Chapter 11- hemostasis, wound healing, and wound closure

multifilament ties

SHOULD BE SUT 1/8IN DUE TO ITS INABILITY TO SLIDE

inflammation

is the body's protective response to injury or tissue destruction.(inflammation occurs when n injured tissue releases histamine from the damaged cells)

hemophilia

is the most common congenital bleeding disorder.

Laparotomy sponge

lap sponges or tape sponges

fascia staplers

not much different than skin staplers and are disposable staplers shaped like a gun and discharge single wide stainless steel staples into tissue

second intention (granulation)

occurs when a wound fails to heal by primary union. Granulated tissue forms the wound causing closure by contraction. The wound heals from bottom up leaving a weak union and wide irregular scar, that may result in herniation

infection

occurs when microbial contamination overrides the resistance of the host

first intention

occurs when wounds have been approximated and eliminated dead space. Healing occurs side to side

blood replacement

often used in cardio and prostate procedures when blood loss is high. Involves admin of WBC,RBC, and Plasma. Either donated homologous (another person) or Autologous (yours) usually stored in blood bank and cross matched

clips

often used in place of suture ligatures for small vessels that are needed to be ligated for short period of time (titanium, stainless steel ,or plastic materials)

arterial or venous/cannula needle

assemblies employ a needle to introduce a plastic indwelling catheter into a vessel(used commonly in IVs)

classification of suture materials

classified as absorbable ,nonabsorbable as well as material wise ,monofilament, or multifilament (mulit should not be used in presence of infection due to the material having the ability to harbor bacteria)

suture complications

either a failure to properly absorb the suture or an irritation caused by a suture that results in inflammation, most frequently with SILK

ligating dividing stapler

ejects 2 ligating clips side by side and then divides the tissue btw the clips with a single activation. Useful in gastrointestional

when is blood loss monitored ?

intraoperative, by all parties (surgeon, circulator, and cst) (cst keeps tract of the irrigation fluids used)

Ideal wound healing

involves restoration of continuity, strength, function, and appearance to the tissue.

argon plasma coagulation

involves the use of argon gas in combination with monopolar electrical energy in the form of white light beam

French-eyed needle

loaded by pulling the taut strand into a v-shaped area just above the eye.

HEMATOMA

localized swelling filled with blood resulting from a break in a blood vessel

packaging of suture

lot #, surgical application, product code #,suture size, material , and size of needle, length & color, expiration date, shape, and quantity of needles, (needles are written in red)

bone wax

made of refined and sterilized bees wax, used as a mechanical barrier to seal off oozing blood

pooled-donor plasma

manufactured from multiple donors. Fibrin must be cleansed and viruses destroyed. Only used in Europe , the US has not approved yet.

granuloma`

mass of inflamed granulation tissue, usually associated with ulcerated infections

seroma

mass or swelling caused by the localized accumulation of serum w/in a tissue or organ that can sometimes develop after surgery. When small vessels rupture blood plasma can seep out.

split lead shots

may be clamped onto the ends of subcuticular sutures after skin closure

hemorrhage

may be concealed or evident and occurs most frequently in the first few postop hours. Usually results in postop shock

eyeless needles

may have a single arm attached or double arm

closed eye needles

may have round or square holes and are loaded by inserting the end of the suture material through the hole.

Laser

provides an intense and concentrated beam of light that is able to cut and coag tissue at the same time with very little surrounding tissue destruction

extracorporal method

refers to creating a knot outside the body prior to instrument transfer through the trocar cannula to the tissue site

intracorporeal method

refers to the surgeon using instruments inserted through a trocar cannula to facilitate the internal suturing of tissues and knot tying, ie endoloop, endostitch

herniation

result of wound dehiscence and occurs most often in lower abdominal incisions. Usually discovered 2-3 months postop and could result in a bowel incarceration

tonsil sponge

round sponge

closing the skin

with interrupted or continuous monofilament, nonabsorbable sutures on a cutting needles or with stainless steel staples. Polypropylene, or nylon are preferred

figure of 8 stick tie

tissue or vessel to be tied is held with a hemostat, the surgeon throws the first knot ,it is then passed back and forth through the tissue around the 2 sides of the clamp> then tied

preferred suture for closure in orthopedic/ abdominal fascia procedures

#1 & #0

ligature for deep bleeders

between 18-30 inchs

ligatures and ties

(stick ties when needle is attached) strands of suture material used to tie off blood vessels, either natural or synthetic, which can either dissolve over time or permanent.

class 3- contaminated wound

-acute inflammation present -major break in sterile techn -open traumatic wound(less than 4hrs old) with retained necrotic tissue -entry to aerodigestive or genitourinary tract with spillage

class 4- dirty/infected

-perforated viscus -microbial contamination prior to procedure -open traumatic wound(more than 4 hrs)

class 1 - clean wound

-primary closure -no inflammation is encountered -closed wound drainage device if necessary -incision made under ideal surgical conditions -no break in sterile techn during a procedure -no entry to aerodigestive or genitourinary tract

class 2-clean contaminated wound

-primary closure -open/mechanical drainage -minor break in sterile techn occurred - controlled entry to aerodigestive or genitourinary tract

benefits of skin staplers

1- less tissue reaction 2- accelerated wound healing 3-less operating and anesthesia time 4-efficiency

disadvantages of skin staplers

1-cost 2-precisions

Phases of the clotting process

1. platelets adhere to subendothelium of vessel walls 2. platelets release ADP 3. release of ADP causes further layers of platelets to adhere 4. platelets aggregate forms a thrombus 5. permanent thrombus forms after clotting factor reaction

ligatures for superficial bleeders

18 inch in length typically

conventional cutting needles

3 cutting edges that are directed along the inner curve of the needle

subcuticular skin closure suture size

3-0 & 4-0

size for dural incisions

4-0

suture size for aortic anastomosis

4-0 & 5-0

raytec

4X4

suture size for smaller vessel anastomoses

6-0 & 7-0 (coronary or carotid arteries)

suture size for microvascular and eye procedures

8-0 & 11-0

pts physical condition

AGE, ALLERGIC RESPONSE, NUTRITIONAL STATUS, OBESITY, DISEASE (chronic/acute) SMOKING,IMMUNOCOMPROMISED

EXTERNAL FACTORS

DRUG THERAPY, FLUID OR ELECTROLYTE BALANCE, HEMATOLOGY,RADIATION EXPOSURE

thermal hemostasis

Is the most common means of obtaining hemostasis during a surgical procedure is the use of heat

Autotransfusion

Is the reinfusion of the patients own blood. Is achieved by a cell saver or cell salvager machine. Blood may be drained from bloody sponges into a basin of saline and aspirated into the auto transfusion machine. Any blood exposed to collagen hemostatic agents antibiotics, gastric or enteric contents and cancer cells should not be put into cell saver

SUTURE TECHNIQUE AND PREVENTION OF INFECTIONS

SUTURE SITE INFECTION -INCISIONAL INFECTIONS, NOSOCOMIAL INFECTIONS, AND DEEP WOUND INFECTIONS PREVENTION OF WOUND INFECTION -DRESSING, WOUND DRAINS, TISSUE PERFUSION,BOWEL TECHNIQUE, WOUND IRRIGATION,ANTIBIOTIC THERAPY,STANDARD PRECAUTIONS, CONTOL ENDOGENOUS INFEFCTION, REDUCE SOURCES OF CONTAMINATION INTRAOPERATIVE TISSUE HANDLING -WOUND SECURITY,TISSUE HANDLING, STERILE TECHNIQUE, DURATION OF SURGERY, METHOD OF HEMOSTASIS, ELIMINATION OF DEAD SPACE, LENGTH OF DIRECTION OF INCISION, DISSECTION TECH

classification of severity of unintentional wounds

Traumatic injury-

blood types and groups

Type A- produces anti-B agglutinins Type B- produce ant-A agglutinins Type O- both B and A agglutinins (universal donor) Type AB- neither A or B agglutinins(universal recipient ) and Rh factor must be checked as well or else hemolysis will occur

vascular clamps

Used for delicate tissue and causes little damage

pursestring stitch

a drawstring is placed in a circular fashion around a structure in such a way that pulling on a suture ends tighten and close the opening. used in the right atrium and ascending aorta for introduction of cannulae for cardiopulmonary bypass

another classification of traumatic wounds by mechanism injury

abrasion- scrape contusion-bruise laceration- cut/tear puncture- penetration thermal-hot/cold

Chemical hemostasis

absorbable gelatin (gelfoam) absorbable collagen (avitene) microfibrillar collagen oxidized cellulose (Nu-Knit, and Surgi-Cel) silver nitrate epinephrine and thrombin

skin closure tapes

are adhesive-backed strips of nylon or polypropylene tapes used to reinforce a subcuticular skin closure or approximate wound edges of small incisions or superficial lacerations when sutures may not be necessary

suture anchors

are for ortho surgery for fixing tendons and ligaments to bone

retention sutures

are large gauge, interrupted, nonabsorbable sutures that are placed lateral to a primary suture line for wound reinforcement

bolsters

are pieces of plastic or rubber tubing threaded over the retention suture ends before the ends are tied.

buried stitch

are placed so the knot is located under the layer to be closed and is not projecting outward

bridges

are plastic devices that bridge the closed incisions

chronic wounds

are those that persist for an extended period of time

cutting needles

are typically used for the sclera of the eye, tendons, or skin

intraluminal staplers

are used to anastomose tubular structures w/in the gastrointestional tract. Used more in distal colon and rectum procedures

skin staplers

are used to approximate skin edges during skin closure usually 35 wide or regular width staples

clamps

are used to compress the walls of vessels and to grasp tissue. (hemostat)

stick ties

are used to prevent suture slippage that can lead to uncontrollable hemorrhaging. for superficial bleeders- 18 in stick ties are used, for deeper vessels-27in are use

traction suturing

are used to retract a suture that may not be easily retracted w a conventional retractor instrument, nonabsorbable sutures are used and ends are clamped with a hemostat used in sclera of the eye, myocardium of the heart and tongue.

irrigation needles

aren't actually needles but small diameter cannulated tubes attached to a plastic needle hub for placement on a syringe. Used during eye and microsurgery

tensile strength

at about the third month plateaus is about 70-80% of original strength

heparin needl

attached to syringes and are used in cardiovascular procedures to irrigate open arteries with saline-heparin solution

phase 3-maturation or differentiation phase

begins on the 14th postop day and last until wound is completely healed. Scar forms with a pale tissue color called cicatrix.

phase 1- wound healing by first intention

begins within minutes of injury to 3-5 days. Inflammation occurs and a scab forms.

tapercut needles

combine a sharp taper point with a cutting tip used primarily in vascular tissue

edema

condition of abnormally large fluid volume in tissues between the bodys cells, can be either too much fluid or too little which then causes swelling

what effects the patients ability to naturally form blood clots?

congenital hemostatic defects and acquired hemostatic disorders

ultra sonic (harmonic) scalpel

consists of a single use titanium blade attached to a hand piece and a portable generator. Converts to mechanical energy and causes the blade to move by rapid ultrasonic motion which cuts and coags simultaneously. The movement causes it to produce a sticky coagulum that seals the vessels.

patties

cottonoids smaller compressed radiopaque sponges used in neuro

gangrene

decay or death of a organ or tissue caused by lack of blood supply

ischemia

deceased supply of oxygenated blood to a body part

wound drains

designed to remove fluids or gases from the body. Intraop,postop,preop

kittners and peanuts

dissection sponges (small tightly rolled sponge)

simple interrupted stitch

each stitch is individually placed, tied, and cut for the length of the wound. Wound is approximated and everted

proud flesh

excessive granulated tissue

wound tension

excessive tension on the wound edges caused by heavy lifting or straining, or the wound being located on a highly mobile or high tension area such as the back, shoulders,legs

pressure devices

external pressure to occlude the flow of blood until a cot can form. (tourniquet) This alone doesn't achieve hemostasis.

types of wound healing

first intention( primary union), second intention (granulation), third intention (delayed primary closure)

exudate

fluid with high content of protein and cellular debris that has escaped from blood vessels and has been deposited in tissue or on tissue surfaces, usually as a result of inflammation

ligature reels

for absorbable- subcutaneous tissue. Most commonly used reels are chromic, plain,or polyglactin 910 sutures in sizes 2-0, 3-0, and 4-0

endoscopic suturing

has 2 methods extracorporal, and intracorporeal

blunt point

have a round shaft at the end in a blunt tip primarily used for kidney or liver due to tissue being so friable or weak

regular tapered point needles

have a round shaft w/o a, so they penetrate tissue w/o cutting it. Used for delicate tissue such as gastrointestinal tract

vessel loops

have for the most part replaced umbilical tape as isolation/ retraction devices for vessels, nerves, or ducts. Are used for delicate structures. white & yellow loops are for nerves and ducts, red are for arteries and blue are for veins.

arterial needles

ie potts-Cournand needle/cannula assembly, used to introduce diagnostic or angioplasty guiding catheters over guiding wires into the arterial system

hemolytic transfusion reactions

if blood isn't properly matched is can be fatal. Conscious patients exhibit- rapid pulse, shortness of breath, pounding of heart, jaundiced and pallor mostly on palms. Unconscious patients do not show those signs - general loss of blood, lowered blood oxygen saturation level due to RBC inability to carry oxygen. if occurs blood transfusion must stop and sample sent to lab to determine mismatch. Urine output must be closely monitored as hypervolemia may hinder kidney function

intentional wounds

include chemical, occlusion banding, surgical site incision or excision. Incision- intentional cut excision- removal of tissue. occlusion banding- intentional wound that results from ischemia of tissue by means of banding.\ chemical- most used in plastics but overall uncommon form of intentional wound, is placed on skin in effort to denude or coag the area (often causes Inflammation and reepithelialization)

Unintentional Wound

include traumatic injuries, closed wounds, and open wounds

fibrin glue

is a biologic adhesive and hemostatic agent. the cst mixes the calcium chloride and thrombin in a specimen cup and draws the solution into syringe and attaches a 14 gauge IV catheter and cryoprecipitate is drawn in another syringe. The surgeon is handed one syringe and discharges and simultaneously the cst discharges the other syringe.

closing the peritoneum

is a fast healing, thin membrane lining the abdominal cavity may nit req suturing if posterior fascia is closed properly. a continuous 3-0 absorbable suture is frequently used

continuous or running stich

is a primary suture line consisting of a single strand of suture placed as a series of stitches often used for closure of a long incision. Should not be used on tissues that are under a lot of stress

subcuticular stitch

is a single suture technique at the end of wound; multiple subcuticular bites are made opposite ends other the length of the wound. Are usually reinforced with dermabond or steri strips

skin adhesive

is a sterile liquid that is applied topically after the area has been cleaned and remains 5-10 days after and comes off naturally

closing the subcuticular layer

is a tough layer if connective tissue beneath the skin and subcutaneous layer. Is often utilized to minimize scarring. Short lateral stitches are placed in a continuous or interrupted fashion just under the epithelial layer of skin, with absorbable sutures

closing the fascia

is a tough layer of connective tissue covering the bodys muscles. It heals slowly and endures the brunt of wound stress. therefore interrupted heavy-gauge, nonabsorbable multifilament suture is preferred. If fascia is weak polypropylene surgical mesh may be sutured in w polypropylene sutures

interrupted horizontal mattress

is a two-bite suture technique. The first bite is a simple the second bite is placed parallel to the first bite and travels back across the wound edge to end on the same side as the first bite.

Autologous and homologous

is a type of fibrin glue that must be warmed at 98.6F drawn up separately and released simultaneously

adhesion

is an abnormal attachment of 2 surfaces or structures that are normally separate

fistula

is an abnormal tract between two epithelium-lined surfaces that is open at both ends. occurs most often in bladder, bowel, and pelvic procedures. Abnorm drainage is common

phase 2- proliferative phase

is approximately the 3rd postoperative day and continues for 20 days. Fibroblasts multiply and bridge the wound edges. ~25-30% of orig tensile strength. On the fifth to eighth day the capillaries and lymphatic networks are reformed.

Wound

is described as any tissue that has been damages by surgical or traumatic means

Hemostasis

is stopping the loss of blood (clot formation, pressure, ligation, or hemostatic agents)

Electrosurgery

is the most commonly used thermal hemostatic device (electrode and bovie pencil)

secondary suture line

is useful for support of the primary suture line

what is the rule of thumb in regards to suture ?

it should be as strong as the tissue on which is it being used (tensile strength)

keloid scar

keloid formation is a hypertrophic scar formation and occurs most frequently in dark-skinned individuals

Handling of blood replacement components

most common type of homologous blood replacement is packed red blood cells (PRBC) and should be stored at 1-6C or 33.8-42.8F. Individuals must read out loud while others check and verifies information. Bag must be checked for expiration date and clots. Doctors orders should be double-checked as well

Acquired hemostatic disorders

most commonly seen in the OR (liver disease, anticoagulant, ie heparin and warfarin and aplastic anemia.)(can be requested that the pt not take aspirin one week prior to surgery)

surgical needles

must be smooth and free of burrs and have the characteristics of- eye,point,body

loading the suture

must choose the appropriate needle holder, loaded 1/3rd the distance of the swagged end of needle. Do not tug and when passing the needle holder and suture w needle are pointed toward surgeons chest.

ligated vessel ties

must use the smallest possible diameter in order to reduce tissue reaction, and are placed at the base of a hemostat then clamp end of vessel>hemostat removed>ligature tightened>tied>cut ends as close as possible (monofilament material ends are cut 1/8 inch long from the knot)

reverse cutting needles

opposing cutting edges in a triangular configuration that extend into the full length of the shaft.

incidental wounds

or iatrogenic wounds, wounds that happen as a result of therapy or treatment

continuous running/ locking stitch

or the blanket stitch. Increases wound edge eversion and reduces the skin tension more than simple continuous

interrupted vertical mattressq

or the two bite suture techn. first bite is placed close to the wound edge, the 2nd bite is placed slightly behind the 1st bite and deeper in the tissue

ligatures

or ties. Used to occlude vessels for hemorrhaging

what are the classic signs of inflammation?

pain, heat, redness, swelling, and loss of function

dehiscence

partial or total separation of a layer or layers of tissue after closure is seen most often in friable tissue

side cutting needles

primarily for ophthalmic procedures bc they will not penetrate into deeper tissues and separate the tissue layers during placement

evisceration

protrusion of the viscera through the edges of a totally separated wound

monofilament ties

should be cut 1/4in ends due to knots ability to slide

other names for hemostat

snap, clamp, crile, stat

alternative skin closure methods

surgical zipper, cyanoacrylate ie dermabond

button holes

tendon sutures may be pulled through these . and tied over the button to prevent tissue damage

Coagulation

the body uses this in order to stop blood flow. (thrombus, or clots), is naturally occurring

factors that influence wound healing

the physical condition of the patient , external factors, suturing techniques and prevention of wound infection

what is a way the circulator can monitor blood loss?

they must weight the sponges (that were used)

closing the muscle

typically not closed with suture bc they do not tolerate the material well. If incised they must be loosely approximated with interrupted absorbable sutures

third intention (delayed primary closure)

typically used for traumatic wounds that need debridement and are purposely left open to heal by second intention for ~4-6 days. They are treated with systemic antibiotics. It then is closed and allowed to start the healing process through first intention. Works well for CONTAMINATED OR DIRTY WOUNDS

simple continuous stitch

used for long straight incisions when the wound edges easily evert.

sponges

used to apply pressure on bleeding areas or vessels (absorb blood)

meshes and fabric

used to bridge for tissues that cannot be brought together w/o placing a great deal of tension on the tissue or to reinforce fascia defects

hypodermic needles

used to inject medications into tissues or intravenous tubing

linear staplers

used to insert 2 straight, staggered ,evenly spaced, parallel rows of staplers into tissue, used to be transected w/in alimentary tract or thoracic cavity and other procedures

biopsy needles

used to obtain tissue samples w/in the body for biopsy

ligating clips

used to occlude a single small structure such as a blood vessel of a duct. Must be divided and have at least two individual clips placed, the structure is then divided by a scalpel or scissors . Useful in endoscopic procedures especially cholecystecotomy

linear cutters

used to staple and transect the tissue, it delivers 2 double staple lines and contains a knife blade that passes btw the 2 staple lines dividing tissue . Used for gastrointestional procedures

pledgets

used when bleeding occurs through needle holes in vessel anastomosis, small squares of Teflon(pledgets) are used as buttresses over suture line. Sewn over holes to prevent bleeding. Used in cardio and peripheral vascular cases

factors that may modify the normal condition of tissues

vitamins, proteins, dehydration, carbohydrates, vascularization, radiation therapy, metabolic factors, age, weight, incision relative to fiber direction, thickness of tissue at a given time, amount of devitalized tissue w/in a wound, edema

umbilical tape

was once used to ligate the severed ends of the umbilical cords after child birth. Is best used moistened with saline and loaded on a hemostat