Surgical Facilities and Basic Monitoring

What is closed loop communication

3 step process of communication often in healthcare or other high stakes environments

What are the three verbal comms of close loop communication

• Given (sender)

• Received (receiver)

• Confirmed (sender)

Why do we teach closed loop communication

Reduce errors, build safety/ trust within teams

What are the principles of ergonomics

• Relaxed shoulders

• Back straight (Skeletal alignment: neutral posture)

• Table height/tilt

• Sitting vs standing (Once you sit, you stay sitting- this is a one-way street!)

• Moving in the space for multi-step procedures

What are the special needs for a surgical area of LA

▪ Species/ anatomy

▪ Procedure, positioning and surgical approach

• Local/ regional anesthesia, pain control

What does the field of surgery consist of

▪ As above plus facility/ location concerns including post op care capacity

▪ Standing?

▪ What do you need to bring with you?

▪ Personnel

▪ Cleanliness

What are the consideration for large animal field surgery

• Same as SA: Limitations of patient, facility, personnel

Species and location considerations

What do we mean by Pre-disposing factors for infection in large animal field surgery

▪ Ex: Equines UTD on tetanus vaccination?

▪ Role of antibiotics: never to cover for poor or lapsed surgical technique

• Know regs for withdrawal times in food animals

• Procedure classifications for risk of infection, degree of contamination

What do we mean by Is this a "herd" case or a single individual?

▪ Recordkeeping

▪ Pain control and aftercare

What do we mean by weather condition in large animal services

Cleanliness and personnel able to assist

What are the pre-surgery checklist

• Confirm:

o Patient ID- Signalment and tagging/medical collar, ASA status

o Procedure and incision site/ location

▪ Clipping/ prep margins

• Introductions of personnel in the room

• Confirm pre-op procedures are complete

• Verify patient risks and concerns

• Confirm all needed equipment is present and operational

Before you cut... WHAT DO YOU ALWAYS CHECK

check the anesthesia equipment

• Do it the same every time! No exceptions.

oComplacency leads to errors which leads to poor outcomes and patient or staff harm

What else should we be checking other then the anesthesia

• Oxygen levels

• Isoflurane/sevoflurane levels

• Pressure test (Pop off valves- a word of extreme caution)

• Will be covered in more depth in Anesthesia course

• Don't start a procedure if you can't safely complete

At the end of the surgery what should we do before the of the procedure

oDiscuss concerns for recovery related to progression of procedure

▪ Relay and confirm any anticipated events or changes to pre-op plan for recovery

• Where will patient go once initial recovery is complete? Level of care needed in the post- op hospitalization period? Supportive care indicated? Sample submission?

During the recovery stage of the post surgery what should we be asking or doing

oEnsures all needed ancillary services completed with documentation

oWho is responsible for documentation of monitoring during recovery and what is the endpoint for that monitoring and documentation?

• Checklists are often customized to the facility/ caseload

What are the post surgery check list during the time of recvoery to discharge

• Confirm removal of IV catheters, related wraps, paper collars or temporary bandage material related to hospitalization

• Document communication with client for discharge instructions

• Confirm any biological samples are labeled and prepared for submission

• Confirm completion of invoicing

What does the pulse ox measure

oPeripheral capillary oxygen saturation (SpO2) of hemoglobin (%), pulse rate, some info for rhythm if waveform (plethysmograph- "pleth")

Wavelengths of light pass through what

a body part and the sensor detects the difference in light absorption through the vascular tissue.

how do you use a pulse ox

o Place probe on well perfused, non-pigmented areas whenever possible.

What are the limitations of a pulse ox

o Inaccurate with pigmented areas, motion artifacts, and when perfusion is altered (such as with certain anesthetics)

What does the ECG measure

o Electrical activity of the heart

Electrodes detect what

electrical impulses generated by the heart and create a waveform pattern

How do we use an ECG

o Electrodes attached (usually clamps) using a "white on the right, snow in the tree" (right front – white, right back – green) and a "smoke over fire" (front left – black, back left – red) fashion. Follow the labels on the wires or diagram on the port.

What are the limitations for an ECG

o Movement artifact, difficult to read on small screens to detect early changes, requires training to interpret appropriately

How do you messure BP

oSystolic, diastolic, mean arterial pressure depending on type used

Indirect methods detect (for BP) is

blood flow via ultrasound (Doppler) or pressure oscillations (oscillometric)

How do you use a BP

o Ensure correct cuff size (40% rule), place limb at heart level when measuring

What are the limitations of a BP

oDifficult to detect small changes via manual/ indirect methods

What does the capnography measure

o End tidal CO2 (EtCO2)- reflects ventilation adequacy, respiratory rate and waveform

Capnography Measures carbon dioxide concentration in what

exhaled air

How do you use a capnography

Attach unit to sampling line between ETT and breathing circuit

What are the limitations for a capnography

oImpacted by leaks in system, low tidal volumes, masks

What does the esophageal stethoscope measure

o Heart rate and auscultation

What is a esophageal stethscope

Flexible tube placed into esophagus to transmit sounds from level of the heart, the stethoscope does not have a standard bell and is meant to be internally placed

How do we use it the esophageal stethescope

o Measure depth by incisors to last rib, pass gently, adjust until heart sounds are loudest

What are the limitations for Esophageal Stethoscope

o Only intermittent usage typically, though the equipment may be left in place during procedures. Easily displaced with moving patient, must be removed prior to adjusting patient position

What does manual monitoring measure

o Heartrate, respiratory rate, perfusion (CRT), temperature

• "TPR" values

What are the manual monitoring limitations

o Intermittent usage, not as sensitive even to a trained individual as a piece of equipment that is functioning well (ECG, Capnography, BP) but NOT SpO2

Why is the manual monitoring so important

Should be performed as part of anesthesia monitoring when the procedure allows- do not break sterility for this

Who is in the OR

• Surgeon(s), Assistant(s), techs, VAs, interns, residents, students

What is the minimum attire for the OR

oCap

oMask

o +/- booties or designated shoes

oClean scrubs

What are the don’t in the OR

• Wear a white/ lab coat in the OR

• Wear street clothes

Are we allowed to talk in the OR

• Minimize talking, movement and number of personnel

oPrevent unnecessary air disturbance and introduction of bacteria and spores

What is the importance of air flow in sterility

oThe importance of air flow

▪ Positive pressure systems and frequent air exchanges- pushes clean air out of the OR

▪ Keep the door closed

▪ Do not enter/ leave the OR unless you NEED to (if non-sterile)

oScrubbed and gowned personnel face the sterile field at all times

▪ Do not move around the room unless you need to

▪ Keep hands clasped/ together at chest height when moving- body/spatial awareness