4- Intro to Surgery/ the PA Role Flashcards
What was the goal of the 7 project guidelines of the Surgical Care Improvement Project (SCIP) Protocol?
Prevent avoidable/ infection-related deaths
What is used to indicate preoperative health/ operative risk?
ASA classifications I-VI
(I- healthy, VI- brain dead)
What is the Mallampati score used for?
Assess for ability to intubate, class I-IV
I- complete visualization of soft palate
II- complete visualization of uvula
III- visualization of only base of uvula
IV- soft palate not visible
What pre-op study should be ordered for a healthy pt who is older than 50 yo or has hx of cardiac/ pulm disease?
CXR
When should you obtain a pre-op 12-lead ECG?
Men > 45 yo
Women > 55 yo
Hx of cardiac disease, DM, HTN, diuretic use
Major surgery
What is the #1 RF for pulmonary complications during surgery?
Cigarette smoking/ vaping
If pt has hx of myocardial infarction, what is the protocol for elective surgeries?
Postpone until > 6 months post-MI
What cardiac specific RFs place pts at a greater risk for peri-operative MI? (2)
(want < 10 pts when evaluating RFs)
MI in previous 6 mos
S3 gallop/ JVD
When evaluating for coagulation abnormalities, what specific medication use should be noted? (2)
NSAIDs
Anti-coagulants
Pre-op elevations in glucose or A1C levels in pt w/ DM are a/w what?
Increased risk of post-op infections
What adjustments should be made for pt w/ DM prior to surgery?
NPO after midnight- adjust insulin regimens, hold oral agents in a.m.
What post-op management is included in a pt with DM?
Follow blood sugar q 6 hrs, maintain between 150-200
Restart insulin/ oral agents when resume eating
What precaution should be taken for surgery if adrenal insufficiency?
Additional steroids peri-operatively
What is the meaning of -pexy?
Fixation
What is the meaning of -rrhaphy?
Suturing
What is the use for a McBurney incision?
Appendectomy only
What is the most important part of positioning the pt for surgery?
Protect the patient
What type of positioning is most commonly used for general surgery (from diaphragm to pelvis)?
Supine
What type of positioning allows for increased exposure to pelvic organs and is used when placing central lines?
Trendelenburg
What type of positioning allows for enhanced exposure to upper abdominal viscera?
Reverse Trendelenburg
What type of positioning is used for craniotomies of the posterior fossa and cervical spine surgery?
Sitting
What type of positioning is used for urologic procedures, gynecologic procedures, and rectal surgery?
Lithotomy
What type of positioning is used for spinal surgery?
Prone
What type of positioning is used for thoracotomies, nephrectomies, and retroperitoneal approaches?
Lateral
What type of gas is used to insufflate the peritoneum in laparoscopic surgery?
CO2 (better solubility in blood)
What is an adverse effect a/w laparoscopic surgery?
Post-op referred shoulder pain
(due to CO2 on diaphragm and diaphragm stretches)
Which operations are commonly done laparoscopically? (4)
Cholecystectomy
Appendectomy
Inguinal/ ventral hernia repair
Nissen fundoplication
What is included as part of post-op daily rounds?
Check wounds daily
Vital signs/ I+O
- I+O q 4-6 hrs POD 1
- Fever POD 3-5, r/o infection
Advance diet/ control blood sugar
Meds, blood products, and malignant hyperthermia are most likely causes of post-op fever after how long?
Immediate (hours)
Nosocomial infections, UTI, and aspiration pneumonia are most likely causes of post-op fever after how long?
Acute (first week)
SSI, infection from central venous catheters, abx associated diarrhea are most likely causes of post-op fever after how long?
Subacute (1-4 weeks)
Infection/ abscess is the most likely causes of post-op fever after how long?
Delayed (> 1 month)
What diagnostic work-up is indicated if fever is noted 48 hrs post-op or > 102 deg?
(aside from looking at the pt)
[CBC, UA, cultures] x 2
CXR
What is the most common cause of fever in the first 48 hrs after surgery and what is the tx?
Atelectasis
Tx: incentive spirometry, cough/ deep breathing, ambulation
What is the tx for post-op fever 0-48 hrs if due to wound infection (group A strep)?
Open wound + abx
What is the tx for post-op fever 0-48 hrs if due to leakage of bowel anastomosis?
Back to OR
What is the tx for post-op fever 0-48 hrs if due to aspiration pneumonia?
Pulmonary toilet + abx
What common complications are a/w fever POD #3-5?
Wound infection
Intra-abdominal abscess
Although DVT can occur anytime, it usually presents w/ fever at POD #?
7-10
Fever due to UTI most commonly occurs after POD#?
3
What local factors affecting wound healing are a/w increased rate of infection and would dehiscence?
Hematoma/ seroma
Epinephrine can be used to control bleeding but should be avoided where?
Areas where distal ischemia may occur- fingers, toes, ears, nose, penis
Irrigation w/ saline removes gross contaminates but does NOT do what?
Sterilize
How long should a wound dressing be left in place for a clean surgical wound?
48 hrs to allow for epithelialization
What type of wound dressing is used for contaminated wounds?
Packed open to promote hemostasis/ drainage
(wet to moist changes q 8-12 hrs)
Infection accounts for 1/2 of all post- op complications and is most common 3-7 days after surgery. IF within 1-2 days, what are the likely causative agents?
Claustridia, group A strep
What is the management for expanding hematomas vs small hematomas?
Expanding hematomas - evacuated and control bleeding
Small hematomas- may be left alone
Sudden drainage of pink, serosanguineous, salmon-colored peritoneal fluid noted at 5-8 days post-op is suspicious for what type of wound complication?
Fascial would dehiscence
Back to OR
What is the biggest source of surgical infection?
The patient
What is the optimal time for admin of parenteral abx for prophylaxis?
30-60 min prior to incision
D/c after 24 hrs post-op
What abx satisfy the criteria for most operations and are used prophylactically?
1st and 2nd gen Cephalosporins
What pulmonary complication is seen in the elderly and in pts with decreased mental status, and is often a/w NG feedings?
Aspiration
(tx: elevate HOB- 30 deg, NG suction, nasotracheal suctioning)
Pt w/ indwelling cath, urinary retention, and stasis is at risk for what surgical complication and what is the tx?
(PE = cloudy urine, fever)
UTI
Tx: abx, remove indwelling cath → intermittent cath q 4-6 hrs
Surgical complications can lead to what intra-abdominal infections? Suspected etiology?
Abscess, peritonitis
E.coli, enterobacter, bacteroides
What is included in evaluation if suspicious for bacteremia?
(fever, chills, tachycardia, leukocytosis, hypotension)
Check IV sites (redness, tenderness, palpable cords, gross purulence)
Blood cultures x 2
What is the management for bacteremia? (4)
Change IV lines q 3 days
Make sure lines are properly sealed
Abx
I+D/ vascular consult if suppurative vein
What type of debridement uses the body’s own enzymes to liquify necrotic debris and maintain a moist wound environment and when can it NOT be used?
Autolytic
NOT used for infected wounds
What type of debridement uses chemical enzymes to turn necrotic tissue into slough, causes minimal/ no damage to surrounding tissue and when is it best used?
Enzymatic
Hard/ large amounts of eschar
What type of debridement includes a wet to dry dressing or hydrotherapy, is painful, and can cause maceration/ risk of exposure to waterborne pathogens?
Mechanical
When is sharp surgical debridement best used?
Large amounts of necrotic tissue, especially in infected wounds
How long are disinfected fly larvae placed in a wound for maggot debridement therapy (MDT) and what is the primary disadvantage?
2-3 days
Highly perishable (use w/i 24 hrs of delivery)
What is included in the management of wound exudate?
Maintain moisture (add moisture if dry)
Absorb excess drainage (foam, negative wound pressure)
AVOID wet to dry
What tool is used to create sub-atmospheric pressure in the wound bend to enhance granulation and increase perfusion to the wound bed?
Negative pressure wound therapy (NPWT)
The following are contraindications to what type of wound therapy?
Necrotic tissue, untreated osteomyelitis, fistula to body cavity, malignancy in wound, exposed artery/ vein
Negative pressure wound therapy
What should be suspected if a wound isn’t healing/ worsens, if exudate/ pain increases, or if odor develops?
Infection
What type of suture is a/w increased risk of infection but is less apt to tear?
Braided
(silk, vicryl)
What type of suture reduces risk of infection, and can expand w/ tissue swelling?
Non-braided
(prolene, monocryl)
The larger the suture number, the smaller the what?
Suture/ needle
What size suture is used on abdominal muscle and fascia?
1.0-2.0
What size suture is used for skin closure, NOT on face?
3.0-4.0
What size suture is used on the face?
5.0-6.0
What size suture is used on vessels (microsurgery) and anastamoses?
> 7.0
What type of suturing is good for all types of wounds, and allows for selective removal in case of infection?
Interrupted
What type of suturing is used for clean wounds, fast to sew, easy to remove, and a/w compromised wound integrity if secondarily infected?
Continuous
What type of wound closure is a 2 person job, and you must approximate skin edges/ do not invert skin edges?
Staples
(surgeon preference to use)
