Exam 2 Flashcards

Question

1. List the major areas addressed in the preoperative assessment of the surgical patient.

Answer 1

1. Patient History -Frame questions to avoid vague responses -Signalment -Presenting Complain -Diet, exercise, environment, past medical history/problems. -Recent treatments: anti-inflammatory, bacterial, etc. 2. Physical exam -Systematic evaluation including all body systems -General condition -Attitude, mental status Emergencies: deal with big problems first -Evaluation of the preanesthetic status is one of the best determinants of the likelihood of cardiopulmonary emergencies during or after surgery. 3. Laboratory data: "Big 4" or "Quats" at minimum for healthy animals undergoing elective surgery -PVC (hematocrit) -Total Protein (TP) -Blood glucose -BUN Animal >5-7 years old should get "Minimum database" -CBC and differential -Serum Biochemical profile -Urinalysis 4. Associated underlying disease Identification of associated or underlying disease influences -Preoperative management -Surgical Procedure performed -Prognosis -Postoperative care required Examples: -Neoplasia: evaluate for metastasis. Radiographs, abdominal ultrasound, lymph node aspiration. -Cardiac disease: Thoracic radiographs, cardiac ultrasound, ECG. -Testing for endemic diseases: heartworm disease, etc. -Trauma patients should get radiographs a. Diaphragm: diaphragmatic hernia b. Pleural space: pneumothorax, pleural effusion c. Lungs: Pulmonary contusion 5. Patient stabilization -Obtaining preoperative information allows comparison of the animal's status before and after surgery (e.g., ability to micturate before and after spinal surgery). -Patient should always receive a complete physical examination, followed by the appropriate laboratory work-up. -Thorough history helps determine the extent of needed physical and laboratory examination

Answer 2

-Once history, physical exam, and lab work are completed, the surgical risk can be estimated, and a prognosis given. **the surgical procedure risk may outweigh its potential benefits** -Quality of life must be considered for veterinary patients -Patients with severe debilitating untreatable disease may not benefit from surgery -For some patients surgery may improve the quality of life even if length is limited -**Professional communication with owners is critical!** Prognosis Criteria -Excellent: potential for complication is minimal, high probability return to normal -Good: some potential for complications, high probability of good outcome -Fair: Serious complications are possible, but uncommon. Recovery may be prolonged. Animal may not return to its pre surgical function. -Poor: underlying disease, may lead to severe complications during surgery. Prolonged recovery. Unlikely to return to its pre-surgery function -Guarded: Outcome is unknown or uncertain Client Communication Inform owners before surgery -Diagnosis -Surgical and nonsurgical options -Potential complications -Postoperative care -Prognosis -Cost: can not be predicted because of anticipated complications. -Owners should be kept appraised of the animal's status and of procedures that may affect the initial cost estimate. -Waiver signed by the owner authorizing surgery and accepting anesthetics risks. -Neutering should be recommended in hereditary diseases -A signed estimated form -Special concerns for euthanasia Patient Stabilization -IV fluids are indicated general anesthesia and surgery -Preoperative antibiotics may be indicated Dietary restrictions Adult animals: 6-12 prior NPO, access to water. Young animals: 4-6 hours NPO, hypoglycemia concerns.

Answer 3

Physical Status Scale, add E for emergency I. Healthy with no discernible disease (elective procedure) -Ovariohysterectomy -Declaw -Orchiectomy II. Healthy with localized disease or mild systemic disease (patellar luxation, skin tumor) -Skin tumor -Cleft palate without aspiration pneumonia III. Severe systemic disease (pneumonia, dehydration) -Heart murmur -Anemia, acute <20 or single digits IV. Severe systemic disease that is life threatening (heart failure, renal failure, hepatic failure, hemorrhage, severe hemorrhage) V. Moribund; patient not expected to live longer than 24 hours with or without surgery (endotoxic shock, multi organ failure, severe trauma).

Answer 4

SSIs Classification -Must occur within 30 days of the surgical procedure -Occur within one year of its associated surgical implant and related to the operation -Incisional: infection of the actual site of the surgical incision a. Superficial: involving the skin and SQ tissue. b. Deep: involving deep soft tissue layers such as incisional fascia and muscle. -Organ space: infection of the anatomical part that was manipulated during the surgery Normal flora -Staphylococcus epidermis -Corynebacterium spp. -Pityrosporum spp. Transient Pathogens -Staphylococcus aureus -Staphylococcus intermedium -Escherichia coli -Streptococcus spp. -Enterobacter spp. -Clostridium spp.

Answer 5

Preparation of the Operative Site *Patient is not a table *Soiled sponges will not be placed back on the instrument table, trash or floor. *Patient positioning is ultimately the responsibility of the surgeon *Arrange your surgical table in a manner that is logical to allow you find instruments quickly and accurately Surgical Site Infection -Most common source: Staphylococcus aureus, Streptococcus app. -preoperative preparation reduces the number of bacteria and the likelihood of infection Antisepsis -The prevention of sepsis by preventing pr inhibiting the growth of resident and transient microbes Antiseptic -Product capable of producing antisepsis, antimicrobial agent ex: Chlorhexidine Gluconate superior, Povidone Iodine Clipping and prepping your patient -Bathing the day before maybe good or even necessary -Infections should be identified and addressed prior to surgery -Shaving should be done as close to surgery time as possible. DO NOT SHAVE NIGHT BEFORE -NEVER SHAVE in the OR -Use #40 clipper or #10 if dense hair. Pencil grip on clippers -20 cm on each side of incision -Vacuum hair -OHE clip from just above the xyphoid to the pubis and laterally beyond the nipple line. -Flush the prepuce of male dogs before sterile preparation -Patient positioning: before application of the epidermal germicide, warm blankets, ground plate, etc. -Exclude the paw if not included in surgery using VetRap -Sterile skin Prep: handle sponges with sterile sponge forceps or gloved hand using aseptic technique -Use less dominant hand to remove sponges -Prevent pooling of alcohol based solutions, flammable electrocautery

Answer 6

1. List Methods of reducing tension when closing a wound surgically. 2. Summarize the direction that surgical incisions should be made and why. 3. Summarize the considerations made when planning the surgical removal of a skin tumor. 4. Summarize the methods for recruiting skin to close wounds under tension. 5. Illustrate methods used for preventing or correcting “Dog ears,” or puckers.

Answer 7

-Relaxing incisions or "Plasty" techniques -Correct defect trauma related, congenital abnormalities -It is important to select the appropriate technique 1. Relaxing incisions or "plasty techniques" V-to-Y, Z-plasty 2. Pedicle flaps: tissue that is partly detached from the donor site and mobilized to cover defect 3. Grafts: transfer of segment of skin to a distant (recipient) Prevent: -Excessive tension -Kinking -Circulatory compromise Vascular beds -properly developed and transferred local flaps can survive on avascular beds Hirudiniasis -Attachment of leeches to skin -Tissues with impaired venous circulation When planning consider Tension Lines and Tension Relief **Incision should be parallel to tension lines** -Location of the wound -Elasticity of surrounding tissue -Regional blood supply -Character of the wound -Apposing incision edges under too much tension causes incisional discomfort and pressure necrosis, resulting in sutes "cutting out" and partial or complete incisional dehiscence Reducing tension -Undermining wound edges: by using scissors to separate the skin or penniculus muscle DEEP (or both) from underlying tissue. Bleeding may be significant. Prevent subdermal plexus injury, avoid crushing instruments. Preserve cutaneous circulation. -Selecting appropriate suture patterns a. Subdermal sutures: buried knot, 3-0 or 4-0 polydioxanone. b. Walking sutures: distribute tension over the wound surface. should be through fascia of the body wall c. External tension relieving sutures: placing sutures farther from the skin edge or using mattress or cruciate helps disperse pressure. Vertical mattress = 2cm away from primary row of sutures, placing pad material beneath the suture loops is stenting. -Using relief incisions -Skin stretching: can be done hours to days before surgery. AXIAL PATTERN FLAPS preferable for large wound reconstruction a. Presuturing b. Adjustable sutures c. Skin stretches d. Skin expanders: inflatable tissue expanders -Tissue expansion: tissue lines breed, conformation, gender, age

Answer 8

Reducing tension -Undermining wound edges -Selecting appropriate suture patterns -Using relief incisions: relaxing incisions adjacent to the wound allows skin apposition. -Skin stretching -Tissue expansion: tissue lines breed, conformation, gender, age Tension lines -Incisions made across tension lines require more sutures for closure and are more likely to dehisce than those made parallel -Incisions made at an angle to tension lines take a curvilenear shape -Traumatic wounds should be closed in the direction that prevents or minimizes tension -Wound edges should be manipulated before closure to determine which direction the suture line should run to minimize tension -If tension is minimal a wound should be closed in the direction of its long axis -The direction of closure should prevent or minimize the creation of "dog ears" or puckers, at the ends of suture lines.

Answer 9

1. Skin tension and elasticity should be assessed 2. Avoid excessive tumor manipulation 3. Direction of skin tension line, shape of the incision, and method of closure should be planned before surgery 4. Large area needs to be clipped and aseptically prepared, skin to be use for possible flaps needs to be ready just in case 5. Excision should include tumor and prior biopsy sites, wide margins, length width and depth 6. Benign = 1 cm additional tissue 7. Malignant = 2-3 cm margin, deep margin next fascia layer and cut it out. 8. Tissue easily infiltrated by tumor cells (e.g., fat, parenchyma) should be resected with the tumor Skin tumors -Excision of infiltrative or aggressive tumors should extend at least one fascial layer below the detectable tumor margins -> 2-3 cm of normal tissue -Recur often because the surgical margins of original tumor were inadequate

Answer 10

-Skin stretching: can be done hours to days before surgery. AXIAL PATTERN FLAPS preferable for large wound reconstruction a. Presuturing b. Adjustable sutures c. Skin stretches d. Skin expanders: inflatable tissue expanders -Tissue expansion: tissue lines breed, conformation, gender, age V-to-Y Plasty -Provides and advancement flap to cover wound -Make a V incision -Close the top incision first -Close starting at the edges -Last close the bottom Z Plasty -can be adjacent or involving the wound to allow wound closure -Z line perpendicular to the incision line that you want to close and parallel to the tension line -Cut at 60 degree angle -1/3 to 1/2 the size of the original incision

Answer 11

-Prevented by incise in the center to form two triangles one should be incised and the other used to fill the resultant defect. or both may be excised creating a linear suture line. -At the end of suture lines by using a center suture and unequal suture spacing. Also, resecting an elliptic segment of the skin, or resecting a large triangle or two smaller triangles of skin. -Playing sutures close together on the convex side of the defect and farther apart on the concave side -Outlining with and elliptic incision, removing redundant skin and opposing the skin edges in a linear or curvilinear fashion

Answer 12

1. Advancement flaps -Local subdermal plexus flaps -Single-pedicle, bipedicle, H-plasty, V-Y plasty. Parallel to lines of least tension 2. Rotational flaps: local and pivoted over a defect with which they share a common border -Semicircular or paired or single -A curved incision is made and the skin is undermined in a stepwise manner until it covers the defect without tension -Larger wounds 3. Transposition flaps -Rectangular, local flaps, bring additional skin when rotated into the defects. 90 degrees transposition. 4. Interpolation flaps -A variation of transpositional, but it lacks a common border with the wound. -Leaves an area of interposed skin between the donor bed and the recipient wound -Created the same way than the transpositional 5. Tubed medical flaps -Advanced procedure that should be done by a specialist. -"walk" multisegmented 6. Axial pattern Flaps -Include a direct cutaneous artery and vein at the base of the flap -Have better perfusion than pedicle flaps with a circulation from the subdermal plexus one

Answer 13

M(2): Massive hemorrhage, Muzzle A: Airway R: Respiration C: Circulation H(2): Head injury, Hypothermia E: evacuate/Pain management/Abx

Answer 14

-Initial focused examination: determine life-threatening injuries or medical problems first -Target critical organs -2 minutes or less 1. Level of consciousness 2. Unusual activity 3. Unusual body or limb postures 4. Position that suggests bone fractures, dislocations 5. Traumatic injuries

Answer 15

-Compressible -Non-compressible MARCHE Massive Hemorrhage -Ensure safety of team Muzzle dog -Massive hemorrhage: PRESSURE!!!, hemostatic dressing. Ace bandages, Oales Bandages. Airway -Restrain jaw if unconscious -Abnormal sounds, face, chest, neck. -Examine obstructions of oral cavity -Clear airway of obstructions -Soup bone caught is a common problem: pull tongue straight out between lower canines and gently pull bone up from chin to dislodge. May need sedation. -Tracheotomy: incision through annular cartilage 3-4th or 4-5th cartilages. Facilitate tube placement, depressing cranial cartilage with hemostat, secure tube with encircling suture. Tie all the way around the neck. Sternohyoid muscle. Respiration -Tension pneumothorax: needle decompression 7th to 10th intercostal space. -Thoracocentsis -Irregular breathing may indicate brain injury -Look at the gums, blue serious problem Circulation -Recheck bandages -Initiate IVs and IO -Fractures and immobilization of joint -Pulse, rate, character (strong or weak), Rhythm -MMs = or <2Secs -Absence of pulse or heart rate indicate serious problem with hear = emergency Hypothermia -Space blankets, rescue blankets -Equality of pupils = indicator of head trauma Evacuation and Antibiotics -Preplan and Practice evacuation procedures -Antibiotics should be administered quickly once need is identified

Answer 16

Forelimb -Carpal bones -Metacarpal 3 = Cannon bone -P1-3. Proximal, middle, distal phalanx -Distal Sesamoid bone = navicular bone -Stifle joint: shoulder, humeral joint -Cubital joint: elbow joint -Carpus: knee -Metacarpal phalangeal joint: fetlock -Proximal interphalangeal joint (pastern) -Distal interphalangeal joint (coffin bone = P3). Hind limb -Tarsal bones -Metatarsal 3 = Cannon bone -P1-3. Proximal, middle, distal phalanx -Distal Sesamoid bone = navicular bone -Stifle joint: Femoropatelllar and medial and lateral femorotibial joints. -Cubital joint: elbow joint -Tarsus: Hock, hock bones -Metatarso phalangeal joint: fetlock still -Proximal interphalangeal joint (pastern) -Distal interphalangeal joint (coffin bone = P3).

Answer 17

0: not perceivable 1: difficult to observe not consistently apparent 2: difficult to observe but consistently apparent under certain circumstances ex: under saddle 3: Visible at a trot all circumstances 4: Obvious at walk 5: Minimal weight bearing in motion or completely unable to move *If cannot determine the cause, treat as fracture until proven otherwise. -Digital pulsing -swelling -Wounds -Crepitus -Pain on palpation -Hoof testers -Nerve blocks if needed, never block if likelihood of fracture present is high -Always block out the foot before assuming proximal fracture -Imaging

Answer 18

-Robert Jones Bandage -Needs splints to be stable -1-2 cm thick each layer KIMZEY Splint -P1, P2, Distal cannon Bandage Cast -more expensive

Answer 19

1. Dorsal or plantar splint: distal limb. Fetlock = Metacarpal phalangeal or Metatarsal phalangeal joints and below. -Fracture on proximal or middle phalanx, distal phalanx has the hoof wall for protection and stabilization. 2. Robert jones bandage with caudal and lateral splint: Knee (carpus), Hock (tarsus) and below -Fracture Metacarpal or metatarsal 3. -From hoof to elbow/stifle -Caudal to lateral 3. Hind limb: Robert-jones with extended lateral splint. 3a. Front limb: Robert-jones bandage with extended lateral splint. Elbow and below -Fractures in tibia or radius 3b. Front limb: Caudal splint to lock carpus in extension. Shoulder joint. -Loss of triceps function, dropped below. -Caudal full length of splint -Goal is to fix carpus 4. No immobilization necessary both hind and front limb.

Answer 20

-Foot cast -Half limb cast -Full limb cast -Bandage cats -Transfixation pin cast Application -Stockinette (doubled) -Cast padding -Casting tape Bandage cast -easy to apply -can apply in the field -can be difficult to make your bandage fit again -not as stable as half limb or full limb cast Complications -Cast sores

Answer 21

1. Communication with owner, referring veterinarian, agent, insurance company. -Risks of anesthesia -Financial discussion -Outcomes -Intra-operative communication -euthanasia discussion -Before surgery: ASA score and risks with owners -Sign a consent form -Get a witness for euthanasia discussion with owner while on operating table, name on medical record. -Risks during anesthesia recovery 2. Animal preparation -history, physical exam, additional diagnostics, preparation for anesthesia.

Answer 22

-Increased complexity -Decreased surgeon experience - Increased surgical time -Increased morbidity and mortality risk -Clean -Clean contaminated -Contaminated -Dirty Manage before surgery -Electrolytes imbalance -Anemia -Dehydration -hypoproteinnemia: colloids fluid -Cardiopulmonary abnormalities: wait or not perform surgery -Unstable patient, ex: severe anemia: delay Preparation fasting -Equine: fast overnight, free choice of water, place jaguar catheter -Ruminant: fast for 24-48 hours, withheld water for 24 hrs

Exam 2 Flashcards

(46 cards)