Surgery
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Surgery Sterilization, Aseptic Technique, Surgical Instruments, Wound Healing, Basic Suture Patterns HIGH Degree of control Technique 100% control Sterilization 99 – 100% control Disinfection Up to 99% control Sanitization Variable control cleaning LOW Controlling microbes Objective is to control microorganisms (pathogens) to protect the patient ◦ Can be found in the environment, fomites, each person, and the patient ◦ Sterilization is the elimination of all life from an object (complete microbial control) Important in surgical environment ◦ Sanitizing and disinfecting often create acceptable levels of control Sterilize, Disinfect, Sanitize, Clean Antiseptic-chemical agent that kills or prevents the growth of microorganisms on living tissue Disinfectant- chemical agent that kills or prevents growth of microorganisms on inanimate objects Sanitize -to make something free from dirt, infection, disease (pathogens) by cleaning, disinfecting, or sterilizing. Clean- removal of dirt, and other unclean material Definitions Physical Methods Chemical Methods Methods of microbial control Physical 1. Dry Heat (oxidation) Incineration-red hot/ fire Hot Air Ovens- 1 hour exposure to high heat (340) 2. Moist Heat (denatures proteins) Hot water – incomplete ◦ Why do we add detergents –emulsifies oils and suspends soils…water is the universal solvent Boiling – 3 hours for complete Steam (90 min) Steam under pressure (autoclave) Methods of microbial control Autoclaves Increase in pressure=increase in steam temperature=less time needed to sterilize minimum 15 psi = steam at 121 degrees C (15 min) can get up to 35 psi = steam at 135 degrees C (1 min) Steam and temperature indicators ◦ Did the steam reach everything in the autoclave ◦ Did the temperature reach target temperature (changes color) autoclaving 3. Radiation (damages cell/ dna) Ultraviolet-close range/ no penetration Gamma radiation 4. Filtration (physically traps organisms) Fluid filtration ◦ Pore size of 0.45 microns removes most bacteria ◦ 0.01 – 0.1 micron for viruses Air filtration ◦ Surgical masks, air duct filters, HEPA (high efficiency particle absorption) filters 5. Ultrasonic vibration- (disrupts cell walls/coagulates proteins) Useful for cleaning surgical instruments prior to sterilization in autoclave 6. Cleaning –physical removal of organic and inorganic soils and microbes Methods of microbial control List 5 physical methods of microbial control: What is autoclaving? ◦ Which physical method is it? ◦ Minimum effective pressure is _____psi? ◦ How long to achieve sterilization at this pressure? Bell Work Monday April 21 Chemicals work by penetrating the organism cell walls and reacting with parts of the cell to destroy or inhibit growth. Many chemicals are disinfectants with varying levels of activity; a few achieve sterilization Remember Antiseptics are used on tissues and disinfectants are used on inanimate objects Chemical Methods of Microbial Control Contact Time - The length of time an object is required to be exposed to a sanitizing or disinfecting agent before wiping or rinsing to ensure the effectiveness of the products’ kill claims. Contact time for sanitizing is generally 2 minutes. (Check the Product label for contact times) Contact time is 10 minutes for disinfecting. Chemical Methods: Contact Time is important! 1. Soaps and Detergents Soaps in general have minimal disinfecting ability Soaps can be used for cleaning Detergents emulsify oils and suspend particles Detergents have some disinfecting ability Chemical Methods 2. Chlorines Chlorine gas, chlorine dioxide, Sodium hypochlorite (household bleach) Disinfectant: most bacteria, viruses, protozoa, fungi disinfect water, inanimate objects…irritating to skin Chemical Methods Alcohols 3. ◦ ◦ ◦ ◦ ◦ ethyl alcohol= 75% ethyl isopropyl alcohol = 70% isopropyl most effective because of dilution with ethyl, isopropyl Useful as a skin disinfectant (antiseptic) Irritating to tissues Rapid antiseptic Used as a solvent for other disinfectants and antiseptics (solvent: the liquid in which a solute is dissolved to form a solution) Ineffective after evaporation (which is pretty quick) Porous surfaces such as furniture disinfectant Both disinfectant and antiseptic Chemical Methods 4. Peroxygen compounds paracetic acid, hydrogen peroxide , benzyl peroxide oxidizing agents active against bacteria, fungi considered a sterilant, although there are some things it does not kill bubbling action releases oxygen…helps to remove pus and cellular debris [benzyl peroxide-can be used on skin, as a shampoo, for pyoderma, keratyltic, antiseborrheic (flaky, itchy skin conditions)] Chemical Methods 5. Halogens iodine iodine is used in solution with water or alcohol alcohol enhances antibacterial activity of iodine kills bacteria, viruses, fungi, not spores The darker the color, the greater the activity iodophors iodine plus detergent used as surgical scrub-non staining/ non irritating Betadine, Povidone-Iodine Antiseptic-used on tissues Chemical Methods 6. Biguanides -Chlorhexadine gluconate -Has bacteriostatic and bacteriocidal properties, some viruses, fungi -Useful as a disinfectant and antiseptic surgical scrub of animal, wounds, skin, mouth, and inanimate objects/surfaces Nosocomial infections by Pseudomonas spp have developed from the use of contaminated chlorhexidine solutions in which the bacteria persisted Chemical Methods 7. Quaternary ammonium compounds (Quats) benzalkonium chlorides, centrimide, roccal -disinfectant -check formulations –bacteria/ some bacteria, some viruses, some fungi -roccal-parvovirus -inactivated by organic material, soap, hard water Chemical Methods 8. Phenols carbolic acid (C6 H5 O H), coal tar, Lysol synthetic phenols are nonirritating/ non toxic Disinfectant…but in some formulations antiseptic check labels: may be toxic particularly to cats, also rabbits and rodents Not generally used as antiseptic, but sometimes combined Pine tar is a viscid blackish brown liquid, used primarily for antiseptic bandaging of wounds of the hoof and horn. Pine tar contains phenol derivatives that provide antimicrobial properties activity decreased by quats not inactivated by organic matter, soap, or hard water bacteria, some viruses, some fungi Chemical Methods 9. Aldehydes formaldehyde, gluteraldehyde active against bacteria, most viruses, fugi, bacterial spores considered to be a sterilant, but may require 12 hours contact time formaldehyde-can be diluted with alcohol toxic/ irritant to tissue, respiratory tract “Cold Sterilization” gluteraldehyde with 70 % alcohol is a potent germicide -useful for instruments, particularly endotracheal tubes, laryngoscopes, endoscopy equipment, rubber, plastics Chemical Methods 10. Ethylene Oxide (EO) colorless, odorless gas, rapid penetration flammable, explosive, toxic, carcinogenic, and irritant useful against bacteria, viruses, fungi, bacterial spores specialized procedure-similar to autoclaving, but more specialized due to precautions Chemical Methods High –cidal activity Ethylene acids Aldehydes Paracetic acid/ chlorine dioxide Halogens (iodine, chlorine) Phenols Quats (Roccal-D) Alcohols Low –cidal activity Chlorhexidine Which kill better? Why do we need to know how chemicals are grouped and their properties? Antiseptics with antifungal activity ◦ Phenols, Chlorhexidine, Iodine, Povidone Iodine, Sodium Hypochlorite (bleach), Cetrimide (quat) Antiseptics with antiviral activity ◦ Isopropanol alcohol, ethyl alcohol, formaldehyde, sodium hypochlorite (bleach), phenols, H2O2 (hydrogen peroxide), iodophors (betadine) Preferred Antiseptics GENERAL GUIDELINES FOR CLEANING/ DISINFECTING For cleaning and disinfecting the following hard non-porous surfaces: including equipment, utensils, instruments, cages, kennels, stables, stalls and catteries. (Non- porous surfaces means they are solid and do not absorb any fluid…surface is nonpenetrable.) Remove all animals and feeds from premises, animal transportation vehicles, crates etc. Remove all litter, droppings and manure from floors, walls and surfaces of facilities occupied or transversed by animals. Thoroughly clean all surfaces with soap or detergent and rinse with water. Saturate surfaces with an appropriate disinfectant for a period of 10 minutes. Ventilate buildings and other closed spaces. Do not house animals or employ equipment until treatment has been absorbed, set or dried. Thoroughly scrub all treated feed racks, automatic feeders, waterers and other equipment which dispenses food or water with soap or detergent, and rinse with potable water before reuse. Cleaning and Disinfecting of animal facilities Disinfecting Detergents for clothing, blankets, gowns (soak in water prior) Sodium Hypochlorite (bleach) for clothing, gowns, blankets, floors, blood spills, other objects and surfaces Quats and Phenols for floors, some surfaces (such as Roccal for kennels) Chlorhexadine Gluconate formulated for surfaces, instruments, kennels Glutaraldehyde for instruments, laryngoscopes, endotracheal tubes, endoscope (germicidal/sterilant) Surgical instruments: immersed, rinsed, ultrasonic vibration, autoclaved---achieves sterility Antiseptics and Disinfectants for hospital use (including veterinary) Antiseptics Hydrogen peroxide- removal of blood clots from tubes, dressing/ cleaning wounds ◦ After a wound is cleaned, debrided, sutured up, use of hydrogen peroxide can be detrimental because can cause destruction of healthy cells, also carries contaminants from outside sterile field Ethyl alcohol (isopropanol alcohol)- can use at injection sites, has many advantages including rapid onset of action, synergistic with chlorehexidine, remember-irritant of tissues ◦ Furniture disinfection (furniture is a porous surface) Antiseptics and Disinfectants for hospital use (including veterinary) Antiseptics Povidone Iodine for surgical scrub of patient, handwash/ presurgical hand scrub, dressings (wounds) Chlorhexadine gluconate formulated as surgical scrub (synegistic with alcohol), can use in mouth (dilute), wounds ◦ Has residual activity, low toxicity Antiseptics and Disinfectants for hospital use (including veterinary) Some things to note: Contamination of chemical agents can occur: For example Nosocomial infections by Pseudomonas spp have developed from the use of contaminated chlorhexidine solutions in which the bacteria persisted Always pay attention to proper concentrations- more is not better! Physically remove organic matter as part of first step before moving on to disinfecting/ antiseptic use Use the proper chemical for the situation Here is a label from a quaternary ammonium compound. Interpret the label as best as you can: Broad spectrum, hospital grade disinfectant cleaner and deodorizer. Bactericide, virucide and fungicide. Effective at 1 oz. per gallon of water against antibiotic resistant bacteria, HBV, HBC, Avian Influenza, HIV and many others. Effective in the presence of high organic soil and 400 ppm hard water. Bell Work Wednesday April 23 ASEPTIC TECHNIQUE Definition: Aseptic technique is a procedure used by medical staff to prevent the spread of infection. The goal is to reach asepsis, which means an environment that is free of harmful microorganisms. Each healthcare setting has its own set of practices for achieving asepsis. In veterinary medicine is most used for surgery of patients Major procedures require a dedicated surgery room similar to what is used for human patients. MAJOR SURGERY: Major surgery (e.g., laparotomy, thoracotomy, joint replacement, and limb amputation) penetrates and exposes a body cavity, produces substantial impairment of physical or physiologic functions, or involves extensive tissue dissection or transaction. Aseptic Technique: Where Many minor procedures use aseptic technique in a clean environment, such as the treatment room MINOR SURGERY: Minor surgery does not expose a body cavity and causes little or no physical impairment; this category includes wound suturing, and most procedures routinely done on an “outpatient” basis in veterinary clinical practice. Aseptic Technique: Where Initial procedures: During surgical procedures: Contamination prevention procedures: ◦ preparation of surgical team, operating room, instruments, patient ◦ Contact of a sterile surface with other surfaces avoided. 1. Cleansing and disinfection of operating room 2. Preparation of incision site and draping the animal 3. Aseptic preparation of the surgical team 4. Sterilization of surgical instruments and materials Prevention also includes responsibility of surgeon. ◦ gentle handling of tissue and proper suturing technique Aseptic Technique: Like a chain, aseptic technique is only as strong as its weakest link… What is the definition of aseptic technique? Aseptic technique is a procedure used by medical staff to prevent the spread of infection. The goal is to reach asepsis, which means an environment that is free of harmful microorganisms. What are some things that contribute to aseptic technique preparation of surgical team, operating room, instruments, patient, surgeon’s handling of tissues/ suturing surgical site closed Bell Work Thursday April 24 Preparing the patient ◦ ◦ ◦ ◦ Where the incision will be Clipping the area How to scrub Keeping the area around the animal sterile by draping The patient Some common incisions 1. Ventral midline incision Most abdominal surgeries 2. Paramedian –near midline (sagittal plane) 3. Paracostal incision Near the ribs for kidney or liver surgeries 4. Flank Incision Incisions Sternum ◦ Manubrium cranially ◦ Xiphoid caudally Umbilicus Midpoint of pubic bone (pubic symphysis) Rib arch (costal arch) Identify useful landmarks prior to clipping fur for surgery Clip away hair With #10 blade Get rid of loose hairs Preparation of the patient Ask the surgeon ◦ Varies, 1 inch to 4 inches around expected incision (on all sides) ◦ Keep it neat (for the owner) How do you know how much fur to clip? Surgical scrub of patient Wet fur along borders so fur lays flat before beginning Most common antiseptics are chlorhexadine scrub, povidone iodine, betadine, alcohol Sterile water or alcohol commonly used as rinse To begin scrub, start with where the incision will be and continue in a spiral or circular pattern outward until you reach the end of the clipped area. The scrub is generally followed by either a rinse or use of a soaked sponge (gauze squares) of sterile water or alcohol to get rid of detergent. This ensures that contaminants are moved from inside to outside of circles…away from incision site Surgical Scrub of patient Recommended scrub solutions are chlorhexidine or povidone-iodine Scrubs have detergent in them (must be rinsed off) and solutions have alcohol or sterile water Your first preps would be with scrub and final would be with solution ◦ Detergents help clean skin (dirt and soils) ◦ Solutions have no detergent, correct concentration of chemical Chlorhexadine has residual effect ◦ Chlorhexidine-alcohol mixtures are particularly effective in that they combine the antiseptic rapidity of alcohol with the persistence of chlorhexidine. ◦ Povidone Iodine needs prolonged contact, so you usually don’t rinse off Surgical Scrub of patient Start with incision site and work away from site in circles. Discard the gauze when you reach the end (the periphery) There is no one correct method ◦ May use alcohol between detergent scrub and non-detergent solution ◦ Each clinic will have its own protocol/ it’s own procedure The scrub process is repeated. Patients are usually scrubbed three to five times. Why the repetition…contact time! Some surgeons like the area to be dried after the final scrub and rinse. Accomplished with sterile dry gauze. A final “paint” of betadine is often applied with spray or same process of scrub. Surgical scrub of patient Clip ◦ Generally clip both sides of ear flap (pinna) ◦ If ear canal surgery clip side of face also Antiseptics - ask surgeon ◦ Usual skin prep on ear flaps but may need to plug the ear canals ◦ Use of antiseptics in ear canal may depend on whether ear drum (tympanic membrane) is open or not Ear prep Difficult to achieve asepsis in pads and under nails ◦ Clip nails ◦ Consider soaking whole foot in antiseptic for several minutes ◦ Hold foot by placing a towel clamp into a long toenail Paw Pads/ foot prep 1. • 2. • • 3. Apply Sterile Lubricant (e.g. K-Y) into wound and onto surrounding hair it will wipe & rinse out well Clip an outside ring first Then clip towards the wound Finally clip wound margins last Rinse wound with sterile saline Wound prep Clip hair around eye-check with surgeon how much area to clip Rinse eye with dilute betadine solution due to sensitive membranes Final surgical skin prep around eye with betadine solution Eye prep Preparation of the incision site and draping the animal. Preparation of the incision site and draping the animal Principles of Draping 1. Isolate Dirty from clean (e.g., unclipped fur on patient and equipment from the area to be prepped). Isolation is accomplished by using an impervious drape, usually fabricated from a plastic material. Any impervious material can be used. 2. Barrier Provides a first layer and/ or additional layer to prevent transport of microorganisms (microbes move by way of air or moisture/ fluid) 3. Sterile Field Creation of a sterile field is through sterile presentation of the drape and aseptic application technique. Drape from sterile to unsterile…need to know sterile zones in reference to body, your position to the animal and your surroundings It goes without saying, a drape shall be free of dirt, organic material, and lint and is made of certain acceptable materials that maintain the integrity of the principles of surgery and sterility. http://partnersah.vet.cornell.edu/veterinarians/bovine/surgicalscrubbing-gowning-and-gloving http://www.youtube.com/watch?v=mWHb 48AflcY Handwash, gowning, gloving What are some things that need to be done to prepare a patient for surgery? ◦ ◦ ◦ ◦ Where the incision will be How to clip the area How to scrub the area How to keeping the area around the animal sterile by draping When scrubbing a patient, what pattern do we use and why ◦ Circular motion, start with incision and work outward, do not overlap circles ◦ Bring bacteria out towards unsterile/ away from incision site Bell Work Monday April 28 Before handwash begins prepare area by having all materials necessary “Prep area” will contain items such as antiseptic cleaner, sterile hand towel, running water, ideally with “no hands” faucet, sterile gown, sterile gloves, face mask, surgical cap or bonnet Handwash is first step in achieving aseptic technique in regards to the surgeon Handwash Wear reasonably clean clothes and shoes Tie loose hair back to prevent pathogens Surgery cap and facemasks Shoecovers Remove all jewelry to prevent objects possibly penetrating gloves It is recommended to wash and dry hands before beginning scrub process, clean under fingernails with disposable nail cleaner Before Handwash begins… Mechanical component of scrubbing removes soils and organisms acquired from environment, direct contact Handwash Chemical component reduces amount of, inactivates, inhibits growth of microorganisms Water is usually turned on by “hands free” method If prepackaged, scrub and brush are opened before beginning Scrub starting with hands, keeping hands elevated which allows water to drip from elbows Scrub all surfaces, leave on to allow contact time ◦ 5 minutes ◦ According to manufacturer ◦ Count strokes Nails 30 times each side of finger 20 times Back of hand, 20 times Etc Handwash Start with thumb, each finger, back of hand, palm, over wrist, up the arm in thirds Always keep in mind, four surfaces Work way up arms to elbows (human medicine states 2 inches above elbows, veterinary medicine usually a couple inches below elbow) Do complete hand and arm, before doing other hand and arm Rinse hands and arms thoroughly Hand wash Dry hands and arms with sterile towel continuing to use aseptic technique Often times the sterile towel is placed in a package with a gown…the towel should be on top of the gown and is picked up without touching the gown If you did not open packaging prior to scrubbing, an assistant needs to open the packaging for you (without touching the inside) Getting ready to gown Discard the towel away from you and any other sterile items Drying hands When picking up gown, the inside is considered unsterile and remains so Remember although hands are scrubbed they are not sterile either Unsterile to unsterile, so ok to touch inside of gown Outside of gown is sterile-don’t touch ◦ exception is upper neck area and shoulders (axillary) and back of gown Gowning Pick up gown by grasping inside of gown/placing hands into sleeves of gown ◦ When lifting gown out of package, stay clear of table or any other unsterile obstacle that might inadvertantly come in contact with outside of sterile gown Assistant then pulls up gown, using only “unsterile” areas of neck and shoulders, ties at back of gown. Gloving will be next step ◦ If using Closed Method of Gloving, sleeves and cuff stay over hands ◦ If using Open Method of Gloving, hands will be exposed Gowning Gowning What are some things you should do before beginning your handwash? ◦ Set up prep area with sterile gown, sterile gloves, sterile towel, handwash supplies ◦ Remove jewelry, tie back loose hair ◦ Cap, facemask, shoe covers ◦ Change clothes/ shoes if particularly soiled ◦ Wash hands, clean nails Which parts of the surgical gown are considered unsterile and which parts are considered sterile? ◦ Back of gown, inside of gown, axillary areas (upper shoulder, neckline) ◦ Front of gown and sleeves, sleeve cuffs Bell Work Tuesday April 29 Closed Technique ◦ No exposure of skin ◦ In veterinary medicine most often used for orthopedic surgery, laparatomy Open Technique ◦ Skin to skin, glove to glove Open Technique without gowning ◦ aseptic technique, clean room Gloving Open Technique Rules to observe while wearing sterile gown and gloves. NEVER drop hands below the level of the sterile area at which you are working. NEVER touch surgical gown above the level of the axilla or below the level of the sterile area where you are working. NEVER put hands behind your back; must keep them within full view at all times. NEVER tuck gloved hands under his armpits, as the axillary region of gown is considered contaminated. NEVER reach across an unsterile area for an item. NEVER touch an unsterile object with gloved hands Once gowned and gloved… Where is sterile? 1 2 3 4 A pack is a group of similar objects that are wrapped in cloth and then sterilized all together Ex: surgery instruments, Gown and towel for drying hands Opening sterile packs Opening and pouring sterile fluids Assisting with withdrawl of sterile solution from a vial ◦ Outside of vial is contaminated from handling ◦ Contents are sterile and vial is unopened ◦ Assistant opens vial, maintains sterility Adding sterile objects to a sterile field ◦ New pair of gloves for surgeon to reglove ◦ Additional instruments, sponges, suction, additional suture material Maintaining sterility A disinfected or sterile area ◦ field = surgery site and adjacent areas, surgery table, area where instruments will be placed ◦ Only sterile objects are allowed into the surgical field ◦ Invisible “force field” / sometimes physical barriers (draping) Aseptic Technique: Achieve sterility-Preparation of patient, surgeon, support staff, room, equipment Scrubbed persons function within a sterile field Maintain sterility If contamination occurs during any part of the procedure, stop and correct the situation immediately. Summary of Aseptic Technique Other precautions for maintaining a sterile field are: 1. Never turn backs on a sterile surface. 2. An unsterile area not touched or leaned over. 3. Sterile instruments never be below the edge of the surgical table. 4. Arms and hands remain above the waist and below the shoulder. 5. Lift up materials, do not drag over edges of containers. 6. Keep all sterile surfaces dry. 7. Avoid excessive movement during surgery. 8. Avoid shaking of gowns, towels, drapes, and other materials. 9. Keep conversation to a minimum during surgery. 10. If waiting, clasp hands in front of your body above the waist. If contamination occurs during any part of the procedure, stop and correct the situation immediately. Always maintain sterility True or False? ◦ The surgeon’s hands are considered sterile after the handwash. True or False? ◦ The method of gloving that was practiced yesterday was Open Method of Gloving. True or False? ◦ The everted cuff on the sterile gloves is considered sterile and that is why that portion can be handled by the surgeon after handwashing. Bell Work Thursday May 1 Basic Anatomy of an instrument ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Finger rings Box lock Ratchet Shank Jaws Blade Serrations Teeth Surgical Instruments Hemostatic Forceps Scissors Needle Holders Scalpels Thumb forceps Misc Surgical Instruments Halsted mosquito forceps small, all the way up, small vessels Kelly halfway, moderate sized vessels Crile all the way up, moderate sized vessels Hemostatic forceps Rochester -Pean Rochester -Carmalt Rochester Carmalt Both are used for large vessels such as arteries Hemostatic Forceps Sharp Sharp Blunt Sharp Blunt Blunt Scissors Mayo Metzenbaum Dense tissue Delicate tissue Scissor Lister Bandage Scissors Special scissors Littauer Suture Scissors Olsen Hagar Needle Holders with scissors Needle Holders Mayo Hagar Needle Holder without scissors Blade Handle Scalpel Handle (#3) Scapel Blades #10 and #11 Adson Tissue Forceps Thumb forceps Adson Brown Tissue Forceps Smooth Thumb forceps Rat toothed Allis Tissue Forceps Other forceps Alligator forceps Backhaus towel clamps Spay Hook (snook) Gelpi Retractor Retractors Weitlaner Retractor Senn Miller retractors Retractors Balfour Retractor And by the way… Lengthwise serrations on the jaws of hemostatic forceps are called: Transverse Longitudinal Describe Kelly hemostatic forceps Describe Rochester Carmalt forceps What is the difference between hemostatic forceps and thumb forceps? Small, medium, large? Serrations in which direction How far up do the serrations go Small, medium, large? Serrations in which direction How far up do the serrations go Bell Work Tuesday, May 6 Know your alcohol! Alcohol is neither a sterilant nor a high-level disinfectant. Alcohol has been used historically for disinfection in a variety of species and situations. In certain cases, alcohol may actually achieve the desired outcome, but this is highly variable and inconsistent, since it depends on duration of contact time, agents being killed, contamination present on the skin surface, and organism life stage (vegetative organisms are killed more quickly than spores). According to the Association for Professionals in Infection Control and Epidemiology, “ethyl alcohol and isopropyl alcohol are not effective in sterilizing instruments because they lack sporicidal activity and cannot penetrate proteinrich materials and cannot kill hydrophilic viruses.” http://www.youtube.com/watch?v=LEsK3 2zBUO0 7 minute video (instruments are easy to see, also suture) http://www.youtube.com/watch?v=tWKu DbXZm5E very detailed…25 min dog spay http://www.youtube.com/watch?v=LC7kyTXPqFs 4 minute dog castration http://www.youtube.com/watch?v=IwRXXW3CU6s 45 minute video (more current, more “real”) Note to self: Worksheet to go with 1st video…instrument identification Surgery videos What is the purpose of a Backhaus Towel Clamp? What is the purpose of Mosquito Forceps? What is the purpose of retractors? Can you name one retractor? Bell Work Wednesday May 7 How wounds heal 1st intention tissue healing 2nd intention tissue healing Seromas, hematomas and abscesses ◦ ◦ ◦ ◦ Injury Inflammation Organization Regeneration Wound Healing 1. Inflammatory Stage ◦ Hemostasis is included in this stage Constriction of vessels to stop bleeding Dilation of vessels to bring oxygen and nutrients Release of histamine and heparin ◦ The body’s initial/ immediate response to injury or trauma Smaller arteries and capillaries bring blood to the area through circulation / bringing Oxygen and nutrients ◦ Rush of blood = extra fluid/ plasma =swelling and inflammation 3 stages of wound healing ◦ The blood brings in oxygen and nutrients for healing of tissue (epithelial tissues) ◦ Clot Formation ◦ Brings in white blood cells to fight infection ◦ Pus is dead white cells ◦ Clot is formed network of protein (fibrin) ◦ This stage last about 2-3 days 2. Proliferation (Repair or Organization) ◦ Granulation Tissue forms-layers of collagen fibers with new capillaries ◦ Forms under scab ◦ Has appearance of small granules Very red, bleeds easily Called proud flesh in the horse when becomes too thick are larger than wound Granulation tissue is resistant to infection because it produces substances Can take 2-3 weeks 3 stages of wound healing 3. Remodeling (Regeneration) ◦ Epithelial cells are regenerating over the granulation tissue (under the scab) ◦ Granulation tissue becomes more fibrous resulting in a scar Scar tissue is thicker than original tissue Not as flexible as original tissue Does not perform same function as original tissue ◦ Heart ◦ Muscles ◦ Organs ◦ Can last 6 months to 2 years 3 stages of wound healing 1st Intention Wound Healing ◦ Also called primary wound healing or closure ◦ Edges of wound are placed together in apposition to each other. ◦ Very little to no granulation tissue therefore no fibrous scar tissue Classification of wound healing 2nd Intention Wound Healing ◦ ◦ ◦ ◦ Large wounds with tissue loss Edges are separated Granulation tissue forms to close the gap Scar tissue formation Classification of wound healing Scar tissue is undesireable ◦ Interupts normal tissue function Cardiac tissue Skeletal muscle ◦ Is thicker and can decrease the diameter of a lumen (space) Esophagus Intestines Scar Tissue Seroma ◦ A seroma is a pocket of clear serous fluid that sometimes develops in the body after surgery. When small blood vessels are ruptured, blood plasma can seep. The remaining serous fluid causes a seroma that the body usually gradually absorbs over time (often taking many days or weeks); however, a knot of calcified tissue sometimes remains. Seroma Hematoma ◦ A hematoma is a localized collection of red blood cells outside the blood vessels. Hematoma Abscess ◦ An abscess is a collection of pus (neutrophils) that has accumulated within a tissue because of an inflammatory process in response to either an infectious process or foreign body. The body “isolates” the infection is a “pocket”. ◦ Great abscess video ◦ http://www.youtube.com/watch?v=txET8DCFLn4 Abscess A Penrose drain, named for Dr. Charles Bingham Penrose, is a surgical drain which is left in place after a procedure to allow the site of the surgery to drain. Facilitating drainage of blood, lymph, and other fluids helps reduce the risk of infection and keeps the patient more comfortable. Drains Pathogens are opportunistic freeloaders? Pathogens are living organisms living within systems, sometimes “our” systems Pathogens don't even need to try to cause contamination. They thrive when the conditions (such as pH, temperature, water activity etc) are optimal for their growth. To stop them from contaminating, just make the conditions unsuitable for their growth. Pathogens-why do they exist? What are the three stages of wound healing? Describe 1st intention healing. Describe 2nd intention healing. Bell Work Thursday May 8 Materials Patterns and tension Knots Suturing Suture Needles ◦ Straight, curved, half curved, half circle Curved most common Described by circle size ◦ ¼ 3/8 ½ 5/8 ◦ Needle Points Cutting ◦ Types of cutting points can be reverse, triangular or side cutting for skin, cartilage or tendons Tapered (non cutting) ◦ Round or oval with reverse cutting points for tissue that may tear easily Materials Curved needles • • • • Cutting edge is on inside of curve Penetration of dense tissue cut edge is where the tension is on the tied suture so this type of needle predisposes the suture to cutting through the tissue use has generally been replaced by the reverse cutting needle Cutting needle (triangular) • • • • cutting edge on outer surface of the curve more efficiently uses the cutting surface when curve wrist during insertion more resistant to suture cutting through tissue because the cut edge is opposite to the direction of tension on the tied suture preferred by most surgeons Reverse cutting needle Cutting vs Reverse cutting • have a round body with a sharp pointed tip • generally used for viscera, muscle and light fascia • penetrates tissue, without cutting, creating a round hole Tapered or non cutting needle Suture Material ◦ ◦ ◦ ◦ ◦ Absorbable Non Absorbable Monofilament Braided Sizes Materials Nonsynthetic ◦ Cat gut or gut or chromic gut (coated with chromic salt) natural fiber found in the walls of animal intestines ◦ Sheep, goats, “cat”tle Synthetic suture material: Made of various “formulations” to absorb ◦ Vicryl (braided) ◦ Monocryl (monfilament) ◦ Ethicon ◦ P.D.S ◦ Maxon ◦ significant loss of tensile strength by 14 days (rapid) -60 days depending on which is used Absorbable suture material Nonsynthetic ◦ Silk (could “absorb by 2 years) Silkworm cocoon ◦ Stainless Steel Synthetic Different formulations, some are coated, braided, monofilament ◦ ◦ ◦ ◦ ◦ Prolene Vetafil Ethicon Ethilon Supramid Nonabsorbable suture material Standardized labeling of sizes based upon diameter of thread: ◦ Most veterinary suture material is smaller than #0 so the “larger” the first number, the thinner the suture material is ◦ Examples: 6-0 is extremely thin, very fine 4-0 is thin (cats) 3-0 and 2-0 are common to use for routine surgeries 0 is thicker, used for tying off large vessels ◦ Why “ought” ◦ As procedures improved, #0 was added to the suture diameters, and later, thinner and thinner threads were manufactured, which were identified as ◦ #00 (#2-0 or #2/0) to #000000 (#6-0 or #6/0). Sizes Interrupted Suture Patterns ◦ Simple interrupted ◦ Cruciate ◦ Horizontal mattress Suture Patterns Properties: interrupted appositional appropriate for normal tension on the incision's edges local tension is managed by adjusting tension on individual sutures not recommended if significant tension minimal impact on the local blood supply to the incision's edges unless over tightened http://emap-projects.usask.ca/vsac205/Lab3/lab/lab3_1.3.1.1.php Simple interrupted Properties interrupted appositional pattern a tension suture less effect on blood supply than the horizontal mattress but more than a simple interrupted Cruciate Continuous Suture Patterns ◦ Simple continuous ◦ Ford interlocking ◦ Lembert Suture Patterns Properties continuous appositional less effect on blood supply than the horizontal mattress but more than the simple interrupted Simple continuous The knot is the weakest part of a suture line Knot security depends on A throw is the motion of wrapping the strands of the suture around each other and pulling on the ends to tighten them ◦ the technique used to tie the knot ◦ the physical characteristics of the suture material ◦ a simple knot consists of 2 throws (it tends to untie when under tension) ◦ a secure knot requires at least 4 throws (specific number varies with how slippery the suture material is) ◦ for continuous patterns, ◦ 5-6 throws are placed on the beginning knot while 5-7 are placed on the ending knot ◦ ends of the suture should be left long enough that they do not untie (at least 3 mm, but varies with the suture size and material) Why Knot? • • • • most common method of tying knots consistent quick and adaptable efficient use of suture Square Knot Surgeon’s knot Common Instrument Knots Square Knot ◦ Wrap once, then once (2 throws) ◦ Tighten after each throw Surgeons Knot ◦ Wrap twice, then once, then once (3 throws) ◦ Tighten after each throw University of Saskatchawan http://emapprojects.usask.ca/vsac205/Lab1/lab1_intro.php Fantastic vet site
