ANZCVS 2011 Flashcards
a) Discuss the role of steam sterilisation, ethylene oxide and hydrogen peroxide gas plasma in the sterilisation of surgical equipment. Include the conditions required for sterilisation and possible limitations of each of these methods.
• Steam sterilization: Most popular method of sterilization of surgical instruments in veterinary medicine. Sterilizes by denaturation and coagulation of proteins by heat. Gravity-displacement sterilizers are the most common models currently in use in Vet Med. Pre-vaccum units operate in a similar fashion but are faster since air is pumped out before the beginning of the cycle. Water acts a catalyst, hastening the process and allowing the use of lower temperatures, but must contact all instrument. Steam is lighter than cool air and raises, forcing cool air out of the bottom of the chamber. The required conditions for sterilization are 121 C for 30 min or 132C for 15 min followed by 30 min drying time. A “flash sterilization” (immediate use steam-sterilization – IUSS) can be used for metallic non-porous (no lumen) unwrapped instruments at 135C for 3 minutes, followed by 1 min drying time, but should only be used in emergency situations (i.e dropped instrument during surgery) and SHOULD NOT be used for implantable devices. Advantages: cost effective, efficacious against spores, non-toxic. Disadvantages: Instruments with concavities, such as bowls, must be placed with the opening facing down to avoid trapping cool air, potentially leading to sterilization failure.
• Ethylene Oxide: popularly used for temperature-sensitive equipment (i.e plastics, electronics); sterilizes by alkylation of proteins which obstructs cell metabolism and reproduction. Conditions: 1000mg/L, 65C, 85% humidity and 2 to 5 hours.
Advantages: readily diffuses through wrapping materials, safe on temperature-sensitive items
Disadvantages: EO is flammable and potentially toxic. May require EO emission abatement system to reduce environmental impact.
• Hydrogen Peroxide: Sterilizes via exposure of materials to hydroxyl and hydroperoxyl microbicidal free radicals. Advantages: Non-toxic, non-pollutant, rapid cycle (30-60 min). Disadvantage: relatively high cost of units; cannot be used for linens, liquids, powders or cellulose materials.
b) Discuss the use of indicators for determining the effectiveness of sterilization. (8 marks)
Indicators are utilized to verify that the necessary conditions for sterilization have been met, and are typically process-specific. They do not guarantee sterility. The most common indicators are chemical strips, which are divided in 6 classes. The higher classes provide more parameter-specific information. The current recommendation is that a Type 1 indicator, such as sterilization tape, be placed on the outside of every surgical pack, and that an additional indicator be placed at the deepest part of the pack. Biological indicators are the best method to determine that the sterilization method was effective. Devices containing Geobacillus stearothermophilus are processed and cultured afterwards to verify inactivation (negative culture).
a) Discuss the major factors that contribute to fracture non-union. (10 marks)
- Instability: Typically caused by poor technical judgement and/or execution on the part of the surgeon. Examples include the use of external coaptation in distal radial fractures, IM pins without added constraints against rotational and axial forces, ExFix with insufficient stiffness and loose cerclage wire.
- Poor biological environment: fracture location (small muscle envelope), extensiveness of soft tissue damage (high energy trauma) and surgical trauma may affect blood supply and prolong the debridement phase delaying healing.
- Nutrition: Adequate supply of protein, calcium, vitamin C and D are essential for bone healing and must derive from a well-balanced diet. Supplements are rarely indicated except for malnourished patents.
b) List and describe the types of viable fracture non-unions based on radiographs. (6 marks)
- Vascular nonunion: characterized by cartilage and fibrous tissue formation within the fracture line. Radiographically characterized by a lucent line through the fracture observed on sequential radiographs.
- Hypertrophic nonunion: similar to vascular, but characterized by the presence of a prominent non-bridging callus.
Atrophic nonunions are not “viable” and thus do not meet the question. They are biologically inactive pseudoarthrosis. Radiographically they demonstrate no evidence of bone reaction and various degrees of bone sclerosis
c) List and describe the properties of cancellous bone grafts that are beneficial in the treatment of fracture non-unions. (6 marks)
- Osteogenic property: synthesis of new bone from donor cells, which include MSC’s, osteoblasts and osteocytes.
- Osteoinductive property: MSC’s from donor site are recruited to produce chondroblasts and osteoblasts which produce new bone through endosteal ossification. The process is mediated by growth factors such as bone morphogenic proteins (BMP) ad platelet-derived growth factor (PDGF).
- Osteoconductive property: implanted scaffold passively allows ingrowth of host capillaries , perivascular tissue and MSC’s.
d) Give three (3) examples of anatomical sites from which autogenous cancellous bone grafts are commonly harvested. (3 marks)
- Proximal humerus, distal to the greater tubercle
- Proximal tibia
- Ilial wing
- a) Name and describe the four (4) stages of acceptance of full-thickness free-
skin grafts. (12 marks)
- Imbibition – first 24-48 hours, thin film of fibrin and plasma separate the graft from recipient site, providing oxygenation and nutrition (although precarious). After 48 hours a fine vascular network begins to form withing the fibrin layer.
- Inosculation – (day 2 to 3) capillary buds interface with the deep surface of the dermis and provide more robust oxygenation and nutrition.
- Revascularization – (day 3 to 7) new blood vessels either directly invade the graft or anastomose with to open dermal vascular channels, establishing a permanent vascular supply.
- b) Describe the factors that influence successful take of a full-thickness free- skin graft during wound bed preparation, the grafting procedure and the post- operative period. (13 marks)
- Wound bed preparation: The recipient ved must be free from debris, necrotic tissue, old/hypertrophic granulation and poorly vascularized tissue such as adipose. Bone, tendons, cartilage or nerve denuded of their fibrovascular connective tissue do not support grafts. A healthy granulation bed is ideal, and light debridement to assure direct contact between graft/vascular bed should be performed. The graft should be immobilized with sutures strategically placed to prevent motion but not excessively as to create ischemia.
- Grafting procedure: poorly vascularized tissue, such as adipose, must be adequately removed. The graft must be harvested as atraumatically as possible.
- Post-op care: strong and continuous contact between graft and recipient site is fundamental. Bandages are usually necessary,but should be carefully placed to avoid excessive compression. They should be well padded and bulky to limit limb motion. Vaccum-assisted devices are advisable if available. Fluid accumulation limits inosculation and revascularization, so a nonadherent hydrophilic bandage should be applied for the first 24-48 hours. Close monitoring for infection is very important. Bacteria such as B-hemolytic streptococci and pseudomonas secrete plasminogen activators and proteolytic enzymes which disrupt the fibrin seal preventing graft adhesion.
a) Describe the gross anatomy of the salivary glands and ducts in both the dog and cat. (7 marks)
Dog
- Parotid gland – paired, large, triangular-shaped, located ventral to the horizontal ear canal. Closely associated with the maxillary vein, facial nerve and superficial temporal artery. Parotid duct opens on the parotid papilla adjacent to 104/204
- Mandibular gland – paired, large, oval shaped, located caudal and ventral to the parotid gland within a fibrous capsule at the confluence of the maxillary and linguofacial veins. Mandibular duct runs with the sublingual duct and opens on the floor of the mouth lateral and rostral to the lingual frenulum.
- Sublingual – smaller than the previous two, divided in monostomatic and polystomatic. The former originates in the rostroventral border of the mandibular gland and its duct runs with the mandibular duct, but opens in a separate papilla. The later is divided into several lobules along the mandibular duct and drain directly into the oral cavity.
- Zygomatic – irregular to ovoid-shaped, located on the floor of the orbit ventrocaudal to the eye and medial to the zygomatic arch. Has several dusts that open immediately caudal to the last molar.
Cat
• Same as dogs with the addition of a well-developed pair of molar salivary glands located caudomedial to the mandibular first molar. These are polystomatic mixed serous/mucoid glands.
b) List the reasons for the high incidence of dehiscence in oesophageal wounds. (6 marks)
Factors that contribute to a higher risk of dehiscence include lack of a serosal layer, presence of saliva and food/water boluses and constant motion from head/neck motion and respiration.
c) Briefly describe the different types of hiatal hernia. (6 marks)
- Sliding/axial hiatal hernias – characterized by laxity of the phrenicoesophageal ligaments, allowing gradual protrusion and dilation of the gastroesophageal junction into the thorax.
- Paraesophageal or rolling hiatal hernia – part of the gastric fundus herniates into the thoracic cavity
- Combination Sliding and paraesophageal hernia – combo laxity of phrenicoesophageal ligaments amd herniation of part of the gastric fundus
- Gastroesophageal intussusception – intussusception of the gastric cardia into the gastroesophageal junction
d) Briefly explain the current theories regarding the pathogenesis of perianal
fistulas. (6 marks)
Currently believed to be a multifactorial immune-mediated disorder. Other theories include poor local conformation, crypt fecalith impaction and abscessation or spread of infection from anal sacs. Colitis and enteral triggers may initiate the disorder, which is complicated by abscessation of glands and hair follicles around the anus. Breeds with a higher density of perianal glands, like the German Shepherd, are thus more predisposed to the disorder.
- Answer all subparts of this question: Illustrate the anatomy of the major veins of the gastrointestinal tract, liver and spleen. You may use a diagram if you wish. (12 marks)
b) List four (4) commonly reported types of congenital extrahepatic portosystemic vascular anomalies. (8 marks)
- Portal v. to Cd Vena Cava
- Portal v. to Azygous v.
- Left gastric to Cd Vena Cava
- Splenic V to Cd Vena Cava
- Cr Mesenteric to Cd Vena Cava
- Cd Mesenteric to Cr. Vena Cava
- Gastro-duodenal to Cd. Vena Cava
c) Briefly describe the proposed aetiopathogenesis of multiple acquired portosystemic shunts. (5 marks)
Acquired PSS are believed to occur as a result of persistent portal hypertension leading to opening of vestigial fetal blood vessels. These are typically multiple, tortuous and extra-hepatic. Most connect a portal tributary to a renal vein or directly to the Cd Vena Cava adjacent to the kidneys. The most common causes of increased hydrostatic pressure are hepatic fibrosis, congenital non-cirrhotic portal hypertension and hepatic arteriovenous malformations.
A 16-week-old kitten sustains a fracture of the distal femoral metaphysis
after minor trauma. History taking reveals the kitten is fed only minced beef.
i. Explain the likely aetiopathogenesis of the fracture in this patient.
This patient likely has Nutritional Secondary Hyperparathyroidism. The condition is induced by chronic feeding of a calcium-deficient/phosphorous rich diet leading to elevated parathormone levels. This hormone imcreases bone calcium resorption, leading to osteopenia and pathologic fractures.
A 16-week-old kitten sustains a fracture of the distal femoral metaphysis after minor trauma. History taking reveals the kitten is fed only minced beef.
ii. Other than pathologic fractures, list three (3) radiographic changes that may be seen in the skeleton of this patient. (41⁄2 marks)
Generalized demineralization, characterized by decreased bone radiopacity; cortical thinning, widening of the medullary cavity.