Surgery Lecture - 05 Management Of Surgical Patient

Management of surgical patient

Investigation of the surgical patient lection

Investigation of the surgical patient     

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Blood test Coagulation test Biochemical test Urinary test Microbiological investigation /antibiotic's screening/ Markers of tumor

Investigation of the surgical patient 

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Function tests: ECG, ECG + stress test Echocardiography Function of lungs – is criteria for prediction of postoperative risk / P CO2 >45 mm Hg Forced vital capacity > 70% of that predicted

Imaging    

Radiological / X- rays Ultrasound / US Magnetic resonance imaging / MRI Isotope scanning / IS

Roentgenological investigation  

Plain X-ray films Tomography – plain film tomography - computed tomography

Roentgenological investigation 

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Intravascular contrast studies: intravenous / urography, venography Intra-arterial / direct imaging //interventional procedures

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Intraluminal contrast agents: Barium sulfate Water – soluble contrast /Iodine

Ultrasound   

Brightness mode / B / Motion mode / M / Doppler mode / Duplex, energy /

Brightness mode / B / In general, the higher the ultrasound frequency, the better resolution and the lower sensitivity. New scanner automatically optimizes the scan frequency for depth providing the best combination of resolution and sensitivity for the region of interest

Brightness mode / B /

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A gallbladder with many small stones in the neck and a thickened wall at the fundus

Brightness mode / B /

Brightness mode / B / 

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Dynamic Line Density control The scanning density of a zoomed image, for instance, can be increased threefold at maximum within the zoomed range

Doppler mode / Duplex, energy / 

The scanner's echo signals arriving from two different directions simultaneously

Doppler mode / Duplex, energy /

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A middle hepatic vein with normal blood flow and a heterogeneous liver tumor next to it

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Doppler mode / Duplex, energy /

Blood flow is dynamically pulsating and blood is not flowing at the same velocity in all parts of a vessel. In Color Capture mode, the system retains color information (maximum detected velocity) which is captured during a preset time

Doppler mode / Duplex, energy /

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Visual contrast resolution is improved by coloring gray-scale images. Different colors can be set for the B-mode and M or Doppler.

Comparison of cross-sectional imaging techniques Uses ionizing radiation IMAGES bone LUNGS

CT Y

Y Y

US NO

NO NO

MRI NO

Y NO

ENDOSCOPY 

Rigid Laparoscopy Torocoscopy

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Flexible Gastroscopy Colonoscopy

Biopsy  

Closed / FNA – fine needle aspiration Open

Stomach lavage / equipment      

Plastic apron Pair of gloves Nasogastric or gastric tube Funnel / syringe 150 ml Bowl / jug with boiled water vaseline

Stomach lavage /steps  

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Inserting tube into patient's throat Reaching the first mark on the tube / 50 cm / - position at the cardiac portion of stomach Introducing of tube to second mark, connecting syringe, passage 0,5-1,0 liter of water Aspiration of contents Removing of tube

Insertion of urethral catheter / equipment    

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Sterile gloves Sterile rubber/plastic / urinary catheter Sterile vaseline oil / or lignocaine gel 0,5%/ Pre- prepared catheterisation pack – kidney dish, gauze swabs, sterile towels/салфетки Antiseptic solution: furacilin 1:5000 10 ml syringe and 10 ml sterile water Urine drainage bag

Insertion of urethral catheter/procedure  

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Wash hands and don sterile gloves Open out everything that is needed onto sterile towel Lay the patient flat Hold the penis with a sterile gauze swab with the left hand to prevent the penis from slipping; then retract foreskin and clean the urethral opening with swab

Insertion of urethral catheter/procedure 

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Gently squeeze the contens of a tube of lignocaine gel into the urethra Using the forceps the catheter is picked 2-3 cm from the end and dipped into the sterile vaseline oil Using the forceps the catheter is inserted into the urethra. During insertion the external end of the catheter remains in the kidney dish because, when the bladder is entered, urine usually spills out.

Enema/ equipment 

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Esmarch`s cup with rubber tube, plastic tip / end –piece/ Plastic apron Pair of gloves 1-1,5 liters of water

Enema/ procedure 

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The patient must placed on the left side The tip is to be lubricated end inserted into the rectum 10-15 cm deep After the water has finished flowing into the colon, the piece is removed and patient turned to lie supine

intravenous infusion system

intravenous infusion system/ equipment Sterile gloves Tourniquet of latex tube Needle with cannula To hold a cannula in place – adhesive tape 5 ml syringe Normal saline flush Cotton wool

intravenous infusion system/ procedure 

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Place the tourniquet above the site of insertion Advance the cannula-and- needle combination into the vein Remove the tourniquet Connect the infusion system immediately

intravenous infusion system

Transferring the patient to the operating theatre 

Patient may be transferred with: intravenous infusion system, tourniquet or transportation splint, nasogastric tube

Operation   

Operative access Primary step / operation itself Finishing the operation

Arrest of bleeding     

Compression Ligation Application of a clip Thermal coagulation Chemical application

Wound closure 

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Suture with needle and the appropriate material- traditional method Techniques that mimic suturing, e.g. tapes and staples Plastic procedures – mainly to close defects that can't be deal by the above two methods

Needles and sutures   

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Straight needles Curved needles and a needle holder Swaged attachment of the suture material or with eye Profile with cutting and stick edge

Sutures 

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Absorbable materials are broken dawn by PROTEOLISIS - /catgut – treated sheep intestinal submucosa / By hydrolysis -/ polymers and monomers of polyglycolic acid Do not persist as a foreign body

Sutures non absorbable material 

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/high tensile strength for long periods/ Natural materials – LIEN and SILK Synthetic materials – polyamide NYLON and polypropylene PROLENE / monofilaments /

Disorders of wound healing 

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Seromas – are collections of serous exudate in hollow spaces within wounds Cause: foreign body, coagulation necrosis, mass ligatures treatment: aspiration with a syringe, revision, drainage Complication - infection

Wound heamatomas 

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Cause: inadequate haemostasis, hay blood pressure, anticoagulant therapy treatment: aspiration with a syringe, revision, drainage Complication - infection

Soft tissue necrosis 

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Cause: injury of vessels, inadequate type of incision, severe trauma treatment : Must be kept dry, should`t be removed before demarcation Complication - infection

Wound rupture/dehiscence/ 

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Parts of wound do not adhere and become bound by connective tissue despite apposing sutures Cause: ischaemia, early removing of sutures treatment: by operation

Hypertrophic scar formation  

Develop soon after operation Complication:The scar crossing a joint restricts the rannge of motion with increasing scar contracture

Keloids 

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Ther structure consists of thick glassy or hyaline cords of collagen embedded in a mucilaginous matrix NOTE : Surgical correction often aggravates the situation !!!

Wound infection 

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Sings of infection: ruber/erythema/, tumor /swwelling/, calor/ warmth/, dolor/ pain/ describt by Roman scientist Aulus Cornelius Celsus / 1St century AD / General sings and symptoms include: Fever, rigor, leucocytosis and lymphadenopathy

Pyogenic infection 

Cause: Staphylococci - cremy yellow pus Streptococci runny yellov-grey pus Pseudomonas - blue-green sweet-smelling Escherichia coli brownish faeculentsmelling pus

Specific wound infection 

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Anaerobic /gas/ gangrene: Clostridial myositis Clostridial cellulitis Clinical course: Fulminant Fast progressive Slow progressive

Factors that predispose to gas gangrene 

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Injurie to the limb with tissue contusion and contamination soil blood circulatory disorders vascular occlusion inadequate transportation and immobilisation

Sings of anaerobic infection      

Serios ill patient / intoxication/ Jandice of the sclera and skin The increase in body temperature Tachycardia 120-140 beats per min pain in the wound Oedema and presence of gas in the subcutaneus fett and muscels

Treatment/prevention/ 

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TEST: 0,1 ml of serum /concentration 1:100/ are injected inradermaly from test ampoule / size of hyperaemia less 10 mm / - 0,1 ml serum subcutaneosly Average prophylactic dose: 10,000 IU for Cl.perfringens 10,000 IU for Cl.oedematiens 10,000 IU for Cl.septicum_ Total : 30,000 IU__

Treatment 

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Serum 50,000 IU to 150,000 IU during operation / in 300-400 ml normal saline / Surgical wound debridment or amputation of limb detoxicating transfusion therapy / at 4 l of fluid Antibiotics: carbopenems or vancomycin antiseptics: metronidazole or dioxydine Hyperbaric oxygenation

Tetanus 

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Specific tetanus prophylaxis: 0,5 ml of toxoid are given twice a month REVACCINATION is done after 1 year - 0,5 ml of toxoid Repeaded REVACCINATION after 5 years - 0,5 ml toxoid`

Tetanus / emergency prophylaxis/ 

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Immunised patients: 0,5 ml toxoid as a single dose Non- immunised patients: 1,0 ml toxoid + 1,500-3,000 IU Antitenanus serum/ 450-600 IU Antitetanus gamma globulin/ After 1 month - 0,5 ml toxoid After 1 year - 0,5 ml toxoid