Category Archives: Pearls

Legal and Ethics for Surgeons – Highlights – Notes

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Legal Issues and Ethics

  • When a patient has a DNR order and needs a surgery with anesthesia, consider discussing the revoking the DNR order temporarily or focusing on what the patient wants for quality of life.
  • Unrelated urgent surgery to terminal illness + DNR order = some hospitals rescind the DNR order x 24 hours with careful documentation of the time.
  • High quality X-ray and multiple views of the X-ray may be required when looking for a possible retained sponge from surgery.
  • Some surgeons believe that the patient should be informed when the sponge / instrument counts are inaccurate at the end of a case even if there is no retained objects found on X-ray.
  • Laws vary regarding protection from apologizing.
  • Negligence = failure to exercise standard of care (reasonably prudent person / same situation).
  • First element of informed consent, decide whether the person is competent of making decisions on behave of themselves, their child or their family member.
  • To honor a patient’s request to make a medical/surgical decision for them, you must have already established a relationship with the patient, no other good options, believe that the course of the option is best for the patient.
  • Parents disagreeing, first determine if only one parent or both parents have the legal right to give permission.
  • A durable power of attorney is a type of advanced directive which may include other legal issues such as financial issues.
  • The advanced directive of a patient trumps the wishes or demands of a family member or surrogate.
  • A surgeon’s fine motor skills doesn’t appear to decline with age.

 

 

Skin and Soft Tissue Surgical Highlights – Notes

Calciphylaxis, Compartment Syndrome, Hidradenitis supperativa, ICU, Infection, Inflammatory Bowel disease, MRSA, Nectrotizing soft tissue infection, Pearls, Pyoderma Gangrenosum, Skin, Smoking Cessation, Soft tissue, Surgical ICU, Surgical Preps, , , , , , , , , , , , , , , ,

Skin and Soft Tissue – Surgical Issues

  • Various classification systems for necrotizing skin and soft tissue infections help in the study of the disease, doesn’t necessarily help in the care of the patient.
  • Dish water exudates and grey necrotic tissue are macroscopic findings of necrotizing soft tissue infection.
  • Along with early debridement, very broad spectrum IV antibiotics is the mainstay of necrotizing soft tissue infection.
  • Hyperbaric oxygen is not a proven therapy of necrotizing soft tissue infection.
  • Switching from castille soap to a once daily 2% chlorhexidine body wash reduces MRSA colonization rates of Surgical ICU patients.
  • MRSA (Methicillin Resistant Staphylococcus Aureus) is currently the leading pathogen of surgical site infection
  • Chloraprep (contains alcohol) use must be selective – beware of starting a fire on the surgical site.
  • After fasciotomies, negative wound therapy could be helpful for getting rid of edema and keeping wound clean and dry.
  • Negative pressure wound systems have been associated with complications of death and injuries.
  • Measuring compartment pressures, position of the head and trunk relative to the extremities is important when zeroing the transducer
  • When performing a Fasciiotomy – one approach anterolateral incision and then posteromedial incision
  • Calciphylaxis is associated with high calcium phosphorus product (Ca x P).
  • Infected Calciphylaxis lesions must be completely excised which is associated with a high mortality rate.
  • Pressure sores is a “never” event.
  • Smoking cessation is a mainstay of managing hidradenitis supperativa
  • Carbon dioxide laser excision is now being tried to treat moderate infections of hidradenitis supperativa (not severe enough for hospitalization).
  • Biopsy of complex skin lesions is important for diagnosis
  • Pyoderma Gangrenosum – 50-70% will have systemic disease (like inflammatory bowel disease (UC / Crohn’s Disease).

 

Oncology Surgery Highlights – Notes

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Surgical Oncology – Cancer

  • Melanoma in-situ.  5mm resection margin is needed.  (only 5 mm).  In Situ = outer layer of the skin only (epidermis only)
  • Currently Melanoma SLN positive mandates lymphadenectomy in melanoma.
  • Patients with Familial Adenomatous Polyposis and Desmoids, ~10% of the tumors will have a very rapid and aggressive course.  In FAP, there is a nearly 100 percent risk of colorectal cancer in the absence of treatment for polyposis.
  • Uncontrolled local recurrence is the main cause of death with retroperitoneal sarcomas.
  • Radiation therapy generally has not been shown to help low grade completely resected extremity sarcomas.
  • Flat colorectal polyps:  ~25% contain high grade dysplasia.
  • SLN in colorectal cancer increases the accuracy of lymph node cancer status but often does not change the operation.
  • Stage III colorectal cancer, all chemotherapy regimens seem to improve outcome. Another related topic:  Stage 4 colon cancer.
  • T2 colorectal lesions have a local recurrence rate of about 22%.  With resection you induce a 20% local recurrence rate on a T2 cancer which had a 80% cure rate before resection.  Salvage operations for local recurrence are associated with a 40-60% cure rate.  Therefore, there is a 20% chance that a T2 patient survival will be reduced by doing a local resection (ie. transanal).
  • Rectal cancers.  Size of an adenocarcinoma after initial preoperative chemotherapy is more predictive than the initial size of the tumor.
  • More advanced Gallbladder tumors, stage II, should be treated with a completion radical cholecystectomy – partial hepatectomies of the gallbladder bed with hepatoduodenal lymphadenectomy.  Stage II:  This means that cancer has grown through the muscle layer of the gallbladder wall and into the connective tissue underneath. It has not spread outside the gallbladder. Stage 2 in the TNM stages is the same as T2, N0, M0.
  • Metastasis found in remote lymph nodes in gallbladder cancer portend a poor prognocis.
  • PET scans doesn’t help distinguish acute or chronic cholecystitis vs. gallbladder cancer.
  • Endoscopic ultrasound should be used often in evaluating patients with pancreatic cysts.
  • If a pancreatic cyst wall has any nodularity then it may be malignant or on it’s way.
  • Pancreatic cancer, the risk of malignancy is lower for side branch intraductal papillary mucinous neoplasm than for main duct IPMNS.
  • Statistically, patients with pancreatic intraductal papillary mucinous neoplasms have an increased risk of colon and breast cancer.
  • Jaundice is not an emergency.  First understand the root cause before reflexively draining the bile duct.
  • Parenchymal metastasis from a primary tumor such as lung metasis or liver metastasis, etc – those pts tend to do very poorly with peritoneal chemotherapy.
  • GIST (Gastro Intestinal Stromal Tumors) – standard therapy is gleevec (IMATINIB).  Metastatic disease may have resistance to the drug
  • For patients with Colon cancer primary with metastasis to the liver with < or = 6 tumors in the liver where  R0 resection (resection for cure) can be done, then these patients are reasonable candidates for resection surgery.

Related Surgical Specialties

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Related Surgical Specialties

Pediatric Surgery, Thoracic Surgery, Gynecology, Urology

  • Pregnant women with appendicitis:  Early surgical intervention (appendectomy) and IV antibiotics
  • Pediatric appendicitis – use single antibiotic regimen
  • Most cases of blunt pediatric pancreatic trauma, may be non-operative due to delay in diagnosis
  • Bilious emesis in the New Born is the hallmark of intestinal malrotation with midgut volvulus.
  • Esophageal atresia in infants present with immediate feeding intolerance and respiratory failure
  • Ingested multiple magnets can lead to perforation or obstruction
  • Acute urinary retention in a adolescent female is virtually diagnostic for imperforate hymen.
  • Most babies with bilateral cryptorchid testes tend to be premature males who have not had normal testicular descent
  • Resection of thyroglossal duct cyst, and removal of the mid portion of the hyoid bone to the base of the tongue.
  • External bracing to repair pectus carinatum – to be worn nearly continuously for 1.5 -2 years.
  • Spontaneous pneumothorax – typically occur in young men who are very tall and thin who have had previous episodes.
  • after thoracoscopic bleb resection and mechanical pleuridesis, the recurrence rate of spontaneous pneumothorax is 5-15%.
  • undrained hemothoraces may lead to chronic fibro-thorax resulting in entrapment and compromise of pulmonary function.
  • Lung abscesses who respond to medical therapy should have bronchoscopy to diagnose foreign body or previous undiagnosed tumor.
  • Massive hemoptysis, hypoxemia is the true cause of mortality.
  • Massive hemoptysis related to PA catheter – leave balloon inflated – it might tamponade.
  • Hypoglycemia may predispose to sternal wound infection and mediastinitis after cardiac surgery
  • Squamous cell esophageal cancer – thoracoscopic resection of the esophagus reduces post operative complications.
  • Thoracic endovascular repair may work in causes of traumatic aortic disruption in patients who are not normally operative candidates.
  • Intima, media, adventitia injury in the aorta most likely need operative intervention (all three walls).
  • If only the intima is injured in the aorta – healing is possible by itself.

 

Immunocompromised Surgical Patients Highlight Notes

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Immunocompromised surgical patients

  • Sirolimus slows down wound healing.  Consider switching transplant patients to a different immunosupressive drug to limit wound healing problems.
  • Patients on Sirolimus also exhibit higher post operative complications of seromas, hernias, and wound dehiscence.
  • We have gotten away from the practice of administering stress dose steroids on most general surgery patients on maintenance steroids
  • Avoid placing hemodialysis catheters if possible because of the short-term and long-term complications.
  • Most likely wouldn’t remove a catheter just for a febrile episode on hemodialysis.  But if the patient is septic – still try to maintain the catheter if possible.
  • UNOS = united network of organ sharing.  When an organ donor is identified, the info is sent to UNOS who then generate a list of possible recipients.
  • Travel outside of the US.  Big question is who is the donor?
  • Organ trafficking is illegal in the US.  But not illegal to take care of the patient postop in the US after the patient had gone overseas.
  • AV fistulas are considered to be better than AV grafts – short-term and long term.
  • Peritoneal Dialysis use is expanding – many people who weren’t considered eligible in the past are now eligible.
  • Immunosuppression increases the risk for cancer.
  • Typhlitis, non-surgical protocol is used whenever possible when the patient is not toxic.  Typhlon = cecum (Greek).  Necrotizing enterocolitis, neutropenic enterocolitis., caecitis.  Typhlitis affects immunocompromized patients such as those undergoing chemotherapy, patients with AIDS, transplant patients, or the elderly.

Perioperative General Surgery Highlights

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Perioperative ICU Topics

Transfusion related acute lung injury must be distinguished from cardiogenic and non cardiogenic pulmonary edema and pulmonary contusion.

  • TRALI – acute onset of non-cardiogenic pulmonary edema after transfusion of blood products.
  • Leading cause of transfusion related fatalities in the US
  • Occurs within first 6 hours following transfusion
  • Due to leukocyte antibodies in transfused plasma
  • Incidence 1:5000

Transfusion related circulatory overload – diurese early

  • Furosemide is a loop diuretic

Intubated patients should be transported in Semi fowler recumbent position, 30 degree head of bead to help prevent ventilator associated pneumonia

  • Semi fowler – knees bent, head of bed not as high as fowler position

Hydration of the patient is an important measure to prevent contrast induced nephropathy

With ICU patients with Renal insufficiency, aggressive dialysis does not lead to significant improvements in renal recovery and 30 day mortality rates

Analgesics and sedatives may blunt ACTH stimulation test for adrenal insufficiency

  • ACTH stim test for asessing the functioning of adrenal glands.
  • ACTH is made by the anterior pituitary gland which stimulates the adrenal glands to release cortisol, DHEAS, and aldosterone.
  • Adrenal insufficiency is a potentially life threatening problem
  • ACTH stimulation test is primarily used to deterine the presence of Addison’s diaseas and pituitary impairment
  • Addison’s disease: Adrenal glands do not produce sufficient steroid hormones.  Also known as primary adrenal insufficiency.
  • The test is extremely sensitive to primary adrenal insufficiency but less so to secondary adrenal insufficiency.  Secondary adrenal insufficiency is caused by deficiency of ACTH.

Precedex:  use less than 24-48 hours.

  • Dexmedetomidine – a sedative used in ICU which does not cause respiratory depression

Outcomes protonics vs. H2 blockers not that different in stress gastritis prophylaxis

Advanced directives in ICU – pastoral care staff to bring up on initial contact

Family like ICU rounds – transparency

Refeeding syndrome – low phosphate levels is a hallmark.  Happens in 10 days or more of not feeding.  When feeding resumes:  hyperglycemia – creates even lower levels by moving phosphate and potassium into cells.

Abdominal Compartment Syndrome – open abdomen immediately with elevated intra-abdominal pressure and renal failure, hypotension, or high pulmonary ventilation pressures.

Use of diuretics in ACS (Abdominal Compartment Syndrome) is controversial.  Some surgeons diurese early to decrease bowel edema and to get the abdomen closed.

ICU central lines to be assessed daily and document need for it daily

Trauma patients, erythropoetin may predispose to DVT

  • Liver production of erythropoetin predominates in the fetal and perinatal period
  • Renal production is dominant during adulthood

Induced coma clouds the issue of brain death in regards to organ donation.

Elderly ICU with hyperactive delirium have better outcomes than those with hypoactive delirium.

Elevated CK levels hallmark in propofol infusion syndrome.

  • Potentially and often fatal
  • cardiac failure, rhabdomyolysis, renal failure, hyperkalemia, hypertriglycerdemia, hepatomegaly.
  • Maybe caused by impaired mitochondrial function
  • CK = creatine kinase = present in all muscles
  • Elevated CK levels indicated muscle damage/strain – could be from heart attack or muscles being overworked (ie. weight lifting).
  • Propofol infusion syndrome is at higher risk when patients are already on catecholamines or corticosteroids.

Inhaled PGE2, selectively vasodiates the pulmonary vasculature, it improves VQ mismatch in severe hypoxemia

  • An area with no ventilation (V/Q = zero) = shunt
  • The area with no perfusion = dead space
  • PGE2 = prostaglandin E2
  • PGE2 softens cervix and causes uterine contraction, causes fever, direct vasodilator, relaxes smooth muscles.

In sepsis, norepinephrine raises heart rate less than dopamine.

  • Vasoactive drug use in septic shock
  • Used to increase blood pressure
  • Dopamine is the immediate precursor of norepinephrine and epinephrine
  • Less tachycardic reaction with NorEpinephrine compared to Dopamine.

Trauma Pearls

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  • 2 incision fasciotomy for compartment syndrome of extremity fractures – a common problem is incision is made too far laterally to help the anterior compartment (missed)
  • After 24-48 h of open abdomen management,  fistula rate is approx 15% if abdomen is not closed.
  • If stable hemothorax – 24-48 h to see if evac.  By day 2-3 it would be increasingly difficult to evacuate blood beyond that time, thorascopically.
  • Thoracic aortic injuries.  Endovascular repair typically not used in young patients or less than 20mm diameter aorta.
  • Complication of LMA = vomiting
  • Splenic injury, > or = 20% do not heal in three months.
  • Elderly patients with elevated INR, small head bleed on coumadin.  Rx with early plasma infusions, and early factor 7A use.
  • Carotid injuries do not occur commonly in easily accessible locations; put patient on antiplatelet  therapy and most of these injuries will heal.
  • Serial cardiac enzymes are rarely needed in patients with suspected blunt cardiac injury.
  • Zone I retroperitoneal hematomas = central periaorta hematomas.  Explore gun shot wound Zone I retrperitoneal hematomas even without expanding hematoma.
  • To evaluate  distal perfusion, proximity GSW to both extremities, use ankle brachial index rather than arterial pressure index.  (The API is the ratio between systolic blood pressures measured distal to a penetrating injury in one extremity and the systolic pressure measured at the same location in the contralateral uninjured extremity.)
  • solid organ injury, CT vascular extravasation should not determine management approach – instead depend on hemodynamics.
  • Injury to kidney after blunt trauma – prefer nonoperative treatment for better renal salvage even with urinary extravasation.
  • Head trauma, small epidural hematoma, no other injuries, observation in ICU x 24h – neuro exams, and repeat CT in 6h.
  • Leg with crush type wound with venous injury.  Re-establish blood flow quickly with shunt.  Tie a suture around shunt, do not debride the vessel back before placing shunt because the vessel will be injured more with the shunt tying.
  • Blunt traumatic arrest cases – not likely to survive to discharge from hospital.   Consider terminating resusitation.
  • Comatose patients, can remove cervical-collar if a good helical CT scan of the spine is completely normal.
  • A true transpelvic GSW (gunshot wound) should go to OR even with (or without) gross blood on rectal exam.
  • Complication and mortality rates  with rib fractures are twice higher in elderly patients than younger patients.
  • Physical exam with seatbelt sign is often not helpful, small bowel injury association is not 100%.
  • Side curtain airbags are more helpful than frontal airbags for additional protection in addition to seatbelts which do not do as well with lateral movement.
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