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Surg Seminars

Surgery

QuestionAnswer
2 basic kinds of suture. absorbable and nonabsorbable
4 types of absorbable sutures. plain gut, chromic gut, Dexon, and Vicryl
Source of plain and chromic gut sutures. tough submucosal layer of the hog intestine
Plain vs chromic gut sutures (tensile strength) Plain gut is unmodified & loses tensile strength in 1 to 2 wks; chromic gut is soaked in chromic acid salts, retains its strength for 2 to 3 wks
How long tensile strength is maintained in Dexon and Vicryl 2 to 3 weeks
4 groups of nonabsorbable sutures silk and cotton, braided synthetics, monofilament synthetics, and wire
3 reasons silk is most commonly used suture material. Silk is easy to handle, easy to tie, and holds knots well. Silk will stay securely tied if tied with three knots
Advantages of braided synthetic sutures over silk. less reactive than silk; good retention of tensile strength; relatively inert in uninfected tissue
Pos & cons of monofilament sutures. more difficult to handle and tie and hold knots poorly; very inert & do not shelter bac; heal without stitch abscesses; hold their strength well with time
Pos & cons of using wire suture. adapt to tissue more poorly than monofilaments, small open spaces; hard to tie; larger must be twisted (adv in suturing bone); retains its strength well
Grading system for suture sizes Largest = 5; smallest = 10-0
Absorbable vs. nonabsorbable sutures use absorbable if continued strength not important, or infxn issue favors absorbable; Nonabsorbable used if need minimal tissue rxn, or continued strength beyond 2-3 wks, or suture will be removed
4 surgical needle characteristics eye, shape, point and cross section, and size
Mayo needle stout, curved, tapered needle, available in several sizes; often for suturing fascia
Keith needle 6 - 7 cm straight cutting needle used on the skin; needle itself is 3-4 times as big as the suture
French eye needle fine curved needle in the 1.5 to 2 cm range, has a spring-like eye
Swaged needle fastened to the end of the suture during manufacture & needs to be no larger than the suture itself; for CV & intestine surg; for and for nylon or polypropylene sutures
Taper (atraumatic) for soft tissues and fascia, the tapered needle, round in cross section is best.
Conventional cutting needle puts a small cut in the direction of pull of the suture; easier to pass through the tissue
Reverse cutting needle have a flat edge in the direction of pull
Ground point wire saber point that has sharp edges, while the body of the needle is round in cross section; sharp enough to penetrate & sew grafts
Square knot = Strongest knot; 80-90% of tensile strength of uninterrupted strand.
Four principles of suturing Approximate-do not strangulate; use smallest size suture necessary to maintain closure; small sutures placed close together = lg sutures placed farther apart; wound tension is best relieved by using subcutaneous absorbable sutures
Bite = amount of tissue taken when placing the suture needle
Throw = Each suture knot consists of a series of throws
Skin closure Sutures, usually of a nonabsorbable material, placed in the skin with the knot tied on the surface
Dermal closure Sutures, usually of an absorbable material, that are placed in the superficial(subcutaneous) fascia and dermis with the knot buried in the wound
Subcuticular (pull-out) suture an excellent cosmetic closure because it eliminates the crosshatching caused by suture marks. This technique is limited to straight lacerations less than 2-3 inches long
Why is layer matching important when closing wounds. Failure to appose layers meticulously can cause improper healing with an unnecessarily large scar
Wound edge eversion sl raised wound edge above plane of normal skin will flatten w/ healing; edges that are not everted will contract into linear pits = noticeable cosmetic defects.
Define dead space These spaces tend fill with fluid and can be potential sites for infection
Problems caused by too much wound edge tension minimize tension in order to preserve capillary blood flow to the wound edge
3 techniques to reduce wound edge tension Dermal (Deep) Closures; Wound Undermining; More Sutures
Pros of wound taping Pro: less need for anesthesia, ease of application, even distn of tension across wound, no residual suture marks, elim need suture removal.
Cons of wound taping Cons: do not work well near joints, on hair bearing surfaces, wounds under tension, in very young or noncompliant pts, or on wounds that cannot be made free of blood or secretions
Describe the correct methods to hold forceps Pencil grip
most important principle of wound care: copious irrigation and adequate debridement
Langers lines Conn tissue bundles usu follow a predictable course within the dermis; wound closures parallel to these lines remain thin leaving small scars
Wound closure: if time after injury is <8 hours: Primary closure
Contaminated wounds or wounds treated after 6 - 8 hrs: delayed-primary closure or delayed closure
Puncture wound: leave open
List five causes of shock cardiac compressive; cardiogenic; hypovolemic; neurogenic; septic
initial tx: cardiac compressive shock: correction of the mechanical abnormality.
initial tx: cardiogenic shock: cautious fluid administration to increase preload; ACEI, beta blockers
initial tx: hypovolemic shock: lg bore IV access; crystalloid infusion; PRBCs?
initial tx: neurogenic shock: IV fluids; Peripheral vasoconstrictors?
initial tx: septic shock: clear offending infxn (Abx, débride, resect); supportive / resp
Indications for PRBCs hypovolemia + anemia; symptomatic anemia
Indications for platelets Plts <50,000 (bleeding); Plts <15,000 (asymptomatic)
Indications for fresh frozen plasma bleeding & coagulopathy; coumadin reversal
Indications for cryoprecipitate Fibrinogen <100 mg/dL
Risks of transfusion hemolytic rxn; febrile nonhemo rxn (vs WBCs); dz transmission
Organisms: skin/scalp staph epi & staph aureus
Organisms: nose/sinus strep & H flu
Organisms: mouth strep spp & Eikenella
Organisms: feet pseudomonas
Organisms: cat bite Pasteurella
Organisms: dog bite Strep viridans
Post-op diarrhea often due to: C. diff (tx: PO Flagyl)
Phases of wound healing inflam (1-10 d); proliferation (5d – 3 wks); remodeling (3 wks-1 yr)
Ways to handle tissue that minimize risk of infection Sterile technique; Minimize tissue damage; Prophylactic Abx (peak = same time as skin incision); outcomes clinical research to systematically identify problems
Infections occurring within 48 hours post-op: If rapidly spreading: possibly necrotizing fasciitis due to Clostridia or Strep. B
Most common post-op infxn UTI
Post-op infxn <POD3 pneumonia
Most common cause of post-op fever atalectasis
Post-op infxn POD3 UTI
Post-op infxn: usu POD5 Wound infxn
Veins for IV: usu first choice metacarpal veins
Created by: Abarnard