Surgery II Lab Practical

The scenarios won't fit the narrow width of this blog, so you can see the it in a document format at:
https://docs.google.com/etc

Abscesses:

• result from wounds sustained at least 3 days ago
• Step 1: surgical debridement
• don gloves and face mask
• surgically prep the puncture site
• use scalpel blade or hypodermic needle to lance abscess usually where original puncture was
• empty the abscess
• lavage with 1:40 dilution of Chlorhexidine
• remove necrotic tissues
• suture edges of wound if it's large
• create 2 new holes for Penrose drain to enter and exit, keep gravity in mind when choosing the location
• insert drain and suture on both ends
• clean drain site daily
• remove drain within 3 days
• remove drain as you would sutures so that nothing that's been outside the wound gets drug back through the wound upon removal
• Step 2: medical treatment
•  antibiotics

 Caution Numbers:

• HR: below 80Bpm
• RR: below 12 bpm
• CRT: under 1sec or over 2sec
• T: under 99F or more than a 2 degree drop
• Doppler, Systolic: below 100mmHg
• Doppler, Oscillometric: below 80mmHg
• CVP: 8cmH2O
• ET CO2: less than 25mmHg or over 45mmHg
• SpO2: 90%

 Cleaning/autoclaving:

• Autoclave 121C/250F 15 PSI 15min
• Flash Autoclave 133C/272F 35PSI 1min
• Detergents:
• Ethylene Oxide 1-18hrs + 24-48hrs to vent
• NOT inactivated by organic materials: Phenols (Pine-Sol), Biguanides (Chlor-Hex)
• Sporicidal:  Chlorine (Bleach), Aldehydes (Cidex)
• Scrubbing:
• fingernails
• wash w/ soap
• scrub fingertips, fingers, then hand  on hand  #1 (20 strokes on each surface)
• scrub fingertips, fingers, then hand on hand and wrist area of hand #2
• scrub wrist area of arms, then elbow area of arm #1
• scrub elbow area of arm #2

CPR:

• start in right lateral recumbency
• do compressions about where the elbow rests
• at costochondral junction
• compress no more than 30% to avoid cracking ribs
• thoracic pump: do compressions in time with breaths
• in dorsal recumbency, compressions are done on caudal end of sternum and at an angle down and cranial
• never stop for more than 10sec for any reason
• compressions contraindicated with:
• rib fracture
• pleural effusion
• pneumothorax
• cardiac tamponade

Drugs:

• Analgesics:
• Ketamine/Telazol
• A2A's
• Butorphanol
• Controlled:
• Diazepam
• Torbutrol
• Butorphanol
• Morphine and derivatives
• Fentanyl
• Ketamine

Equipment:

• Manometer max for giving breath: 20cmH20/14mmHg
• Manometer max for regular use: 4cmH20/2-3mmHg
• F-tubes: blue inner tube = inspiration, clear outside = exhalation
• Staining:
• Black/White spots = minerals in water
• Corrosion = wet, dry time cut short?
• Rust deposits = hard water, corrosion
• Blue/Grey = reverse metal plating, in cold sterile too long, chlorhex residue, exposure to saline?
• Brown/Orange w/o pitting = iron in water, high pH detergent
• Dark Brown = dried blood
• Multi-color = excessive heat exposure
• Read flow meter at center of ball, or at top of bobbin.  If there are 2 balls, there should be 2 scales, the top ball will read on the smaller scale, the bottom on the larger scale.
• APM, Audio Patient Monitor: esophageal stethoscope w/ speaker to amplify the sound.
• Direct BP monitor(MAP, Mean Arterial Pressure -most accurate) inside body (uncommon),atrial or CVP which must be measured on expiration.
• Indirect BP monitor = Doppler or Sphagnometer: hold the part with the reading at the animal's heart level; the 1st sound is systolic, 2nd is diastolic; not accurate, so take 5 readings, eliminate the highest and lowest, then average the other 3.
• Ocillometer -gives digital readout, measures size change.  Cuff size: width more important than circumference, width should be 40% of the circumference of the limb it will be used on.
• Laser: Think of the laser workpiece as looking like a mechanical pencil.  If you take the lead out, the "lead" is the tip and the empty pencil is the laser handpiece.

Math:

• # of L of O2 left in an H tank:  psi x 3.3
• # of L of O2 left in an E tank:  psi x 0.3
• Reservoir bag:  5-6 x tidal volume, always round up
• Tidal volume: 10ml/kg minimum
• 2.5% = 25mg/mL
• 1:1000 = 1g/L? = 1mg/mL?
• max lidocaine for cats= 4mg/kg (3 spots per paw)
• fluid deficits =  % lost x kg (10% of 20kg = 2kg = 2L lost)
• Fluid rates
• shock in dogs = 60-90ml/kg/hr
• shock in cats = up to 60ml/kg/hr
• maintenance = 40-60ml/kg/day
• surgery = 10ml/kg/hr
• drip rate: (calibration x volume)/time
• max potassium rate =0.5meq/kg/hr

Oxygen supplementation:

• flow-by
• face mask
• nasal prongs
• tube pointed at nose/mouth
• oxygen tent
• zip-lock bag
• e-collar
• oxygen cage
• nasal catheter -for longer term administration
• numb nostril
• measure tube from nose to medial canthus
• mark tube w/ tape
• lube tube
• insert tube when at leats 4min have passed since numbing
• suture a loop next to the nose
• suture tape on tube to suture loop through skin
• secure tube above forehead with tape?, glue? or more suture

 Suture Patterns:

• simple interrupted -J-J-J-
• uninterrupted/continuous -/-/-/-
• horizontal mattress = = =
• vertical mattress -| -| -|-
• cruciate/cross mattress  -X-X-X-

Triage:

• Airway
• make sure patent
• clear obstructions
• place ET tube
• Heimlich?
• tracheostomy?
• Breathing
• O2 supplementation
• manual ventillation?
• mouth to snout?
• Circulation
• IV catheter, fluids
• hemorrhage control
• CPR
• Drugs
• bolus IV drugs with 10-20cc saline
• dilute intratracheal drugs with 5-10cc sterile water
• Exam/Electrical Defibrillation
• defibrillation is only for v-fib or v-tach
• Follow-up

• Immediate:
• airway obstruction
• cardiac or respiratory arrest
• DOA
• Critical:
• respiratory or cardiac distress (pulmonary edema, arrhythmias)
• shock
• active bleeding (arterial or venous)
• active seizuring
• Serious:
• large wounds, compound fractures, traumatic injury
• bloat (GDV)
• toxin ingestion
• blocked male cats
• puppy and kitten sickness/weakness
• Less Serious:
• fractured tooth, toenail injury, URI, etc

 Misc:

• MAC:  high MAC = high safety = less potent = more required to maintain anesthesia
• Methoxyflurane is nephrotoxic
• Halothane is hepatotoxic
• Intubation:
• size according to width of space between nares
• ready one size smaller as well just in case
• check for leaks
• measure to thoracic inlet on the animal
• lube
• push epiglottis down with ET tube
• push down while inserting tube between arytenoid cartilage/vocal folds and into trachea
• tie in
• verify it's in place:
• watch for fogging INSIDE the tube
• palpate neck, if you feel 2 tubes, it's in the esophagus
• watch for bag movement during breathing
• listen to lung sounds on both sides
• Prep:
• cat spay:  midway between umbilicus and pubis bone
• dog spay: 1/4 to 1/3 down from umbilicus
• Review nerve block sites
• Monofilament:
• less traumatic to tissues
• does not wick
• Multifilament:
• greater strength
• holds knots better
• less memory (easier to work with)
• Storage times for packs:  4w muslin, 6m paper, double if double-wrapped
• Black handled instruments are "extra sharp", but dull more quickly.
• Gold handled instruments hold their edge longer  and have stronger gripping surfaces
• Osteotome has a point at it's center, slices bone.
• Bone chisel has it's point off-center and is used to chip away bone.
• O2 flow by: connect O2 to flow meter to outlet to patient (ET tube, mask, etc)
• ECG:
• measuring mv: 10cm = 1mv  (at standard calibration)
• if not standard, squared off wave = 1mv
• complexes are measured in height (mv) and width (sec)?
• intervals are measured in width (sec) only ?
• lead placement
• front: just proximal to elbow (on the caudal aspect)
• rear: just proximal to stifle (on cranial aspect)
• precordial clip goes on end of sternum
• Tourniquet placement:
• front: proximal to elbow, metal clasp over tricep (caudal aspect, not medial or lateral)
• rear: proximal to knee, metal clasp lateral or medial (check) 
• Landmarks for Ortolani's sign:  ischium and greater trocanter