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radiography > 手術道具 > Flashcards

手術道具 Flashcards

1
Q
A

Debakey forcepts

thumb forceps

adson forceps (右面兩個

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2
Q
A

DeBakey

Thumb

Adson forceps

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3
Q
A

tower forceps 窗巾夾

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4
Q
A

Blunt

sharp

mayo x2

metzenbaum x2

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5
Q
A

Metzenbaum: finer design, typically have a long handle to blade ratio. Used for cutting delicate tissue and blunt tissue dissection (such as subcutaneous and light fascia)

Mayo: very strong and are mainly used for cutting connective tissues (such as linea alba and fascia. They can also be used for cutting sutures

Sharp and blunt

(scissors)

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6
Q

手術包原則

A

先大後小

先直後彎

彎面向左

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7
Q

手術包的刀具順序

A
  1. 3、4號刀柄
  2. Adson, Thumb , debakey (forceps)
  3. 4小 towel forceps：扣上一格、并使用allis forcep把他們的下方全部串起。面朝左
  4. 4大的 tower forcepts
  5. 3 Allis forceps
  6. 2 Metzenbaum scissors（直的然後灣的）
  7. 2 Mayo scissors（直的然後灣的）
  8. Sharp and blunt
  9. Blunt and blunt
  10. Needle holder（大的然後小的）
  11. 大的直的heomostat、大的彎的hemostat
  12. 10 mosquito forceps （直的然後灣的，各五把）
  13. Alis forcep固定
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8
Q

手術包non-手術用具準備

A
  1. 準備器械盤、碗、紗布、毛巾墊在器械盤下層
  2. 手術用具+Alis forcep固定
  3. 放入裝滿紗布的碗
  4. 4條摺成正方形的小毛巾
  5. 蓋上兩條長形的毛巾
  6. 蓋上Draping
  7. 窗巾：開口方向往內折，須完全蓋住器械，留一角反折
  8. 貼上滅菌膠帶，協商器械貼紙顏色、器械包種類、日期、姓名代表字
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9
Q

Premedication preparation for dog

A

先嘗試開籠⾨戴頭套＋繫牽繩 (若無牽繩可⽤綁腳繩暫時取代)

⼀出來在最鎮靜的狀況下，先儘速戴頭套、上針

Inspection first

Body weight examination (first weigh cage with animal then weigh the empty cage)

出籠（zolatil injection for cats & stressful dog before)、冷氣帶for cats

Preoxygenation

Catherization + blood glucose test

Physical examination

Shaving

IV injection: famo / cepha (slow!)

Setting up monitor

Preparing for intubation (tube, 麻醉機, laryphargnscope)

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10
Q

premedication for cat

A

1確認貓咪來源（淡海/曾⼩姐/相信），由研究⽣確認接送⼈員聯絡⽅式、貓咪名字、病史、 是否中途、能否餵藥、懷孕是否結紮、有無發情、是否剪耳

Inspection first

Body weight examination (first weigh cage with animal then weigh the empty cage)

出籠（zolatil injection for cats & stressful dog before)、冷氣帶for cats

Preoxygenation

Catherization + blood glucose test

Physical examination

Shaving

IV injection: famo / cepha (slow!)

Setting up monitor

Preparing for intubation (tube, 麻醉機, laryphargnscope)

Intubation (check 漏氣）, lidocaine, for cat

  1. 無論乖貓兇貓，出籠前⼀律先確認⾨窗關緊
  2. ⼀律使⽤洗衣袋先罩住籠⾨/提籠開⼝，確認所有開⼝和接縫處都有完整⽤洗衣袋套住，並且 有⼈抓住洗衣袋⼝
  3. 根據問診、視診評估動物，但主要依據現場狀況評估個性
  4. 在籠內、洗衣袋中

⼀出來在最鎮靜的狀況下，先儘速戴頭套、上針

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11
Q

Telazol

A

concentration: 100mg/ml; total dose: 1-3mg/kg

dog (eg 10 kg)

  • 若不能開籠⾨則隔籠 2mg/kg (ie 0.2ml)
  • 若可以戴上頭套 - 但不能牽出來則籠內 1.5 (ie 0.15 ml)
  • 若可以戴上頭套且可以牽出來則籠外: 1mg/kg (ie 0.1 ml)
    • 仍激動、感覺第⼀劑藥量完全沒有作⽤：1.5mg/kg, IM (ie 0.15 ml)
    • 有比⼀開始鎮靜⼀些，部分作⽤：1mg/kg, IM (ie 0.1 ml

cat (eg 2.5 kg)

  • 會伸爪or哈氣：隔洗衣袋 2mg/kg (ie 0.05ml)
  • 不會伸爪、也不會哈氣：隔洗衣袋 1.5mg/kg (ie 0.4 ml)
  • 仍激動、感覺第⼀劑藥量完全沒有作⽤：1.5mg/kg, IM (ie 0.15 ml)
  • 有比⼀開始鎮靜⼀些，部分作⽤：1mg/kg, IM (ie 0.1 ml

Route of administration: IM

成分：tilatamine (NMDA antagonist and dissociateive)，但是會造成肌肉僵硬，這時候需要zolazepam (BZD)做muscle relaxing

side effect

  1. _over-sali_vation
  2. High dose: respiratory depression
  3. Canine: 心跳過速tachycardia occurs frequently lasts for 30minutes
  4. Involuntary musclular twitching
  5. excessive tracheal and bronchial secretions

contraindication：胰髒病、心肺功能嚴重dysfunction、懷孕

Renal failure 的貓會有delayed recovery，因為是腎臟排出

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12
Q

Premedication會用到的藥物

A

telazol

famotidine (減少胃酸）

cephazolin：慢推+observation

meloxicam：afterBMBT test

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13
Q

famotidine

A

concentration: 10mg/ml
dose: 1mg/kg, SC，體重/10 (ie for a 10kg dog –>1ml)

H2 blocker

  1. reduce bronchial secretion
  2. protect mucosal from ulceration caused by meloxicam (NSAID)
  3. 術中真的不小心regurgitation，reduce the pH of gastroesophageal reflux –> 可以減少食道粘膜傷害
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14
Q

meloxicam

A

**** give during surgery when BMBT done: 確保coagulation是正常的、血壓是正常的，否則AKI***

concentration: 10mg/ml
dose: 0.1mg/kg, IV 體重/100加dilute 3 times (ie 10 kg –> 抽0.1 ml之後加0.2ml稀釋3倍, total inject 0.3ml) ensure 藥都有推進去

side effect

  1. PG production減少 –> damaging mucosa –> famotidine
  2. 腎毒性 renal failure：azotemia, elevated creatinine
  3. 抑制血小板的凝集，延長出血時間 –> BMBT
  4. GI effects (vomiting, anorexia, diarrhea, melena, ulceration), elevated liver enzymes, pruritus瘙癢症
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15
Q

Cephazolin

A

diltue 3 times 慢推（減少血管不良反應、過敏、疼痛）

conc：250mg/ml (PS 準備新的藥品要加入2ml saline）

dose：25mg/kg, IV 體重/10ml + dilute 3 times (ie 10kg 狗要抽1ml的cepha and then dilute into total of 3ml)

慢推****

Observe eye during inflammation：allergic reaction 例如紅腫

Such as rashes, fever, eosinophilia, lymphadenopathy, or full-blown anaphylaxis

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16
Q

每次IV injection都要注意什麼

A

每次推針前都要打一下flush

前：確保沒有塞住

後：確保把藥都打進去了

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17
Q

何時驗glucose

A

通常是上針同時要驗glucose，用血糖機前要記得先用校正試片校正；且驗的時候動作要夠快以免血滴clot (血若clot就可能吸不起來無法驗，或驗出偽低值)

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18
Q

基本備台list

A
  • [] 儀器測漏
  • [] EKG貼片*3
  • [] EKG紙膠
  • [] 插管（貓通常用#4±0.5）
  • [] 無菌KY gel 潤滑劑
  • [] EtCO2轉接器
  • [] 人工鼻
  • [] 紗布條（兩長一短）
  • [] 喉頭鏡
  • [] 空針筒stylet（貓用5）
  • [] stylet for cat
  • [] lidocaine for cat（0.2-0.3ml）
  • [] IV fluid
  • [] 綁腳繩
  • [] 血氧probe
  • [] 血壓cuff（先認顏色）：30-40% of forelimb圓周
  • [] BMBT
    （11號刀片+ mosquito +擦手紙）

暖包

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19
Q

術中生理數值

body pressure (SAP, MAP)

Heart rate

body temperature

EtCO2

SpO2

A
  • BP: SAP>90 mmHg, MAP>60 mmHg

Ÿ 如果覺得震盪式血壓計給的數值太奇怪，就用Doppler確認一次血壓

- HR: 60<dog></dog>

Ÿ 更精確來說應該是要手術前的 ± 10-20%，所以術前HR很重要!!

- BT: Dog: 37.5˚C to 39.2˚C, Cats: 37.8˚C to 39.5˚，恢復時至少要大於37.5才安全

- EtCO2: 35-45mmHg

- SpO2: >96%, 98% ideal（夾在舌頭會是最穩定的）

20
Q

EKG patch

A

left forelimb: black

right forelimb: white

left hind limb: red

Prepare 貼片*3 and EKG紙膠

21
Q

how to monitor 血氧？

A

Pulse oximeter probe

Ear/oral mucosal membrane/ 舌頭/external genitalia/foot pats

但如果太黑的面，就會擋住光綫穿透，比較不建議！ （eg foot pats)

22
Q

什麼時候給予oxygen

A

鎮靜過後/出籠子馬上讓動物吸氧

原理：增加肺内的oxygen concentration; during induction, apnea may occurs, a higher oxygen concentration in circulation provides a buffer for that period and reduces harm cuased by hypoxia，也可以爭取intubation的時間

給氧氣要給5min以上，要對到鼻頭，越早給越好

23
Q

Propofol

A

BW÷10 = 1mg/kg

(induction: 2-6mg/kg, slow IV for 30s for first 2mg/kg

then titrate to effect)

  1. Rapid hepative and lung metabolism –> rapid and complete recovery
  2. No tissue irritation caused by perivascular injection (but may cause pain)
  3. Excellent muscle relaxation

cons

  1. respiratory and cardiovascular depression!
  2. Cat: not suggested as maintaining agent, coz may delay recover + produce heinz body (as a result of oxidative damage to RBC) which reduces oxygen capacity of RBC –>傷口愈合不良
  3. No analgesic effect
24
Q

插管、拔管時機

A

插管

動物慢慢倒下之後，去看palpebral reflex和jaw tone，等這兩個消失後再去看吞嚥反射，等到吞嚥反射也消失過後才可以插管（但如果動物已經無法自主呼吸卻還是有吞嚥反射，仍然要在這時插管!!）

拔管

  • 貓一有咳嗽就要拔管，狗要等有吞嚥反射之後才可以（咳嗽會先出來）
    *
25
Q

拔管notes

A
  1. 拔管cuff一定要記得全洩氣!!!!!
  2. 但如果有喉頭分泌物或是液體呼吸音，可以partial deflate）
  3. Check: mucous membrane color, any respiratory noise, sudden excitement (因為很痛或沒辦法呼吸）
  4. 一旦拔管後就失去對動物氣道的控制，故要格外小心
26
Q

notes of intubation

A
  1. 開嘴後就要進行插管
  2. 喉頭鏡壓舌根，下降會厭軟骨epiglottis
  3. Do not touch epiglottis，否則容易造成喉頭水腫edema而增加插管困難
  4. 看清聲門glottis> 插入插管 >確認插管在氣管內，對齊剛剛記下的插管深度 ，利用紗布條於舌根處緊緊綁住插管（插管only），需注意不得綁到 cuff 的管線，
  5. 接著將綁嘴繩 /紗布固定於上顎或是耳後，須注意固定在上顎時要綁在犬齒後方。若要固定於耳後，則需繞過雙耳並且綁緊 à 最後進行測漏地方
  6. **貓: 容易遇到喉頭痙攣（oropharyngeal spasm）或勺狀軟骨（arytenoid cartilage）僵硬的狀況，而造成插管困難，此時可將 lidocaine 滴在兩片勺狀軟骨上，幫助緩解喉頭痙攣的現象，也可利用 stylet 協助插管，使插管更容易進入氣管深部。
  7. **若動物出現過多呼吸道分泌物時，利用小棉棒清理喉頭，以維持良好插管視野
  8. 負責保定動物的人：不要block掉視線，插管后馬上hold住插管，固定好位置讓另外一個人可以綁繩子
27
Q

how to confirm well-intubation has been done?

A

接上生理監視儀器，看有沒有EtCO2

P氣聽有沒有同時產生肺音，確定雙側皆有肺音，確認插管並無過深而進入單側支氣管的狀況，或是插入食道

28
Q

麻醉機器測漏方式 after intubation

before 手術如何側漏

A
  • 插管固定完成後，需再次確認氧氣是否開啟，並開始測漏。此時著首先輕壓一次氣袋， 讓插管者聽漏氣聲。
  • 接著再以輕壓氣袋到 20cmH2O 並持續 5 秒的方式，讓插管者將 cuff 打飽至漏氣聲消失。此時需回抽適量 cuff 內空氣至有漏氣聲，並再次打入少量氣體，確認沒有聽見漏氣聲。
  • 如此也可以確認cuff不會打太飽，導致氣管撕裂傷
  • 接下來可先打開 isoflurane，嗅聞管插管連接處有無 iso 的味道以進行測漏。

before 手術如何側漏

  • 鎖最緊、關O2
  • 把開口堵住
  • flush 20mmHg O2 ，之後用手壓氣袋，讓pressure升到30再放開
29
Q

Eye ointment

A

○ Perioperative corneal protection：麻醉狀態下à角膜反應消失、眼淚分泌減少，給予眼藥膏做角膜的保護
○ Dip in conjunctival cavity (not the surface) à 揉一揉
○ Tetracycline：allergy risk in catsàprohibited!!!
○ Duratear：脂溶性，手術時間較長可以給
○ Optixcare：水溶性，較舒服

30
Q

IV fluid

A

Initial rate：3ml/kg/hr for cats; 5ml/kg/hr for dogs

Adjust according situation of each animal

若在理學檢查時就發現動物水和狀況不佳，根據體重*脫水百分比*1000 ml先補足動物脫水 再進行手術

成分：LRRS

如果病患有因為RS LR成分有任合狀況而不能用的話，就會選NS

Blood glucose 過低 –> 補充

31
Q

isoflurane

A

MAC (minimal alveolar concentration)

Concentration that 50% of animals could be maintained at the anesthetic stage

  1. Dog: 1MAC=1.3%
  2. Cat: 1MAC=1.7%

Pros

  1. Elimination via respiration
  2. Quick metabolism, no accumulatiion
  3. Can adjust to the depth you want easily

Cons

  • Cardiovascular depression: blood resistance –> fall in blood pressure
  • Respiratory depression: Respiration rate and tital volume fall

NOTE: over-anethesia ->oxygenation only

32
Q

術後 POM

A

(公如無意外不做⽌止痛藥)

  1. 抗⽣生素Cephalexin(⽝犬) / Amoxicillin(貓) 20-23 mg/kg, BID for 3 days(250 mg/cap)
  2. ⽌止痛藥+制酸劑組, SID for 3 days

1 Meloxicam 0.1 mg/kg(7.5 mg/tab) 2 Famotidine 1mg/kg(20mg/tab)

33
Q

how to choose Endotracheal tube?

A

鼻徑、觸診、體重對照查表然後 ± #0.5（最後取一個折衷尺寸）

深度：入胸處（也就是第一胸骨的位置），用犬齒或鼻頭當作深度landmark

34
Q

how to choose BP cuff?

A

比前手臂的寬度，綁在前手臂的中後段

35
Q
A
36
Q

Peri-operative fluid rate

A

Ÿ Initial rate: Cats: 3ml/kg/hr, Dogs: 5ml/kg/hr

Ÿ Maintain: Cat: 2-3ml/kg/hr, Dog: 2-6ml/kg/hr

Ÿ 血壓過低的話，可能可以調高（在hypovolemic的狀況下），但是不能超過10 ml/kg/hr

37
Q

麻醉過程要不斷去監測麻醉深度, by how?

A
  1. 每隔5mins紀錄一次，可以先把5, 10, 15, 20, 25……時間先寫好在上面，前面可以留半小時的空白(induction的那段過程) (因為induction時通常比較忙可能會來不及抄寫)。
  2. 先抄當下會立即變動的數值：HR、SpO2、EtCO2；再抄過一段時間還會留著的數值：BP(SAP, MAP, DAP)、BT。抄完檢查是不是7項數值都有。
  3. 了監測麻醉深度外，也要不定時去看手術當下的步驟，尤其在一些會很痛的步驟（像是結紮血管、彈斷suspensory ligament）會需要注意好動物的心跳血壓有沒有變化太大。或是麻醉深度很淺
38
Q

Post-operative Fluid therapy

A

RER*某個常數* 1/2 - 1/3再扣掉’’手術中給的輸液量’’

Ÿ RER = BW^0.75 * 70

Ÿ 常數: 未結紮的成年狗通常用1.8，貓可能再少一點到1.6之類的

39
Q

Mouth – opening

A
  1. 確認病患達到適當的麻醉深度後，助手一手扣住上犬齒後方，掀起嘴皮往上，將上顎抬起，另一手藉由紗布拉住舌頭
  2. 從下顎犬齒間往下拉出舌頭，並將下顎打開，此時需注意，扣住上顎並抬起時需收起臉 部毛髮並調整手指位置，以避免阻礙插管視線
  3. 開嘴時病患氣道要呈現一直線，避免彎折，但也不能過度仰起，否則同樣會使氣折，而阻礙插管視線
  4. 側躺插管特別注意，要使病患口吻部與脊椎呈現一直線
40
Q

Comparing absorbable suture

A

monosyn

  1. Shorter time to be absorbed
  2. softer
  3. Suitable for 皮下、表皮

PDS

  1. 30 days to be absorbed, strength reduces to a large extent at day15
  2. Tougher
  3. Suitable for peritoneum, organs
41
Q

physical exam

A
  1. male or female
  2. estrus? pregnant? discharge?
  3. RR/HR/BT (esp important for comparison with value under 麻醉
  4. MM & CRT
  5. 拉皮
  6. ascultation
  7. palpation, such as lymph node
  8. abdominal scar, ear cut
  9. 眼耳口鼻
42
Q

針盒

A
  1. cap （no need T-set）
  2. flush
  3. ominent
  4. catheter
  5. 針筒 （1cc, 3cc）
  6. 膠帶（已經撕好的）
  7. 彈繃 （一小段）+棉花包在裡面
43
Q

一般貓會用幾號的插管

用多大的larypharygscope

A

for 3-4 kg cat –> 4號

44
Q

how to know cavity is reached when incising into abdominal cavity?

A

use of blunt scissors to check

45
Q

除跳蚤藥

A

body Weight！

dip on the area that it could not touch, such as 耳後

要拔開毛再點下去

radiography (7 decks)

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