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Surgery > Surgical basics > Flashcards

Surgical basics Flashcards

1
Q

What forms part of the ward checklist?

A

Surgical check = operating surgeon / deputy to meet patient to confirm identity, operation, mark site of operation

Nursing check = infection risk assessed, appropriate VTE prophylaxis, baseline observations

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2
Q

When should surgical marking be checked? And how

A

During intra-operative time out checks

  • Against patient records
  • Consent form
  • Verbally with patient (if possible)

Marking should remain visible after drapes placed

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3
Q

When may surgical site marking not be appropriate?

A

Emergency surgery

Procedures on teeth or mucous membranes

Bilateral simultaneous organ surgery

If site of pathology needs to be confirmed following an examination under anaesthesia

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4
Q

What may happen is the mark extends into incision site?

A

Tattooing

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5
Q

Who should complete the WHO surgical checklist?

A

Registered theatre practitioner

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6
Q

What are the three sections to the WHO surgical safety checklist?

A

Sign in (before induction of anaesthesia - in presence of anaesthesist)

Time out (before first incision - final oppourtunity to identifty patient, procedure and site)

Sign out (prior to key members of operating team leaving operating room)

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7
Q

What are the steps for infection control in theatre?

A

Sterile surgical equipment

Effective scrubbing up technique

Empirical abx

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8
Q

When is surgical prophylaxis given?

A

High risk of wound infection

Infection causes severe consequences e.g. prosthesis

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9
Q

When are prophylatic abx given?

A

Single IV dose within 60 mins before first incision

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10
Q

What prophylactic abx are given in the following situations:

Open GI surgery without sepsis

Intra abdominal sepsis

Laparoscopic abdo surgery

Vascular procedures

Open urological surgery

Prostatic biopsy

Joint replacement

Open fractures

A

Open GI surgery without sepsis = gentamicin + metronidazole

Intra abdominal sepsis = gentamicin + piperacillin-tazobactam

Laparoscopic abdo surgery = co-amoxiclav

Vascular procedures = flucloxacillin

Open urological surgery = gentamicin + metronidazole + amoxicillin

Prostatic biopsy = co-amoxiclav

Joint replacement = flucloxacillin + gentamicin

Open fractures = co-amoxiclav + gentamicin + metronidazole

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11
Q

What is the role of the scrub nurse? Who are they?

A

Work with surgeon in sterile field - look after surgical equipment

Nurse who has subspecialised or ODPs

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12
Q

What is the role of recovery nurses?

A

Nurses who provide critical care after surgery - monitor progress of patients condition until stable and return to ward

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13
Q

What are the WHO 5 moments for hand hygiene?

A

Before touching patient

Before clean / aseptic procedure

After toughing patient

After body fluid exposure

After touching patients surroundings

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14
Q

What is the correct hand washing technique?

A

Palm to palm

Palm over each dorsum

Palm to palm interlaced

Monkey grip

Thumbs

Tips of fingers on palms

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15
Q

List the steps in scrubbing in?

A

Remove watches / rings

Roll sleeves two inches above elbows

Open gown pack onto clean table grabbing outer edges

Collect nail brush

Put on a face mask

Run water, cover nail brush with soap, wash nails then hands/ arms three times

Dry hands with sterile towel in pack

Pick up sterile gown, place hands into sleeve and ask for an assistant to tie it

Put on gloves with gown sleeves covering hands

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16
Q

What is the operating note?

A

Document that records what operation the patient had and what was found during surgery and post-op instructions

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17
Q

When are absorbable sutures commonly used?

A

Deep tissues

Tissues which heal rapidly (small bowel anastomosis, suturing in urinary / biliary tracts)

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18
Q

When are non-absorbable sutures used?

A

Tissues which heal slowly

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19
Q

When is diathermy contraindicated?

A

Pacemakers

Spinal cord stimulators

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20
Q

What are the two main settings of diathermy?

A

Monopolar or bipolar

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21
Q

What is an interrupted suture?

A

Individual stitches are not connected

High tensile strength

Individual sutures can be removed without jeopardising closure (e.g. in infection)

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22
Q

What are continuous sutures, what is the disadvantage?

A

Stiches are connected

Greater risk of dehiscence (but faster)

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23
Q

What are mattress sutures?

A

Individual sutures which tie together on one side

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24
Q

Give examples of when local anaesthetic is used?

A

Excision of skin lesions

Post op analgesia in major surgery

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25
Q

Why is local anaesthetic given with adrenaline? When should adrenaline not be given?

A

To increase amount of anaesthetic that can be used (also reduces bleeding)

Not to be used in end-arterial supply areas e.g. digits, pinna, penis / nose (causes ischaemia and gangrene)

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26
Q

What to remember when administering local anaestetics?

A

Check expiry date and concentration of anaesthetic

Warm anaesthetic in hand (shown to reduce pain of injection)

Start with fine bore needle (longer and wider can be used after initial infiltration)

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27
Q

What can inadventent injection of local anaesthetic into circulation lead to? How is it prevented?

A

Paraesthesia

Light-headedness

Arrhythmias

Cardiac arrest

Aspirate to ensure no flashback of blood

28
Q

Why is a surgical drain used?

A

Tube for removal of blood, pus, or other fluids

Drainage of a potential space e.g. post abscess drainage

Monitoring of outputs e.g. bile from abdomen

Detection of bleeds e.g. anastomotic leaks

29
Q

Give examples of where abscesses may be drained under general or local anaesthetic?

A

General = perianal

Local = infected sebaceous cyst on back

30
Q

How is an abscess drained?

A

Stab incision

Sample of pus for MC + S

Place finger inside and pull out pus

Wash out cavity with saline

Pack and allow to heal by secondary intention

31
Q

What is the management of a diabetic patient with an abscess?

A

Drained on same day of admission - even out of hours

32
Q

What can be a side effect of abscesses?

A

Necrotising fasciitis

33
Q

Which incision is normally used when a skin lesion is excised?

A

Elliptical incision

34
Q

What is the indication for excision of a skin lesion?

A

Malignant lesions

Chronic irritation

Cosmetic

Diagnostic purposes

35
Q

What are some complications of excision of a skin lesion?

A

Bleeding

Infection

Scarring (including keloids)

Pain

Reccurrence of lesion

36
Q

Which ‘lines’ should incisions in the body follow?

A

Langer’s lines

37
Q

What are the four characteristic features of acute inflammation?

A

Redness (rubor) - secondary to vasodilation and increased blood flow

Heat (calor) - localised increase in temp - dur to increased blood flow

Swelling (tumour) - increased vessel permeability = fluid loss into interstitial space

Pain (dolor) - stimulation of local nerve endings

38
Q

What are the two stages of acute inflammation?

A

Vascular phase

Cellular phase

39
Q

What happens in the vascular phase of acute inflammation?

A

VasodilatiIncreased permeability of vascular barrier (regulated by chemical mediators)

Oedema occurs = medium for inflammatory proteins (e.g. complement and immunoglubulins) migrate through

Oedema helps to remove pathogens and cell debris in area

40
Q

What happens in the cellular phase of acute inflammation?

A

Neutrophilsare attached to thesite of injuryby the presence ofchemotaxins

These begin phagocytosis

41
Q

What are the four stages of the migration of neutophils?

A

Margination - cells line up against endothelium

Rolling - roll along endothelium

Adhesion - connect to wall

Emigration - move through vessel wall to affected area

42
Q

What are the potential outcomes of acute inflammation?

A

Complete resolution - total repair

Fibrosis and scar formation - if inflammation significant

Chronic inflammation - from persisting insult

Formation of abscess

43
Q

What is an abscess?

A

Localised collection of pus (necrotic tissue with dead and viable neutrophils) surrounded by granulation tissue

44
Q

What are the complications of an abscess?

A

Systemic dissemination of a pathogen

Pain

Destruction of local structures

45
Q

What is chronic inflammation?

A

Ongoing inflammatory response (may be a continuation of acute or arise de-novo)

46
Q

What are the main cells in chronic inflammation?

A

Macrophages

47
Q

What do macrophages do?

A

Phagocytosis

Antigen presenting cells (APCs)

Fuse and form multinucleated giant cells

Secrete growth factors to help - aid cell repair

Synthesise complement components and cytokines

48
Q

What are the 3 different types of giant cells? When do they occur?

A

Foreign-body giant cell = foreign body

Langhans giant cell = mycobacterium tuberculosis

Touton giant cell = fat necrosis

49
Q

What is the role of antibodies produced from plasma cells?

A

Neutralising microbes and toxins

Promoting natural killer cells (destroy targeted and tagged pathogens)

Facilitate easier phagocytosis by innate immune system (opsonisation)

50
Q

What is the role of T lymphocytes:

CD4+ (T helper)

CD8+ (T killer)

A

CD4+ = coordinate targeted inflammatory responses

CD8+ = coordinate targetted destruction of infected cells

51
Q

What are granulomas?

A

In chronic inflammation - macrophages and lymphocytes combine to form granuloma - wall off an agent resistant to destruction

52
Q

What is contained in granulomas?

A

Elongated macrophages = epithelioid cells

Surrounding a core of lymphocytes and giant cells

53
Q

When are granulomas seen?

A

Tuberculosis

Sarcoidosis

Crohn’s disease

Rheumatoid arthritis

Granulomatosis with polyangiitis (GPA)

54
Q

When does healing by primary intention occur?

A

Wounds with dermal edges that are close together (e.g. scalpel incision)

55
Q

What are the four stages of healing by primary intention?

A

Haemostasis (platelets and cytokines action forms a haematoma and causes vasoconstriction)

Inflammation (to remove any cell debris and pathogens)

Proliferation (cytokines drive proliferation of fibroblasts and formulation of granulation tissue)

Remodelling (collagen fibres deposited in wound to provide strength in region)

56
Q

What may happen wound is sutured too tightly?

A

Blood supply = compromised leading to tissue necrosis and wound breakdown

57
Q

What is healing by secondary intention?

A

Sides of wound are not opposed - healing must occur from bottom of wound upwards

58
Q

What are the four stages of healing by secondary intention?

A

Haemostasis = large fibrin mesh forms, filling wound

Inflammation = to remove cell debris (larger amount than in primary)

Proliferation = Granulation tissue at the bottom of the wound (grows up to the level of original epithelium - then epithelia can cover the wound)

Remodelling = wound contraction can occur

59
Q

Which cells are vital in secondary intention?

A

Myofibroblasts (modified smooth muscle cells - can contract)

60
Q

Which factors affect wound healing?

A

Local blood supply

Infection

Foreign material

Radiation damage

Increasing age

Co-morbidities (DM)

Nutritional deficiencies (especially vit C)

Obesity

61
Q

What are the basic principles for management of a wound?

A

Haemostasis (spontaneous / pressure, elevation, tourniquet, suturing)

Cleaning the wound (disinfect around wound with antiseptic, manually remove any foreign bodies, debride any devitalised tissue, irrigate wound with saline, abx doe signs of infection)

Analgesia (local anaesthetic and paracetamol - max level of lidocaine is 3mg/kg)

Skin closure (adhesive strips e.g. steri-strip, tissue adhesive glue e.g. indermil, sutures if greater than 5cm long or on locations prone to flexion, tension or wetting, staples for scalp wounds)

Dressing and follow-up advice (first layer of non-adherent e.g. saline-soaked gauze, followed by absorbent layer, followed by soft gauze tape to secure in place)

62
Q

What are some risk factors for wound infection?

A

Foreign body present

Heavily soiled wounds

Bites

Open fractures

63
Q

What prophylaxis may be needed in wounds?

A

Tetanus

64
Q

What advise after wound management?

A

Medical attention for signs of infection

Simple analgesia e.g. paracetamol

Keep wound as dry as possible

65
Q
A
66
Q
A

Surgery (2 decks)

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