Surgery Marrow Pg 21-30 (General Surgery)
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Questions and Answers

Which of the following procedures is NOT typically performed in day care surgery?

  • Sentinel node excision
  • Laparoscopic cholecystectomy
  • Open-heart surgery (correct)
  • Therapeutic arthroscopy of knee

    • Patients with ASA Class III can only undergo surgery in a stand-alone day care centre.

    False

    What is the maximum BMI for a patient to qualify for laparoscopic procedures in day care surgery?

    38

    The patient must be admitted and discharged within __________ hours in day care surgery.

    <p>12</p> Signup and view all the answers

    Match the procedure with its corresponding region of surgery:

    <p>Hemorrhoidectomy = Abdominal Laser prostatectomy = Genitourinary Therapeutic arthroscopy = Orthopedic Varicose vein procedures = Vascular</p> Signup and view all the answers

    What constitutes a superficial wound infection?

    <p>Infection above the fascia</p> Signup and view all the answers

    A wound infection is classified as an organ space infection if it occurs within 30 days of surgery.

    <p>False</p> Signup and view all the answers

    What is one risk factor associated with surgical site infections?

    <p>Diabetes mellitus</p> Signup and view all the answers

    A patient who stays as an inpatient for more than _____ days due to a wound infection is considered at a higher risk for complications.

    <p>14</p> Signup and view all the answers

    Match the following Southampton wound scores with their descriptions:

    <p>0 = Normal healing. 1 = Normal healing with mild bruising or erythema. IV = Pus/purulent discharge. V = Deep or severe wound infection with or without tissue breakdown.</p> Signup and view all the answers

    What is the best route for enteral nutrition?

    <p>Oral</p> Signup and view all the answers

    A Nasojejunal tube is inserted into the stomach.

    <p>False</p> Signup and view all the answers

    What is the best position for inserting a Ryles tube?

    <p>Sitting with neck slightly flexed</p> Signup and view all the answers

    The Ryles tube is used for feeding or __________ stomach contents.

    <p>draining</p> Signup and view all the answers

    Match the types of feeding tubes with their primary functionalities:

    <p>Feeding gastrostomy = Inserted into the stomach Feeding jejunostomy = Inserted into the jejunum Ryles tube = Feeding or draining stomach contents Nasojejunal tube = Bypasses the stomach</p> Signup and view all the answers

    What is the optimum temperature range for the operating theater (OT)?

    <p>18-22°C</p> Signup and view all the answers

    Relative humidity in the operating theater should be maintained between 40-50%.

    <p>False</p> Signup and view all the answers

    What is the purpose of a Bair hugger in the operating theater?

    <p>To prevent hypothermia.</p> Signup and view all the answers

    The laminar airflow system in the operating theater requires _____ fresh air changes per hour.

    <p>4</p> Signup and view all the answers

    Match the following OT parameters with their correct values:

    <p>HEPA filter efficiency = 90% Optimum temperature = 18-22°C Relative humidity = 50-60% Fresh air changes/hour = 4</p> Signup and view all the answers

    Which of the following is NOT a criterion for patient discharge after surgery?

    <p>Ability to perform a complex math problem</p> Signup and view all the answers

    Patients are allowed to eat solid foods up to 6 hours prior to surgery according to the ERAS protocol.

    <p>True</p> Signup and view all the answers

    Name two medications that can be considered preoperatively for pain control.

    <p>acetaminophen, pregabalin</p> Signup and view all the answers

    Patients should be able to ambulate within ______ hours post-surgery.

    <p>24</p> Signup and view all the answers

    Match the drug to its appropriate use:

    <p>Toradol = Postoperative pain management Liposomal bupivacaine = Long-acting local anesthetic NSAIDs = Regular pain relief post-surgery Opioids = Breakthrough pain relief</p> Signup and view all the answers

    What is the maximum blood pressure allowed before proceeding with surgery?

    <p>180/100</p> Signup and view all the answers

    Patients with a HbA1C level greater than 8.5 are advised to skip their morning dose of oral hypoglycemic agents.

    <p>True</p> Signup and view all the answers

    What is the time frame referred to as reactionary haemorrhage after surgery?

    <p>4 to 24 hours</p> Signup and view all the answers

    The anaesthesia method used is known as TIVA, which stands for __________.

    <p>Total intravenous anaesthesia</p> Signup and view all the answers

    Match the types of post-operative haemorrhage with their respective definitions:

    <p>Primary = During surgery Reactionary = 4 to 24 hours after surgery Secondary = Few days after surgery due to infection</p> Signup and view all the answers

    Which of the following is considered a better indicator of nutritional status than low albumin?

    <p>S. pre-albumin</p> Signup and view all the answers

    A significant weight loss is defined as an unintentional weight loss of over 5% of total body weight in 6 months.

    <p>False</p> Signup and view all the answers

    What does a low albumin level indicate in patients?

    <p>Poor outcome</p> Signup and view all the answers

    Unintentional weight loss of more than __________ of body weight in 6 months indicates poor prognosis.

    <p>10%</p> Signup and view all the answers

    Match the following indicators with their descriptions:

    <p>Low albumin = Indicator of poor outcome S. pre-albumin = Better marker than low albumin Significant weight loss = Unintentional weight loss &gt;10% in 6 months BMI = Body Mass Index assessment</p> Signup and view all the answers

    Which of the following statements about the Stamm Peridrain is true?

    <p>It has a high risk of aspiration.</p> Signup and view all the answers

    The Witzel Peridrain has a higher risk of aspiration compared to the Stamm Peridrain.

    <p>False</p> Signup and view all the answers

    What is the first step in the PEG procedure?

    <p>Stab incision</p> Signup and view all the answers

    The __________ string suture is used in the PEG procedure.

    <p>purse</p> Signup and view all the answers

    Match the feeding tubes with their characteristics:

    <p>Red Robinson tube = High risk of aspiration Witzel Peridrain = Lower peridrain leakage Percutaneous endoscopic gastrostomy (PEG) = Stab incision and purse string suture</p> Signup and view all the answers

    What is the minimum duration for handwashing to prevent wound infection?

    <p>3 minutes</p> Signup and view all the answers

    Shaving hair before surgery is recommended as it reduces the risk of surgical site infections.

    <p>False</p> Signup and view all the answers

    List the first step of the Five Moments of Hand Hygiene.

    <p>Before touching a patient.</p> Signup and view all the answers

    Prophylactic antibiotics should be administered ________ minutes before surgery.

    <p>30-60</p> Signup and view all the answers

    Match the cleaning direction with the body part:

    <p>Abdomen = Medial to lateral Thigh = Lateral to medial Limbs = Until one joint up Female patient = From inframammary crease to mid-thigh</p> Signup and view all the answers

    Which of the following is the recommended sterilizing agent before surgery?

    <p>Chlorhexidine + alcohol then betadine</p> Signup and view all the answers

    What is the role of prophylactic antibiotics in clean wounds?

    <p>Only when an implant or mesh is used</p> Signup and view all the answers

    Cleaning the incision site should be done last when preparing for surgery.

    <p>False</p> Signup and view all the answers

    How frequently should the dose of prophylactic antibiotics be repeated in prolonged surgeries?

    <p>Every 4 hours</p> Signup and view all the answers

    Contaminated wounds require antibiotics to be given during and after surgery.

    <p>True</p> Signup and view all the answers

    What is the antibiotic prophylaxis percentage for clean contaminated wounds without antibiotics?

    <p>6-9%</p> Signup and view all the answers

    A dirty wound can result from neglected traumatic wounds that are older than __________ hours.

    <p>6</p> Signup and view all the answers

    Match the type of wound to its corresponding features:

    <p>Clean Wound = No role of prophylactic antibiotics, except with implants Contaminated Wound = 6% infection with antibiotics, 20% without Clean Contaminated Wound = 3% infection with antibiotics, 6-9% without Dirty Wound = 7-8% infection with antibiotics, 20-40% without</p> Signup and view all the answers

    Study Notes

    Day Care Surgery

    • Patients are admitted and discharged within 12 hours.
    • Examples of procedures include:
      • Abdominal: Anal lesions excision, hemorrhoidectomy, hernia repair, laparoscopic cholecystectomy, fundoplication, pilonidal sinus surgery
      • Breast: Excision/biopsy of lesions, sentinel node excision
      • Genitourinary: Laser prostatectomy, orchidectomy, circumcision, hydrocele/varicocele/epididymis excision, TURP, Dupuytren's fasciotomy, carpal tunnel release
      • Orthopedic: Therapeutic knee/shoulder arthroscopy, bunion operations, metalwork removal
      • Vascular: Varicose vein procedures, thoracoscopic sympathectomy
    • Patient selection criteria includes:
      • Medical: ASA status I & II for stand-alone day care, ASA status III for integrated day care, BMI ≤38 for laparoscopic procedures, BMI ≤40 for surface procedures.
      • Social: Responsible adult care availability for 24 hours, suitable home conditions, ability to contact hospital in an emergency.
      • Surgical: Operations up to 2 hours, ability to eat and drink within a reasonable timescale.
    • Surgery scheduling prioritizes stand-alone day care cases for comorbid patients and day care cases in a mixed list.
    • Anesthesia commonly used for day care surgery is TIVA (Total intravenous anesthesia) using Propofol.
    • Analgesia often includes infiltration of Bupivacaine.

    Surgical Site Infection (SSI)/Wound Infection

    • Wound infection occurs within 30 days of surgery or within one year of implant placement.
    • Types:
      • Superficial: Above fascia
      • Deep: Below fascia
      • Organ Space: Collection in organ/cavity
    • Asepsis Score criteria includes:
      • Serous discharge
      • Erythema
      • Purulent exudate
      • Separation of deep tissues
      • Isolation of bacteria from the wound
      • Prolonged inpatient stay due to wound infection
    • Risk factors for SSI:
      • Extremities of age: Neonates, older adults
      • Recent surgery: Especially chest/abdomen
      • Coexisting infection: Remote to surgical site
      • Diabetes mellitus
      • Corticosteroid therapy
      • Hypocholesterolemia
      • Obesity
      • Malnutrition
      • Chronic inflammation
      • Prior site irradiation
      • Hypothermia
      • Hypoxemia
    • Southampton wound score:
      • 0: Normal healing
      • 1: Normal healing with mild bruising or erythema
      • II: Erythema plus other signs of inflammation
      • III: Clear or haemoserous discharge
      • IV: Pus/purulent discharge
      • V: Deep or severe wound infection with or without tissue breakdown

    Enteral Nutrition

    • Best route: Oral
    • Duration of requirement: 3 weeks for poor gastric emptying
    • Types of tubes: Nasogastric and Nasojejunal
    • Nasogastric tube examples: Ryles tube
    • Nasojejunal tube bypasses the stomach
    • Feeding tube types: Gastrostomy and Jejunostomy
    • Feeding gastrostomy categories: Stamm and Witzel
    • Feeding jejunostomy categories: Stamm and Witzel

    General Surgery OT Parameters

    • Ultra-clean laminar air flow with HEPA filters (90% efficient for particles >0.5 mm)
    • Temperature: 18-22°C
    • Avoid hypothermia
    • Relative humidity: 50-60%
    • Laminar airflow: 4 fresh air changes/hour from clean to dirty area
    • Positive pressure inside the OT
    • Prevent hyperglycemia
    • Ensure proper hemostasis
    • Administer O₂ in the immediate postoperative period

    Discharge Criteria

    • Stable vital signs for at least 1 hour
    • Oriented to time, place, and person
    • Adequate pain control with oral analgesia
    • Understanding of how to use oral analgesia
    • Ability to dress and walk appropriately
    • Minimal nausea, vomiting, or dizziness
    • Intake of oral fluids
    • Minimal bleeding or wound drainage
    • Passing urine (if appropriate)
    • Responsible adult available to take them home
    • Written and verbal instructions given about postoperative care
    • Knowledge of when to come back for follow-up (if appropriate)
    • Emergency contact number supplied

    ERAS Protocol (Enhanced Recovery after Sx)

    • Preoperative:
      • Patient counseling and expectations
      • Avoid mechanical bowel preparation
      • Solids up to 6 hours prior to surgery
      • Carbohydrate loading 2 to 3 hours before surgery
      • Clear liquids up to 2 hours prior to surgery
      • Consider acetaminophen, pregabalin, gabapentin, or celecoxib prior to surgery
    • Intraoperative:
      • Minimally invasive surgical approach
      • Local anesthetic or long-acting local (liposomal bupivacaine)
      • Keep patient warm
      • IV fluid maintenance
      • Prophylaxis for nausea and vomiting
      • Toradol (if appropriate)
    • Postoperative:
      • NSAIDs, acetaminophen, gabapentin
      • Opioids only for breakthrough pain
      • Regular diet within 24 hours
      • Discontinue IV fluids within 24 hours
      • Ambulate within 24 hours

    Surgical Nutrition

    • Nutritional Assessment:
      • No single reliable biochemical marker to identify malnutrition
      • Low albumin: Indicator of poor outcome
      • Pre-albumin: Better marker
      • Significant weight loss: Unintentional weight loss >10% in 6 months, indicator of poor prognosis
      • BMI

    Prevention of Wound Infection

    • Hand Hygiene:
      • Most important factor
      • Minimum handwash duration: 3 minutes
      • Use soap and water or alcohol-based hand rub
      • Perform hand hygiene after toilet visits and when hands are visibly soiled
      • 5 Moments of Hand Hygiene:
        • Before touching a patient
        • Before a clean/aseptic procedure
        • After exposure to body fluids
        • After touching a patient
        • After touching the patient's surroundings
    • Part Preparation:
      • Removing hair before surgery using a hair clipper
      • Shaving is not recommended due to risks of microabrasions and SSI
    • Cleaning of the Body Part:
      • Sterilizing agent: Chlorhexidine + alcohol then betadine
      • Cleaning areas:
        • Abdomen: Cleaned medial to lateral
        • Thigh: Cleaned lateral to medial
        • Limbs: Cleaned until one joint up
      • Allow the area to dry completely after cleaning.
      • Important Considerations:
        • Always clean the incision site first, then move outwards
        • Female patient: Clean from the inframammary crease to the mid-thigh
        • Male patient: Clean from the nipple to the mid-thigh
    • Prophylactic Antibiotics:
      • Best time to administer: 30-60 minutes before surgery
      • In prolonged surgeries: Repeat the dose every 4 hours

    Types of Wounds and Surgical Procedures

    • I: Clean Wound:
      • Clean incised wound examples: Thyroid surgery, breast surgery, CABG, knee replacement, uncomplicated inguinal hernia surgery
      • No role of prophylactic antibiotics except when an implant or mesh is used.
    • II: Clean Contaminated Wounds:
      • GI/GU system procedures (with no inflammation): Elective/interval cholecystectomy, elective appendectomy, urinary stone removal (no UTI), LSCS, laparoscopic abdominal hysterectomy, bowel surgery (with enema or Peglec preparation)
      • GI/GU system (non-purulent inflammation)
      • Antibiotic prophylaxis percentage: 3% with antibiotics, 6-9% without.
    • III: Contaminated Wounds:
      • Emergency cholecystectomy, emergency appendectomy, bowel opened during surgery for intestinal obstruction, open cardiac massage, pus present (abscesses, peritonitis, neglected traumatic wounds >6 hours)
      • Antibiotic prophylaxis percentage: 6% with antibiotics, 20% without.
      • Antibiotics should be continued.
    • IV: Dirty Wound:
      • All abscesses, peritonitis, neglected traumatic wounds >6 hours (with/without fecal contamination)
      • Antibiotic prophylaxis percentage: 7-8% with antibiotics, 20-40% without.
    • Golden Period:
      • Traumatic wound: 6 hours
      • Trauma: 1 hour following trauma
      • Decisive period: 4 hours (Time between skin incision and bacterial colonization)
    • In an elective operating room (OT) list, clean cases are scheduled first.

    General Surgery

    • Percutaneous endoscopic gastrostomy (PEG) procedure description:
      • Stab incision
      • Purse string suture
    • Two types of feeding tubes: Stamm and Witzel.
    • Stamm peridrain leakage risk is high, while Witzel peridrain leakage is lower.
    • Both are considered more physiological gastrostomies.
    • Image shows diagrams illustrating the placement of tubes and endoscopic images of the procedure.
    • The Red Robinson tube is a type of Nasogastric tube.
    • The Ryles tube, a type of nasogastric tube, is used for feeding or draining stomach contents.
    • It is inserted through the nose and extends to the stomach.
    • The best position for insertion is sitting with the neck slightly flexed.
    • Placement is assessed by aspirating gastric contents and pushing air while auscultating in the epigastrium.
    • The nasojejunal tube is inserted into the jejunum, bypassing the stomach, under fluoroscopic guidance.
    • Placement is assessed using a similar method as for the Ryles tube.

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    Description

    Explore the key aspects of day care surgery including various procedures and patient selection criteria. This quiz covers abdominal, breast, genitourinary, orthopedic, and vascular procedures. Understand the medical and social considerations for day care admissions.

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