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Principles of Sterile Technique

1. Only Sterile Items Are Used Within the Sterile Field. 2. Gowns Are Considered Sterile Only from the Waist to Shoulder Level in Front and the Sleeves. 3. Tables Are Sterile Only at Table Level. 4. Persons Who Are Sterile Touch Only Sterile Items or Areas; Persons Who Are Not Sterile Touch Only Unsterile Items or Areas. 5. Edges of Anything That Encloses Sterile Contents Are Considered Unsterile. 6. Sterile Field Is Created as Close as Possible to Time of Use. 7. Sterile Areas Are Continuously Kept in View. 8. Sterile Persons keep Well within the Sterile Area. 9. Sterile Persons Keep Contact with Sterile Areas to a Minimum. 10. Destruction of Integrity of Microbial Barriers Results in Contamination.

Only sterile items are used within sterile field. Sterile objects become unsterile when touched by unsterile objects. Sterile items that are out of vision or below the waist level of the nurse are considered unsterile. Sterile objects can become unsterile by prolong exposure to airborne microorganisms. Fluids flow in the direction of gravity. Moisture that passes through a sterile object draws microorganism from unsterile surfaces above or below to the surface by capillary reaction. The edges of a sterile field are considered unsterile. The skin cannot be sterilized and is unsterile. Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis

Anesthesia, or anaesthesia has traditionally meant the condition of having sensation (including the feeling of pain) blocked. This allows patients to undergo surgery and other procedures without the distress and pain they would otherwise experience. The word was coined by Oliver Wendell Holmes, Sr. in 1846. Another definition is a reversible lack of awareness, whether this is a total lack of awareness (e.g. a general anaesthestic) or a lack of awareness of a part of a the body such as a spinal anaesthetic or another nerve block would cause. Anesthesia differs from analgesia in blocking all sensation, not only pain. Classification: A. General Anesthesia - is the loss of all sensation and consciousness. Protective reflexes such as cough and gag reflexes are lost. A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation (rendering a part of the body less tense) occur. General anesthetics are usually administered by intravenous infusion or by inhalation of gases through a mask or through an endotracheal tube inserted into the trachea.

Advantages: 1. Because the client is unconscious rather then awake and anxious, respiration and cardiac function are readily regulated. 2. The anesthesia can be adjusted to the length of the operation and the clients age and physical status. Disadvantage: 1. It depresses the respiratory and circulatory systems. 2. Some clients become more anxious about a general anesthetic that about the surgery itself. Often this is because they fear losing the capacity to control their own bodies. B. Regional Anesthesia - is the temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body. The client loss sensation in an area of the body but remains conscious. Several techniques are used: Topical (surface) Anesthesia Is applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns. The most common used topical agents are lidocaine (Xylocaine) and benzocaine. Topical anesthetics are readily absorbed and act rapidly. Local Anesthesia (Infiltration)is injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performng a biopsy. Lidocaine or tetracaine 0.1% may be used. Is a technique in which the anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a small area of the body. Major blocks involve multiple nerves or a plexus (e.g. the brachial plexus anesthetizes the arm); minor blocks involve a single nerve (e.g. a facial nerve) Is used most often for procedures involving the arm, wrist and hand. An occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected intravenous agent beyond the involved extremity. It requires a lumbar puncture through one of the interspaces between lumbar disc 2 (L2) and the sacrum (S1). An anesthetic agent is injected into the subarachnoid space surrounding the spinal cord. Categorized into Low Spinals (saddle or caudal blocks) are primarily used for surgeries involving the

Nerve Block

Intravenous block (Bier block)

Spinal anesthesia (Subarachnoid block)

perineal or rectal areas. Mild Spinals (below the level of the umbilicus T10) can be used for hernia repairs or appendectomies. High Spinals (reaching the nipple line T4) can be used for surgeries such as cesarean sections. Epidural (peridural) anesthesia Is an injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater.

Conscious Sedation may be used alone or in conjuction with regional anesthesia for some diagnostic tests and surgical procedures. Conscious sedation refers to minimal depression of the level of consciousness in which the client retains the ability to maintain a patent airway and respond appropriately to commands. Intravenous narcotics such as morphine or fentanyl (Sublimaze) and antianxiety agents such as diazepam (Valium) or midazolam (Versed) are commonly used to induce and maintain conscious sedation. Conscious sedation increases the clients pain threshold and induces a degree of amnesia but allows for prompt reversal of its effects and a rapid return to normal activities of daily living. Procedures such as endoscopies, incision and drainage of abcesses, and even balloon angioplasty may be performed under conscious sedation. Risk Factors for Complications During the Procedure:

Current or past health problems Taking medications, supplements, or herbal remedies, blood thinners Allergies (eg, food allergies, medication allergies, latex allergies) Smoking Drinking alcohol Taking recreational drugs Personal or family history of adverse reactions to anesthesia

Possible Complications:

Pain and tenderness around the injection site Bruising, infection, or bleeding of the injection site Hematoma (a mass of clotted blood that forms in a tissue, organ, or body space as a result of a broken blood vessel) Spinal headache (a severe headache that may occur after spinal or epidural anesthesia) Decrease in blood pressure Nerve damage Medication mistakenly injected into a vein; symptoms include dizziness, rapid heartbeat, and funny taste or numbness around the mouth Horners syndrome (change of pupil size on one side) Ptosis (drooping of the eyelid) Pneumothorax (air trapped between the lung and rib cage)

Call Your Doctor If Any of the Following Occurs:


Signs of infection, including fever and chills Redness, swelling, increasing pain, or discharge from the injection site Tingling, numbness, or trouble moving around the affected area Headache Persistent coughing Chest pain Trouble breathing or shortness of breath Dizziness Heartbeat abnormalities Funny taste or numbness of the mouth Other worrisome symptoms

Effects of surgery No medical or surgical treatment is void of side effects. Obviously the sympathectomy has some and potential patients should know about them and discuss with the surgeon before proceeding with the procedure. The first one is compensatory sweating also known as reflex sweating or compensatory hydrosis. The patient will develop sweat on other parts of the body such as the lower legs, thighs, abdomen, or the back. The upper body from the chest and up will be dry. All patients will develop some degree of compensatory sweating. The majority on a level that will be tolerated. In most cases 93% to 94% the patients prefer the compensatory sweating to the original sweating. About 5% to 6% of the patients will develop severe compensatory sweating that will render those patients to be unhappy. With the changing of the sympathectomy level to T3-T4 statistically the number of patients who suffer from severe compensatory sweating has been reduced.

Medication can sometimes help with severe compensatory sweating. For those patients who had the clamping method done the clamps can be removed and give the patient a possibility of reversal. So far about 50% of the patients who underwent clamp removal showed improvement with regard to their side effects. The exact timing between application of the clamps and removal is not yet established but its thought to be effective within the first 6 months. This number is not etched in stone yet because there is a need for many more patients to get into a statistical pool so one can come with meaningful data. Those patients on whom the clamps were removed describe some return of upper body sweating and hence reduction in their compensatory sweating. For those patients who had the cutting method done nerve graft reversal will be needed if they decide to try to reverse their severe compensatory sweating. Another side effect is gustatory sweating. Here the patient will develop facial sweating while eating spicy or sour foods. This happens to about 5% of the patients but the majority on a mild to moderate fashion. Also here the change of the sympathectomy level from T2 to T3-T4 showed a definite reduction in the number of cases suffering from gustatory sweating. The basic working theory is that by leaving the T2 in tact there is less interference with the sympatheticparasympathetic balance. Severe cases can be treated with medicated roll-on or botox injections. The horner's syndrome or the droopy eye syndrome used to be more common when sympathectomy was done in an open fashion. The endoscopic approach almost eliminated this possibility. Reduction in heart rate was described by a few patients. Here on heavy physical activity one can note a lowering of the heart rate under maximum physical activity. Here again the lowering of the sympathectomy level from T2 to T3/T4 level has shown that the changes in the heart rate in maximum activity is not as prominent. There are other side affects which were described by patients such as tingling sensation and the upper arms, initial night sweating mild weight gain are temporary in nature and disapear after a short time. Few patients will describe loss of stamina and of hair loss. Those are not necessarily associated with the sympathectomy. Hair loss was also described by a very small number of patients that had the ETS procedure done. The exact correlation is still not know however it is interesting that female patients who represent about 50% of ETS patients typically do not complain about this problem as much as their male counterparts. Male baldness is a much more common clinical presentation so we will need more scientific data to connect hair loss after sympathectomy. As to other side effects that you might have heard of or read about it is better to direct those questions to the surgeon who may be able to shed more light on those possible side effects.

It is suggested that any potential patient should talk with his or her surgeon before making any final decision with regard to surgery.