Lecture 4: Operative Process Flashcards
What is the general rule for NPO guidelines prior to surgery?
Nothing to eat or drink after midnight prior to surgery (except sips of water/meds)
In general how long before surgery should NG tubes be stopped?
8 hours prior to surgery
What is the one exception for stopping feeding tubes 8 hours prior to surgery?
If the feeding tube is post-pyloric
What is the timeframe that a SSI must occur within?
Within 30 days or 90 days if a prosthetic was implanted
What are the 4 criteria that define an SSI? (only 1 is needed to make a Dx)
- Purulent exudate
- culture
- Reopened wound d/t signs of infection
- Surgeon’s diagnosis
What are the 2 major differences between SSIs and colonization?
SSI - bacteria elicit a host response, impedes wound healing
Colonization - bacteria DONT elicit a host response, usually doesnt impede would healing in healthy pts
What are the 2 MC organisms that cause SSIs?
- Staph aureus
2. Staph epidermis
What is the difference between clean-contaminated (CC) and contaminated wounds?
CC - body tracts are entered under controlled conditions
Contaminated - body tracts are entered under UNcontrolled conditions (breaks in sterile technique & inflammation present)
What are 1st generation cephalosporins (Cefazolin/Ancef) used for in ABX prophylaxis?
Clean-contaminated wounds
What type of ABX do you use if you need added Gram (-) anaerobic coverage?
- in what types of procedures are these needed?
2nd & 3rd generation cephalosporins alone
Needed in Abdominal procedures
In general is routine prophylaxis with Vancomycin recommended?
NO
- unless severe type 1 allergy to PCN
What are the 3 situations that prophylaxis with Vancomycin is appropriate?
- Hospitals where MRSA is freq cause of SSIs
- Pts w/known MRSA colonization
- Pts at high risk for MRSA (nursing home, recent hospitalization)
When should ABX prophylaxis be administered?
What is the exception?
Within 60 minutes of the surgical incision
Give Fluroquinolones & Vancomycin 120 minutes before (longer infusion time)
What is the duration for ABX prophylaxis?
Single dose OR no longer than 24 hours
If a patient has an indwelling catheter or drain is ABX prophylaxis necessary?
NO
When should you consider performing pre-op staph aureus screening?
Cardiac or Ortho procedures, Immunocompromised
high risk for complications if S. aureus infection develops
What is the Universal Protocol designed to prevent and what are its 3 elements?
Prevent wrong person, time, procedure
Elements
- Pre-procedure verification process
- Mark procedure site
- Time Out
What are the guidelines for surgical markings?
Made by surgeon
Mark must be:
- unambiguous (surgeon’s initials)
- near site w/surgical marker that wont be washed off after surgery prep
- must designate L/R, multiples levels or structures
“X” cannot be used!
How do you evaluate airway assessment in a preoperative patient?
"LEMON" L - Look (general impression) E - Evaluate (using 3-3-2 rule) M- Mallampati Score (good is <3) O - Obstruction/obesity N - Neck Mobility
What are the factors associated with a difficult airway for mask ventilation?
BMI >30, beard, edentulous, age >55, Mallampati >3, poor mandibular protrusion, male, airway mass
What are the factors associated with a difficult airway for laryngoscopy/ intubation?
Prior difficult intubation, Mallampati >3, intubate w/out NMBA, male, large neck, cant extend neck
What are the components of a surgical time out prior to incision?
- Team members introduce themselves by name/role
- Surgeon, anesthetist, nurse confirm right pt, site, procedure
- Surgeon, anesthetist, nurse address anticipated events
- Confirmation of ABX prophylaxis w/in last 60 min
- Essential imaging displayed
What are the 3 main types of anesthesia?
- General
- Regional
- MAC (Monitored Anesthesia Care)
What types of procedures use general anesthesia and what are the main IV agents used?
Abdominal, Head, & Neck procedures
Propofol, Ketamine, Etomidate
How does general anesthesia differ from the other two types?
It involves airway management and affects the entire body
What is the most common IV agent used for general anesthesia and what are its S/E?
Propofol
- hypotension
- Resp depression
- painful injection
Why are IV adjuvants used in general anesthesia?
- Reduce dose of hypnotic/sedative
- blunt airway reflexes (gag reflex)
- minimize pain of injections
What are the 3 MC used IV adjuvants?
Opioids (fentanyl)
Lidocaine
Benzos: Versed/midazolam - for anxiety
What are the three phases of anesthesia?
- Induction
- Maintenance
- Emergence
What type of agents are used during the induction phase?
fast acting IV agents
Why are inhaled agents used during the maintenance phase and what are they (3)?
They are volatile/irritative, causing post-op N/V so they’re given after pt is asleep
- Sevoflurane
- Desflurane
- Nitrous Oxide
What inhaled agents is used as an adjuvant?
Nitrous Oxide
What types of agents in general anesthesia relax striated muscle and are used for paralysis?
NMBA (Neuromuscular Blockade Agents)
What drug/type of NMBA is used for RSI (rapid sequence intubation)?
Succinylcholine
depolarizing NMBA
What is true of non-depolarizing NMBAs but not true for depolarizing NMBAs?
Non-depolarizing NMBAs have a reversal agent, depolarizing NMBAs do not
How is maintenance usually accomplished?
inhaled agent + NO + opioid + muscle relaxant
How do you mitigate autonomic hyper-responsiveness (HTN, tachycardia, bronchospasm) in the emergence phase of anesthesia?
Beta blockers, lidocaine, narcotics
Where is spinal anesthesia administered and what procedures is it used for?
injected into subdural space at L3-4/L4-5
Total hip/knee surgery
Where is epidural anesthesia administered and what procedures is it used for?
injected b/t ligamentum flavum & dura
Childbirth (works until it’s stopped)
What are the risks/complications of regional anesthesia?
Epidural hematoma/abscess, urinary retention, spinal HA
What types of procedures is MAC used for and what does it enable that other anesthesia types dont?
Used for short painful procedures (debridement, breast Bx, peds procedures, colonoscopy)
It enables spontaneous breathing the entire time (no complete LOC, just sedation)
What kind of ABX coverage do you need to add if you give Vancomycin?
Gram negative coverage
When are ketamine and etomidate preferred for induction of anesthesia
When pt is hemodynamically unstable
What is a dirty wound?
Old traumatic wound or existing infection (pus, perforated viscera)
