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