Note
Studied by 52 peopleSurgical Semiology Lecture 1-7
L1
Surgery: Overview and Definition
Surgery is defined as the art or practice of treating injuries, deformities, and disorders through manual operations or instruments. It encompasses a wide range of techniques and procedures, from minimally invasive interventions to major operations.
Short History of Surgery
Early 20th Century
In the early 20th century, surgery began to achieve professional status, transitioning from a trade to a respected medical discipline. During this period, self-trained 'surgeons' often had high mortality rates, particularly when handling even simple cases, demonstrating the need for formal training and education in surgical practices.
Knowledge of Human Anatomy
Andreas Vesalius (1514-1564)
Andreas Vesalius made significant contributions to human anatomy with his publication, De humani corporis fabrica. This groundbreaking work corrected long-held misconceptions derived from ancient texts, particularly those of Galen. Vesalius emphasized the importance of hands-on education and conducted systematic dissections, which transformed the understanding of human anatomy and laid the groundwork for modern surgical practices.
Methods of Controlling Hemorrhage
Ambroise Paré (1510-1590)
Ambroise Paré is renowned for his revolutionary approach to controlling hemorrhage during surgical procedures. He advocated for ligating individual blood vessels rather than using mass ligature techniques, which not only improved patient outcomes during amputations but also advanced the understanding of vascular systems in surgeries.
Understanding Surgical Diseases
John Hunter (1728-1793)
John Hunter utilized experimental methods to delve into various surgical diseases, exploring the effects of blood flow, inflammation, and the impact of gunshot wounds on human health. His work established critical links between the structure and function of organs, influencing the future of surgical practices and medical studies.
Antisepsis and Infection
Joseph Lister (1827-1912)
Joseph Lister pioneered the use of antiseptics in surgery, introducing carbolic acid for sterilizing instruments and cleaning surgical environments. His antiseptic principles drastically reduced infection rates post-surgery, marking a pivotal shift towards safer surgical practices and a new standard for maintaining hygiene in medical settings.
Development of Anesthesia
The understanding and use of anesthesia have evolved significantly, tracing back to ancient analgesics to the development of modern anesthetics such as chloroform and ether. These advancements facilitated painless surgeries and transformed surgical practices, allowing surgeons to focus not only on the speed of operations but also on patient comfort and safety.
Turn of the 20th Century
As the 20th century progressed, surgeons increasingly adopted antiseptic practices, leading to improved hygiene and patient outcomes. Post-World War II innovations in medical technologies and techniques allowed for earlier diagnoses and more complex surgical procedures, reshaping the landscape of modern surgery.
Current Medical Practices
Today's surgical practices emphasize patient-centered care and multidisciplinary teamwork. Surgeons play a crucial role in improving patient outcomes and reducing surgical errors through collaboration with other healthcare professionals. This approach aims to provide comprehensive care throughout the surgical process.
Surgical Fields
Surgery encompasses a variety of specialized fields, including General Surgery, Trauma Surgery, Orthopedic Surgery, Urology, Ear, Nose, and Throat (ENT), Oral and Maxillofacial Surgery, Pediatric Surgery, Plastic Surgery, Cardiothoracic Surgery, and Neurosurgery. The increasing complexity of surgical cases necessitates a robust surgical team, which may include consultants, trainees, and various allied health professionals to ensure optimal care.
Surgical Training
Training for aspiring surgeons begins during medical school and continues through residency programs. Trainees gain extensive practical experience by participating in elective and emergency surgical cases, enabling them to develop their skills and competence in various surgical methods.
Patient’s Path to Surgery
Types of Patients
Elective Patients: These patients have non-urgent conditions that require surgical intervention, often planned in advance to improve quality of life or resolve long-standing issues.
Emergency Patients: These individuals present with acute issues requiring immediate evaluation and treatment to prevent serious complications or death.
Legal and Ethical Issues for the Surgeon
Beneficence and Nonmalfeasance
Beneficence: Surgeons hold an ethical obligation to act in the best interest of the patient, providing care that promotes their well-being.
Nonmalfeasance: This principle emphasizes the importance of not causing harm to patients. Surgeons must navigate complex ethical dilemmas while ensuring patient safety and informed consent throughout the surgical process.
Trendelenburg Position: The bed is tilted downwards for pelvic surgeries or to improve venous return, caution is advised to avoid increased intraocular pressure.
Reverse Trendelenburg Position: The head of the bed is tilted upwards, suitable for upper abdominal surgery but may lead to venous pooling in the legs, so compression stockings are often recommended.
Lateral Position: Optimal for kidney and thoracic surgeries, requiring careful securing to maintain spinal alignment and prevent skin trauma.
Classifications of Surgery Types of Patients:
Elective Patients: Non-urgent conditions requiring surgical intervention, planned in advance to improve quality of life.
Emergency Patients: Acute issues requiring immediate evaluation and treatment to prevent serious complications or death.
Legal and Ethical Issues for the Surgeon:
Beneficence: Ethical obligation to act in the best interest of the patient.
Nonmalfeasance: Principle of not causing harm to patients.
Surgical Positions:
Trendelenburg Position: Bed tilted downwards for pelvic surgeries, requires caution to avoid increased intraocular pressure.
Reverse Trendelenburg Position: Head of the bed tilted upwards for upper abdominal surgery, may cause venous pooling in the legs.
Lateral Position: Used for kidney and thoracic surgeries, requires careful securing to maintain spinal alignment.
L2
ORGANIZATION OF SURGERY
Introduction
Surgery requires careful coordination for timely and quality services.
Increasing complexity in surgery necessitates a sophisticated infrastructure.
Key components of the surgical team include:
Surgical consultant
Surgeons in training
Anesthetists
Nurses
Allied health professionals (e.g., physiotherapists)
Importance of Organization
Surgery is a significant life event for patients.
Effective organization instills confidence and promotes efficiency.
Surgical operations can range from simple day-case procedures to complex treatment programs (e.g., cancer treatment).
THE SURGICAL TEAM
Role of the Surgical Consultant
Leads clinical teams and coordinates the pathway to surgery.
As surgery becomes more complex, specialization among surgeons increases.
Emergency care and elective services are provided by all surgical disciplines.
Hierarchy in the Surgical Team
Attending Surgeon
Leads the surgical team, performs surgery, and manages patient recovery.
Consults with patients preoperatively and supervises the team during operations.
Assistant Surgeon
Supports the attending surgeon through various roles during surgery.
Can include surgical residents and credentialed surgical assistants.
Surgical Resident
Medical school graduates undergoing specialized residency training.
Actively participates in surgeries under supervision, gaining the skills needed to become attending surgeons.
Nursing Role in Surgery
Nurses provide essential organizational support and are responsible for 24-hour OR staffing.
Their responsibilities include:
Overseeing operatives suite operations.
Coordinating equipment and ensuring case efficiency.
Assisting with procedures and maintaining documentation.
Specific Nurse Roles
Circulator Nurses
Registered nurses ensure the appropriateness of setup and patient verification.
Responsible for all necessary supplies and documentation during surgery.
Scrub Technicians
Prepare sterile instruments and assist the surgeon with supplies during operations.
Maintain awareness of instruments used to prevent retention in patients.
Additional Surgical Roles
Surgical Assistants
Assist in major tasks such as suturing, suctioning, and retraction, supporting the surgical team beyond the scope of a scrub technician.
Housekeeping and Sterile Processing
Ensure room cleanliness and instrument sterilization, which is crucial for patient safety and operational timing.
Anesthesia Team Responsibilities
Roles include:
Anesthesiologists oversee anesthesia provision, ensuring patient safety and appropriate medication administration.
Nurse anesthetists assist in administering anesthesia and performing monitoring tasks.
Anesthesia residents train under supervision executing similar duties.
PATIENT PATHWAY TO SURGERY
Classifications of Patients
Elective Patients: Non-urgent cases requiring surgical management but no immediate treatment.
Emergency Patients: Require immediate assessment/response due to severe medical concerns.
Surgical Consultation Process
Involves full patient history, clinical examination, and necessary investigations.
Patients may be scheduled for surgery or placed on a waiting list after consultation.
Surgical Types and Preparation
Day-case Surgery: Performed in units designed for efficient same-day discharge, accounting for approximately 50% of general surgeries.
In-Patient Surgery: Requires hospital stay, typically involving major surgical cases or emergency procedures.
PATIENT PREPARATION PRIOR TO SURGERY
Preoperative Assessment
Prepare medically and psychologically through comprehensive examinations.
Patients informed on pre-surgery requirements (food, consent).
Specific Preparations
Bowel Preparation: Necessary for specific surgeries (e.g., gastrointestinal tract).
Medication Management:
Anticoagulants (e.g., warfarin) must be paused to reduce bleeding risks.
Assess thromboembolic event risks against bleeding complications.
Antibiotics:
Administered typically 60 minutes before skin incisions for infection prevention.
OPERATING SUITE DESIGN
Key Zones in Operating Suite
Transfer Zone: Patient arrival and initial processing areas.
Clean Zone: Transition area with storage for pre-sterilized equipment.
Sterile Zone: Operating rooms where procedures take place and sterile tools are managed.
Disposal Zone: Responsible for handling and disposing of used materials.
POSTOPERATIVE CARE
Recovery Process
Patients are monitored in a recovery area, ensuring vital functions and post-surgery complications are managed.
High-risk patients may be moved to intensive care units for continued treatment.
Classifications:
Classifications of Patients:
Elective Patients: Non-urgent cases requiring surgical management but do not need immediate intervention.
Emergency Patients: Cases requiring immediate assessment and response due to urgent medical needs.
Surgical Types and Preparation:
Day-Case Surgery: Surgeries performed in a unit designed for same-day discharge, often routine and not requiring an overnight stay.
In-Patient Surgery: Surgeries requiring a hospital stay, generally for major or complex procedures, including emergency surgeries.
Operating Suite Design (Zones):
Transfer Zone: Area where patients arrive and initial processing occurs.
Clean Zone: A transition area for pre-sterilized equipment storage.
Sterile Zone: The operating room where procedures and use of sterile tools occur.
Disposal Zone: Designated area for handling and disposing of used materials post-operation.
Medication Management (Specific Preparations for Surgery):
Anticoagulants: Medications like warfarin that need to be paused to reduce bleeding risks.
Antibiotics: Typically administered 60 minutes before incision to prevent infections.
L3
Short History of Asepsis and Antisepsis
19th Century Innovations
Germ Theory of Disease:
Proposed by Louis Pasteur, suggesting that bacteria cause infection via air transmission.
Joseph Lister’s Contributions:
First to use phenol as a spray in operating theatres.
Aimed to sterilize surgical instruments and clean wounds.
20th Century Developments
Alexander Fleming:
Discovered Penicillin, marking the start of effective antibacterial treatment.
Pre-Antibiotic Era Challenges
Infected wounds:
Before antibiotics, infections often led to radical surgery, such as amputations.
What Might Cause an Infection
Body surfaces host commensals (microorganisms) that usually do not cause harm.
Breaches in skin barrier during surgery allow these commensals to become pathogens.
Other Infection Causes:
Changes in pH.
Immunosuppressive treatments.
Health conditions: AIDS, cancer, diabetes.
Definitions in Asepsis and Antisepsis
Asepsis:
Preventive measures to avoid germ contact with patients and surgical wounds.
Antisepsis:
Curative actions to destroy germs in wounds, skin, or environment.
Sterilization:
Complete destruction of all germs, including viruses and spores.
Disinfection:
Reduces viable microorganisms but may not inactivate all viruses & spores.
Methods of Asepsis
Aim to minimize organisms around the operating field:
Surgeries must include:
Handwashing and use of surgical gloves.
Disinfection of the operating field.
Sterilization of instruments and equipment.
Skin preparation and draping the patient.
Sterile clothing for the surgical team.
Preventing Infection in Surgical Patients
WHO Five Moments of Hand Hygiene:
Before touching a patient.
Before aseptic procedures.
After exposure to body fluids.
After touching a patient.
After contact with patient surroundings.
Antisepsis
Measures taken to kill or remove microbes from surgical fields, skin, and wounds.
Disinfectants: Kill or remove microbes from surfaces.
Antiseptics: Safe for use on living tissues.
Chemical Antiseptics
Iodine Compounds:
Povidone-iodine (Betadine): Rapid reduction of bacterial count, effective against a range of pathogens.
Chloric Compounds:
Chlorhexidine: Rapid bacterial reduction, long-lasting.
Hexachlorophene: Effective against Gram-positive bacteria.
Ideal Antiseptic Characteristics
No current antiseptic is ideal but should be:
Efficient against all germs.
Non-irritating, non-allergic, non-toxic.
Cost-effective with positive organoleptic properties.
Sterilization Techniques
Physical Methods
Heat Sterilization:
Autoclaving: Uses steam under pressure; appropriate for packaged items.
Dry Heat: Suitable for metal instruments that are heat-sensitive.
Low-Temp Steam/Formaldehyde: Ideal for heat-sensitive materials.
Chemical Methods
Cold Sterilization:
Ethylene Oxide: Good for delicate items like electrical equipment.
Glutaraldehyde: Effective but highly toxic and irritant.
Patient Skin Preparation
Up to 50% of wound infections arise from skin bacteria.
Prevention Strategies:
Preoperative shaving, showering with antiseptics.
Cleaning incision site with antiseptic solutions.
Ensuring a Sterile Operation Field
Utilize heat-sterilized surgical drapes to isolate the surgical area.
Use self-adhesive drapes for irregular sites and recognize the aseptic operating zone.
Preparation of the Operating Team
Scrubbing up: Hand and arm cleaning prior to surgery.
Remove jewelry; thorough hand washing with antiseptics for several minutes.
Rinse with hands positioned upwards to avoid contamination.
Gowning and Gloving Protocols
Surgical gowns must remain sterile; only touch the inside.
Gloves must be worn correctly to maintain sterility.
Consider double-gloving in high-risk cases.
Protecting Against Cross-Infection
Use impervious gowns and drapes to prevent contact with patient body fluids.
High-Risk Patients require added precautions:
Use of double gloving; plastic aprons.
Avoid hand-held needles, use blunt needles instead.
Conclusions on Asepsis Practices
Understanding of bacteria and their relationship to patient infection has evolved.
Comprehensive management combining asepsis and antisepsis principles is required to prevent infections.
Regular handwashing and maintaining a sterile field are crucial in preventing surgical site infections.
Classifications in Asepsis and Antisepsis
Germ Theory of Disease:
Proposed by Louis Pasteur
Suggests bacteria cause infections via air transmission
Joseph Lister’s Contributions:
Use of phenol for sterilization in operating theatres
Focus on sterilizing surgical instruments and cleaning wounds
Pre-Antibiotic Era Challenges:
Infected wounds leading to radical surgeries, such as amputations
Causes of Infection:
Commensal microorganisms become pathogenic via skin breaches
Other causes: changes in pH, immunosuppressive treatments, health conditions (AIDS, cancer, diabetes)
Definitions:
Asepsis: Preventive measures to avoid germ contact
Antisepsis: Curative actions to destroy germs
Sterilization: Complete destruction of all germs
Disinfection: Reduces viable microorganisms, may leave some active
Methods of Asepsis:
Include handwashing, disinfection of the field, sterilization of instruments, patient preparation, and sterile clothing
WHO Five Moments of Hand Hygiene:
Before touching a patient
Before aseptic procedures
After exposure to body fluids
After touching a patient
After contact with patient surroundings
Chemical Antiseptics:
Iodine Compounds: Povidone-iodine
Chloric Compounds: Chlorhexidine, Hexachlorophene
Ideal Antiseptic Characteristics:
Efficient, non-irritating, non-toxic, cost-effective
Sterilization Techniques:
Physical Methods: Heat sterilization (Autoclaving, Dry Heat)
Chemical Methods: Ethylene Oxide, Glutaraldehyde
Patient Skin Preparation:
Up to 50% of infections arise from skin bacteria
Ensuring a Sterile Operation Field:
Use of sterilized surgical drapes and recognition of aseptic zones
Preparation of the Operating Team:
Scrubbing and proper hand washing protocols
Gowning and Gloving Protocols:
Sterility maintenance protocols
Protecting Against Cross-Infection:
Use of impervious gowns and special precautions for high-risk patients
Conclusions:
Evolving understanding of bacteria's role in infections
Importance of management combining asepsis and antisepsis principles
Regular handwashing and sterile field maintenance crucial for preventing infection.
L5
Objectives of Investigations
Primary Goals:
Establish a diagnosis.
Diagnose comorbidities (e.g. pulmonary or cardiac) and assess surgical treatment risks.
Screen for common but asymptomatic disorders (e.g. undiagnosed hypertension, diabetes mellitus, coronary artery disease).
Sensitivity and Specificity
Sensitivity: Ability of a test to correctly identify patients with an abnormality but may also include false positives.
Specificity: Ability of a test to correctly identify individuals without the abnormality but may miss some true positives.
Predictive Values:
Positive Predictive Value: Probability that a positive test result is a true positive.
Negative Predictive Value: Probability that a negative test result is a true negative.
Hematological Investigations
Full Blood Count (FBC)
Most common investigation in surgical patients for:
Assessing hemoglobin levels for oxygen carriage during anesthesia.
Ensuring adequate platelet count for hemostasis.
Red Cell Count
High Levels: Indicate:
Severe dehydration, chronic respiratory failure compensation, or polycythemia vera.
Low Levels: Indicate anemia.
White Cell Count
High Levels with Neutrophilia: Suggest bacterial infection (may be low in severe sepsis).
Low Levels: May indicate effects of cytotoxic chemotherapy.
High Lymphocyte Count: Indicates viral infection.
Low Lymphocyte Count: Seen in HIV patients.
Platelet Count
Thrombocytopenia: Causes can include drug reactions, hypersplenism, autoimmune processes, leukaemias, or excessive consumption due to disseminated intravascular coagulation (DIC).
Thrombocytosis: Seen in chronic sepsis, following splenectomy, or hemorrhage.
Coagulation Investigations
Coagulation Screen Indications
Required in cases of:
Obstructive jaundice due to vitamin K absorption issues.
Patients on anticoagulants.
Significant hemorrhage.
Suspected coagulation defects.
Suspected DIC; measure fibrinogen, D-dimers, etc.
Coagulation Results Interpretation
APTT: 42.1 sec (reference 22-32 sec)
D-dimer: Positive, indicating >400 ng/mL (plasma)
Fibrinogen: 330.5 mg/dL (reference 180-380 mg/dL)
Biochemical Tests
Urea, Creatinine and Electrolytes
Indicated for patients:
Elderly or presenting for major surgery.
With renal dysfunction, cardiovascular disease, or fluid balance issues.
Serum Creatinine: Better indicator of renal function; creatinine clearance (GFR) should be monitored in renal disease.
Potassium Levels: Critical for avoiding arrhythmias.
Liver Function Tests
Indicated for:
Patients with known liver disease, alcohol consumption, liver disease symptoms, or coagulopathies.
Serum Test Results Summary
Total Proteins: 6.7 g/dL
Triglycerides: 152 mg/dL
Cholesterol: 229 mg/dL
ALT/AST: 18/54 U/L
Bilirubin: Total 1.01 mg/dL
Electrocardiogram (ECG) Investigations
ECG Types
Standard ECG: Assesses rhythm disorders and past cardiac events.
Stress ECG: Evaluates cardiac function during physical stress (e.g., treadmill).
Echocardiography: Assesses heart function and helps in major surgeries assessment.
Lung Function Tests
At-Risk Groups: Smokers, obese patients, elderly, or those with pre-existing respiratory diseases.
Assessment: Requires measuring arterial blood gas concentrations and lung volumes.
Imaging Techniques
Types of Imaging
Radiological: X-rays, CT scans.
Ultrasonography: Non-invasive assessment of organ function and blood flow (Doppler).
MRI: Offers clear images using magnetic fields for various conditions.
Precautions in Interpretation
Verify patient information, orientation of images, exposure conditions.
Contrast Use in Imaging
Intravascular Contrast Media: Used to enhance CT scans for better organ visualization.
Barium Sulphate: Historically used for gastrointestinal tract imaging but has significant contraindications (e.g. perforation risk).
Conclusion
The outlined investigations and tests are crucial for preoperative assessments, guiding management decisions and understanding patient health risks prior to surgical procedures.
Classifications of Investigations
Objectives of Investigations
Primary Goals:
Establish a diagnosis.
Diagnose comorbidities and assess surgical treatment risks.
Screen for asymptomatic disorders.
Sensitivity and Specificity:
Sensitivity: Correctly identifies patients with an abnormality.
Specificity: Correctly identifies individuals without the abnormality.
Predictive Values:
Positive Predictive Value: Probability that a positive test result is a true positive.
Negative Predictive Value: Probability that a negative test result is a true negative.
Hematological Investigations
Full Blood Count (FBC)
Red Cell Count
High Levels: Severe dehydration, chronic respiratory failure, polycythemia vera.
Low Levels: Anemia.
White Cell Count
High Levels with Neutrophilia: Bacterial infection.
Low Levels: Effects of chemotherapy.
High Lymphocyte Count: Viral infection.
Low Lymphocyte Count: Seen in HIV patients.
Platelet Count
Thrombocytopenia: Causes include drug reactions, hypersplenism, etc.
Thrombocytosis: Seen in chronic sepsis, following splenectomy, etc.
Coagulation Investigations
Coagulation Screen Indications
Required in cases of jaundice, anticoagulant therapy, significant hemorrhage, etc.
Coagulation Results Interpretation
APTT, D-dimer, and Fibrinogen results with normal ranges.
Biochemical Tests
Urea, Creatinine and Electrolytes
Liver Function Tests
Indicated for patients with liver disease, symptoms of liver disease, etc.
Electrocardiogram (ECG) Investigations
Types: Standard ECG, Stress ECG, Echocardiography.
Lung Function Tests
At-risk groups: Smokers, obese patients, elderly, etc.
Imaging Techniques
Types of Imaging: Radiological, Ultrasonography, MRI.
Contrast Use in Imaging: Intravascular contrast media, Barium sulphate.
Conclusion
Investigations and tests are crucial for preoperative assessments and understanding patient health risks prior to surgical procedures.
L6
Vital Signs Monitoring in Surgical Patients
1. Introduction
Monitoring vital signs in surgical patients is critical to ensuring patient safety and effective anesthesia management. Key vital signs include heart rate, blood pressure, respiratory rate, oxygen saturation, and body temperature. Accurate monitoring helps detect physiological changes that may indicate complications such as hypovolemia or adverse reactions to anesthesia.
Monitoring Methods
Monitoring methods can be categorized into invasive and non-invasive techniques. Non-invasive methods allow for continuous monitoring without penetrating the skin, while invasive methods involve the insertion of devices into the body to provide direct measurement of physiological parameters.
Direct observation of the patient is also important. For example, a warm, well-perfused, pink patient with adequate urine output indicates stable hemodynamic status and no signs of hypovolemia. Additionally, observing the patient’s pupils can help guard against awareness during surgery, providing insight into their neurological status.
2. Standard Monitoring
Standard monitoring during surgery includes both non-invasive and invasive techniques to provide a comprehensive view of the patient’s physiological status.
2.1 Non-Invasive Monitoring
ECG (Electrocardiogram): Continuously monitors heart rhythm and can detect arrhythmias.
Non-Invasive Blood Pressure (NIBP): Utilizes occlusion of the artery to measure blood pressure at regular intervals without the need for IV access.
Pulse Oximetry: Measures the oxygen saturation of the blood, providing ongoing assessments of respiratory function.
End-Tidal Carbon Dioxide Levels (EtCO2): Monitors ventilatory status by measuring the concentration of carbon dioxide in exhaled air, critical for assessing the patient’s respiratory effectiveness.
Temperature: Continuous monitoring of body temperature is essential, as hypothermia is a common complication during surgery due to exposure and anesthetic effects.
Degree of Muscle Relaxation: Assesses the effectiveness of neuromuscular blocking agents used during anesthesia, which is important for airway management and surgical access.
Inspired Oxygen Concentration: Measures the concentration of oxygen being delivered to the patient, ensuring adequate oxygen supply during anesthesia.
2.2 Invasive Monitoring
Invasive monitoring is essential for assessing hemodynamic status in anesthetized patients, particularly in high-risk surgeries such as cardiac, neurosurgical, or lengthy procedures. These techniques allow for the continuous measurement of parameters such as central venous pressure and pulmonary artery pressures, helping to ensure adequate tissue perfusion and prevent organ dysfunction.
3. General Anesthesia
3.1 Induction
The induction phase is a critical moment when the patient loses the ability to maintain their airway. Muscle relaxation of the tongue can lead to airway obstruction, making it imperative to utilize techniques such as careful positioning and the use of specialized equipment like oral airways or endotracheal tubes to prevent this.
3.2 Patient Positioning
Optimal patient positioning is crucial. A common position is the supine position, with the head resting on one pillow and the shoulders flat to minimize airway obstruction. Extending the head and elevating the jaw can lift the base of the tongue away from the pharynx, enhancing airway patency.
4. Endotracheal Intubation
4.1 Procedure
The endotracheal tube is passed across the vocal cords into the trachea, securing an open airway, which is vital to mitigating aspiration risks. Key steps in the procedure include:
Neck positioning: The neck should be flexed, and the head extended to facilitate visualization.
Laryngoscopy: Insert the laryngoscope blade into the mouth, advancing into the oropharynx while pushing the tongue to the left.
Visualization: Continue to move the laryngoscope upward and forward to lift the tongue and jaw, thereby revealing the epiglottis and vocal cords, which aids in placing the tube accurately.
4.2 Tube Sizing
Simultaneous consideration of patient gender and age is important in determining tube size:
Typical cuffed tube sizes are 9 mm for men and 8 mm for women; pediatric patients generally require uncuffed tubes sized based on age (approximately age/4).
After successful intubation, inflate the cuff to create an airtight seal, preventing air leaks and aspiration risks.
4.3 Complications
Complications associated with intubation include the risk of tube misplacement into the esophagus or right bronchus. Proper recommendations include visualizing the tube’s passage during laryngoscopy and auscultating breath sounds to confirm adequate ventilation in both lungs.
5. Aspiration of Stomach Contents
The risk of aspiration increases under anesthesia due to lost protective reflexes. To mitigate this risk, patients should undergo fasting prior to elective procedures. In emergencies, it's critical to intubate and apply cricoid pressure to prevent gastric reflux during induction.
6. Nasogastric Tube
6.1 Uses
Nasogastric tubes are frequently placed for gastrointestinal surgeries, bowel resections, or to prevent postoperative ileus. They facilitate gastric decompression and nutritional support.
6.2 Indications
Indications for nasogastric tube placement include:
Vomiting due to obstruction.
Acute gastric dilatation.
Requirement for enteric feeding.
6.3 Equipment and Procedure
Key equipment includes:
Non-sterile gloves, nasogastric tubes (sizes 10-16), suction devices, lubricant, and water.
The procedure involves inserting the lubricated tube gently into the nostril, advancing it until it reaches the stomach while securing and testing placement to ensure it is correctly positioned.
7. Urethral Catheterization
7.1 Indications and Equipment
Vital for major surgeries and addressing urinary retention or incontinence. Necessary equipment includes:
Urinary catheter, gloves, antiseptic, and drainage bag.
7.2 Catheter Types and Sizes
Types include:
Foley Catheter: Self-retaining due to an inflatable balloon.
Three-way Catheters: Used for irrigation.
Catheter sizes vary based on patient age and condition: 8-10F for strictures; 12-14F for a normal urethra; larger sizes may be required for prostate issues.
7.3 Procedure for Catheterization
High hygiene standards must be followed:
Clean the genital area meticulously, and insert the catheter gently, avoiding any resistance to reduce trauma.
8. Arterial Access
8.1 Choosing Site
Common arterial access sites include the radial and femoral arteries. Employing the Allen test prior to a radial puncture helps ensure adequate collateral supply, reducing the risk of complications.
8.2 Equipment and Procedure
Equipment required:
Sterile gloves, antiseptics, needles, syringes.
The procedure involves identifying the artery, cleaning the site, applying local anesthetic, and inserting the needle at the appropriate angle to minimize discomfort and injury.
9. Central Venous Catheterization
9.1 Technique
The Seldinger technique is commonly employed for central venous access, which involves precise needle placement, guide wire insertion, and threading of a catheter into the central vein.
9.2 Complications
Potential complications include:
Hematoma at the site of insertion.
Infection risks, which may require further intervention.
Pneumothorax, a serious risk requiring immediate attention.
10. Arterial Blood Gas Analysis
10.1 Interpretation
Understanding arterial blood gas (ABG) results is essential:
PaO2 Levels: Low levels indicate possible respiratory issues or shunting, while high levels may suggest hyperventilation.
PaCO2 Levels: Low values can be attributed to hyperventilation; high values may indicate respiratory failure, necessitating further evaluation.
pH Levels: A pH <7.35 suggests acidosis, while >7.45 indicates alkalosis. Assessing compensation helps differentiate between chronic and acute processes, guiding appropriate clinical management.
Classifications of Vital Signs Monitoring in Surgical Patients
Monitoring Methods
Invasive Techniques
Non-Invasive Techniques
Types of Monitoring:
Standard Monitoring
Non-Invasive Monitoring
ECG (Electrocardiogram)
Non-Invasive Blood Pressure (NIBP)
Pulse Oximetry
End-Tidal Carbon Dioxide Levels (EtCO2)
Body Temperature
Degree of Muscle Relaxation
Inspired Oxygen Concentration
Invasive Monitoring
General Anesthesia Stages:
Induction
Patient Positioning
Endotracheal Intubation
Procedure
Tube Sizing
Complications
Aspiration of Stomach Contents:
Nasogastric Tube
Uses
Indications
Equipment and Procedure
Urethral Catheterization
Indications and Equipment
Catheter Types and Sizes
Procedure
Arterial Access
Choosing Site
Equipment and Procedure
Central Venous Catheterization
Technique
Complications
Arterial Blood Gas Analysis
Interpretation
L7
Operating Room Considerations
Needs of Special Services
Special procedures require specific environments to ensure optimal outcomes:
Orthopedic devices: These procedures necessitate ultraclean environments and smooth airflow systems to minimize the risk of infections and ensure the proper function of devices used during surgeries.
Cardiac surgeries: A dedicated perfusion room is essential for cardiopulmonary bypass equipment, allowing for specialized monitoring and management of the patient’s heart-lung function throughout the procedure.
Accessibility
Quick and effective access is crucial for patient safety and operational efficiency:
Intensive therapy unit: Fast access for critically ill patients needing immediate treatment.
Accident and emergency department: To facilitate rapid transfer of trauma or emergency cases into surgery.
Imaging department and X-ray facilities: Proximity aids in quickly obtaining necessary imaging for diagnosis and surgical guidance.
Patient accommodation areas pre and post-surgery: Ensures swift transitions before and after surgical procedures, allowing for constant monitoring and care.
Safety Protocols
Ensuring patient and staff safety is paramount. Effective safety protocols must include:
Comprehensive training of staff on emergency procedures.
Regular drills for various emergency scenarios, such as fire or equipment failure.
Development of a checklist to confirm all surgical instruments are accounted for before closing.
Patient Transfer to Operating Room
Handover Process
The transfer from preoperative care to theatre staff includes several verification steps:
Confirming the identity bracelet is correct and complete to prevent patient misidentification.
Ensuring the consent form is signed and documented to prevent any legal issues.
Noting the time of last food and drink to prepare for anesthesia safely.
Checking for any safety impediments such as false teeth, nail polish, or jewelry that could interfere with the procedure.
Documenting known allergies to prevent any adverse reactions during surgery.
Confirming diagnosis, procedure, and site of operation to ensure accurate surgical planning.
Anesthesia and Positioning
After completing the checks, the patient is moved to a trolley and then to an anesthetic room:
Following induction of anesthesia, close monitoring of vital signs commences, and the patient is then transferred to the operating table with careful attention to their safety and comfort.
Infection Control in Surgery
Antisepsis
To protect against infections, adhering to antisepsis protocols are critical:
Maintaining a sterile field around the operating site is essential.
Key aspects include:
Sterilization of all surgical instruments prior to use.
Proper skin preparation and draping of the patient to create a barrier against microorganisms.
Ensuring all surgical team members wear appropriate attire to reduce contamination risks.
Operating Table Characteristics
Types
Free-standing table: These are portable, facilitating easy cleaning and maneuverability.
Fixed-base table: Designed with removable sections that can be adjusted depending on the type of operation required.
Must-have features:
Divided into multiple sections allowing for independent adjustments based on patient needs.
Heavy and stable with soft rubber padding to prevent creating pressure points that could lead to injuries during surgery.
Patient Positioning
General Overview
Correct patient positioning is vital for surgical success and patient safety, with different positions serving specific surgical needs:
Supine Position: Most commonly used for intra-abdominal surgeries and some head/neck procedures. Requires proper arm alignment to facilitate surgical access and minimize risks.
Prone Position: Ideal for spine surgeries, careful padding must be applied to prevent nerve injuries. Ongoing monitoring is required to prevent complications such as pressure ulcers.
Trendelenburg Position: The bed is tilted downwards for pelvic surgeries or to improve venous return, caution is advised to avoid increased intraocular pressure.
Reverse Trendelenburg Position: The head of the bed is tilted upwards, suitable for upper abdominal surgery but may lead to venous pooling in the legs, so compression stockings are often recommended.
Lateral Position: Optimal for kidney and thoracic surgeries, requiring careful securing to maintain spinal alignment and prevent skin trauma.
Anesthesia Management
Key Aspects
Airway Management: Techniques such as endotracheal tubes or bag-mask ventilation must be appropriate to the procedure's duration and complexity.
Monitoring: Continuous monitoring of vital signs and anesthesia levels throughout the surgical process to ensure patient safety.
Vascular Access: IV lines established for medication and fluid administration, and larger bore lines may be utilized in complex surgical cases to ensure rapid access.
Surgical Approaches and Incisions
Skin Incisions
Proper incision placement is key for tissue healing and minimizing surgical complications:
Thoracic Incisions: Include Median Sternotomy for access to the heart and thoracic structures, and Thoracotomy, which is common for pulmonary procedures, though it poses higher risks for pain and complications.
Thoracoabdominal Incisions: Provide extensive exposure but come with a heightened risk for postoperative complications due to their size.
Abdominal Incisions: Various techniques such as Upper Midline for upper GI access, and Paramedian and Chevron Incisions, each with distinct access and recovery profiles.
Minimal Access Surgery: Techniques like Laparoscopy and Thoracoscopy are less invasive, leading to reduced pain and recovery time but require specialized skills to perform successfully and can increase operative challenges.
Summary of Positioning Precautions
Protecting nerves during positioning is crucial; particular attention should be paid to the risks associated with the brachial, ulnar, radial, and common peroneal nerves.
Regular monitoring for pressure points is essential, especially during longer surgical procedures, to prevent serious complications such as compartment syndrome, which can have lasting consequences for the patient.
Classifications in Operating Room Considerations
1. Needs of Special Services
Orthopedic Devices
Cardiac Surgeries
2. Accessibility
Intensive Therapy Unit
Accident and Emergency Department
Imaging Department and X-ray Facilities
Patient Accommodation Areas Pre and Post-surgery
3. Safety Protocols
Comprehensive Training of Staff
Regular Drills for Emergency Scenarios
Development of a Surgical Instruments Checklist
4. Patient Transfer to Operating Room
Handover Process including:
Identity Confirmation
Consent Form Verification
Last Meal Documentation
Safety Impediments Check
Allergy Documentation
Diagnosis and Procedure Confirmation
5. Anesthesia and Positioning
Patient Transfer to Anesthetic Room
Monitoring of Vital Signs
6. Infection Control in Surgery
Antisepsis Protocols including:
Sterilization of Instruments
Proper Skin Preparation
Surgical Team Attire
7. Operating Table Characteristics
Types of Tables:
Free-standing Tables
Fixed-base Tables
Must-have Features:
Independent Adjustments
Heavy and Stable Design
8. Patient Positioning
Supine Position
Prone Position
Trendelenburg Position
Reverse Trendelenburg Position
Lateral Position
9. Anesthesia Management
Airway Management
Continuous Monitoring
Vascular Access
10. Surgical Approaches and Incisions
Skin Incisions:
Thoracic Incisions
Thoracoabdominal Incisions
Abdominal Incisions
Minimal Access Surgery
11. Summary of Positioning Precautions
Protecting Nerves
Monitoring Pressure Points
Compartment Syndrome Risks
This classification outlines the categories involved in operating room considerations, ensuring quality patient care and safety.