EMS 2 Quiz

ESM I Week 2 Objectives

• ESM7: Describes the mechanism of aseptic technique, including disinfection, sterilization, instrument/surgical packs, scrubbing and gowning, skin preparation, and surgical asepsis rules.
• ESM8: Describes the physiologic effect of surgical procedures on blood and hemostasis, and wound healing.
• ESM9: Discusses risk factors, pathophysiology, diagnosis, and initial management for postoperative complications such as emboli (DVT, fat, and air embolism).
• ESM10: Recognizes common postoperative infections, including microbial causes, typical onset times, preventative measures, and initial treatment options.

Surgical Patient Approach

• Pre-op Management: Discussed last week
• OR Prep: ESM 7
• Surgical Operation: Performed throughout the course
• Wounds: Post-operative recovery & complications
• Disposition: Throughout the course
• Documentation: Multiple notes throughout the surgical process (EENT Week 1)

OR Prep (ESM 7)

• Sterilization: Uses saturated steam under pressure (autoclave), is relatively inexpensive and nontoxic, and can be prepackaged or made.
• Reprocessing Steps: Includes storing, sorting, sterilization, packing, and inspection of instruments.

Scrubbing and Gowning

• Essential for perioperative practice
• Includes scrubbing 101, gowning and gloving, and self-gowning technique
• Key Step Details:
  • Keep nails short and pay attention to them when washing your hands
  • Don't wear artificial nails or nail polish
  • Remove all jewelry before entering the operating theatre.
  • Wash hands and arms with a non-medicated soap or, if visibly soiled.
  • Clean subungual areas with a nail file. Nailbrushes are not used, as they damage skin and encourage shedding of cells. Use only if necessary and should be sterile, once only (single use)
• Essential steps for scrubbing include:
  • Properly scrub all sides of fingers, between fingers, the back and front of the hands for 2 minutes.
  • Move to scrubbing arms, keeping hands above elbows to prevent recontamination.
  • Wash each arm (wrist to elbow) for 1 minute.
  • Repeat the process on the opposite hand and arm, extending the scrub time by an additional minute for any areas the hand touches after the initial scrub.

Skin Preparation of the Patient

• The skin is cleaned using sterile technique.
• Apply Betadine in circular motions, starting from the center and working outwards.
• Drape the area.

Rules of Surgical Asepsis

• Goal: Maintain the sterile field.
• If contact with unsterile objects, discard or re-sterilize the objects.
• If questionable sterility, assume it is unsterile
• Never turn your back on the sterile field.
• Keep sterile gloved hands in view (above the waist and below the neckline).

Sterility Conclusion

• Know how to scrub in
• Watch gowning and gloving videos
• Know skin prep steps
• Know how to maintain surgical asepsis

Perform the Procedure

• Follow instructions of the surgeon and OR team

Wound Closure (ESM 8)

• Analgesia: Uses lidocaine (max 3mg/kg), with epinephrine (max 7mg/kg). Important to not administer epinephrine in or near appendages.
• Clinical Wound Management: Includes hemostasis, wound closure, and wound dressing.
• Hemostasis: process that stops bleeding. In most wounds, hemostasis is spontaneous; however, significant injury or lacerations may need intervention to reduce bleeding, and aid in hemostasis
• Wound Healing: Describes primary, secondary, and tertiary healing.
• Primary Wound Closure: Detailed steps for closing deep layers with nonabsorbable sutures, subcutaneous tissues with absorbable sutures, approximating skin edges using methods like dermal sutures, or staples, reinforcing with skin tapes, and dressing the wound.

Sutures

• Ideal suture material is flexible, strong, easily tied, and securely knotted.
• Minimize tissue reaction and avoid serving as a nidus for infection
• Pick the smallest suture needed—to hold wound layers in approximation

Suture - Read the Packaging

• Type of Suture: Absorbable vs non-absorbable, braided vs monofilament
• Size of Suture: 3-0 is smaller than 2-0
• Type of Needle: Tapered vs cutting

Suture Material

• Non-absorbable Sutures: Not dissolved by body, must be removed, less scarring (faster removal time), primarily used on skin.
• Absorbable Sutures: Dissolved by body, no need removal, best suited for under-skin use; warns of increased scarring potential if non-removed.
• Braided Sutures: Twisted strands, easier to tie, risk of bacterial harboring from gaps.
• Non-braided/Monofilament Sutures: Single strand, reduces infection risk, frequently used in skin closure and infection-prone wounds

Suture Size

• Uses specific suture sizes based on areas of the body, ranging from fine ophthalmologic and microsurgeries to larger areas like abdominal walls, arterial lines, and orthopaedic procedures.

Types of Needles (page 26)

• Cutting: Preferred for skin
• Tapered/Round: Used on delicate tissues inside the body
• Double-armed: Used at both ends of the suture

Wound Dressings

• Purpose: Provide an ideal wound healing environment
• Functions; Covering to prevent further damage; Compression to provide homeostasis and limit edema; Control hydration/oxygen tension
• Allows for gas and water vapor transfer; Promotes dermal collagen synthesis and epithelial cells migration; Minimizes tissue desiccation
• Contraindicated in infected or highly exudative wounds
• Types: Primary, secondary, nonadherent (paraffin, petroleum jelly, etc.), occlusive/semi-occlusive (waterproof & impervous), hydrophilic/hydrophobic (composite dressings), absorbable dressing materials (collagen, gelatin, oxidized cellulose), medicated dressings (drug delivery systems)

Disposition

• Wound care: Frequency of dressing changes; When to shower/avoid baths; Pat dry; Protect the wound for a sufficient amount time to minimize scarring
• Follow-up: Signs and symptoms of infection; Routine check-ups; Urgent concerns
• Work/school excuses

Surgical Complications

• Postoperative Fever; Emboli (DVT, fat, air); Infections (SSI, UTI, Pneumonia, Intravascular catheder Infection, Peritonitis); Bacteremia/Sepsis

Postoperative Fever

• What is a fever?: Temperature above 38°C (100.4°F) and is common after surgery
• The cause is usually a normal physiologic response.
• Differential diagnosis for fever: Surgical site infection, other hospital-related conditions, PNA, drug fever, DVT, etc.

Timing of Fever

• Immediate: Starts during or within hours of surgery
• Acute: Onset within the first week of surgery
• Subacute: Onset within one to four weeks of surgery
• Delayed: Onset more than one month after surgery

Cause Related to Timing and Risk Factors

• Immediate: Medications, blood products, trauma, infections, malignant hyperthermia
• Acute: Nosocomial infections, viral infections, UTI, SSI (Streptococcus, E. coli, Clostridium), and myocardial infarction.
• Subacute: Surgical site infection, central venous catheters, antibiotic-associated diarrhea, febrile drug reactions, and thrombophlebitis
• Delayed: Infection, some SSIs, viral, or parasitic infections
• Risk Factors: preoperative trauma, ASA class above 2, fever onset after the second postoperative day, initial temperature elevation, high postoperative white blood cell count, and high postoperative serum urea nitrogen

Helpful W's Mnemonic

• Waves (POD 0) –acute MI EKG
• Wind (POD 2) – Pneumonia, PE, aspiration, atelectasis
• Water (POD 3)– UTI
• Walking (POD 5 +) – VTE
• Wound (POD 5-7) – SSI, Infection
• Wonder drugs/What did we do? -Drug fever

Postoperative Fever Approach

• Not every patient needs diagnostic testing
• Thorough chart review, history, & physical essential
• Discontinue unnecessary medications & catheters.
• Evaluation of the patient based on history, symptoms, and physical findings.
• Obtain diagnostics guided by your evaluation.

Postoperative Fever Treatment

• Scheduled antipyretics (acetaminophen) for 48 hours for patient comfort.
• Antibiotics generally not indicated early in the postoperative course, only indicated in critically ill or hemodynamically unstable patients; causes must be determined if used. If no cause found after 48 hours, antibiotics should be discontinued.
• Tailored evaluation/management based on the individual patient, with unnecessary medications and catheters discontinued.

Thromboembolism

• Virchow's Triad
• Hypercoagulable state, stasis, and endothelial damage
• Diagnosis: US of Leg, D-dimer
• Treatment: Minor – oral anticoagulants; Extended DVT – can consider tPA infusion
• Prevention: Limit surgical time, SCDs, early mobilization, anticoagulant therapy
• Risk Factors: Trauma, cancer, operations of the pelvis, nonmodifiable (thrombophilia), and modifiable (type of surgery, central lines, HRT)

Fat Embolisms (FES)

• Rare condition, associated with orthopedic trauma
• Presence of fat globules in pulmonary circulation
• Clinical features: hypoxemia, neurologic abnormalities, petechial rash
• Imaging: CT chest, CT/MRI brain (neuro symptoms)
• Treatment: Supportive care
• Prevention: Early immobilization of fractures, limiting intraosseous pressure in orthopedic procedures

Air Embolisms

• Rare complication in cardiac, neurological, and ENT surgeries
• Result: Air entering the vasculature; pressure gradient to the vasculature; and direct communications, air enters the venous circulation; incomplete filtration; air introduced directly into the arterial system; or paradoxical embolization.
• Clinical manifestation: Sudden onset respiratory distress (venous), neurological event (arterial), and/or a known risk factor
• Diagnosis: Imaging, but often retrospective
• Symptoms:
  • Pulmonary: Dyspnea, gasp reflex, sucking sounds
  • Cardiac: Substernal chest pain
  • Neurologic: Sense of doom, dizziness/lightheadedness
  • Skin:
  • Ocular
• Treatment: Supportive therapy (O2, pressor support, positioning); Definitive therapy in some cases (hyperbaric oxygen, HBO therapy, withdrawing air from right atrium), and cardiac massage.

Postoperative Complications Infections

• Surgical Site Infection (SSI): Staphylococcus, Streptococcus, Escherichia, others
• Typical time of onset within 30 days
• Preventative measures: Strict aseptic technique during surgery
• Initial treatment: Antibiotics specific to suspected pathogen
• Urinary Tract Infection (UTI): Escherichia, Klebsiella, Proteus
• Typical time of onset within 7 days
• Preventative measures: maintain catheter hygiene
• Initial treatment: Broad-spectrum antibiotics (based on antibiogram), followed by antibiotics based on urine culture results
• Pneumonia (Hospital Acquired): Staphylococcus, Streptococcus, Gram-negative bacteria
• Typical time of onset 48 hours to a week
• Preventative measures: Early mobilization, respiratory exercises.
• Initial treatment: Empiric IV antibiotics, followed by antibiotics based on culture/sensitivity.
• Intravascular catheter infection: Staphylococcus aureus, Streptococcus, Gram-negative Bacteria (Escherichia coli, Klebsiella)
• Typical time of onset: Any time
• Prevention: Sterile Technique; avoid dirty areas.
• Treatment: Blood culture from catheter, peripheral site; catheter removal and culture (rarely exchange); Empiric antibiotics to be followed up with culture-guided antibiotics.
• Peritonitis: Escherichia coli, Enterococcus, Clostridium(spontaneous or secondary)
  • Spontaneous: Idiopathic
  • Secondary: Intraabdominal infection or irritation (bile, blood, barium, gastric acid, etc.)
  • Typical time of onset: Sudden, symptoms within hours
  • Prevention: Careful surgical techniques
  • Treatment: Intravenous antibiotics; may require surgery.

Bacteremia/Sepsis

• Microbial Causes: Staphylococcus, Escherichia, Klebsiella.
• Typical time of onset: 48 hours-weeks.
• Preventative measures: Strict aseptic technique during central line insertion
• Initial treatment: Broad-spectrum IV antibiotics
• If an infection occurs; it could be traced to the complications previously discussed in the powerpoint. Typically, patients will present with s/s of infection. Check blood cultures, check urine, do additional imaging if needed (ventilator patient)

Questions (page 62)

• There are no questions provided.