surgery 2 Flashcards
when not to close a wound
superficial wounds
wounds open longer then 8 hours (exception is face, scalp, and neck)
grossly contaminated wounds
absorbable sutures
surgical gut
vicryl
mucosal areas and subcutaneous tissue (deep sutures)
non absorbable
nylon stainless steel polyprolene monofilament braided
skin, ligament and tendon repairs
size of suture
larger the number the smaller the suture
4-0 foot, trunk, extremities
5-0 hand, scalp
6-0 face, ear, nose
7-0 eyelid
most common suture
simple interrupted
other options to close wounds
steri strips
glue
staples
butterfly bandages
scalp
6-8 days
face
4-5 days
chest/abdomen
8-10 days
back
10-14 days
arm/leg
8-10 days
hand
8-10 days
fingertip
8-12 days
foot
12-14 days
scip (surgical care improvement project) national goal
reduce preventable surgical morbidity and mortality 25% by 2010
surgical infxn prevention
glucose control in cardiac surgery pts (<200)
prophylactic abx (begin 1 hr before surgery and stop w/in 24 hrs of end of surgery)
proper hair removal
normothermia in colorectal surgical pts
prevention of ventilator associated pneumonia
ppl on ventilators need head of bed at 30 degrees
give these pts peptic ulcer prophylaxis
pulmonary risks
pneumonia
atelectasis
hypoventilation
physiology of respiratory during surgery
effects of surgery and opiods depress respiratory
vital capacity decresead 50-60%
functional residual capacity decreased 30%
chest and abdomen surgeries put you at higher risk of pulmonary complications
pulmonology risk factors
copd >50 asthma (if NOT controlled) smoking >20 pack year history CHF URI albumin 30
when to get pft
Obtain for pts w/ COPD or asthma if clinically cannot determine if pt at their best baseline
Obtain for pts w/ dyspnea or exercise intolerance that remains unexplained
how to reduce post op pulmonary comp
copd:
bronchodilators, abx, systemic steroids
pts should receive daily ipratorium bromide (anticholinergic)
beta agonsit as needed
asthma:
well controlled w/ beta agonist and steroids if needed
uri:
delay elective surgery in presence of viral uri
post op strategies to decreased pulmonary complications
incentive spirometry
deep breathing strategies
adequate pain control so pt can ambulate early and makes it easier for pt to take deep breaths
use of NG tube has increased risk of pulmonary comp
cardiac risks
MI
CHF
HTN
increased mortality post op day 3
who is at risk for cardiac comp (major factors)
recent mi vascular heart disease decompensated heart failure unstable angina strongly positive stress test significant arrithmias (high grade av block, symptomatic ventricular arrhythmia, supra ventricular arrhythmia w/ uncontrolled rate
intermediate risk factors for cardiac
Mild Angina Previous MI by history or by Q-waves Compensated or prior CHF Diabetes Renal Insufficiency (Creat>2.0)
endocrine risk
thyroid storm
adrenal insufficiency
diabetic complication
dvt medical prophylaxis
low dose unfractioned heparin:
5000 Units SQ q8 or q12 hrs
First dose pre-op or post-op
low molecular weight heparin(lovenox)
post op fever immediate diff (during operation to a few hours after)
fever due to surgery (release of cytokines stimulate fever; fever >38 degrees common in first couple days after surgery)
rxn to blood products or med
malignant hyperthermia
post op fever acute (within 1st week0
Nosocomial infections Community acquired infections Surgical site infection Intravascular catheters Pneumonia UTI
post op fever sub acute 1st week to 4th week
Surgical site infection Central venous catheter related infections Thrombophlebitis Antibiotic associated diarrhea Drug Fever Deep Vein Thrombophlebitis Pulmonary Embolism
post op fever delayed (>1month)
wound infection
infection from blood products
orthopedic procedures post op fever diff
DVT/thrombophlebitis
surgical site infxn
hematoma
5 w’s
wind water wound walking wonder drugs/whopper
wind
usually the cause of fever in first 24-48 hrs post op
atelectasis
pneumonia
embolism (pe)
Physical exam: bronchial breathing, deviated trachea, sob, etc
water
usually in 48-72 hours post op
UTI
usually due to indwelling urinary catheters or GU instruments
physical exam: cloudy urine, positive urine cultures, dysuria, frequency, or urgency
wound
usually after 72 hrs (most common cause of fever after 72 hrs)
Staph Aureua is most common cause
physical exam: mild change in vital signs is seen early, and pain may or may not be present at site of infxn, look for drainage and erythema, swelling, and warmth
walking
after 72 hrs
thrombophlebitis (usually associated w/ intravascular catheters.
physical exam:
superficial- purulent drainage around catheter w/ induration of the vein
deep- can be associated w/ indwelling central lines or dot
exam could show humans sign, unilateral edema is more specific of dvt
wonder drugs
anesthetics, sulfa containing abc, and others
usually a diagnosis of exclusion
persistent fever w/ negative cultures should raise suspicion of this
whopper
presence of postoperative abscess
intra abdominal abscesses may present w/ blood cultures that are polymicrobial
what to tx fever w/
tylenol
prevention of wound infxn
cefazolin 1-2 mg IV 60 min before surgery
for bowl procedures cefoxitin or ampicilin/sulbactam
vanco if pcn allergic
wound healing
initial inflammatory response (days)
epithelialization (days)
fibroplasia (weeks)
maturation (weeks - months)
dehisence
wound bursting open
evisceration
a total separation of all wound layers and protrusion of internal organs through the open wound
hematoma
collection of blood in the wound
seroma
collection of fluid in the wound other then pus or blood
gangrene
complication of necrosis (cell death) characterized by decay of body tissues
rick factors smoking, diabetes, decrease blood supply
