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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
Why is **local anaesthetic** given with **adrenaline**? When should adrenaline **not be given**?
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)
26
What to remember when **administering local anaestetics**?
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)
27
What can **inadventent injection of local anaesthetic into circulation lead to**? How is it prevented?
Paraesthesia Light-headedness Arrhythmias Cardiac arrest **Aspirate** to ensure no **flashback of blood**
28
Why is a **surgical drain** used?
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
Give examples of where **abscesses** may be drained under **general** or **local anaesthetic**?
**General** = perianal **Local** = infected sebaceous cyst on back
30
How is an **abscess drained**?
**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
What is the **management** of a **diabetic patient** with an **abscess**?
Drained on **same day of admission** - even out of hours
32
What can be a side effect of **abscess****es**?
**Necrotising fasciitis**
33
Which incision is normally used when a **skin lesion** is **excised**?
**Elliptical incision**
34
What is the indication for **excision** of a **skin lesion**?
**Malignant lesions** Chronic irritation Cosmetic Diagnostic purposes
35
What are some **complications** of **excision** of a **skin lesion**?
**Bleeding** **Infection** **Scarring** (including keloids) **Pain** **Reccurrence** of lesion
36
Which 'lines' should **incisions in the body follow**?
**Langer's lines**
37
What are the **four characteristic features** of **acute inflammation**?
**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
What are the **two stages** of **acute inflammation**?
**Vascular phase** **Cellular phase**
39
What happens in the **vascular phase** of **acute inflammation**?
**Vasodilati**Increased **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
What happens in the **cellular phase** of **acute inflammation**?
**Neutrophil****s**are attached to the**site of injury**by the presence of**chemotaxins** These begin **phagocytosis**
41
What are the **four stages** of the **migration** of **neutophils**?
**Margination** - cells line up against endothelium **Rolling** - roll along endothelium **Adhesion** - connect to wall **Emigration** - move through vessel wall to affected area
42
What are the **potential outcomes** of **acute inflammation**?
**Complete resolution** - total repair **Fibrosis and scar formation** - if inflammation significant **Chronic inflammation** - from persisting insult Formation of **abscess**
43
What is an abscess?
**Localised collection of pus** (necrotic tissue with dead and viable neutrophils) surrounded by **granulation tissue**
44
What are the **complications** of an **abscess**?
**Systemic dissemination** of a pathogen **Pain** **Destruction** of local structures
45
What is **chronic inflammation**?
**Ongoing inflammatory response** (may be a continuation of acute or arise de-novo)
46
What are the **main cells** in **chronic inflammation**?
**Macrophages**
47
What do **macrophages** do?
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
What are the 3 different types of **giant cells**? When do they occur?
**Foreign-body** giant cell = foreign body **Langhans** giant cell = mycobacterium tuberculosis **Touton** giant cell = fat necrosis
49
What is the role of **antibodies** produced from plasma cells?
**Neutralising microbes and toxins** **Promoting natural killer cells** (destroy targeted and tagged pathogens) **Facilitate easier phagocytosis** by innate immune system (opsonisation)
50
What is the role of T lymphocytes: CD4+ (T helper) CD8+ (T killer)
CD4+ = coordinate targeted inflammatory responses CD8+ = coordinate targetted destruction of infected cells
51
What are **granulomas**?
In **chronic inflammation** - macrophages and lymphocytes combine to form **granuloma** - wall off an agent resistant to destruction
52
What is **contained in granulomas**?
Elongated macrophages = **epithelioid cells** Surrounding a **core of lymphocytes and giant cells**
53
When are **granulomas** seen?
**Tuberculosis** **Sarcoidosis** **Crohn's disease** **Rheumatoid arthritis** **Granulomatosis with polyangiitis** (GPA)
54
When does **healing by primary intention** occur?
Wounds with **dermal edges** that are **close together** (e.g. scalpel incision)
55
What are the **four stages** of **healing by primary intention**?
**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
What may happen wound is **sutured** too **tightly**?
Blood supply = compromised leading to **tissue necrosis** and **wound breakdown**
57
What is **healing by secondary intention**?
Sides of wound are not opposed - healing must occur from **bottom of wound upwards**
58
What are the **four stages** of **healing by secondary intention**?
**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
Which **cells** are vital in **secondary intention**?
**Myofibroblasts** (modified smooth muscle cells - can contract)
60
Which **factors** affect **wound healing**?
Local **blood supply** **Infection** **Foreign material** **Radiation damage** Increasing **age** **Co-morbidities** (DM) Nutritional deficiencies (especially vit C) Obesity
61
What are the basic principles for **management of a wound**?
**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
What are some **risk factors** for **wound infection**?
**Foreign body** present Heavily **soiled wounds** **Bites** **Open fractures**
63
What prophylaxis may be needed in wounds?
**Tetanus**
64
What **advise** after **wound management**?
**Medical attention** for **signs of infection** **Simple analgesia** e.g. **paracetamol** Keep wound as **dry as possible**
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Surgery (2 decks)

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