What does the American Animal Hospital Association (AAHA) recommend concerning the layout of a surgical facility?
AAHA recommends three distinct and separate areas for a surgical facility - the preparation area, the scrub area, and the surgery room.
What are the AAHA recommendations concerning the preparation area?
The preparation area is used for patient preparation, storage of surgical supplies, clipping the patient, and "dirty" procedures such as abscessed wound care and treatment of impacted anal sacs.
What are the AAHA recommendations concerning the scrub area?
The scrub area is a transitional area where the veterinarian and technician can prepare to move into the surgery room. It is a small area with a scrub sink, autoclave and room to gown and glove.
What are the AAHA recommendations concerning the surgery room?
The surgery room should be a dedicated room reserved for clean surgical procedures, and not used for other types of procedures that may introduce bacteria into the room. It should be easily cleanable and be able to be closed off as needed. If possible, the air pressure should be greater in the surgery room to reduce the influx of bacteria from the rest of the veterinary facility.
How and when should permanent equipment be cleaned?
These items should be wiped down daily before surgery with a cloth dampened with isopropyl alcohol or some other disinfectant.
How and when should movable equipment be cleaned?
If removed from the surgery room, removable equipment must be cleaned and disinfected thoroughly before being returned to the surgery room.
What are some examples of patient warming devices?
circulating warm water blankets, heating pads, Bair Hugger, rice sock
What is the purpose of using patient warming devices?
to reduce hypothermia which can occur during surgery
What is the advantage of using a split top surgical table?
The split top table has the double advantage of a tray under the space in the table to collect any fluid that may run off the surgical field and the ability to be adjusted to help maintain the patient in dorsal recumbency.
What is a necessary feature of a surgical table?
Surgical tables should have the capability to be raised and lowered and to tilt in one direction.
What is a disadvantage of a solid top surgical table?
fluids may pool on the tabletop and can soil the patient
What is the purpose of the electrocautery tool?
to use electricity via a special hand piece to cut or coagulate vessels
What is necessary when performing monopolar electrosurgery?
a ground plate must be placed under the patient
Why is alcohol never used to saturate the sponge that is placed between the ground plate and the patient?
alcohol may combust and lead to patient burns or fire
Why is a ground plate not necessary for bipolar electrosurgery?
bipolar electrosurgery utilizes a hand piece that looks like thumb tissue forceps; as the hand piece is activated electric current passes from one tip to the other
Suction can be defined as the abiity to remove fluid or air from an area by using either a manual or a mechanical device.
What may be used to apply suction?
a syringe, a bulb syringe, or a mechanical pump
For application in surgery, a mechanical pup is most frequently used.
What are some risks associated with suction?
Inappropriately low vacuum settings will not adequately suction the field and inappropriately high vacuum settings may damage tissue.
What type of instrument pack will suffice for most surgical procedures?
a general soft tissue pack
What is the purpose of setting up the surgical suite in advance?
to minimize the traffic in and out of the surgery room for reasons of maintaining sterility and time management
What is a good rule to follow when scheduling surgical procedures?
schedule cases from cleanest to dirtiest, taking into consideration the difficulty and anticipated length of the procedure
What factors should be taken into consideration when scheduling surgical procedures?
patient status, difficulty, length of procedure, contamination risk, equipment needs and turnover
What benefit does the placement of an IV catheter offer the patient?
easier to recieve multiple IV medications
What length of time are peripheral catheters appropriate for?
short term use 1-3 days
When should a central line jugular catheter be placed?
for long term use greater then 3 days, extended fluid therapy, or systemic monitoring
Where are peripheral catheters most often placed in the canine patient?
cephalic and lateral saphenous veins
What sites are most often used to place a peripheral catheter in the feline patient?
cephalic, medial saphenous, and femoral vein
What supplies are required for the placement of an IV catheter?
IV fluid bag, cotton balls and scrub product, IV fluid administration set, IV catheters, gauze squares, tape, and clippers
What are the three most common types of IV catheters?
over the needle, through the needle, and the butterfly catheter
When and where is the over the needle type of catheter used?
short term and surgical catheters, usually placed in a peripheral vein
When and where is the butterfly catheter most useful?
when vascular access is required for medications that need to be administered once (as in outpatient treatments) and slowly (ie over 1-3 minutes)
butterfly catheters are not intended to remain in a patient that is not being directly monitored
When and where is the through the needle catheter type most used?
through the needle catheters are often placed in the jugular veins of animals that will need intensive nursing care postoperatively
What five factors influence the choice of catheter size?
site of placement, length of time the catheter will be needed, reason for placement, diameter of the vessel, and the length of the vessel working area
When may an injection cap be placed?
injection caps may be placed on the catheter if occasional injections or blood sample collections are anticipated
What purpose do t-ports/t-sets serve?
they serve the same purpose as an injection cap and also allow easier access to the catheter
When is a fluid administration set used?
if continuous infusion of fluids or iv medications is anticipated and the set can be connected to the t-port
Why may an extension set be used?
may be used in conjunction with an administration set to allow for better animal mobility in the cage postoperatively
How long should the pieces of tape used to secure the catheter be?
long enough to encircle the patient's neck or limb - three pieces of 1 inch and 1/2 inch tape are used in varying order
How are clippers used to prep the IV catheter site?
#40 blade used to remove the hair with a margin of 1 1/2 - 2 inches on all sides of the proposed puncture site
When and why is flush or heprinized saline needed during the IV catheterization process?
either continuous infusion or regular flushing of the catheter is needed to maintain patency of the catheter once placed
When are bandage materials needed during the IV catheterization placement process?
bandage materials - antibiotic ointment, elastic gauze and elastic tape - are needed if the catheter is to remain in place after the surgical procedure is completed
What is the maximum length of time a peripheral IV catheter should remain in place?
What is the purpose of central venous pressure (CVP) monitoring?
CVP monitoring is done to assess how well blood is returning to the heart as well as how effectively blood is pumped from the heart
What are the two main purposes of endotracheal intubation?
to administer oxygen and inhalation anesthesia, and to assist with resuscitative needs
What is the purpose of the cuff on the endotracheal tube?
preventing the patient from inhaling room air, exhaling anesthetic gas into the operating room, and aspirating any vomitus while intubate
What purpose does the Murphy eye serve on the ET tube?
it allows airflow in the event that the end of the tube becomes occiluded with respiratory secretions
How is the properly sized ET tube selected?
tube size is based on weight aided by palpation of the trachea and expirence
in addition to the size thought to be needed, a tube 0.5 MM smaller and 0.5 MM larger should also be chosen and set aside
What supplies are needed for endotracheal intubation?
endotracheal tube, rolled gauze to secure the tube, sterile lubricant, cuff syringe, lyringoscope/light source, oral speculum
What is a laryngospasm?
if excessively stimulated the muscles of the larynx spasm and the vocal folds clamp shut - happens most often in cats and rabbits
Where should the tip of a properly placed ET tube be?
halfway between the larynx and the thoracic inlet
How may proper ET tube placement be confirmed?
coughing, fogging in the tube, air movement at the connector end of the tube, palpation
What steps should the patient preparation process include?
patient should be bathed if extremely dirty, double and triple check patient identity and procedure, ensure that anesthesia form has been started
What is the purpose of the anesthesia form?
the anesthesia form documents vital signs and their trends intraoperatively
When does the hair removal portion of the patient preparation process take place?
after the patient has been stabilized under anesthesia
What is the general rule for the amount of hair to be removed for soft tissue surgery?
remove 2 clipper blade widths in every direction from the proposed incision site
What is the general rule for clipping during orthopedic preps?
clip the limb from the joint distal to and the joint proximal to the surgical incision, circumferentally to allow for complete draping and manipulation
What is the general rule for clipping neurologic surgical patients?
clip two vertebral spaces cranial and two spaces caudal to the affected site
What advantages does povidone-iodine offer as a surgical scrub?
it is bacteriacidal, fungistatic, and fungicidal, with low toxicity to tissues and is inexpensive and readily available
What disadvantages does povidine-iodine have as a surgical scrub?
it stains clothing and white hair
How is povidone-iodine usually diluted for use as a surgical scrub?
50 : 50 with tap water
What are the advantages of chlorhexidine gluconate for use as a surgical scrub?
residual effect is best of any available product, works well in the presence of organic material, bacteriacidal, viricidal, and fungicidal, low tissue toxicity, non staining
What is the disadvantage of chlorhexidine gluconate for use as a surgical scrub?
How is chlorhexidine gluconate diluted for use as a surgical scrub?
60 : 40 with tap water
When is alcohol contraindicated for use as a rinsing agent?
on open wounds and mucous membranes
What is the advantage of isopropal alcohol as a rinsing agent?
inexpensive, readily available, well tolerated by patients, enhances the residual effect of chlorhexidine
What is the disadvantage of alcohol's rapid evaporation?
the extreme cooling effect can contribute to hypothermia
What are two products used as surgical scrubs?
providone iodine, chlorhexidine gluconate
What are three products used as rinsing agents?
alcohol, sterile water, sterile saline
When is sterile water or sterile saline used as a rinsing agent?
for prepping of open wounds, compound fractures, or mucous membranes
What special consideration must be taken when prepping male dogs for abdominal surgery?
the prepuce must be flushed
What three scrubbing patterns may be used during patient preparation?
target pattern, orthopedic pattern, perianal pattern
When is the target pattern used for surgical scrubbing?
abdominal, thoracic, and neurologic procedures
How is the target pattern of surgical scrubbing performed?
the scrub is applied in a circular pattern starting at the proposed incision site and moving progressively outward until the hair is reached
How is the orthapedic pattern of surgical scrubbing performed?
after suspending the limb, the limb is scrubbed circumferentally around the limb from distal to proximal
How is the limb suspended when preparing a patient for orthopedic surgery?
an inverted examination glove is placed over the foot and secured with tape, then the rest of the gloved foot is covered with tape and a stirrup (also made of tape) for suspending the limb is attached to the wrapped limb
How is the perianal pattern of surgical scrubbing performed?
a purse string suture is placed in the anus, then three target patterns are performed - one to the left of the anus, one to the right of the anus, and one on the anus itself - the anus is scrubbed last
How many times must the process of scrub and rinse be performed?
a minimum of three times, but the gauze used for the last rinse must come away clean
What are two potential reactions to the surgical scrub process?
clipper related reactions and chemical related reactions
Where and when is the final sterile scrub performed?
in the surgical suite after the patient has been positioned appropriately on the surgical table
Why must the patient be properly secured to the surgical table?
to aid in aseptic preparation of the surgical site and ensures that the surgeon has an immobile subject with adequate room for working
How should the patient be positioned for abdominal surgery?
the patient is placed in dorsal recumbancy and secured by all four legs to the table
How is the canine patient positioned for castration?
dorsal recumbency with or without the front legs secured
How is the feline patient positioned for castration?
dorsal recumbency with the hind legs pulled toward the head and tied, taped or manually held in position
How is the patient positioned for procedures involving the extremities?
lateral recumbency with the affected limb suspended
How is the patient positioned for tail and perianal surgery?
ventral recumbency with the forelegs secured to the table, the hind legs hanging over the edge at the end of the table, and a rolled towel placed under the caudal abdomen for extra padding
the tail is suspended with adhesive tape
What is the final step in the surgical site prep process?
the application of the solution product, or "paint"
What two products may be used as "paint"?
povidone-iodine solution or chlorhexidine gluconate WITHOUT the detergent
What consideration must be taken when selecting a solution product for the final "paint" step?
only povidone-iodine scrub should be followed by povidone iodine solution, and likewise chlorhexidine gluconate scrub should only be followed with chlorhexidine gluconate solution
What is the technique for applying the final "paint" solution?
the solution is applied with a spray bottle - the first spray goes into the kick bucket and then using a swiping motion the technician applies a light mist from the spray bottle to the center of the proposed surgical site and allows to dry
What is involved in the patient history taking process?
establishing the patient's signalment, chief complaint, current medications if any, previous medical conditions
Why is the physical exam important?
it reveals the needs of the patient more then any other diagnostic procedure
How can you stop a dog from panting during thoracic auscultation?
use a hand to extend the neck by gently lifting on the dog's mandible using the top surface of the hand while the other hand holds the stethescope to the patient's chest
How can you stop a cat from purring during the thoracic auscultation?
restrain the cat firmly near a sink and turn on the water to a slow stream
How is the patient's temprature taken?
rectally with a well lubricated thermometer
What information should a consent form include?
patient identifying information, the specific procedure to be performed and associated risks, the physician to perform the procedure and the signature of the owner consenting to the procedure
What is the minimum preanesthetic diagnostic database/minimum database (MDB) and what does it include?
the diagnostic tests necessary before a patient can be safely anesthetized, at a minimum to include a packed cell volume, total solids, blood glucose, blood urea nitrogen (BUN) and alanine aminotransferase