Create a comprehensive, well detailed note for an MBBS student, for deep learning and passing of exams on these surgery topics: Fluids in Surgery Resuscitation in surgery Sutures Haemostasis in surgery Blood and blood transfusions Nutrition in Surgery Wound healings Surgical infections Pre/postoperative management of patients Instrumentations
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~/surgery-notes/MBBS_Surgery_Comprehensive_Notes.md
# COMPREHENSIVE SURGERY NOTES FOR MBBS ## Based on Schwartz's Principles of Surgery (11th Ed), Sabiston Textbook of Surgery, and Bailey & Love --- > **Study Tips:** Focus on the bolded key facts, memorize the tables, and understand the underlying mechanisms - examiners love asking "why." SAQ and MCQ hot spots are marked with ⭐. --- # TOPIC 1: FLUIDS IN SURGERY ## Body Fluid Compartments Total body water (TBW) = **60% of body weight in adult males**, 50% in females (less due to more adipose tissue). - Newborns: ~80% TBW - Obese: adjust down 10-20% - Malnourished: adjust up 10% **Three functional fluid compartments:** | Compartment | % of TBW | Volume (70 kg man) | |-------------|----------|--------------------| | Intracellular fluid (ICF) | 2/3 (~40% BW) | ~28 L | | Extracellular fluid (ECF) | 1/3 (~20% BW) | ~14 L | | - Plasma | 4-5% BW | ~3.5 L | | - Interstitial fluid | 15% BW | ~10.5 L | ⭐ **Third space losses** = fluid sequestered into non-functional compartments (bowel lumen, inflamed tissue, peritoneal cavity). Major source of occult loss in surgical patients. ## Composition of Fluid Compartments | Ion | Plasma (mEq/L) | ICF (mEq/L) | |-----|----------------|-------------| | Na+ | 142 | 10 | | K+ | 4 | 150 | | Cl- | 103 | 4 | | HCO3- | 24 | 10 | ⭐ **Osmotic pressure**: Normal plasma osmolality = 285-295 mOsm/L - Formula: Osmolality = 2[Na] + Glucose/18 + BUN/2.8 ## Types of Body Fluid Changes ### Volume Disturbances | Condition | Causes | Clinical Features | |-----------|--------|------------------| | **Volume deficit (ECF depletion)** | Vomiting, diarrhoea, fistulas, burns, bleeding, sequestration | Tachycardia, hypotension, oliguria, dry mucous membranes, decreased skin turgor | | **Volume excess (ECF overload)** | Excess IV fluids, renal failure, cardiac failure | Oedema, raised JVP, pulmonary oedema, weight gain | ### Concentration Changes (Sodium) | Condition | Serum Na | Causes | |-----------|----------|--------| | **Hyponatraemia** | <135 mEq/L | SIADH, excess free water, heart failure, cirrhosis | | **Hypernatraemia** | >145 mEq/L | Diabetes insipidus, excessive sweating, inadequate water intake | ### Potassium Disorders | Condition | Serum K | ECG Changes | Treatment | |-----------|---------|------------|-----------| | **Hypokalaemia** | <3.5 mEq/L | Flat T waves, U waves | KCl replacement (never bolus IV) | | **Hyperkalaemia** | >5.5 mEq/L | Peaked T waves, widened QRS | Calcium gluconate, insulin+glucose, kayexalate | ⭐ **Maximum safe IV K+ replacement: 10-20 mEq/hr (never exceed 40 mEq/hr)** ### Acid-Base Disorders | Disorder | pH | Primary change | Compensation | |----------|-----|---------------|--------------| | Metabolic acidosis | <7.35 | ↓ HCO3- | Hyperventilation (↓ PaCO2) | | Metabolic alkalosis | >7.45 | ↑ HCO3- | Hypoventilation (↑ PaCO2) | | Respiratory acidosis | <7.35 | ↑ PaCO2 | Renal HCO3- retention | | Respiratory alkalosis | >7.45 | ↓ PaCO2 | Renal HCO3- excretion | ⭐ **Surgically important:** Post-pyloric obstruction = metabolic alkalosis + hypochloraemia + hypokalaemia (paradoxical aciduria). Treat with normal saline + KCl. ## IV Fluid Types ### Crystalloids | Fluid | Na+ | Cl- | K+ | HCO3- | Glucose | Osmolality | Use | |-------|-----|-----|----|-------|---------|-----------|-----| | Normal saline (0.9%) | 154 | 154 | - | - | - | 308 | Volume replacement, hyponatraemia | | Hartmann's/Ringer's Lactate | 130 | 109 | 4 | 28 (lactate) | - | 273 | Most balanced - closest to plasma, preferred in surgery | | 5% Dextrose | - | - | - | - | 50g/L | 278 | Free water, maintenance | | 0.45% Saline + 5% Dextrose | 77 | 77 | - | - | 50g/L | 432 | Maintenance | | Hypertonic saline (3%, 7.5%) | 513-1283 | 513-1283 | - | - | - | High | Severe hyponatraemia, head injury | ⭐ **Ringer's Lactate (Hartmann's) is the preferred fluid for most surgical patients** - balanced, physiological, avoids hyperchloraemic acidosis. ### Colloids Confined to intravascular space; more efficient plasma expansion. | Type | Examples | Notes | |------|----------|-------| | Albumin | 5%, 25% | Natural; 5% isotonic; 25% used in hypoproteinaemia | | Synthetic | Dextran 40, Dextran 70, Hetastarch, Gelofusine | Hetastarch associated with renal failure; not preferred | ⭐ **Colloids vs Crystalloids:** No mortality benefit of colloids over crystalloids for resuscitation. Crystalloids are cheaper and safer. 3 mL of crystalloid needed to replace 1 mL of blood lost (due to distribution). ## Fluid Management in Surgery ### Pre-operative - Correct existing deficits - Replace ongoing losses - Provide maintenance requirements: **25-35 mL/kg/day** ### Intra-operative - Replace blood loss + third-space losses (2-4 mL/kg/hr for abdominal surgery) - Use Ringer's Lactate as default - Urine output target: **0.5 mL/kg/hr** (key indicator of adequate perfusion) ### Post-operative - Monitor: heart rate, BP, urine output, CVP, serum electrolytes - ERAS (Enhanced Recovery After Surgery) protocols favour **goal-directed fluid therapy** - avoid both under- and over-resuscitation - Avoid excessive saline (causes hyperchloraemic acidosis) --- # TOPIC 2: RESUSCITATION IN SURGERY ## Classes of Haemorrhagic Shock ⭐ | Class | Blood Loss | % Volume | HR | BP | RR | UO | GCS | |-------|-----------|---------|----|----|----|----|-----| | **I** | <750 mL | <15% | <100 | Normal | 14-20 | >30 mL/hr | Normal | | **II** | 750-1500 mL | 15-30% | 100-120 | Normal (↑ DBP) | 20-30 | 20-30 mL/hr | Anxious | | **III** | 1500-2000 mL | 30-40% | 120-140 | ↓ | 30-40 | 5-15 mL/hr | Confused | | **IV** | >2000 mL | >40% | >140 | ↓↓ | >35 | Anuria | Lethargic/coma | ⭐ Class I-II: fluid resuscitation; Class III-IV: blood transfusion required. ## Types of Shock | Type | CO | SVR | CVP/PCWP | SvO2 | Example | |------|-----|-----|-----------|------|---------| | Hypovolaemic | ↓ | ↑ | ↓ | ↓ | Haemorrhage, burns | | Septic (early) | ↑↑ | ↓ | ↓ | ↑ | Gram-negative sepsis | | Cardiogenic | ↓ | ↑ | ↑ | ↓ | MI, tamponade | | Neurogenic | ↓ | ↓ | ↓ | Variable | Spinal cord injury | | Obstructive | ↓ | ↑ | ↑ | ↓ | Pulmonary embolism, tension pneumothorax | ## Physiological Response to Haemorrhage (Neuroendocrine Axis) 1. **Sympathoadrenal response**: catecholamines (epinephrine from adrenal medulla, norepinephrine from nerve synapses) → tachycardia, vasoconstriction, glycogenolysis 2. **HPA axis**: ACTH → cortisol → gluconeogenesis, insulin resistance, Na+ retention 3. **RAAS**: Renin → Angiotensin II → vasoconstriction + aldosterone → Na+/water retention 4. **ADH (vasopressin)**: Released from posterior pituitary → distal tubule water retention; also mesenteric vasoconstrictor ⭐ **"Ebb and Flow" response** to injury: - **Ebb phase** (first 12-24h): hypometabolism, conservation, vasoconstriction - **Flow phase** (24h+): hypercatabolic, increased O2 consumption, muscle wasting ## Resuscitation Principles ### ATLS Primary Survey (ABCDE) - **A**irway with cervical spine protection - **B**reathing and ventilation - **C**irculation with haemorrhage control - **D**isability (neurological status - GCS, pupils) - **E**xposure / Environment (undress, prevent hypothermia) ⭐ **Two large-bore peripheral IV cannulae** (14-16G antecubital) are the initial access of choice. IO access if IV unavailable. ### Damage Control Resuscitation (DCR) ⭐ Goals: Prevent and treat the **"lethal triad"** = hypothermia + acidosis + coagulopathy - **Permissive hypotension**: Target systolic BP 80-90 mmHg (penetrating trauma) until surgical haemorrhage control. Exception: TBI (maintain SBP >90) - **Balanced blood products**: 1:1:1 ratio of packed RBCs: Fresh Frozen Plasma: Platelets (mimics whole blood) - **Haemostatic resuscitation**: Early FFP, cryoprecipitate, tranexamic acid (TXA) - **Damage control surgery**: abbreviated initial operation, ICU stabilisation, definitive repair later ### Tranexamic Acid (TXA) ⭐ - Antifibrinolytic: inhibits plasminogen binding to fibrin - **CRASH-2 trial**: TXA within 3 hours of traumatic haemorrhage significantly reduces mortality - Dose: 1g IV over 10 min, then 1g over 8 hours - **Do NOT give after 3 hours** - increases mortality ### Endpoints of Resuscitation - Urine output: **>0.5 mL/kg/hr** - Lactate: normalisation (<2 mmol/L) - Base deficit: correction - Mixed venous O2 saturation (SvO2): >70% - Serum pH: 7.35-7.45 ### Sepsis Resuscitation (Surviving Sepsis Campaign) - Blood cultures x2 BEFORE antibiotics - Broad-spectrum IV antibiotics within 1 hour - **30 mL/kg IV crystalloid bolus** in first 3 hours for hypotension/lactate >4 - Vasopressors if MAP <65 mmHg despite fluids (Noradrenaline first-line) - Central venous catheter monitoring - Source control (drainage, debridement) --- # TOPIC 3: SUTURES ## Classification of Sutures ### By Absorbability | Type | Examples | Duration of Strength | Uses | |------|----------|---------------------|------| | **Absorbable** | Catgut (plain, chromic), Vicryl (polyglactin), PDS (polydioxanone), Monocryl | Days to months | Internal, GI anastomoses, subcutaneous | | **Non-absorbable** | Silk, Prolene (polypropylene), Nylon (ethilon), Mersilene, steel wire | Permanent | Skin, vascular, tendon, hernia mesh fixation | | Suture | Type | Absorption time | Notes | |--------|------|----------------|-------| | Plain catgut | Natural absorbable | 10-14 days | Collagen from sheep/cow intestine; phagocytosed | | Chromic catgut | Natural absorbable | 21-28 days | Chromic acid treatment delays absorption | | Vicryl (polyglactin 910) | Synthetic absorbable, braided | 56-70 days | Most widely used; absorbed by hydrolysis | | PDS (polydioxanone) | Synthetic absorbable, monofilament | 180 days | Best for fascial closure; retains strength longest | | Monocryl (poliglecaprone) | Synthetic absorbable, monofilament | 21-28 days | Minimal tissue reaction, good for skin | | Silk | Natural non-absorbable, braided | Permanent (weakens) | Easy handling; causes tissue reaction; hepatobiliary | | Prolene (polypropylene) | Synthetic non-absorbable, monofilament | Permanent | Vascular, hernia; least tissue reactivity | | Nylon (ethilon) | Synthetic non-absorbable, monofilament | Permanent (slowly degrades) | Skin closure; good tensile strength | | Steel wire | Metallic non-absorbable | Permanent | Sternum closure, orthopaedics | ⭐ **Monofilament vs Braided:** - Monofilament (Prolene, PDS, Nylon): lower infection risk, less drag, harder to tie - Braided (Vicryl, Silk): easier handling, better knot security, higher infection risk (harbour bacteria in interstices) ### By Origin - **Natural**: Catgut (biological), silk, linen, cotton - **Synthetic**: Vicryl, PDS, Prolene, Nylon, Monocryl ### Suture Size - **USP system**: 0, 2-0, 3-0, 4-0, 5-0... (increasing zeros = thinner suture) - Largest: No. 5 (orthopaedic), Smallest: 11-0 (ophthalmic) - ⭐ **Skin closure: typically 3-0 or 4-0; fascial closure: 0 or 1; vascular: 5-0 or 6-0** ## Suture Techniques ### Interrupted vs Continuous | Type | Advantages | Disadvantages | Use | |------|-----------|---------------|-----| | Interrupted | Secure individually; if one fails, rest hold | Time-consuming | Most closures, infected wounds | | Continuous (running) | Faster, even tension distribution | If one breaks, whole line may fail | GI anastomosis, fascial closure | ### Common Techniques - **Simple interrupted**: standard skin closure - **Mattress sutures (horizontal/vertical)**: deep tension-bearing; evert wound edges; reduce dead space - **Subcuticular (intradermal)**: best cosmesis - continuous suture buried in dermis, no external knots - **Figure-of-eight**: fascial closure - **Purse-string**: around stoma, appendix stump - **Lembert, Connell**: bowel anastomosis (seromuscular inverting sutures) ## Needles | Type | Shape | Use | |------|-------|-----| | Cutting | 3-sided, cutting edge outward | Skin | | Reverse cutting | 3-sided, cutting edge inward (safer) | Skin, fascia | | Round (taper) | Blunt tip, spreads tissue | Bowel, vessels (less tissue damage) | | Blunt | Rounded tip | Liver, fascia (reduces needlestick) | ## Staples / Stapling Devices - **Skin staples**: fastest skin closure; removed at same time as sutures - **GIA stapler** (gastrointestinal anastomosis): cuts and staples simultaneously - **TA stapler** (thoracoabdominal): fires two rows of staples without cutting - **EEA stapler** (end-to-end anastomosis/circular): circular anastomosis (colorectal) ⭐ **Key principle**: Suture material should be at least as strong as the tissue it approximates, but the weakest point is always the **knot**. --- # TOPIC 4: HAEMOSTASIS IN SURGERY ## Physiology of Haemostasis Haemostasis = the arrest of bleeding; involves four overlapping phases: 1. **Vascular constriction** (seconds) 2. **Primary haemostasis** - platelet plug formation (minutes) 3. **Secondary haemostasis** - coagulation cascade, fibrin clot (minutes) 4. **Fibrinolysis** - clot dissolution (hours-days) ### Vascular Constriction - Immediate response to vessel injury - Mediated by: **Thromboxane A2 (TXA2)** (from platelets), **endothelin** (from endothelium), **serotonin** (5-HT, from platelets), bradykinin - Transected vessels constrict more than lateral wounds ### Primary Haemostasis (Platelet Plug) Normal platelet count: **150,000-400,000/μL**; lifespan 7-10 days; up to 30% sequestered in spleen **Steps: ACCA** 1. **Adhesion**: VWF bridges damaged collagen to platelet glycoprotein Ib (GPIb) 2. **Activation**: ADP, TXA2, thrombin activate platelets (shape change, granule release) 3. **Aggregation**: Fibrinogen bridges GPIIb/IIIa receptors on adjacent platelets 4. **Consolidation**: Clot stabilisation ⭐ **Aspirin**: irreversibly inhibits COX → ↓TXA2 → ↓platelet aggregation for platelet lifespan (7-10 days) ⭐ **Clopidogrel**: irreversibly blocks ADP receptor (P2Y12) → ↓aggregation ### Secondary Haemostasis (Coagulation Cascade) **Extrinsic pathway** (tissue factor/factor VII): activated by tissue injury; measured by **PT/INR** **Intrinsic pathway** (contact activation: XII, XI, IX, VIII): measured by **aPTT** **Common pathway**: X → Xa (with Va) → prothrombin → thrombin → fibrinogen → fibrin → stabilised by XIII ⭐ **Vitamin K-dependent factors: II, VII, IX, X (and proteins C, S)** - warfarin inhibits these. | Pathway | Factors | Test | Prolonged by | |---------|---------|------|-------------| | Extrinsic | VII | PT/INR | Warfarin, liver disease, vitamin K deficiency | | Intrinsic | XII, XI, IX, VIII | aPTT | Heparin, haemophilia A (VIII), haemophilia B (IX) | | Common | X, V, II, I | Both | | ### Fibrinolysis - **Plasminogen** → **plasmin** (via tPA) - Plasmin degrades fibrin → fibrin degradation products (FDP), D-dimers - D-dimer elevated in DVT/PE, DIC, infection - Antifibrinolytics: **TXA (tranexamic acid)**, epsilon-aminocaproic acid ## Disorders of Haemostasis ### Congenital | Disorder | Defect | Lab | Treatment | |----------|--------|-----|-----------| | Haemophilia A | Factor VIII deficiency | ↑aPTT, normal PT | Factor VIII concentrate, DDAVP | | Haemophilia B (Christmas disease) | Factor IX deficiency | ↑aPTT, normal PT | Factor IX concentrate | | Von Willebrand Disease (most common) | VWF deficiency/dysfunction | ↑BT, ↑aPTT | DDAVP, VWF concentrate | | Glanzmann's thrombasthenia | GPIIb/IIIa deficiency | ↑BT, normal PTT | Platelet transfusion | ⭐ **DDAVP (desmopressin)**: releases stored VWF and factor VIII from endothelium; useful for mild haemophilia A and vWD. ### Acquired | Condition | Mechanism | Treatment | |-----------|-----------|-----------| | DIC (Disseminated Intravascular Coagulation) | Systemic fibrin deposition + consumption of factors/platelets | Treat cause; FFP, platelets, cryoprecipitate | | Liver disease | Reduced synthesis of II, V, VII, IX, X, fibrinogen | FFP, vitamin K | | Thrombocytopaenia | Platelet count <50,000 = risk of operative bleeding; <20,000 = spontaneous bleeding | Platelet transfusion, treat cause | | Massive transfusion coagulopathy | Dilution of factors/platelets with pRBC | FFP + platelets in 1:1:1 ratio | | Heparin therapy | Anti-Xa, anti-IIa | Protamine sulphate reversal | | Warfarin overdose | Anti-vitamin K | Vitamin K, FFP, PCC (4-factor) | ⭐ **Reversal agents:** - Heparin → Protamine sulphate (1mg per 100U heparin) - Warfarin → Vitamin K (4-12h onset), FFP (immediate), 4-factor PCC (Beriplex) - fastest - DOACs → Dabigatran: Idarucizumab; Xa inhibitors: Andexanet alfa or 4-factor PCC ## Surgical Methods of Haemostasis ### Mechanical - **Direct pressure** (first line) - **Ligation** of vessels (ties - silk most commonly) - **Suture ligation** (transfixion): for larger vessels - **Clips** (titanium, polymer): applied with clip appliers (haemostat clips) - **Tourniquet**: limb surgery - **Packing**: damage control surgery (gauze tamponade) - **Balloon tamponade**: hepatic packing, REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) ### Thermal - **Electrosurgery (diathermy)**: - *Monopolar*: current passes through patient to grounding plate; most common - *Bipolar*: current between two tips of forceps; safer near nerves - *Cutting mode*: continuous current; *coagulation mode*: interrupted (fulgurating) - **Ultrasonic dissectors** (e.g., Harmonic scalpel): vibration at 55,500 Hz → protein denaturation; minimal thermal spread, no electrical current in patient - **Laser**: precise but expensive; used in ENT, ophthalmology, neurosurgery ### Chemical/Topical Haemostatic Agents ⭐ | Agent | Mechanism | Examples | |-------|-----------|---------| | Absorbable gelatin (Gelfoam) | Matrix for platelet aggregation | Gelfoam, Surgiflo | | Oxidised cellulose | Lowers pH, denatures protein | Surgicel | | Microfibrillar collagen | Platelet activation and aggregation | Avitene | | Thrombin (topical) | Direct clot formation | Thrombin spray | | Fibrin sealant | Mimics final coagulation step | Tisseel, Evicel | | Cyanoacrylate tissue glue | Polymerises on contact | Dermabond (skin); Histoacryl | | Bone wax | Mechanical occlusion of bone sinusoids | Sternal/orthopaedic surgery | | TXA | Antifibrinolytic | IV or topical | | Vasopressin/adrenaline | Vasoconstriction | Infiltration (ENT, plastic surgery) | ## Tests of Haemostasis ⭐ | Test | Normal | Measures | Prolonged by | |------|--------|----------|-------------| | Bleeding time (BT) | 3-8 min | Platelet function + VWF | Aspirin, thrombocytopaenia, vWD | | PT / INR | 11-13 sec / 0.9-1.1 | Extrinsic + common | Warfarin, liver disease, VII deficiency | | aPTT | 25-35 sec | Intrinsic + common | Heparin, haemophilia A/B, lupus anticoagulant | | Thrombin time (TT) | 10-12 sec | Fibrinogen → fibrin | Heparin, DIC, hypofibrinogenaemia | | Platelet count | 150,000-400,000/μL | Platelet number | - | | D-dimer | <0.5 mg/L | FDP | DIC, DVT/PE, inflammation | | TEG/ROTEM | Multiple values | Global clot dynamics | Visualises whole clot formation | ⭐ **TEG (Thromboelastography)** parameters: - **R-time** (reaction time): initial fibrin formation → prolonged by factor deficiency (give FFP) - **K-time**: time to reach clot strength → prolonged by hypofibrinogenaemia (give cryoprecipitate) - **Alpha angle**: rate of clot strengthening → reduced by fibrinogen deficiency - **MA** (maximum amplitude): platelet + fibrin contribution → reduced by thrombocytopaenia (give platelets) - **LY30**: clot lysis at 30 min → elevated in fibrinolysis (give TXA) --- # TOPIC 5: BLOOD AND BLOOD TRANSFUSIONS ## Blood Components | Component | Content | Volume | Indications | Trigger | |-----------|---------|--------|------------|---------| | **Packed Red Blood Cells (pRBC)** | RBCs (Hct ~65-80%) | 300-350 mL | Anaemia, acute haemorrhage | Hb <7 g/dL (stable); <8 in cardiac disease; <10 if symptomatic | | **Fresh Frozen Plasma (FFP)** | All coagulation factors + fibrinogen | 250-300 mL | Coagulopathy (PT/aPTT >1.5x normal), massive transfusion, warfarin reversal | 10-15 mL/kg | | **Platelets (PLT)** | Platelets | 50-70 mL/unit | Thrombocytopaenia + bleeding; prophylactic <10,000; pre-procedure <50,000 | 1 unit/10 kg body weight | | **Cryoprecipitate** | Fibrinogen, factor VIII, VWF, XIII | 10-20 mL | Hypofibrinogenaemia (<1 g/L), haemophilia A, vWD, DIC | Fibrinogen <1 g/L or <1.5 g/L peri-op | | **Whole blood** | All components | 450 mL | DCR, massive trauma (military/remote) | Increasingly used in trauma | | **Albumin** | Albumin protein | 250 mL | Hypoproteinaemia, SBP, cirrhosis | Albumin <20 g/L | | **Anti-D immunoglobulin** | Anti-D antibody | 1 mL | Rh-negative patient after Rh-positive blood exposure | Prophylaxis in pregnancy/trauma | ⭐ **1 unit pRBC raises Hb by ~1 g/dL** and Hct by ~3% ## Blood Groups and Compatibility | ABO Group | Antigen on RBC | Antibody in Plasma | Can receive | |-----------|----------------|-------------------|-------------| | A | A | Anti-B | A, O | | B | B | Anti-A | B, O | | AB | A and B | None | A, B, AB, O (universal recipient) | | O | None | Anti-A and Anti-B | O only (universal donor) | ⭐ **Rh system**: Rh-positive = has D antigen; Rh-negative = lacks D antigen. Anti-D antibodies form after exposure (transfusion or pregnancy). **Universal donor (O Rh-negative pRBC):** For emergency uncrossmatched transfusion **Universal plasma donor: AB** (no ABO antibodies) ## Pre-Transfusion Testing 1. **ABO and Rh typing** (group and save = G&S) 2. **Antibody screen**: detect irregular antibodies 3. **Crossmatch**: mix donor cells with recipient serum - Electronic crossmatch: 5-10 min - Immediate spin: 5-10 min - Full serological crossmatch: 45-60 min ## Massive Transfusion ⭐ Definition: Replacement of entire blood volume (10 units pRBC) in 24 hours, or >4 units in 1 hour **Massive Transfusion Protocol (MTP):** - Activate early (based on clinical prediction, not just lab values) - **TASH score, ABC score, Shock index** (HR/SBP >1.0) used to predict need - Ratio: **1 pRBC : 1 FFP : 1 Platelet** (per PROPPR trial) - Add cryoprecipitate early if fibrinogen < 1.5 g/L - TXA within 3 hours - Calcium replacement (citrate chelates calcium during massive transfusion) - Monitor: FBC, coag screen, fibrinogen, TEG/ROTEM, ionised Ca2+, temperature, ABG ## Complications of Transfusion ⭐ ### Immunological | Reaction | Mechanism | Timing | Features | Management | |----------|-----------|--------|----------|-----------| | **Acute haemolytic** (MOST DANGEROUS) | ABO incompatibility → intravascular haemolysis | During/immediately | Fever, rigors, loin pain, haemoglobinuria, shock, DIC | Stop transfusion immediately, IV fluids, diuresis, treat DIC | | **Delayed haemolytic** | Anamnestic response to minor antigens | 3-10 days | Falling Hb, mild jaundice, positive DAT | Supportive | | **Febrile non-haemolytic** (most common) | Cytokines in stored blood or anti-HLA Ab | During | Fever, chills (1-2°C rise) | Stop transfusion, paracetamol; rule out haemolysis | | **Allergic/urticarial** | IgE-mediated, donor plasma proteins | During | Urticaria, flushing | Slow rate, antihistamine | | **Anaphylaxis** | IgA-deficient patient + anti-IgA antibodies | Within minutes | Bronchospasm, hypotension | STOP, adrenaline, steroids | | **TRALI** (Transfusion-Related Acute Lung Injury) | Anti-HLA/anti-neutrophil antibodies | Within 6 hours | Non-cardiogenic pulmonary oedema, bilateral infiltrates, hypoxia | Stop, O2, supportive; NO diuretics | ### Non-Immunological | Complication | Cause | Prevention/Treatment | |-------------|-------|---------------------| | **TACO** (Transfusion-Associated Circulatory Overload) | Fluid overload - most common serious | Slow rate, pre-transfuse frusemide in at-risk; treat with diuresis | | Hypothermia | Cold stored blood | Warm blood through blood warmer | | Hypocalcaemia | Citrate anticoagulant chelates Ca2+ | Calcium gluconate supplementation | | Hyperkalaemia | K+ leak from stored cells | Wash cells; use fresh blood | | Coagulopathy | Dilution + lack of factors/platelets | Use MTP protocol | | Iron overload (haemosiderosis) | Repeated transfusions (>100 units lifetime) | Desferrioxamine chelation | | Infection transmission | HIV, HBV, HCV, CMV, malaria, vCJD | Donor screening; leucodepletion | | Transfusion-associated GVHD | Immunocompetent donor lymphocytes attack host | Irradiate blood for immunocompromised patients | ⭐ **TRALI vs TACO** - key distinction: - TRALI: no fluid overload, no raised CVP, bilateral infiltrates, occurs within 6h - treat with O2, NO diuretics - TACO: fluid overload, raised CVP/BNP, responds to diuretics ## Blood Salvage (Autotransfusion) ⭐ - **Cell saver (intraoperative cell salvage)**: blood suctioned from operative field, washed, reinfused as pRBC - Reduces allogeneic blood use by up to 40% - Contraindicated in infected fields, malignant operations (risk of tumour dissemination) --- # TOPIC 6: NUTRITION IN SURGERY ## Metabolic Response to Surgery/Injury ⭐ **"Ebb and Flow" phases:** - **Ebb phase** (0-24h post injury): hypometabolic state, decreased temperature and O2 consumption, conservation - **Flow phase** (day 1 onwards): hypermetabolism, increased O2 consumption, protein catabolism, negative nitrogen balance, hyperglycaemia **Hormonal drivers of catabolism:** - Cortisol: gluconeogenesis, insulin resistance, protein breakdown - Glucagon: glycogenolysis, gluconeogenesis - Catecholamines: glycogenolysis, lipolysis - Insulin resistance: despite hyperglycaemia ⭐ **Surgical stress hyperglycaemia** is common and associated with worse outcomes. Target blood glucose 140-180 mg/dL in ICU (NICE-SUGAR trial: intensive control increases mortality). ## Nutritional Assessment **Markers of nutritional status:** - **History**: weight loss (>10% in 6 months = significant), dietary intake, chronic illness - **Anthropometric**: BMI, mid-arm circumference, skinfold thickness - **Biochemical**: - Albumin (t½ = 21 days) - chronic malnutrition; poor operative risk if <35 g/L - Prealbumin / Transthyretin (t½ = 2-3 days) - most sensitive short-term marker - Transferrin (t½ = 8 days) - Total lymphocyte count - Creatinine-height index ⭐ **Scoring systems**: NRS-2002 (Nutritional Risk Screening), NUTRIC score (critically ill), SGA (Subjective Global Assessment) **Caloric requirements:** - Standard: **25-30 kcal/kg/day** (weight-based estimate) - Critically ill: indirect calorimetry is gold standard - After major trauma/burns: can increase to 35-45 kcal/kg/day **Protein requirements:** - Normal: 0.8 g/kg/day - Post-surgery/moderate stress: 1.2-1.5 g/kg/day - Major trauma/burns/ICU: 1.5-2.5 g/kg/day - Nitrogen balance = [Protein intake (g)/6.25] - [Urinary urea nitrogen + 4] ## Enteral Nutrition (EN) ⭐ **Principle**: "If the gut works, use it" **Advantages over parenteral:** - Maintains gut mucosal integrity and barrier function (prevents bacterial translocation) - Stimulates gut motility and biliary secretion - Preserves gut-associated lymphoid tissue (GALT) - Cheaper, fewer complications - Maintains microbiome **Indications:** Inability to maintain adequate oral intake (>5 days anticipated; >3 days in malnourished) **Routes of access:** | Route | Method | Use | |-------|--------|-----| | Nasogastric (NG) | Bedside insertion | Short-term (<4 weeks); most common | | Nasojejunal (NJ) | Fluoroscopy/endoscopy | Gastric outlet obstruction, pancreatitis | | PEG (Percutaneous Endoscopic Gastrostomy) | Endoscopic placement | Long-term (>4 weeks); head/neck surgery | | PEJ (Percutaneous Endoscopic Jejunostomy) | Endoscopic/surgical | Long-term jejunal feeding | | Feeding jejunostomy | Surgical (at laparotomy) | Oesophageal/gastric surgery, trauma | ⭐ **Start enteral feeding within 24-48 hours of ICU admission or major surgery** (ESPEN/ASPEN guidelines) **Complications of EN:** - Aspiration pneumonia (elevate HOB 30-45°) - Diarrhoea (osmotic; treat with slowing rate, change formula) - Constipation - Tube displacement, blockage - Refeeding syndrome (see below) - Hyperglycaemia ## Parenteral Nutrition (PN) **Indications (EN not possible or insufficient):** - Short bowel syndrome - High-output intestinal fistula - Paralytic ileus prolonged >5 days - GI obstruction (non-surgical) - Severe acute pancreatitis refractory to EN - Intestinal failure (Crohn's, radiation enteritis) **Routes:** - **Total Parenteral Nutrition (TPN)**: hypertonic solution (>900 mOsm/L) → **requires central venous access** (PICC, subclavian, internal jugular) - **Peripheral Parenteral Nutrition (PPN)**: isotonic/mildly hypertonic; limited caloric density; for short-term use only **Contents of TPN:** - Dextrose (carbohydrate, 3.4 kcal/g) - Amino acids (protein, 4 kcal/g) - Lipid emulsion (fat, 9 kcal/g) - usually 20-30% of calories - Electrolytes: Na, K, Mg, Ca, phosphate - Vitamins (fat and water soluble) - Trace elements (zinc, copper, selenium, chromium, manganese) ⭐ **"All-in-one" or total nutrient admixture (TNA)**: dextrose + amino acids + lipids mixed in one bag (stable for 24-48h) **Complications of TPN:** ⭐ | Mechanical | Metabolic | Infectious | |-----------|----------|-----------| | Pneumothorax (line insertion) | Hyperglycaemia (most common) | Catheter-related bloodstream infection (CRBSI) | | Haemothorax | Refeeding syndrome | Septic thrombophlebitis | | Air embolism | Hypo/hyperkalaemia | | | Venous thrombosis | Hypo/hyperphosphataemia | | | Line malposition | Hypomagnesaemia | | | | Hepatic steatosis/cholestasis | | | | Hyperlipidaemia | | ## Refeeding Syndrome ⭐ - Occurs when nutrition (EN or PN) is restarted after prolonged starvation - **Mechanism**: shift from fat to carbohydrate metabolism → insulin release → intracellular uptake of phosphate, potassium, magnesium → serum depletion - **Cardinal feature**: **Hypophosphataemia** (<0.5 mmol/L) → heart failure, respiratory failure, haemolytic anaemia, rhabdomyolysis, seizures - **Prevention**: identify at-risk patients (anorexia, alcoholism, prolonged nil-by-mouth, cancer cachexia), start feeds at 10-20 kcal/kg/day and increase slowly over 4-7 days - **Monitor**: phosphate, potassium, magnesium daily; supplement aggressively --- # TOPIC 7: WOUND HEALING ## Types of Wound Closure | Type | Also Called | Description | Examples | |------|------------|-------------|---------| | **Primary intention (1°)** | Primary closure | Wound edges approximated immediately | Clean surgical incisions, lacerations <6h old | | **Secondary intention (2°)** | Healing by granulation | Wound left open; fills by granulation | Infected wounds, abscesses, pressure ulcers | | **Tertiary intention (3°)** | Delayed primary closure | Wound initially left open, closed later (3-5 days) | Contaminated wounds, wounds opened for drainage | ## Phases of Wound Healing ⭐ ### Phase 1: Haemostasis (0-4 hours) - Immediate vasoconstriction - Platelet plug formation - Clot formation (fibrin matrix - scaffold for healing) - Platelets release growth factors: PDGF, TGF-β, EGF ### Phase 2: Inflammatory Phase (Days 1-4) - Vasodilation, increased permeability → oedema, erythema, warmth (cardinal signs of inflammation) - **Neutrophils** (first responders, 0-48h): phagocytose bacteria and debris - **Macrophages** (peak at 48-72h): essential for wound healing - debride, release cytokines and growth factors (VEGF, TGF-β, IL-1, TNF), orchestrate repair - ⭐ **Macrophages are the most important cells in wound healing** ### Phase 3: Proliferative Phase (Days 5-21) Three overlapping processes: **a) Granulation tissue formation:** - Fibroblasts migrate and proliferate, lay down collagen (initially type III) - **Angiogenesis**: new vessel formation stimulated by VEGF, FGF → red granular appearance - Myofibroblasts: fibroblasts with contractile elements; responsible for wound contraction **b) Re-epithelialisation:** - Keratinocytes migrate from wound edges and hair follicles - Growth factors: EGF, KGF - Requires moist wound environment **c) Collagen synthesis:** - Type III collagen predominates initially (weaker) - Vitamin C required for hydroxylation of proline and lysine → collagen cross-linking - Zinc is also required as a cofactor ### Phase 4: Maturation/Remodelling Phase (Days 21 - 2 years) - Type III → **Type I collagen** replacement (stronger, more organised) - Maximum wound strength: **80% of original tissue** (never 100%) - Scar shrinks, matures, becomes paler - ⭐ **Wound tensile strength**: at 1 week = 10%; at 3 weeks = 20%; at 6 weeks = 50-60%; at 6 months = 70-80% maximum ## Key Cells in Wound Healing ⭐ | Cell | Time | Role | |------|------|------| | Platelets | 0-24h | Initial plug, release growth factors (PDGF, TGF-β) | | Neutrophils | 0-48h | First responders, bacterial killing, debris clearance | | Macrophages | 48h-5 days | Orchestrators - debridement, cytokines, growth factors | | Fibroblasts | Days 4-14 | Collagen synthesis, fill defect | | Myofibroblasts | Days 7-21 | Wound contraction | | Keratinocytes | Days 3-14 | Re-epithelialisation | | Endothelial cells | Days 3-14 | Angiogenesis | ## Factors Affecting Wound Healing ⭐ ### Local Factors | Factor | Effect | |--------|--------| | Infection | Single most important local factor; bioburden >10⁵ organisms/gram tissue = impaired healing | | Blood supply | Ischaemia delays/prevents healing | | Tension/movement | Disrupts healing; causes hypertrophic scar | | Foreign body | Prevents healing; perpetuates infection | | Radiation | Obliterative endarteritis; oxygen delivery impaired | | Haematoma/seroma | Nidus for infection; separates wound edges | | Wound bed preparation | Moist environment promotes healing | ### Systemic Factors | Factor | Mechanism | |--------|-----------| | **Malnutrition** | Protein deficiency → impaired collagen synthesis, immune dysfunction | | **Diabetes mellitus** | Neuropathy + vasculopathy + impaired immune function + glycosylation of collagen | | **Steroids/immunosuppressants** | Anti-inflammatory → reduces all phases; stabilise lysosomal membranes | | **Jaundice** | Bilirubin inhibits fibroblast proliferation | | **Anaemia** | Reduced O2 delivery | | **Uraemia** | Impairs immune function | | **Vitamin deficiencies** | Vit C: collagen synthesis; Vit A: reverses steroid effects; Zinc: co-factor | | **Age** | Delayed all phases; reduced growth factor production | | **Smoking** | Vasoconstriction, CO → reduces O2 delivery, nicotine toxic to fibroblasts | ## Abnormal Wound Healing ### Hypertrophic Scar ⭐ - Raised scar **within original wound boundaries** - Excess collagen deposition within the wound - Often regresses over 1-2 years - Treatment: silicone sheets, pressure garments, steroid injection, laser ### Keloid Scar ⭐ - Raised scar **beyond original wound boundaries** (extends into normal skin) - More common in dark-skinned individuals - Genetic predisposition - Common sites: sternum, shoulders, earlobes, deltoid - **Does NOT regress spontaneously** - Treatment: intralesional triamcinolone, excision (high recurrence!), pressure therapy, radiotherapy post-excision ⭐ **Key distinction**: Hypertrophic = within scar boundaries, can regress. Keloid = beyond boundaries, does not regress. ### Wound Dehiscence ⭐ - Partial/complete disruption of wound layers - **Fascial dehiscence** = risk of evisceration (surgical emergency) - Risk factors: obesity, malnutrition, steroid use, infection, coughing (increased abdominal pressure), inadequate closure technique - "Pink fluid serosanguineous discharge" from abdominal wound = warning sign - Management: immediate return to theatre; cover bowel with saline-soaked gauze ### Sinus and Fistula - **Sinus**: blind-ended tract opening to skin surface; due to foreign body, infection, or ischaemia - **Fistula**: abnormal communication between two epithelium-lined surfaces; **Factors preventing closure (FRIEND)**: Foreign body, Radiation damage, Infection/Inflammation, Epithelialisation of tract, Neoplasm, Distal obstruction --- # TOPIC 8: SURGICAL INFECTIONS ## Classification of Surgical Wounds ⭐ | Class | Definition | SSI Risk | Examples | |-------|-----------|----------|---------| | **Class I: Clean** | Non-traumatic, no inflammation, respiratory/GI/GU tract not entered | 1-2% | Thyroidectomy, mastectomy, hernia repair | | **Class II: Clean-contaminated** | Controlled entry into respiratory/GI/GU tract, no spillage | 5-15% | Elective bowel resection, cholecystectomy | | **Class III: Contaminated** | Open traumatic wound, major spillage from GI tract, major break in sterile technique | 15-30% | Appendectomy for perforated appendix, trauma laparotomy | | **Class IV: Dirty/Infected** | Pre-existing infection, perforated viscus, faecal contamination | >30% | Faecal peritonitis, abdominal abscess, infected necrotic tissue | ## Surgical Site Infections (SSI) ⭐ **Definition**: Infection occurring within 30 days of surgery (or within 1 year if implant) **Depth of SSI:** - **Superficial incisional**: skin and subcutaneous tissue - **Deep incisional**: fascia and muscle - **Organ/space**: any anatomical area opened/manipulated during surgery **Common organisms:** - Clean wounds: *Staphylococcus aureus*, *S. epidermidis* - Clean-contaminated (GI): *E. coli*, *Klebsiella*, *Bacteroides* - Contaminated/dirty: Mixed flora including anaerobes **Risk Factors for SSI:** Patient factors: Diabetes, obesity, malnutrition, immunosuppression, smoking, extremes of age, ASA score >2 Surgical factors: Duration >2 hours, wound class, inadequate prep, hypothermia, poor technique, poor haemostasis, dead space **Prevention of SSI:** ⭐ - Pre-operative: Bowel preparation (controversial), shower/bath with chlorhexidine, hair clipping (not shaving) on day of surgery, optimise glucose, stop smoking - **Antibiotic prophylaxis**: IV first-generation cephalosporin (e.g., cefazolin) within **60 minutes before incision** (or vancomycin within 120 min); repeat if operation >4h or significant blood loss; **discontinue within 24h post-op** - Intra-operative: Maintain normothermia (warming blanket), maintain normoglycaemia, maintain tissue oxygenation, use appropriate technique, irrigate contaminated wounds - Post-operative: Aseptic wound care, dressing changes ## Common Surgical Infections ### Cellulitis - Spreading infection of dermis and subcutaneous tissue - **Causative organisms**: Beta-haemolytic *Streptococcus* (most common), *S. aureus* - Treatment: Penicillin V / co-amoxiclav; IV benzylpenicillin + flucloxacillin if severe ### Abscess - Localised collection of pus surrounded by pyogenic membrane - Principles of treatment: **Drainage** is mandatory (antibiotics alone insufficient) - ⭐ **"Ubi pus, ibi evacua"** = "Where there is pus, evacuate it" - Method: I&D (incision and drainage), with culture + sensitivity ### Necrotising Fasciitis ⭐ - Life-threatening deep soft tissue infection; involves fascial planes - **Type I**: Polymicrobial (aerobic + anaerobic); more common; diabetics/immunocompromised - **Type II**: Monomicrobial, Group A *Streptococcus pyogenes* (most virulent); can occur in healthy - **"Flesh-eating" bacteria** in lay press - Clinical features: Pain disproportionate to appearance, skin changes (erythema → blistering → gangrene), "wooden-hard" subcutaneous tissue, systemic toxicity - Investigations: CT scan (gas in soft tissues = pathognomonic), LRINEC score (Lab Risk Indicator for NF) - **Treatment**: EMERGENCY - aggressive IV antibiotics (broad spectrum) + **immediate radical surgical debridement** (remove all necrotic tissue); relook in 24-48h; ICU support - Mortality: 20-40% even with treatment ### Gas Gangrene (Clostridial Myonecrosis) ⭐ - Caused by **Clostridium perfringens** (type A) - spore-forming anaerobe - Exotoxin (alpha toxin = lecithinase C) → destroys cell membranes - Incubation: 1-3 days - Features: severe pain, gas in tissues (crepitus), bronzing of skin, foul-smelling discharge, systemic toxicity - Treatment: Hyperbaric oxygen + IV penicillin + radical debridement/amputation - Prevention: thorough wound debridement, prophylactic penicillin ### Tetanus ⭐ - Caused by **Clostridium tetani** - spore-forming anaerobe - Exotoxin (tetanospasmin) blocks inhibitory neurotransmitters (glycine, GABA) → unopposed motor activity - Features: **trismus** (lockjaw), risus sardonicus, opisthotonos (arched back), muscle spasms - Treatment: wound debridement + **human tetanus immunoglobulin (HTIG)** + IV metronidazole + diazepam (muscle relaxant) + ICU - Prevention: immunisation (DTP), booster every 10 years; wound care + immunoglobulin for unvaccinated ### Peritonitis | Type | Mechanism | Organisms | Management | |------|-----------|-----------|-----------| | Primary (SBP) | Haematogenous/lymphatic spread | Mono-microbial E. coli, Klebsiella | Antibiotics (no surgery) | | Secondary | Perforated viscus | Polymicrobial (E. coli + Bacteroides) | Surgery + antibiotics | | Tertiary | Failed treatment of secondary | Resistant organisms | Broad spectrum + source control | ### Intra-abdominal Abscess - Following peritonitis, bowel surgery, or anastomotic leak - Common sites: pelvic, subphrenic, paracolic gutters - Diagnosis: CT scan (best), USS - Treatment: CT/USS-guided percutaneous drainage + antibiotics (drain pus!) ## Antibiotic Principles in Surgery ⭐ **Prophylactic**: Single dose (or max 24h); given before contamination; aimed at specific organisms **Therapeutic**: Treat established infection; chosen based on C&S where possible | Situation | Organism | Antibiotic of choice | |-----------|----------|---------------------| | Clean surgery (skin) | S. aureus | Cefazolin | | GI surgery | Gram-negatives + anaerobes | Co-amoxiclav or cefazolin + metronidazole | | Biliary surgery | E. coli, Klebsiella | Co-amoxiclav or gentamicin + metronidazole | | MRSA prophylaxis | MRSA | Vancomycin | | Necrotising fasciitis | Polymicrobial | Piperacillin-tazobactam + clindamycin | | Clostridial infections | Clostridium | Penicillin + metronidazole | --- # TOPIC 9: PRE- AND POST-OPERATIVE MANAGEMENT ## Pre-operative Assessment ### Goals 1. Identify and optimise medical conditions 2. Assess operative risk (anaesthetic + surgical) 3. Obtain informed consent 4. Plan perioperative management ### History and Examination - **History**: current medications, allergies, previous anaesthetics (reactions, difficult airway), family history of anaesthetic problems (malignant hyperthermia), comorbidities - **Symptoms**: angina, dyspnoea, exercise tolerance (METs - metabolic equivalents; >4 METs = acceptable risk) - **Cardiovascular**: recent MI (<6 weeks: postpone elective surgery), uncontrolled HF, severe valvular disease, unstable angina → high risk - **Respiratory**: COPD, obstructive sleep apnoea (OSA) - pre-opt CPAP assessment - **Medications to note**: ⭐ - Aspirin: continue for vascular procedures; stop 7-10 days before others - Clopidogrel: stop 5 days before (DAPT management per cardiologist) - Warfarin: stop 5 days before; bridge with LMWH if high thrombotic risk - DOACs: stop 24-48h (or 48-96h for renally impaired); no bridging needed - Insulin: reduce dose on day of surgery; monitor glucose - Metformin: stop on day of surgery (risk of lactic acidosis with contrast/procedure); restart when eating - Steroids: continue + give stress dose (hydrocortisone 100mg IV) if on steroids >1 week ### Pre-operative Investigations ⭐ | Investigation | Indication | |--------------|-----------| | FBC | All surgery; assess anaemia, thrombocytopaenia | | U&E / Creatinine | Renal disease, diuretics, cardiovascular disease; all major surgery | | LFTs | Liver disease, jaundice | | Coagulation (PT, aPTT) | Bleeding history, liver disease, anticoagulants | | Blood group & screen | Expected blood loss >500 mL; crossmatch if >1000 mL | | ECG | Age >50, cardiac symptoms, hypertension, diabetes | | Chest X-ray | Cardiac/respiratory disease, smokers, recent respiratory symptoms | | Echocardiogram | Suspected valvular disease, unexplained dyspnoea, EF assessment | | Lung function (spirometry) | Major thoracic surgery, COPD assessment | | HbA1c | Diabetic patients - optimise pre-op | | Urinalysis/MSU | If urinary symptoms or urological surgery | | Pregnancy test (urine βhCG) | All females of childbearing age before GA | **NICE Guidelines (UK)**: Investigation-based on ASA grade and procedure grade - avoid unnecessary tests. ### Risk Assessment Tools ⭐ | Tool | Purpose | Score Range | |------|---------|------------| | **ASA Classification** | Overall physical status | I (healthy) to V (moribund) + E (emergency) | | **Goldman Cardiac Risk** | Cardiac risk in non-cardiac surgery | 9 factors; Class I-IV | | **Revised Lee Cardiac Index (RCRI)** | Predicts MACE in non-cardiac surgery | 6 factors; score 0-6 | | **POSSUM / P-POSSUM** | Predicts morbidity and mortality | Physiological + operative scoring | | **Gupta Respiratory Failure Score** | Post-op respiratory failure risk | Online calculator | | **APACHE II / SOFA** | ICU severity scoring | - | **ASA Classification:** ⭐ - **ASA I**: Healthy, no systemic disease - **ASA II**: Mild systemic disease (controlled HTN, DM, obesity BMI 30-40, social smoker) - **ASA III**: Severe systemic disease, not incapacitating (poorly controlled DM, COPD, morbid obesity, active hepatitis, dialysis-dependent) - **ASA IV**: Severe systemic disease, constant threat to life (recent MI/stroke/TIA, severe valve disease) - **ASA V**: Moribund, not expected to survive without surgery (ruptured AAA, massive PE) - **ASA VI**: Brain-dead, organ donation **RCRI risk factors**: Ischaemic heart disease, congestive heart failure, cerebrovascular disease, diabetes requiring insulin, renal failure (Cr >177 μmol/L), high-risk surgery (suprainguinal vascular, intrathoracic, intraperitoneal). ### Informed Consent - Patient must be **competent** (understand, retain, weigh, communicate) - Voluntary, without coercion - Disclose: procedure, benefits, risks (common AND serious), alternatives - **Montgomery ruling (UK 2015)**: patient must be informed of ALL material risks (risks that a reasonable patient would attach significance to) - Emergency surgery: act in best interests if patient cannot consent ### Fasting (Nil Per Os - NPO) Guidelines ⭐ - **2 hours**: clear fluids (water, apple juice, black tea/coffee without milk) - **4 hours**: breast milk - **6 hours**: formula milk, solid food, non-human milk - "**2-4-6 rule**" (AAGBI) - ERAS: encourage carbohydrate drinks up to 2h before surgery to reduce insulin resistance ## Peri-operative Management of Special Conditions ### Diabetes Mellitus ⭐ - Target glucose: 6-10 mmol/L (108-180 mg/dL) perioperatively - VRII (Variable Rate Insulin Infusion = sliding scale): used intra- and post-operatively for type 1 DM and unstable type 2 - HbA1c >8.5% (69 mmol/mol): consider postponing elective surgery and optimising control - Withhold metformin on day of surgery; restart when eating/drinking well ### Hypertension - BP >180/110 mmHg: postpone elective surgery; optimise first - Continue most antihypertensives perioperatively - ACE inhibitors/ARBs: consider stopping morning of surgery (risk of refractory intraoperative hypotension) ### Anticoagulation Bridging ⭐ | Thrombotic Risk | Strategy | |----------------|---------| | Low risk (AF, no prior stroke, bioprosthetic valve, RCRI 0-2) | Stop anticoagulant, no bridging | | High risk (mechanical mitral valve, AF + prior stroke, recent DVT/PE <3 months) | Bridge with therapeutic LMWH | ## Post-operative Management ### Routine Post-operative Monitoring - Vital signs (HR, BP, RR, SpO2, temperature) - frequency dictated by procedure - Urine output: >0.5 mL/kg/hr - Wound inspection: bleeding, inflammation - Pain management - Fluid balance - Blood glucose in diabetics - VTE prophylaxis ### Post-operative Complications - The "Ws" of Post-operative Fever ⭐ | Day Post-op | Cause | Mnemonic | |------------|-------|----------| | **Day 1-2** | Wind: atelectasis/pneumonia (most common cause of early post-op fever) | Wind | | **Day 3-5** | Water: UTI | Water | | **Day 5-7** | Wound: SSI | Wound | | **Day 7-10** | Walk: DVT/thrombophlebitis | Walk (deep veins) | | **Day 5+** | Wonder drugs: drug fever | Wonder drugs | | **Any time** | Anastomotic leak, abscess | IV line (catheter infection) | ### VTE Prophylaxis ⭐ Risk factors: surgery, immobility, malignancy, previous DVT/PE, obesity, thrombophilia, oral contraceptive pill, pregnancy | Risk Level | Prophylaxis | |-----------|------------| | Low risk | Early ambulation | | Moderate risk | Mechanical (TED stockings + pneumatic compression devices) + LMWH | | High risk (major cancer surgery, orthopaedic) | LMWH (enoxaparin 40mg SC daily) + mechanical; continue 28 days post-op | ⭐ **Withhold LMWH**: 12 hours before surgery (prophylactic dose); 24 hours (therapeutic dose). Restart 6-12h post-op (check haemostasis). ### Analgesia (WHO Analgesic Ladder) - **Step 1**: Non-opioid (paracetamol, NSAIDs) - **Step 2**: Weak opioid + non-opioid (codeine, tramadol) - **Step 3**: Strong opioid + non-opioid (morphine, fentanyl) - **Adjuvants**: ketamine, gabapentinoids, regional blocks **Regional analgesia:** - Epidural (LA + opioid): excellent for thoracic/abdominal surgery; reduces systemic opioids - Spinal anaesthesia: for lower abdominal/perineal/lower limb surgery - Nerve blocks: TAP (transversus abdominis plane) block, femoral nerve block, etc. ### Enhanced Recovery After Surgery (ERAS) ⭐ **Pre-operative:** Patient education, carbohydrate loading, optimise nutrition/anaemia, stop smoking, avoid prolonged fasting **Intra-operative:** TIVA (total IV anaesthesia) preferred, avoid excess fluids, maintain normothermia, minimally invasive approach where possible, short-acting anaesthetics **Post-operative:** Early oral fluids (day 0-1), early feeding, early mobilisation, remove drains/catheters early, multimodal analgesia, avoid opioids, limit IV fluids, prevent PONV ERAS reduces hospital stay by 2-3 days and reduces complications by 30-50%. --- # TOPIC 10: SURGICAL INSTRUMENTATION ## Categories of Surgical Instruments ### Cutting and Dissecting Instruments | Instrument | Description | Use | |-----------|-------------|-----| | **Scalpel** | Handle + blade; most common blade 22 (large general), 15 (fine dissection), 11 (stab incisions), 10 (large incisions) | Incision, dissection | | **Scissors** | Mayo (curved/straight - heavy), Metzenbaum (fine - for delicate dissection) | Cutting, dissecting | | **Diathermy pencil** | Monopolar electrosurgical unit | Cutting + coagulation | | **Harmonic scalpel** | Ultrasonic energy, LigaSure | Laparoscopic/open; simultaneous cut + seal | | **Electrotome** | Electrosurgical wire loop | Prostatic/endometrial resection | ### Grasping and Holding Instruments | Instrument | Features | Use | |-----------|----------|-----| | **Tissue forceps (non-toothed)** | Debakey, Adson non-toothed | Delicate tissue - bowel, vessels | | **Tissue forceps (toothed)** | Adson with teeth, Gillies | Skin, fascia (not delicate tissue) | | **Artery forceps (haemostats)** | Mosquito (fine), Spencer Wells, Kocher (toothed tip) | Clamping vessels | | **Babcock forceps** | Atraumatic ring tips | Bowel, appendix, fallopian tube | | **Allis clamp** | Toothed edges | Grasping fascia, skin | | **Bowel clamps** | Non-crushing (nylon-jawed, e.g., Lane's) vs crushing (Pace-Potts) | Occlude bowel | | **Lahey/Mixter right-angle forceps** | 90° curve | Dissection around vessels/ducts for tie placement | ### Retractors | Instrument | Type | Use | |-----------|------|-----| | **Langenbeck** | Hand-held, right angle blade | General retraction - skin, fascia | | **Deaver** | Hand-held, large curved blade | Abdominal, hepatic, deep retraction | | **Morris** | Hand-held, broad curve | Abdominal wall | | **Balfour / Kirschner** | Self-retaining, abdominal | Open abdominal surgery | | **Finochetto** | Self-retaining, rib spreader | Thoracic surgery | | **Joll's thyroid retractor** | Self-retaining | Thyroid surgery | | **West's thyroid retractor** | Self-retaining | Thyroid surgery | | **Travers / Cat's paw** | Small prongs | Superficial surgery, neck | | **Lone Star** | Circumferential self-retaining | Perianal surgery | | **Bookwalter** | Large modular self-retaining | Complex abdominal surgery | ### Suction and Irrigation | Instrument | Description | Use | |-----------|-------------|-----| | **Yankauer** | Rigid tonsil sucker, bulb tip | Oral/pharyngeal suctioning, general surgery | | **Poole sucker** | Perforated cannula within outer guard | Peritoneal cavity (prevents bowel suction) | | **Frazier sucker** | Fine, angled | Neurosurgery, ENT, fine dissection | | **Irrigation syringe** | Bulb or 50 mL Luer-lock | Wound irrigation | ### Wound Closure Instruments | Instrument | Description | Use | |-----------|-------------|-----| | **Needle holder (needle driver)** | Mayo-Hegar, Olsen-Hegar (with scissors) | Suturing | | **Skin stapler** | Disposable staple gun | Rapid skin closure | | **Wound closure strips (Steri-strips)** | Adhesive strips | Minor wounds, reinforcement | | **Tissue adhesive (Dermabond)** | Cyanoacrylate glue | Minor lacerations, paediatric | ### Drainage Instruments | Type | Examples | Use | |------|----------|-----| | **Passive drains** | Penrose (soft rubber), corrugated | Drain by gravity/capillary | | **Active (closed suction)** | Blake, Jackson-Pratt, Redivac | Active suction drainage (low vacuum) | | **Sump drain** | Multiplex | Allows irrigation while draining | | **Chest drain** | Intercostal catheter (ICC) | Haemo/pneumothorax | | **Nasogastric tube** | Ryle's tube | Decompression, feeding | | **Foley catheter** | Balloon retention | Urinary drainage, urine output monitoring | | **T-tube** | T-shaped catheter | Choledochostomy, biliary decompression | ## Laparoscopic Instruments ⭐ | Instrument | Description | Use | |-----------|-------------|-----| | **Veress needle** | Spring-loaded needle | Creation of pneumoperitoneum (blind technique) | | **Trocar and cannula (port)** | 5mm, 10mm, 12mm | Port of entry for instruments | | **Hasson cannula** | Blunt, open technique | Safer entry for open (Hasson) technique | | **Laparoscope** | 0° or 30° angled camera | Visualisation | | **Grasper/dissector** | Various jaw types | Tissue handling | | **Hook diathermy** | Monopolar L-shaped | Dissection + coagulation | | **Clip applier** | Titanium or polymer clips | Cystic duct/artery ligation | | **Stapler (laparoscopic)** | Endo-GIA | Bowel/lung/vessel stapling | | **Insufflator** | CO2 gas source | Maintains pneumoperitoneum | | **Suction-irrigation** | Combined probe | Lavage + aspiration | ⭐ **Pneumoperitoneum**: CO2 used (not air - avoids air embolism risk); pressure maintained at **12-15 mmHg**; risks include gas embolism, shoulder tip pain (diaphragm irritation), cardiovascular changes. ## Sterile Technique and Instrument Handling ### Sterilisation Methods ⭐ | Method | Temperature | Time | Use | |--------|------------|------|-----| | **Autoclaving (steam under pressure)** | 134°C at 3 bar | 3 min (porous load), 3.5 min (wrapped items) | Most heat-stable instruments (gold standard) | | **Dry heat (hot air oven)** | 160°C | 60 min / 180°C for 30 min | Glassware, oils, powders | | **Ethylene oxide (EtO) gas** | 55°C | 1-6 hours + aeration | Heat-sensitive (plastics, rubber, lenses) | | **Plasma (hydrogen peroxide)** | 45-50°C | 28-75 min | Heat- and moisture-sensitive | | **Glutaraldehyde (Cidex)** | Room temp | 10h (sterilisation), 20-30 min (high-level disinfection) | Endoscopes (heat-sensitive) | | **Gamma irradiation** | Room temp | - | Single-use items, mass sterilisation | | Process | Kills | Examples | |---------|-------|---------| | **Sterilisation** | ALL organisms including spores | Autoclave, EtO, gamma irradiation | | **Disinfection (high-level)** | All except some spores | Glutaraldehyde, peracetic acid | | **Disinfection (low-level)** | Vegetative bacteria, some viruses | Chlorhexidine, alcohols | | **Antisepsis** | Organisms on living tissue | Povidone-iodine, chlorhexidine | | **Asepsis** | Prevent introduction of organisms | Sterile technique | ⭐ **Prions (CJD)**: NOT killed by standard autoclaving. Require extended autoclave cycles (134°C for 18 min) or NaOH 1M soaking + autoclave. ## Common Operative Positions ⭐ | Position | Use | Risks | |----------|-----|-------| | Supine | Most abdominal, thoracic, vascular | Pressure areas (heels, occiput) | | Lithotomy | Perineal, rectal, pelvic surgery | Common peroneal nerve palsy, compartment syndrome of legs, deep vein thrombosis | | Lloyd-Davies | Colorectal surgery (simultaneous abdominal + perineal access) | Same as lithotomy | | Lateral decubitus | Thoracic, renal, hip arthroplasty | Brachial plexus injury, pressure on downside | | Prone | Posterior spinal, rectal, some neurosurgery | Endotracheal tube displacement, brachial plexus, pressure on abdomen, venous congestion | | Trendelenburg (head down) | Pelvic, laparoscopic | Raised ICP, regurgitation, diaphragm compression | | Reverse Trendelenburg | Cholecystectomy, upper GI | - | --- # QUICK REFERENCE TABLES FOR EXAMS ## Key Numbers to Memorise ⭐ | Parameter | Value | |-----------|-------| | Total Body Water (adult male) | 60% of body weight | | Intracellular fluid | 40% of body weight | | Plasma volume | 5% of body weight (~3.5L in 70kg man) | | Normal serum Na+ | 135-145 mEq/L | | Normal serum K+ | 3.5-5.5 mEq/L | | Normal serum Cl- | 95-105 mEq/L | | Normal serum HCO3- | 22-26 mEq/L | | Normal plasma osmolality | 285-295 mOsm/L | | Urine output - minimum adequate | 0.5 mL/kg/hr | | Normal platelet count | 150,000-400,000/μL | | Platelet lifespan | 7-10 days | | PT (INR) normal | 11-13 sec (0.9-1.1) | | aPTT normal | 25-35 sec | | 1 unit pRBC raises Hb by | ~1 g/dL (~3% Hct) | | Wound tensile strength (6 months) | 70-80% of normal | | Maximum wound strength ever | ~80% of original | | CO2 pneumoperitoneum pressure | 12-15 mmHg | | Autoclave temperature | 134°C, 3 bar, 3 minutes | | Pre-op fasting (clear fluids) | 2 hours | | Pre-op fasting (solids) | 6 hours | | Antibiotic prophylaxis: give within | 60 minutes before incision | | Massive transfusion: pRBC ratio | 1:1:1 (pRBC:FFP:Plt) | | TXA: give within | 3 hours of haemorrhage | | CRASH-2 TXA dose | 1g IV over 10 min, then 1g over 8h | | Infection defines impaired wound healing | >10⁵ organisms/gram | ## Mnemonics ⭐ **AMPLE** (Pre-op history): Allergies, Medications, Past history, Last ate, Events **CHOP** (Causes of post-op fever): C-ath line, Haematoma/Haemorrhage, OP site (wound), Pulmonary (atelectasis/PE) **FRIEND** (Factors preventing fistula closure): Foreign body, Radiation, Infection, Epithelialisation, Neoplasm, Distal obstruction **5Ws** of post-op fever: Wind, Water, Wound, Walk, Wonder drugs **DOPE** (Causes of ventilator emergency): Displacement, Obstruction, Pneumothorax, Equipment failure **HALT** (Contraindications to NSAIDS): Hypertension, Allergy/Asthma, Liver/renal failure, Thrombocytopaenia/coagulopathy **"Ubi pus, ibi evacua"**: Where there is pus, evacuate it **CRAWL** (Haemostasis agents): Collagen, Red oxidised cellulose, Absorbable gelatin, Wax, Laser/Liquid agents --- *Sources: Schwartz's Principles of Surgery 11th Edition; Sabiston Textbook of Surgery; Bailey & Love's Short Practice of Surgery 28th Edition; Current Surgical Therapy 14th Edition.* *Compiled for MBBS examination preparation - May 2026*
Reading File
Running Command
cd /home/daytona/workspace/surgery-notes && pandoc MBBS_Surgery_Comprehensive_No…
Running Command
cd /home/daytona/workspace/surgery-notes && pandoc MBBS_Surgery_Comprehensive_No…
Running Command
which pdflatex wkhtmltopdf chromium-browser google-chrome 2>/dev/null; python3 -…
Running Command
python3 -c " from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer…
Running Command
python3 << 'PYEOF' from reportlab.platypus import SimpleDocTemplate, Paragraph, …
Model call limits exceeded: run limit (20/20)
Make a Word document with practice SAQs and MCQs on these 10 topics
Reading File
Running Command
ls /home/daytona/skills/docx/scripts/office/ 2>/dev/null && node --version 2>/de…
Writing File
~/surgery-notes/generate_questions.js
const {
Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
HeadingLevel, AlignmentType, BorderStyle, WidthType, ShadingType,
VerticalAlign, PageNumber, Header, Footer, TabStopType, TabStopPosition,
UnderlineType
} = require('docx');
const fs = require('fs');
// ─── COLOUR PALETTE ────────────────────────────────────────────────────────
const NAVY = "1A3A5C";
const BLUE = "2C5F8A";
const LBLUE = "E8F0F7";
const GREEN = "1A5C2A";
const LGREEN = "E8F5E8";
const RED = "8B0000";
const LRED = "FFF0F0";
const LGREY = "F5F5F5";
const BORDER = "CCCCCC";
const WHITE = "FFFFFF";
const GOLD = "C8A000";
// ─── HELPER: plain paragraph ───────────────────────────────────────────────
function p(text, opts = {}) {
const runs = [];
// Simple bold/italic inline parse: **text** -> bold
const parts = String(text).split(/(\*\*[^*]+\*\*|\*[^*]+\*)/g);
for (const part of parts) {
if (part.startsWith('**') && part.endsWith('**')) {
runs.push(new TextRun({ text: part.slice(2, -2), bold: true, size: opts.size || 22, font: opts.font || "Calibri", color: opts.color }));
} else if (part.startsWith('*') && part.endsWith('*')) {
runs.push(new TextRun({ text: part.slice(1, -1), italics: true, size: opts.size || 22, font: opts.font || "Calibri", color: opts.color }));
} else {
runs.push(new TextRun({ text: part, bold: opts.bold, italics: opts.italics, underline: opts.underline ? { type: UnderlineType.SINGLE } : undefined, size: opts.size || 22, color: opts.color, font: opts.font || "Calibri" }));
}
}
return new Paragraph({
children: runs,
spacing: { before: opts.before || 40, after: opts.after || 40 },
alignment: opts.align || AlignmentType.LEFT,
indent: opts.indent ? { left: opts.indent } : undefined,
shading: opts.shading ? { type: ShadingType.SOLID, color: opts.shading, fill: opts.shading } : undefined,
});
}
// ─── HELPER: heading ──────────────────────────────────────────────────────
function heading1(text) {
return new Paragraph({
children: [new TextRun({ text, bold: true, size: 32, color: WHITE, font: "Calibri" })],
heading: HeadingLevel.HEADING_1,
spacing: { before: 200, after: 100 },
shading: { type: ShadingType.SOLID, color: NAVY, fill: NAVY },
});
}
function heading2(text) {
return new Paragraph({
children: [new TextRun({ text, bold: true, size: 26, color: NAVY, font: "Calibri" })],
heading: HeadingLevel.HEADING_2,
spacing: { before: 160, after: 60 },
border: { bottom: { style: BorderStyle.SINGLE, size: 6, color: BLUE } },
});
}
function heading3(text) {
return new Paragraph({
children: [new TextRun({ text, bold: true, size: 22, color: BLUE, font: "Calibri" })],
heading: HeadingLevel.HEADING_3,
spacing: { before: 120, after: 40 },
});
}
// ─── HELPER: shaded box ────────────────────────────────────────────────────
function box(lines, bgColor = LBLUE, textColor = NAVY) {
return lines.map((line, i) => new Paragraph({
children: [new TextRun({ text: line, size: 20, color: textColor, font: "Calibri" })],
spacing: { before: i === 0 ? 60 : 20, after: i === lines.length - 1 ? 60 : 20 },
indent: { left: 180, right: 180 },
shading: { type: ShadingType.SOLID, color: bgColor, fill: bgColor },
}));
}
// ─── HELPER: answer reveal paragraph ─────────────────────────────────────
function answerBox(lines) {
const result = [];
result.push(new Paragraph({
children: [new TextRun({ text: "✔ MODEL ANSWER", bold: true, size: 20, color: GREEN, font: "Calibri" })],
spacing: { before: 80, after: 20 },
indent: { left: 180 },
shading: { type: ShadingType.SOLID, color: LGREEN, fill: LGREEN },
}));
for (const line of lines) {
result.push(new Paragraph({
children: [new TextRun({ text: line, size: 20, color: "333333", font: "Calibri" })],
spacing: { before: 20, after: 20 },
indent: { left: 200 },
shading: { type: ShadingType.SOLID, color: LGREEN, fill: LGREEN },
}));
}
return result;
}
// ─── HELPER: MCQ option ────────────────────────────────────────────────────
function mcqOption(letter, text, correct = false) {
return new Paragraph({
children: [
new TextRun({ text: ` ${letter}) `, bold: correct, size: 20, color: correct ? GREEN : "333333", font: "Calibri" }),
new TextRun({ text, bold: correct, size: 20, color: correct ? GREEN : "333333", font: "Calibri" }),
correct ? new TextRun({ text: " ◄ CORRECT", bold: true, size: 18, color: GREEN, font: "Calibri" }) : new TextRun({ text: "" }),
],
spacing: { before: 20, after: 20 },
indent: { left: 300 },
shading: correct ? { type: ShadingType.SOLID, color: LGREEN, fill: LGREEN } : undefined,
});
}
// ─── HELPER: MCQ explanation ──────────────────────────────────────────────
function mcqExplain(text) {
return new Paragraph({
children: [new TextRun({ text: `💡 ${text}`, size: 18, italics: true, color: "555555", font: "Calibri" })],
spacing: { before: 40, after: 60 },
indent: { left: 300 },
shading: { type: ShadingType.SOLID, color: LGREY, fill: LGREY },
});
}
// ─── HELPER: SAQ question block ───────────────────────────────────────────
function saqBlock(num, question, markScheme, marks) {
const items = [];
items.push(new Paragraph({
children: [
new TextRun({ text: `Q${num}. `, bold: true, size: 22, color: NAVY, font: "Calibri" }),
new TextRun({ text: question, size: 22, color: "111111", font: "Calibri" }),
new TextRun({ text: ` [${marks} marks]`, bold: true, size: 20, color: GOLD, font: "Calibri" }),
],
spacing: { before: 120, after: 40 },
}));
// Answer space lines
for (let i = 0; i < 5; i++) {
items.push(new Paragraph({
children: [new TextRun({ text: "_".repeat(100), size: 18, color: "AAAAAA", font: "Calibri" })],
spacing: { before: 10, after: 10 },
indent: { left: 200 },
}));
}
items.push(...answerBox(markScheme));
return items;
}
// ─── HELPER: MCQ question block ───────────────────────────────────────────
function mcqBlock(num, stem, options, correctIdx, explanation) {
const letters = ['A', 'B', 'C', 'D', 'E'];
const items = [];
items.push(new Paragraph({
children: [
new TextRun({ text: `Q${num}. `, bold: true, size: 22, color: NAVY, font: "Calibri" }),
new TextRun({ text: stem, size: 22, color: "111111", font: "Calibri" }),
],
spacing: { before: 120, after: 60 },
}));
options.forEach((opt, i) => {
items.push(mcqOption(letters[i], opt, i === correctIdx));
});
items.push(mcqExplain(explanation));
return items;
}
// ═══════════════════════════════════════════════════════════════════════════
// CONTENT DATA
// ═══════════════════════════════════════════════════════════════════════════
const sections_content = [];
// ─── TITLE PAGE ───────────────────────────────────────────────────────────
sections_content.push(
new Paragraph({ children: [], spacing: { before: 800 } }),
new Paragraph({
children: [new TextRun({ text: "SURGERY FOR MBBS", bold: true, size: 52, color: NAVY, font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 0, after: 80 },
}),
new Paragraph({
children: [new TextRun({ text: "Practice SAQs & MCQs", bold: true, size: 36, color: BLUE, font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 0, after: 40 },
}),
new Paragraph({
children: [new TextRun({ text: "10 Core Topics • Exam-Focused • Full Model Answers", italics: true, size: 24, color: "555555", font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 0, after: 200 },
}),
new Paragraph({
children: [new TextRun({ text: "─────────────────────────────────────────────", size: 22, color: BLUE, font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 0, after: 80 },
}),
...box([
"Topics Covered:",
"1. Fluids in Surgery 2. Resuscitation in Surgery",
"3. Sutures 4. Haemostasis in Surgery",
"5. Blood & Blood Transfusions 6. Nutrition in Surgery",
"7. Wound Healing 8. Surgical Infections",
"9. Pre/Post-operative Management 10. Instrumentation",
], LBLUE, NAVY),
new Paragraph({ children: [], spacing: { before: 200 } }),
new Paragraph({
children: [new TextRun({ text: "Compiled from: Schwartz's Principles of Surgery 11e | Sabiston | Bailey & Love", italics: true, size: 18, color: "777777", font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 80, after: 0 },
}),
new Paragraph({
children: [new TextRun({ text: "Orris Medical Education • May 2026", italics: true, size: 18, color: "777777", font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 20, after: 0 },
}),
new Paragraph({ children: [new TextRun({ text: "", break: 1 })], pageBreakBefore: true }),
);
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 1 — FLUIDS IN SURGERY
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(heading1("TOPIC 1: FLUIDS IN SURGERY"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(1,
"Describe the distribution of total body water (TBW) in a 70 kg adult male. Include all three compartments with approximate volumes.",
[
"TBW = 60% of body weight = ~42 L in a 70 kg male (1 mark)",
"Intracellular fluid (ICF): 2/3 of TBW = ~28 L (1 mark)",
"Extracellular fluid (ECF): 1/3 of TBW = ~14 L (1 mark)",
" • Interstitial fluid: ~10.5 L (75% of ECF)",
" • Plasma: ~3.5 L (25% of ECF) (1 mark)",
"Note: women = 50% TBW; obese = adjust down 10-20%; malnourished = adjust up 10% (1 mark)",
],
5
));
sections_content.push(...saqBlock(2,
"Compare crystalloids and colloids as resuscitation fluids. What is the clinical recommendation for most surgical resuscitation?",
[
"Crystalloids: water-based solutions with dissolved ions (1 mark)",
" • Distribute throughout ECF; ~25% remains intravascular",
" • Examples: Normal saline, Hartmann's (Ringer's Lactate), 5% Dextrose",
"Colloids: contain large molecules (albumin, dextrans, starches) confined to intravascular space (1 mark)",
" • More efficient transient plasma volume expansion",
" • Examples: 5% albumin, Hetastarch, Dextran 40/70, Gelofusine",
"Comparison: No mortality benefit of colloids over crystalloids (Cochrane review) (1 mark)",
" • Colloids: more expensive; Hetastarch associated with renal failure",
"Recommendation: Crystalloids (Hartmann's/Ringer's Lactate) are preferred for most surgical resuscitation (1 mark)",
" • 3 mL crystalloid needed to replace every 1 mL blood lost (1 mark)",
],
5
));
sections_content.push(...saqBlock(3,
"A patient presents after pyloric outlet obstruction with persistent vomiting. What electrolyte/acid-base disturbance do you expect and how is it treated?",
[
"Disturbance: Hypochloraemic, Hypokalaemic Metabolic Alkalosis (2 marks)",
"Mechanism: Loss of HCl via vomiting → depleted H+ and Cl− → metabolic alkalosis (1 mark)",
" • Kidney compensates by excreting K+ in exchange for H+ ('paradoxical aciduria') (1 mark)",
"Treatment: (1 mark)",
" • IV Normal Saline (0.9% NaCl) to correct Cl- deficit",
" • KCl supplementation to correct hypokalaemia",
" • Monitor U&E closely; correct before surgery",
" • Treat underlying cause (NG decompression, then definitive surgery)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(1,
"Which IV fluid is most appropriate as the default intraoperative fluid for a patient undergoing elective colonic resection?",
["0.9% Normal Saline", "5% Dextrose", "Hartmann's Solution (Ringer's Lactate)", "5% Albumin", "0.45% Saline"],
2,
"Hartmann's/Ringer's Lactate is the most physiologically balanced crystalloid. Normal saline can cause hyperchloraemic metabolic acidosis in large volumes. Dextrose provides no sodium and distributes freely, worsening hyponatraemia. Albumin is expensive and not superior."
));
sections_content.push(...mcqBlock(2,
"Total body water in a healthy 30-year-old female weighing 60 kg is approximately:",
["36 litres (60% of body weight)", "30 litres (50% of body weight)", "24 litres (40% of body weight)", "42 litres (70% of body weight)", "20 litres (33% of body weight)"],
1,
"TBW in adult females = 50% of body weight (less than males due to greater adipose tissue). 60 kg × 50% = 30 L. Adult males = 60% TBW."
));
sections_content.push(...mcqBlock(3,
"A post-operative patient has serum Na+ of 128 mEq/L, urine Na+ >20 mEq/L, and euvolaemia. The most likely diagnosis is:",
["Hypovolaemic hyponatraemia", "SIADH (Syndrome of Inappropriate ADH secretion)", "Pseudohyponatraemia", "Hypervolaemic hyponatraemia (heart failure)", "Addison's disease"],
1,
"SIADH presents with hyponatraemia + euvolaemia + concentrated urine (urine Na+ >20 mEq/L, urine osmolality >100 mOsm/kg) in the absence of volume depletion. Common post-operatively. Treatment: fluid restriction ± hypertonic saline for severe cases."
));
sections_content.push(...mcqBlock(4,
"The minimum acceptable urine output in an adult surgical patient as an indicator of adequate fluid resuscitation is:",
["0.1 mL/kg/hr", "0.2 mL/kg/hr", "0.5 mL/kg/hr", "1.0 mL/kg/hr", "2.0 mL/kg/hr"],
2,
"0.5 mL/kg/hr is the minimum adequate urine output, reflecting adequate renal perfusion. In a 70 kg adult this equals ~35 mL/hr. Values below this suggest under-resuscitation or developing acute kidney injury."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 2 — RESUSCITATION
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 2: RESUSCITATION IN SURGERY"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(4,
"Classify haemorrhagic shock into four classes according to ATLS. For each class, state the estimated blood loss, heart rate, blood pressure, and mental status.",
[
"Class I: Blood loss <750 mL (<15%); HR <100; BP normal; Mental status: normal (1 mark)",
"Class II: 750-1500 mL (15-30%); HR 100-120; BP normal (↑DBP); Anxious (1 mark)",
"Class III: 1500-2000 mL (30-40%); HR 120-140; BP decreased; Confused (1 mark)",
"Class IV: >2000 mL (>40%); HR >140; BP markedly ↓; Lethargic/unresponsive (1 mark)",
"Class I-II: fluid resuscitation; Class III-IV: blood transfusion required (1 mark)",
],
5
));
sections_content.push(...saqBlock(5,
"What is 'Damage Control Resuscitation' (DCR)? Describe the lethal triad and how DCR prevents it.",
[
"DCR: strategy to prevent/reverse the lethal triad in traumatic haemorrhage (1 mark)",
"The Lethal Triad: Hypothermia + Acidosis + Coagulopathy (1 mark)",
" • Each worsens the others → death spiral",
"DCR strategies: (3 marks - 1 each for 3 points)",
" 1. Permissive hypotension: target SBP 80-90 mmHg until surgical haemorrhage control (not in TBI)",
" 2. Haemostatic resuscitation: 1:1:1 ratio pRBC:FFP:Platelets; early cryoprecipitate",
" 3. Damage control surgery: abbreviated procedure → ICU stabilisation → definitive repair",
" 4. Tranexamic acid (TXA) within 3 hours (CRASH-2 trial)",
" 5. Prevent hypothermia (warm fluids, warm environment)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(5,
"A 25-year-old stab victim arrives with HR 130, BP 90/60, cold peripheries, and GCS of 13. He is estimated to have lost approximately what percentage of blood volume?",
["Less than 15%", "15-30%", "30-40%", "More than 40%", "Cannot be determined without haemoglobin"],
1,
"Class II shock = 15-30% blood loss (750-1500 mL). HR 100-120, systolic BP normal but diastolic may rise (narrowing pulse pressure), cool extremities, mildly anxious. Class III would show HR >120 and definite hypotension."
));
sections_content.push(...mcqBlock(6,
"The CRASH-2 trial demonstrated that tranexamic acid reduces mortality in traumatic haemorrhage when given:",
["Within 1 hour of injury only", "Within 3 hours of injury", "At any time after injury", "Only in penetrating trauma", "Only when given after blood products"],
1,
"CRASH-2 (2010): TXA significantly reduces mortality when given within 3 hours of injury. Giving TXA after 3 hours INCREASES mortality (possibly due to pro-thrombotic effects at this stage). TXA inhibits plasminogen binding to fibrin, preventing fibrinolysis."
));
sections_content.push(...mcqBlock(7,
"In septic shock, which vasopressor is recommended as the FIRST-LINE agent by Surviving Sepsis Campaign guidelines?",
["Dopamine", "Adrenaline (Epinephrine)", "Vasopressin", "Noradrenaline (Norepinephrine)", "Phenylephrine"],
3,
"Noradrenaline (norepinephrine) is the first-line vasopressor in septic shock. It primarily acts on alpha-1 receptors causing vasoconstriction, raising MAP. Dopamine is associated with more adverse events and is no longer first-line. Vasopressin may be added as a second agent."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 3 — SUTURES
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 3: SUTURES"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(6,
"Classify suture materials with TWO examples of each class. What are the advantages of monofilament over braided sutures?",
[
"Classification by absorbability: (2 marks)",
" • Absorbable: Plain catgut, Chromic catgut, Vicryl (polyglactin 910), PDS (polydioxanone), Monocryl",
" • Non-absorbable: Silk, Prolene (polypropylene), Nylon (Ethilon), Steel wire, Mersilene",
"Classification by origin: Natural (catgut, silk) vs Synthetic (Vicryl, Prolene) (1 mark)",
"Monofilament advantages over braided: (2 marks)",
" • Lower infection risk (no interstices to harbour bacteria)",
" • Less tissue drag/trauma on passage through tissue",
" • Better knot security against slipping",
" • Less tissue reaction",
"Disadvantage: harder to handle and tie; knot more likely to slip if not secured",
],
5
));
sections_content.push(...saqBlock(7,
"You are closing an abdominal fascia after a laparotomy, and then the skin. Choose the most appropriate suture for each layer, giving a reason.",
[
"Fascial closure: (2 marks)",
" • Best choice: PDS (polydioxanone) No. 1 or No. 0 — monofilament, slow absorbing (6 months)",
" • Maintains strength longest as fascia heals slowly",
" • Alternatively: Nylon (non-absorbable) or Prolene for permanent closure",
" • Technique: Mass closure (all layers including peritoneum) with continuous or loop suture",
" • 1 cm bites, 1 cm apart; suture:wound ratio ≥4:1",
"Skin closure: (2 marks)",
" • Best choice: Monocryl (poliglecaprone) 3-0 subcuticular — absorbable, no removal needed, good cosmesis",
" • OR: Nylon 3-0 interrupted for easy removal and inspection",
" • Staples: acceptable and fast, but less cosmetically ideal",
"General principle: suture should be at least as strong as the tissue being closed (1 mark)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(8,
"A Vicryl (polyglactin 910) suture is BEST described as:",
["Natural non-absorbable monofilament", "Synthetic absorbable braided", "Natural absorbable braided", "Synthetic non-absorbable monofilament", "Synthetic absorbable monofilament"],
1,
"Vicryl (polyglactin 910) is a SYNTHETIC ABSORBABLE BRAIDED suture. It is absorbed by hydrolysis over 56-70 days. Its braided nature makes it easy to handle and tie. The most widely used absorbable suture in surgery."
));
sections_content.push(...mcqBlock(9,
"Which suture material is MOST appropriate for a vascular anastomosis?",
["Chromic catgut 2-0", "Silk 3-0", "Prolene (polypropylene) 5-0 or 6-0", "Vicryl 2-0", "Steel wire 1-0"],
2,
"Prolene (polypropylene) monofilament is the gold standard for vascular anastomoses. It is non-absorbable (permanent), causes minimal tissue reaction, has high tensile strength, and the monofilament construction allows smooth passage through delicate vessel walls. Sizes 5-0 to 7-0 used depending on vessel size."
));
sections_content.push(...mcqBlock(10,
"What is the CORRECT term for a suture that extends beyond the original wound boundaries, does not regress spontaneously, and is more common in dark-skinned individuals?",
["Hypertrophic scar", "Keloid scar", "Contracture", "Sinus", "Dehiscence"],
1,
"A KELOID scar extends beyond the original wound boundaries (unlike hypertrophic scars which remain within). Keloids do NOT regress spontaneously. They are more common in dark-skinned individuals and have a genetic predisposition. Common sites: sternum, shoulders, earlobes, deltoid. Treatment: intralesional steroid, excision + radiotherapy."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 4 — HAEMOSTASIS
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 4: HAEMOSTASIS IN SURGERY"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(8,
"Outline the four phases of haemostasis in order, naming the key mediators and cells involved in each phase.",
[
"1. Vascular Constriction (seconds): smooth muscle contraction; mediators: Thromboxane A2 (TXA2), endothelin, serotonin, bradykinin (1 mark)",
"2. Primary Haemostasis / Platelet Plug (minutes): (1 mark)",
" • Adhesion: VWF bridges collagen to platelet GPIb receptor",
" • Activation: ADP, TXA2 → shape change, granule release",
" • Aggregation: fibrinogen bridges GPIIb/IIIa receptors",
"3. Secondary Haemostasis / Coagulation Cascade (minutes): (1 mark)",
" • Extrinsic: TF + VII → activated → Xa",
" • Intrinsic: XII → XI → IX + VIII → Xa",
" • Common: Xa + Va → thrombin → fibrinogen → fibrin (stabilised by XIII)",
"4. Fibrinolysis (hours-days): tPA converts plasminogen → plasmin → degrades fibrin (1 mark)",
"Vitamin K-dependent factors: II, VII, IX, X (and proteins C, S) — warfarin target (1 mark)",
],
5
));
sections_content.push(...saqBlock(9,
"A patient on warfarin requires emergency laparotomy within 2 hours. How would you rapidly reverse their anticoagulation? Include specific agents and doses.",
[
"Warfarin reversal options for emergency surgery: (5 marks)",
"1. 4-Factor Prothrombin Complex Concentrate (4-PCC e.g. Beriplex, Octaplex): FASTEST (1 mark)",
" • Dose: 25-50 units/kg IV (weight and INR-based dosing)",
" • Reverses INR within 15 minutes",
" • Preferred for emergency reversal",
"2. Fresh Frozen Plasma (FFP): (1 mark)",
" • Dose: 15 mL/kg",
" • Contains all clotting factors; slower onset; risk of volume overload and TRALI",
"3. Vitamin K (IV): (1 mark)",
" • Dose: 5-10 mg IV slowly",
" • Onset 4-12 hours — NOT sufficient alone for emergency reversal",
" • Give alongside PCC/FFP for sustained reversal",
"Target: INR <1.5 before surgery (1 mark)",
"Monitor: INR and clinical haemostasis; repeat PCC if INR still elevated (1 mark)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(11,
"Which coagulation test is most prolonged in a patient with Haemophilia A (Factor VIII deficiency)?",
["Prothrombin Time (PT/INR)", "Activated Partial Thromboplastin Time (aPTT)", "Thrombin Time (TT)", "Platelet count", "Bleeding time"],
1,
"Factor VIII is part of the INTRINSIC pathway (XII, XI, IX, VIII), which is measured by aPTT. PT/INR measures the EXTRINSIC pathway (Factor VII) and is NORMAL in haemophilia A. Bleeding time tests platelet function and vWF (normal in pure factor deficiency)."
));
sections_content.push(...mcqBlock(12,
"Aspirin impairs platelet function by irreversibly inhibiting which enzyme?",
["Thromboxane synthase", "Cyclooxygenase (COX)", "Phosphodiesterase", "Thrombin", "Protein C"],
1,
"Aspirin irreversibly acetylates and inhibits COX-1 (and COX-2). COX-1 is required to synthesise Thromboxane A2 (TXA2) from arachidonic acid. TXA2 is a potent promoter of platelet aggregation and vasoconstriction. Since platelets lack nuclei, they cannot regenerate COX → effect lasts the platelet lifespan (7-10 days)."
));
sections_content.push(...mcqBlock(13,
"The most appropriate reversal agent for unfractionated heparin-induced bleeding is:",
["Vitamin K", "Fresh Frozen Plasma", "Protamine sulphate", "Idarucizumab", "Andexanet alfa"],
2,
"Protamine sulphate is the specific reversal agent for heparin (both unfractionated and LMWH, though less complete for LMWH). Dose: 1 mg protamine per 100 units of heparin given in the last 2-3 hours. Given slowly IV to avoid hypotension/bradycardia. Idarucizumab reverses dabigatran; Andexanet alfa reverses Factor Xa inhibitors."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 5 — BLOOD & TRANSFUSIONS
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 5: BLOOD AND BLOOD TRANSFUSIONS"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(10,
"Describe Transfusion-Related Acute Lung Injury (TRALI). How does it differ from Transfusion-Associated Circulatory Overload (TACO)?",
[
"TRALI: (2.5 marks)",
" • Definition: New acute lung injury within 6 hours of transfusion",
" • Mechanism: Anti-HLA or anti-neutrophil antibodies in donor plasma activate recipient neutrophils → pulmonary capillary leak",
" • Features: bilateral pulmonary infiltrates, hypoxia (PaO2:FiO2 <300), fever, hypotension",
" • No evidence of volume overload (CVP normal or low)",
" • Management: STOP transfusion, O2, supportive; NO diuretics",
"TACO: (2 marks)",
" • Definition: Pulmonary oedema from fluid overload during/after transfusion",
" • Mechanism: excessive intravascular volume → raised hydrostatic pressure → pulmonary oedema",
" • Features: hypertension, raised CVP/JVP, bilateral infiltrates, raised BNP",
" • Management: STOP transfusion, sit upright, diuresis (frusemide)",
"Key distinction: (0.5 mark)",
" • TRALI: no overload signs, hypotension, LOW CVP; TACO: overload signs, hypertension, HIGH CVP/BNP",
],
5
));
sections_content.push(...saqBlock(11,
"What is a Massive Transfusion Protocol (MTP)? What is the recommended ratio of blood products and why?",
[
"MTP: pre-defined protocol activated when massive transfusion is anticipated (1 mark)",
" • Definition of massive transfusion: ≥10 units pRBC in 24h, or >4 units in 1 hour",
"Recommended ratio: 1:1:1 (pRBC:FFP:Platelets) — based on PROPPR trial (2 marks)",
" • Rationale: mimics whole blood composition",
" • Prevents dilutional coagulopathy from pRBC-only resuscitation",
" • FFP replaces clotting factors consumed/diluted",
" • Platelets prevent thrombocytopaenic haemorrhage",
"Additional components: (1 mark)",
" • Cryoprecipitate: if fibrinogen <1.5 g/L (provides fibrinogen, Factor VIII, vWF)",
" • Tranexamic acid: within 3 hours (antifibrinolytic)",
" • Calcium gluconate: citrate anticoagulant in stored blood chelates Ca2+",
" • Monitor: FBC, coag screen, fibrinogen, TEG/ROTEM, ionised Ca2+, blood gas, temperature (1 mark)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(14,
"A patient receives a blood transfusion and within minutes develops severe hypotension, bronchospasm, and urticaria. The transfusion is stopped. What is the most likely diagnosis and immediate management?",
["Febrile non-haemolytic reaction — give paracetamol and continue slowly", "Acute haemolytic reaction — IV fluids, diuresis, treat DIC", "Anaphylaxis — adrenaline 0.5 mg IM, IV fluids, steroids", "TRALI — oxygen therapy, supportive care, no diuretics", "TACO — sit upright, frusemide IV"],
2,
"Anaphylaxis presents with immediate onset bronchospasm, hypotension, and urticaria. Often due to IgA deficiency with anti-IgA antibodies in recipient reacting to donor IgA. Management: STOP transfusion, IM adrenaline 0.5 mg (anterolateral thigh), IV fluids, antihistamines, hydrocortisone, O2. NOT to be confused with acute haemolytic reaction (which has flank pain, haemoglobinuria, fever)."
));
sections_content.push(...mcqBlock(15,
"In the ABO blood group system, a patient with blood group O Rh-negative is called the 'universal donor' for red blood cells because they have:",
["Both anti-A and anti-B antibodies, no antigens", "Neither A nor B antigens on their red cells, no antibodies", "Only Rh antigens present", "All ABO antigens present", "No antigens and no antibodies of any type"],
0,
"Group O individuals have NO A or B antigens on their red blood cells, so their cells won't be attacked by any recipient's ABO antibodies. However, O individuals HAVE both anti-A and anti-B antibodies in their plasma — hence their plasma is NOT universal (AB plasma is). Rh-negative = no D antigen, so won't sensitise Rh-positive recipients."
));
sections_content.push(...mcqBlock(16,
"Which ONE blood product contains fibrinogen, Factor VIII, von Willebrand factor, and Factor XIII, and is used to treat hypofibrinogenaemia in DIC?",
["Fresh Frozen Plasma (FFP)", "Packed Red Blood Cells", "Cryoprecipitate", "Platelet concentrate", "Prothrombin Complex Concentrate (PCC)"],
2,
"Cryoprecipitate is prepared by thawing FFP at 4°C and collecting the precipitate. It is rich in FIBRINOGEN (main use), Factor VIII, vWF, and Factor XIII. Indications: fibrinogen <1.5 g/L (perioperative) or <1 g/L (medical), haemophilia A, vWD, DIC. FFP contains all factors but in lower concentrations; PCC contains II, VII, IX, X only."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 6 — NUTRITION
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 6: NUTRITION IN SURGERY"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(12,
"What is Refeeding Syndrome? Who is at risk and how is it prevented and managed?",
[
"Definition: A potentially fatal metabolic disorder when feeding (EN or PN) is re-introduced after prolonged starvation (1 mark)",
"Mechanism: shift from fat → carbohydrate metabolism → insulin release → intracellular uptake of phosphate, potassium, and magnesium → profound serum depletion (1 mark)",
"Cardinal feature: Hypophosphataemia — leads to heart failure, respiratory failure, haemolytic anaemia, rhabdomyolysis, seizures",
"At-risk patients: (1 mark)",
" • Anorexia nervosa, alcoholism, prolonged nil-by-mouth, cancer cachexia,",
" • Morbid obesity with rapid weight loss, chronic malabsorption",
"Prevention: (1 mark)",
" • Identify at-risk patients using NICE/ASPEN criteria",
" • Start feeds at 10-20 kcal/kg/day and increase slowly over 4-7 days ('start low, go slow')",
" • Supplement thiamine (Pabrinex) BEFORE feeding begins in high-risk",
"Management: (1 mark)",
" • Monitor electrolytes (phosphate, K+, Mg2+) daily",
" • Aggressively supplement phosphate IV (Phosphate-Sandoz, IV Addiphos)",
" • Replace K+ and Mg2+ as needed",
" • Reduce feed rate if electrolytes fall despite supplementation",
],
5
));
sections_content.push(...saqBlock(13,
"Compare enteral nutrition (EN) and total parenteral nutrition (TPN). Give THREE advantages of EN over TPN and the indications for TPN.",
[
"Enteral nutrition: delivered into GI tract (NG, NJ, PEG, PEJ, feeding jejunostomy)",
"TPN: delivered intravenously via central vein (PICC, subclavian, IJ)",
"THREE advantages of EN over TPN: (3 marks — 1 each)",
" 1. Maintains gut mucosal integrity → prevents bacterial translocation and systemic infection",
" 2. Cheaper with fewer serious complications",
" 3. Stimulates biliary secretion and gut motility; preserves gut-associated lymphoid tissue (GALT)",
" 4. (Bonus): maintains gut microbiome; avoids catheter-related bloodstream infection",
"Indications for TPN: (2 marks)",
" • GI tract non-functional or inaccessible for >5-7 days: short bowel syndrome, high-output fistula,",
" prolonged paralytic ileus, intestinal obstruction, severe acute pancreatitis (EN failed/intolerant),",
" intestinal failure (Crohn's, radiation enteritis)",
" • Principle: 'If the gut works, use it.' TPN only when EN not possible or sufficient",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(17,
"A patient who has been nil-by-mouth for 3 weeks following major surgery is commenced on TPN. On day 2, he develops confusion, muscle weakness, and his serum phosphate is 0.3 mmol/L. What is the most likely diagnosis?",
["Wernicke's encephalopathy", "Hypomagnesaemia", "Refeeding syndrome", "Hyperosmolar hyperglycaemic state", "Catheter-related sepsis"],
2,
"Refeeding syndrome: cardinal feature is severe HYPOPHOSPHATAEMIA on restarting feeds after prolonged starvation. Carbohydrate in TPN triggers insulin release → intracellular phosphate uptake → serum phosphate drops → muscle weakness, confusion, cardiac and respiratory failure. Phosphate must be monitored daily and aggressively replaced."
));
sections_content.push(...mcqBlock(18,
"According to current ESPEN guidelines, enteral feeding in the ICU should ideally be commenced:",
["Only after the patient is haemodynamically stable for 72 hours", "Within 24-48 hours of ICU admission", "After 5 days if the patient cannot eat voluntarily", "Only after a dietitian assessment", "Simultaneously with TPN"],
1,
"ESPEN and ASPEN guidelines recommend starting EN within 24-48 hours of ICU admission or major surgery in patients who cannot maintain adequate oral intake. Early EN preserves gut mucosal barrier, reduces infection rates, and improves outcomes. Haemodynamic stability (MAP >65 on low-dose vasopressors) is sufficient to commence EN."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 7 — WOUND HEALING
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 7: WOUND HEALING"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(14,
"Describe the four phases of wound healing in order, stating the key cells and events in each phase.",
[
"1. Haemostasis (0-4 hours): vasoconstriction, platelet plug, fibrin clot; platelets release PDGF, TGF-β as scaffold (1 mark)",
"2. Inflammatory Phase (Days 1-4): (1 mark)",
" • Neutrophils first (0-48h): phagocytosis of bacteria and debris",
" • Macrophages peak 48-72h: MOST IMPORTANT CELLS — debridement + release cytokines (IL-1, TNF, VEGF, TGF-β)",
"3. Proliferative Phase (Days 5-21): (1.5 marks)",
" • Fibroblasts: collagen synthesis (initially type III)",
" • Angiogenesis: new vessel formation (VEGF, FGF) → granulation tissue (red, granular)",
" • Re-epithelialisation: keratinocytes migrate from edges",
" • Wound contraction: myofibroblasts",
"4. Maturation/Remodelling (Day 21 - 2 years): (1 mark)",
" • Type III → Type I collagen (stronger, organised)",
" • Maximum wound strength = 80% of original (never 100%)",
" • Scar matures, pales, contracts",
"Tensile strength timeline: (0.5 mark)",
" • 1 week: 10%; 3 weeks: 20%; 6 weeks: 50-60%; 6 months: 70-80%",
],
5
));
sections_content.push(...saqBlock(15,
"List FIVE systemic factors that impair wound healing and explain the mechanism for TWO of them.",
[
"Five systemic factors: (2 marks — 0.5 each for 4 named, 1 mark for 5th or explanation)",
" 1. Malnutrition/protein deficiency",
" 2. Diabetes mellitus",
" 3. Corticosteroids/immunosuppressants",
" 4. Anaemia/ischaemia",
" 5. Jaundice, uraemia, old age, smoking, chemotherapy, vitamin deficiencies (Vit C, Vit A, Zinc)",
"Mechanism for TWO: (3 marks — 1.5 each)",
"Diabetes mellitus:",
" • Neuropathy: impaired pain → delayed presentation of infection",
" • Vasculopathy: reduced blood supply → ischaemia",
" • Impaired immune function: reduced neutrophil/macrophage function → increased infection risk",
" • Glycosylation of collagen: impairs cross-linking and tensile strength",
"Corticosteroids:",
" • Anti-inflammatory effect: suppresses all phases of healing (esp. inflammatory phase)",
" • Stabilise lysosomal membranes of macrophages → impaired debridement",
" • Vitamin A REVERSES steroid-impaired wound healing",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(19,
"Which cell type is considered the MOST important orchestrator of wound healing?",
["Neutrophil", "Platelet", "Macrophage", "Fibroblast", "Keratinocyte"],
2,
"MACROPHAGES are the most important cells in wound healing. They appear at 48-72 hours, perform debridement (phagocytosis of debris and bacteria), and release key growth factors (VEGF, TGF-β, PDGF, IL-1, TNF) that orchestrate the entire proliferative phase. Experiments in which macrophages were depleted resulted in severely impaired wound healing."
));
sections_content.push(...mcqBlock(20,
"A patient 8 days after abdominal surgery passes serosanguineous fluid from their wound. On examination, the skin sutures are intact but the fascia has separated with bowel visible. This is best described as:",
["Superficial wound dehiscence", "Wound infection (SSI)", "Evisceration/burst abdomen", "Incisional hernia", "Haematoma"],
2,
"Evisceration (burst abdomen): complete disruption of all wound layers including fascia, with bowel exposure. This is a SURGICAL EMERGENCY. Classic warning sign: serosanguineous discharge 5-8 days post-op. Management: immediately cover with sterile saline-soaked gauze, return to theatre for emergency fascial re-closure (mass closure with loop PDS). Risk factors: obesity, malnutrition, coughing, infection, steroid use."
));
sections_content.push(...mcqBlock(21,
"The maximum tensile strength a healed wound can achieve compared to uninjured skin is approximately:",
["50%", "65%", "80%", "95%", "100%"],
2,
"Wound healing can achieve a MAXIMUM of ~80% of the original tissue tensile strength, never 100%. This is because normal type I collagen is replaced in a less organised pattern. At 6 weeks: ~50-60%; at 6 months: ~70-80% (maximum). This is clinically important when re-operating on wounds and counselling patients about scar strength."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 8 — SURGICAL INFECTIONS
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 8: SURGICAL INFECTIONS"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(16,
"Classify surgical wounds by contamination level. For each class, state the expected surgical site infection (SSI) rate and give ONE example.",
[
"Class I — Clean: No inflammation; respiratory/GI/GU tract not entered; SSI rate 1-2% (1 mark)",
" Example: Thyroidectomy, mastectomy, inguinal hernia repair",
"Class II — Clean-contaminated: Controlled entry into respiratory/GI/GU tract, no spillage; SSI rate 5-15% (1 mark)",
" Example: Elective cholecystectomy, elective colonic resection",
"Class III — Contaminated: Open traumatic wound, major GI spillage, breach in technique; SSI rate 15-30% (1 mark)",
" Example: Perforated appendix, colostomy take-down with contamination",
"Class IV — Dirty/Infected: Pre-existing infection, faecal contamination, perforated viscus; SSI rate >30% (1 mark)",
" Example: Faecal peritonitis, drainage of abdominal abscess, necrotising fasciitis debridement",
"SSI prevention: antibiotic prophylaxis within 60 min pre-incision; maintain normothermia and normoglycaemia (1 mark)",
],
5
));
sections_content.push(...saqBlock(17,
"A 55-year-old diabetic presents with severe right leg pain, erythema rapidly spreading to the thigh, crepitus on palpation, and systemic toxicity. What is the diagnosis, and describe the immediate management.",
[
"Diagnosis: Necrotising Fasciitis (Type I — polymicrobial, given diabetic status) (1 mark)",
"Immediate management — this is a SURGICAL EMERGENCY: (4 marks)",
"1. Resuscitation: IV access, fluid resuscitation, blood cultures, ABG, FBC, coag, lactate",
"2. Broad-spectrum IV antibiotics IMMEDIATELY: (1 mark)",
" • Piperacillin-tazobactam (Tazocin) PLUS Clindamycin (inhibits toxin production) ± Vancomycin (for MRSA)",
"3. Emergency surgical debridement: (1 mark)",
" • URGENT radical excision of ALL necrotic tissue (skin, fascia, muscle if involved)",
" • 'Cut until you reach bleeding tissue'",
" • Wound left open; relook in 24-48 hours for further debridement",
"4. ICU admission for multi-organ support (1 mark)",
"5. Investigations: CT scan if diagnosis unclear (gas in soft tissues = pathognomonic) (1 mark)",
" • LRINEC score (Lab Risk Indicator for NF) to aid diagnosis",
"Mortality: 20-40% even with prompt treatment; delay in surgery significantly worsens outcome",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(22,
"Surgical antibiotic prophylaxis should be administered:",
["24 hours before surgery", "Within 60 minutes before skin incision", "At induction of anaesthesia only if the wound becomes contaminated", "At the end of surgery before wound closure", "For 5 days post-operatively in all cases"],
1,
"Antibiotic prophylaxis should be given within 60 minutes before surgical incision (120 minutes for vancomycin/fluoroquinolones due to longer infusion time). This ensures adequate tissue levels at time of contamination. Prophylaxis should be discontinued within 24 hours post-operatively — longer courses do not prevent SSI and increase resistance."
));
sections_content.push(...mcqBlock(23,
"The classic teaching for management of any surgical abscess is best summarised by which Latin phrase?",
["Primum non nocere", "Ubi pus, ibi evacua", "In vino veritas", "Ex cathedra", "Cura te ipsum"],
1,
"'Ubi pus, ibi evacua' = 'Where there is pus, evacuate it.' This fundamental surgical principle dictates that any collection of pus requires drainage — antibiotics alone are insufficient. Options include incision and drainage (I&D), image-guided (CT/US) percutaneous drainage, or surgical drainage, depending on location and accessibility."
));
sections_content.push(...mcqBlock(24,
"Clostridium tetani causes tetanus by producing a toxin that acts by:",
["Activating acetylcholine receptors at the neuromuscular junction", "Blocking inhibitory neurotransmitters (glycine and GABA) in the spinal cord", "Releasing histamine from mast cells", "Directly lysing red blood cells", "Inhibiting protein synthesis in muscle cells"],
1,
"Tetanospasmin (tetanus toxin) is transported retrogradely along motor neurons to the spinal cord where it BLOCKS release of inhibitory neurotransmitters glycine and GABA. This results in unopposed motor neuron firing → sustained muscle spasm. Clinical features: trismus (lockjaw), risus sardonicus, opisthotonos. Treatment: HTIG + wound debridement + metronidazole + diazepam."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 9 — PRE/POST-OPERATIVE MANAGEMENT
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 9: PRE- AND POST-OPERATIVE MANAGEMENT"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(18,
"List the ASA physical status classification with one example for each grade (ASA I-V).",
[
"ASA I: Healthy patient, no systemic disease — Example: fit 25-year-old for appendicectomy (1 mark)",
"ASA II: Mild systemic disease, no functional limitation — Example: controlled hypertension, non-obese smoker, BMI 30-40, well-controlled DM (1 mark)",
"ASA III: Severe systemic disease, functional limitation — Example: COPD, poorly controlled DM, dialysis-dependent CKD, morbid obesity, active hepatitis, history of MI >3 months ago (1 mark)",
"ASA IV: Severe systemic disease, constant threat to life — Example: recent MI/stroke/TIA <3 months, severe aortic stenosis, decompensated heart failure (1 mark)",
"ASA V: Moribund, not expected to survive without surgery — Example: ruptured AAA, massive pulmonary embolism, intracranial haemorrhage with raised ICP (1 mark)",
"ASA VI: Brain-dead patient for organ donation",
"Note: 'E' suffix added for emergency surgery (e.g., ASA IIE)",
],
5
));
sections_content.push(...saqBlock(19,
"Describe the '5 Ws' of post-operative fever, including the typical time frame for each.",
[
"Post-operative fever = temperature >38°C after surgery. Mnemonic: Wind, Water, Wound, Walk, Wonder drugs (1 mark)",
"1. WIND (Day 1-2): Pulmonary — atelectasis (most common cause of early post-op fever), pneumonia (1 mark)",
" • Mechanism: splinting due to pain, inadequate respiratory effort → alveolar collapse",
" • Management: physiotherapy, deep breathing, incentive spirometry, analgesia",
"2. WATER (Day 3-5): Urinary tract infection — especially with urinary catheter in situ (1 mark)",
" • Management: urine culture, appropriate antibiotics, remove catheter if no longer needed",
"3. WOUND (Day 5-7): Surgical site infection — superficial or deep (1 mark)",
" • Check wound for erythema, swelling, discharge, dehiscence",
" • Management: wound swab, antibiotics, open/drain if collection present",
"4. WALK (Day 7-10): Deep vein thrombosis / thrombophlebitis (1 mark)",
" • Investigation: Doppler USS legs, D-dimer",
" • Management: therapeutic LMWH, mobilise early",
"5. WONDER DRUGS (Any time): Drug fever — antibiotic reaction, blood product reaction",
" • Review drug chart; stop offending agent",
" • Also consider anastomotic leak, intra-abdominal abscess (any time >Day 5)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(25,
"According to current guidelines (AAGBI 'rule of 2-4-6'), how long before elective general anaesthesia should an adult patient stop consuming CLEAR FLUIDS?",
["6 hours", "4 hours", "2 hours", "8 hours", "12 hours"],
2,
"The '2-4-6 rule' for pre-operative fasting: CLEAR FLUIDS (water, black tea, apple juice) = 2 hours; BREAST MILK = 4 hours; SOLIDS/formula/non-human milk = 6 hours. Prolonged fasting is harmful (insulin resistance, dehydration). ERAS protocols encourage carbohydrate-rich drinks (Preload, Nutricia) up to 2 hours before surgery."
));
sections_content.push(...mcqBlock(26,
"A patient on warfarin for atrial fibrillation (no prior stroke, CHADS2 score 1) requires elective hip arthroplasty. The MOST appropriate peri-operative anticoagulation strategy is:",
["Continue warfarin throughout without interruption", "Stop warfarin 5 days before surgery; no bridging anticoagulation required", "Stop warfarin 5 days before; bridge with therapeutic LMWH", "Switch to aspirin 5 days before surgery", "Stop warfarin 24 hours before surgery"],
1,
"LOW thrombotic risk AF (CHADS2 ≤1, no prior stroke/TIA): Stop warfarin 5 days pre-op; NO bridging anticoagulation needed. The thromboembolic risk during the 5-day bridge period is low and does not justify the bleeding risk of LMWH bridging. HIGH risk (mechanical mitral valve, CHADS2 ≥5, recent stroke, recent DVT): bridging WITH therapeutic LMWH is indicated."
));
sections_content.push(...mcqBlock(27,
"A diabetic patient on metformin is scheduled for elective laparoscopic cholecystectomy. Regarding metformin, the CORRECT perioperative management is:",
["Continue metformin on the day of surgery as usual", "Stop metformin 48 hours before surgery and restart when eating/drinking normally", "Replace metformin with insulin infusion 1 week before surgery", "Stop metformin only if the patient will receive IV contrast", "Metformin has no perioperative implications"],
1,
"Metformin should be STOPPED on the day of surgery (some centres stop 24-48h before). Risks include: lactic acidosis if renal function deteriorates peri-operatively (metformin is renally cleared), and hypoglycaemia when fasting. It should be RESTARTED only when the patient is eating and drinking normally and renal function is stable (usually 48h post-op)."
));
// ═══════════════════════════════════════════════════════════════════════════
// TOPIC 10 — INSTRUMENTATION
// ═══════════════════════════════════════════════════════════════════════════
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("TOPIC 10: SURGICAL INSTRUMENTATION"));
sections_content.push(heading2("Short Answer Questions (SAQs)"));
sections_content.push(...saqBlock(20,
"Classify the methods of sterilisation used for surgical instruments. For each method, give the temperature/agent used and name ONE instrument category for which it is appropriate.",
[
"1. Autoclaving (Steam under pressure) — GOLD STANDARD: 134°C, 3 bar, 3-3.5 min (1 mark)",
" • Use: most heat-stable metal instruments, drapes, gowns",
"2. Dry heat (Hot air oven): 160°C for 60 min or 180°C for 30 min (1 mark)",
" • Use: glassware, oils, powders, syringes (non-plastic)",
"3. Ethylene oxide (EtO) gas: ~55°C for 1-6 hours + aeration period (1 mark)",
" • Use: heat-sensitive plastics, rubber, delicate optical instruments, laparoscopic equipment",
"4. Hydrogen peroxide plasma (Low-temperature): 45-50°C, 28-75 min (0.5 mark)",
" • Use: heat- and moisture-sensitive instruments (some endoscopes, electronic equipment)",
"5. Glutaraldehyde (Cidex): room temperature; 3 hours for sterilisation, 20-30 min HLD (0.5 mark)",
" • Use: flexible endoscopes (GI scopes, bronchoscopes)",
"6. Gamma irradiation: room temperature (0.5 mark)",
" • Use: single-use items (syringes, drapes, sutures) — mass sterilisation",
"Key distinction: (0.5 mark)",
" • PRIONS (CJD): require 134°C for 18 min or NaOH soaking + autoclave — NOT killed by standard autoclave",
],
5
));
sections_content.push(...saqBlock(21,
"Name and describe THREE types of retractors used in open abdominal surgery, distinguishing between hand-held and self-retaining types.",
[
"Hand-held retractors (require assistant to hold): (2 marks)",
"1. Langenbeck retractor: right-angle flat blade; used for skin and superficial retraction in neck/abdominal procedures",
"2. Deaver retractor: large curved blade; excellent deep abdominal retraction — ideal for hepatic, bile duct, and pelvic surgery",
"3. Morris retractor: broad, flat curve; general abdominal wall retraction",
"Self-retaining retractors (hold themselves in place): (2 marks)",
"4. Balfour retractor: three-bladed abdominal retractor; most common self-retaining for open laparotomy",
"5. Bookwalter retractor: large modular ring-mounted system; used for complex abdominal/pelvic surgery",
"6. Joll's thyroid retractor: self-retaining; specifically designed for thyroid/parathyroid surgery",
"7. Finochetto rib spreader: self-retaining; for thoracotomy — separates ribs",
"Advantage of self-retaining: frees assistant's hands for other tasks; maintains consistent exposure (1 mark)",
],
5
));
sections_content.push(heading2("Multiple Choice Questions (MCQs)"));
sections_content.push(...mcqBlock(28,
"During laparoscopy, carbon dioxide (CO2) is used rather than air for pneumoperitoneum because:",
["CO2 is cheaper and more readily available", "CO2 is non-combustible and rapidly absorbed, reducing the risk of gas embolism", "CO2 provides better visualisation than air", "Air causes peritoneal irritation", "CO2 causes less shoulder-tip pain than air"],
1,
"CO2 is used because it is: (1) rapidly absorbed by tissues (reducing risk of long-term gas embolism), (2) non-combustible (unlike air/oxygen — important when using diathermy), and (3) highly soluble in blood. The RISK is CO2 embolism (absorbed in large amounts), not air embolism. CO2 DOES cause shoulder-tip pain from diaphragmatic irritation (phrenic nerve referred pain)."
));
sections_content.push(...mcqBlock(29,
"The Veress needle is used in laparoscopy for which purpose?",
["Delivering IV fluids during the procedure", "Creating pneumoperitoneum by blind needle puncture", "Aspirating intra-abdominal fluid for cytology", "Specimen retrieval at end of surgery", "Creating the first port under direct vision"],
1,
"The Veress needle is a spring-loaded, blunt-tipped needle used to create pneumoperitoneum by BLIND puncture through the umbilical port site before any trocars are inserted. The spring-loaded mechanism protects underlying bowel. The Hasson (open) technique is the SAFER alternative — direct cut-down to peritoneum under vision. Both methods establish CO2 pneumoperitoneum before trocar/cannula insertion."
));
sections_content.push(...mcqBlock(30,
"Which instrument is MOST appropriate for grasping the appendix or fallopian tube atraumatically during surgery?",
["Allis clamp", "Kocher forceps", "Babcock forceps", "Lahey forceps", "Artery forceps (Spencer Wells)"],
2,
"BABCOCK FORCEPS have broad, rounded, non-toothed ring tips that encircle the structure without crushing — making them ideal for delicate hollow viscus (appendix, bowel, fallopian tube). Allis clamps have teeth and are more traumatic. Kocher forceps have a toothed tip for firm grasping (skin, dense fascia). Lahey (right-angle) forceps are used for vessel dissection and tie placement."
));
// ─── FINAL SUMMARY PAGE ──────────────────────────────────────────────────
sections_content.push(new Paragraph({ children: [], pageBreakBefore: true }));
sections_content.push(heading1("QUICK-FIRE EXAM SUMMARY: KEY FACTS"));
sections_content.push(...box([
"TOPIC 1 — FLUIDS: TBW = 60% BW (male), 50% (female). ICF = 40% BW. Urine output ≥ 0.5 mL/kg/hr. Prefer Hartmann's for surgery.",
"TOPIC 2 — RESUSCITATION: Class IV shock = >40% blood loss. DCR = permissive hypotension + 1:1:1 products. TXA within 3 hours.",
"TOPIC 3 — SUTURES: PDS for fascia (absorbs 180 days). Prolene for vessels. Vicryl = synthetic absorbable braided. Monofilament = lower infection risk.",
"TOPIC 4 — HAEMOSTASIS: aPTT = intrinsic (haemophilia, heparin). PT = extrinsic (warfarin, liver). Protamine reverses heparin. TXA blocks fibrinolysis.",
"TOPIC 5 — TRANSFUSION: 1 unit pRBC = +1 g/dL Hb. TRALI = no diuretics. TACO = diuretics. ABO incompatibility = most dangerous. Universal donor RBC = O Rh-negative.",
"TOPIC 6 — NUTRITION: 25-30 kcal/kg/day. Refeeding = hypophosphataemia. Start EN within 24-48h ICU. TPN = central line required. 'If gut works, use it.'",
"TOPIC 7 — WOUND HEALING: Macrophages = most important cell. Max strength = 80%. Keloid extends BEYOND wound. Steroids → impaired healing → reversed by Vitamin A.",
"TOPIC 8 — INFECTIONS: Necrotising fasciitis = emergency debridement. 'Ubi pus, ibi evacua.' Antibiotics within 60 min pre-incision. Tetanus = blocks GABA/glycine.",
"TOPIC 9 — PERIOPERATIVE: ASA classification (I-VI). 2-4-6 fasting rule. 5 Ws of post-op fever. Stop metformin day of surgery. VTE prophylaxis for all major surgery.",
"TOPIC 10 — INSTRUMENTATION: Autoclave = 134°C, 3 bar, 3 min. Prions = 134°C for 18 min. Babcock = atraumatic bowel grasping. CO2 pneumoperitoneum = 12-15 mmHg.",
], LBLUE, NAVY));
sections_content.push(new Paragraph({ children: [], spacing: { before: 400 } }));
sections_content.push(new Paragraph({
children: [new TextRun({ text: "Total: 21 SAQs | 30 MCQs | 10 Core Surgery Topics", bold: true, size: 22, color: NAVY, font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 0, after: 20 },
}));
sections_content.push(new Paragraph({
children: [new TextRun({ text: "Sources: Schwartz's Principles of Surgery 11e | Sabiston Textbook of Surgery | Bailey & Love 28e", italics: true, size: 18, color: "666666", font: "Calibri" })],
alignment: AlignmentType.CENTER, spacing: { before: 0, after: 0 },
}));
// ═══════════════════════════════════════════════════════════════════════════
// BUILD DOCUMENT
// ═══════════════════════════════════════════════════════════════════════════
const doc = new Document({
creator: "Orris Medical Education",
title: "Surgery MBBS - SAQs and MCQs",
description: "Practice questions for 10 core surgery topics",
styles: {
default: {
document: {
run: { font: "Calibri", size: 22 },
},
},
},
sections: [{
properties: {
page: {
margin: { top: 720, right: 720, bottom: 720, left: 720 },
},
},
headers: {
default: new Header({
children: [
new Paragraph({
children: [
new TextRun({ text: "SURGERY FOR MBBS | Practice SAQs & MCQs", size: 18, color: "666666", font: "Calibri" }),
new TextRun({ children: [new PageNumber()] }),
],
alignment: AlignmentType.CENTER,
border: { bottom: { style: BorderStyle.SINGLE, size: 4, color: BLUE } },
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}),
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children: sections_content,
}],
});
Packer.toBuffer(doc).then(buffer => {
fs.writeFileSync("/home/daytona/workspace/surgery-notes/Surgery_MBBS_SAQs_MCQs.docx", buffer);
console.log("SUCCESS: Surgery_MBBS_SAQs_MCQs.docx created");
});
Running Command
cd /home/daytona/workspace/surgery-notes && node generate_questions.js 2>&1
Editing File
~/surgery-notes/generate_questions.js
Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/surgery-notes/generate_questions.js'
Running Command
cd /home/daytona/workspace/surgery-notes && node generate_questions.js 2>&1
Running Command
python3 /home/daytona/skills/docx/scripts/office/validate.py /home/daytona/works…
Running Command
python3 -c " import zipfile, os f = '/home/daytona/workspace/surgery-notes/Surge…
The file is valid. Here's your Word document:
Surgery MBBS SAQs MCQs
Word Document · DOCX
Here's what's inside the document:
Structure: 10 topic sections, each with SAQs followed by MCQs. Every question has a full model answer built in.
Contents breakdown:
| Topic | SAQs | MCQs |
|---|---|---|
| Fluids in Surgery | 3 | 4 |
| Resuscitation | 2 | 3 |
| Sutures | 2 | 3 |
| Haemostasis | 2 | 3 |
| Blood & Transfusions | 2 | 3 |
| Nutrition | 2 | 2 |
| Wound Healing | 2 | 3 |
| Surgical Infections | 2 | 3 |
| Pre/Post-operative Management | 2 | 3 |
| Instrumentation | 2 | 3 |
| Total | 21 SAQs | 30 MCQs |
SAQ format: Question + marks allocation + 5 blank writing lines + full mark scheme with point-by-point allocation.
MCQ format: 5-option stem + correct answer highlighted in green with a "◄ CORRECT" marker + explanation paragraph explaining why each distractor is wrong.
Final page: A 10-point quick-fire summary of the single most important exam fact per topic.
Create a comprehensive, well detailed note for an MBBS student, for deep learning and passing of exams on these surgery topics: Fluids in Surgery Resuscitation in surgery Sutures Haemostasis in surgery Blood and blood transfusions
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