1
Q
The surgical scrub definition
A
- The process of removing as many micro-organisms as possible from the hands and arms by mechanical washing and chemical antisepsis before participating in the surgical procedure
- NOTE: you are unable to sterilize your hands and arms, but you can get them surgically clean
2
Q
Types of microorganisms
A
- skin is inhabited with:
- Resident flora (live on skin, can’t get rid of completly)
- Transient flora (picked up along the way)
3
Q
Purposes of surgical scrub
A
- decrease the number of resident flora to an irreducible minimum
- keep population of microorganisms minimal during the procedure by suppression of growth
- reduce hazard of microbial contamination of wound by transient and resident flora
4
Q
Two processes of the surgical scrub
A
- Mechanical- the actual friction of the scrub sponge against the skin
- Chemical- inactivation of microorganisms with a microbial or antiseptic agent, reducing resident flora
*need to have both*
5
Q
Antimicrobial agents (Scrub Soap) must be:
A
- a broad-spectrum, anti-microbial agent
- fast-acting and effective
- non-irritating and non-sensitizing
- prolonged-acting, that is, it leaves an antimicrobial residue on the skin to temporarily prevent growth of micro-organisms on the skin (should last duration of procedure)
- independent of cumulative action
- FDA-approved
6
Q
Antimicrobial agents
A
- Iodophors (Betadine)
- Chlorohexidine Gluconate (CHG)
- Parachlorometaxylenol (PCMX)
- Alcohol
- Hexachlorophene (see less of. No longer used as a scrub)
- Triclosan (see even less of)
7
Q
Iodophors
(Iodine or betadine)
A
- Rapidly antimicrobial (gram- & gram+)
- Some residual effect
- Not sustained very long
- can be irritating
- do not use if allergic to iodine
- available at: 10%, 7.5%, 2% and 0.5% (10 and 7.5 for scrubs usually)
8
Q
Chlorohexidine Gluconate
(CHG)
A
- 4% aqueous concentration or 0.5% in alcohol used in place of betadine
- residual prolonged effect (6 hours)
- Poorly effective on mycobacteria (TB)
- Drying to the skin
- irritating to eyes and ears
- so don’t use around faces
9
Q
Parachlorometaxylenol
(PCMX)
A
- 3rd choice
- no sustained residual activity
- does not reduce microbial count immediately
- available at 1%-3.75%
- may be used in individuals sensitive to iodophors and chlorohexadine gluconate
10
Q
Alcohol
A
- Scrubless Scrub
- leaves film, usually another agent suspended in alcohol
- ethyl or isopropyl 60%-90%
- rapid and kills all microorganisms
- no residual activity
- drying to skin
11
Q
Triclosan
A
- used rarely
- usually used in 1% concentration
- blended with lanolin and petrolatum
- not entirley effective against fungi
- questionable efficacy against viruses
- cumulative effect when used regularly
- may be used by those sensitive to other agents
12
Q
Methods of scrubbing
A
- Timed method
- First scrub of day= 5 minutes
- Subsequent scrubs= 3 minutes
- Brushstroke method
- Brushless or waterless
13
Q
Rules for the scrubber
A
- short, clean nails with cuticles in good shape
- good skin integity of the hands and arms
- NO fingernail polish
- NO artifiial nails
- NO jewelry
- NO oil-based lotions (water based please)
- REMEMBER to wear your goggles
- also remember to but hat and mask where you want it. Last time you can touch these things
14
Q
Needed items for your scrub
A
- Scrub sink
- disposable scrub brushes
- brush side for nails only
- sponge side for skin
- soap dispenser
15
Q
Important concepts:
A
- Hands above elbows always!
- you want your fingertips to be the cleanest. Funcionally, this means you want water to flow from fingers to elbows, not from elbows to fingers, so your hands should be above your elbows. rinse starting with fingertips and hen flowing over hands and arms for the same reason
16
Q
5 success factors of steam sterilization
A
- Time
- Temperature
- Moisture
- Pressure
- Contact
17
Q
Features of steam sterilizers
A
- Two metal “shells”, forming a “jacket” and a “chamber”
- above, a steam introducer; below, a steam-air drain
- pressurized sealing door
- control panel/specification printout
18
Q
Gravity displacement autoclave
A
- common pressure: 15-18 psi
- Temp range: 250-275F
19
Q
Prevacuum Autoclave
A
- Common pressure: 27-30 psi (27 in austin)
- Temp range: 270-276F
20
Q
“Flash” Autoclave
A
- defined by dedicated use: not a type of machine (can be gravity displacement or prevacuum)
- we like to avoid flashing- should not be used routinely to sterilize entire sets; for emergency or special use only
- 1-3 instruments, non-lumen= steam exposure time 3 minutes
- 4 or more instruments or sets, or lumened= 10 minute steam exposure time
21
Q
When placing in flash pan instruments should be…
A
unratcheted
22
Q
Two Important priorities for Laparotomy Set up
A
- Cover mayo stand
- Contain sharps safely in neddlebook
23
Q
What is the next priority after you contain sharps and drape the mayo?
A
get ready to count with the circulator
24
Q
After your count is done, what is the next priority?
A
get mayo ready
25
First step in getting the mayo ready?
load KBs
26
when placing instruments on your mayo they should be...
ratcheted one
27
In laparoscopy hasson set-up
* 12mm hasson trocar has blunt obturator and acorn, stopcock is open
* all other stopcocks should be closed
* bladed trocars should be armed
28
For Hasson set-up you will need:
* suture
* needleholder
* tissue forceps with teeth
29
Verees needle set-up
* 12mm trocar has no acorn and is sharp or bladed
* stopcock is open
* all bladed trocars should be armed
* all other trocar stopcocks should be closed
30
What should you be aware of in relation to your back during set up?
There will be a draped patient so we can learn to throw off cords (Sterile field)
31
Are we going to count laproscopic instruments?
Yes
32
Which corded instrument is LOWEST priority when you are passing off cords?
suction/irrigator
33
Anatomy of Breasts
* Breasts or mammary glands are modified sweat glands located anterior to the pectoralis major muscle between the second & sixth ribs
* the breasts rest lateral to the sternum and extend to the axilla (breast tissue all the way up into the armpit)
* the nipples lie at the level of the fifth rib
* the gland is composed of some fifteen to twenty lobes
* each lobe contains a lactiferous duct
* each lobe is surrounded by loose connective tissue and fat
* the nipple receives the openings of the lactiferous ducts, which open to the exterior
34
Methods of detecting a breast mass
* Monthly self exam
* screening mammograms
* depends on age and insurance
* important screening
* ultrasonography- used to differentiate between a fluid cyst and a solid tumor
* typically fluid filled is not cancerous
* thermography
* really expensive, only detects hot spots, not used often
1/7 women will get breast cancer
35
5 types of breast biopsies
* Aspiration biopsy (FNA)
* Core Biopsy
* Mammotome (vacuum)
* Incisional biopsy
* only takes 1/2 or portion of mass out
* excisional biopsy
* goes around entire mass and remove all tumor (preffered method)
36
Mammotome
Vacuum
37
Breast Biopsy Options
* Palpable
* open excisional biopsy
* fine needle aspiration
* core-needle biopsy
* Nonpalpable (under x-ray guided imaging)
* Open excisional surgical biopsy with needle localization
* fine needle aspiration
* mammotome
38
Needle Localization
* for non-palpable masses
* needle stays in during surgery
* put specimen between tegaderm (clear sheeting)
39
Now that the mass is out, we need to do a...
Sentinel Node Biopsy
* tools to find 1st lymph node:
1. Injection of Isosulfan blue-dye/Lymphyazuran 1%
1. 8 minutes before surgery this will be injected all around mass, may rub mass as well. Dye will go to 1st lymphnode and then we take biopsy
2. Technetium injection
1. Radioactive material
2. pt. goes to nuclear medicine 2 hours before surgery
3. will attach to tumor cells
4. geiger counter will tell you if lymph registers
can do both
40
Excisional Biopsy (Bx.) is performed if any of the following conditions exist:
* clinically suspicious mass persisting through a menstrual cycle
* cystic mass that fails to collapse completely when aspirated
* spontaneous serous or serosanguineous discharged from the nipple
* suspicious mammographic findings
41
General Considerations
(just things to think about before a pt. comes in)
* Patient's emotional status
* a lot of times sedated but not totally knocked out/hearing is still intact
* Position-Supine
* Prepping
* Anesthesia
* Needle Localization
* Sentinel Node Biopsy
* Frozen Section
42
Incisions
* Curvilinear
* Radial
As cosmetically appealing as possible and also for healing
43
Steps for a Breast Biopsy
"clean procedure"
Only count sharps and sponges- not an open cavity (usually only 2 counts)
1. Prep & Drape
2. Skin incision is made, and carried through the subcutaneous fat using a scalpel or electrocautery
3. **_Hemostasis_** of the superficial layer is achieved, using electrocautery
4. **Retraction to expose the breast tissue, using _Senn or Army/Navy_ retractors (always come in pairs. you need traction and countertraction)**
5. the surgeon palpates, and grasps the mass with a grasping clamp, usually an **Allis** (non occluding)
6. dissection of the mass is accomplished using **Metz** scissors
7. bleeders stopped are coagulated
8. specimen sent to pathology
9. close
\*Sometimes we irrigate with water instead of saline because it lyses or bursts cancer cells
44
Instruments & supplies needed
* Adolescent Laparotomy Pack (Breast Pack/Pedi Pack), Basin Set
* Minor or Plastic Instrument set
* K.B.s, suction tubing, bovie handpiece, raytecs
* Towel packs, telfa, gloves, needlebook
* asepto, suture, needle/syringe
* prep tray, saline, local anesthetic, dressings, tape
45
Appendectomy
Removal of Appendix
46
Anatomy of Vermiform appendix
* located in the right lower quadrant of the abdomen
* arises form the cecum (first section of the Large Intestine)
* 6-10 cm long
* plays a role in the immune system (some people think it doesn't do anything)
47
Acute appendicitis
* usually caused by obstruction of appendiceal lumen, which manifests as inflammation that can affect other nearby organs
* if appendix ruptures, it can cause peritonitis
* appendix can become gangrenous
* if it looks inflamed the surgeon just may take it out
48
Symptoms of Appendicitis
* pain
* nausea
* vomiting
* constipation or diarrhea
* elevated white blood cell count
* fever
49
Treatment
* Antibiotics started
* Appendectomy
* open method
* laparoscopic method
50
Open Appendectomy supplies
* Laparotomy Drape
* major or minor set- 2 small richardsons
* bovie, laps, raytecs
* cultures, suture, irrigation or SAS (Saline antibiotic solution)
* irrigate after culture
* KBs, towels, needlebook, gloves
* suture & prep tray
Open cavity so we count instruments, sponges and sharps
51
Appendectomy Procedure
1. Right lower quadrant (RLQ) incision
1. McBurney's
2. Peritoneum is grasped with 2 criles & entered with KB & metzenbaum scissors
3. find ileocecal junction & exteriorize (bring it up into view)
4. the base of the appendix is freed up from the mesentary by clamping, dividing & ligating
5. a kelly clamp is placed at the base of appendix near the cecum another kelly is placed distal (grasp with babcock)
6. using the "skin" knife (because it's dirty, appendix has fecal matter) the appendix is excised, cutting between the clamps. **the instruments or KB that touches the lumen of the stump is now considered contaminated and must be isolated in the basin**
7. the appendix stump is ligated (tied off)
8. a purse string suture is placed around the appendicele stump, kelly goes inside as purse string is tightened
9. wound is irrigated with NaCl
10. drain is placed if necessary
11. wound is closed in layers
12. dressings applied
SRGT 1509
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