Chapter 11 - Hemostasis, Wound Healing, and Wound Closure

Thrombus

Blood clot formed

Drains

Used to eliminate dead space and hematoma formation

ADP (adenosine diphosphate)

Released along with epinephrine, causing platelets to clump and forming a small initial thrombus

Vasoconstriction

Initial response when a blood vessel is cut or injured

Fibrin

Formed from the reaction of thrombin with fibrinogen to form a matrix that leads to a more solid clot

Sequential compression device

Prevents venous stasis and deep vein thrombosis

Endothelial cells

Interacts with platelets and clotting factors after trauma or certain vessel diseases

Coagulation

Bodily process to control blood loss resulting in hemostasis

Thrombin

Formed from the reaction of prothrombin with thromboplastin

Describe why aspirin is discontinued one week prior to surgery?

because it has anti-coagulant properties

Identify at least four conditions or hemostatic defects that can affect coagulation.

hemophilla, liver disease, anticoagulant therapy, aplastic anemia, alcohol liver failure

Second assist function of cutting suture...

using dominant hand place index finger on the screw joint to stabilize, scissors slightly opened and blades angled, slide scissors downward, feeling the knot, and cutting the suture without cutting the knot

When cutting suture for the surgeon who is using monofilament suture, leave a tail of approximately how long?

1/8" long from the knot

What is the purpose of leaving the tail?

to enhance the knot's security

What types of material are ligating clips made of?

a nonreactive metal, such as titanium or stainless steel, or plastic material

What at patties (cottonoids) used primarily for?

neurosurgical procedures

What is a pledget made of?

small squares of Teflon

Describe the purpose of a pledget.

used as a buttresses over the suture line; prevents bleeding & promotes clotting

Describe how the pledget is used.

using suture, they are sewn over the hole in the vessel and exert outside pressure over the small needle holes to prevent bleeding and promote clotting

What is bone wax made of?

refined and sterilized beeswax

Describe the purpose of bone wax.

it is used on cut edges of bone as a mechanical barrier to seal off oozing blood

What is suction used for during surgery?

to evacuate smoke plume, clear fluids from the operative site

What is the purpose of the drain?

prevent edema, prevent hematoma formation, aids in removal of air to eliminate dead space

Describe the purpose of sequential stockings.

prevent venous stasis and DVT and embolism

Describe the purpose of the tourniquet.

used on extremities to keep the operative site free of blood, makes visualization easier and reduces the operative time

What is the most commonly used thermal device? Describe the components of this device.

Electrosurgery; the active electrode (Bovie), electrosurgical or generator unit (ESU), and inactive or dispersive electrode (grounding pad)

What type of energy does the laser use?

light energy

Compare laser and electrosurgical unit utilization. What is the benefit of using the laser?

lasers are able to cut and coagulate tissue at the same time with little surrounding tissue destruction, ESU uses heated wire to cauterize; benefit of using laser is that there is little tissue damage

What is the advantage of using argon plasma coagulation? Why?

there is little to no tissue adherence so there is less charring of the tissue because the handpiece does not come in direct contact with the tissue that is bleeding

What type of energy does the harmonic scalpel use?

mechanical energy

What are the advantages of the harmonic scalpel?

the continuous action does not cause significant increase in temperature so it does not cause charring of the tissue, damage to adjacent tissue is minimal

Blood loss: A. What does EBL mean? B. When utilizing suction canisters from the field to monitor blood loss, what important information must be monitored and reported by the surgical technologist? Why?

A. estimated blood loss

B. the amount of irrigation fluid used because the amount of irrigation fluid used is subtracted from the total volume of fluid in the canister to provide an accurate measurement of blood loss

Describe how blood loss is calculated when using sponges.

the sponges can be weighed using a predetermined formula using the weights of wet and dry sponges

At the end of the case when the closed wound collection device is applied to the drain, what should be monitored or conveyed to the surgeon?

how much blood is lost and if a blood replacement is necessary

Who is responsible for monitoring and reporting the estimated blood loss?

circulator, anesthesia provider, surgeon

Describe four types of blood replacements given. What does the + or - mean after each one?

Type A - has A antigens and anti-B agglutinins

Type B - has B antigens and anti-A agglutinins

Type AB - has both A and B antigens and no agglutinins

Type O - has no antigens and both anti-A and anti-B agglutinins

If they have the Rheus factor they are + and if not they are -

Describe why blood products may be given.

to increase the circulating blood volume, to increase the number of red blood cells, to increase the number of circulating platelets for clotting, and to provide plasma clotting factors that have to be depleted during surgery

What parameters are required for blood that is stored in the operating room prior to use?

should be stored in a refrigerator at 1 degree Celsius to 6 degrees Celsius

Describe how blood is recovered from the sterile field using suction or sponges.

blood may be drained from bloody sponges into a basin of saline, and suctioned into canisters

Describe situations in which lost blood cannot be given back to the patient.

if blood is exposed to collagen hemostatic agents, exposed to gastric contents or amniotic fluid, if the patient has local/systemic infection, suspected cancer cells

If you do not have a cell saver machine, describe two ways that you can still recover the patient's own blood.

a salvage collection bag containing an anticoagulant or an autotransfusion machine

What are the identification requirements when a blood product from the blood bank is administered to the patient?

information needs to be checked verbally by two individuals, blood group info, Rh type, unit number must match the bag tag, patient's arm band, and patient's chart, double check the physician's order, blood expiration date and check the product for clots

Describe typical signs and symptoms of a transfusion reaction.

fatigue, complain of a lack of energy, rapid pulse, shortness of breath, pounding of the heart, skin may appear jaundice or pallor

What signs and symptoms might you see with a patient under general anesthesia?

generalized loss of blood and a lowered blood oxygen saturation level

What actions are taken if a transfusion reaction is suspected?

the transfusion should be stopped immediately and a blood sample sent to the blood bank to rule out a mismatch , give steroids, monitor urine output

When is the wound classification recorded in the intra-operative record?

at the end of the procedure because classification is subject to change

From patient, either stored or cell saver autotransfusion

Autologous

Donated from another; requires type and cross match

homologous

Four main blood type groups

A, B, AB, O

Universal donor

Type O

Universal recipient

Type AB

Occurs when mismatched blood is given (mild to anaphylactic shock)

Transfusion reaction

Antigen found in RBCs of most people

Rh factor

Specific type of reaction that occurs with Rh mismatch

Hemolysis

Persists for an extended period of time

Chronic wound

Penetrating wound

Puncture

Dirty object damages skin

Contaminated wound

Tissue is lost/destroyed or contains a foreign body

Complicated wound

Scrape

Abrasion

Bruise

Contusion

Cut or tear

Laceration

Occurs by heat or cold

Thermal wound

Skin intact with damage to underlying tissue

Closed wound

Incision made, sutured, heals by first intention

Clean wound

What is released from the damaged cells that causes the inflammatory response?

histamine

Normally healing of wounds occurs from ______ to _____ across the wound, not from the inside out.

side, side

Describe the 5 signs of the inflammatory process.

pain, heat, redness, swelling, loss of function

Identify the 3 phases of normal (primary intention) wound healing. What is the normal length of time for each?

Phase 1: Lag Phase or inflammatory phase; 3-5 days

Phase 2: Proliferation phase; about 3rd post op day - 20 days

Phase 3: Maturation or differentiation phase; begins 14th day until wound is completely healed

How can each of the following issues affect wound healing? (Age, nutrition, disease, radiation exposure, smoking, immunocompromised or immunosuppressed)

Age: pediatric and geriatric patients may have decreased vascularity or poor muscle tone

Nutrition: dietary deficiencies can alter the healing process

Disease: the weight and pressure of adipose tissue may make it difficult to achieve a secure wound closure and contribute to incisional hernia, poor blood supply

Radiation Exposure: patients undergoing radiation therapy in large doses may increase a decrease in blood supply

Smoking: it causes vasoconstriction, diminishes oxygenation, and causes coughing that can put stress on a healing wound

Immunocompromised: the patients immune system may be deficient due to congenital or acquired conditions

Describe the appropriate intraoperative tissue handling techniques that should be used during any case.

sterile technique, dissection technique (sharp vs blunt), wound security, methods of hemostasis

When does wound dehiscence most commonly occur? Describe 5 possibly causes of wound dehiscence.

between 5th and 10th post-op day; friable tissue, abdominal distention, too much tension on the wound, improper suture technique, inappropriate type/strength of suture material

Distinguish the difference between dehiscence and evisceration.

dehiscence = partial or total separation of tissue after closure

evisceration = viscera protruding through the edges of a totally separated wound

Which abdominal incision is most likely to be a factor in the cause of dehiscence?

long paramedian or medial

Analyze the factors leading to wound infection and dehiscence and identify measures that the surgical technologist can take to prevent wound infections and dehiscence.

infection occurs when microbial contamination overrides the resistance of the host; use sterile technique, irrigate wounds, close dead spaces

Analyze the term dead space. Describe why it is important to eliminate dead space. How can that be accomplished?

dead space is the open space inside of the wound; it is important to eliminate because it will allow serum or blood to collect and provide a medium for microbial growth resulting in infection; use proper suture techniques, wound drains, pressure dressings

Describe tensile strength and identify what factors affect the tensile strength of the suture.

tensile strength is the maximum strength a material can withstand; type of suture, presence of infection, tissue sites, absorption

Identify one type of suture with very strong tensile strength.

Stainless steal

Describe pliability.

how easily the suture will pass through tissue

Describe how to remove memory.

gentle pull on the suture without placing tension on the swaged end of the suture

Identify one suture type with memory.

Monofilament, Nylon

Absorbable Natural

Plain Gut, Chromic Gut

Absorbable Synthetic

Vicryl, Dexon, PDS II, Ethicon

Non-Absorbable Synthetic

Stainless Steel, Prolene

Non-Absorbable Natural

Surgical Silk