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Three specific areas of surgery
- 1. Patient Treatment/Recovery room
- 2. Preparation room
- 3. Operating Room
How must Patient Preparation room be configured to be AAHA compliant?
A wall and door must separate it from both the Operating and Recovery rooms
Specific Guidelines for Operating Rooms:
- 1. Made of non-porous material and impervious to cleaning agents
- 2. No more than 2 doors (1 for AAHA compliance)
- 3. Air exchanges minimum of 12/hr, ideal at 17/hr
- 4. Cidex to be used for all cleaning of surfaces
- 5. Must wear mask, gown, cap and appropriate clothing
- 6. Know sterile non sterile boundaries and aseptic techniques
Measures to reduce fire hazards in the operating room (oxygen is flammable):
- 1. anesthetics stored 3' away from electrical equipment
- 2. Use 100% cotton textiles/clothing
- 3. Drapes are used on hair/fur to reduce static electricity
- 4. No explosive/flammable cleaning agents
- 5. No smoking
- 6. Humidity >/= 50%
- 7. Temp below 68 F
Early surgical equipment origins:
Stainless Steel is an alloy composed of:
Two instrument basic compositions
1. Martensitic - high carbon low chromium "Pakistani", often used for instruments that aren't used a lot
2. Austenitc - high nickel and chromium, gives superior high tensile strength for instruments used constantly "German"
List the Blade sizes and purposes
- 10 - incising skin
- 11 - severing ligament
- 12 - lancing abscess
- 15 - small/precise curved incision
- 20 to 23 - generally for large animal sx (need #4 handle)
This instrument only has coagulation/cauterization applications
Other than the scissors in a standard general pack, what other types may be seen?
- Iris scissors - mainly opthalmology
- Bandage scissors
- Suture scissors
Another name for Rat Tooth Thumb Forceps
Cushing Thumb Forceps
Name the thumb forceps
- Rat Tooth (Cushing)
Name the dressing forceps
- Rat Tooth (Cushing)
Name the tissue forceps
This general category of instruments are used primarily to clamp off blood vessels and stop bleeding
Name the Hemostatic Forceps
- Halstead Mosquito Forceps (curved or straight)
- Kelley Forceps (curved or straight)
- Rochester Carmalt Forceps (curved or straight)
- Crile Forceps (curved or straight)
Name two grasping surface patterns of Hemostatic forceps
- Transverse serrations
- Longitudinal serrations
(Swiss) Association for the Study of Internal Fixation
This is a cobalt-chromium material used for bone instrument and implantation devices
List the categories of Orthopedic instruments
- 1. Cutting and shaping
- 2. Bone holding
- 3. Internal fixation/implantation devices
- 4. External fixation devices
How long have ligatures been used?
over 4000 years
Cautery in the form of fire rods was used where?
In the 2nd century, this person suggested the use of what kind of suture?
Arabian physicians used what type of material for sutures
Harp strings made from sun-dried sheep gut
Kid and buckskin sutures were produced by whom in 1806?
This chemical was found by Lister to delay suture absorption.
Still used today, chromic acid impregnated sutures come in what 4 varieties?
- Type A - plain
- Type B - Mild
- Type C - Chromic
- Type D - Extra Chromic
List characteristics of the IDEAL suture
- Easy to handle
- Easy to completely sterilize
- High tensile strength at small sizes
- Absorb predictably in 60-90 days
- Maintain knot w/o slippage
List the two major classes of surture material
This is the first of the non-gut absorbable suture made from braided synthetic fibers and is the standard that all other synthetics are measured.
Ployglycolic Acid "PGA" (Dexon)
Absorption time for Polyglycolic Acid sutures
Suture sizes are determined by what feature?
The number of woven strands
This absorbable suture is easy to handle, stable for use in contaminated wounds, causes minimal tissue reaction and is dark PURPLE
Polyglactin 910 or Polyglactic Acid (Vicryl)
Absorption time for Polyglactic Acid sutures
This absorbable suture has a monofilament structure that causes less drag in tissue but does not hold a knot well like woven sutures.
Absorption time for Polidioxanone sutures
This is the most reactive of the absorbable sutures usually made from the sub-mucosal layer of sheep or hog intestine
Surgical Gut (Chromic Gut)
What is the purpose of soaking gut with chromic acid salts?
To prolong absorption time and decreases soft tissue reactions
What are the two most common surgical gut sutures used today and their absorption times?
- Plain gut - Type A (3-5 days)
- Chromic gut - Type C (10-15 days)
List the two things all non-absorbable sutures have in common:
- High tensile strength
- Produce minimal tissue reaction
List the non-absorbable sutures according to their group
- Stainless steel wire
- Metal clips and staples
- Natural fibers:
- Dermal, virgin, linen
- Synthetic fibers:
- Nylon (Ethilon)
- Polymerized caprolactum (Vetafil)
- Polyester fibers
Advantage of nylon:
Disadvantage of nylon:
minimal tissue reaction/strength up to 6 months
knot security due to monofilament structure however, now available in multifilament material
This synthetic non-absorbable suture is most commonly used in veterinary medicine made of a twisted fiber structure with a smooth coating and often soaked in antimicrobial fluid
Polymerized caprolactum (vetafil)
This synthetic, braided non-absorbable suture is often coated with Teflon or silicone
What are the disadvantages of polyester fibers?
- Most tissue reactive of the non-absorbables
- Poorest knot security of the non-absorbables
This natural fiber, non-absorbable suture is most commonly used in human medicine but used primarily in veterinary medicine for specialty surgeries
This natural fiber non-absorbables suture was last used during the Korean War, is the weakest of the natural sutures.
What was the main disadvantage of cotton sutures
Capillary action caused skin abscesses
Stainless steel sutures were first introduced when and by whom?
1934 by Babcock
Another name for the 18 gauge stainless steel wire suture
What purpose is the cerclage wire used?
Orthopedic procedures - holding bone together
What are the advantages of stainless steel wire?
- Least reactive of all the suture materials
- Does not support bacterial growth
The disadvantage of stainless steel wire sutures:
most difficult to handle
Which stainless steel suture gauges are used for skin?
32 and 40 gauge
Which metal suture material causes scarring if not removed early and requires the use of special/expensive devices for application/removal?
Metal clips and staples
This suture class is more likely to be used when prolonged strength is not required or when infection is present or anticipated.
This suture class is more likely to be used when tissue reaction must be minimized
5 characteristics of needle identification
- Shape of body
Two types of attachment in needles
Eye needles - reusable but creates a bigger hole, primarily used for skin
Swaged needles - suture attaches to needle internally, not reusable, primarily used for cardio/intestinal surgery - smaller hole
Two types of body shape
Straight - driven by hand, rarely used in veterinary medicine
Curved - driven by needle holders, e.g: 1/2, 3/8 or 5/8 circle
This type of cross-section leaves small cuts in tissue so no leakage of fluid occurs and is preferred for intestinal surgery
Taper point (atraumatic) - round cross-section
This type of cross-section has three cutting edges that incise the tissue in the direction of the pull that leave a larger than needed hole
Standard cutting (traumatic) - pyramid cross-section
This type of cross-section has three cutting edges that have the apex of the triangle on the back of the needles and the flat edge in the direction of the pull
reverse cutting (traumatic) upside-down pyramid cross-section
- spatula (used for organ sx)
What is the general rule of needle sizing?
The larger the number the smaller the needle; the smaller the number the larger the needle.
This is the most common knot used.
This knot, in conjunction with a square knot will not come untied except in nylon or chromic gut.
This knot is the result of superimposing one hand upon another without reversing the second overhand
Granny or slip knot
This pattern is commonly used with the peritoneum and fascia when closing abdominal wounds
Simple continuous sutures
The disadvantages to simple continuous suture:
- Will unravel if cut
- Poor tissue apposition
This is a modified simple continuous suture pattern that has superior tissue apposition
Ford Interlocking sutures
This suture pattern maintains strength and tissue position even if part of it fails but takes more time and suture material
Simple interrupted sutures
This suture pattern is also known as the tension suture, incorporates large amounts of tissue and is used primarily with large animals
Horizontal mattress suture
This additional classification of suture patterns turns the tissue inward towards the patient
This additional classification of suture pattern tends to turn the tissue edges outward creating a palpable ridge
List 5 purposes of the anesthesia machine and breathing circuit
- 1. Delivery anesthetic inhalant to patient
- 2. Help maintain arterial oxygenation
- 3. Eliminate carbon dioxide
- 4. Help monitor respiration
- 5. Assist Ventilation when required
Components of a rebreathing circuit
- 1. fresh gas inlet
- 2. unidirectional valves
- 3. pop-off valve
- 4. reservoir bag
- 5. CO2 absorbing canister
- 6. pressure manometer
- 7. air intake valve
- 8. breathing tubes
- 9. Y-piece (only with 2 tube system)
This funnels gas from the patient breathing circuit into the scavenging system
This measure positive and negative pressures within the circuit
This allows smaller, portable compressed gas tanks to be attached to the anesthesia machine
List the 4 parts of the anesthetic delivery system:
- 1. Gas source
- 2. Anesthetic machine
- 3. Breathing system
- 4. Scavenging system
Two most common sizes of compressed gas tanks
"H"(central bank system) and "E"(portable)
Level of O2 in a full "E" tank
Level of O2 in a full "H" tank
Pressure of both "H" and "E" tanks containing O2
This is the common gas outlet where the oxygen/medical gas/anesthetic agent mixture exits the anesthesia machine to the breathing system
oxygen flush valve
This is calibrated for each gas used and controls the amount of gas entering the system
How is the flowmeter read?
At the widest part of the ball or float
Formula to determine proper rebreathing bag size
wt in kg x 10mL/kg x 6
Purposes of the rebreathing bag
- Bag movement ensures proper intubation
- Easier for patient to breathe
- Observation of patient respirations
- Positive Pressure Ventilation
Two types of absorbents used in rebreathing circuits
- Barium hydroxide (Soda lime)
- Sodium hydroxide
The granules in the canister chemically react with CO2 to produce what 2 products?
carbonate and water
How often is the Soda lime changed?
Every 8 hours of surgery time
Three portions of a Vaporizor in Circle
Where is the VIC usually located?
Inspiratory side of the circle
What do the numbers on the dial of a VIC indicate?
The degree to which it is opened
3 factors that control the output of a VIC
- 1. Ambient temperaure
- 2. Total gas flow
- 3. Tidal volume
Primary advantage of a VIC
low cost and simplicity
Primary disadvantage of a VIC
lack of concentrations control
Which gas is only used with a VIC?
What method was the first attempts at VOC
Bubble or Saturation Method
List the parts of the anesthetic circle
- 1. Flutter valves
- 2. Hoses
- 3. CO2 absorbing canister
- 4. Pop-off valve
- 5. Reservoir bag
What do the numbers on the dial of a VOC represent?
The percentage of anesthetic gas delivered
Precision Vaporizers deliver exact concentrations because:
they are temperature, flow and back flow compensated
Another name for temperature compensated
Primary advantage of Precision vaporizers
Desired percent concentration are delivered without being affected by variations in ventilation or temperature
Disadvantages of Precision vaporizers
- 1. Complexity - each vaporizer is calibrated for a specific gas and machine must be serviced every 1 - 3 years
- 2. Cost
Three common anesthetic breathing systems
- Total Rebreathing - pop-off valve closed
- Partial Rebreathing - pop-off valve partially open
- Non-rebreathing - pop-off valve completely open
This system allows for the recirculation of exhaled gases (CO2 removed) to the patient
This system has a relatively low oxygen flow rate that provides only the oxygen necessary to meet the patient's metabolic needs where the pop-off valve is closed.
Total or Closed Rebreathing system
Advantages of a total rebreathing system
- 1. Uses less oxygen and anesthetic gas
- 2. More economical surgery
Disadvantages of a total rebreathing system
- 1. Soda lime needs to be changed more often due to CO2 accumulating faster
- 2. Increase pressure in anesthetic circle due to entrance of O2 without a scavenger
- 3. Due to low O2 levels, more flushing is needed
This system uses a much higher oxygen and anesthetic gas flow rate due to gases escaping from partially opened pop-off valve
Partial or Semi-closed rebreathing system
This system is used for patients under 15 pounds to avoid resistance and total dead space of the other breathing systems where the pop off valve is completely open
Non-rebreathing or Open system
List two non-rebreathing units:
Reasons to use a non-rebreathing system
- 1. No valves = no resistance to breathing
- 2. Expired gases warm inspired gases
- 3. Partial humidification of inspired gases by expired gases
- 4. 60" tubing allow system to be away from patient
- 5. No pressure on endo-tracheal tube
Two types of scavenging systems:
- Active - motorized vacuum to the outside
- Passive - non-motorized through tubing to the outside