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CMS 3 Surgery 1 Lec 1-4
Nova Orlando
185
Health Care
04/20/2011

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Cards

Term
removal, excision, resection
Definition
-ectomy
Term
surgical repair, surgical correction
Definition
-plasty
Term
process of visual examination
Definition
-scopy
Term
opening
Definition
-(o)stomy
Term
incision, to cut into
Definition
-(o)tomy
Term
an agent such a heat, radiation, or a chemical that disinfects by destroying, neutralizing, or inhibiting the growth of disease-carrying microorganisms
Definition
disinfectant
Term
destruction of pathogenic organisms to prevent infection. Processes, procedures, or chemical treatments that kill or inhibit microorganisms to prevent infection
Definition
antisepsis
Term
the state of being without contamination or other microorganisms. Not producing microorganisms or free from microorganisms.
Definition
aseptic
Term
preventing bacteria from growing and multiplying but possibly not killing them
Definition
bacteriostatic
Term
an agent that destroys bacteria
Definition
bactericidal
Term
sterile areas
Definition
front of gown from collarbone to waist
gloved hands
arms to the shoulders
draped part of the pt down to the tabletop
covered part of the Mayo stand
top of the back table (instruments are kept here)
Term
anything that falls __________ is considered contaminated
Definition
below the level of the tabletop
Term
purpose of the surgical hand scrub
Definition
to decrease bacterial skin flora via mechanical cleansing of the arms and hands prior to the surgical procedure
Term
what is the needed contact time of the scrub solution in order to be effective.
Definition
3 minute contact
Term
procedure to reduce medical errors while preparing the pt
Definition
read the surgical permit aloud
clearly identify the patient
clearly identify the operation
clearly identify the site of operation
Term
your job as a student in the OR
Definition
wait patiently, out of the way, with hands held above your waist. Do not cross your arms. Remember the sterile areas on your body.
Term
this set of guidelines was established by the CDC to decrease the risk of blood-borne infections. Underlying principle is to treat all pts as if they are infected.
Definition
Universal precautions
Term
surgeon who has completed their general surgical training and have elected to obtain more specialized training to become a surgical specialist.
Definition
fellow
Term
physician who has completed at least one year of residency, can last for 3-7 years
Definition
resident
Term
physician who has completed medical school and is in the first year of residency. Has a medical degree but not license
Definition
intern
Term
this person is responsible for all legal documentation in the OR, what degree must they have?
Definition
circulating nurse, must be an RN
Term
who is responsible for the collection and counting of all needles, sponges, etc, at the end of the procedure
Definition
scrub nurse
Term
what is the order of nerve blockage in anesthesia
Definition
first = autonomic
second = sensory
last = motor
Term
pts are deeply sedated, likely amnestic but can still respond to vocal and noxious stimuli
Definition
MAC - monitored anesthesia care
most common agent = propofol
Term
inhaled agent suitable for outpt surgery
Definition
sevoflurane
Term
why are opioids used in anesthesia?
Definition
produce profund analgesia and minimal cardiac depression.
to reduce the MAC of potent inhaled agents.
Term
only depolarizing agent in use today
Definition
succinylcholine
Term
SEs of succinylcholine
Definition
hyperkalemia, malignant hyperthermia
Term
SE of local anesthesia that is concerning
Definition
oral numbeness (often first sign of systemic absorption)
Term
what can be added to a local anesthetic to increase the percent of nonionized anesthetic --> accelerated penetration of the drug
Definition
bicarbonate
Term
this can be added to local anesthetics to aid in vasoconstriction --> decreased systemic absorption, increased duration of action
Definition
epinephrine
Term
when should epi not be added to a local anesthetic?
Definition
fingers, toes, penis, nose
Term
reversal agent for benzos
Definition
flumazenil (Romazicon)
Term
reversal agent for narcotics
Definition
naloxone (Narcan)
Term
SEs of naloxone use
Definition
sudden return of severe pain --> HTN, stroke, tachycardia, arrhythmia, CHF, cardiac arrest
Term
pneumonic for admission orders
Definition
ADVAANDIMSLC
Admit to
Dx
VS
Allergies
Activity
Nursing Orders - wound care, weights, I&O, etc
Diet
IV fluids - type, rate, time
Medications - med, route, dose
Studies - CXR, EKG, PFT, etc
Labs
Call MD
Term
surgical history pneumonic
Definition
AMPLE
Allergies
Medications
PM/surgical Hx (relavent)
Last oral intake
Events leading up to problem
Term
pneumonic for daily progress note
Definition
SOAP
Subjective
Objective
Assessment
Plan
Term
decision to proceed with an operative procedure is based on
Definition
analysis of the risk-benefit ratio
Term
H&P goals (3)
Definition
determine the dz and if surgery is needed.
recognize co-morbidities
develop a relationship with the pt.
Term
surgery cannot proceed without this in a patient's chart
Definition
informed consent
Term
persons who make decisions when a patient cannot speak for themselves
Definition
surrogate decision makers
Term
legal document to inform health care providers about the pt's wishes regarding the level of care to be delivered when the pt is unable to do so
Definition
advanced directives
Term
elements of the "surgical" social hx
Definition
tobacco, ETOH (prevent DT's), drug use
Term
how long should coumadin be stopped before surgery?
Definition
3 days
Term
how long should ASA be stopped prior to surgery?
Definition
1 week
Term
what may lessen the risk of surgery
Definition
pre-operative intervention
Term
risk factors for surgery
Definition
smoking (8 pack/yr increases risk 2-6 fold)
asthma
obesity
COPD
malnutrition
Term
pulmonary changes usually return to baseline within ________ of surgery
Definition
1-2 weeks
Term
minimal fasting period for clear liquids
Definition
2 hours
Term
minimum fasting period for solids and nonclear liquids (milk or OJ)
Definition
6 hrs
Term
most common cause of post-op morbidity
Definition
pulmonary complications
Term
2 physiologic changes that create stress on the myocardium
Definition
catecholamine surge resulting from anxiety about procedure or pain from procedure.
Vasoconstriction from receptor stimulation --> suppression of the fibrinolytic system --> thrombosis.
Term
how long should you wait after an MI for elective procedures?
Definition
6 months
Term
what impact does a + H/O unstable angina have on surgery?
Definition
should avoid surgery except CABG
Term
diabetes risks with surgery
Definition
derangements in blood sugar (maintain BS between 150-200 mg/dL to avoid hypoglycemia).
CV complications (increase with age and duration of DM).
Increased risk of infection (decreased immune function and vascular disease).
Term
hyperthyroidism risks with surgery
Definition
increased risk of thyroid storm, arrhythmias (A-Fib)
Term
what criteria is used to classify hepatic risks with surgery?
Definition
Child Pugh Criteria
Class A: mortality < 10%
Class B: mortality = 40%
Class C: mortality > 80%
Term
when do alcohol withdraws occur? when do they peak?
Definition
occur in 1-5 days.
peak in 3 days.
Term
what is the "cocktail" for alcoholic pts?
Definition
vitamins, thiamine, folate
Term
how do you treat DT's?
Definition
librium or valium
Term
when can acute adrenal insufficiency be seen? how is it treated?
Definition
pts on steroids > 5 days
tx = supplemental steroids so the pt can stand the stress of surgery
Term
malnutrition complications with surgery
Definition
decreased healing, infection, increased pulmonary complications
Term
surgery precautions with renal disease
Definition
ESRD = consult nephrology first!
DO NOT access dialysis catheters
fluid balance is critical
avoid K+ in IV fluids
use "renal dose" with abx
Term
when is prophylactic abx therapy initiated?
Definition
before surgery!
Term
when should bacterial prophylaxis be used for surgery?
Definition
only when there is a high likelihood of bacterial contamination
Term
indications for abx prophylaxis
Definition
high risk GI procedures (biliary procedures, colon/small intestine resection), cardiac surg via median sternotomy, vascular surgery (lower extremity or aorta), amputation for ischemia, hysterectomy, c-section, head/neck procedures, craniotomies, prosthetic implants, trauma, gross contamination
Term
abx used for prophylaxis when anaerobic flora is NOT suspected
Definition
cefazolin (kefzol)
Term
abx used for prophylaxis with suspected colonic anaerobes or bacteroides
Definition
cefotan
Term
abx used for prophylaxis with colonic surgery
Definition
nichols prep: neomycin, erythromycin
Term
rules for abx prophylaxis
Definition
must be given in tme to reach adequate tissue levels before contamination, adequate levels must be maintained throughout surgery
Term
antibiotics are not effective with continuing contamination such as: (3)
Definition
tracheostomy, indwelling catheters, burns
Term
goals of suture use
Definition
elimination of dead space, even distribution of tension along suture lines, maintain tensile strength along the wound until tissue tensile strength is adequate, approximate and evert the epithelial area of the closure
Term
ideal suture
Definition
easy to handle, minimal reaction in tussie, inhibits bacterial growth, hold securely when knotted, resist shrinking in tissue, non-capillary, non-allergenic, non-carcinogenic, non-ferromagnetic, absorbs with minimal reaction after tissue has healed
Term
absorbable sutures
Definition
chromic catgut, vicryl, dexon simlar, PDA, monocryl
Term
non-absorbable sutures
Definition
silk-braided, nylon monofilament, prolene monofilament, polypropylene, braided synthetic polyesters (mersilene, ethibond), steel wire
Term
suture size used in different places:
face
scalp
trunk & extremities
deep tissues
Definition
face = 5-0, 6-0 nylon or polypropylene
scalp = 3-0 nylon or polypropylene, or staples
trunk & extremities: 4-0, 5-0 nylon or polypropylene
deep tissues: 3-0, 4-0 absorbable sutures (dexon, vicryl)
Term
advantages of monofilament sutures
Definition
less tissue drag, don't have interstices that may harbor bacteria
Term
advantages of multifilament sutures
Definition
more pliable and flexible than monofilament sutures.
results in considerably better knot holding security.
Term
why are multifilament sutures coated?
Definition
to reduce capillarity
Term
what is capillarity?
Definition
process by which fluid and bacteria are carried into the interstices of multifilament fibers
Term
where should capillary sutures not be used?
Definition
contaminated or infected sites.
Term
what can help decrease suture stract epitheliazation?
Definition
using a topical antibiotic (polysporin)
Term
what is the relationship between time a suture is in place and scarring?
Definition
the longer a suture is in place, the more it scars
Term
when are face/neck sutures removed?
Definition
3-5 days
Term
when are scalp/body sutures removed?
Definition
5-7 days
Term
when are extremity sutures removed?
Definition
7-10 days
Term
how is total body water distributed?
Definition
2/3 = intracellular
1/3 = extracellular
85% venous, 15% arterial
Term
what is the average amount of Total Body Volume for an adult?
Definition
5L
Term
what is hydrostatic pressure?
Definition
"out" pressure, maintained by systemic BP
Term
what is oncotic pressure?
Definition
"in" pressure, maintained due to impermeability of capillary walls to protein.
Term
major determinant of capillary oncotic pressure
Definition
albumin
Term
receptors that help to maintain homeostasis by triggering fluid shifts
Definition
arterial/renal baroreceptors, atrial stretch receptors (sense change in circulating volume).
Macula densa in kidney (sense change in Na+ concentration).
osmoreceptors in brain/liver (sense shifts in plasma osmolality)
Term
mediators of homeostasis
Definition
atrial natriuretic factor
adrenotrophic hormone
growth hormone
vasopressin
renin/angiotensin
epinephrine
beta-endorphins
Term
global dehydration
Definition
decrease in total body water, loss>intake
Term
what is the average insensible loss/day? via what?
Definition
750-1000ml
vapor from lungs, skin, etc.
Term
what is included in sensible losses?
Definition
stool (diarrhea), urine (diuretics), sweat (heat, fever, exercise), bodily fluids (drains)
Term
is a pathologic space, fluid "hides" in tissues & cavities due to increased capillary permeablity (capillary leak)
Definition
"third spacing"
Term
what is third spacing stimulated by?
Definition
injury/inflammatory response (trauma, major sugery, intra-abd infections)
Term
preferred fluid replacement in "third spacing"
Definition
crystalloid solutions (NS, LR).
fluids must be replaced even with increasing interstitial fluid (IF) & TBW
Term
failure to replace and maintain adequate fluid volume leads to what?
Definition
tissue ischemia and necrosis from decreased volume and decreased oxygen delivery
Term
fluid used as a volume expander for short term use
Definition
crystalloid
Term
fluid used to provide sustained volume expansion for acute, severe hemorrhage and large volume loss
Definition
colloid
Term
only fluid choice during resuscitation
Definition
crystalloid (NS, LR)
Term
why should dextrose be avoided in aggressive resuscitation?
Definition
body doesn't utilize dextrose during times of severe stress. Hyperglycemia will result which can lead to an osmotic diuresis.
Term
used for maintenance fluid in a 70kg man
Definition
D5 1/4NS with 20mEq KCl @125cc/hr
Term
used for maintenance fluids in a peds pt
Definition
D5 1/4NS with 20mEq KCl
Term
extracellular cations and anions
Definition
cations = Na, K, Ca, Mg
anions = Cl, HCO3, proteins, sulfates, organic acids
Term
intracellular cations and anions
Definition
cations = K, Mg
anions = phosphates (PO4), Sulfates (SO4), proteins
Term
causes of hyponatremia
Definition
<136mEq/L Hypo-osmotic
hypovolemic = GI loss, burns, renal dz, diuretics.
euvolemic = polydipsia, SIADH, decreased renal function, adrenal insufficiency, isotonic replacement of fluid losses.
Hyperostmotic: hypertonic infusion, hyperglycemia, mannitol infusion.
Isosmotic: pseudohyponatremia (increased lipids, increased protein)
Term
symptoms of hyponatremia at 120-130mEq/L
Definition
apathy, confusion, lethary, anorexia, nausea, muscle twitching, hyperactive DTR's
Term
sxs of hyponatremia <120mEq/L
Definition
convulsions, loss of reflexes, coma, death
Term
treatment of hyponatremia
Definition
ID cause, calculate defecit, correct slowly
Term
hypernatremia causes
Definition
> 146mEq/L
hypovolemia: GI loss, diaphoresis, burns, diuretics, glycosuria, mannitol, ARF, CRF.
isovolemia: DI, hypodipsia
hypervolemia: iatrogenic, Cushing dz
Term
sxs of hypernatremia
Definition
dry mucous membranes, lethargy, restless, twitching, ataxia, seizure, delirium, stroke
Term
hyperkalemia causes
Definition
>5.0mEq/L
impaired excretion (renal failure, mineralocorticoid insufficiency), drugs (NSAIDs, K+ sparing diuretics, ACEIs), pseudohyperkalemia (hemolysis), acidosis (DKA), hypocalcemia, insulin deficiency, massive tissue destruction (compartment syndrome), rhabdomyolysis (crush injury)
Term
sxs of hyperkalemia
Definition
>5.5mEq/L
N/V/D, ECG changes, heart block, arrest
Term
treatment of hyperkalemia
Definition
ECG changes = IV calcium
glucose/insulin infusion
kayexalate
loop diuretics
dialysis
Term
hypokalemia causes
Definition
<3.0mEq/L
excessive loss from kidneys, GI losses (V/D), trancellular shifts (alkalosis)
Term
sxs of hypokalemia
Definition
vomiting, constipation, ileus, ECG changes, weakness, hyporeflexia, confusion
Term
treatment of hypokalemia
Definition
ID underlying cause, PO replacement has rapid onset (preferred), slow IV replacement, reverse hypomagnesemia
Term
preferred route of replacement in hypokalemia
Definition
PO - it has a more rapid onset
Term
hypercalcemia
Definition
>10.4mEq/dL
primary hyperparathyroidism, malignancy, vitamin D excess, thiazides
Term
sxs of hypercalcemia
Definition
fatigue, N/V, constipaton, lethargy, arrhythmias
Term
treatment of hypercalcemia
Definition
aggressive hydration, bisphosphonates, calcitonin, dialysis
Term
hypocalcemia
Definition
<8.4 mg/dL
hypoparathyroidism, CRF, vit D deficiency, liver disease, drugs
Term
sxs of hypocalcemia
Definition
Chvostek sign, Trousseau sign, mental status changes, convulsions, arrhythmias
Term
tx of hypocalcemia
Definition
parenteral supplementation
Term
hyperphosphatemia
Definition
>5mg/dL
ARF, CRF, rhabdo
Term
sxs of hyperphosphatemia
Definition
some asx. In conjucntion with hypocalcemia --> tetany
Term
treatment of hyperphosphatemia
Definition
aggressive hydration, calcium carbonate, aluminum based antacids, dialysis
Term
hypophosphatemia
Definition
<2.5 mg/dL
inadequate intake, excess loss (burns), hyperparathyroidism
Term
sxs of hypophosphatemia
Definition
weak, fatigue, rhabdo, cardiomyopathy, obtunded, seizures
Term
treatment of hypophosphatemia
Definition
IV sodium or PO4, dairy products
Term
hypermagnesemia
Definition
>2.9 mg/dL
RF, acidosis, adrenal insufficiency, antacids
Term
sxs of hypermagnesemia
Definition
N/V, weak, fatgue, loss of DTRs, bradycardia, hypotension
Term
treatment of hypermagnesemia
Definition
calcium gluconate, IV saline, loop diuretics
Term
hypomagnesemia
Definition
<1.8 mg/dL
inadequate intake, malabsorption, diuretics, SIADH, DKA
Term
sxs of hypomagnesemia
Definition
anorexia, N/V, weak, confused, tetany, seizurse, psychosis, delirium
Term
treatment of hypomagnesemia
Definition
MgSO4 parenterally, Milk of Magnesia (MOM), mag hydroxide
Term
caused by an underlyng anatomic or mechanical problem which must be addressed to be cured. Not cured by antibiotics alone
Definition
surgical infection
Term
what is of utmost important with post-op infections?
Definition
recognition!
Term
treatment for gram + post-op infections (5)
Definition
cefotazime, ceftizoxime, ceftriaxone, ceftrazadime, aztreonam
Term
treatment of gram - post-op infections
Definition
gentamycin, tobramycin, amikacin, flouroquinalones
Term
SE of gentamycin and tobramycin
Definition
ototoxicity
Term
SE of flouroquinalones
Definition
achilles tendon rupture, don't give < 18 yo
Term
treatment of anaerobic post-op infections (3)
Definition
clindamycin, metronidazole, chloramphenicol (lots of SE)
Term
post op infection days 1-3
Definition
necrotizing soft tissue
Term
dx and tx of necrotizing soft tissue
Definition
dx: STAT gram stain and wound culture
tx = PCN G + clindamycin ( clostridia)
1st generation cephalosporin (non-clostridia)
Term
post op infection 5 days post op
Definition
superficial wound with purulent drainage, erythema, fever
Term
MC organisms for superficial wound infection above the waist? axillae? below the waist?
Definition
above the waist = staph aureus, strep
axillae = prominant gram - bacteria
below the waist = mixed aerobic/ anaerobic gram - flora
Term
tx of intraabdominal wounds
Definition
braod spectrum systemic abx: ampicilln, gentamycin, clindamycin, unasyn, piperacillni, etc. and FIX the problem
Term
when can you d/c abx after post-op infection?
Definition
if pt is afebrile x 48 hrs d/c therapy or cahnge to PO rx for 7-10d
Term
risks inherent to surgery
Definition
bleeding, infection, pulmonary complications, DVT's, etc
Term
significant co-morbid illness for surgery
Definition
DM, heart failure, COPD, etc
Term
cause of post-op fever in first 24 hrs
Definition
may be normal response to surgical trauma
Term
common superficial wound infection:
early
late
Definition
early = necrotizing soft tissue
late (5-10d) = superficial abscess
Term
5 W's of post-op wound care
Definition
Wound infection
Wind - atelectasis, aspiration
Water - UTI
Walk - DVT
Weird drugs/What did we do? (if fever think transfusion related or drug related esp PCN and derivatives)
Term
return of normal GI propulsion post-op
Definition
small bowel = first
stomach = 24-48 hrs
colon activity = 48 hrs
Term
how long is a pt NPO after surgery?
Definition
until bowel sounds are auscultated and pt passes flatus
Term
tx of post op ileus
Definition
usually resolves spontaneously, may need to pass an NG tube
Term
partial or total disruption of any/all layers of post-op wound: early, late
Definition
early = wound dehiscence
late = incisional hernia
Term
collection of liquified fat, serum, and lymphatic fluid, often opened or aspirated
Definition
seroma
Term
a collection of blood, usually in the subcutaneous layer of recent incision
Definition
hematoma
Term
type of closure when wound edges are opposed and closed by either sutures, clips, tapes, or dermal adhesives immediately
Definition
primary intention
Term
2 possible methods used for permanent closure
Definition
running or interrupted sutures
Term
type of closure typically used for GI reapir and closure and external skin/scalp repair
Definition
staples
Term
used for closure of non-tension wounds or as an adjunt to reinforce and provide a watertight seal
Definition
adhesives
Term
method of closure when wound edges are left unopposed
Definition
secondary intention
Term
method of closure used for contaminated wounds, may initially be treated by repeated debridement or antibiotics for several days to prevent infection, closure is completed after several days
Definition
tertiary intention (delayed primary closure)
Term
causes of abnormal wound healing pneumonic
Definition
DIDNTHEAL
Diabetes
Infection
Drugs
Nutritional problems
Tissue necrosis
Hypoxia
Excessive tension on wound edges
Another concurrent wound
Low temperature
Term
MC pathogens of SSI
Definition
staphylococcus aureus
staphylococcus coagulase negative
enterococcus
escherichia coli
Term
malnutrition impact on wound healing: specific parts
Definition
protein catabolism delays wound healing
Vit C deficiency decreases wound healing
Vit A deficiency impedes monocyte activation.
Vit K metabolism impeded antibiotics.
Zinc deficiency results in early wound healing delay.
Term
post op fever day 1-2
Definition
Wind - atelectasis, Tx = spirometry
Term
post op fever day 3-5
Definition
water - UTI. tx = D/C foley, abx
Term
post op fever day 5-7
Definition
wound infection. tx = abx and I&D
Term
post op fever day 7
Definition
wonder drugs, d/c offending agent
Term
S&S of malignant hyperthermia
Definition
rapid rise in body temp (up to 105F or higher), core temp can rise 2-4 degrees every 5 minutes.
muscle rigidity or stiffness
dark brown urine
muscle ache
Term
triggers of malignant hyperthermia
Definition
inhaled halothane anesthetic agents
succinylcholine
Term
gold standard for the dx of malignant hyperthermia
Definition
IVCT - in vitro contracture test
+ occurs with contracture of muscle fibers to halothane or caffeine
Term
treatment of malignant hyperthermia
Definition
danrolene via rapid IVP, d/c tiggering anesthetic
Term
complications of malignant hyperthermia
Definition
rhabdomyolysis, renal failure, myopathy, death
Term
causes of subacute post-op fever
Definition
usually infection
#1 = wound
#2 = UTI
#3 = pneumonias (if on vent or COPD)
C Diff, line sepsis & bacteremia, intra-abd abscess
Term
post op fever, weeks later
Definition
endocarditis, infected prostheses
Term
important portion of post op follow up
Definition
patients should be given strict post-op instructions.