Preventing injury and error

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Surgical Basics

• Preventing injury and error

Jan Moss, RN
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Agenda

• Pre-operative preparation
• Anesthesia Options
• Intraoperative Considerations
• Patient Identification
• Patient Positioning
• Postoperative considerations
• Pain control
• Infection
• Length of recovery

3
Blah, Blah, Blah

• The table was placed in beach chair
  configuration. Head, neck, trunk and limbs were
  padded and protected in appropriate fashion.
• The right lower extremity was prepped and draped
  in the usual sterile fashion.
• Bilateral upper extremities were prepped and
  draped in standard sterile fashion.

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Types of Injuries

• Wrong site, wrong procedure
• Wrong medication
• Skin breakdown/decubiti
• Burns
• Nerve damage
• Ischemia
• Eyesight

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Pre-operative Preparation

• Testing
• Determines ability to sustain surgical insult
• Determines type of anesthesia delivery
• Blood Pressure, Diabetes, EKG, Liver function,
  CBC, Chest X-ray, UA
• Medications
• Day before surgery, anti-inflammatory
• Day of surgery, antibiotics
• Post op pain meds
• Smoking cessation?

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Patient/Procedure Confirmation

• Surgical Consent
• Pre-operative marking
• Time Out in the operating room

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Anesthesia Choices

• Goals of anesthesia
• Exposure, Relaxation
• Keep patient alive
• Pain free, unaware, stable
• Local Anesthesia
• Regional Anesthesia
• Conscious Sedation
• General Anesthesia
• LMA vs. Intubation

Many photos courtesy of John DiPaola, MD
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Surgical Positioning

• Goals
• Exposure for surgeon
• Immobilize patient
• Injury prevention
• Maintain circulation
• Maintain anatomic alignment
• Prevent pressure points

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Surgical Positioning

• Considerations
• No movement for minutes to hours
• No ability to identify pain
• Sometimes exposure wins out over comfort
• Even supine can be injurious

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Knee Arthroscopy

• Tourniquet
• Leg holder (human and mechanical)
• Apply pressure to open the medial aspect of knee
• Possible complications
• Hip injury
• Circulatory d/t tourniquet, thrombosis
• tourniquet abrasion/skin breakdown
• Quadriceps/hamstring muscle injury
• Non-operative leg

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Tourniquet
Leg Holder
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Non-Operative Leg unsupported
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Item laying on Patient
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Shoulder Arthroscopy

• Beach Chair
• Operative arm is free to be moved. May be held or
  rested. Non-operative arm must be secured
• Head is secured with head rest
• Back of table may be removed
• Patients legs must be positioned bent and
  circulation maintained
• Possible complications
• Cervical
• Axillary nerve, brachial plexus
• Thrombosis

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Head Support
Knees Bent Compression Stockings
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Neck injury Potential?
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Ready to prep
Operative arm is vulnerable
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Skinny Model
Add 150 lbs imagine the injury potential
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Spinal Surgery Positioning

• Prone
• Positioning tables
• Supine (infrequent)
• Possible complications
• Cervical
• Axillary nerve
• Pressure Points
• Genital trauma
• Facial trauma

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Patient induced on back and then turned Process
reversed at the end of procedure
Arms supported Face in cradle
Gel pad under knees
Elevated frame
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C-Arm
Table is adjusted to get C-arm under tippy!
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Challenges to positioning

• Obesity
• Trauma
• Pre-existing conditions
• Arthritis, amputation, injury
• Diabetes
• Cardiac/Vascular disease
• Smoking

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Documentation

• The table was placed in beach chair
  configuration. Head, neck, trunk and limbs were
  padded and protected in appropriate fashion.
• The right lower extremity was prepped and draped
  in the usual sterile fashion.
• Bilateral upper extremities were prepped and
  draped in standard sterile fashion.

24
Postoperative Care

• Pain Control
• Pain affects blood pressure, vital signs
• Narcotics affect respiration
• Pain control is a chemical balance
• Challenges in pain control
• Surgical procedure, duration
• History of prior medication use
• Age, co-morbidities
• Experience with pain

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Recovery Times

• Any surgery, requires recovery
• Routine post op MD appt in 1 week
• Generally speaking
• Knee 1week-6mo
• Shoulder 4-6 mo
• Back 3mo
• Infection, complications will delay recovery
• Smoking complicates everything

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Questions?

• Jan Moss, RN
• GENEX Services, Inc
• jan.moss_at_genexservices.com
• [phone]