ABSITE Notes - Nutrition & Metabolism

Nutrition & metabolism RQ of 1 = carbohydrates RQ of 0.7 = lipids Kids with kwashiorkor will have fatty liver because they have decreased carrier protein synthesis o (not increased, this is due to the lack of the availability of amino acids) → unable to transport...

Nutrition & metabolism RQ of 1 = carbohydrates RQ of 0.7 = lipids Kids with kwashiorkor will have fatty liver because they have decreased carrier protein synthesis o (not increased, this is due to the lack of the availability of amino acids) → unable to transport lipoproteins out of the liver o Kwashiorkor is more severe than marasmus Copper deficiency = pancytopenia, neuropathy, ataxia o Mostly seen after using TPN (without trace minerals) and gastric bypass o selenium deficiency = cardiomyopathy, hypothyroidism, neurological changes In terms of hyperkalemic emergency o Calcium chloride has three times the concentration of elemental calcium as compared to calcium gluconate, however is caustic when given peripherally & is typically reserved for code situations. o The typical starting dose of calcium gluconate is 1000 mg given over 2-3 minutes. Prealbumin half life = 48h o Vs albumin half life = 21d  o ∴ prealbumin half life better in the acute setting for marker for nutritional status 25 – 30 kcal/kg = basal energy requirement in a well nourished patient undergoing a mild stress surgery o BEE = 25 kcal/kg/day o + 300 for preggo o + 500 for lactation Preop nutrition look at albumin, Duke PONS o Automatic qualifiers for nutritional support or intervention include an albumin < 3 or vitamin D < 20. Head & Neck If a child presents with a branchial cleft anomaly the management is full surgical excision of the remnant  o watchful waiting is not a strategy because they can / will become infected making operating in the future harder Of the head and neck cancers, the only one that is responsive to hormone therapy is Salivary Duct carcinoma o Salivary Duct carcinoma is physiologically similar to high grade carcinoma of the breast. They express androgen receptors and in 15% of the time, HER2. Can tx with adjuvant hormone therapy o Warthin's tumor is a benign tumor with rare malignant potential. o high grade Mucoepidermoid, Adenoid cystic, & advanced Acinic Cell Carcinomas → adjuvant XRT if they mentioned the mass is soft, they are trying to hint that it's benign, malignant masses tend to be hard just think of the cancers that you have physically touched during operations smoker + FNA with thick turbid fluid + bilateral = warthins tumor o they are not always bilateral, but of the salivary gland neoplasms this is the one that would be bilateral Slow onset, distant Mets, predilection for nerves = adenoid cystic carcinoma o In the stem they might mention some kind of facial nerve weakness or palsy (doubt that it always has to be the facial nerve) o Mucoepidermoid carcinoma → very rare to see mets, don’t give af about nerves usually Ectopic inferior parathyroid = thyrothymic ligament of the thymus Ectopic superior parathyroid = tracheo esophageal groove  The epiglottis and larynx receive sensory innervation from both the superior laryngeal nerve and the glossopharyngeal nerve. Endocrine  Imaging - including ultrasound, four-dimensional computed tomography (4D CT), and sestamibi → only used for surgical planning and does not have any impact on the diagnosis of primary hyperparathyroidism. It is believed that parathyroid carcinoma is radioresistant Breast DCIS/LCIS = stage 0 Invasive lobular carcinoma → “Indian style cells” , a lot less inflammatory o Soft mass o Imaging sucks at seeing, will underestimate Peudea orange in inflammatory breast cancer → dermal lymphatics involved o Read up on this Screening mammo = 2 views, craniocaudad Dx mammo = medial lateral oblique Esophagus Superficial and partial-thickness mucosal injuries in hemodynamically stable patients (ie, grade 1 and 2 esophageal injuries) can be safely observed.  Don’t use barium if you suspect an esophageal perforation o Use Gastrografin instead, it’s water soluble, less mediastinal irritation if you see Invasion into the submucosa is a T1b lesion Most durable non op management for achalasia = Pneumatic Dilation o Compared to pneumatic dilation, botulinum toxin injections have shorter lasting symptom relief and patients tend to require frequent treatments. The swallowing center is located in the medulla. o Not the pons Barrett esophagitis without dysplasia requires endoscopic surveillance but at 3- to 5-year intervals, o not 6 months. Normal LES → 10 mmHg Normal LES with food bolus → should be 0 mmHg Only do an EGD for high risk symptoms / features like advanced age, weight loss, dysphasia, hematemesis, hematochezia o in suspected normal GERD you can just jump straight to PPI Salmon colored patch, goblet cells = describing barretts soft against Thoracic  A minimum of 2–3 cm of intra-abdominal esophagus is required for adequate hiatal hernia repair. If the esophagus is shortened, a Collis gastroplasty can provide additional length. Esophageal adenocarcinoma is treated by endoscopic mucosal resection for lesions limited to the mucosa (cT1aN0). Resectable lesions that invade the muscularis propria (cT2N0) may be treated with upfront esophagectomy in the absence of high-risk features (lymphovascular invasion, > 3 cm, poorly differentiated). A preoperative FEV1 of ≥ 60% is sufficient for a patient to undergo an anatomic pulmonary lobectomy. No further investigations need to be performed. o If preop FEV1 < 60 ▪ Need a minimum predicted postoperative FEV1 of 35–40%. ▪ DLCO should be > 60% Stomach Epstein-Barr can be associated with nasopharyngeal cancer, Hodgkin disease, Burkitt lymphoma, a subset of gastric cancer, and lymphoproliferative disease in AIDS patients.  o Kaposis = HHV 8 Normal phi angle 4 – 58 in gastric band surgery = means band positioning is gucci Stress ulcer prophylaxis with proton pump inhibitor is indicated for patients with o TBI (GCS ≤ 10 or inability to obey commands), o traumatic spinal cord injury, o mechanical ventilation > 48 hours, not 24h o severe burn injury (≥ 20% body surface area), o coagulopathy ▪ INR > 1.5, ▪ PTT > 2 times the control value, ▪ platelets < 50,000/mms Post RYGBP = ↓ MCV = microcytic anemia = iron deficiency o this is because you bypassed the proximal small bowel which is where iron and calcium are absorbed  ▪ So you can also see hypocalcemia which will present with neuromuscular symptoms like cramps, tetany , paresthesias ▪ Don’t forget though vitamin D the MCC def o if you see a ↑ MVC = macrocytic anemia = megaloblastic anemia due to the loss of intrinsic factor production with a small gastric pouch Neoadjuvant chemotherapy = T2 or any N adjuvant therapy = T3, T4, or node positive Afferent loop syndrome = related to excessive length of the afferent loop in a billroth 2 o Will see megaloblastic anemia, NOT microcytic anemia o GIST is the most common type of sarcoma seen in the GI tract o seen mainly in the stomach, followed by the small bowel o yes a gastrointestinal stromal tumor is a sarcoma o originate from the interstitial cells of kajal EMR or SMD = early gastric cancer is 20 polyps or if the polyps are > 1 cm, withdrawal of PPI medications should be considered. bland spindle cells with elongated nuclei = GIST Make sure to preserve the right gastroepiploic if you want to use the stomach as a conduit for a reconstructive surgery following esophagectomy If you see a large ulcer along the greater curvature of the stomach during an EGD just go ahead and biopsy it from both the edge and the core o Does not have to be just greater curvature ulcers, just large ones In the 24 hour period the stomach will secrete approximately 1500 milliliters Small Bowel  most significant indicator for malignant potential in a GIST = > 5 mitosis/50 high- power field, and size > 5 cm o Lymph node involvement in GIST is rare, and lymph node sampling has not proven to provide any additional benefit to staging or prediction to response to treatment and mortality. For post op ileus the best option to improve = correct electrolytes o Ambulation and nasogastric decompression is often recommended but has never been proven in the literature. Following abdominal surgery the quickest return of function from first to last o Small bowel, stomach, colon o small bowel motility returns within several hours, o gastric motility within 24 to 48 hours, o colonic motility in 48 to 72 hours. Small bowel NHL → CT-guided biopsy is usually used for distal small bowel lesions, o whereas proximal lesions are best diagnosed with endoscopic submucosal biopsy. o Gotta bx the submucosa, wont see tumor path within the mucosa ▪ Hella lymphoid tissue in submucosa, peyers patches & shit etc Doing appy on a kid but sus meckels →  o diverticulectomy is warranted in cases of a narrow (< 2 cm) base Meckel diverticulum o segmental resection of the involved small intestine in cases of a broad (> 2 cm) based Meckel diverticulum. o An appendectomy should also be performed. Celiac disease is a risk factor for small bowel T-cell lymphoma. (enteropathy- associated T-cell lymphoma (EATL) o monotonous anaplastic clonal cells expressing T-cell markers such as T- cell receptors, CD3, and CD7. HPB The first step in management for suspected bilomas → abdominal/RUQ US o ERCP or PCT after Soap bubble or paintbrush sign → pathognomonic for villous adenoma Obstructive jaundice leads to malabsorption of the fat-soluble vitamins (A, D, E, and K). → may present clinically with night blindness, osteomalacia, neuromuscular weakness, or coagulopathy. If a patient had a RxY gastric bypass, you really don't want to ERCP them because the roux limb is long as fuck The definitive treatment for PSC is liver transplant, the disease can occur however it is not as aggressive in the transplanted liver  Gallstone ileus tx Adjuvant chemotherapy improves survival in those with gallbladder adenocarcinoma / cancer If you have bili dyskinesia, and get a chole, the symptom most likely to improve is the RUQ pain Pain not significantly relieved by bowel movements, postural changes, acid suppression, and radiates to the back or shoulder → think functional disorder of the sphincter of oddi Cholesterol polyps are the most common non-neoplastic gallbladder polyps Large gallstones ↑ risk of gallbladder cancer ↑ bile salt, low cholesterol, high lectin ratio → favorable outcomes Propranolol is really only used in the setting of variceal hemorrhage, do not use for long term therapy in those with cirrhosis as data has shown it increases morbidity / mortality o it reduces blood pressure and makes the fluid more diuretic resistant o You can however use as prophylaxis for asymptomatic varices ▪ Octreotide has no use in ppx, only in the acute setting Acetaminophen toxicity is the MCC of acute liver failure in the United States. o Viral hepatitis is still the MCC worldwide. Chromogranin A & pancreastatin → think neuroendocrine o Chromogranin A is secreted by neuroendocrine cells, and pancreastatin is a fragment of chromogranin A o Tx → resection of the primary tumor, metastasectomy, and cholecystectomy ▪ Chole because patients will receive octreotide however a side effect is called cholelithiasis  d/t the inhibition of CCK, increasing proportion of cholesterol relative to bile acids favoring cholesterol precipitation, and causing bile stasis For NETs removal of > 7 lymph nodes was associated with better outcomes. The most sensitive modalities for localization of pNETs include endoscopic ultrasound, somatostatin receptor scintigraphy, gallium dotatate PET/CT scan, and angiography with arterial stimulation and portal venous sampling, E. granulosus and E. vogeli cause liver cysts, o while E. multilocularis correlates to venous obstruction, portal hypertension, sepsis, and cholangitis Hep B MCC in asia, ME, Africa Hep C MCC in western world  o Alc 2nd MCC in the west Do NOT TIPS if they have signs of hepatic encephalopathy, remember tips makes that shit worse For variceal bleeding start with the ABC's, then give octreotide or tirellperssin, then attempt EGD, if EGD fails then go on to the balloon tube o historically vasopressin and nitroglycerin were also used but, neither agent alone If you see portal hypertension with thrombocytopenia that indicates advanced cirrhosis and hepatic resection will be contraindicated, start thinking transplant The caudate lobe is segment I  Left lateral hepatectomy (segments II and III, with or without segment I), also known as left lateral sectionectomy, is usually the preferred technique for live donor liver resection for pediatric transplantation. Underlying biliary disease, such as gallstones, is the most significant risk factor for developing a pyogenic liver abscess, especially in the presence of jaundice and Klebsiella pneumoniae bacteremia. o Even greater risk than being immunosuppressed (crohns etc) 1st line for intrahepatic cholangiocarcinoma without mets → R0 resection o Limited evidence that neoadjuvant chemo helps  o HOWEVER patients are not eligible for resection if they are found to have metastatic disease or lymph node metastasis beyond the porta hepatis. Hyperchromasia, increased mitotic activity, and pseudostratification of Lieberkühn crypts in the liver → mets from CRC nucleation of sterol monohydrate aggregates = gallstones CT findings of a multiloculated, hypodense liver lesion, = strongly suggest a pyogenic liver abscess. Resection of the paracellular carcinoma is contraindicated with main portal vein involvement AML is a risk factor for acalc chole Fungal hepatic abscess → perc drainage + caspofungin or micafungin o Not ampho B o All candida is sus to voriconazole Use the step up approach in necrotizing pancreatitis, ideally you want to delay operative intervention for as long as possible at least four to six weeks o proceed with drain placement before you answer video assisted debridement Functional liver remnant % post resection  o normal liver = 20 o some degree of liver dysfunction such as those who preoperative chemo = 30 o Cirrhosis = 40 o significant underlying liver disease = 50 The 2018 AGA guidelines suggest against routine use of urgent ERCP. o ERCP should be performed in patients with high suspicion of retained CBD stones. ▪ so if the CBD normal & T bili < 3 u can just and chole during same admission, judge it clinically pancreatic insufficiency diagnosis → established by fecal fat testing. Reducing central venous pressure to about 5 mm Hg is recommended during liver transection to minimize bleeding from hepatic veins. Choledocol cysts carries risk for both cholangio & gallbladder CA HIDA scan has low radiation Pancreatic debridement is best accomplished bluntly, using finger dissection or ring forceps o Sharp dissection should be avoided to prevent hemorrhage and damage to surrounding structures. Somatostatinoma associated with MEN1 & von Recklinghausen disease (NF1) Pancreatic fistula remains the most frequent, serious complication following pancreaticoduodenectomy (Whipple), with an incidence ranging from 5% to 15%. CT scan with IV contrast is the most sensitive diagnostic test of pancreatic necrosis.  o The role of FNA in the diagnosis of acute pancreatitis is limited to confirming the presence of infected pancreatic necrosis. Cholecystokinin is the most potent stimulator of pancreatic enzyme secretion, while secretin stimulates fluid and bicarbonate secretion. o Acidification (i.e., to a pH < 4.5) of the duodenum causes specialized cells within the mucosa to release secretin into the circulation. Secretin potently stimulates pancreatic duct cells to secrete pancreatic fluid and bicarbonate. cationic trypsinogen gene (PRSS1) mutation – hereditary pancreatitis Spleen patients without portal hypertension, the splenophrenic & splenocolic ligaments are relatively avascular Most likely encapsulated bug post splenectomy = strep pneumo Splenorenal ligament is what contains your splenic vessels and tail of the pancreas Gastrosplenic ligament contains your short gastrics Multiloculated splenic Abscess = splenectomy o CT-guided drainage would be more effective for a uniloculated fluid collection.  o Colorectal Surgical options for persistent anal fissures → Sphincterotomy o NOT fissurectomy A right hemicolectomy is indicated for appendiceal neuroendocrine tumors (formerly called carcinoid tumors) that are > 2 cm o or involve the appendiceal base, o tumors that are between 1 and 2 cm if there is lymphovascular invasion, positive/uncertain margin, higher proliferation rate (grade ≥ 2; mitotic rate > 1 or Ki-67 > 2%), o and mixed histology (eg, goblet cell adenocarcinoma).  Birds beak appearance in the RUQ = cecal volvulus o LUQ birds beak = sigmoid volvulus In a Crohn's patient if you're going in for an appy and the cecum looks normal it's OK to proceed with the appendectomy, Even if the appendix looks normal too Post appy abscess drain if > 3cm o < 3cm → cont IV abx o Only do lap washout if pt cont to get worse despite abx and if perc drain fails o IV abx → perc drain → lap washout if a Crohn's disease patient comes with a SBO secondary to a stricture, do not just strictureplasty the current obstructing point but strictureplasty all of the diseased areas as the other strictures will become a problem in the future If you suspect radiation proctitis perform a rectal exam above proctoscopy and anoscopy o do not do a sigmoidoscopy and biopsy stuff, these random endoscopic biopsies will increase your risk of forming rectal fistulas  o Low-output fistulas (< 200 ml/day) are treated with a regular diet, wound management, and electrolyte repletion ▪ About 1/3 of them will close spontaneously, TPN for high output fistula and its nutrition is inadequate Stapled hemorrhoidopexy tends to be less painful than excisional hemorrhoidectomy though it has a higher recurrence rate. APC gene is the most common genetic defect in colon cancer. Ligation of intersphincteric fistula → complex transsphincteric and intersphincteric fistulas, usually indicated for the repair of fistulas that fail to heal with seton placement or those that recur and less likely to use the first-line treatment. Lynch syndrome = Hereditary nonpolyposis colorectal cancer o MLH1, MSH2, MSH6, and PMS2, Microsatellite instability o No BRAF involvement o Endometrial cancer is the most common extra-colonic malignancy seen in Lynch syndrome. ▪ Others: gastric, small bowel, pancreas, ovarian, endometrial, and urological/renal cancers. o Amsterdam criteria: 3-2-1 rule: 3 affected family members, 2 generations, 1 diagnosed before age 50. o Sus histo for lynch → mucinous or signet-ring differentiation, or medullary growth pattern Diverticulosis is the most common cause of lower gastrointestinal bleeding and is a result of a rupture of an arterial branch vessel.  Adenocarcinoma polyp → 2 mm margin is necessary for cure with polypectomy. o hese can be treated with polypectomy alone if they are pedunculated and do not involve the base or the lymph vasculature. Mass with radially oriented folds or starburst pattern = external hemorrhoids Hernias When patients present after Roux-en-Y gastric bypass with the sudden onset of abdominal pain, nausea, and vomiting, one must assume that there is an internal hernia until proven otherwise. o mesenteric swirl → virtually pathognomonic for an internal hernia If they tell you there is a palpable facial defect, then that rules out diastasis recti o there is no facial defect in diastasis recti For incarcerated femoral hernias, an inguinal approach is recommended The pectineal (Cooper's) ligament forms the posterior boundary of the femoral canal. The superior lumbar hernia of Grynfeltt occurs in the space between the latissimus dorsi, the serratus posterior inferior, and the posterior border of the internal oblique muscle. The inferior lumbar hernia of Petit occurs in the space bounded by the latissimus dorsi posteriorly, the iliac crest inferiorly, and the posterior border of the external oblique muscle anteriorly The incidence of incisional hernia following laparotomy is decreased by the use of running 2-0 PDS taking 5-mm bites every 5 mm. – STITCH trial anterior abdominal wall component separation = release of the external oblique lateral to the semilunar line  Direct = weakness in the transversalis fascia, through the external superficial ring, medial Indirect = patent process vaginalis, through the internal deep ring, ∴ surrounded by spermatic chief, lateral The most common complication to placing staples below the iliopubic tract is an injury to the genitofemoral nerve or lateral femoral cutaneous nerve. McVay repair may be used for the management of both inguinal and femoral hernias. o An anterior inguinal approach involves opening the posterior inguinal wall to attain access to the femoral space. Trauma Bilateral calcaneal fractures sustained from a high distance fall are often associated with lumbar compression fractures due to high axial loading forces. o Bimalleolar fractures are associated with direct trauma to the ankle and twisting injuries (seen in sports injuries). Suspected facial nerve injury o at the medial canthus → non op o at the lateral cantus → operative o If the repair is not undertaken with 72 hours of injury then wallerian degeneration prevents identification of the nerve endings of the transected facial nerve.  Blunt cardiac injury classically presents as sinus tachycardia after a precordial injury. Sinus tachycardia is the most common EKG abnormality. o Followed by premature atrial contractions and premature ventricular contractions also very prevalent Definitive repair of cardiac injuries is performed with either running 3-0 polypropylene suture or interrupted, 2-0 polypropylene suture. Answer D: Injuries adjacent to coronary arteries should be repaired using horizontal mattress sutures because use of running sutures results in coronary occlusion and distal infarction. Diagnostic laparoscopy is indicated for unexaminable patients (GCS ≤ 12) and for patients with left-sided thoracoabdominal stab wounds, to rule out diaphragm injury. o Grade IV injuries are complete disruptions without extensive separation. Grade V injuries are complete, with extensive separation. Emergency department thoracotomy = if they go into cardiac arrest within 15 minutes of the initial penetrating trauma If you see a polytrauma with widened mediastinum and they are unresponsive to resuscitation and you're trying to decide between a thoracotomy or a laparotomy, go with the laparotomy as if they had an injury to the great vessels or any of the thoracic structures they would have likely died on the field, assuming that there is no cardiac arrest and that you see free fluid on a fast exam Posterior hip dislocations are normally involved with sciatic nerve injuries o no need for angiography to rule out a vascular injury  You can repair small portal vein injuries less than 1 cm with a primary repair operative intervention for pediatric splenic trauma → continues to require blood transfusions (packed RBCs > 20–40 mL/kg in 24h) Even for minor pancreatic trauma always place drains, the leaking pancreatic enzymes can damage the surrounding structures o grade 1 and 2 → drainage o grade 3 → start thinking operative In a thoracotomy even if there is no blood, incise the pericardium, even if you want to do intracardiac defibrillation it's better to do it on the myocardium itself o You want to explore everything and rule out cardiac tamponade Steroids are no longer used in cauda equina syndrome o first line is a discectomy urgently If you see pericardial fluid in an otherwise stable patient proceed to the OR for pericardial window, which you can extend to a median sternotomy if there is frank blood within the pericardial sac o the answer is never pericardiocentesis Treat fat embolism with supportive care o no need for steroids or heparin Pronation of the forearm is accomplished by muscles innervated by the median nerve. In children less than 6 years old, an intraosseous line should be placed prior to attempting a central line Anterior dislocations are less common and are of 2 main types o superior, where the femoral head is displaced into the iliac or pubic region, o inferior, where the head lies in the obturator region.  o more frequently associated with fracture of the femoral head, avascular necrosis one Even with long standing chronic diaphragmatic hernias you can still see strangulation, thus you always want to repair them o in an acute setting you go through the abdomen because of the high risk of associated intraperitoneal injury and because the lack of adhesions makes reduction of the abdominal viscera into the peritoneal relatively easy, o in chronic or defect discovered at a later date you can address it through a transthoracic approach which will help you with your lysis of adhesions o ∴ use NE d/t dual α- and β-activity, effectively addressing hypotension and bradycardia.  o Metronidazole is combined with cefazolin to provide adequate preoperative antimicrobial prophylaxis but individually is insufficient. The majority of penetrating gastric injuries can be primarily repaired in one or two layers due to the ample vascular supply of the organ. Critical Care Time of CPR does not apply for hypothermic patients, survival is possible in this group despite long courses o the decision to continue CPR should depend on the patient's core temperature o if asystole persists despite rewarming to a core temperature of 90F, survival is unlikely and CPR is futile o is below 90 F (32 C) focus on rewarming methods first atracurium and cisatracurium metabolizing the blood via Hoffman elimination, ideal for those with hepatic and renal disease o the rest of the –iums get both a mix of hepatic and renal metabolism only defib vfib or pulseless vTach There is no difference in risks of endocarditis when comparing mechanical to bioprosthetic valves o bioprosthetic valves do not require long term anticoagulation, mechanical valves do o the leading cause of death for those who undergo cardiac valve surgery is CHF not infection Unstable afib → synchronized cardioversion o stable afib beta blockers or calcium channel blockers, ▪ if CHF amiodarone tx Methemoglobinemia → methylene blue (meth blue with reduce [ferric] Fe3+ back to Fe2+ [ferrous] form  o Hydroxycobalamin is the antidote for cyanide poisoning The IJ is lateral to the carotid fucker Best way to confirm arterial line placement is transduction (waveform on the monitor) o NOT it's pulsatile flow, this can be unreliable in critical patients in the ICU Torsades de points → replate Mg, NOT Ca o Vancomycin and Linezolid will cover MRSA, but NOT G- keep CPP btwn 60 – 70 o ICP < 20, normal 7 – 15 Elevated peak pressures in abdominal compartment syndrome > 40 normal SVR 700 - 1500 dynes high-frequency decrescendo diastolic murmur best heard at the third or fourth intercostal space at the left sternal border = AR  most effective method for maintaining normal thermia during an operation is increasing the ambient temperature and forced warm air normal CVP = 8 – 12 mmHg IVC diameter > 2 cm suggests elevated CVP IVC diameter < 2 cm suggests low CVP. Etomidate = adrenal suppression o Will see hypotension, should see hyperK but can see hypoK bc ▪ Adrenal suppression might result in altered stress responses. A compensatory increase in catecholamines during stress can drive potassium into cells by stimulating beta-adrenergic receptors, lowering serum potassium levels transiently. Fluids & Lytes  Avg daily secretions: Hematology & Transfusion Medicine Give both FFP and vitamin K if you're trying to correct a Coagulopathy in cirrhosis o FFP = does not last long but quick onset o vitamin K = slow onset but last longer o combo of both is gucci transfuse plts ppx = to 10K to ↓ risk of spontaneous bleeding Burns  silver nitrate → can cause hyponatremia (all hypo-lytes) or methemoglobinemia. Silver nitrate is preferred in cases of eschar in patients with sulfa allergies Mupirocin → MRSA Mafenide acetate → 3rd degree burned with eschar , excellent eschar penetration, pseudomonas, not effective against MRSA  Inhaled NAC does have a morbidity and mortality benefit in burns (contains a thiol group & is a strong reducing agent that breaks the disulfide bonds that give stability to the mucoprotein network of molecules in mucus.) o inhaled nitric oxide does NOT o a low tidal volume approach in ventilating a burn patient may not be appropriate due to the excess CO2 formed in the hypermetabolic response o Peds Hirschsprung disease asc with pathes of hypopigmentation o Waardenburg syndrome, o congenital central hypoventilation (Ondine curse), o Smith-Lemli-Opitz syndrome o  o Transplant  Sirolimus (----| mTOR) fucks with wound healing, o use tacro instead if given a stem about a renal transplant patient that is requiring some kind of other operation for whatever (like a hernia) Gingival hyperplasia → cyclosporine Treat the first episode of acute rejection with high dose pulse steroids o treat subsequent episodes of acute rejection with antithymocyte globulin if they are not responding to steroids hyperlipidemia side effect → Sirolimus o tacro is neuro, nephro sx If you have a immunocompromised patient (transplant) you should strongly consider surgical resection for diverticular disease electively because they can really get fucked by diverticulitis complications o in general family history of diverticular disease does not really predict the severity of diverticulitis or a likelihood that it will progress to a complicated diverticular disease in a patient o The 2016 MLED score includes sodium and is preferred over child Pugh because child Pugh has some subjective agreements to it such as the degree of ascites and encephalopathy intranuclear basophilic viral inclusions without a surround halo, clumping of infected cells, & tubular injury on bx → BK virus if PD cath flow rates are unchanged or not diminished that means it is not clogged up with a fibrin plug, so no need to use alteplase in the catheter  Peritoneal dialysis is more gentle and causes less severe intravascular and interstitial fluid shifts than hemodialysis. o Peritoneal dialysis is less efficient, hence why you have to do daily versus hemodialysis which you do 2-3 times a week ▪ you were thinking in terms of efficiency regarding transportation to hemodialysis centers but when they mean efficiency they're referring to the actual dialyzing efficiency of HD versus PD type 1 DM is an absolute contraindication to living donor nephrectomy regardless the absence of end organ damaged or how well controlled it is o active malignancy is a contraindication, however previously treated / resected is not a contraindication if it's a minimal risk tumor ▪ minimal risk tumors include squamous cell skin, basal cell, small papillary or follicular thyroid cancer, and solitary well differentiated ( < 1cm) renal cancer ▪ remote history of Melanoma, testicular, lung, breast cancers and a few others are an absolute contraindication In the setting of donor nephrectomy, care should be taken to avoid ureter skeletonization to preserve its blood supply.  Vascular Biggest risk factor for AAA smoking o not hypertension The MCC of long term mortality for those treated with acute mesenteric ischemia is myocardial infarction o not fucking renal failure iliofemoral DVT → heparin + catheter-directed thrombolysis Young healthy male with intermittent claudication especially with stuff that involves knee flexion (running) → popliteal artery entrapment s/p stenting of the SMA for CMI clinic f/u → Clinical follow-up & duplex ultrasound in 1 month, six months, 12 months, & then annually after that. Hunters canal If the pseudo aneurysm 3 cm in size should be avoided, as contamination of the surrounding tissue may result in a more extensive resection in the event of malignancy on pathology o Otherwise to a longitudinal incisional bx for > 3 cm o Incisional bx too invasive, only do if you're unable to get adequate core needle biopsy o Wide local excision with 2-cm margins if path confirmed o The two best are core & longitudinal incisional biopsy, with core needle biopsy being first line If palpable nodes (aka clinically +) → you gotta bx them before a WLE in melanoma o Done with core or FNA ▪ If the node is negative → then SNLB ▪ If node + → axillary lymphadenectomy (including levels I, II, and III) Mohs surgery should be considered for basal cell and squamous cell carcinomas that exhibit the higher-risk factors when available. o The spread of infection due to incomplete drainage is the most common complication of abscess drainage procedures Antibiotics are the most common cause of toxic epidermal necrolysis. o Antibiotics are the culprit 40% of the time, o Not Anticonvulsants, Anticonvulsants cause TEN 11% of the time.  T(13;p11) translocation is typically seen in lipomatous tumors such as liposarcoma, pleomorphic liposarcoma, and myxoid/round cell liposarcoma t(17;22) → Dermatofibrosarcoma protuberans o no penetration into the epidermis o proliferation of spindle-shaped tumor cells will only involve the dermis and subcutaneous adipose tissue. The boundaries of the femoral triangle are o sartorius LATERALLY, o adductor longus MEDIALLY, o the cross of the two muscles inferiorly and the inguinal ligament superiorly. The most common form of skin malignancy is basal cell carcinoma. Urology For advanced seminomatous tumors with lymph node involvement after radical orchiectomy, adjuvant treatment includes radiotherapy or chemotherapy. o retroperitoneal lymph node dissection for non-seminomatous tumors for stage II disease. MIS & Random Stuff harmonic ultrasonic scalpel → uses ultrasonic vibrations instead of electric current to cut and cauterize tissue. This may cause less thermal spread and less damage to surrounding tissues. The heat is generated by the jaw of the instrument vibrating at 50,000 Hz. The disadvantage of ultrasonic instruments is cost. The heat generated by conventional electrosurgery is on the order of 150- 400°C (302-752°F).  Cellular vaporization and vacuoles form and coalesce, leading to complete cellular destruction occur at 100°C (212°F). Above 125°C (257°F), complete oxidation of protein and lipids leads to carbon residue or eschar formation. Best results can be achieved by sealing of vessels ≤7 mm in diameter with minimal thermal spread. Stats