Surgical, Wounds, Bandaging & Drains Flashcards
1
Q
What are the five duties of surgery?
A
- To remove what is superfluous (unnecessary) 2. To restore what has been dislocated 3. To separate what has grown together 4. To reunite what has been divided 5. To redress the defects of nature
2
Q
What are the 6 key reasons why surgery is performed?
A
- Therapeutic e.g. bone breaks 2. Diagnostic e.g. exploratory/ biopsy 3. Increase suitability for use e.g. neutering and dehorning 4. Palliative e.g. amputation - neoplasia, chronic pain, disability, mutilation 5. Biomedical 6. Cosmetic e.g tail docking
3
Q
-ectomy
A
Cutting out
4
Q
-otomy
A
Cutting, sharp or separate
5
Q
-ostomy
A
Creating an opening for discharge of bodily wastes
6
Q
-plasty
A
To modify or reshape
7
Q
-pexy
A
To fix or secure
8
Q
-rrhaphy
A
To strengthen - usually with a suture
9
Q
-centesis
A
Surgical puncture
10
Q
-oscopy
A
Viewing of - normally with a scope
11
Q
What is considered cold steel?
A
Scalpel and Scissors
12
Q
Scalpel…
A
Best for dense tissue like the skin - Minimises collateral damage and crushing
13
Q
Scissors…
A
Best for loose tissue like adventitia and fat - More crushing Can be used in dense tissue by slide cutting
14
Q
What is electro surgery?
A
Cautery (burn) and Cutting - More collateral damage than cold steel
15
Q
What can cautery be used for?
A
Disbudding of calves Hand-held units - handy for small animal surgery
16
Q
What can lasers be used for?
A
To remove, vaporise or weld tissue - intense beam of monochromatic coherent radiation in IR, visible or near UV spectrum
17
Q
What is used for tissue desiccation?
A
- Cryosurgery - liquid nitrogen - Photodynamic Therapy- oxygen free radicals release by light application
18
Q
What is an arthroscope?
A
A lensed eyepiece fitted with a camera and a light source
19
Q
What are the advantages of arthroscopy?
A
- Minimally invasive - Decreased hospital stay - Better view arthroscopically than operatively due to magnification and field of view plus optimal lighting
20
Q
What are the disadvantages of arthroscopy?
A
- More Costly - Can take longer - Some joints e.g. canine stifle are too small
21
Q
What are the two most common complications of surgery?
A
- Haemorrhage - Infection Must discuss the potential adverse outcomes and help owners make decisions
22
Q
What makes a good surgeon?
A
- One who weighs the risks of a procedure against the benefits - One who fully informs the patient / owner - One who calls on their experience and skill to plan and carry put the procedure safely
23
Q
What are Halsted’s Principles?
A
- Gentle Tissue Handling 2. Eliminate Dead Space 3. Meticulous Haemostasis 4. Close/ normal approximation of tissues 5. Aseptic Technique 6. Minimise foreign bodies 7. Avoid tension on sutures/ tissues
24
Q
Handle tissues gently… Rough Handling…
A
- Increases likelihood of post-op infection by creating necrotic tissue - Delays the rate of healing - Increases surgical shock - Increases pain and dysfunction
25
What does Effective Haemostasis do?
- Allows better surgical conditions - easier to see - Lessens the chance of Haemorrhagic shock - Lessens the chance of post-op infection - Preserves blood supply
26
What does using aseptic techniques do?
Reduces the chance of post-op infection - Performed in theatre to protect the patient from contact and air-borne bacteria
27
Aseptic Surgery
- Prepare patients skin to protect from their own flora - Surgeons wear protective clothing to protect the patient from us - Use drapes to isolate the surgical area
28
Avoiding tension on wound areas...
- Tight sutures tear through tissues - this reduces wound strength - Death of tissues increases the risk of infection and delays the healing of the wound (no blood supply = no healing)
29
Avoiding creating or leaving dead space between tissues...
- Can lead to accumulation of blood and serum in tissue spaces - Delays healing - Greatly increases the likelihood of wound infection
30
Meticulous approximation of all wound layers...
- Promotes rapid healing - Increases wound strength - Lessens the chances of infection
31
Minimise foreign material in the wound...
Includes suture material and glove powder
32
Which Halsted's Principle applies to drains?
5. Avoid creating or leaving dead space in between tissue planes, as accumulation of blood and serum in tissue spaces delays healing and greatly increases the likelihood of wound infection
33
What are the three principle reasons for using drainage in wounds?
1. To obliterate dead space 2. To remove material that could be harmful to a particular anatomical site 3. Where flushing of a solution, antiseptic or antibiotic is needed through the area after primary closure
34
It is appropriate to use drains when?
- It is impossible to completely debride a wound because vital structures are contaminated - Foreign material must be removed - Massive contamination of the wound is inevitable - The viability of the wound is questionable Dead space needs to be obliterated -There is incomplete drainage - There is anticipated leakage - There is insecure closure of a hollow organ - For treatment of a pneumothorax or to recreate negative pressire in the thoracic cavity after surgery
35
Why is leaving a wound open useful in some circumstances?
It provides natural drainage
36
What are the 9 principles of drain placement?
1. Placed Aseptically 2. Pass through wound separate from surgical incision 3. Exit at most ventral site possible 4. Exit at two points if passive 5. Exit points large enough to allow drainage 6. Suture to the skin 7. Cover with sterile dressing 8. Record where and how long drain is 9. Fit E-collar if left unbandaged
37
What is an open drain?
- Forms a wick around which the wound fluid drains away - Should be covered by bandage for sterility
38
What is a closed drain?
- Collection system attached to the drain - Active or passive
39
What is a passive drain?
A drain that relies on gravity to remove fluids along internal or external surface to the outside of the body - Act by surface area
40
What is an active drain?
Use positive pressure e.g. suction to actively draw fluids out of the body - Require frequent checking to replace or reset vacuum - Rigid tubes - Fenestrated within wound section - Can make homemade ones from winged infusion sets and vacutainers or syringes and needles
41
Describe a Yeates drain?
- Soft PVC - Drainage through lumen and along exterior - Available in two widths
42
When do you remove a drain?
- When the the reason for drainage is gone - When wound fluid drainage is minimal (except for drain induced fluid)
43
What is a sump drain?
Multilumen drain consisting of a large tube with a smaller tube within the wall or lumen of the larger tube - allows air to enter, displacing fluid
44
How are chest drains inserted?
Feeding tubes are inserted through the chest wall using a haemostat or at the time of surgery. - Connected by an adaptor to a three way tap to show periodic drainage - Protect against over penetration with fist
45
What is an intermittent drainage system?
Used in most cases of pleural drainage - Drain is in place between periods - Chest tube kept clamped - Air or fluid is drawn off by syringe - Ensure air isn't accidentally sucked back into the system during attachment of syringes (by three way tap or double clamp) or if the cap comes off the system is still secure - Bandage - E-collar - Good analgesia is essential
46
When should the chest be drawn?
Frequently with the length of time between drainage being increase as the volume being drawn off decreases
47
What is a continuous drainage system?
Used when the rate of accumulation is life threatening - Maintains contact between pleural surfaces - Requires dedicated equipment and constant supervision - Uses either gravity or negative pressure to apply continuous drainage off the chest - Water seal should be used with gravity drainage to prevent air being drawn back into the chest -- seal must be lower than patient at all times so water isn't drawn back into pleural space
48
What are some complications of drain placement?
- Hospital-Acquired -Infection can result from ascending infection - bacteria may be resistant - Foreign body reaction to the drain reduces the number of bacteria required for infection
49
What are the advantages of passive drains?
- Cheap - Easy to place - Effective
50
What are the disadvantages of passive drains?
- Messy - Risk of infection - Needs Bandaging - Dependent on gravity - Inefficient for large areas - Difficult to monitor fluid - Difficult to judge removal
51
What are the advantages of Active drains?
- Vacuum brings tissues into apposition - Easily placed Not gravity dependent - Useful in high motion areas - Collects exudate in container - Doesn't require bulky bandaging
52
What are the different ways to apply a vacuum?
- Concertina - Compressible 'grenade' - Vacutainer - Suction Machine
53
What Post-op care is required for closed suction drains?
- Secure drain with sutures and tape - Loosely bandage with stockinette - Use E-collars if necessary - Empty and recharge cannister once over 1/3 or 1/2 full - Measure and record volumes - Monitor fluid carefully - Remove when fluid \< 5 ml over 12-24 hours - Straight forward removal
54
What requires a chest drain?
- Pyothorax - Pneumothorax - Chylothorax - Other Pleural Effusions
55
What are some complications of chest drains?
- Patient interference - Sepsis / pyothorax - Emphysema - False pneumothorax - Pain - Lung/ pleural injury
56
When should a chest drain be removed?
Depends on: - Degree of fluid production - Nature of the fluid - Clinical response of the patient
57
How much serum and blood fluid (serosanguinous) should drain into a chest drain per kg?
1-3 ml / Kg - does depend on underlying pathological process
58
What is the importance of draining the abdomen?
- Physical removal of bacteria - clearance of bacterial endotoxins - Improves intra abdominal environment
59
What is a wound?
Any injury to body tissue resulting in variable disruption to normal cellular and anatomical continuity
60
Damaged or removed body tissues are either .... OR .....?
Replaced/ Regenerated or Repaired or a combination of the two
61
What two tissues heal by regeneration?
Liver Bone
62
What are the four phases of wound healing?
1. Inflammatory Phase 2. Debridement phase 3. Proliferative phase 4. Remodelling phase
63
What occurs in the inflammatory phase?
5 hours after injury - Skin Retraction - Vessel Reaction - Vasoconstriction - Cellular Response - Clot and scab formation
64
What occurs in the debridement phase?
12- 72 hours after injury Neutrophils accumulate in the wound and phagocytose debris - about 6 hours after injury
65
What occurs about 1 day after injury?
Epithelial and endothelial migration
66
What occurs about 3 days after injury?
Formation of fibrous and granulation tissue
67
What occurs about 7 days after injury?
Vessels become apparent (angiogenesis)
68
What occurs between days 7-21 after injury?
Contraction becomes apparent Fibroblasts become re oriented
69
What occurs after 21 days of injury?
Collagen quantity stabilises Cross- linking occurs
70
What occurs in the proliferative (repair) phase?
- Formation of skin of the wound surface - Migration of fibroblasts into collagen - Formation of granulation tissue - Wound Contraction
71
When does the proliferative phase begin?
Within the first 12 hours after injury - proceeds at variable rate depending on factors like blood clots, necrotic tissue, debris and infection
72
When is wound contraction disadvantageous?
- When formation of a tight web over a flexor surface may limit its movement - Stenosis of a body opening - Insufficient contraction, resulting in large areas of thin epithelium - Increased skin tightness limiting body movement
73
What is epithelialization?
Formation of skin - Completion of the proliferative stage
74
What is Second Intention healing?
Spontaneous Healing - wound left open to granulate and fill in on their own - Granulation tissue eventually becomes epithelialised - Resulting tissue is a scar - Usually has no hair - Can contract and prevent normal gliding motion of adjacent muscles and joints - Otherwise perform secondary closure using grafting
75
What occurs in the proliferative stage?
After ~ 3 weeks there is a reduction in fibroblast numbers and equilibrium develops between collagen production and lysis - The collagen fibres become aligned - Increases tensile strength of the wound - Decrease in blood vessels and collagen fibres
76
What are the tissue features during the stages of wound healing over time?
- Swelling - Receding around the edges - Exudative - Reduced tissue strength - Pink, cobblestone appearance - Thin, Whitish edges - "Puckered" edges - Restored tissue strength
77
What are some examples of complicated wound healing?
- Infection - Excess motion - Self- mutilation - Excess tension - Horses - Debilitated patient e.g. systemic disease - Recumbency - Poor vascularity
78
What are the classifications of wounds?
- Clean - Clean- contaminated - Contaminated - Dirty
79
Why are wounds classified?
To predict the likelihood of complications and put in place appropriate wound management - A good surgeon knows when a wound can be dealt with by primary closure and when secondary closure or second intention healing is indicated
80
Describe a 'Clean' wound?
- Non- traumatic - No inflammation present - No entry into lumen of viscera - Drains not used e.g. removal of skin tumor aseptic technique
81
Describe a ' Clean- Contaminated' wound?
- Entry into the lumen of viscera without infection - No gross spillage - Minor break in sterile technique e.g. ovariohysterectomy
82
Describe a 'Contaminated' wound?
- Traumatic wound - \<4-6 hours old - Spillage of GIT into infected urogenital tract e.g. cystotomy for urolithiasis with active infection
83
Describe a 'Dirty' wound?
- Infection present - Incision into inflamed tissue/ pus encountered - Traumatic wound - \> 4-6 hours old e.g. pyometra
84
What is open wound management?
Wound is left to drain to the environment
85
What are the two types of wound closure?
Primary Secondary
86
What is primary wound closure?
When wound is closed immediately First intention - More rapid - Aesthetically better - Cheaper - Minimal complications
87
What is secondary wound closure?
When wound closure is delayed for a few days
88
What are the factors that influence the magnitude of wound infection?
1. Degree of bacterial contamination 2. Virulence of the organism 3. Type of injury 4. Vascular insufficiency 5. Foreign Material 6. Free fluid accumulation 7. Immunological incompetence
89
What are seromas and when do they form?
Pocket of clear, serous fluid - Tissue rich in lymph vessels has been transected - Excessive movement is present in wound - Tissues respond to suture material as foreign material
90
What are the three basic considerations of wound care?
Cleansing Closing Covering
91
What do dirty wounds require?
1. Prevent further contamination 2. Lavage 3. Debridement 4. Drainage 5. Selection of closure method 6. Selection of bandaging method
92
How do you prevent further contamination?
Open wounds should be covered with sterile and clean dressing to prevent desiccation Wet saline dressings are ideal Broad- spectrum antibiotics may be used but it's better to swab first to determine which bacteria are present.
93
What is a lavage?
Washing out of a body cavity - May be applied using low pressure bulb syringes or high pressure water pik systems - Tap Water - Saline - Ringers - Antiseptics
94
What is Debridement?
Removal of all debris, necrotic tissue or obviously devitalised tissue - essential in preparing the wound for suturing - Use a sharp scalpel for incisions - Lavage may be needed as debridement progresses
95
What solutions can be used for debridement and lavaging?
Chlorhexidine Betadine Hydrogen Peroxide Saline
96
What are the 11 functions of bandaging?
1. Exert pressure to eliminate dead space 2. Pack the wound 3. Debride the wound 4. Absorb exudates 5. Protect the wound from the environment 6. Protect the environment from the wound 7. Immobilise the wound and support fractures 8. Provide comfort by reducing pain 9. Serve as a vehicle for the application of antibiotics and antiseptics 10. Serve as an indicator of wound secretions 11. Provide an aesthetic appearance
97
What are the three key functions of applying bandages?
Pressure Protection Support
98
What are the layers in a bandage?
1. Primary (contact) layer 2. Secondary (intermediate) layer 3. Tertiary (outer) layer
99
What is the function of the primary wound layer?
- Lies against the wound - Allows tissue fluid to pass through to the second layer
100
What dressings can be used in the primary layer?
- Adherent dressings - Nonadherent dressings
101
Describe an Adherent dressing...
- Open Weave - Used when it's desirable to mechanically debride the wound surface e.g. in infected wounds - Wet-to-dry or dry-to-dry
102
Describe a Nonadherent dressing...
- Used when the underlying tissue is healthy granulation - This tissue is ready to epithelialize without debridement
103
How does the adherent primary layer act as a debrider?
- The open weave arrangement allows wound fluid and exudate to enter the dressing and solidify as it dries - Necrotic tissue and exudate is pulled from the wound with the dressing when it is changed
104
How do you determine whether to use wet-to-dry or dry-to-dry adherent primary dressings?
- Determined by the state of the wound - Heavily exudating wounds don't need the extra moisture so dry-to-dry is used - Most wounds benefit from some moisture to liquify necrotic tissue and aid absorption
105
What are the disadvantages of adherent dressings?
- Removal can be painful --Dressing changes are usually OAD - The dry layer can pull off healthy cells and cause damage to budding vessels in granulation bed - Need to time change from adherent to nonadherent well
106
What are some brands of nonadherent dressings?
- Release - Melolin - Allevyn (foam)
107
What advantage does a Allevyn foam nonadherent dressing have?
- A dynamic breathable top film for faster fluid removal - Modified foam has a faster fluid uptake
108
Describe the secondary (intermediate) bandage layer...
- Must be absorbent enough to move tissue fluid away from the primary layer - Must be thick enough to store exudate until bandage change - Must be conformable to mold primary layer to contour of body - Must provide pressure to reduce haematoma and odema formation
109
What material tends to be used for the secondary bandage layer?
Synthetic cast padding or absorbent cotton wool
110
What is secondary layer bindings?
A gauze layer wrapped around the secondary cotton layer to prevent fraying
111
Describe the Tertiary layer...
- Should prevent contamination from external environment - Somewhat waterproof - Should be adherent to itself and hair above the dressing - Tight enough to hold the secondary layer in place but not constrict blood supply
112
What are some brand examples of tertiary bandage layer?
- Co-plus - Vet-Wrap - Elastoplast
113
What are protection/ Support bandages used for?
- Decreasing post-op swelling - Support fractured limbs before surgery - Casts - Immobilising joints
114
What is a classic example of pressure bandaging?
Robert- Jones - Heavily padded cotton wool - Conforming Gauze applied tightly and evenly to create pressure on the cotton wool - Outer protective layer - Monitor! - Remove if wet or cold toes
115
Where can a Robert-Jones bandage be used and not used?
Can: Fractures below the knee or stifle Cannot: Femoral or humeral fractures
116
What are some signs of bandage complications?
- Toe swelling - Discomfort - Odour or discharge
117
How many toes should be kept exposed in a limb bandage?
Only leave tips of middle two toes exposed
118
What occurs if bandages aren't kept dry?
Tissue may begin to waste away
119
How often do you tell the owner to check their animal's dressing?
Twice a day
120
What is a modified Robert-Jones bandage?
- Less padding - Fluid absorbance is needed without pressure
121
What is a splint?
Soft padded bandage reinforced with cast material or aluminium bars - After secondary layer - For rigid support
122
Describe a cast...
Minimal cast padding over a stockinette with layers of rigid cast material
123
What is the procedure used when splinting a limb?
1. Contact layer against wound 2. Stirrups on foot 3. Stockinette over limb 4. Layer of cast padding 5. Conform padding with stretch gauze 6. Splint against leg 7. Conform splint with stretch gauze 8. Tertiary Layer
124
Why is a splint used?
To protect joints or limbs before or after surgery
125
When should a Spica Splint be used?
Injury above the stifle or elbow
126
Describe a Spica Splint...
- Cast padding and gauze are taken high over the shoulder or trunk and around opposite limb in a figure 8 pattern - Cast material taken to at least the dorsal midline
127
What are some broad-spectrum antimicrobial topical wound preparations?
- Bacitracin - Neomycin - Polymixin - Framycetin - Nitrofurazone
128
What are some other forms of topical wound treatments?
- Hydrophilic gels useful for early stages of wound healing by moistening and stimulating debridement and scab desloughing - Enzymatic agents used where vital to spare normal tissue - Aloe vera for burns, frostbite and dying flaps
129
What does application of aloe vera gel do to burns. frostbite and dying skin flaps?
- Prevents vasoconstriction - Prevents ischaemia - Prevents progression of tissue necrosis
130
Are ointments usually used on clean wounds?
No - but certain ointments may be useful
131
What is intrasite gel?
A hydrogel - helps support epithelial cells in granulating or epithelialising wounds
132
What is silverzine cream?
Useful in wounds with surface bacterial contamination - especially with pseudomonas (type of gm-ve bacteria) Helps clear the inital infection
133
What is a tie over bandage?
- Suture loops created around the edge - At each bandage change a pad ( primary and secondary layers) can be tied over the area using the loops - Used where area can't normally be bandaged
134
What type of gauze is this?
Primary Layer
Gauze
135
What type of bandaging is this?
A tie-over bandage
- used to bandage somewhere that can't normally be bandaged
136
What type of bandage is this?
A Splica Splint
137
What layer and type of dressing is this?
Non-adherent
Primary Layer
138
Would you use a Robert-Jones bandage for this animal's injury?
No
RJB's shouldn't be used in fractures above the elbow/ stifle
139
What layer is this used in?
The tertiary (outer) layer
140
What is this?
Secondary layer binding gauze
141
What layer is this used in?
The secondary (intermediate) bandage layer
142
What type of drain is this? What is its name?
Passive Drain
Penrose Drain
143
What type of drain is this?
Chest Drain
144
What type of drains are these?
Passive drains
L: Yeates Drain
R: Penrose Drain
145
What type of drain is this? What is its name?
Active Drain
Uno Drain
146
What type of drain is this? What is its name?
Active Drain
Butterfly catheter and vacutainer
147
What type of drain is this? What is its name?
Active Drain
Grenade drain
148
What is this?
Heimlich Valve
- One way valve used with a chest drain
- Stops air entering chest through the chest drain tube with breaths
149
What do wet-wet/ wet-dry/ dry-dry orders mean?
Refers to how the layer is when it is applied and when removed
150
Describe a wet-dry adherent dressing...
- Allowed to dry
- Removes debris
- Most common in vet med
- Antibacterial may be used if it doesn't harm cells
- Use for 3-5 days
151
Describe a wet-wet adherent dressing...
- Stays wet through to next bandage change
- Moist environment helps clean the wound but doesn't debride
- Used with large amounts of viscous exudate
- May macerate the wound
152
Describe a dry-dry adherent dressing...
- Used with loose debris or a large amount of low viscosity exudate e.g. burns
- Primary layer allowed to dry
153
What is a non-adherent contact layer?
- Simplest is petroleum impregnated gauze - actually slows epithelialisation
- Others have a film covering over the absorbant padding with many small pores (instead of open weave)
- Must use after fibroplasia and epithelialisation have begun
