Ebook Nutshell series for general surgery: Part 1

(BQ) Part 1 book Nutshell series for general surgery presents the following contents: Basics in general surgery, shock, blood transfusion and organ transplantation, oral cavity, trauma, head and neck (general), salivary glands, thyroid disorders, parathyroids and adrenal glands, breast disorders, diseases of esophagus, stomach and duodenum.

FMGE/dNb/NEEt-pG

GENEral surGEry

http://vip.persianss.ir/

Madras Medical College, Chennai, Tamil Nadu, India

Founder and Faculty Koncpt Postgraduate Medical Coaching Center, Tamil Nadu

Faculty, Global Institute of Medical Sciences, China Faculty, Karol Institute of Medical Sciences, Chennai and Delhi

Faculty, ADR Plexus Postgraduate Medical Coaching Center, Chennai

Panchadcharam Harinath MD (Russia)

Molecular Pathologist Senior Lecturer Liaoning Medical University

China

Forewords

Seyed Abdul Cader

D Arunkumar

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

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© 2013, Jaypee Brothers Medical Publishers

All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

This book has been published in good faith that the contents provided by the authors contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the authors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug

BangladeshMobile: +08801912003485

111 South Independence Mall East

Suite 835, Philadelphia, PA 19106, USA

Phone: + 267-519-9789

Email: joe.rusko@jaypeebrothers.com

Zhengzhou, China who really motivated me to write the book.

http://vip.persianss.ir/

Being the Academic director of karol institute of medical sciences (kims), which has coached thousands

of students in preparation for the mCi screening tests and postgraduate entrance examination with a very

good track record of successful candidates since 2005, i felt this book to be very concise, illustrative and

with a very simple and systematic narrative

The authors have gone into laborious and painstaking work in bringing out this book They both have a

spectacular flare in teaching students and to make them understand the subject conceptually After going

through the book, I felt both elated and satisfied at the same moment

i highly recommend this book for FmGE and NEET candidates as these materials have already been

successfully used for our students in their preparation for the examinations i wish them the very best in

their efforts to create a knowledgeable and conceptually educated medicos.

seyed Abdul Cader md

director karol institute of medical sciences Chennai, Tamil Nadu, india

http://vip.persianss.ir/

The need for an easily understandable, concise and illustrated guide in surgery has been felt by all

concerned at different levels of the medical field in India.

Dr Rajamahendran and Dr Harinath are highly qualified and experienced faculties teaching in our

Academia Grandiosa medicinae (AGm) which is renowned for FmGE and PGmE teaching programs since

2008 Their unique way of presentation and materials made a quick impact among students and gasped

number of students across india

Authors association with AGm, AdR-Plexus and kims successfully taught for more than 3000 students

yielded in more 750 toppers in FmGE and more than 500 toppers in various PGmEs till now.

it gives me an immense pleasure to know that these two authors have been endeavored to author an

illustrated guidebook in surgery i assure this book will be an essential aid for successful exam-preparation

and i highly recommend it for FmGE, NEET-PG and other PGmEs.

d Arunkumar md

Associate Professor Academic director Academia Grandiosa medicinae

New delhi, india

director AdR-Plexus Chennai, Tamil Nadu, india

http://vip.persianss.ir/

P reFace

FmGE: Foreign medical Graduate Examination (medical Council of india—mCi screening test) and NEET:

National Eligibility Entrance Test are standard examinations conducted by National Board of Examination

(NBE) to validate the standard of indian students with the international ones.

Unimagined raise in the standards of FmGE and other postgraduate entrance examinations including

NEET brought an absolute necessity for candidates to acquire concept-based knowledge in the subjects

than a superficial MCQ-based knowledge.

We are presenting this admirably concise and illustrated Nutshell Series for FMGE/DNB/NEET-PG—

General Surgery to annihilate the deficiency of concept-based guides with MCQ review; that created a

dilemma in candidates to choose the way of exam-preparation and maximize its efficiency while currently

available texts fail to provide with any enthusiasm among students.

Nutshell series: surgery for FmGE covers all the chapters systematically in a succinct and didactic

fashion of presentation to aid in the glory of its users.

Our own experience in a unique way of teaching and as an examiner at different levels has been distilled

here as an ultimate synopsis of surgery for exam-preparation.

This guide is presented in tabular format with highlighted high yield points and equipped with more

than 350 detailed illustrations that will enable the users to understand the core concepts clear and make

the revisions faster.

MCQs are organized by the end of each chapter give users orientation towards the examination patterns.

We extend our appreciation to our inspired and esteemed professors and colleagues from Germany

and Russia for their zest in illustrated presentation of teaching.

We hope and believe this book is going to serve the purpose of students and doctors who are setting

their goals higher to achieve ‘Topper Ranks’ in examinations like FmGE, NEET, Aims, PGi, ERPm, AmC,

PmdCE and NmCE.

We appreciate your feedback to improve the scientific and writing accuracy of our publications and to

help us build up a highly knowledgeable society of doctors.

Feedback can be mailed to: minnalraja@gmail.com, spharii@yahoo.com, studtatagm@gmail.com

R Rajamahendran Panchadcharam Harinath

a cknowledgments

Special thanks:

dr G Bhanu Prakash, md, Professor of Pathology, Zhengzhou University—who is a renowned teacher in the field of undergraduate teaching in China, USMLE and FMGE programs all over the globe He successfully taught more than 5 USMLE batches yielded in more than 500 top residents in USA He is the first one to introduce multimedia lectures for foreign students in China and currently associated with more than 1000 indian students We extend our appreciation to him for the involvement and contribution to this book.

R Rajamahendran Panchadcharam Harinath

I first of all thank my co-author Dr Panchadcharam Harinath who motivated me to write this book and made excellent designing of the book with extraordinary pictures The Legend who introduced me to the world of FmGE dr syed, md, Russia, director of karol institute of medical sciences, delhi and Chennai, needs a special thanks than anyone else He motivated and encouraged me like anything to do this job

He is the creator of many extraordinary teachers in this FMGE field Also, I would take this opportunity to thank Dr Banuprakash Kulkarni, Director of Global Institute of Medical Sciences in China and Hyderabad, for giving me opportunities to show my talent in abroad.

i would like to thank my Professor sm Chandramohan, mCh, surgical Gastroenterologist, role model for our specialization i also thank my Assistant Professors, dr Amudhan, mCh; Dr Benet Duraisamy, mCh, and dr Prabhakaran, mCh, for giving me encouragement and support in all my academic activities.

my thanks to all the students in karol institute of medical sciences, Global institute of medical sciences and koncpt Postgraduate medical Coaching Center for bringing me to this level in teaching field.

i give a special thanks to all my friends who always stood behind me in my bad times and saying the encouraging words, “if you cannot, then no one else,” which lifted me to the level of writing my 5th book

in a short period of time, especially dr Antan Uresh kumar, mCh, Urology, Founder, koncpt Postgraduate medical Coaching Center and Dr Raja Rajan, MCh, Urology, Stanley medical College.

my thanks to all my teachers, well wishers, my parents, my loving wife dr shanthi dCP and my cute little daughters—Saadhana and Rajahansa

— R Rajamahendran

Family:

• mr s Panchacharam and Family (Chief Engineer and Project manager, Al Jafr, ksA): Father and teacher who imitated me to embrace the world of knowledge and brought me to this position

• Evgenia Kratenko (HR Manager, Avon, Russia): Greatest moral support, care and encouragement for

my works.

• mr P Aravinth B Tech: Brother and technical support for designs and applications.

• mr k Arumugam and family (Chennai): Familial support and care.

Working circle and friends:

• mr Ravikumar Giri: Technical assistant and co-designer.

• mr mohit kumra, mBA: Administrator and manager.

• Associate Professor d Arunkumar, md: Lecturer in stanley medical College, Chennai and Academic director of AGm.

• Associate Professor Nirpam Adhalka, MS, DNB (Urology): Lecturer at khanpur medical College A good friend and advisor.

• Dr Arun Mukherjee, MD: Friend and advisor.

• dr Vikram kalra, md, dm (Nephrology): An experience and good friend

• dr m deepesh, md: Good friend, colleague and contributor of this book.

• dr A Ramprasath, md: Good friend, colleague and contributor of this book.

• I am thankful to all my friends and people who are helpful and supportive in our projects.

• Professor EA sarev (Cariology, ksmU): Passion for knowledge and teaching

• Professor Glasichev (Physiology, mmA): Esteemed teacher and a great personality.

• Professor GG Manishramani (WHO, Consultant of Geriatric Medicine): Ex-HOD, Department of Internal medicine, mAmC, delhi most respected personality and my mentor in india.

Teachers who showed the path to universe of knowledge:

• Professor Tatiyana Boronikhina (Histology, MMA): Wonderful teacher who showed the correct path

in early stages.

• Associate Professor TP Nekrasova (Pathology, mmA): Remarkable and sweet teacher who made me

a pathologist.

• Associate Professor Galina N Goryainova (Pathology, ksmU): Teaching with personal care.

• Associate Professor svetlana V Chava (Anatomy, mmA): strict but very encouraging.

• Late Dr L Ribakova (Anatomy, MMA): Known for her sweetest way of teaching.

• Professor EV Budanova (microbiology, mmA): Unique application of teaching with a strict plan.

• Professor Gubareva AE (Biochemistry, MMA): Well known for her successful teaching by posing questions

• Associate Professor Enikeeva (Pharmacology, mmA): Viva-based teaching that made us explore more.

• Associate Professor Ala N maistrenko (Topographic Anatomy, KSMU): Confident and punctual teaching

• Associate Professor E Evgevivna (Neurology, ksmU): simplified and easy teaching.

• dr RN kalra, md, dm (Cardiology, FRCP): Taught me morals of medicine in a practical way.

—Panchadcharam Harinath

1 Basics in General Surgery 1

Indications of Total Parenteral Nutrition 5

Fluids and Electrolytes 6

Hypercalcemia and Hypocalcemia 7

Hypernatremia and Hyponatremia 7

Fluid Therapy: Two Types of Fluids

Crystalloids and Colloids 7

Complications of Blood Transfusion 14

Complications from Massive Transfusion 14

Points to be Emphasized 15

Better Indicator for Transfusion 15

Septic Shock 15

Organ Transplantation 16

Types of Allograft Rejection 16

Graft versus Host Disease (GvHD) 16

NICE Guidelines for CT Scan in Head Injury 22

Primary Treatment for Head Injury 22 Types of Head Injury 22

Extradural Hematoma 22 Acute Subdural Hematoma 22 Chronic Subdural Hematoma 23 Subarachnoid Hemorrhage 23 Cerebral Contusions 23 Thoracic Trauma 24 Flail Chest 25 Emergency Thoracotomy 26 Abdominal Trauma 26 Investigations of Abdominal Injury 27 Spleen 27

Carcinoma Tongue 34 Carcinoma Hard Palate 35 TNM Staging of Oral Cancer 35 Types of Neck Dissection 35 Reconstructions 36

Mandibulectomy 36 Carcinoma Lip 36 Basic Points for Head and Neck Cancers 37 Syphilis in Oral Cavity 37

Cancrum Oris 37 Epulis 38 Ludwig’s Angina 38 Cysts of Jaw 38 Impacted Tooth 39

5 Head and Neck (General) 40

Carotid Body Anatomy 40 Branchial Cyst 44

Cystic Hygroma 45

Cold Abscess in Neck 46

Triangles of Neck 46

Anatomy 48

Submandibular Gland 49

Salivary Gland Tumors 49

Classification of Salivary Gland Tumors 50

Benign Mixed Tumor

Acinic Cell Tumor 51

Minor Salivary Gland Tumor 51

Investigations for Tumor 52

Reason for Nodule Formation 59

Clinical Indicators of Malignancy in

B-Cell Non-Hodgkin’s Lymphoma 66

Metastatic Cancer Thyroid 66

Important MCq Points in

Carcinoma Thyroid 66

Postsurgical Complications 66 Perioperative Complications 67 Hypoparathyroidism 67 Surgery for Intrathoracic Goiter 67

8 Parathyroids and Adrenal Glands 70

Parathyroids 70 Hyperparathyroidism 71 Primary Hyperparathyroidism 71 Secondary Hyperparathyroidism 72 Tertiary Hyperparathyroidism 73 Adrenal Glands 73

Pheochromocytoma 73 Malignant Pheochromocytoma 74 Cushing’s Syndrome 75

Conn’s Syndrome 76

Anatomy 78 Lymphatic Drainage 78 Benign Breast Diseases 80 Mondor’s Disease 81 Duct Ectasia/Periductal Mastitis 81 Important Points 81

Carcinoma Breast 81 Types of Carcinoma Breast 82 Invasive Cancers 82

TNM Staging of Breast 84 Treatment Modality 85 Advantage Over Radical Type 85 Radical Mastectomy: Halstead’s Radical

Mastectomy 86

Chemotherapy 86 CMF Regimen 86 Hormone Therapy 86 Tamoxifen 87 Radiotherapy 87 Distant Metastasis 87 Phyllodes Tumor 88 Skin Involvement 88 Prognostic Factors of Carcinoma Breast 88 Breast Conservation Surgery 89

Anatomy 92 Surgical Anatomy at a Glance 92 Lower Esophageal Sphincter (LES) Zone 93 Factors Causing 93

Small Bowel Tumors 121

Small Bowel Carcinoids 121

Inflammatory Bowel Disease (IBD) 121

Local Complications of IBD 123

Treatment for IBD 123

Extraintestinal Manifests 123 Tuberculosis of Abdomen 124 Short Bowel Syndrome 125 Superior Mesenteric Artery (SMA)

Syndrome 125

Enterocutaneous Fistula 125 Acute Appendicitis 126 Mucoceles 127

Carcinoid Appendix 127 Intestinal Obstruction 128 Meconium Ileus 128 Congenital Atresias 129 Small Bowel Obstructions 129 Cause of Distension 129 Adhesion: Causes 129 Paralytic Ileus (Inorganic Cause) 130 Large Bowel Obstructions 130 Salient Points in Large Bowel Obstruction 130 Acute Mesenteric Ischemia 131

Ischemic Colitis 131 Pseudo-obstructions 131 Cancer Rectum 132 Anal Cancer 132 Fissure-In-Ano 134 Normal Fecal Continence Require 135 Anorectal Abscess 135

Pilonidal Sinus 135 Pruritus Ani 135 Imperforate Anus 136 Rectal Prolapse 136 Solitary Rectal Ulcer 137 Abdominal Compartment Syndrome 137

13 Hepatobiliary and Pancreatic System 144

Gallbladder and Biliary Tract 144 Moynihans Hump and Caterpillar Turn 144 Anomalies of Gallbladder 145

Cystic Duct variations 145 Functions of GB 145 Investigation 145 Gallstones 146 Pigment Stones 146 Complications 147 Limey Bile 148 Treatment Options 148 Common Bile Duct Stones 148 Treatment Options 148

Missed/Retained/Residual Stones

(< 2 Years) 149

Choledochal Cysts 149

Extrahepatic Biliary Atresia 149

Differential Diagnosis of Jaundice in

Acute Liver Failure Causes 162

Modified Child-Pugh Classification 163

Chronic Liver Disease 163

Investigations 163

Portal Hypertension and Cirrhosis 163

Transjugular Intrahepatic

Portal Shunt (TIPS) 166

Prevention of Recurrent Bleed 166

Purpura (ITP) 178

Kidney and Ureters 180 Methods of Stone Removal 181 Ureteroscopy 181

Percutaneous Nephrolithotomy (PCNL) 182 Renal Cell Carcinoma 183

MC Points 184 Renal Cell Carcinoma 184 Wilm’s Tumor 185 Differentiating Feature Between

Neuroblastoma and Wilm’s Tumor 185

Angiomyolipoma of Kidney 185 Genitourinary Tuberculosis 186 Renal Trauma 186

Polycystic Kidney Disease 187 Ectopic Ureter 187

Congenital Pelviureteric Junction

Obstruction 188

Medullary Sponge Kidney 188 Renal Transplantation 188 Renal Casts 189

Xanthogranulomatous

Pyelonephritis 189

Nephrectomy Approaches 190 Ureterocele 190

Carcinoma Bladder 190 Management of Bladder Cancer 191 Bladder Calculi 192

Rupture of Bladder 192 Tuberculosis of Bladder 193 Anatomical Division of Prostate 193 Complications of TURP 194

Absolute Indications for

Surgical Treatment of BPH 194

Solutions in TURP 194 Medical Treatment of BPH 194 Cancer Prostate 195

Tumor Markers in Carcinoma

Prostate 195

More About Testicular Malignancy 203

Worth Mentioning about

Tuberculosis of Kidney and Bladder 207

Vesicoureteral Reflux (vUR) 207

17 Hernia, Umbilicus, Abdominal Wall and

20 Burns and Cosmetic Surgery 234

Burns 234 Major Determinants of the Outcome of

a Burn 235

Superficial Burns Have Capillary Filling 236 Degrees of Burns 236

Management of Burns 236 Topical Treatment 237 Cosmetic Surgery 238 Facts about Skin Grafts 238 Cannot We Graft Every Wound? Why do

We Need Flaps? 238

Types of Flaps 238 Axial and Random Flaps 238 Local Flap 239

Terms in Plastic Surgery 239 Cleft Lip/Palate 239

Venous System 244 Tests for varicose veins 244 Short Saphenous Incompetency 245 Perforator Incompetence 245 Deep vein Thrombosis 245 Few Line about Duplex Scan 247 Points from Bailey and Love 247 Arterial System 247

Popliteal Artery Aneurysm 248 Mycotic Aneurysm 248 Amputations 248 Gangrene 249 Arterial Stenosis and Occlusion 249 Subclavian Aneurysm 249

Ainhum 249 Seldinger’s Technique 249 Buerger’s Disease/Thromboangitis

Obliterans 250

Lumbar Sympathectomy 250

Raynaud Disease 250

Arteriovenous Fistula 251

Lymphatic System 251

Limb Reduction Procedures 252

Points for Memory 252

Basal Cell Carcinoma 256

Squamous Cell Carcinoma 257

Treatment of Skin Cancers 258

Malignant Melanoma 258 Prognostic Factors 259 Satellite Nodules Treatment 259 Soft Tissue Sarcomas 259 Spontaneous Regression 260 Radiation Induced Cancers 260 Sentinel Node Biopsy 260

Omphalocele 261 Gastroschisis 261 Exstrophy of Bladder (Ectopia vesicae) 262 Congenital Diaphragmatic Hernia 262 Points from CDH 262

Index 265

latest FMGE syllabus and analysis of pattern

Surgery is a high yield subject in FMGE that covers 15% of MCQs in average According to the latest syllabus

of FmGE, surgery is subcategorized into important 23 chapters:

(1) Basics in General Surgery; (2) Shock, Blood Transfusion and Organ Transplantation; (3) Trauma; (4) Oral

Cavity; (5) Head and Neck (General); (6) Salivary Glands; (7) Thyroid Disorders; (8) Parathyroids and Adrenal Glands;

(9) Breast Disorders; (10) Diseases of Esophagus; (11) Stomach and Duodenum; (12) Intestinal System; (13)

Hepato-biliary and Pancreatic System; (14) Liver; (15) Spleen; (16) Urological Surgery; (17) Hernia, Umbilicus, Abdominal

Wall and Peritoneum; (18) Elective Neurosurgery; (19) Cardiothoracic Surgery; (20) Burns and Cosmetic Surgery;

(21) Vascular Surgery; (22) Oncosurgery, and (23) Pediatric Surgery.

New syllabus is reflecting in the change of pattern towards more clinically oriented MCQs since 2011 There were many MCQs devoted to “Basic Surgery” especially fluid therapy and burns in recent years.

it is worth emphasizing that Basic surgery, shock, Burns, Gastrointestinal Tract (GiT), Urology and Breast are proved to be the high yield chapters according to analysis of pattern.

Our book is designed for quick and easy review of surgery in the following algorithm:

 Familiarizing with chapters

• Edge—that connects floor to margin

• Floor—is one that is seen

• Base—is one on which the ulcer rests May be bone or soft tissue

4 Raised + beaded and rolled out

 Basal cell carcinoma (BCC)

o An abnormal communication between lumen of one viscus to lumen of

another viscus (internal fistula) or

o An abnormal communication between one hollow viscus with the exterior, i.e

body surface (external fistula)

Examples of internal fistula:

• M/c benign tumor in the body

• Universal tumor—occur anywhere in body complications:

• Cyst is a collection of fluid in a sac lined by epithelium or endothelium

cysts that are transilluminant:

• Occurs at line of embryonic fusion

SwellingS in Skin 2-Tubulo-dermoid 4-Teratomatous dermoid

• Arises from embryonic structures

1 Thyroglossal cyst

2 Post-anal dermoid

• Arises from all germinal layers ecto, endo and mesoderm

• Occurs in ovary, testis, retroperitoneum and mediastinum

• Contains hair, teeth, cartilage and muscle

• Can be benign or malignant

• Teratomatous dermoid

3-implantation dermoid

• Due to minor pricks or trauma, epithelium get

buried into deeper subcutaneous tissue

• M/c site is fingers

e-Sebaceous cyst

• It is a retention cyst due to blockage of the duct of sebaceous

gland causing cystic swelling

• Not seen in palms and soles

characteristic feature

1 Smooth, soft and non-tender, mobile

2 Moulds on finger indentation

3 Punctum—70% cases

4 30 percent cases the cyst opens into hair follicles and punctum

not seen

F-Punctum with sebum: Mcq points in sebaceous cyst

• Parasite seen in the cyst—demodex folliculorum

• Cock peculiar tumor—surface gets ulcerated leading to painful

• Fordyce’s diseaseectopic sebaceous glands in lip

and oral mucosa

inFecTionS in general

1 Chronic fibrous and infective disease of skin-bearing apocrine sweat glands

2 Apocrine glands are those, which open into hair follicle

inFecTionS in general c-Pott puffy tumor

• It is a misnomer

• Diffuse external swelling in scalp due to subperiosteal

pus formation and scalp edema

• Etiology—chronic frontal sinusitis, trauma

• Complications—frontal bone osteomyelitis, intracranial scess formation

ab-cellulitis erysipelas

• Spreading inflammation of subcutaneous tissue and

fascial planes • Spreading inflammation of skin and subcutaneous tissue

• m/c due to Streptococcus pyogenes • m/c due to streptoccal pyogenes

• Sequelae—abscess, bacteremia, pyemia, local gangrene • Toxemia is always a feature

• Red shiny stretched warm skin • Always associated cutaneous lymphangitis + vesicles form

• Milian ear sign—cellulitis not involve because skin is

closely adherent to subcutaneous tissue • Positive in ear lobule

Pyogenic abscess cold abscess

 Pyogenic bacteria- Staphylococcus, Streptococcus  Tuberculosis

 Red warm with inflammatory signs  No signs of inflammation

inFecTionS in THe HanD

• Acute paronychiasubcuticular

infection caused by

Staphylococ-cus aureus

• Chronic paronychiachronic

nail infection caused by Candida

• FelonTerminal pulp space

infection

• Deep Palmar abscessabscess

beneath flexor tendons (Frog

• Any patient,who has sustained 5–7 day of inadequate intake

• Any patient, who is anticipated to have no intake for 5–7 day • Enteral nutrition• Parenteral nutrition

Contd

TyPeS oF enTeral nUTriTion

feeding

A Nasogastric tube B Gastrostomy C Jejunostomy

 Ryles tube is the preferred method for most patients

 If the tube has to be left for more than a week a fine bore tube (diameter < 3 mm) is used, which is inserted via a guide

wire

gastrostomy Jejunostomy

• Indication: If a patient needs enteral nutrition for a period of

4–6 weeks then percutaneous endoscopic gastrostomy (PEG) is

preferred

• Types of insertion:

Surgical gastrostomy or PEG under local anesthesia

• Main indication of jejunal feed is where we want to give rest to gastric secretion and function

• For example, pancreatitis

• Types: surgical or nasojejunal tubes

complications of enteral nutrition

 Tube related—malposition, blockage

 Gastrointestinal—diarrhea (30%), nausea, bloating, aspiration

and constipation

 Electrolyte and metabolic disturbances

 Infection

ParenTeral nUTriTion

• Provision of all nutrients by means of intravenous route and without utilizing the alimentary tract

• Types: Peripheral and central nutrition

Peripheral central

• Appropriate for feeding less than 2 week.

• Types:

1 Conventional wrist vein canulas

2 Peripherally inserted central venous catheter (PICC)

3 Mean survival period 7 days

4 Major disadvantage is thrombophlebitis

○ Parenteral feeding for greater than 2 week.

Via: subclavian vein, external or internal jugular vein

• Infraclavicular subclavian vein approach is best because

of the suitable location of the catheter in the chest

• Always do a post insertion chest X ray—to r/o thorax and to confirm distal tip lies in the distal superior vena cava to minimise central vein or cardiac thrombosis

pneumo-inDicaTionS oF ToTal ParenTeral nUTriTion

as primary therapy as supportive therapy

1 Gastrointestinal fistulas

2 Renal failure (Acute tubular necrosis)

3 Short gut syndrome

4 Weight loss preliminary to surgery

• In acute pancreatitis cases, there will be mild GOO hence nasojejunal feeding or jejunostomy advised But if the patient cannot tolerate give them total parenteral nutrition (TPN)

complications Metabolic complications

1 Catheter related

2 Infection

3 InjuriesPneumothorax, hydrothorax,

cardiac tamponade,

injury to artery and vein,

injury to thoracic duct, nerves

6 Glucose imbalance(hyperglycemia, hypoglycemia)

7 Trace element and vitamin deficiency

8 Electrolyte abnormalities

character Hypertrophic scar keloid

shoulder

Salmon patch Port-wine stain Strawberry angioma

• Present since birth

• Disappears before 1 yr • Since birth • Does not disappear • Not present at birth • Appears 1–3 week

• Starts disappearing after 1 yr and completely disappears at 7 yr

FlUiDS anD elecTrolyTeS Hyperkalemia & Hypokalemia characteristics Hyperkalemia Hypokalemia

• Hypoventilation if respiratory muscle involved

• Cardiac toxicity causing ventricular fibrillation

4 Electrocardiogram (ECG)  Tall peaked T wave*

 Sine wave pattern

 Increased PR and increased QRS duration

HyPercalceMia anD HyPocalceMia characteristics Hypercalcemia Hypocalcemia

1 Definition • Serum calcium >5.5 mEq/L • Serum Ca+ < 4.5 mEq/L

2 Etiology  Milk alkali syndrome

 Chronic renal failure

 Heparin, protamine, glucagon

 Decreased fluid intake

 Central diabetes insipidus (DI)

 Chronic renal failure (CRF)

 Nephrotic syndrome and cirrhosis

• Nausea, headache, confusion

• Stupor, seizure, coma

• lncreased ICT

• Correct etiology • Fluid and salt restriction• Diuretics

• Hypertonic saline

FlUiD THeraPy: Two TyPeS oF FlUiDS crySTalloiDS anD colloiDS crystalloids colloids

2 Expands plasma volume for less time 2 Expands plasma volume for 2–4 hour

4 Can precipitate cerebral edema 4 Decreased cerebral and pulmonary edema

5 For blood loss replacement 3 times of the lost be given 5 Replaced in 1: 1 ratio of lost fluid

Contd

FlUiD THeraPy: Two TyPeS oF FlUiDS crySTalloiDS anD colloiDS

 Liver failure (albumin)

3 normal saline 4 Hypertonic saline

 Hyponatremia

 Brain injury

 Diabetic ketoacidosis

 Hypochloremic metabolic alkalosis

 Cerebral and pulmonary edema

 Hyponatremia

Types of wound clean uncontaminated

(infection rate < 2%) clean contaminated (infection rate upto 30%) infected wound (infec- tion rate> 50%) Unclean contaminated

• Examples are wound of

heart, brain, joint and

trans-plant surgery

• Wounds of herniorrhaphy

• Excision

• Wounds of bowel surgery, biliary and pancreatic surgery appendicectomy, gastrojejunostomy

• Traumatic wound

• Bowel obstruction with enterotomy and spillage of content

Type of wound suturing

 Primary suturing—done for clean

wound within 6 hour  Delayed primary suturing—done for lacer-ated wound within 48 hour  Secondary suturing—done for infected wound in 10–14

day

absorbable suture materials Time of absorption

6 Polydiaxanone (PDS) 180 day (longest absorbable suture material)

Contd

FMge qUeSTionS

1 Commonest complication of parenteral nutrition

includes all, except: (Sep 2003)

2 Which of the following is preferred cannulation

site for total parenteral nutrition: (Sep 2003)

a Subclavian vein

b Great saphenous vein

c Median cubital vein

d External jugular vein

Ans: a (Subclavian vein)

3 Which is best method for supplementing

nutri-tion in patients, who have undergone massive

re-section of the small intestine is: (Sep 2004)

5 Which of the following is true regarding

tubercu-lous lymphadenitis: (Sep 2005)

a History of contact with TB patient may be

present

b Commonly seen in the young and children

c Mostly in the cervical region

d All of the above

Ans: d (All the above)

6 Pneumoperitoneum is created by: (Sep 2008)

a Inadequate surgical drainage

b Virulent strain of offending organism

c Prolonged course of antibiotic therapy

d Presence of foreign body

Ans: b (Virulent strain of offending organism)

8 Cock’s peculiar tumor is: (March 2006)

a Infected sebaceous cyst

b Osteomyelitis of skull

c Cyst in the skull

d Tumor of the skull

Ans: b (osteomyelitis of skull)

9 Cellulitis is most commonly caused by: (Sep 2006)

10 All of the following are complications in a patient

on total parenteral nutrition, except: (March 2006)

11 Bed sore is an example of: (Sep 2003, 2009)

Trophic ulcer (Neurogenic ulcer): Trophic ulcers

oc-cur in diseases and injuries to the spinal cord and

pe-ripheral nerves; for example, they may arise on the foot

after injury to the sciatic nerve It may also result from

local circulatory impairment as in bed sore.

12 Marjolin ulcer is: (Sep 2003)

a Malignant ulcer found on the scar of burn.

b Malignant ulcer found on infected foot

c Trophic ulcer

d Meleney gangrene

Ans: a (Malignant ulcer found in scar of burn)

13 Which of the following catheter material is most

suited for long term use is: (Sep 2007)

Silicone materials can be used for even upto 12 weeks

14 Potts puffy tumor is: (Sep 2005)

a Osteomyelitis of frontal skull

b Abscess in the skull

c Carcinoma of the frontal bone

d None of the above

Ans: a (osteomyelitis of frontal bone)

15 Most common mode of spread to cervical

lymph-node in TB is: (Sep 2005)

18 Best prophylaxis by surgeon in preventing the gas gangrene as a complication is: (Sep 2009)

a Antibiotics

b Strict antiseptic protocol

c Sterilization methods

d All the above

Ans: d (All the above)

19 The following are absorbable suture materials,

Ans: c (Tuberculous ulcer)

21 Dermoid cyst are commonly seen in: (Sep 2011)

2 S hock , B lood T ranSfuSion and

 Decreased perfusion results in decreased urine output*

 Activation of renin angiotensin system vasopressin(Antidiuretic hormone) is released leading to vasoconstriction and reabsorption of water

 Cortisol is also released resulting in sodium and water reabsorption*

Classification of shock

○ Hypovolemic

Hypovolemic shock Cardiogenic shock obstructive shock

• Causes—decreased preload due

to cardiac tamponade tension pneumothorax, massive pulmo-ary and air embolism

distributive shock Endocrine shock

ism and adrenal insufficiency

• Causes of endocrine shock include hypo and hyperthyroid-Contd

IntroductIon Cardiovascular and metabolic characteristics of shock Hypovolemia Cardiogenic obstructive distributive

SeverIty oF SHock Compensated Decompensated

Progressive renal, respiratory and cardiovascular decompen-○ In general, loss of 15% of blood volume is compensated*

○ lating volume has been lost*

Blood pressure is maintained and falls after 30–40% of circu-○ Mild, moderate and severe types

Compensated Mild Moderate Severe

• Drugs like phenylephrine, noradrenaline are used in distributive type of shock (sepsis or neurogenic shocks) In these cases, the vasodilatation is the cause hence, the drugs are beneficial

• If the vasodilatation is resistant add vasopressin

Contd

Contd

Monitoring of response: Mixed venous oxygen saturation

• Urine output (Best monitor)

• The percentage saturation of oxygen returning to heart

from body is a measure of oxygen delivery and extraction

by tissues.

• Normal mixed venous oxygen saturation = 50–70%

• Levels below 50% indicate inadequate oxygen delivery and increased oxygen consumption by cells This situation is seen in cardiogenic shock and hypovolemic shock

• High mixed venous oxygen saturation (> 70%) are seen

in sepsis and some other forms of distributive shock Less oxygen is delivered to cells and cells cannot utilize what lit-tle oxygen is presented and hence, venous blood has higher oxygen concentration than normal

ally occurs 7–14 days after injury and is precipitated by factors such as infection, pressure necrosis or malignancy

• Rich in coagulation factors than packed cells and more metabolically active than stored blood

Contd

Blood ProductS Packed red cells Fresh frozen plasma:

For patients undergoing elective surgery, they pre-Perioperative blood transfusion

 Dilutional thrombocytope-♦ Decreased oxygen delivery (due to decrease

in 2, 3 DPG)

♦ Alkalosis (eventhough, the stored blood contains pH 6.3, because of massive transfu-sion sodium citrate is metabolized in liver to sodium bicarbonate)

• Most common sign of hemolytic transfusion reaction in a conscious patient oliguria* > hemoglobinuria.

blood component temperature of storage Shelf life

Allografts trigger a graft rejection response because of allelic differences at polymorphic genes that give rise to histocom-patibility antigens (transplant antigens), of which ABO blood group antigens and human leukocyte antigens (HLAs) are

the most important.

• For all types of organ, allograft is vitally important to ensure that recipients receive a graft that is ABO blood group

com-patible otherwise naturally occurring anti-A or anti-B antibodies will likely cause hyperacute graft rejection.

• There is no need to take account of Rhesus (Rh) antigen compatibility*

○ tant in organ transplantation

 Non-immune factors may contribute to pathogen- Characterized by myointimal proliferation in graft arteries leading to ischemia and fibrosis

Risk factors for chronic kidney graft rejection manifestation of organs of their chronic graft rejection

The donor liver and small bowel** both contain large num-to graft-versus-host disease (GVHD)

• erative disorder*

living liver donor

○ The concept was first pioneered to allow children to receive the left lobe* or lateral segment from an adult donor

○ Split-liver transplantation, first performed by Pichlmayr in 1988

Ans: c (Hypovolemic shock)

2 Which of the following is true for shock?

Ans: d (All the above)

3 In traumatic cases, shock is most likely due to:

Ans: a (Injury to intra-abdominal solid organ)

4 Which of the following is ideal in moderate

hem-orrhagic shock? (Sep 2003, 2009, 2010)

a Dextrose

b Ringer lactate

c Blood

d Dextran

Ans: b (Ringer lactate)

5 Cryoprecipitate contains: (March 2006)

a Factor II

b Factor V

c Factor VIII

d Factor IX

Ans: c (Factor VIII)

6 Highest chance of success in renal transplant is

possible when the donor is: (March 2007, 2009)

Ans: a (Liver transplant)

8 Which of the following are colloids? (Sep 2007)

Ans: b (Graft from One species to other species)

10 For shock best guidelines to check for adequacy of fluid therapy: (Sep 2010, 2009)

a Hemoglobin

b Urine output

c Blood pressure

d CVP

Ans: b (Urine output)

11 Which of the following is the best parameter to sess fluid intake in a polytrauma patient:

Ans: a (Urine output)

12 Mismatched blood transfusion manifests eratively as: (March 2011)

intraop- a Rise in BP

b Excessive bleeding from the surgical site

c Dyspnea

d Hematuria

Ans: b (Excessive bleeding from surgical site)

13 Massive transfusion in healthy adult male can cause hemorrhage due to: (March 2011)