surgery II Flashcards
Informed Consent
Ethical and legal obligation of medical practitioners
The Joint Commission requires documentation of all the elements of informed consent “in a form, progress notes, or elsewhere in the record”
Requiredelements for documentation of the informed consent discussion:
Nature of the procedure
Risks and benefits and the procedure
Reasonable alternatives
Risks and benefits of alternatives
Assessment of the patient’s understanding of the first 4 elements
Patient must be competent to make a voluntary decisionabout whether to undergo the procedure
When possible, the medical provider initiating the treatment or procedure should obtain consent from the patient
Preoperative Antibiotic Prophylaxis
Timing of antibiotic administration
At least 30 minutes, but no greater than 60 minutes before the skin incision is made; continue 24 hours postoperatively
Goal: antibiotic(s) concentration in the tissues at its highest at the start and during surgery
Most common organisms implicatedas causes of surgical site infections:
Staphylococcus aureus
Staphylococcusepidermidis
Aerobic streptococci
Anaerobic cocci
Antibiotic selection is generally based on the anatomic region undergoing the specific surgical procedure
Relatively narrow spectrum of activity while ensuring the most common organisms are targeted
Cefazolin is used most often for surgical prophylaxis in patients with no history of beta-lactam allergy or of MRSA infection
Alternatives: vancomycin and clindamycin
Bowel surgery: cefazolin + metronidazole
Aseptic/sterile technique
Joseph Lister
British surgeon
Established the founding principles of aseptic/sterile technique
Aseptic/sterile technique encompasses practices performed immediately before and during a surgical procedure to reduce post-operative infection
Handwashing
Surgical scrub
Using surgical barriers, including sterile surgical drapes and proper personal protective equipment, including head coverings, surgical masks and gowns, gloves, and shoe coverings
Patient surgical prep
Maintaining a sterile field
Hospital-acquired infections occur in ~1% of the 27 million surgical procedures performed yearly
~8,000 deaths from surgical site infections (SSI) yearly
Intraoperative Phase
Essential to be familiar with the general principles of the operating room and surgery in general
Primary priority in the OR is the patient
Don’t touch anything covered in blue/green as this is STERILE
The Surgical Team
Surgeon – performs the technical aspects of the procedure; rely heavily on the scrub nurse
Scrub Nurse – provides instruments to the surgeon during the procedure
Anesthesiologist – responsible for the induction of anesthesia and maintaining the patient stable throughout the procedure
Circulating Nurse – helps in a wide variety of tasks that cannot be performed by the sterile team; getting extra supplies, adjusting equipment settings, documentation
Patient Positioning/protection
Appropriate position that allows the best access for the given procedure
Patient protection:
Pressure points
Nerve damage
Ulnar or brachial plexus injuries in the upper limbs
Arm abduction maintained less than 90° prevents undue pressure of the humerus on the axilla, thereby preventing brachial plexus injury
Arm in neutral position with palms facing the body or supinated with elbow padding decreases external pressure on the ulnar nerve
Sciatic or femoral nerve damage in the lower extremities
Joint injury
Fall prevention
Strap the patient to avoid movement and falls
Supine
Patient lies flat on their back
Head, neck, and spine in neutral positioning
Most common position for open abdominal/pelvic procedures
Modifications of the supine position:
Trendelenberg
Head is tilted down
Used in lower abdominal or pelvic procedures to move visceral organs out of the way
Reverse Trendelenberg
Head is tilted up
Used for upper abdominal procedures, and head and neck procedures
Prone
Patient lies on their abdomen and chest
Used when a posterior approach is required (spinal or kidney surgery)
Risk of dislodgement of monitors and tubes
Special caution must be taken to avoid undue pressure on the eyes – perioperative vision loss
Lateral
Patient is placed on their left or right side
Padding placed under lower leg, to ankle and foot of upper leg, and to lower arm (palm up) and upper arm
Pillow placed lengthwise between legs and between arms (if lateral arm holder is not used)
Used when a lateral incision is required (thoracotomy or renal surgery)
Lithotomy
Patient lying supine withlegs abducted 30 to 45 degrees from midline with knees flexed and legs held supported with the foot of the bed lowered or removed to facilitate the procedure
Lower extremity padding prevents nerve compression against leg supports; common peroneal nerve injury is most common as the peroneal nerve wraps around the head of the fibula, which rests against leg supports
Used in urological and gynecological procedures
Prolonged procedure time increases the risk for lower extremity compartment syndrome secondary to inadequate perfusion; periodically lowering the extremities
Anesthesia
Temporary state that causes loss of consciousness along with analgesia, amnesia and muscle relaxation
Analgesia: relief from pain or prevention of pain
Amnesia: loss of awareness and/or memory
Hyponosis: temporary unconsciousness of the absence of anxiety
Paralysis: muscle relaxation
Induced via administration of gaseous or injectable agents
Types of anesthesia
Local
Epidural
Spinal
Regional
General
Local Anesthesia
Anesthesia of a small confirmed area of the body
Used for procedures such as performing a skinbiopsyor breastbiopsy, repairing a broken bone, or suturing a laceration
Local anesthetics:
Reversibly block sodium influx and inhibit the conduction of painful stimuli via afferent nerves
Lidocaine
Bupivacaine (Marcaine)
Epidural Anesthesia
A type of anesthesia that involves anesthetizing the nerves of the CNS
Slow-flow continuous administration ofopioidinto the epidural space via a catheter
Painrelief:
Continuouspainrelief while running
Excellentpainrelief at T8 and below
Side effects:
Orthostatic hypotension, urinary retention
Spinal Anesthesia
A type of anesthesia that involves anesthetizing the nerves of the CNS
Single injection ofopioidinto the subarachnoid space
Painrelief:
Lasts 2–4 hours
Excellentpainrelief at T10 and below
Side effects:
Urinary retention, hypotension (neurogenic shock)
Regional Anesthesia
Anesthesia (long-acting) injected near a specific nerve or a bundle of nerves to block sensation of pain
Used for procedures involving the upper and lower extremities
General Anesthesia
Drug-induced loss of consciousness
Five main classes of anesthetic agents:
Intravenous (IV) anesthetics, inhalational anesthetics, IV sedatives, synthetic opioids, and neuromuscular blocking drugs
Affects the entire body
Used for major surgical procedures
Three stages of general anesthesia
Induction
Accomplished via inhalation or IV
Induction agents: propofol, midazolam, sodium thiopental
Airway management initially via a face mask followed by transition to endotracheal intubation
Maintenance
Depth of anesthesia sufficient to allow surgical manipulation and continues until completion of the procedure
Emergence
Removing anesthetic agents and reversing their residual effects for the return of consciousness and movement
Extubation can be performed when the patient can protect their airway, follow simple commands, and ventilate without assistance
Surgical Incisions
Surgical incisionwill depend on the underlying pathology, site,patient factors, and thesurgeon’s preferenceand experience
Important to keep in mind anatomy, and blood supply that may promote complications
Incisions should try tofollowLanger’s lineswhere possible, for maximal wound strength with minimal scarring
Musclesshould besplitand not cut (where possible)
Surgical excisions can be closedby sutures, staples, steri-strips, tissue glue, or a combination of these agents
Wound can becovered in a protective dressingand kept dry for 2 days, before normal washing can resume
Types
Midline
Kocher
Paramedian
McBurney’s (Gridiron)
Lanz (Rockey-Davis)
Pfannenstiel(Kerr/Pubic)
Midline Incision
Also known as the laparotomy incision
Used for awide arrayof abdominal surgery
Can be used foremergency procedures
Can run anywhere from the xiphoid process to the pubic symphysis, passingaround the umbilicus
Can produce significant scarring
Kocher incision
Subcostal incision on the right side of the abdomen used for open exposure of the gallbladder and biliary tree
Associated with a slight increase in pain during the post-operative phase due to the severing of the rectus muscle
paramedian incisino
Incision runs ~3 cmlateral to the midline
Used to access much of thelateral viscera, such as the kidneys, the spleen, and the adrenal glands
Rarely used
Mc Burneys incision
Oblique incision
Incision are made atMcBurney’s point(two-thirds from the umbilicus to the anterior superior iliac spine)
Used for performing open appendectomies
lanz incision
Transverse incision
Used toaccess theappendix, predominantly for appendicectomy
Incision are made atMcBurney’s point
Produces aesthetically pleasing results with reduced scarring due to continuation with Langer’s lines
Pfannenstiel Incision
Transverse, curved lower abdominal incision that is made 2-5 cm above the pubic symphysis
Used for urologic, orthopedic, pelvic, and cesarean sections
