Role of the Surgical PA Flashcards
Who are the different members of the surgical team?
Surgeon Anesthesia (Anesthesiologist, CRNA) PA/First Assist Residents/Med students Nursing (Preop, Scrub Nurse, Circulator, Monitor, Recovery)
When assessing a patient’s hydration status preoperatively, who are we most concerned about?
Elderly and chemo patients
Do you need to d/c ASA, NSAIDs, Plavix, and warfarin 3-5 days prior to surgery?
Possibly
Depends on the type of procedure (IR May WANT them on these)
What should the pre-op H&P include?
Age, overall health, and specific risk factors
Hydration status
Review meds and allergies
Review prior surgical and anesthesia history
SHx: TOB, EtOH, illicit drugs
Elective v. Emergency procedure
Document discussion of risks/benefits (ie blood loss)
ID potential problems early
ID need for specialty consult (ie Pulm, Cardio, Heme, Endocrine)
What is SCIP?
Surgical Care Improvement Project protocol
Adopted and enforced by The Joint Commission to improve patient care and prevent avoidable deaths
Adopted in response to 77% of deaths related to infection
Classification system used by anesthesia providers to indicate overall preoperative health and predict operative risk
ASA classifications
On a scale of I-VI
Describe ASA I Patients
Healthy with no known comorbidities
Describe ASA II Patients
Patients with mild systemic disease (ie well controlled HTN, DM)
Smokers
BMI 30+
Pregnant
Describe ASA III Patients
Severe systemic disease (ESRD on dialysis, poorly controlled HTN/DM)
Substance abuse
Moderate CHF
Describe ASA IV Patients
Systemic disease that is a constant threat to life (ie recent MI, CVA, TIA, stents, severe CHF, active CAD, ESRD not on dialysis)
Describe ASA V Patients
Moribund patient who is not expected to survive w/o the operation
Ruptured TAAA, ruptured AAA, massive trauma, ICH with MLS
Describe ASA VI Patients
Organ harvest
Scoring system for determining ease of intubation
Mallampati Score
Class I-IV
Name the Mallampati Score:
Complete visualization of the soft palate
Class I
Name the Mallampati Score:
Complete visualization of the uvula
Class II
Name the Mallampati Score:
Visualization of only the base of the uvula
Class III
Name the Mallampati Score:
Soft palate is not visible at all
Class IV
What pre-op studies would you order for an otherwise healthy patient?
CBC
Electrolytes (BUN/Cr if potential renal concerns)
No need for LFTs
PT/INR
U/A
Pregnancy test
CXR if >50 or Hx of CV/pulm disease
Who gets an ECG prior to surgery?
Men >45
Women >55
Known Hx of cardiac dz
Hx of diuretic use
Hx of DM or HTN
Major surgical procedure planned
What are the risk factors for pulmonary complications?
Smoking (including vaping) - 2-6x increased risk
COPD/Asthma
Thoracic and upper abdominal procedures
Obesity
When should smokers ideally quit prior to surgery?
2 months (8 weeks)
What pre-op assessments do you want to do on patients at risk for pulmonary complications (smokers, COPD, obesity, etc)?
H&P
CXR
PFTs
ABGs
Pulmonary consult
Patients with these things in their prior history are at higher risk of peri-operative MI
HTN MI*** CHF Dysrhythmias Valvular heart disease
A patient who recently had an MI should postpone elective surgery until…
> 6 months post-MI
What patient history items can clue you in to potential coagulation abnormalities?
Use of NSAIDs vs. anti-coagulants
Hx of Abnormal bleeding (easy bruising, frequent epistaxis, increased bleeding w/ dental or surgical procedures)
Chronic liver disease
Chronic EtOH
(+) FH of bleeding disorders
If indicated, check PT, PTT, CBC w/ platelets
Check with hematologist regarding special precautions
What do you need to add to your pre-op assessment for diabetic patients?
Average glucose levels (HbA1C) - elevations in glucose and A1C levels pre-op are associated with increased risk of post-op infections
ECG
Meds:
• Hold any oral meds in the morning
• Insulin regimens should be adjusted as needed due to above
What are the biggest post-op risks for DM patients?
Hypo or hyperglycemia
Infections
What special post-op care do you need for a patient with DM?
Follow BS q6h - maintain between 150-200
Cover BS with sliding scale, allowing for dosing of insulin based on BS levels
• “If BS 201-250, give X units insulin”
• Parameters to call physician (ie BS <70 or >450)
May restart regular insulin and/or oral agents when patient has resumed eating
How do you prevent adrenal insufficiency in patients with metabolic risk factors?
Cover with additional steroids peri-operatively
Pre-op: 100mg hydrocortisone
Post-op: 100mg/day tapered over ~5 days
How do you adjust peri-operative care for patients with renal disease?
Need strict attention to fluids
Watch electrolytes (esp K+)
Adjust meds that are excreted by the kidneys
What is consent?
Outlines procedure and potential complications of the procedure
Imperative that the patient is “consentalbe”
• May require MPA for signature
• In trauma, done regardless if question of survival
What does -otomy mean?
Incision into
Ex: Thoracotomy, craniotomy, laparotomy
What does -ectomy mean?
Removal of
Ex: Laryngectomy, cholecystectomy
What does -ostomy mean?
Creation of a new opening
Ex: Tracheostomy, colostomy, gastrostomy
What does -plasty mean?
Surgical repair
Ex: Palatoplasty, septoplasty
What does -pexy mean?
Fixation
Ex: Orchiopexy
What does -rrhaphy mean?
Suturing
Ex: Herniorrhaphy
What is the name for an incision into the thorax between two ribs?
Thoracotomy
What is the name for the oblique incision running form the epigastric area to the RLQ?
McBurney
Not used so much anymore since a lot of the surgeries in this area are now done laparoscopically
Position most commonly used for general surgery (cholecystectomy, colon resection, hernia repair, etc)
Supine
Don’t forget to put the patient’s seat belt on!
Patient position that increases exposure to pelvic organs
Also used when placing central lines (to reduce risk of air embolus)
Trendelenburg
Patient position that enhances exposure to upper abdominal viscera (ie diaphragm, liver)
Reverse Trendelenburg
What types of surgeries are done with the patient in the sitting position?
Craniotomies (esp posterior fossa)
Cervical spinal surgery
What patient position is used for urologic procedures, gynecological procedures, and rectal surgeries?
Lithotomy
What patient position is used for most spinal surgeries?
Prone position
What patient position is used for thoracotomies, nephrectomies, retroperitoneal approaches?
Lateral position
General surgery covers ______ to _______
Diaphragm to pelvis
Includes: Gastric dz Biliary dz Pancreatic dz Liver dz Bowel dz Breast dz Thyroid dz Trauma
Why do you have to pay close attention to ABGs with patients who have undergone laparoscopic procedures?
B/c CO2 is used to inflate the abdomen for visualization
Which gas is used for laparoscopy and why?
CO2
Better solubility in blood
Why do patients frequently get post-op shoulder pain with laparoscopic procedures?
Referred pain from CO2 on diaphragm and diaphragmatic stretch
Advantages of laparoscopy
Shorter hospitalization Less pain Less scarring Lower cost Decreased ileus
Tips for “driving” the camera in laparoscopy
Keep action centered
Watch all trocars enter the peritoneal cavity
Watch all instrument as they come through the trocars
Keep camera oriented (ie up and down)
FRED (fog reduction elimination device) for the lens, or use liver or peritoneum
Don’t let camera lens come into contact with the bowel
Watch the trocars being removed to check for bleeding
What can help maintain visibility with the camera during laparoscopic procedures?
FRED (fog reduction elimination device)
Use liver or peritoneum to de-fog
DON’T use the bowel
How often should wounds be checked post-op?
Every day
How often should vitals and I&Os be reviewed post-op?
I&O q4-6h POD1
If fever POD 3-5, r/o infection (CBC, UA, CXR)
Why do we want to encourage early ambulation post op?
To reduce risk of blood clots
Post-op fever immediately (within hours) is usually due to …
Medications
Blood products
Malignant hyperthermia
Acute post-op fevers (within the first week) are usually due to…
Nosocomial infections
UTI
Aspiration PNA
Subacute post-op fevers (1-4 weeks later) are usually due to …
Surgical site infection
Infection from central venous catheters
Abx associated diarrhea (ie C. diff)
Delayed post-op fevers (>1 month later) are usually due to …
Infection abscess - get a CT!
What you need to know about prepping a patient …
Pressure points to avoid (esp with injury to extremities
Prevent cross-contamination
Prevent infection
Check for allergies to preps
Shave?
ALWAYS prep above and below surgical site
What are the different types of pickups to be familiar with and what are they used for?
Adson - grasping skin or tissue/vessels
Adson with teeth - for suturing/skin
Debakey - for grasping tissue or vessels
What are the different types of retractors we should know and what are they used for?
Army Navy - smaller areas
Deaver - for abdomen/thorax
Weitlander - for carotid or other artery
Straight mayo scissors are used for…
Cutting sutures only
Curved mayo scissors are used for…
Dissection and cutting tissue
What are the different types of clamp?
Straight crile Curved crile Kelly Snap Mosquito
Used for holding tissue, holding suture, dissection, and occluding vessels
What size sutures are used on the abdominal muscle and fascia?
1.0-2.0
What size sutures are used on skin closure but not the face?
3.0-4.0
What size suture is used on the face?
5.0-6.0
What size suture is used for vessels (microsurgery) and anastamoses?
> 7.0
When are absorbable sutures used?
On muscle
Sub Q
When removal would be traumatic
What types of suture are absorbable?
Vicryl and monocryl
Non-absorbable sutures are used on…
Fascia, Rectus muscle, Vessels, Skin
Examples of non-absorbable suture material
Prolene, Silk, Nylon
What type of suture are available as braided?
Silk and Vicryl
What are the pros/cons of braided sutures?
Pros:
Good tensile strength
Less apt to tear
Cons:
Risk of infection (unless coated)
What types of suture are non-braided?
Prolene, monocryl
Reduces risk of infection, good tensile strength, can expand with tissue swelling but can also tear tissue
