Periop Care & Surgical Texhnique Flashcards
Phases of a clinical trial?
1- small group- safety and PK and PD
2- 50-300- side effects and effectiveness
3 multi enter Rct
4 post marketing study, benefits and optimal use
Levels of clinical evidence
A= systematic review of b
1 rct 2 cohort stud 3 case control study (retrospective, compares disease to controls) 4 case series 5 expert opinion
Methods of thromboprophylaxsis
Conservative- hydrate well, leg exercises, vte stockings, early mobilisation, TEDs
Medical- IVT, lmwh, stop COCP 4 weeks prior
Surgical- vena cava filter, avoid GA
Reasons for patient positioning and complications?
Surgical access, anaesthetic access, prevent harm
Air embolus Join dislocations Skin damage Neuropathies Eye compression Decreased lung capacity
Common neuropathies?
Ulnar Radial Common peroneal Sciatic Saphenous Obturator Brachial plexus
What is laminar flow?
Unidirectional flow of air
What is acceptable air flow targets in theatre
20-40 air changes per hour
<35/m3 of bacteria carrying particles
<1 colony per m3 of clostridium/staph a
Sterilisation equipment?
Steam
Dry heat
Ethylene oxide- scopes
Irradiation
What does laser stand for?
How does it work?
Light amplification by stimulated emission of radiation
Excitation of a medium by energy leading to photon production
Types of lasers
Co2- haemostasis
Argon- photocoagulation
Ruby- tattoo removal
Indications for tourniquet’s?
Bloodless op Stop bleeding Biers block Isolated limb chemo Cannulation
Principles of safe tourniquet use?
Size of cuff- width >1/2 diameter of limb
Padding
No fluid
Exaguinate
Pressure limits-
Lower limb- SBP + 70-130 (max 350)
Upper limb- SBP + 50-100 (max 250)
Max 2 hours
Check NVI post op
Complications of tourniquets
Skin changes Lactic acidosis Post tourniquet syndrome- swollen, stiff, pale limb with weakness but no paralysis usually after 1–6 weeks of tourniquet application Bleeding/haematoma Muscles ischaemia Nerve injury- radial
What is diathermy?
Passage of high frequency AC (400-10) through body which creates high temperatures of 1000
Why high frequency for diathermy?
Low frequency causes muscle stimulation/vf/cardiac stimulation.
Means a higher amp can be used
Different types of diathermy
Mono polar- pad on patient is the other pole. High power, less precise
Bipolar- low power, current between forceps, safer for end arteries / pace makers
Complications of diathermy use?
Burns- patient/surgical team Explosions Channeling Capacitor coupling- think lap ports Direct coupling- buzz forceps Pacemakers- reprogramming of pacemakers/myocardial burn
How can you classify sutures?
Composition- natural/synthetic
Structure- braided (vicryl) vs monofilament (monocryl)
Absorbable
How are sutures absorbable?
Proteolytic enzyme
Hydrolysis
Requirements of a perfect suture?
Sterile Hypoallergenic Carcinogen free Uniformity High tensile strength Pliable Predictable absorption pattern Cost effective
Types of absorbable sutures
Vicryl rapide- 42 days
Vicryl- 60 days
Monocryl- 100 days
PDS- 200 days
Needles shape and geometry
Straight vs curved vs j vs compound Geometry Round body- friable tissues Cutting- tough surfaces- skin/sternum Reverse cutting- on convex edge- subcuticular suture/tendons
Blunt vs sharp
Types of drains
Passive drains- penrose drain
Active drain- vac/redivac
Indications for dressings?
Dressing if in doubt?
Granulating tissue- aquacel/jelonet
Sloughy- aquacel
Necrotic- aquacel
Cavity- simple packing
AQUACEL
Leeches indication
Maggots
Leeches- encourage vasodilation, anticoagulant and anaesthesia via secreting substances
Maggots
Digests necrotic and sloughy tissue
Indication for negative pressure dressings
Promote granulation
Remove excess fluid/blood/pus
Needlestick transmission rate of HIV, Hep B and C?
HIV 0.3%
Hep B 30%
Hep C 3%
Timing of needlestick bloods?
At time of event for you and patient
6 weeks and 3 month post event
Post renal causes of anuria?
Bilateral renal stones
Bladder/Prostate/Urethral blockage
Describe steps of chest drain insertion?
Intro and wash hands
Consent, allergies/anticoagulation
Prep equipment- 11 blade, 24 Fr chest drain, silk suture
LA
Incision and blunt dissection
Insert chest drain (upwards air, downwards blood)
Suture and connect seal system- bubbles
What are the indications for inserting a chest drain?
Trauma/tension haemopnuemothorax
Large spontaneous pneumothoax
Symptomatic/large 2o pneumothoax
When to refer a pneuomothotax to the cardiothoracic surgerons?
Spontaneous haemothorax Bilateral pnuemothorax First ContraL pneumothorax 2nd IpsiL pnuemothorax Failure of lung to re-expand after 5 days Pregnant
What to do if chest drain stops bubbling?
A2E
Disconnected/dislodged
CXR
Prepare to remove
Technical considerations for skin lesion excision?
Mark at least 3:1 length to width, 2mm excision width 15 blade for incision 3/0 monocryl for intradermal 4/0 prolene for skin Histology +- marking stitch
What excision margin is needed for SqCC/BCC/Melanoma?
4mm for SqCC/BCC at least
1cm at least for melanoma
What is the histology of a SqCC?
Keratin pearls
Atypical keratinocytes
Dermal invasion
Where should a diathermy plate be placed?
> 70cm2 covered
Dry, shaved skin, away from bony prominence
What is diathermy?
Alternating current generates high localising heat temperatures that result in coagulation or cutting
LA toxicisty management?
A2E, CCRISP
No more infusion
Intralipid 20%
LA is a negative inotrope and vasodilator
What makes up a pacemaker pre op check and peri operative management?
Model, indication and date of insertion Degree of HF Placed in basic mode Post op check Continous ECG monitoring Pacing available Limit monopolar- make sure current does not pass through monopolar
Pre op warfarin management?
As per haem/trust guidelines
Stop 5 days before
High risk will need bridging LMWH/unfractionated heparin
Restart Warfarin post op when eating and drinking (haemostais achieved)
Stop heparin when INR in range
What is C diff? and risk factors?
Nosocomial GI infection
Gram +ve bacilli
Associated with Cephlasporin, co amox, clindamycin, ciprofloxacin
Treat with vanc/met
How to manage a diabetic patient peri operatively?
Pre op- optimise, anaesthetic/ DSN appointment, lose weight, echo, ecg, cxr
Peri op- 1st on list, 1 missed meal- reduce insulin/VRIII- trust guidelines
Post op monitor BMs, aim for early feed and restarting of regular insulin
Risk of cardiac complications if pre op MI?
Within 30 days- 30% risk
Within 1 -3 months- 15%
3-6 month- 5%
Long term steroid use and operative risk?
Addisonian crisis
Poor wound healing
Infection risk
Pre and post op hydrocortisone
Difference between chlorahexdine and betadine (iodine)
Chlorhex- NICE recommended, better bacterial coverage, some viral and poor fungal/spore coverage. Works for >4 hours
Betadine- potent against bactera, fungi, viral and TB, <4 hours, skin irritator
Important points of scrubbing in?
Pre scrub wash
First scrub of the day 5 minutes
Next ones can be 3 minutes
Difference between cleaning, disinfection and sterilisation?
Cleaning- gross removal of debris and dirt
Disinfection- reduction in microorganisms
Sterilisation- Eradication of microorganisms
Types of sterilisation?
Heat/dry (autoclaving)
Chemical- ethlene oxide, glutaraldhyde
Irradiation
How to rank operative emergency and co-morbities?
NCEPOD 1- immediate/life threatening/limb threatening 2- Urgent 3- Expedited 4- Elective
ASA 1- fit and well 2- mild systemic disease 3- severe systemic disease 4- severe uncontrolled systemic disease of constant risk to life 5- moribund
What is the use of a paramedian incision?
Splenic access?
How to classify wounds?
Location
Depth
Contamination
Mechanism- abrasion, incision, laceration, de gloving (morell-lavelle)
Rate of suture absorption?
This is for complete suture absorption Vicryl rapide- 42 Vicryl 70 days Monocryl 90 days PDS 180 days
Suture type used for deep tissue closure, stoma formation, face laceration, bowel anastomosis?
PDS
PDS
Nylon/prolene
PDS
Different types of diathermy settings?
Coagulation- pulsing low temp current which leads to cell death
Cutting- continous high temp current which leads to cell vaporising
Blended- mixed
Spray- coag over a wide area
Principles of wound debridement-talk through procedure?
Intro, consent, mark, anaesthetic Drape and clean Gross removal of debris Wound toilet Deep exploration Excision of dead skin/deep tissue/bone Photos Pack and dress Reinspect in 48-72 hours Abx and tetanus Confirm no bony injuries/vascular injuries
Describe an I&D of an abscess
