June 4, 2014

Neil Vincent J. Sanico, M.D., DPBS

 Be on time
Dress in a professional
Be pleasant

manner

Do not challenge a treatment plan/diagnosis

Im sorry I dont quite understand, could

you please explain?

Be empathetic towards patients

Be

aware of Heirarchy

Ward questions Interns/residents

Medical Questions - Attending

 Address

patients and staff in a

respectful way
Sir, Mam, Mr., Mrs., Miss
Attendings Doctor

Take

Responsibility for your patients

Know there is everything to know abut your

patient
Never give bad news to your patients
Be
Be

a Team player
Honest

 All

patients have the right to have

their personal medical information
kept private
All patients have the right to
refuse treatment
Exception no capacity to make

decisions; suicidal; homicidal

All

patients should be informed of

the right to seek advanced
directives on admission

proper history
and physical
exam will arrive
at a diagnosis
70% of the time
Introduce
yourself

 General

Data

Name, Age, sex,

occupation, etc..

Chief

Complaint
Pain, lump/mass,

weight loss,
anorexia,

Pain
Pnemonic (OLD CARTS)

O onset
L location
D Duration
C Character ( sharp, dull,
stabbing,
aching,
burning)
A Alleviating/aggravating
factors
R radiation
T Timing (intermittent,
continuous)
S Severity (scale 1-10)

 Lump/mass/lesion
Location
How/When did you notice

it?
Change in size/color of the
skin
Pain?
Discharge/Bleeding?
Affecting function/daily
activities?
Any other ones?

 Constitutional

Symptoms
Weight

loss/gain
Fever/night
sweats
Anorexia

 Past

Medical History

Diabetes, Hypertension, Asthma, etc..

Past

Surgical History

Operations in the past? What? Where?

When?
Any Complications?
Medications taken
Pregnant?
Allergies
Smoking/alcohol intake?

 Review

of systems

GI
Respiratory
Cardiovascular
Urogenital
Nervous
Musculoskeletal

 Pre-operative

evaluation

What does the patient

need in order to undergo

the operation with the
lowest risk possible?
Type of anesthesia
Optimization of any
medical problems
Cardi0-pulmonary risk
assessment
Other organ assessment

 For

a patient less than 35 years old with no

cardiac history: Obtain elec- trocardiogram
(ECG); if normal, no further workup
required

For

a patient of any age with cardiac

history, or for an older patient: Obtain ECG;
consider stress test and echocardiogram
Goldmans risk assessment for noncardiac
surgery

 Up

to 35% of Post operative deaths

are due to Pulmonary Complications

 Liver

High Risk for Cirrhotic Patients

Utilize Child-Pugh Classification of Operative

Risk
Operative Mortality Ranges from 2-80%

 Kidney

 CBC

platelet ct, Prothrombin Time, aPTT

Thrombocytopenia

 NPO
To decrease the risk of aspiration with

intubation, patients should re- frain from

solids 68 hours prior, and from liquids
23 hours prior to surgery.
In bowel surgery, when patients require
bowel preps, the duration of NPO may be
preceded by a day of clear liquids only
with the prep to clear the bowel of stool
and facilitate the operation.

 Bowel

Preparations

Purpose: To clear bowel of stool, thereby

reducing bacterial count and risk of

contamination with fecal spillage.
Types:

Mechanical prep: Facilitates operation.

Oral antibiotics

 Usual

medications

Aspirin: Avoid for 10 days preoperatively

to allow platelets to regenerate.

Hold Clopidogrel (Plavix) for 7 days
Antihypertensives: Continue,
especially -blockers; hold diuretics the
morning of surgery.
Antithyroid medications: Hold on
morning of surgery.

 Surgical

Hand
Antisepsis
Process of removing as

many microorganisms
as possible from the
hands and forearms by
mechanical washing
and chemical
antisepsis before
participating in a
surgical procedure.

Water flows down so

hands should be held
above the level of
the
elbow both during
the scrub and rinsing
if a surgical hand
scrub is
used. Contact with
the faucet or other
potential

 Gloving

and Gowning

Following completion of the surgical hand

antisepsis, it is important to correctly don

a sterile surgical gown and sterile gloves
Gowns are only considered sterile in the
front from the axilla (armpit) to the level
of the sterile field and sleeves from 5cm
(2inches) above the elbow to cuff. The
neckline, shoulders, under arms, sleeve
cuffs and the back are considered
unsterile

 Sterile

drapes
used to cover
surfaces or
operative fields
shall provide a
barrier against
micro-organisms,
liquids, and
particulate matter

 Anesthesia

- a technique using
drugs (inhalational, intravenous
or local) that renders the whole
or part of the organism insensible
for variable periods of time.
Analgesia - the loss of pain
sensation
Hypnotic agent - a sleep-inducing
drug

 Muscle

Relaxant - a drug that

reduces muscle tension by affecting
the nerves that supply the muscles
or the myoneuronal junction (e.g
curare, succinylcholine)
Sedation - the production of a calm
and restful state by the
administration of a drug.

 Local

Anesthesia any technique to

induce the absence of sensation in
part of the body, generally for the
aim of inducing local analgesia
Common agent: Lidocaine

 Regional

Anesthesia - relies upon

blockage of nerve impulses or spinal
transmission of impulses to induce
analgesia and immobility.

 Regional

(NeuroAxial block)
contraindicated in patients with
anticoagulants
Epidural Anesthesia - local anaesthetic is

injected as a bolus or via a small catheter into

the epidural space. It can be used as the sole
anesthetic for surgery below the waistline
Spinal anaesthesia local anesthetic is injected
into the CSF in the subarachnoid space. The
extent and duration of anesthesia depend on
the position of the patient, the specific gravity
of the LA and the level of injection

 General

Anesthesia - relies upon

generalized suppression of some
functions of the cerebral cortex to induce
a generalized state of insensibility.

An

incision is made to access the surgical

site.
Blood vessels - clamped to prevent bleeding
retractors - expose the site or keep the
incision open
The surgery may involve several layers of
incision and dissection, as in abdominal
surgery (laparotomy), where the incision
must traverse skin, subcutaneous tissue,
three layers of muscle and then peritoneum

 In

certain cases, bone may be cut

sacrificially or for further access

 Blood

and/or fluid expanders (colloid)

may be administered to compensate for
blood lost during surgery
Once the procedure is complete, sutures
or staples are used to close the incision
Once the incision is closed, the
anesthetic agents are stopped and/or
reversed, and the patient is taken off
ventilation and extubated (if general
anesthesia was administered).

 Excision

- the complete removal of an

organ, tissue, bone or tumor from a
body
Usually ends with the suffix ectomy (e.g.

Gastrectomy, Cholecystectomy, etc)

Incision

and Drainage- are minor

surgical procedures to release pus or
pressure built up under the skin, such
as from an abscess, boil, or infected
paranasal sinus

 Debridement

- is the surgical removal

of dead, damaged, or infected tissue
to improve the healing potential of
the remaining healthy tissue
Grafting - refers to a surgical
procedure to move tissue from one
site to another on the body, or from
another person, without bringing its
own blood supply with it.

similar technique where tissue is

transferred with the blood supply
intact is called a flap
In some instances a graft can be an
artificially manufactured device
skin, bone, nerves, tendons,
neurons, blood vessels, fat, and
cornea are tissues commonly grafted
today

 After

surgery, the patient is

transferred to the post anesthesia
care unit and closely monitored
Vital signs, urine output (0.5-1 cc/kg/hr),

Sensorium, etc
Patient

are then transferred to a

regular room or ICU for close
monitoring

 Fever
5Ws of Post-Op

Fever
Wind most
common cause of
fever Day 1
Water (UTI)
Wound
Walking (DVT)
Wonder Drugs

 Wound

Infection

Classic signs
Calor (heat, warmth)
Rubor (redness)
Tumor (swelling)
Dolor (pain)
More severe infections may produce

systemic symptoms such as fever, chills,

and rigors
Unusual for a wound infection to cause
fever before postoperative day 3

 Hematoma

- Collection of blood that may

form in the vicinity of a surgical wound.

 Seroma

- Collection of fluid in the

vicinity of a wound that is not blood
or pus
Due to creation of a potential space

combined with disruption of local

draining lymphatic channels

end of part 2