Understanding Hemostasis and Wound Healing in Surgical Procedures, Exams of General Surgery

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Lecture Chapter 11 PowerPoint Notes Reverse Cutting Needle - consists of opposing cutting edges in a triangular configuration that extend into the full length of the shaft Memory - the ability of monofilament suture to hold its shape after being removed from its package Monofilment - has look and feel of "fishing-line" Wicking - action of moisture along a suture strand Approximation - when tissue edges are perfectly aligned together Primary Suture Line - row of sutures directly holding wound together Phagocytosis - the absorption process of the suture in the body Multifilament strands are ___ - braided Suture Book - holds multiple suture lines for use Animal Derived - natural/from the earth Suture Routine - the surgeon's usual preference in suture material and sizes Tensile Strength - breaking point Ligature - tie Hydrolysis - a natural enzymatic process Permanent sutures are ___ - nonabsorbable CR/8 - control release sutures that are red Cutting Suture Needle - for tougher tissue Swaged - implies a suture needle that is crimped onto the suture strand unintentional wounds incidental and chronic wounds Mechanical Hemostasis - hemostatic instruments ligatures clips sponges pledgets bone wax pressure devices Chemical Hemostasis - absorbable gelatin (Gelforam) oxidized cellulose (Surgi-Cel) absorbable collagen (Avilene) silver nitrate thrombin microfibrillar collagen epinephrine Blood Replacement Components - platelets packed red blood cells (pRBC) fresh-frozen plasma (FFP) plasma whole blood Blood Component Replacement - autologous (from self prior to procedure) homologous (from another human) autotransfusion (from self during procedure) Hemolytic Transfusion Reactions - improper blood match -S&Sx conscious patient -S&SX unconscious patient -stop immediately and rule out mismatch; steroid therapy and urine output monitored Hemostasis - -mechanical -biological -thermal -chemical Clotting Process - 1. platelets adhere to subendothelium of vessel walls 2. platelets release ADP 3. release of ADP causes further layers of platelets to adhere 4. platelet aggregate forms a thrombus 5. permanent thrombus forms after clotting factor reaction Estimated Blood Loss - EBL H&H - hemoglobin and hematocrit Measuring Blood Loss - calibrated suction devices subtract irrigation from collected blood weight sponges removed from sterile field Hemophilia - ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury. typically caused by a hereditary lack of coagulation factorm often factor VIII acquired: -liver disease -aplastic anemia -asprin therapy Heparin, Warfarin (Coumadin) - anticoagulants that prevent venous clot formation Ligatures or Ties - (referred to as stick ties when a needle is attached) are used to tie off blood vessels Ligaclips - can be used for open procedures or laparoscopic procedures and the ST must have the appropriate applier for each size Fibrin Glue - biological adhesive and hemostatic agent which consists of fibrinogen, cryoprecipitate, calcium chloride, and thrombin Autologous Plasma - Contusion - bruise Laceration - cut or tear Puncture - penetration Thermal - heat or cold (can be chemical) Inflammation - body's protective response for an extended period of time Process of Inflammation - injured tissue releases histamines from damaged cells; histamine causes small blood vessels in area to dilate, increasing blood flow to area, resulting in heat, redness, and swelling Dead Space - space that remains in the tissues as a result of failure or proper closure of a surgical wound; separation of wound layers that have not been closely approximated or air that has become trapped between tissue layers Wound Tensile Strength - amount of strength of a wound in regards to the original strength, usually only 70-80% by third month postoperatively Lag Phase - begins within minutes of injury and lasts approx. 3-5 days; physiological changes includes heat, redness, swelling, pain, and loss of function Proliferation Phase - begins 3rd postoperative day - day 20 Maturation Phase - begins day 14 until wound completely healed (usu 12 months); cicatrix - mature surface scar Age - pediatric and geriatric pts may have decreased vascularity or poor muscle tone Allergic Response - patients may have known or unknown allergies to different types of medications, metals, and materials (latex) Nutritional Status - dietary deficiencies can alter healing, e.g. balanced meal, extra protein, anorexia/bulimia Obesity - weight and pressure may make difficult to secure wound closure and poss cause incision hernia, adipose tissue has a poor blood supply contributing to slow healing Disease - chronic or acute; metabolic, cv, respiratory insufficiency, malignancy, and infection all negatively impact wound healing Smoking - causes vasoconstriction, diminishes oxygenation, may cause coughing that puts stress on wound poss dehiscence Immuno - congenital or acquired conditions Drug Therapy - medications taken routinely have potential interactions with medications given during surgery Fluid and Electrolyte Balance - fluids are needed for oxygen profusion, hydration to the wound, and to transport waste away from the cells Hematology - patients' blood samples are tested for different types of blood conditions such as anemia, hemophilia, blood clots, and blood cancers Radiation Exposure - patients undergoing radiation treatment in large doses may experience a decrease in blood supply to the irradiated tissue Dehiscence - partial or total separation of a layer or layers of tissue after closure of the wound (Table 11-2, page 294) Evisceration - interruption of a closed wound or traumatic injury that exposes the viscera Hemorrhage - uncontrolled bleeding that may be concealed or evident and may result in postoperative shock, surgery re-op is frequently required to achieve hemostasis Needle Eyes - closed; french; swaged Closed-Eyed - round or square holes and loaded by inserting the end of suture material through the hole; may cause more tissue damage than swaged French-Eyed - loaded by pulling the taut strand into the V-shaped area above the eye; loaded more quickly that closed eye but more tissue damage Eyeless/Swaged - suture strands are manufactured with the strand inserted into one end; includes double-ended suture (one needle at each end of strand) and controlled-release suture needles Cutting Needles - used for tough tissue that is difficult to penetrate; typically used for sclera of eye, tendons, or skin Side Cutting Needles - used primarily for ophthalmic procedures because they will not penetrate into deeper tissues and separate the tissue layers during placement Tapered Needles - penetrate tissue without cutting it; used for delicate tissues such as GI tract Blunt Needles - round shaft that ends in a blunt tip; used primarily for kidneys or liver because of the friable or weak tissue/organ Hypodermics - inject medications into tissue or IV tubing, length sizes ½" - 4", gauge sizes 12 - 30 Arterial - used to introduce a guide wire or catheter for diagnostic imaging or lines; Example Potts- Cournard Intravenous - used to aspirate fluid or puncture veins Irrigation - small diameter plastic/metal, straight or angled, disposable or nondisposable, varies in length, Example: Heparin Biopsy - obtain tissue samples for diagnostic examination; Example: Dorsey, Chiba, Franklin-Silverman, Tru-cut Insufflation - used during laparoscopic procedures to instill CO2 into abdomen, Example: Veress Spinal - 3-4" usually used to instill anesthetic agents into epidural or subdural space to obtain CSF Vessel Loops - isolation/retraction devices for vessels, nerves, or ducts: White and yellow - nerves and ducts Red - arteries Blue- veins Packaged in set or twos Skin Staplers - 35R or 35W Fascia Staplers - similar to skin staplers Linear Staplers - Used to staple or transect tissue Deliver two double staple lines and contain a knife blade to cut after stapling Often used in GI Available in multiple sizes Examples include GIA and TA staplers Ligating Clips - Used to occlude a vessel or duct Automatic or manual loading Multiple sizes (sm 9.0, med 11.5, lg 13.0) Handheld for open procedures or endoscopic procedures Intraluminal Staplers - Anastomose tubular structures within GI tract Multiple sizes (must use sizers before stapler); 28, 32, 36, 42 Example- EEA Tissue Response to Injury - Phase I: Lag - inflammation and debridement Phase II: Proliferation - collagen formation (scar) Phase III: Maturation/Differentiation - sufficient collagen