Total Surgical Care Flashcards
Systemic Risk Factors for Infection
DM Corticosteroid use Obesity Age Malnutrition Second surgery Co-morbidities
Local Risk Factors for Infection
Foreign body Electrocautery Wound drains Injection with epinephrine Hair removal Previous radiation Prolonged operation
Most Commonly Given Antibiotic
Cefazolin (Ancef, Kefzol)
Antibiotics to Cover Gram-Negative & Anaerobic Pathogens
Cefotetan
Cefoxitin
Cefizoxime
+/- metronidazole (Flagyl)
Cardiac Complications & Diabetes
Men 2x the risk
Women 4x the risk
Hypotension from neuropathy
Gastroparesis & Diabetes
Aspiration risk
Infection & Diabetes
Reduced blood flow decreases healing
Risk Factors for Venous Thromboembolism Disease (VTE)
Extent of surgery or trauma Duration of hospital stay Previous VTE Immobility Central line placement Ortho procedures Age Obese patients
Appropriate Prevention of VTE in Very Low Risk Patients
Early & frequent ambulation
Appropriate Prevention of VTE in Low Risk Patients
Mechanical methods when contraindication to medicinal prophylaxis
Appropriate Prevention of VTE in Moderate Risk Patients
Pharmacologic
Appropriate Prevention of VTE in Very High Risk Patients
Combination
Medications Given for VTE Prophylaxis
Low molecular weight heparin
Low dose unfractionated heparin (UFH)
Warfarin
Aspirin
Mechanical Methods of VTE Prophylaxis
Intermittent pneumatic compression (IPC)
Graduated compression stockings (GCS)
Venous foot pump (VFP)
Define Surgical Site Infection
Infection related to an operation that occurs at or near the surgical incision within 30 days of the procedure or 90 days of an implant
Impact of Surgical Site Infections
Increase in mortality
Increase cost to patient & hospital
Risk Factors for Surgical Site Infections
Surgical technique Prolonged surgery time Instrument sterilization Pre-op preparation Thermoregulation & glycemic control Medical condition of the patient Surgical environment
Surgical Environment Risk Factors
Personnel traffic
Excessive use of electrosurgical cautery units
Prosthesis or foreign body
Need for blood transfusion
Presentation of a Surgical Site Infection
Localized erythema
Induration
Warmth
Pain at incision site
Treatment of Surgical Site Infections
Prophylactic antibiotics
Infected wounds
Antibiotics: broad spectrum, culture & gram stain
Surgical technique
Surgical Technique Treatment of Surgical Site Infections
Limit electrocautery Closure of subQ tissue Skin closure Delayed closure & heal by secondary intention Limit hypothermia
Define Hematoma & Seroma
Collection of blood or serum under the incision
Presentation of a Hematoma or Seroma
Few days post-op Pain May have sebum like fluids Fever Erythematous Edematous
Treatment of Hematoma or Seroma
Percutaneous drains
Wound exploration: pack & heal by secondary intention
Prevention of Hematoma’s and Seroma’s
Closure of dead space
Meticulous hemostasis
Placement of drains (controversial)
Risk Factors for Fascial Dehiscence
Age
Males
COPD
Ascites
Define Fascial Dehiscence
Abdominal wall tension overcoming tissue or suture strength
Main Cause of Fascial Dehiscence
Failure of the sutures to remain anchored, knot failure, large stitch intervals
Presentation of Fascial Dehiscence
Profuse serosanguinous drainage
Popping sensation with abdominal bulge
Treatment of Fascial Dehiscence
Closure in the operating room
Prevention of Fascial Dehiscence
Continuous mass closure or interrupted
Internal or external retention sutures
Wound Healing via Primary Intention
Wound closed with stitches or staples
Covered with a sterile dressing
Drain small amount of fluid
Keep protected from getting wet for 2-10 days
Monitor for erythema, swelling, warmth, & drainage
Wound Healing via Secondary Intention
Epidermis & dermis not closed
Usually due to contamination, infected wound, or peritonitis
Pack daily with saline moistened gauze/sponge & covered with a sterile dressing
Pulmonary Complications
Hypoventilation
Pneumonia
Atelectasis
1/2 peri-op mortality
Categories of Pulmonary Complications
Atelectasis
Infection
Prolonged mechanical ventilation & respiratory failure
Exacerbation of underlying chronic lung disease
Bronchospasm
Risk Factors for Pulmonary Complications
50+ Chronic lung disease Asthma Smoking: 20+ pack year history General health status: CHF, URI
Procedure-Related Risk Factors for Pulmonary Complications
Surgical site: abdominal & thoracic
Duration: 3+ hours
Type of anesthesia
Type of neuromuscular blockade
When should you obtain PFT’s on a patient pre-operatively?
Lung resection
COPD
Asthma
Unexplainable dyspnea or exercise intolerance
When should a chest x-ray be performed pre-operatively?
Known CVD
50+ years with a high risk surgical procedure
Strategies to Reduce COPD Complications Post-Operatively
Bronchodilators + antibiotics + systemic steroids
Inhaled ipratropium or tiotropium QD
Beta-agonists (as needed)
Strategies to Reduce Asthma Complications Post-Operatively
Beta-agonists
Peri-operative systemic steroids
URI & Surgery
Delay elective surgery
Patient Education for Reduce Pulmonary Complications
Coughing
Incentive spirometry
Deep breathing
Intra-Operative Strategies to Prevent Pulmonary Complications
Spinal or epidural if possible
Neuromuscular blockade intermediate agents
Short procedures in high risk patients
Post-Operative Strategies to Prevent Pulmonary Complications
Deep breathing exercises
Incentive spirometry
Adequate pain control
5 Reasons for Post-Op Fever
Wind Water Walking Wound Wonder drugs
Wind Issues for Post-Op Fever
Pneumonia
PE
Water Issue for Post-Op Fever
Indwelling catheter
Walking Issues for Post-Op Fever
DVT
PE
Wound Issues for Post-Op Fever
Surgical site infections
Wonder Drug Issues for Post-Op Fever
Infections from lines
Drug induced
Treatment of Post-Op Fever
Remove unnecessary treatments (meds or catheters)
Suppress fever with Tylenol
Antibiotics per judgement or culture results
Define Malignant Hyperthermia
Uncommon but life-threatening reaction to some anesthetic agents
Unsafe Medications for Patients with Risk of Malignant Hyperthermia
Depolarizing muscle relaxants (Anectine) Halothane Isoflurane Enflurane Desflurane Sevoflurane Succinylcholine
Medications that are Safe for Patients with Malignant Hyperthermia
Barbiturates Benzodiazepines Droperidol Ketamine Local anesthetics Nitrous oxide Non-depolarizing muscle relaxants Opioids Propofol
Clinical Manifestations of Malignant Hyperthermia
Hypercarbia Skeletal muscle rigidity Tachycardia Tachypnea High temp HTN Cardiac dysrhythmias Acidosis Hypoxemia Hyperkalemia Myoglobinuria
Pathophysiology of Malignant Hyperthermia
Genetic predisposition
Increased intracellular calcium
Continuous muscle contraction
Treatment of Malignant Hyperthermia
Call for help Stop triggering agents Hyperventilate Finish/abort procedure Administer Dantroline Cool patient Monitor & treat acidosis Promote urine output Treat hyperkalemia Treat dysrhythmias with procainamide & CaCl Monitor creatinine kinase, urine myoglobin, & coagulation for 24-48 hours
Surgical Care Improvement Project National Goal
Reduce preventable surgical morbidity & mortality
Complications That are Preventable
Infection
Cardiovascular
VTE
Infection Prevention in SCIP
Antibiotics 1 hour prior to incision
Glucose control in cardiac surgery patients
Proper hair removal
Normothermia
Prevention of Cardiac Events with SCIP
Maintain patient on a beta-blocker
Risk Factors for VTE
Hospitalization or nursing home Active malignant neoplasm Trauma CHF CV catheter Neurologic disease with paresis Superficial vein thrombosis Varicose veins/stripping
SCIP 1-2-3 Antibiotics
1: one hour prior to incision
2: appropriate selection of antibiotic
3: discontinue within 24 hours after anesthesia end time
SCIP 4- Blood Glucose
SCIP 6- Hair Removal
Clippers in OR
SCIP 9- Foley D/C
Discontinue by post-op day 2
SCIP-CARDIAC-2: Beta Blocker
Continue on home regiment pre-op
Continue on post-op day 1 or 2
SCIP-VTE-2: Timing of VTE Prophylaxis
24 hours prior to surgery OR
Within 24 hours after anesthesia end time
SCIP-10 Normothermia
96.8+ within 15 minutes of anesthesia end time or warmer
