroscopy (NIRS) |
Blood Transfusion
- Massive Blood Transfusion:
- Replaces the entire circulating volume in 24 hrs.: >10 units of blood
-
4 units in one hour
Blood Transfusion Complications
- Hypothermia
- Hypocalcemia/hypomagnesemia: Due to citrate (anticoagulant) chelating Ca2+ and Mg2+
- Metabolic alkalosis: Due to citrate toxicity
- Hyperkalemia >> hypokalemia: Stored blood → RBC lysed → K+ released → ↑ serum K+
General Surgery
Coagulopathy (most common cause of death):
- Reasons:
- Dilutional coagulopathy
- Acidosis
- Hypothermia
- Prevention:
- Limit crystalloids
- PRBC: Platelets: FFP - 1:1:1 ratio
Haemolytic reaction:
- Reason: Mismatched transfusion
Febrile reactions:
- Prevention: Use of a leukoreduction filter
Transfusion-related acute lung injury (TRALI):
Transfusion-associated cardiac overload (TACO):
TACO vs TRALI
| Feature | TACO | TRALI |
|---|---|---|
| Mechanism | Cardiac overload | Antibody against HLA antigen |
| Implicated donors | ||
| Clinical features | Facial puffiness, Pedal edema, Breathlessness, X-ray: Normal | Non-cardiogenic pulmonary edema (within 6 hours), Multiparous women, Patient receiving FFP, Breathlessness, CXR: ARDS (Acute respiratory distress syndrome) |
| Management | Lasix/diuretics |
Surgical Anatomy & Assessment
Surgical Anatomy of the Breast
- Modified sweat gland
- Axillary tail of Spence: Extends up to the axilla (can be mistaken for a lump)
- Location: From the midline to the anterior mid-axillary line, and to the 6th rib
- Pectoralis major
- Pectoralis fascia
- Lactiferous ducts (9-12): Open at the nipple
- Suspensory ligaments of Cooper:
- Connect the pectoralis fascia to the skin
- Maintain the breast shape
Clinical Signs of Breast Cancer
- Dimpling: Due to malignancy affecting Cooper's ligament. Not a sign of skin involvement.
-
Retraction of nipple: Not a sign of skin involvement in breast cancer.
- Types:
- Slit-like
- Circumferential (sign of cancer)
- Types:
- Peau d'orange (PDO): Orange peel appearance. Indicates involvement of sub-dermal/superficial lymphatics in cancer. If >1/3rd of the breast is involved, it may indicate Inflammatory breast cancer.
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Description
Test your knowledge on the Sepsis Six and Surviving Sepsis Guidelines. This quiz covers essential actions needed for effective sepsis treatment and the critical timeframes for intervention. Understand the components required to enhance patient outcomes in sepsis care.
