PERIOPERATIVE EXAM

10 questions, 10 marks each, 2 pages space

 6 independent questions (6 different topics);

 4 based on scenarios
o Scenario:
 Identify risk
 How do you prepare for that
 Not formal essay writing, can dot point and elaborate.
 Can mind map/use steps in exam (eg: this leads to > this > then this > then this)
 Consider marks, wording, etc for questions before writing.
 10 point question = 5 examples MINIMUM with very good detail

WHAT TO KNOW?
 NSQHS Standards (2ND EDITION)
o MUST BE ABLE TO RELATE EACH STANDARD TO ACTIONS IN THE THEATRE
 WEEK 9 PARU EXAM CONTENT:
o Complications (identify and manage);
o Prioritising care (A-G assessment);
o Handover (ISBAR).
o WEEK 9 workshop similar scenario in exam: assessment (showing prioritisation), potential
complications and interventions (preventative and management).
 PATIENT RISKS
 SSI  IIH (inadvertent intraoperative
 pain hypothermia)
 PONV  airway complications
 VTE/DVT  hypoglycaemia
 haemorrhage/shock
o What causes each?
o How can we limit risks?
 Prevention of VTE's (pharma, mechanical)
 Transfusion management (CHECKS, OBSERVATIONS, REACTIONS)
 Handover

EXAMPLE OF QUESTIONS AND HOW TO ANSWER THEM

Q: Identify (=list AND discuss) the complications associated with minimally invasive surgery.

A:

 Risk factors  Damage to structures

 Infection  Equipment failure
 Blood loss  Referred pain with lap surg.
 Prolonged surgery

Q: Discuss your interventions to address the complications identified in the previous Q.

A:

 Pre-emptive AND Treatment interventions.

 Week 1 – Introduction to Perioperative

SETTINGS PHASES
 Procedural  Preoperative
 Interventional o Day of surgery admission (DOSA)
 Day surgery/ambulatory surgery centre
 Emergency or elective theatres  Anaesthesia
o Holding bay or anaesthetic bay
 Intraoperative
o Operating theatre or procedural room
 Post Anaesthesia Care Unit (PACU)

PERSONNEL
 Preadmission nurse
o ROLE
 Assessment
 Physiological
 Psychological
 Medications
 Diagnostic/test results
 Cultural
 Consent
 Fasting
 Special requirements
 Point of contact
 Discharge planning
 Anaesthetic nurse
o ROLE
 Participate in patient identification and other processes outlined in the ‘Surgical Safety
Checklist’
 Advocate for the patient
 Collaborate with and assist the anaesthetist
 Anticipate and provide equipment & supplies
 Assist in maintaining patient airway
 Assess & monitor the patient
 Assess and document fluid balance
 Assist with patient transfer before and after surgery
 Collaborate with PACU staff
 Circulating nurse
o ROLE
 Participate in processes outlined in the SSC
 Advocate for the patient
 Anticipate the needs pf the surgical team before & during surgery
 Monitor breaches in aseptic technique & initiate corrective action
 Perform surgical count with the instrument nurse
 Ensure correct handling and labelling of surgically removed human tissue and explanted
items
 Document intraoperative nursing care & patient outcomes
 Instrument nurse
o ROLE
 Participate in the process outlined in the SSC
 Advocate for the patient
 Prepare instruments & equipment required for surgery
 Anticipate needs of the surgical team prior to & during surgery
 Work directly with surgical team
 Adhere to & maintain aseptic technique throughout the procedure
 Monitor breaches in aseptic technique & initiate corrective action
 Perform surgical count with the circulating nurse
 Ensure correct handling and labelling of surgically removed human tissue and explanted
items
 Document intraoperative nursing care & patient outcomes
 Perioperative surgical nurse assistant (PSNA)
o ROLE
 Undertake physical patient assessment, including medical history, and (in collaboration with
the surgeon) organise clinical investigations
 Collaborate with the patient, surgeon and other healthcare team members to develop a
clinical pathway
 Develop education programs for patients/ staff
 Assist with intraoperative skin preparation, draping, haemostasis, cutting sutures/ ligatures,
retracting organs and skin closure
 Provide postoperative care in wound management, education, & dressing application
 Post anaesthesia care unit (PACU) nurse
o ROLE
 Conduct patient assessments and monitor vital signs
 Perform resuscitation
 Manage patient’s acute pain, nausea & vomiting
 Monitor and manage the patients haemodynamic status
 Document nursing care and patient outcomes
 Respond promptly to and report any changes in patient condition to the anaesthetist and/or
surgeon
 Provide comprehensive clinical patient handover to ward/unit nurse
 Nurse Practitioner
o ROLE
 Undertake a comprehensive health assessment and make decisions using diagnostic
capability
 Order & interpret diagnostic and laboratory tests
 Plan care and engage others, working in partnership with patients, families and communities
 Prescribe and implement therapeutic interventions
 Refer to other healthcare professionals for management outside of NP scope of practice
 Evaluate patient outcomes and improve practice
NATIONAL SAFETY QUALITY HEALTH CARE STANDARDS
S1 CLINICAL GOVERNANCE

 Compliance with policies and protocols  ACTIONS:

 Implementing effective incident management o Acorn Standards
reporting

S2 PARTNERING WITH CONSUMERS

 Patient input through consumer review  ACTIONS:

o Preop and postop education

S3 PREVENTING AND CONTROLLING HEALTHCARE-ASSOCIATED INFECTIONS

 ACTIONS:
o WHO safe surgery checklist o Aseptic techniques
o Antimicrobial stewardship o Surgical conscience
o HH o Gown/Glove
 Surgical scrub o Opening sterile equipment
 5 moments of HH o Acknowledgement of prophylaxis A.B.

S4 MEDICATION SAFETY

 Safe handling of intraoperative medications  ACTIONS:

 Regulations regarding dispensing and o Mostly written orders
preparation  2 person visual and verbal
 Labelling of intraoperative medications checks

S5 COMPREHENSIVE CARE

 Identify anticipated patient risk  ACTIONS:

o Risk assessment o Waterlow assessment
 Preventing and managing pressure injuries o Patient positioning
 VTE prevention o PARU staged recovery

S6 COMMUNICATING FOR SAFETY

 ACTIONS: o TIME OUT

o Pre Op checks o ISBAR clinical handover
 Patient identification and  Nursing and Medical
procedure matching  Ward > OR; OR > PARU; PARU
o Safe surgical checklist > Ward

S7 BLOOD MANAGEMENT

 BloodSafe  ACTIONS:
o Safe administration and patient o TIME OUT
monitoring  Acknowledging anticipated
 ANZCA endorsed blood management loss
guidelines o Procedural checking of blood
products
o Recognition of transfusion-related
adverse events
S8 RECOGNISING AND RESPONDING TO CLINICAL DETERIORATION IN ACUTE HEALTHCARE

 Know the postoperative complications

o Difficult airways
 Cant intubate; cant oxygenate
o Malignant hyperthermia
 Recognising potential for complications

SURGICAL ORGANISATIONS
 Australian College of Operating Room Nurses (ACORN)
 Australian and New Zealand College of Anaesthetists (ANZCA)
 Royal Australasian College of Surgeons (RACS)
 Week 2 – Anaesthesia

DEFINITION
“The condition of having the feeling of pain and other sensations blocked, allowing patients to undergo
surgery and other procedures without the distress and pain they would experience otherwise.”

Anaesthetic Triad:

1. Unconsciousness (hypnosis)
2. Paraesthesia (Analgesia)
3. Paralysis (Muscle relaxation)

DETERMINANTS
 Patient preference  Patient condition
 Surgeon preference o Anaes hx
 Demands of surgery o Surgical hx
o Site o Airway access
o Access o Pt general wellbeing

AMERICAN SOCIETY OF ANAESTHESIOLOGIST CLASSIFICATION (ASA PHYSICAL STATUS)

ASA Physical Status Classification System

1. A normal healthy patient

2. A patient with mild systemic disease
3. A patient with severe systemic disease
4. A patient with severe systemic disease that is a constant threat to life
5. A moribund patient who is not expected to survive without the operation
6. A declared brain-dead patient whose organs are being removed for donor purposes

MALLAMPATI AIRWAY CLASSIFICATION SYSTEM

1. Soft palate, fauces, uvula, pillars entire

glottic opening.
2. Soft palate, fauces, uvula, posterior
commissure.
3. Soft palate, uvular base, tip of epiglottis.
4. Hard palate only, no glottal structures.
TYPES OF ANAESTHESIA
LOCAL +/- SEDATION

 Local anaesthetics are drugs that block conduction when applied locally to nerve tissue. The block produced
is entirely reversible.
 ADVANTAGES:  DISADVANTAGES:
o Effective alternative to GA o Limited scope
o Avoids polypharmacy o Higher failure rate
o Allergic reactions o Time constraints
o Extended analgesia o Anticoagulants/bleeding
o Patient can remain awake predisposition
o Early drink/feed o Risk of neural injury
 DRUGS:
o Lignocaine - quick/short acting
o Bupivacaine - slow and long action
o Ropivacaine - as above
o Amethocaine – topical spray
o Prilocaine – intravenous
o Cocaine

REGIONAL BLOCK – BRACHIAL PLEXUS; FEMORAL NERVE;

 Loss of sensation to a region of body without loss of consciousness

 Involves blocking a specific nerve or group of nerves with administration of a local anaesthetic agent
 TYPES:
o Central Nerve Blocks
 e.g. spinal, caudal and epidural anaesthesia, where the LA is injected into spinal roots
where they emerge from the spinal canal.
o Peripheral Nerve Blocks where the LA is injected into the vicinity of a nerve trunk
 e.g. brachial plexus block - (Interscalene, infraclavicular or supraclavicular) ,popliteal,
femoral, sciatic)
 SURGERIES:
o Abdominal, pelvic & lower limb surgery.

Epidural Spinal – below diaphragm

 Extradural;  Intradural;
 Fat, blood vessels, nerve fibre endings;  CSF;
 15-20mls + infusion;  Single shot;
 2-4hrs + 2-3 days;  3-5mls;
 Sensory not motor;  2-4hrs;
 Patchy – dermatomes;  Motor & sensory;
 Peripheral vasodilation
o = VR = CO = BP.
GENERAL

 Drug induced loss of consciousness during which patients are nonresponsive, even to painful stimulation.
 REQUIRES:  BENEFITS:
o IV access o No absolute contraindications;
o Oxygen o Quick to establish;
o Airway o Never fails to work;
o Breathing spontaneous; o Often the only option available for
Or major operations;
o Paralysed & ventilated. o Can provide the best operating
conditions for the surgeon;
o The patient is completely
 COMPLICATIONS:
o Polypharmacy;
 the more drugs administered to a patient the greater risk of antagonist or synergistic effects;
metabolism & excretion – hepatic & renal systems.
o Effects on various systems;
o Allergic reactions;
 prolonged apnoea; malignant hyperthermia;
o Recovery profile;
 thiopentone vs propofol.
o PONV;
o 'Awareness' during surgery
 PHASES:
o INDUCTION
 Intravenous- majority
 Propofol (diprivan); Thiopentone (sodium pentothal); Fentanyl
 Inhalational- children, needle phobics
 Sevoflurane; Desflurane; Isoflurane
 Monitoring
 Preoxygenation
 Hypnotic/analgesic and or relaxant
 Mask/LMA/ET tube
o MAINTENANCE
 Intravenous or inhalational
 Oxygen – 40%-100%
 Nitrous oxide
 Muscle relaxant
 Analgesia
o REVERSAL
 Recovery Profile
 Turn off agent
 Reverse relaxation
 Cough reflex
 Extubate when awake
 Recovery position
 Monitor until discharge
o RECOVERY
  ADJUNCT DRUGS:
o Drugs added to an inhalation anaesthetic (other than an IV induction agent) to achieve
unconsciousness, analgesia, amnesia, muscle relaxation or autonomic nervous system control .
 opioids
 benzodiazepines
 neuromuscular blocking agents (muscle relaxants)
 antiemetics

DISSOCIATIVE ANAESTHESIA

 Interrupts associative brain pathways while blocking sensory pathways bringing about;
o Amnesia, profound analgesia extending into the postoperative period & can have a catatonic effect
o Ketamine is the most common, however can cause hallucinations & nightmares
 It is used in asthmatic patients undergoing surgery because it promotes bronchodilation, and in trauma
patients requiring surgery because it increases heart rate and helps maintain cardiac output.
NEUROMUSCULAR JUNCTION
WHAT HAPPENS:

 One motor neuron (nerve cell) may stimulate a few or many skeletal muscle cells depending upon site. Nerve
impulses follow paths to nerve axon terminals;
 Axon terminals release a neurotransmitter, called acetylcholine.
 Acetylcholine is released to jump across the synaptic cleft & bind with receptors to stimulate the skeletal
muscle at the motor end plate and continue the nerve impulse;
 Acetylcholine changes the permeability of the cells, temporarily allowing more na+ in and for K+ to diffuse
out. The change results in action potential & once begun is unstoppable, spreading widely over the cell
surface resulting in depolarisation of the cell and muscle cell contraction.

CHOLINESTERASE

 Cholinesterase’s are naturally produced enzymes.

 Acetylcholinesterase is the primary cholinesterase in the body and is responsible for breaking down
acetylcholine at the neuromuscular junction. This is essential for continual flow of movement.
 Neostigmine is an Anticholinesterase drug commonly used to reverse non-depolarising neuromuscular
blockade.

NEUROMUSCULAR BLOCKING AGENTS

 DEPOLARISING:
o Suxamethonium
 NON-DEPOLARISING:
o Atracurium
o Cisatracurium
o Mivacurium
o Pancuronium
o Rocuronium
o Vecuronium
RAPID SEQUENCE INDUCTION
 Technique used to secure an airway rapidly to reduce the risk of pulmonary aspiration of the stomach
contents.
 Involves applying cricoid pressure (Sellick’s manoeuvre)

PATIENTS AT RISK:

 unknown fasting status

 pregnancy
 hiatus hernia
 bowel obstruction gastrointestinal bleeding
 gastric reflux
 trauma

REQUIREMENTS:

 Good IV access
 O2
 Suction
 Introducer, loaded through an endotracheal tube
 Air syringe
 2 working laryngoscopes (possibly a C-MAC)
 Stethoscope
 Trachy tape (or alternative method to secure ETT)
 Monitoring
o NIBP; PSaO2; ECG; ETCO2

STEPS:

 Pre-oxygenation 100% O2 - 3 mins

 Thiopentone followed in rapid sequence by suxamethonium (succinylcholine)
 Rocuronium (reversed by Sugammadex if required)
 Cricoid pressure applied
 Fasciculations
 Laryngoscopy and intubation
 ETT cuff inflated, test ventilation; check for ETCO2
 Confirm position – stethoscope
o apex x2, base x2 & over stomach.
 ETT secured
 Cricoid pressure released – seek permission first.

DRUGS USED:

 Suxamethonium
o depolarising neuromuscular blocker; ultra-quick acting = 1 circulation time; short duration 3-5 mins;
o Can contribute to malignant hyperthermia.
 ALTERNATIIVE^: Rocuronium
o non-depolarising neuromuscular blocker; 60 sec onset;
o Reversable with Sugammadex
 Thiopentone
o quick acting barbiturate induction agent
CATASTROPHIC EVENTS
CICO (Cant Intubate, Cant Oxygenate)

 Occurs when an obstruction exists in the upper airway that cannot be overcome by routine airway
management techniques such as use of LMA or ETTT
 CAUSES:
o Congenital abnormalities
o Trauma to the head, neck and cervical spine
o Tumours in mouth
 TREATMENT OPTIONS:
o Different sizes and designs of laryngoscopes
o Intubating LMA’s
o Video laryngoscopes
o Reversal of neuromuscular blocking agent to facilitate alternative airway management options.
 Sugammadex = reversal agent
o Crycothyroidotomoy/tracheostomy last option

TOTAL SPINAL BLOCKADE

 A complication that follows inadvertent introduction of local anaesthetics into the intracranial subarachnoid
space. It has been reported during attempted interscalene, epidural, and spinal blocks.
 SYMPTOMS:
o Dyspnoea
o Numbness or weakness in the upper extremities
o Nausea
o Bradycardia

ASPIRATION

 A patient’s airway reflexes are depressed by general anaesthesia, which increases the risk of aspiration of
gastric contents into the lungs.
 Vomiting and regurgitation when the airway is unprotected can lead to bronchospasm, hypoxaemia,
atelectasis, tachypnoea, tachycardia and hypotension.
 TREATMENT OPTIONS:
o Rapid Sequence Induction
o Difficult airway trolley (similar procedure to CICO treatment options)

ANAPHYLACTIC REACTIONS

 Most severe form of an allergic reaction, manifesting with life-threatening pulmonary and circulatory
complications.
 Manifestation may be masked by anaesthesia.
 Vigilance and rapid intervention are essential.
 SYMPTOMS:
o Hypotension
o Tachycardia
o Bronchospasm
o Pulmonary oedema
 Antibiotics and latex main instigators
 TREATMENT OPTIONS:
o If causative agent is known, stopping administration immediately.
o Administering 100% oxygen while maintaining the airway
o Ceasing all anaesthetic drugs
o Commencing fluid replacement with colloid or crystalloid
o Treating bronchospasm with salbutamol
o Administering adrenaline – bolus IV
MALIGNANT HYPERTHERMIA

 Is a rare life-threatening condition that is triggered by exposure to all volatile anaesthetics and the
neuromuscular blocking agent succinylcholine.
o Can induce a drastic and uncontrolled increase in skeletal muscle oxidative metabolism, which
overwhelms the body's capacity to supply oxygen, remove carbon dioxide, and regulate body
temperature, eventually leading to circulatory collapse and death if not treated quickly.
 SYMPTOMS:
o Tachycardia
o Tachypnoea
o Hypercarbia
o Ventricular arrhythmias
o Rise in body temperature NOT an early sign.
 Can result in cardiac arrest and death
 TREATMET OPTIONS:
o Dantrolene sodium via injection
 Only effective treatment for MH and functions by inhibiting calcium uptake.

MINOR EVENTS
POST OPERATIVE NAUSEA AND VOMITING (PONV)

 Nausea and/or vomiting or retching in the post-anaesthesia care unit (PACU) and in the immediate 24
postoperative hours.
 CAUSES:
o Side effect of anaesthesia.
 TREATMENT OPTIONS:
o PREVENTION
 Avoiding hypotension
 Giving high concentrations of oxygen
 Treating pain
 Avoiding sudden movement
o DURING SYMPTOMS
 Antiemetics
 Oxygenate
 Left lateral position (if semi/full-unconscious patient)

AWARENESS

 A potential complication occurring during general anaesthesia where the intended state of complete
unconsciousness is not maintained throughout the whole procedure.
 CAUSES:
o Failure to deliver sufficient anaesthetic medication to the patient
o Individual patient factors that mean the patient is resistant to what would normally be an adequate
dose of anaesthetic medication
 PREVENTION:
o Careful checking of drugs, doses and equipment
o Good monitoring, and careful vigilance during the case
 EEG monitoring

NERVE INJURY

 Nerve injury most often occurs from ischemia, compression, direct neurotoxicity, or needle laceration, and
inflammation.
 TREATMENT OPTIONS:
o Physiotherapy and exercise
o Analgesics (is pain is present)
ROLE OF THE ANAESTHETIC NURSE
 Primary role is checking anaesthetic equipment & supplies and supporting the anaesthetist
o Anaesthetic machine
 Gas supplies
 Ventilator function
 Suction & scavenging systems
 Inhalational agents
 Anaesthetic circuit
 CO2 absorber (soda lime)
 Gas analyser (ETCO2)
 Monitoring (BP; PSaO2; ECG)

LARYNGEAL MASK INTUBATION ENDOTRACHEAL TUBE INTUBATION

***LEFT OUT DRUG DESCRIPTIONS ON TUT SLIDES FROM SLIDE 11 ON***

 Week 3 – General Surgery

STAGES OF WOUND HEALING

INFLAMMATORY

 Begins with surgical incision or injury

 Continues for 4 – 5 days
 Classic signs of inflammation
 Increased blood supply to tissue
 Leukocytes and other cells dissolve and remove debris
– preparing site of repair phase
 No wound strength – relies on sutures

PROLIFERATIVE

 Starts around day 3

 Fibroblasts form collagen matrix – granulation tissue
o Collagen – protein substance – chief component
of connective tissue
o Will determine the tensile strength (ability to
withstand stress) and pliability of wound
 Fills with new blood vessels – tissue bright beefy red
– lots of nutrients and oxygen brought to site
 Wound contraction occurs – varies depending on site
o Wound contraction – process of bringing wound edges together – reduces the open area and
hopefully reduces scarring. Surgical wounds have minimal contraction response. Sometimes grafting
is used to reduce contraction in undesirable places and large open wounds eg wide excisions on face
where scarring would disfigure

REMODELLING OR MATURATION

 Starts approx. 21 days and can last up to 1 year

 Collagen production continues and is thicker,
providing added tensile strength
 Excess collagen is eventually reabsorbed, and scar looks pale
 Suture line contracts and whole scar is remodelled
 Final scar dependent on initial granulation tissue
TYPES OF WOUND HEALING
PRIMARY

 Clean incision
 Surgical incision is best example
 Wound approximated with sutures/clips or steri strips
 Minimal scarring

SECONDARY

 Wound breakdown caused by infection, poor suture technique

 Traumatic wound, tissue loss ++ or pressure ulcer
 Wound often left open
 Granulation from inner layers outward occurs
 Slow process
 Scarring ++ - poor cosmetic effect

DELAYED PRIMARY

 Considered the safest way to treat contaminated, infected, traumatic wounds where tissue loss is great
 Debridement of non-viable tissue
 Wound left open and packed/VAC dressings etc
 May be left to heal by 20 intention
OR
 When no further evidence of infection – wound can be approximated with sutures or steri strips
FACTORS AFFECTING WOUND HEALING
TYPE OF WOUND – clean vs dirty

 Clean wound deliberately made with scalpel will obviously heal quicker with less complications
 Traumatic injury which has been contaminated at scene of accident is likely to heal more slowly – may be
skin loss requiring grafting or leaving open to heal by delayed primary closure

INFECTION

 Will delay healing considerably, may require further surgery, debridement antibiotics etc

CO MORBIDITIES

 poor blood supply

o decreased amount of oxygen and nutrients getting to the tissues
o (poor supply > infection > necrosis > gangrene)
 diabetes
o large amounts of sugar in the blood can provide a nice medium for bugs to grow
o poorly controlled diabetics often have PVD and peripheral neuropathy which diminishes sensation
and can lead to injury without pt being aware
 malignancy
o poor immunological state of patients make them susceptible to infection, often poorly nourished
 renal disease
o if on steroids for chronic disease this can inhibit formation of granulation tissue and reduce anti-
inflammatory response

NUTRITION

 Vit C essential for collagen synthesis – part of wound healing process

 Vit K and Zinc important for wound healing
 Anaemia
 Chronic alcoholics, pts with ca are often poorly nourished
 Obese patients present technical problems, increased risk of wound dehiscence and if incision in large skin
folds this presents a moist, warm environment for bugs eg Pfannenstiel

OLD AGE

 Combination of all the above issues

 Old age isn’t a huge problem on its own, it is the disease processes which go along with getting older.
 Skin loses its elasticity, poorly nourished

DEAD SPACE

 Cavity that remains after a surgical procedure which if not drained or closed effectively can become focus for
collection of air, serous fluid, blood.
o Especially in fatty layer which doesn’t have a good blood supply.
 Can cause haematomas, lead to infection if collection not drained.
 Careful suturing and use of drains or pressure dressings can avoid this occurring
CHOICE OF INCISION
EXPOSURE

 Surgeon needs maximum exposure of area being operated on.

o What organ/tissue is being operated on.
o Position of patient must be taken into account when planning incision to ensure that max exposure
is produced

POST OP STRENGTH

 Properly planned and executed incision should result in strong, intact abdo wall
 Para rectus abandoned due to problems with wound breakdown
 McBurney’s incision considered one of the strongest due to criss-cross arrangement of muscle fibres.
o Transverse seen as strongest due to way muscles arranged causing a lateral pull away from midline,
thus holding incision closed, however many of these do not allow for extension of incision in the way
in which longitudinal incisions do

RAPID ACCESS

 In emergency abdo procedure midline through linea alba often best choice
o It provides good access to whole abdo, it can be extended if required and midline incision can be
made through the relatively bloodless linea alba, so blood loss in an already compromised pt is less

BODY BUILD

 Some surgeons may choose vertical incision in skinny patients and transverse in larger patients
o eg Kocher’s incision for open cholecystectomy.

OTHER STRUCTURES

 Scars, drains, sinuses, colostomy need to be avoided.

COSMETIC

 Secondary consideration
 Pfannenstiel (Bikini line) and McBurney’s (very small) incisions example of good cosmetic results

SURGEONS PREFERENCE

 How they’ve been trained/experience.

LANGER’S LINES
 Named by anatomy professor, Karl Langer. He first
discovered these by puncturing cadavers with a
round sharp object and noted they formed elliptical
holes due to tension in the skin, thus he put forward
that making surgical incisions around natural creases
would produce less tension.
 Incisions made parallel to these lines tend to heal better
with minimal scarring, less tension on the wound

MIDLINE INCISION
 Can be made in upper or lower abdomen or extended from
xiphoid process to above symphysis pubis.
 Advantages
o Used for rapid entry into abdomen (linea alba)
o Can be extended easily if started in upper abdo
o Relatively quick incision as no muscles need to be
cut or split
 Disadvantage
o high incidence of incisional hernia as there are
no muscles to give post op strength to wound
 (PICTURE >) Note the apons fusing in the midline to form linea
alba (white line)
o It is significant in making midline incision in an emergency
due to very few blood vessels in this area.
 Suturing
o Peritoneum and fascia
 Usually sutured together with 0 or 1 PDS/Vicryl
 An absorbable suture.
o No muscle to be sutured with a midline incision, but
important to get a good strong closure to reduce risk of hernia
o Fat
 2/0 or 3/0 Vicryl
o Skin
 3/0 or clips

RETENTION SUTURES
 To give extra strength to midline incisions in obese patients
or those who have had previous incisional hernias – may use
retention sutures of a heavy nylon
o Takes a big bite of all tissue layers down into muscle sheath.
 Skin is protected from sutures cutting into it by the rubber or
plastic ‘bumpers’, ’bolster’ or protectors.
 Usually skin sutures placed between tension sutures.
PFANNENSTIEL INCISION
 Used for gynae and urology surgery
 Incision made just above symphysis pubis
along the pubic hair line
 Advantages
o Good cosmetic effect, strong closure
 Disadvantages
o Cannot be extended, danger of incising
bladder, possible infection in obese patients
o Patients should be catheterised due to danger
of incising the bladder.
 Week 4 – Perioperative Nursing Principles
RISKS OF SURGERY
PATIENT RISKS

 SSI  Premedication  Pressure injury

 Consent  Implants  Hypothermia
 Wrong site surgery  Return body parts  Retained items
 Surgical site marking  Jewellery  Specimen handling
 Allergies/sensitivities  VTE/DVT
 Fasting 2,6,8 hours  Positioning

RISKS OF ANAESTHESIA
PATIENT RISKS

 CICO  Delayed emergence

 Aspiration o Suxamethonium apnoea
 Anaphylaxis  Awareness under anaesthesia
 Malignant hypertension

PERIOPERATIVE MEDICO-LEGAL ISSUES

 Consent  Coroners’ court
 Code of conduct o any death within 24hrs of surgery is
o Duty of care reportable to the NSW State Coroner
 Accountability for investigation.
o Levels of documentation  Specimen collection
 Advocacy o essential for diagnosis. Labelling and
 Scope of practice documentation. Handling so as not to
 Organ transplantation contaminate.
 Sentinel events

CONSENT

Influencing factors:

 Capacity
o >14yrs
o Intellectual capacity
o X mental illness; dementia; intellectual disability; brain damage; influenced by drugs /ETOH
 Freely given
o Not pressured by medical staff or family members
 Specific to treatment or procedure
 Patient to be informed in broad terms in a way easy to understand

NEGLIGENCE

 Incorrect positioning  Incorrect operation/site

o Pressure injury  Medication error
o Nerve palsy  Equipment failure
o Weakness and loss of function o Surgical instruments breaking in
 Retained surgical items patient.
 Lost tissue specimen
o Inability to correctly diagnose
PERIOPERATIVE ATTIRE
 Perioperative attire shall replace all outer garments and shall be worn correctly at all times
o Two piece scrub suits
o Dresses worn with pantyhose
o Boilersuits
 The effectiveness of cover gowns and shoe covers in limiting microbial load and reducing potential surgical
site infection has not been demonstrated.
 Head and facial hair shall be completely covered
o Laundering of personal cloth headwear
 Designated footwear to comply with WH&S standards
o Overshoes debate: gross contamination vs increased microbial counts
 Disposable surgical masks with filtration and eye protection
o High level filtration; fluid repellent
o Completely cover nose & mouth
o Avoid touching once in place
o Removal process
 Fingernails
o Short, clean and free from artificial nails, nail additives and nail polish
 Jewellery
o Minimal and limited to items contained within the perioperative attire
o Body piercings shall be removed or covered
o Bracelets, rings (apart from plain bands), wrist watches…
o Single strand gold or silver chain contained within perioperative attire
o Beads, shells, wood, cotton strands, leather
o Earrings – stud/ sleeper only & confined within perioperative attire

PERIOPERATIVE ENVIRONMENT
RESTRICTED

 Operating theatre and anaesthetic bay

SEMI-RESTRICTED

 Post-anaesthesia recovery unit (PARU)

NON-RESTRICTED

 Reception, admissions, holding bay and

stage 3 recovery.
 Week 5/6 – Perioperative Patient Risks
VENOUS THROMBOEMBOLISM
WHAT IS IT?

 DEEP VENOUS THROMBOSIS (DVT)

o a blood clot (thrombus) that forms in the veins of the legs; thrombus is attached to the vessel wall.
 EMBOLUS
o a blood clot that breaks off from the vessel wall and travels freely throughout the circulation; likely
to become lodged in either pulmonary (PE) or cerebral vessels causing complete obstruction to
blood flow.

RISK FACTORS

 Hospitalization
o Immobility
o Not eating/drinking as usual
 Age
o Risk increased exponentially with age
 Gender
o Access economics (2008) – male
o Assareh (2016) – female
 Ethnicity
o Caucasians & African Americans OVER Hispanic & Pacific Islanders
 Season
o Winter
 Comorbidities
o Malignancies; surgical & medical treatments

INPATIENT FACTORS

 WEAK RISK
o Bed rest >3 days o Lap surgery
o Seated immobility o Obesity
o Age o Varicose veins
 MODERATE RISK
o Central lines o HRT
o Chemotherapy o Malignancy
o Congestive heart/respiratory failure o Oral contraceptives
o Pregnancy/post-partum o Previous VTE
 STRONG RISK
o Fracture (hip or leg) o Spinal cord injury
o Hip/knee replacement o Major general surgery
o Major trauma
PREVENTATIVE STRATEGIES

 Consider REDUCING FASTING TIMES

o Viscosity of blood when dehydrated
 IV FLUIDS
o increasing circulating volume; reduces blood viscosity allowing it to flow easily, hence reducing the
risk of clot formation.
 POSITIONING
 POST OP MOBILITY/EXERCISES
 THROMBO-EMBOLIC DEVICE
o TED’s
 SEQUENTIAL COMPRESSION DEVICE
o Calf compressors
 Ensuring they are attached correctly and turned on – always double check!
 DRUGS
o Prophylactic anticoagulants
 Heparin

POST OPERATIVE ASSESSMENT

 A-G
o Breathing
 Signs of dyspnoea
o Circulation
 Hypovolaemia
 Hypotension
o Drips, Drains, Dressings and Drugs
o Disability
 Sensation
 Movement
o Exposure
 Temp
 Wound assessment
o Fluid
 Resuscitation?
 Transfusion?
 IV infusion
 Drain
 PCA
 Circulation
o Neurovascular observations
o Potential for haemorrhage
 Pain
o Early and consistent
o Visual analogue scale
SURGICAL SITE INFECTION
WHAT IS IT?

SUPERFICIAL INCISIONAL DEEP INCISIONAL/ORGAN SPACE

 Skin & subcutaneous tissue  Deep soft tissues; fascia/ muscle

 Occurs within 30 days post op
o Purulent discharge
o Positive culture of fluid/tissue
o Pain or tenderness; localized swelling;
redness or heat.
 Surgical exploration & +ve
 Diagnosis or antimicrobials
 Organs/cavities opened or manipulated
during surgery;
 Within 30 days post op; 1 year post implant.
o Fever >38C;
o localized pain or tenderness;
o Abscess or other evidence of infection

RISK FACTORS

PROCEDURAL

 Wound class/type  Blood transfusions

 Length of surgery (>3 hours)  Maintenance of asepsis
 Shaving of hair at site  Glove perforations
 Hypoxia  Surgical technique
 Hypothermia  Antibiotic Prophylaxis given incorrectly (dose
 Type of procedure (emergency or complex) and timing)

FACILITY

 Poor ventilation
 Sterilization of instruments
 Ineffective surgical hand scrub
 Traffic in OR room

PATIENT

 NON-MODIFIABLE  MODIFIABLE
o Diabetes o Glycaemic control
o Age o Dyspnea
o Recent radiotherapy o Alcohol use
o History of tissue/skin infections o Smoking status
o ASA score >3 o Albumin and bilirubin levels
o Renal failure o Hematocrit levels <36
o Obesity
o Immunosuppression
o Malnutrition
o Anaemia
PREVENTATIVE STRATEGIES

 Risk assessment
 Wound classification scale

 Environmental
o Safe handling and storage of sterile items
o Air conditioning filtration and cycles
 Laminar flow
o OR design: traffic patterns, flooring materials.
 Clinical practice
o Opening sterile items
o Preparing and maintenance of aseptic surgical field
o Movement around the aseptic surgical field
o Aseptic surgical technique
o Scrub, gown and glove
o Prep and drape
o Surgical conscious
 Admitting to mistakes
 Pharmacotherapy
o Antimicrobials patient wash pre-op
o Prophylactic AB’s*
o Anti-microbial impregnated drapes & dressings
o Antibiotic irrigation solutions
PRESSURE INJURIES
WHAT IS IT?

A pressure injury noted within 72 hours of surgery.

RISK FACTORS

INTRAOPERATIVE

 Procedure duration
 Bony prominences
 Friction/shearing forces in patient transfer

INTRINSIC (NON-MODIFIABLE)

 >60 years  Hypotension

 Low albumin levels o Increased risk of tissue trauma
 ASA >3  Pulmonary disease
 Diabetes  Renal insufficiency
 BMI <19 or >40  Low core temp
 CVA o Low peripheral circulation

EXTRINSIC RISK FACTORS (MODIFIABLE)

 Time
o Immobilised prior to surgery
o Operative duration
o to mobilisation postop
 Positioning (prone)
 Trauma
 Hypotensive episodes
 Extended use of vasopressors
 SURGERY TYPE
o Cardiac
 Specifically on heels
 Peripheral circulation is impacted on BiPass
o Orthopaedic
o Vascular
o Transplants
o Bariatric

VARIABLES COMORBIDITIES

 Positioning  Vascular disease

 Anaesthetics  Immobility
o Hypotension  Advancing age
 Body temperature  Severe illness
 Blood flow  Moisture
PREVENTATIVE STRATEGIES

 RISK ASSESSMENT TOOLS

o Waterlow

o Braden scale
 Not specific to perioperative
 Talks around mobilisation and nutrition
o Munro risk assessment
 Includes ASA score
 Very specific to perioperative environment

 POSITIONING
 VISUAL INSPECTION PRE AND POST
 OPEN TEAM COMMUNICATION
RETAINED SURGICAL ITEMS
WHAT IS IT?

Any surgical item inadvertently left within the patient’s body at the completion of a surgical procedure.
Common items:

 Swabs, sponges, instruments – scissors, forceps, needles and retractors.

RISK FACTORS

 Invasive surgery
 Emergency surgery
 Extended duration of surgery
 Timing of the event – after hours
 Increased BMI
 Multiple surgical teams

PREVENTATIVE STRATEGIES

 WHO Surgical Safety Checklist  Two person visual and verbal verification
 Surgical count process
 Instrument tray lists

WRONG SITE SURGERY

WHAT IS IT?

Wrong site surgery represents a classic systems error rather than a human failure by an individual surgeon; Systems
are designed to back up human error.

CONTRIBUTING FACTORS

SCHEDULING PRE-OP & HOLDING

 Verification of surgical booking documents  Primary documents required

 Written only o Consent; admissions or OR booking
 Abbreviations/ legible handwriting form; OR schedule;
 Site marking
 Time out for regional blocks
 Patient identification

OPERATING ROOM ORGANISATIONAL CULTURE

 Multiple procedures = multiple verifications?  Inconsistent patient safety focus

 Team ‘briefing’ pre-operatively for verification o Low level accountability
 Use of primary documentation for verification  Staff passive; not empowered
process  Policy change & staff education
 Site markers removed during surgical prep o Celebrate success.
 Distractions; rushing;
 Team Time Out

PREVENTATIVE STRATEGIES

 Verification  Team Time-Out

o Site and procedure o Prior to incision
 Marking of site o All team members engaged
o Unambiguous  WHO Surgical Safety Checklist
o Patient included
INADVERTENT INTRAOPERATIVE HYPOTHERMIA
WHAT IS IT?

Core temperature <36C

Causes:

 Convection (32%)
o Air con wind chill
 Conduction (minimal)
o Physical contact with OR table mattress
 Radiation (40%)
o Ambient air temp
 Evaporation (28%)
o Dry respiratory gases

RISK FACTORS

 Surgical time >1hr

 Exposed position
 Low BMI
o Frail/elderly; neonate/ infant vs obese
 High volume intraoperative irrigation
 Ambient air temperature
 Anaesthesia
o Anaesthetic induced vasodilation (associated heat loss).
 Unnecessary exposure preoperatively prior to prep & drape.
 Use of alcohol-base prep solutions.
 Dehydration related to extended fasting.
o Reduced perfusion and heat distribution
o Further complicated by IV fluids at room temp.

COMPLICATIONS

 Increased length of stay

 Increased hospital costs
 ‘thermal discomfort’ - Shivering
 Increased surgical site infection
 Increased cardiac ischaemia; Arrhythmias
 Impaired platelet function; Increased blood loss
 Pressure injuries
 Altered drug metabolism

PREVENTATIVE STRATEGIES

 Monitoring of temperature
 Team approach
o Not just nursing; not just anaesthetist;
 Warmed & humidified gases;
 Warmed Iv fluids;
 Warmed irrigation fluids;
 Pre-warm patient with full body forced air warmer;
 Upper body blanket forced air warmer intraop;
 Full body forced air warmer postop;
 Head covering;
 Week 7 – Minimally Invasive Surgery

DEFINITION
Surgeons use a variety of techniques to operate with less damage to the body than in open surgery; in general
minimally invasive surgical techniques are:

 associated with less pain

 shorter length of hospital stay
 fewer complications

EXAMPLES

 Laparoscopy: as recent as 1985 first laparoscopic cholecystectomy.

 Arthroscopy
 Thoracoscopy
 Neuro endoscopy
 MIS spine techniques

CONSIDERATIONS
BENEFITS
 Specialized training required
 Shorter length of stay
 Gentle Learning curve
 Shorter rehabilitation time
 Technical difficulties
o *reduced operating time
 Potential for open conversion
 Started off as long surgeries,
 Expense of specialized instrumentation &
became quicker with
equipment
development.
 Disposable items
o waste & expense

EQUIPMENT
CAMERA AND CAMERA HEADS

 3-CHIP ideal – provides primary colour representation in images

 Ensure white balance prior to use
o Checking it against something white to start with, and then will balance colour from there.
 Ideal autoclaveable camera heads
o Autoclaveable = loses integrity in high temperature.
 Those not autoclaveable should be sterilized via low heat systems such as Sterrad.
 Care taken not to coil camera leads tightly as this will damage internal fibres.

LIGHT SOURCE AND LIGHT LEADS

 Halogen or Xenon light source

 Check globe life & spare availability
 Even though ‘cold light’ still has risk of burning drapes (particularly disposable)
o Generate alot of heat and quickly.
o Disposable drapes = highly flammable.
 Check light leads for dark spots (indicate broken fibres)
o >30% dark/broken replace lead.
 Care not to coil tightly as this will damage internal fibres
INSUFFLATOR

 Pumps gas into peritoneal cavity to expand it and give a better view.
 CO2 is used as it does not distort images.
o Cheap and accessible.
o Non-combustible.
 Intra-abdominal pressure should be between 10-13mmHg
o Too high = blood flow with become obstructed, and the diaphragm is restricted in movement
causing respiratory difficulties.
 Patients are ventilated for that reason; to increase lung compliance and ventilation
pressures.

MONITOR

 Typically 20” High Definition LED or LCD

 Horizontal resolution is the number of vertical lines;
 Vertical resolution is the number of horizontal lines;
 The more lines of resolution, the better detail in the image.

TELESCOPES

 Wide range available depending on the intended purpose;

o Eg: laparoscopes 5mm & 10mm; 00, 300, 450, & 600 standard options
 All laparoscope are autoclaveable, however to extend the life they tend to be sterilized through low heat
systems such as Sterrad.
o Dramatic heat changes shortens life.

ACCESS PORTS AND TROCARS

LAPAROSCOPY

 Different positioning requirements

 Different risks for bleeding
 Standard instrument set; used differently per procedure
WHY ARE THEY DONE?

 Diagnosis & surgical repair or removal.  Perforated ulcer – closure of perforation

 Gallstones – cholecystectomy  Hiatus hernia – hiatus hernia repair
 Appendicitis – appendicectomy  Carcinoma – gastrectomy; hemicolectomy;
 Hernia – hernia repair anterior resection; esophagogastrostomy.
 Adhesions – division of adhesions

INTRA-UMBILICAL ENTRY

 Fixed peritoneum
o Not stuck on any organ; nil risk of inadvertent puncture to organs.
 Thin
 Least vascular
o Even small amounts of blood blocks telescope visual
 Cosmetic

PRIMARY PORT – CLOSED ENTRY

Insertion of a Veress needle vertical, then towards the pelvis.

VERESS NEEDLE

 The Veress needle should be sharp, with a good

and tested spring action.
o A disposable needle is recommended, manual
labour to decontaminate = expensive and timely.
 The lower abdominal wall should be stabilised in such a
way that the Veress needle can be inserted at right angles to the skin
 Saline test
o Withdraw
o Instil
o Withdraw
 If no fluid, frank blood (or faeces) then proceed with insufflation.
 The greater the gas bubble & abdominal wall tension the less
the risk of bowel injury.
 Closed entry can still cause bowel injury especially if adhesions
are present.
 Other injuries
o Vascular injury
o Retroperitoneal haemorrhage
o Bladder injury
o Injury to over inflated stomach
SECONDARY PORTS

ARTHROSCOPY
WHY ARE THEY DONE?

 Diagnosis & surgical repair or removal

o Cartilage – menisectomy
o Bone surface repair – chondroplasty
o Ligament repair – reconstruction
o Bony fragment – removal of foreign body

THORACOSCOPY
WHY ARE THEY DONE?

 Diagnosis & surgical repair or removal

o Bullae – a large blister containing serous fluid.
o Carcinoma – wedge resection; lobectomy;

NEURO ENDOSCOPY
WHY ARE THEY DONE?

 Endoscopic third ventriculostomy

o Aids flow of CSF
o Preventing obstructive hydrocephalus
MIS SPINE
WHY ARE THEY DONE?

 Surgeons work through a ‘tube’ to access the spine;

 Most suitable for ‘simple’ discectomy;
 Can be used for advanced level spinal fusion in both posterior
lumbar & lateral thoracic approaches.

ELECTROSURGERY
PROPERTIES OF ELECTRICITY

 CURRENT
o Flow of electrons during a period of time
o Generator is the source of the current
 CIRCUIT
o Pathway for the uninterrupted flow of electrons;
o Must be closed or completed
o Follows a pathway
 IMPEDANCE/RESISTANCE
o Obstacle to the flow of current
o Patients tissue provides the resistance > heat generated
 VOLTAGE
o Force pushing current through the resistance
o As voltage increases, the surgeons control decreases

DIATHERMY

 Coagulates and Cuts tissue

 Alternating current does enter patient

In isolated units, the electrical current produced by the

generator is referenced to the generator and will ignore
all grounded objects that may touch the patient except the
return electrode. With isolated generators current division
cannot occur and there is no possibility of alternate site burns.
An isolated generator will not work unless the patient return
electrode is applied to the patient. The perioperative nurse
must be certain that the patient return electrode is in good
contact with the patient throughout the surgical procedure.

ALTERNATIVE SITE INJURY

The current exited the patient’s body through an electrocardiograph lead, concentrating the current and resulting in
a burn.
ISOLATE SYSTEM

The diagram on this slide depicts an isolated generator.

Note how the current from the wall outlet enters the
generator and then returns to ground. As it passes through
the generator, an isolated current is generated. It is this
second current that is delivered to the patient. This current
recognizes only the generator as ground. If it does not have a
pathway back to the generator, the current will not flow. In
other words, if the circuit from the generator to the patient
and back to the generator through a return electrode is not
complete or closed, the current will not flow.

PATIENT RETURN ELECTRODES

REM PLATE POSITIONING

Surface area impedance can be compromised by excessive hair, adipose tissue, bony prominences, fluid
invasion, adhesive failure, scar tissue, other equipment (SCD’s).

In situations where tissue perfusion at the plate site becomes inadequate (shock, hypotension, hypothermia,
tissue compression at the plate area,) the lack of adequate heat dissipation may cause injury.

SITE PREPARATION

 Follow manufacturers instructions for hair removal, cleaning and drying site.
 Protect return electrode from fluid invasion.
 Do not use flammable agents for PRE-site preparation.

TWO PATIENT RETURN ELECTRODES

 Placement of an additional Pad increases dispersion of electrosurgical current and heat at the pad-
to-patient interface.
o Obesity
o Emaciation
o Fluid environment
o Long duty cycles
 RETURN ELECTRODE SITE INJURY

 Historically the most common injury has been a skin injury at the patient return electrode (Pad) site.
 This risk has been minimized through the use of return electrode contact quality monitoring (CQM)
Split Pads

GENERAL SAFETY PRECAUTIONS

 Test alarm systems

 Plug accessories into correct receptacles
o When plugging accessories into the bipolar and monopolar receptacles, ensure that the accessory is
plugged into the correct receptacle. Plugging an accessory into the wrong receptacle can result in
patient injury, staff injury, as well as damage to the instrument.
 Set activation tone to audible level
 Confirm power settings
o If the proper power settings are not know, set the power to a low setting and cautiously increase the
power until the desired effect is achieved.

CURRENT CONCENTRATION AND DISPERSAL

When current is concentrated, heat is produced.

The amount of heat produced determines the extent
of tissue effect. Current concentration or density
depends on the size of the area through which the
current flows.

A small area that concentrates the current offers more

resistance, which necessitates more force to push the
current through the limited space and, therefore, generates
more heat. Because the electrosurgical pencil is referred to
as an active electrode, many people think of the return
electrode as inactive, passive, or neutral. The determining
factor of whether enough heat is generated to produce a
burn is the size of the surface area through which the current
flows. The more concentrated the energy, the greater the
thermodynamic effect. There should be minimal temperature
rise at the return electrode (pad) site, if it is applied correctly.
A large area offers less resistance to the flow of current, reducing
the amount of heat produced.
ACTIVE ELECTRODES

 The active electrode should be placed in a clean, dry, well-insulated safety holster when not in use to
minimize the risk of injury from unintentional activation. Injuries have resulted when the active electrode
has been left lying on the patient between uses.
 Electrodes that do not fit in the holster should be placed in a designated location with tips away from
flammable material (eg, drapes).
 The active electrode tips should be securely seated into the hand piece. A loose tip may cause a spark or
burn to tissue contracting the exposed, noninsulated section of the tip.

CURRENT LEAKAGE

Radiofrequency current, unlike the 60 cycle current

from the wall outlet, can and does “leak” through the
insulation on the cord or electrode. No matter how
thick the layer of insulation is, there will be some current
leakage with the use of this high frequency current. The
higher the voltage, the more insulation it can overcome,
resulting in a higher amount of leakage current. Consequently,
avoid wrapping active electrode cords around metal instruments
and bundling cords together.

DURING PREGNANCY

 No evidence to contraindicate use

 Dispersive amniotic fluid protects fetus from concentration of electrical current
 No neuromuscular stimulation above 100 kHz — radiofrequency range

JEWELLERY

 Jewellery should be removed if it is within the activation range of the active electrode.
 Avoid direct contact with the activated electrode tip (or deactivated electrode to prevent conduction of
residual heat)
 If it can’t be easily removed cover with gauze and tape in place.

HEMOSTAT BURNS

 Use lowest power setting

 Activate low voltage (cut)
 Avoid touching patient
 Hold hemostat with full grip
 Avoid metal to metal arcing

SURGICAL SMOKE

 The gaseous byproducts of the disruption and vaporization of tissue protein and fat.
 Surgical smoke is called by a variety of names, including cautery smoke, diathermy plume, plume, smoke-
plume, aerosols, bio-aerosols, vapor, and air contaminants.
 It can be seen and smelled. Surgical smoke is the result of the interaction of tissue and mechanical tools
and/or heat producing equipment such as those that are used for dissection and hemostasis.
 Both the visible and the odorous components of surgical smoke are the gaseous byproducts of the disruption
and vaporization of tissue protein and fat.
CUTTING

Divides tissue with electrosurgical sparks. These focus intense heat at the surgical site, producing maximum current
concentration. Tissue is ‘vaporised.’

FULGURATION

Electrosurgical sparking with a coagulation waveform. Coagulates and chars over a wide area. ‘On’ time is only about
6%, so dramatically less heat produced. Coagulation rather than vaporisation occurs. In order to overcome the
relatively high impedance of air, a higher voltage is required in comparison to cutting. NB: ARGON

DESSICATION

Occurs when electrode is in direct contact with the tissue. Used most efficiently with the cutting settings,
 Week 8 – Orthopaedics and Trauma

BONES
 Architectural framework
 Anchor for other structures
 Protects internal organs
 Which fracture sites most concern a trauma surgeon?
TYPES OF FRACTURES
SUBLUXATION FRACTURE/DISLOCATION DISLOCATION

CLOSED (SIMPLE) OPEN (COMPOUND)

COMMINUTED
COMPRESSION OR BURST FRACTURES

AVULSION FRACTURES

DEPRESSION FRACTURES
CLASSIFICATION
 Classified in many ways:
o Anatomical positioning
o Description/exposure
o Fracture line/type and appearance
o Classical nomenclature
o Alignment- displaced, undisplaced, angulated, rotated
PROXIMAL FEMORAL FRACTURES

GARDEN FRACTURE

WEBER FRACTURE
ASSESSMENT
 Inspection
 ?swab for microbiology if able.
 Antibiotics
 Clean – irrigate from inside out.
 Apply sterile dressing, sterile forceps etc.
 Splinting even if only temporary.
 X-Ray when able.

CIRCULATION

 Heart Rate
 Blood Pressure
 Level of Consciousness

After assessment of circulatory compromise

fluid resuscitation needs to occur

COMPARTMENT SYNDROME
DEFINITION

“Increased pressure within the limited space of a muscle compartment”

 This causes decreased blood flow to tissues below the level of the injury
 CS should be considered in patients who have sustained a significant orthopaedic or vascular injury
 If untreated, irreversible necrosis and permanent loss of function to the limb can occur
 Signs and symptoms develop slowly
 They may not appear until increased pressure becomes critical.

6 P’S

1. Pain (severe)
2. Pressure (swollen tense limb)
3. Paraesthesia (loss of sensation)
4. Paralysis (loss of movement)
5. Pallor (late sign!)
6. Pulses (present until very late stages)

CAUSES/INJURIES AT RISK

 Severe crush injuries

 Vascular injuries
 Fractures
 Severe contusions
 Swollen limbs beneath casts/splints

TREATMENT

 Fasciotomy
o An incision is made releasing the muscle compartments in the affected limb
o Symptoms develop 6-8 hours after injury but can be delayed up to 48-96 hours after
RECOGNITION OF A FRACTURE
 Pain on movement
 Loss of function
 Deformity
 Abnormal motility
 Crepitus
 Bruising / swelling
 Spasm

ALTERED VITALS IN RESPONSE TO HAEMORRHAGE

HEART RATE

 Tachycardia (early sign)

WEAK PULSE

 Reduced stroke volume

ALTEREED MENTATION

 Anxiety and confusion due to decreased brain perfusion

CAPILLARY REFILL TIME

 Delayed >2 seconds (systemic vasoconstriction)

BLOOD PRESSURE

 Normal or increased (vasoconstriction)

 Low BP is a late sign

SKIN COLOUR

 Pale/cool peripheries (vasoconstriction)

 Possible sweating due to catecholamine release

URINE OUTPUT

 Decreased output and increased concentration

BLOOD LOSS BY FRACTURE SITE

FRACTURE SITE BLOOD LOSS

Humerus 500-2500

Elbow 250-1500

Radius/Ulna 250-1000

Pelvis 750-6000

Hip 1500-3000

Knee 1000-2500

Femur 500-3000

Tibia/Fibula 250-2000

Ankle 250-1000

Spine/Ribs 1000-3000

TRACTION
 Reduce fracture and realign bone fragments
 Reduction and treatment of dislocations
 Immobilise to prevent further soft tissue damage
 Relieve muscle spasms occurring as a result of musculoskeletal trauma in absence of a #
 Rest a diseased joint

BEFORE AFTER
HIP

CAUSES OF JOINT DISORDERS

 Osteoarthritis
 Rheumatoid arthritis
 Post traumatic arthritis
 Avascular necrosis

HEMIARTHROPLASTY
HIP RESURFACING

KNEE
 Arthroscope +/- chondroplasty

KNEE OSTEOARTHRITIS
KNEE HEMIARTHROPLASTY

 Not too old; not too young.

 Low demand (couch potato).
 Not obese.
 Structurally sound.
 Understands limitations.

FOOT AND ANKLE

BUNIONS

 Myths:
o A bunion is a bump or growth of bone.
o Wearing high heels causes bunions.
o Bunion surgery involves cutting off the bump

TOURNIQUET SAFETY
 Purpose
o Restrict arterial blood flow to limb;
o Provide relatively blood-free surgical site
 Intravenous regional anaesthesia
o Biers block
 Questions to ask:
o When to inflate?
o What pressure to be applied?
o How long for?
o When to release tourniquet pressure?
 Placement
o Correct size for limb; (7.5 – 15cm overlap)
o Underwrap to protect skin (velband/ softband);
o Prevent ‘pinching’;
o Aware of ‘pooling’ of prep solutions
 May result in chemical burn.
o Exsanguination
 Eschmark bandage; elevation.
 Inflation Pressure  Risks
o Blood pressure; o Nerve injury;
o Cuff design, fit and snugness of o Blood vessel injury – ischaemia;
application; o Chemical burns related to prep
o Limb circumference; solutions;
o State of the tissues; o Without correct exsanguination -
o Vascular status;  > risk of intravascular
thrombosis
NEUROVASCULAR ASSESSMENT
PREPARATION

 Remove dirt, nail polish, blood or surgical antiseptics;

 Ensure good lighting;
 Ensure your hands are not overheated;
 Rest patient prior as ankle pulse may be difficult/unable to be detected;
 Always assess the unaffected limb for comparison;

ASSESSMENT

 Checking sensation and motor function of extremity

 Always compare affected to unaffected
 In upper extremity evaluate radial, median and ulnar nerves
 In lower evaluate femoral, sciatic, peroneal and tibial nerves

SENSATION

 Ask pt to close their eyes.

 Lightly touch extremity in course of nerve asking, “where am I touching you?” rather than “do you
feel this?”
 Have pt describe limb sensation to determine if burning, pins/needles or numbness are present

MOVEMENT

 Assesses the pts ability to perform normal movements of muscles in the course of a nerve
innovation
 Assess movement distal to injury
 Examples
o radial nerve impairment = wrist drop
o ulnar nerve impairment= claw hand
o Peroneal nerve impairment = foot drop
PERIPHERAL VASCULAR ASSESSMENT

The vascular assessment examines:

COLOUR

 Pts skin tones are individual.

 Skin tone keeping in mind pts general condition i.e. respiratory status.
 Pale = arterial insufficiency.
 Cyanotic or mottled = inadequate venous return.

SWELLING

 A physiological response to injury or surgery.

 Can threaten NV status and increase risk of compartment syndrome.
 May indicate inadequate venous return.
 Some pts have pre-existing oedema bilaterally (cardiac dx) or unilaterally (chronic venous/lymphatic
obstruction).

TEMPERATURE

 Ax with the dorsum (back) of hand

 A cool or cold temperature = inadequate arterial supply
 A hot temperature suggests venous congestion
 Environmental factors can alter skin temp

CAPILLARY REFILL

 Measure CR by squeezing the nail bed for 1-3 secs

 Normal CR should return in 2-3 secs, or by the time it takes to say “capillary refill”
 Delayed CR indicates insufficient circulation to distal extremity

PERIPHERAL PULSE

 Peripheral pulses
o Upper extremity = axillary,
brachial, radial & ulnar
o Lower extremity = femoral,
popliteal, posterior tibialis & dorsalis
pedis
 Which one will you assess?
 Doppler may be required
 Mark with “X” for difficult pulses
 Dorsalis pedis absent in 10-17% of people
 Sometimes inaccessible
 Week 9 – Post Anaesthesia Care/Recovery Unit

DEFINITION
The post anaesthesia recovery unit provides continuous, individual, critical assessment, care, and treatment for post-
operative/post-anaesthesia patients who are emerging from general anaesthesia or from spinal, regional, or local
sedation anaesthesia.

DAY SURGERY UNIT ERCOVERY

STAGED RECOVERY

1. PARU
2. Eating
3. Post-operative education
 Are they safe to go home?
 How are they getting home?
4. Home

PATIENT TRANSFER TO PARU

STAFF INVOLVED

 Anaesthetist
 Nurse
 Wards person

MONITORING

 02 (prongs/mask, ETT/LMA)
o 02, suction and ventilation ready.

POSITIONING

 Always kept supine (lateral)

COMPLICATIONS

 Always observe for complications

 Special attention to airway compromise
HANDOVER
ANAESTHETIST

 Patient identification  Relaxants/reversal

 Age
 Surgical procedure
 Type of anaesthesia
 Medical history
 Allergies
 Intraoperative events
 Blood loss
 Local
 IV access/orders
 Drugs given
 Narcotics/sedatives
 Antibiotics (dose and time)
 Post op drug orders
 Clinical observations & monitoring
 Pain relief
 Management of complications; PONV
 Fluid therapy
 Respiratory therapy
 Residual regional anaesthesia block
 Discharge expectations from PARU
 Ongoing care related to anaesthesia

NURSE

 Process, from;  What they hand over:

 Ward nurse o Patient identification
 Anesthetic nurse o Procedure
 Instrument nurse o Dressing, drain, catheter
 PARU nurse o Specific pt care (skin integrity)
 Ward nurse o Documentation
o Whatever comes in with the patient
leaves with them;
 X-rays
 Extras (teeth, glasses,
clothing)

DISCHARGE (from ward)

o Patient identification
o Surgical procedure
o Anaesthetic
o Relevant medical history
o Condition/progress
o A-G summary
o Observations
o Medications
o Pain/scores
o Drips (IV fluid orders)
Drains (including catheters)
Dressings
o Post-operative orders
INITIAL ASSESSMENT (A-G)
AIRWAY

 Self-maintained
 Hudson mask
 Tubed or talking
o LMA or ETT
o Re-breathing bag

BREATHING

 Spontaneous
 Rise and fall (See-saw)
 Signs of obstructions
 Sounds
o Noisy
 Some degree of obstruction
 Check to make sure sats are okay
o Wheezing
 Slightly worse than noisy.
o Silent
 Dangerous situation; unsure if air is moving freely or not.
 Rate
 Saturations (Sa02 first priority)

CIRCULATION

 Colour
o Pink, pale or cyanotic
 BP
o NIBP (Non-invasive blood pressure)
o ECG if cardiac history
 HR
o +/- 20% hypo/hyper
 Neurovascular observations
 Potential for haemorrhage

DRIPS, DRAINS, DRESSINGS AND DRUGS

 Drips
o IV site
o Orders
 Drains
o Site
o Volume
o Suction/No suction
 Dressings
o Ooze
o Intact
 Drugs
o Allergies
o Antiemetics
o Analgesia
EXPOSURE

 Temperature
o <36 degrees = hypothermia
 Active/passive warming
 Wounds

FLUIDS

 IV orders
 Transfusions
 Drains
 PCA

GLUCOSE

 Only when necessary.

 Pre-op fasting.

SECONDARY

 ECG
o Necessary for “at risk patients”
 cardiac history
 large blood loss
 temp <35
 Intraoperative arrhythmia
o 3-lead ECG
 Pain
o Early and consistent
PARU COMPLICATIONS
CNS

 Consciousness
 Delayed emergence
o Systematic evaluation/assessment
 Pre-op status
 Unusual intraoperative events?
 Ventilation
 Response to stimulation
 Cardiovascular status
 Tachycardia
 Hypotensive
 Neurological status
 Panic/stressed
o CAUSES
 Residual anaesthesia is the most common cause
 Suxamethonium
o (Depolarising neuromuscular blocking agent)
 No reversal agent; enzymes in body must break it down naturally.
Some people lack these enzymes.
 Hypothermia
 Endocrine
 Most effective; process drugs differently
o Diabetes
o Muscular dystrophy/MS
o Hepatic/renal disease

RESPIRATORY

 Hypoxia
o CAUSES
 Low O2
 Hypoventilation
 Residual anaesthesia: narcotics, inhalation agent, residual relaxant; post op
analgesia;
 Laryngeal spasm/ stridor;
o TREATMENT
 Depends on cause:
 Reverse relaxant
 Reverse narcotic
 Reverse midazolam
 Stay with patient.
 Recognise as a medical emergency.
 Nonspecific treatment
 Increase O2
 ? Mask bag ventilation
 ? Intubation
 Diagnose cause.
  Obstruction
o CAUSES
 Most common: tongue in posterior pharynx
 Chin lift to fix
 May be foreign body
 More likely secretions irritating the larynx
 Vomitus
 Ensure there is always suction equipment around
 Inadequate relaxant reversal
 Residual anaesthesia
 See-saw chest movement
 Slight obstruction
 Chin lift to fix
o TREATMENT
 Verbal/physical stimulation
 Jaw support
 Oral airway/nasal airway
 Nasal airway tolerated better; soft and pliable.
 Endotracheal intubation
 Crico-thyroidotomy
 Tracheostomy

CARDIOVASCULAR

 Hypotension
o Definition: <20% change from baseline
o CAUSES
 Causes of  venous return
 Regional anaesthesia
o Epidural or spinal local anaesthetic
 Hypovolemia
o Inadequate fluid replacement
 Blood
 Crystalloids
o Preoperative dehydration
o Active bleeding
o TREATMENT
 Common scenario:
 Arrive hypothermic,
 Vasoconstricted, and
 Normotensive.
 As patient rewarms, he/she
 Vasodilates and becomes
 Hypovolaemic.
 Initially treat with fluid bolus.
  Hypertension
o Definition: >20% baseline
o CAUSES o TREATMENT
 Response to CNS stimulation  Treatment may take time
 Pain!  Assess urgency of need to 
 Full bladder – urinary blood pressure
retention post  Active bleeding
anaesthetic 5-70%  Type of surgical
 Consider fluid overload procedure
 TURP syndrome (20%  Consider pharmacological
incidence; 0.2 – 0.8% techniques
mortality rate)  Pain control
 Risk of pulmonary and  Beta blockers
cerebral oedema o Metoprolol,
o DIAGNOSIS OF CAUSE esmolol
 Pain  Alpha blockers
 Check chart o Hydralazine,
 Ask patient clonidine
 Fluid  Calcium channel
 Check chart blockers
 Urine output (? insert o Verapamil
catheter)  Diuretics
 ? Insert CVC  IDC
 Hypothermia  Warm patient
 Measure temperature
 Arrhythmia

FLUID BALANCE

 Hypovolemia
o URINE OUTPUT
 Oliguria
 Hypovolemia
 Surgical trauma to ureters
 Impaired renal function
 Mechanical blocking of catheter
 Assess catheter patency
 Fluid bolus
 Lasix
 Hypervolemia

TEMPERATURE

 Hypothermia
o CAUSES o TREATMENT
 Expect hypothermia  Get baseline temperature
 Surgical time >1hr  Actively re-warm
 Exposed position  Administer oxygen if shivering
 Frail/elderly vs obese  Potential to  O2
demand x4
 Hypoxaemia
 Lactic acidosis
 Hypercarbia
PAIN

 COMFORT MEASURES
o Non-pharmacological
 Environment within recovery
 Quiet & calm
 With no rush to move
 Repositioning
 Hot/cold packs
 Cold packs most effective in joint surgeries
 Elevate affected limb
 Reduces inflammation, throbbing and increased pressure.
 Pressure area care
 Breathing
o Non-pharmacological
 Environment
 quiet & calm
 Repositioning
 Hot/cold packs
 Elevate affected limb
 Pressure area care
 Breathing
o Additional
 Regional anaesthesia
 A nerve block that lasts well into recovery phase.
 Must perform neuromuscular obs regularly whilst on.
 Pain pump
 Infusion of local anaesthetic directly into the surgical site.
 Pain buster
 Ketamine infusions
 More effective on chronic pain or pain that doesn’t respond to other medications.
 Be cautious; fairly significant psychological changes on the medication
(hallucinations).
 NSAIDS

PONV

 Leading cause of unexpected admission

 RISK FACTORS
o Type of surgery
 Gynaecology
 Including laparoscopic
o Type of anaesthesia
 General
o Gender
 Female
o Lifestyle
 Smoker
o History
 Known from previous –ve anaesthetic episodes
 Hearing/Vision problems
o Extended pre-op fasting times
 = Dehydration = Hypotension = N&V
DISCHARGE CRITERIA
 Awake with muscle strength
 Patent airway
 Good respiratory function
 Stable vital signs
o Minimum 3 sets of stable conscious observations
o Do not rush these observations.
 Patency of tubes, catheters, IV’s
 Post op orders documented
 Condition of surgical site
 Intact and assessed
 Comfort / anxiety
 Documentation

CASE STUDY QUESTIONS FROM WORKSHOP

 Describe your initial assessment of your patient in PARU. In your answer show you understand prioritisation.
 Identify the potential complications your patient may experience in the immediate post-operative period in
PARU.
 Describe the nursing interventions, both preventative & management for these complications.
 Using ISBAR write a script for your handover to the nursing staff on the ward.
 Week 11 – Specialist Surgery

INCREASED TECHNOLOGY = MORE COMPLEX PROCEDURES

 Microsurgery  Implant mechanical devices
 Laser  Reattachment body parts
 Robotic  Sophisticated haemodynamic monitoring
 Minimally invasive  New pharmacological agents
 Transplant multiple organs

ENDOVASCULAR
 Replacing need for CABGs, aneurysm repair, carotid.
 Neuroglide microbot

COMPUTER AIDED
 Navigation
 Orthalign

DA VINCI ROBOT NOTES/NOS

 Urology  Natural orifice transluminal endoscopic
 General surgery
 Gynaecology  Natural orifice surgery
 Cardiac o Transvaginal laparoscopic assisted
 Transoral robotic surgery (TORS) cholecystectomy
FILLERS
Injectable fillers, also known as dermal fillers or soft tissue fillers, are materials injected under the skin to reduce the
appearance of facial wrinkles, lines, folds and indented scars.

Injectable fillers can also be used to enhance facial contours by adding volume to lips or cheeks.

BOTOX (3-4 MO)

 also known as ‘Botox’ is a potent bacterial neurotoxin – with consequences of not used correctly. While
considered ‘low risk’ that does not mean ‘no risk’. In high doses this is lethal. Cosmetic use tends to be
@20% max dose.
 In rare cases, the toxin can spread away from the injection site, causing serious side effects with swallowing,
speaking, or breathing due to weakening of associated muscles which can be severe with larger doses.
 Botox actually paralyses muscles in the face so that they atrophy; the muscles thin and weaken, preventing
wrinkles forming.

COLLAGEN

 used to be standard filler; more recently replaced by hyaluronic acid fillers; Collagen is the natural protein
within the dermis that provides support for the skin. The Collagen that is used as injectables typically comes
from cows.

HYALURONIC ACID (6-12MO)

 naturally found in connective tissue, cartilage, joint space, around eyes – in fact almost in every part of the
body in some aspect. Synthetic forms of hyaluronic acid have been developed; when the gel is injected is
acts to inflate sagging tissues and provide additional support to skin structures.

SYNTHETICS (12-18MO)

FAT (LIFE?)

 fat transfers involves patients own fat being extracted from one site & transferred to another; may last years
but may also be reabsorbed into the system.
 Other
TRANSFUSION MANAGEMENT
 Checks
o Unit no.; Group; Rh factor; patient ID; expiry;
 Observations
o Baseline; frequency;
 Reaction symptoms
o 10C & /or chills, rigors
o Hypotension, tachycardia
o Dyspnoea, airway obstruction
o Decreased saturation

TRANSFUSION RELATED REACTIONS

 Acute haemolytic reaction

o A haemolytic transfusion reaction is a serious complication that can occur after a blood transfusion.
The reaction occurs when the red blood cells that were given during the transfusion are destroyed
by the person's immune system.
 Febrile non-haemolytic reactions
o Defined as a temperature increase of 1°C over 37°C occurring during or after the transfusion of
blood components.
 Minor allergic reactions
 Severe allergic reactions
 TRALI
o Transfusion-related acute lung injury (TRALI) is a serious blood transfusion complication
characterized by the acute onset of non-cardiogenic pulmonary edema following transfusion of
blood products.
 Delayed haemolytic reactions
o A delayed hemolytic transfusion reaction (DHTR) is a type of transfusion reaction. It is defined as
fever and other symptoms/ signs of hemolysis more than 24 hours after transfusion; confirmed by
one or more of the following: a fall in haemoglobin (Hb) level or failure of Hb level to rise after
transfusion.

MANAGING SUSPECTED REACTIONS

 Stop the transfusion immediately

 Check & monitor vital signs
 Maintain IV access
o Do not flush existing IV line & seek new IV access if required
 Re-check
o Blood & patient
 Notify MO & blood bank
ISBAR
EXAMPLE

INTRODUCTION

I’m Susan; I’m the RN who’s been looking after Mrs Reiser post-operatively.

SITUATION

This is Mrs Reiser; she is 58yrs old and has had a left-sided radical mastectomy under a general anaesthetic.

Mrs Reiser returned to the ward 11:30hrs from PARU and has been stable since her return.

BACKGROUND

Mrs Reiser has a surgical history of a cholecystectomy 10yrs prior; breast biopsies as part of her recent
diagnostic series.

Medical history includes mild asthma, which is managed by inhalers. She has not experienced any shortness
of breath during her post-operative phase to date.

ASSESSMENT

Mrs Reiser has been stable postoperatively;

While she is sleeping at the moment, she is easily rousable;

Vital signs are within normal values; Pain has been regularly assessed using the Wong-Baker VAS, recent
score of 4;

PCA of 50mg morphine in 50ml sodium chloride is connected to the IV in her R forearm, with Hartmann’s
solution running 8hrly. Ondansetron 12mg IV prn.

Peripheral sensation is present, with good capillary return and good motor function.

Wound dressing is intact with minor prior leakage; dressing to remain intact for 48 hrs.

10Fr Varivac drain insitu, with minimal drainage; 40mls haemoserous fluid only, with nil drained in past hour.

RECCOMENDATION

Continue to assess pain regularly and encourage use of PCA as required.

PCA requires vital signs observations to be taken hrly.

Monitor for signs of post operative nausea related to PCA, knowing that there’s the Ondansetron available.

Continue with neurovascular observations: cap refill, motor & sensation.

IV fluids to continue with Hartmann’s Solution 8hrly as charted.

Wound & drain assessment to continue hrly in line with vital signs.