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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Back of Book > Resources > Appendices Appendices P.586
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Appendix A: Instruments and Materials in the Office Surgery Tray The following instruments and materials are included in the suggested office surgery tray:

  • No. 15 scalpel blade
  • Scalpel blade handle
  • Webster needle holder
  • Metzenbaum tissue scissors
  • Straight iris scissors
  • Adson forceps with teeth
  • Adson forceps without teeth
  • 2 mosquito hemostats
  • 2 inches of 4 × 4 gauze
  • Fenestrated disposable drape
  • 21-gauge, 1-inch needle (bent into a skin hook)

These materials are dropped onto a sterile disposable drape laid across a metal stand. Anesthetic is applied with nonsterile gloves and a syringe not placed on the tray. Sterile gloves are then applied away from this sterile tray. Added to the tray are sterile suture materials (e.g., 4-0 nylon suture) that are required for the particular procedure. Gloves, materials, and instruments can be ordered from the following sources:

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Appendix B: Instruments and Materials in a Standard Gynecologic Tray The following instruments and materials are included in the standard gynecologic tray:

  • Gloves
  • Graves metal speculum
  • Tenaculum
  • Uterine sound
  • Ring or sponge forceps
  • Basin with cotton balls and povidone-iodine
  • Add scalpel or scissors if needed
  • Add cervical dilators if needed

These items should be sterile for most procedures, except for removal of cervical polyps and treatment of Bartholin’s gland abscesses. The instruments can be ordered from the following sources:

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Appendix C: Recommended Suture Removal Times The following times for suture removal are approximate. Patient factors such as age, presence of vascular or chronic disease, and nutritional status influence healing times and suture removal times.

Face 3 to 5 days
Neck 5 to 7 days
Scalp 7 days
Trunk 10 to 14 days
Upper extremity 10 to 14 days
Extensor surface of the hands 14 days
Lower extremity 14 to 28 days

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Appendix D: Suggested Tray for Soft Tissue Aspiration and Injection Procedures The following instruments and materials can be placed on a nonsterile sheet on the Mayo stand:

  • Nonsterile gloves
  • Fenestrated drape, if desired
  • Two 10-mL syringes
  • 20- or 21-gauge, 1-inch needle for drawing up injecting solution
  • 21-, 22-, or 25-gauge, 1¼ inch needle for aspiration or injection
  • 1 inch of 4 × 4 gauze soaked with povidone-iodine solution
  • Hemostat for stabilizing the needle when exchanging the medication syringe for the aspiration syringe
  • 1% lidocaine hydrochloride stock bottle (20 mL)
  • Steroid of choice (e.g., betamethasone sodium phosphate and acetate, 5-mL multiuse bottle)
  • Band-Aid or sterile bandage

For intraarticular injections and certain soft-tissue injections, it may be preferable to use sterile gloves, drapes, and tray. An assistant should assist in drawing up the injecting solution to allow the practitioner to avoid contamination. When using multiuse stock bottles, it is preferable to draw up the lidocaine first and then the steroid solution. This order prevents contamination of the lidocaine with steroid that may be on the needle. Lidocaine on the needle does not significantly alter the steroid solution. P.591
Appendix E: Recommendations for Endoscope Disinfection The following recommendations are offered for disinfection of endoscopes:

  • Every endoscopy should be performed with a clean, disinfected endoscope. Use of disposable-component systems (i.e., sheathed endoscopes) can eliminate infectious transmission from endoscopes.
  • Manual cleaning of the endoscope’s surface, valves, and channels is the most important step for preventing the transmission of infections during endoscopy. Manual cleaning should occur immediately after each procedure to prevent drying of secretions or formation of a biofilm, both of which may be difficult to remove. The endoscope should be immersed in warm water and detergent, washed on the outside with disposable sponges or swabs, and brushed on the distal end with a small toothbrush. Valves should be removed and cleaned by brushing away adherent debris, and the hollow portions should be flushed with detergent solution. The biopsy-suction channel should be thoroughly cleaned with a brush that is appropriate for the instrument and channel size. Automatic washing devices can be used but do not replace manual cleaning.
  • Disinfection can be achieved by soaking the endoscope, valves, and all internal channels for at least 10 minutes in 2% glutaraldehyde. Many authorities prefer a minimum of 20 minutes. Alternately, newer systems that use acidic electrolytic water (AEW) may achieve disinfection with less potential for subsequent tissue irritation or toxicity.
  • Endoscope channels should be rinsed with 70% alcohol, dried with compressed air, and hung vertically overnight to reduce bacterial colonization when the endoscopes are not in use.
  • Accessories such as biopsy forceps should be mechanically cleaned and autoclaved after each use.

BIBLIOGRAPHY Axon AT. Working party report to the World Congresses. Disinfection and endoscopy: summary and recommendations. J Gastroenterol Hepatol 1991;6:23–24. P.592
Nelson D. Newer technologies for endoscope disinfection: electrolyzed acid water and disposable-component endoscope systems. Gastrointest Endosc Clin North Am 2000;10: 319–328. Spach DH, Silverstein FE, Stamm WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993;118:117–128. Tandon RK. Disinfection of gastrointestinal endoscopes and accessories. J Gastroenterol Hepatol 2000;15(Suppl):S69–S72. P.593
Appendix F: Guidelines for Monitoring the Patient Receiving Conscious Sedation for Gastrointestinal Endoscopy The following guidelines are provided for monitoring patients who receive conscious sedation while undergoing gastrointestinal endoscopy:

  • Monitoring of patients is one part of an overall quality assessment program for the endoscopy unit. Monitoring policies should be periodically evaluated and updated.
  • A well-trained gastrointestinal assistant, working closely with the endoscopist, is the most important part of the monitoring process. The assistant and endoscopist should work as a team in assessing the patient’s status and in responding to changes in clinical parameters.
  • The use of monitoring equipment is a useful adjunct to patient surveillance but is never a substitute for conscientious clinical assessment. Rapid visual assessment of the patient’s skin color, breathing pattern, and level of comfort with the procedure may provide useful information during the procedure.
  • The amount of monitoring should be proportional to the perceived risk to the patient from the procedure. Minimal clinical monitoring for all sedated patients includes periodic evaluation of blood pressure, heart rate, and respiratory rate before, during, and after the procedure, as well as at the time of discharge from the endoscopy unit. Consensus does not exist for monitoring cardiac rhythm and oxygen saturation. Routine monitoring with electrocardiograms and oximetry is recommended by many authorities, but selective use of these monitoring modalities can be performed for patients with known comorbidities (e.g., cardiac disease).
  • Oxygen administration before and during conscious sedation reduces the incidence of desaturation episodes during the procedure. Oxygen administration is advocated for individuals with cardiovascular or pulmonary compromise and may be of value when routinely administered to elderly individuals (>65 years old).
  • The primary modification in conscious sedation practices required for the geriatric population is administration of fewer agents at a slower rate and to a P.594
    lower cumulative dose. Reversal agents (e.g., flumazenil, naloxone) should be readily available in the endoscopy unit.

BIBLIOGRAPHY Eisen GM, Chutkan R, Goldstein JL, et al. Modifications in endoscopic practice for the elderly. Gastrointest Endosc 2000;52:849–851. Fleisher D. Monitoring the patient receiving conscious sedation for gastrointestinal endoscopy: issues and guidelines. Gastrointest Endosc 1989;35:262–266. P.595
Appendix G: Suggested Anesthesia Tray for Administration of Local Anesthesia, Nerve Blocks, Field Blocks, or Digital Blocks The following items are placed on a nonsterile sheet covering the Mayo stand:

  • Nonsterile gloves
  • Povidone-iodine solution soaked into a 4 × 4 gauze (or in a sterile basin)
  • 5- or 10-mL syringe
  • 20- or 21-gauge, 1-inch needle for drawing anesthetic from the stock bottle
  • 25-, 27-, or 30-gauge, ½ inch or 1-inch needle for administering anesthetic
  • 1 inch of nonsterile 4 × 4 gauze
  • 1% lidocaine hydrochloride with or without epinephrine (choice determined by procedure and site of administration)
  • Antibiotic ointment and Band-Aid if no procedure will follow at the injection site

All of the items are readily available through local pharmacies, hospital purchasing groups, or surgical supply houses. P.596
Appendix H: Skin Preparation Recommendations Patient characteristics associated with an increased risk of surgical site infections include remote site infections, colonization, diabetes, cigarette smoking, systemic steroid use, obesity, extremes of age, poor nutritional status, and preoperative transfusion of certain blood products. Apply greater vigilance when performing office procedures on patients with these risk factors. Preoperative shaving for hair removal is associated with higher rates of surgical site infections. Clipping hair immediately before a surgical procedure has the lowest rates of associated infection and should be considered the preferred preparatory activity for hair removal. Several effective antiseptic agents are available for preoperative skin preparation, including alcohol-containing products, the iodophors (e.g., povidone-iodine), and chlorhexidine gluconate:

  • Alcohol is readily available, inexpensive, and the most rapid-acting skin antiseptic. Disadvantages include potential for spores to be resistant, and potential for flammable reactions
  • Iodophors provide broad-spectrum coverage, are associated with lack of microbial resistance, and provide a bacteriostatic effect as long as it exists on the skin
  • Chlorhexidine gluconate offers broad-spectrum coverage, appears to provide greater reductions in skin microflora than povidone-iodine, and has greater residual activity after a single application

The following recommendations are provided for applying skin preparation agents:

  • Remove gross contamination from the skin, including soil, debris, or devitalized tissue.
  • Apply the skin-cleansing agent in concentric circles, starting from the intended surgical site.
  • Extend the area of skin cleansing to a wide enough area to cover the proposed operation, allowing for extension of the surgical field for the creation of additional incisions or drains.
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  • Do not rub or scrub the skin during application of the antiseptic agent. Damaging the skin during application can lead to increased surgical site infections.

BIBLIOGRAPHY Kaye ET. Topical antibacterial agents. Infect Dis Clin North Am 2000;14:321–339. Mangram AJ. Guidelines for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97–132. P.598
Appendix I: Bacterial Endocarditis Prevention Recommendations Endocarditis is a relatively uncommon, life-threatening disease that may result in substantial morbidity and mortality. Endocarditis usually develops in individuals with underlying structural cardiac defects who develop bacteremia (Table 1). Although bacteremia is common after many invasive procedures, only certain bacteria commonly cause endocarditis. Most cases of endocarditis are not attributable to an invasive procedure. Primary prevention of endocarditis should be attempted, whenever possible. If patients have a cardiac condition that puts them at moderate or high risk for endocarditis and undergo a procedure that puts them at risk for bacteremia (Table 2), the American Heart Association recommends prophylactic antibiotics (Table 3). To reduce the likelihood of microbial resistance, it is important that prophylactic antibiotics be used only during the perioperative period. They should be initiated shortly before a procedure and should not be continued for more than 6 to 8 hours afterward. In the case of delayed healing or of a procedure that involves infected tissue, it may be necessary to provide additional doses of antibiotics for treatment of the established infection. P.599

TABLE 1. CARDIAC CONDITIONS ASSOCIATED WITH RISK FOR BACTERIAL ENDOCARDITIS

High-risk individuals—prophylaxis recommended
   Prosthetic heart valves
   History of endocarditis (even in the absence of other heart disease)
   Complex cyanotic congenital heart disease
   Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk individuals—prophylaxis recommended
   Congenital cardiac conditions, including patent ductus arteriosus, ventricular septal defect, primum atrial septal defect, coarctation of the aorta, and bicuspid aortic valve
   Acquired valvar dysfunction (rheumatic heart disease or collagen vascular disease)
   Hypertrophic cardiomyopathy
   Mitral valve prolapse (MVP) with prolapsing and leaking mitral valves, evidenced by audible clicks and murmurs of mitral regurgitation or by Doppler-demonstrated mitral insufficiency
   Careful evaluation is required in children who have isolated clinical findings, such as nonejection systolic click, since this may be the only indicator of important mitral valve abnormality requiring prophylaxis
Negligible-risk individuals—prophylaxis not recommended
   MVP with normal mitral valves, prolapse without leaking, no murmurs, or minimal Doppler-demonstrated mitral regurgitation
   Pediatric patients with innocent heart murmurs
   Isolated secundum atrial septal defect
   Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residual beyond 6 months)
   Previous coronary artery bypass graft surgery
   Previous Kawasaki disease without valvar dysfunction
   Previous rheumatic fever without valvar dysfunction
   Cardiac pacemakers (intravascular and epicardial and implanted defibrillators)

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TABLE 2. BACTEREMIA-PRODUCING PROCEDURES AND AMERICAN HEART ASSOCIATION RECOMMENDATIONS FOR BACTERIAL ENDOCARDITIS PROPHYLAXIS

Bacterial Endocarditis Prophylaxis Recommended

Respiratory tract procedures
   Tonsillectomy or adenoidectomy
   Operations involving respiratory mucosa
   Rigid bronchoscopy
Gastrointestinal tract procedures
   Esophageal stricture dilatation
   Endoscopic retrograde cholangiography
   Sclerotherapy for esophageal varices
   Biliary tract surgery
   Surgery that involves intestinal mucosa
Genitourinary tract procedures
   Cystoscopy
   Prostatic procedures or surgery
   Urethral dilatation
   Removal of an infected intrauterine device

Bacterial Endocarditis Prophylaxis Not Recommended

Respiratory tract procedures
   Endotracheal intubation
   Flexible bronchoscopy
   Tympanostomy tube insertion
Gastrointestinal tract procedures
   Endoscopic ligation (banding) of varices
   Transesophageal echocardiography
   Endoscopy with or without gastrointestinal biopsy
Genitourinary tract procedures
   Vaginal hysterectomy
   Normal vaginal delivery
   Cervical biopsy
   Cesarean section
   Urethral catheterization in uninfected tissue
   Uterine dilation and curettage in uninfected tissue
   Therapeutic abortion in uninfected tissue
   Sterilization procedures in uninfected tissue
   Insertion or removal of intrauterine devices in uninfected tissue
   Circumcision
Cardiac procedures
   Cardiac catheterization, including balloon angioplasty
   Implanted cardiac pacemakers, defibrillators, and coronary stents
Dermatologic procedures
   Incision or biopsy of surgically scrubbed skin

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TABLE 3. RECOMMENDED PROPHYLACTIC ANTIBIOTIC REGIMENS

Condition Prophylactic Antibiotic Regimens

Standard, general prophylaxis Amoxicillin: adults, 2.0 g; children, 50 mg/kg PO 1 hr before procedure
Patient unable to take oral medications Ampicillin: adults, 2.0 g IM or IV; children, 50 mg/kg IM or IV within 30 min before procedure
Allergic to penicillin Clindamycin: adults, 600 mg; children, 20 mg/kg PO 1 hr before procedure
Cephalexin or cefadroxil: adults, 2.0 g; children, 50 mg/kg PO 1 hr before procedure
Azithromycin or clarithromycin: adults, 500 mg; children, 15 mg/kg PO 1 hr before procedure
Clindamycin: adults, 600 mg; children 20 mg/kg IV within 30 min before procedure
Cefazolin: adults, 1.0 g; children, 25 mg/kg IM or IV within 30 min before procedure
High-risk patient undergoing GI or GU procedure Adults: 2.0 g of ampicillin IM or IV plus 1.5 mg/kg of gentamicin (not to exceed 120 mg) within 30 min before procedure; 6 hr later, 1 g of ampicillin IM or IV or 1 g of amoxicillin PO
Children: 50 mg/kg of ampicillin IM or IV (not to exceed 2.0 g) plus 1.5 mg/kg of gentamicin within 30 min before the procedure; 6 hr later, 25 mg/kg of ampicillin or 25 mg/kg of amoxicillin PO
High-risk patient undergoing GI or GU procedure and allergic to ampicillin or amoxicillin Adults: 1.0 g of vancomycin IV over 1-2 hr plus 1.5 mg/kg of gentamicin IV or IM (not to exceed 120 mg), with complete injection or infusion within 30 min before procedure
Children: 20 mg/kg of vancomycin IV over 1–2 hr plus 1.5 mg/kg of gentamicin IV or IM, with complete injection or infusion within 30 min before procedure
Moderate-risk patient undergoing GI or GU procedure and allergic to ampicillin or amoxicillin Adults: 1.0 g of vancomycin IV over 1–2 hr, with complete infusion within 30 min before procedure
Children: 20 mg/kg of vancomycin IV over 1–2 hr, with complete infusion within 30 min before procedure

GI, gastrointestinal; GU, genitourinary.
Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. JAMA 1991;227:1794–1801.

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Appendix J: Informed Consent The principle of self-determination is the cornerstone of the American legal system. Rooted within this principle is the doctrine of informed consent, which posits that an individual has the right to receive adequate information to form an intelligent decision regarding a proposed procedure. Although the information included in informed consent varies from state to state, the key component that must be included is what a reasonable patient would need to know about the risks of a proposed procedure that would cause the patient not to undergo that treatment. There are several key issues:

  • The medical record is considered a faithful documentation of what information was transmitted to the patient; the medical professional must provide complete notes.
  • Courts assume that “if it’s not written, it didn’t happen.”
  • The physician’s word that informed consent occurred is not sufficient.
  • All preoperative discussions about a procedure should be documented, including phone calls the night before a procedure.
  • There are exceptions to the need to obtain informed consent, including emergency care when immediate treatment is required to prevent death or serious harm to the patient.

To prevail in a negligence action, a patient must prove each of the following claims:

  • The physician had a duty to disclose certain information to the patient.
  • The physician did not disclose the information (i.e., breach of duty).
  • The patient was harmed by the treatment.
  • The harm was the result of undisclosed risk.
  • The patient would have refused the procedure had the risk been disclosed.

BIBLIOGRAPHY Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999;17:327–340. Weintraub MI. Documentation and informed consent. Neurol Clin 1999;17:371–381.

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