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Flashcards in Total Surgical Care Deck (70):
1

Systemic Risk Factors for Infection

DM
Corticosteroid use
Obesity
Age
Malnutrition
Second surgery
Co-morbidities

2

Local Risk Factors for Infection

Foreign body
Electrocautery
Wound drains
Injection with epinephrine
Hair removal
Previous radiation
Prolonged operation

3

Most Commonly Given Antibiotic

Cefazolin (Ancef, Kefzol)

4

Antibiotics to Cover Gram-Negative & Anaerobic Pathogens

Cefotetan
Cefoxitin
Cefizoxime
+/- metronidazole (Flagyl)

5

Cardiac Complications & Diabetes

Men 2x the risk
Women 4x the risk
Hypotension from neuropathy

6

Gastroparesis & Diabetes

Aspiration risk

7

Infection & Diabetes

Reduced blood flow decreases healing

8

Risk Factors for Venous Thromboembolism Disease (VTE)

Extent of surgery or trauma
Duration of hospital stay
Previous VTE
Immobility
Central line placement
Ortho procedures
Age
Obese patients

9

Appropriate Prevention of VTE in Very Low Risk Patients

Early & frequent ambulation

10

Appropriate Prevention of VTE in Low Risk Patients

Mechanical methods when contraindication to medicinal prophylaxis

11

Appropriate Prevention of VTE in Moderate Risk Patients

Pharmacologic

12

Appropriate Prevention of VTE in Very High Risk Patients

Combination

13

Medications Given for VTE Prophylaxis

Low molecular weight heparin
Low dose unfractionated heparin (UFH)
Warfarin
Aspirin

14

Mechanical Methods of VTE Prophylaxis

Intermittent pneumatic compression (IPC)
Graduated compression stockings (GCS)
Venous foot pump (VFP)

15

Define Surgical Site Infection

Infection related to an operation that occurs at or near the surgical incision within 30 days of the procedure or 90 days of an implant

16

Impact of Surgical Site Infections

Increase in mortality
Increase cost to patient & hospital

17

Risk Factors for Surgical Site Infections

Surgical technique
Prolonged surgery time
Instrument sterilization
Pre-op preparation
Thermoregulation & glycemic control
Medical condition of the patient
Surgical environment

18

Surgical Environment Risk Factors

Personnel traffic
Excessive use of electrosurgical cautery units
Prosthesis or foreign body
Need for blood transfusion

19

Presentation of a Surgical Site Infection

Localized erythema
Induration
Warmth
Pain at incision site

20

Treatment of Surgical Site Infections

Prophylactic antibiotics
Infected wounds
Antibiotics: broad spectrum, culture & gram stain
Surgical technique

21

Surgical Technique Treatment of Surgical Site Infections

Limit electrocautery
Closure of subQ tissue
Skin closure
Delayed closure & heal by secondary intention
Limit hypothermia

22

Define Hematoma & Seroma

Collection of blood or serum under the incision

23

Presentation of a Hematoma or Seroma

Few days post-op
Pain
May have sebum like fluids
Fever
Erythematous
Edematous

24

Treatment of Hematoma or Seroma

Percutaneous drains
Wound exploration: pack & heal by secondary intention

25

Prevention of Hematoma's and Seroma's

Closure of dead space
Meticulous hemostasis
Placement of drains (controversial)

26

Risk Factors for Fascial Dehiscence

Age
Males
COPD
Ascites

27

Define Fascial Dehiscence

Abdominal wall tension overcoming tissue or suture strength

28

Main Cause of Fascial Dehiscence

Failure of the sutures to remain anchored, knot failure, large stitch intervals

29

Presentation of Fascial Dehiscence

Profuse serosanguinous drainage
Popping sensation with abdominal bulge

30

Treatment of Fascial Dehiscence

Closure in the operating room

31

Prevention of Fascial Dehiscence

Continuous mass closure or interrupted
Internal or external retention sutures

32

Wound Healing via Primary Intention

Wound closed with stitches or staples
Covered with a sterile dressing
Drain small amount of fluid
Keep protected from getting wet for 2-10 days
Monitor for erythema, swelling, warmth, & drainage

33

Wound Healing via Secondary Intention

Epidermis & dermis not closed
Usually due to contamination, infected wound, or peritonitis
Pack daily with saline moistened gauze/sponge & covered with a sterile dressing

34

Pulmonary Complications

Hypoventilation
Pneumonia
Atelectasis
1/2 peri-op mortality

35

Categories of Pulmonary Complications

Atelectasis
Infection
Prolonged mechanical ventilation & respiratory failure
Exacerbation of underlying chronic lung disease
Bronchospasm

36

Risk Factors for Pulmonary Complications

50+
Chronic lung disease
Asthma
Smoking: 20+ pack year history
General health status: CHF, URI

37

Procedure-Related Risk Factors for Pulmonary Complications

Surgical site: abdominal & thoracic
Duration: 3+ hours
Type of anesthesia
Type of neuromuscular blockade

38

When should you obtain PFT's on a patient pre-operatively?

Lung resection
COPD
Asthma
Unexplainable dyspnea or exercise intolerance

39

When should a chest x-ray be performed pre-operatively?

Known CVD
50+ years with a high risk surgical procedure

40

Strategies to Reduce COPD Complications Post-Operatively

Bronchodilators + antibiotics + systemic steroids
Inhaled ipratropium or tiotropium QD
Beta-agonists (as needed)

41

Strategies to Reduce Asthma Complications Post-Operatively

Beta-agonists
Peri-operative systemic steroids

42

URI & Surgery

Delay elective surgery

43

Patient Education for Reduce Pulmonary Complications

Coughing
Incentive spirometry
Deep breathing

44

Intra-Operative Strategies to Prevent Pulmonary Complications

Spinal or epidural if possible
Neuromuscular blockade intermediate agents
Short procedures in high risk patients

45

Post-Operative Strategies to Prevent Pulmonary Complications

Deep breathing exercises
Incentive spirometry
Adequate pain control

46

5 Reasons for Post-Op Fever

Wind
Water
Walking
Wound
Wonder drugs

47

Wind Issues for Post-Op Fever

Pneumonia
PE

48

Water Issue for Post-Op Fever

Indwelling catheter

49

Walking Issues for Post-Op Fever

DVT
PE

50

Wound Issues for Post-Op Fever

Surgical site infections

51

Wonder Drug Issues for Post-Op Fever

Infections from lines
Drug induced

52

Treatment of Post-Op Fever

Remove unnecessary treatments (meds or catheters)
Suppress fever with Tylenol
Antibiotics per judgement or culture results

53

Define Malignant Hyperthermia

Uncommon but life-threatening reaction to some anesthetic agents

54

Unsafe Medications for Patients with Risk of Malignant Hyperthermia

Depolarizing muscle relaxants (Anectine)
Halothane
Isoflurane
Enflurane
Desflurane
Sevoflurane
Succinylcholine

55

Medications that are Safe for Patients with Malignant Hyperthermia

Barbiturates
Benzodiazepines
Droperidol
Ketamine
Local anesthetics
Nitrous oxide
Non-depolarizing muscle relaxants
Opioids
Propofol

56

Clinical Manifestations of Malignant Hyperthermia

Hypercarbia
Skeletal muscle rigidity
Tachycardia
Tachypnea
High temp
HTN
Cardiac dysrhythmias
Acidosis
Hypoxemia
Hyperkalemia
Myoglobinuria

57

Pathophysiology of Malignant Hyperthermia

Genetic predisposition
Increased intracellular calcium
Continuous muscle contraction

58

Treatment of Malignant Hyperthermia

Call for help
Stop triggering agents
Hyperventilate
Finish/abort procedure
Administer Dantroline
Cool patient
Monitor & treat acidosis
Promote urine output
Treat hyperkalemia
Treat dysrhythmias with procainamide & CaCl
Monitor creatinine kinase, urine myoglobin, & coagulation for 24-48 hours

59

Surgical Care Improvement Project National Goal

Reduce preventable surgical morbidity & mortality

60

Complications That are Preventable

Infection
Cardiovascular
VTE

61

Infection Prevention in SCIP

Antibiotics 1 hour prior to incision
Glucose control in cardiac surgery patients
Proper hair removal
Normothermia

62

Prevention of Cardiac Events with SCIP

Maintain patient on a beta-blocker

63

Risk Factors for VTE

Hospitalization or nursing home
Active malignant neoplasm
Trauma
CHF
CV catheter
Neurologic disease with paresis
Superficial vein thrombosis
Varicose veins/stripping

64

SCIP 1-2-3 Antibiotics

1: one hour prior to incision
2: appropriate selection of antibiotic
3: discontinue within 24 hours after anesthesia end time

65

SCIP 4- Blood Glucose

66

SCIP 6- Hair Removal

Clippers in OR

67

SCIP 9- Foley D/C

Discontinue by post-op day 2

68

SCIP-CARDIAC-2: Beta Blocker

Continue on home regiment pre-op
Continue on post-op day 1 or 2

69

SCIP-VTE-2: Timing of VTE Prophylaxis

24 hours prior to surgery OR
Within 24 hours after anesthesia end time

70

SCIP-10 Normothermia

96.8+ within 15 minutes of anesthesia end time or warmer