Part 32 Flashcards
Why operate on a patient generally? (5)
- Preferred treatment for condition
- only other treatment option rather than comfort care
- palliative surgical intervention
- elective treatment
- weighing out the benefits vs the risks
Steps of the surgical process (7)
- Preop eval H&P
- Immediate perioperative period (pre-op holding, not sterile) prep by anesthesiologist
- transfer to operating theatre and OR table, anethesia begins
- patient prep once intubated (foley, cautery pad, chloraprep and 3 min drying period)
- scrub in and draping
- operation
- post op move patient to PACU (post anesthesia care unit) or ICU if severely ill, eventually back to holding area (write post op note and orders, complete post op check within 4 hours and record day of surgery (DOS), post op day 1, 2, etc (POD) as part of daily rounds)
Maintenance fluid therapy 4,2,1 rule
- first 10 kg give 4ml/kg/hr (40ml/hr)
- second 10kg give 2ml/kg/hr (20ml/hr)
- remainder give 1ml/kg/hr (xml/hr)
-Add these 3 for total ml per hour
IV solution type used most often in surgery
Lactated Ringers
Most common type of drain to be left in a patient post op for drainage
Jackson Pratt and Blake drains
Patient expectations about a surgery
Importance of educating patient providing accurate info before procedure regarding process, risk benefit, complications, etc and give them realistic expectations regarding pain and of course obtain consent
General basic labs in preop eval H&P (5)
- CBC
- nutritional status (albumin)
- chemistry panel
- blood type
- coags
“Toeing in”
Tipping the angle of the retractor more vertical or sharply to allow a surgeon to manipulate the retracted tissue and stretch it out of the way
Procedure Note
Completed by operator for bedside procedure including PAs
Operative note
Completed by attending surgeon for an operation they complete, NOT a PA
Nasogastric (NG) tubes
PVC, polyurethane, or silicone flexible tube inserted thru the nose with the end terminating at the stomach, a salem sump tube is most commonly used for decompression (additional lumen tube for decompression of the stomach or blowing off the wall)
NG tube indications (2)
- treat ileus or small bowel obstruction with decompression (removal of contents of GI which is a good measure of how severe a small bowel obstruction is)
- enteral nutrition and administer medications short term in patients who cannot swallow
NG tube contraindications (5)
- esophageal stricture
- esophageal varices or diverticuli
- basilar skull fracture
- prophylactic placement is NOT done (such as after bariatric surgery)
- long term enteral nutrition
Placement of an NG tube steps
- gather supplies
- measure estimated length based on zyphoid to earlobe and earlobe to nares
- have patient positioned sitting up chin to chest
- insert tube horizontally
- have patient sip on water as NG tube is advanced
- ensure patient can speak
- tape in place
- connect to suction
- confirm placement thru aspiration of contents/simultaneous auscultation or abdominal x ray
NG tube complications (4)
- coiling
- reflux
- cribiform plate perforation
- pneumonia or tracheal perforation
Orogastric tube (OG)
Same idea as a nasogastric tube but thru the mouth in intubated patients, eliminates worry for nasal ulcerations, sinusitis, etc
When is a post pyloric feeding tube utilized? What 2 complications occur with it?
-When there is concern for aspiration (A simple NG tube can cause reflux into the esophagus), concerns over difficulty in placement and causing “dumping syndrome”
Long term enteric feeding options
If greater than 2 weeks, may refer to
-Percuaneous endoscopi gastrostomy/jejunostomy (PEG/PEJ) or a PEG-J which is both
What to do if a long term enteric feeding tube falls out
- courtesy call to surgeon who placed it for instruction first and foremost
- if well healed around it (well formed tract) can often just return PEG tube manually, but dangerous if new and cannot replace PEJ manually
Venting PEGs
Indications for a PEG tube in palliative care where a patient who has a distal obstruction and is terminal can continue to eat and suck out the contents as needed
Indications for a drain
Prevent accumulation of fluid (blood, pus, and infected fluids) as well as air
Open drain (penrose)
A type of drain that is open type with passive pressure simply to keep the skin open, drainage usually occurs around the tube not necessarily thru it
Closed drain
Can utilize active or passive pressure
Clean wounds
Uninfected operative wounds in which no inflammation is encountered and the wound is closed primarily, the respiratory, alimentary, genital, and urinary tracts do not qualify
Clean contaminated wound
Operative wounds in which a viscus is entered under controlled conditions and without unusual contamination
Contaminated wounds
Open, fresh, accidental wounds, operations with major breaks in sterile technique, or gross spillage from a viscus, wounds in which acute, nonpurulent inflammation was encountered as well
Dirty wounds
Old traumatic wounds with retained vitalized tissue, foreign bodies, or fecal contamination or wounds that involve existing clinical infection or perforated viscus
Nichols prep
Given a day before surgery, includes 4 components (polyethylene glycol, neomycin, azithromycin base, and metronidazole) to clean bowel before surgery
Operative techniques as infection prophylaxis after sedation but before operating (7)
- eliminate hair (trim don’t shave)
- effective skin prep and wait for it to dry (betadine or chlorohexadine)
- gentle tissue handling
- effective hemostasis
- eradicate dead space (possibility of becoming infected)
- operative time less than 2 hours
- closed suction drainage remote from incision
Postoperative fever
Low grade (100-101) fever that occurs after surgery, if develops 24 hrs after then atalectasis (try incentive spirometry), if next 48 hours then think UTI, if days 3-4 think wound infection, if day 5 DVT, and anything after that can be due to a drug fever
(wind, water, wound, walking, wonder drugs)
ASA classification of physical status in eval and prep for anesthesia and surgery
-ASA class 1 - no disturbance of any kind
-ASA class 2 - mild to moderate disturbance that may or may not be related to reason for surgery
-ASA class 3 - severe systemic disturbance that may or may not be related to reason for surgery, does limit activity
-ASA class 4 - severe systemic disturbance that is life threatening with or without surgery
-ASA class 5 - patient who has little chance at survival but is submitted to surgery as last resuscitative resort
-ASA class 6 - organ donation in declared brain dead patient
E - adding an E status to any of the above designates an emergency operation
High risk procedures (>5% cardiac complication rate) (2)
- emergency surgery
- prolonged surgeries with large fluid shift or blood loss
Medium risk procedures (1-5% cardiac complication rate) (3)
- neurosurgery
- abdominal or thoracic surgery
- minor vascular surgery
Low risk procedures (<1% cardiac complication rate) (3)
- breast surgery
- endoscopic procedures
- eye surgery
Example of a passive drain, example of an active drain
- Pentrose drain
- Jackson pratt drain (has grenade to squeeze for negative pressure to draw out material)
Pulmonary toilet
Encouragement of patients to take deep breaths, cough, and be elevated after surgery in order to increase clearing of secretions
Post op red flags (5)
- tachycardia
- hypotension
- tachypnea
- decreased urine output
- mental status changes
Minimum urine output we want to see in a patient
.5 cc/kg/hr
BUN/creatinine ratio and determination if prerenal, normal or post renal, or intrarenal
> 20 prerenal
10-20 normal or post renal
<10 intrarenal
Enhanced recovery after surgery (ERAS)
Program proven to decrease length of stay and complications in patients that begins before surgery thru pre op optimization (nutritional support, smoking cessation at least 6-8 weeks before, decrease alcohol consumption), intra op considerations (maintain euvolemia and can have liquids up to 2 hours before surgery, avoidance of systemic narcotics), post op care (early feeding, mobilization, multi modal pain management NOT just narcotics)
Pulmonary complications are responsible for up to 25% of deaths within 6 days of ____
surgery
Preop pulmonary function tests
Indicated only in patients with high risk for complication, allows for prophylactic treatment to decrease complication risk
5 elements of preop regimen
- Stopping smoking 4-8 weeks before surgery
- Dilate airways (B2 agonsits, ipratropirum bromide, inhaled steroids)
- Loosen secretions (airway humidifcation, mucolytic and expectorant drugs, chest physiotherapy)
- Adjunct medication (antibiotics or antacids)
- increase education, motivation, and facilitation of post op care
Nicotine use effects on surgical patients (2)
- Nicotine induced tachycardia
- vascoconstriction resulting in impaired wound healing
Incentive spirometer
Device with tube that placed in mouth and sucked in helps expand lungs and open airways and alveoli to prevent atelectasis and pneumonia often in post op patients
Atelectasis sequalae
-Pneumonia
Appropriate post op pain management in thoracic surgeries which tend to be very painful and result in patients decreasing their deep breathing (3)
- thoracic epidural
- intrapleural caths
- rib blocks
Common types of wounds (5)
- Abrasion (superficial violation of epidermis and part of dermis, doesn’t need to be repaired)
- skin tears (skin peeled off, doesn’t need to be repaired)
- lacerations (an UNINTENTIONAL cut - differentiating it from an incision, from a sharp carve)
- avulsions (type of laceration that involve significant portion of tissue and skin being ripped off, can be hard to get good supply to flap)
- puncture (something piercing deep into the body)
Risk factors to consider in determining treatment of a wound (4)
- location (some areas more vascular)
- type of wound (MOA, depth)
- patient characteristic (diabetic, NSAIDS or anticoags, obese, immunosuppressed)
- Timing (longer wait, greater risk of infection)
The golden period of wound healing/closure (4)
- No evidence exists to guide clinical decision making on the timing for closing traumatic wounds
- some recommend to close neck face or scalp wounds within 24 hours
- some recommend upper extremity and torso within 12 hours
- some recommend lower extremities within 8 hours
A wound that has been open and not tended to within 4 hours is automatically classified as a ___ type wound
dirty type
3 options if a patient is at higher risk (for infection) or if they fall out of the general golden rule for when to close a wound?
- close with a pentrose drain or stapling not completely shut
- secondary intention (leave wound open and apply packing changed daily)
- tertiary closure (dressing for a period then once confident no infection bring patient back in for suturing)
Does a patient need antibiotics if they have a clean uncomplicated wound and are relatively healthy?
No, typically can heal on own or with petroleum
When should antibiotics be considered in a wound? (7)
- open fracture
- cartilage involvement
- grossly contaminated wounds
- bite wounds
- foreign bodies (some)
- delayed presentation
- diabetics
Tetanus prophylaxis in wounds
-given when patient has not received tetanus vaccine in more than 5 years or if they cannot remember, if pregnant or 11 and older and has not received Tdap get Tdap if unknown can give tetanus toxoid
Lidocaine with epi is contraindicated in what areas (4) and why?
- Fingers, toes, tip of nose, and penis
- epi increases duration of lidocaine action and decreases local hemorrhage but can be so strong it results in necrosis of these distal tissues in some cases
Skin prep vs wound prep
Substances used on skin can be very harmful to subQ tissue such as betadine, hydrogen peroxide. Wounds should be prepped with normal saline or water and the skin around should be treated with betadine to disinfect
Common nonabsorbable sutures types (4)
- nylon (good workability)
- prolene/polyester (fair workability)
- surgical stainless steel
- silk (most workable)
Common absorbable suture types (4)
- vicryl (braided)
- PDS (monofilament)
- monocryl (monofillament)
- fast absorbing gut
When should braided vs nonbraided sutures be used?
Braided should not be used in cases of increased risk of infection as they are sources of bacteria to hide
Suture sizing USP sizing
The higher number such as 10-0 has the smallest diameter at .020-.029mm, all the way down to 1-0 or 0 which is the larger .35-.339mm diameter, then 1, 2, 3,4 (.4, .5, .6mm respectively)
Simple interrupted suture
Nonabsorbable suture method that is go to method of repair, goes across the wound transversely moving up
Horizontal mattress suture
Nonabsorbable suture method used to repair high tension lacerations
Vertical mattress suture
Nonabsorbable suture method used to repair deep gaping lacerations without using separate deep sutures, uses far far near near technique
Running subcuticular suture
Nonabsorbable suture method used to quickly repair non tensile lacerations, used most often in the OR
Wound care guidelines (2)
- initially should leave dressing on for 48 hours
- clean with soap and water, can shower but no tub soaks
When should sutures be removed on the face? What about the scalp, trunk, or lower extremities
Within 3-5 days, 7-10 days
4 stages of wound healing
- hemostasis (wound closed by clotting, blood vessels constrict to restrict blood flow, platelets stick together and fibrin reinforces)
- inflammatory (blood vessels get leaky causing localized swelling, should see decrease within 24-48 hours)
- proliferative (wound is rebuilt, angiogensis, rate of .6-.75mm a day)
- remodeling (longest stage, increased tensile strength, collagen is reorganized)
Aborsable vs nonabsorbable suture use
Absorbable must always be used in deep tissue and can be used in superficial as well, debatable regarding the face, nonabsorbable can be used in any superficial structure
Anethesia definition
State of controlled temporary loss of sensation or awareness that is induced for medical purposes, can include analgesia, paralysis, amnesia, and unconsciousness
General anesthesia
State that produces amnesia and analgesia with or without reversible muscle paralysis, controlled reversible state of unconsciousness involving combo of inhaled and IV medications, some benefits include good control and adaption, rapid administration, and can be reversed, but some disadvantages include the pre-op prep, cost, nausea, malignant hyperthermia, and emergence delirium as side effects
Physical exam findings a anesthesiologist focuses on during assessment
-head and neck findings such as poor dentition, large tongue, immobile neck, difficulty obtaining IV access
Mallampati scoring (I-IV)
A scoring system assessing how visible anatomic structures are in the back of the throat to determine the ease or difficutly of intubation, class I sees everything, class II loses pillars and tips of uvula but still has soft and hard palate, class III can only see base of uvula and hard and soft palate and have lost pillars, class IV has lost everything, class III and IV will see difficulty intubating
Thyromental distance
Measured from thyroid notch to tip of jaw with head extended to determine if less than 6.5cm, if it is less then suggests difficult intubation will be present
NPO rules pre op (4)
- No solid food 6 hours prior
- no clear fluids 2-4 hours prior
- don’t take any anticoagulants, ACEs, herbs and vitamins
- B blockers the morning of surgery is recommended and protective
Essentials to monitor under general anesthesia intraop (6)
- Have IV access peripheral or central
- heart monitor
- noninvasive BP
- temp
- pulse ox
- end tidal CO2
General anesthesia induction steps (6)
1) preoxygenation either by mask or nasal canula
2) sedative drug via IV access (propolol, ketamine, thiopental, or midezelam)
3) analgesic drug administered (morphine, fentanyl, dilaudid)
4) paralytic drugs (succinylcholine, rocuronium)
5) establish endotrachial tube placement
6) anesthesiologist begins maintenance anesthesia (nitrous oxide, isoflurane)
Sedative and analgesic used in intubated patients post op that will go to ICU
Propophol and fentanyl
Sedation/monitored anesthesia care (MAC)
Type of anesthesia technique where patient is responsive and maintains airway, continuum either light to moderate to deep sedation, used with local or regional anesthesia, benefits include keeping patients awake and avoiding hemodynamic instability, risks include over sedation or patient discomfort
Regional/local anesthesia
Reversible loss of sensation over a specific body area without producing unconsciusness, includes spinal, epidural, peripheral nerve blocks, local/field, and topical anesthesias, benefits include preservation of cerebral function, general less hemodynamic effect, improved early mobilization, but disadvantage is time consumption, patient discomfort, risk of nerve injury
Spinal vs epidural anesthesia
A spinal sees injection of anesthetic drug into subarachnoid space below L1-2, rapid acting and good for lower limb or pelvic surgeries vs injection of anesthetic drug into epidural space at any level, is slower acting, uses medication thru an indwelling catheter and requires multiple dosing and is most often used in lower limb, pelvic surgery, and child delivery
Peripheral nerve blocks
Injection of anesthetic around peripheral nerve or plexus, single injection typically, used for intra op anesthesia or post op pain relief, not associated with nausea/vomiting, headaches, or hypotension
Malignant hyperthermia
Life threatening clinical syndrome of hypermetabolism involving the skeletal muscle triggered by inhaled certain anesthetic agents and paralytic agent succinylcholine***, autosomal dominant inherited with reduced penetrance (not always received but is dominant) - not an allergy! Sees large quantities of calcium released from SR of skeletal muscle causing hypermetabolic state and aerobic and anaeroic metabolism producing heat, acidosis, and rigidity
Malignant hyperthermia signs and symptoms (5 early and 6 late)
- arterial CO2
- tachypnea
- flushing
- rigidity or masseter spasm
- pyrexia
- mottled skin and cyanosis
- rhabdo
- DIC
- cerebral edema
- death
Malignant hyperthermia treatment** (6)
- stop surgery
- discontinue inhalation agents and succicholine
- hyperventilate 100% O2
- dantrolene 2.5mg/kg Q 5 min PRN*****
- monitor and treat temp, urine output, hyperkalemia, ABGs, etc
- ICU admission
Malignant hyperthermia diagnosis (3)
- clinical diagnosis in the surgical setting
- caffeine halothane contracture test (muscle biopsy)
- molecular genetic testing (these last 2 are for future cases)
Tenae coli
Longitudinal smooth muscle straps that travel along the wall of the colon existing along entire colon except for rectum where they become a splayed out form of continuous muscle, important surgically to determine the level of the rectum from the sigmoid colon, important to remove all diverticuli below
What separates the ascending and transverse colon? What about the descending and transverse? What are the epiploica?
The hepatic flexture, the splenic flexture,
fatty extensions off of the colon that aren’t surgically relevant but can become torsed and mimic appendicitis or diverticulitis
The blood supply to the small bowel and colon (4)
- The superior mesenteric supplies the entire small bowel and the right colon, hepatic flexture, and proximal 2/3 of the transverse colon
- the inferior mesenteric supplies the distal 1/3 of the transverse, descending colon, sigmoid, and part of the rectum
- the internal iliac supplies the distal rectum
- the venous supply enters the portal circulation before re-entering systemic,
3 branches of the superior mesentaric artery
- Middle and Right Colic Arteries
- Ileocolic Artery
3 branches of the inferior mesenteric artery
left colic artery, sigmoid artery and superior rectal artery
Intracorporeal vs extracorporeal anastamosis
Intracorporeal is laproscopic leaving the bowel inside the body vs extracorporeal is drawing out the bowel to the outside of the body for anastamosing before reinserting into the body
Why do hemicolectomies require large excisions beyond the boundary of the lesion?
Because of the mesenteric supply and 12 lymph nodes need to be sampled from a large section in determination of staging
Rectal cancer surgical options (2)
- lower anterior resection (most of sigmoid colon to lower portion leaving cuff of rectum below, includes entire section of mesentery posterior to it)
- abdominal perineal resection (removing entire rectum including anal opening, includes transabdominal incision portion and anal incision portion, then freed thru transabdominal area leaving hole for colostomy for rest of patients life)
Indocyanine green
IV dye that gives an image of the vascularization of a bowel to determine where to divide bowel so when anastamosed blood supply is accurate, used often in robotic approaches to colon surgery
Different ways to perform an anastamosis (5)
- End to end
- end to side (for discrepencies in size)
- side to end (for discrepencies in size)
- functional end to end
- side to side
-typically done hand sown or with staple techniques
What considerations exist for right and transverse hemicolectomy? (5)***
- Right ureter (travels at the base of the mesentery, we often need to remove the mesentary for its lymph nodes!)
- duodenum
- duodenal veins
- omentum
- gastrocolic ligament (connects greater curvature of stomach to the colon)
What considerations exist for a left hemicolectomy (2)***
- spleen (splenocolic ligament can rip capsule of spleen)
- left ureter (travels at base of mesentery and we often remove the mesentery for its lymph nodes)
What considerations exist for a rectal resection? (7)***
- total mesorectal resection
- bladder
- lateral stalks
- prostate
- urethra
- vaginal wall
- presacral venous plexus (buried in the waldayer’s fascia, used to be controlled with sterile thumb tacks)
Should an NG tube be used after anastamosis?
Not typically, after surgery the GI tract goes into ileus (cessation of peristalsis after surgical intervention) but we see faster return in patients who do not use an NG tube generally
DVT prophylaxis in colon surgery (3)
- compression stockings
- chemical prophylaxis (fractionated heparin, lovonox) unless a contraindication everyone gets
- ambulation as soon as possible
Primary indication for gastric surgery
Carcinoma of the stomach
Blood supply of the stomach (3)
- Right gastroepiploic vessels that travel on the greater curvature which is a branch off the gastroduodenal artery - duodenal ulcers erode this
- left gastroepiploic attaches at the spleen,
- left and right gastric artery, which are branches of the celiac trunk and the common hepatic artery respectively and supply the lesser curvature
Parts of the stomach (4)
- cardia (esophageal entrance)
- fundus (dome over top the cardia)
- body (has lesser and greater curvatures)
- antrum (lower area exiting at the pylorus, houses parietal cells that secrete acid - important if needs to be resected)
Roux en y esophagojejunostomy/gastrojejunostomy
Division of the jejunum from the duodenum and bringing it up to anastamose with the esophagus (or the stomach in a gastrojejunostomy), then reanastamose the duodenum and biliary tree to the distal jejunum so secretions are maintained (jejunojejunostomy)
Billroth I and billroth II procedures
- Removal of the distal stomach and pylorus by attaching the duodenum directly to the stomach
- Removal of the distal stomach and attachment of the jejunum sideways to end of the stomach so the duodenum floats proximally while being sealed off (its often too inflamed to do a billroth I in this case, can cause bile reflex gastritis)
Postgastrectomy syndromes (4)
- Smaller capacity
- bile reflex gastritis
- dumping syndrome (high carb load in gut draws fluid into the lumen causing diarrhea and dumping)
- afferent/efferent loop syndrome (obstruction of portion leading up to stomach or portion after so see vomiting of food in efferent but not afferent as there is no flow of obstruction thru the GI tract, mechanical obstruction due to length or adhesion)
Distance from incisors to gastroesophageal junction (GE junction)
35-40cm
Gastroesophageal junction (Z line)
Transition point from squamous cells to columnar as the esophagus becomes the stomach with a physiologic sphincter existing just above it
Vascular supply of the esophagus (3)
- Upper by branches of inferior thyroid artery
- middle from thoracic aortic branches
- lower from phrenic artery for GE junction
Ivor Lewis approach
Right thoracotomy at 5th rib and abdominal incision for malignant middle and upper esophagus surgery that is difficult to reach any other way because of the great vessels
Left thoracotomy
Used for malignant lower esopagus lesion via incision around the 7th intercostal space
Transhiatal esophagectomy (orringer) procedure and one complication
Total esophagectomy involving division of esophagaus proximally, attach pentrose ring thru the esophagus, pull it thru the abdomen, divide the stomach, then attach stomach to tube, draw tube out of mouth to translocate stomach into the posterior mediastinum
-mediastinitus with leaked anastamosis
Achalasia definition and surgical treatment
Aperistaltic esophagus or where the LES will not relax due to demyelination of the ganglions of the myenteric plexus, has characteristic birds peak finding on barium swallow, typically treated with muscle relaxants or botulinum toxin
-Heller myotomy (esophagocardiomyotomy with 6cm proximal and 2cm distal to GE junction divisions to take away the majority of the constricture away - the LES remvoal), vulnerable to GERD, some take the cardia of the stomach and wrap it creating a toupet as it will constrict and dilate helping to preserve some of the function of the LES
Internal hemorrhoids are located just above the ___ line making them painless compared to external
Dentate line (separates analderm from rectal mucosa)
Most common cause of small bowel obstruction
Adhesions
What considerations exist for a sigmoid colectomy (3)***
- left ureter
- right ureter
- bladder
Anterior to the rectum guarding the genitals is ____ fascia, between the rectum and the sacrum is the ___ fascia
denonviller’s, waldeyer’s
Colon cancer with ovarian metastasis mortality rate
very very high, often indicates question of oopherectomy alongside colon resection
Per oral Esophageal Myotomy (POEM) procedure
Endoscopic treatment for achalasia that involves penetration of the mucosa of the esophagus into the submucosa but within the muscle to then open a submucosal channel, draw it back up and divide the musculature with a cautery tool to divide the musculature all the way to the stomach and then seal the mucosa moving back out so this kills the functionality of the LES, does not assist with antireflex
