PAINE #PANCE Pearl – Surgery



Question

 

What is the main difference between these two instruments?

 

Image result for allis clampImage result for allis clamp

 

vs

 

Image result for babcock clampImage result for babcock clamp



Answer

 

The first instrument is an Allis clamp, which has sharp teeth and can crush tissue.  It is used for grasping fascia or tissue that needs to be removed or manipulated during procedures.

 

The second instrument is a Babcock forceps,  which is non-toothed and has a wider grasping surface.  These forceps do not damage tissue and are considered non-crushing and can be used to grasp delicate tissue.  The head of the forceps is open and helps for rapid identification.

Ep-PAINE-nym



Debakey Forceps

 

Other Known Aliases – atraumatic vascular forceps

Definitionlarge, coursely ribbed tissue forceps

 

Clinical Significanceused for delicate vascular surgery as these forceps do not crush or damage tissue

 

History – Named after Michael Ellis DeBakey (1908-2008), an American cardiac surgeon who received his medical degree from Tulane University School of Medicine in 1932.  He spent the majority of his career with Baylor in Texas and was prolific medical trailblazer and pioneered, among many others,:

  • The roller pump for the heart-lung machine and made open-heart surgery possible
  • Postulating the link between smoking and lung cancer
  • One of the first surgeons to perform coronary artery bypass
  • Performed the first successful carotid endarterectomy
  • Using synthetic grafts for blood vessel repair
  • Video live surgery for medical purposes

In 2005, at the age of 95, he suffered an aortic dissection (for which there is the DeBakey classfication for) and became the oldest person to survive the operation.  He died 2 months before his 100th birthday.  Dr. DeBakey received so many awards and recognition that they are too numerous to count and is arguable one of the main reasons modern cardiac surgery has advanced to where it is today.

 


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. U.S. National Library of Medicine https://www.nlm.nih.gov/news/debakey_dies.html
  7. The Michael E. BeBakey papers https://profiles.nlm.nih.gov/ps/retrieve/Narrative/FJ/p-nid/322
  8. NY Times https://www.nytimes.com/2008/07/13/health/12cnd-debakey.html
  9. Academy of Achievement http://www.achievement.org/achiever/michael-e-debakey-m-d/

#42 – Postoperative Fever



***LISTEN TO THE PODCAST HERE***

 



My JAAPA article from October 2016 (JAAPA. 2016;29(10):23-28)



 

Introduction

Postoperative fever an elevation of body temperature to ≥ 38.3oC (100.4oF) following major surgical procedures.  The vast majority of postoperative fevers occur within the first 5 days of surgery, which is why the timing of the fever is so important in differentiating the potential causes.

 

Physiologic Response to Surgery

Surgery cause a massive inflammatory cascade due to the physiologic and cellular damage injury.  This is a completely normal homeostatic response, but the release of IL-1, IL-6, and TNF-alpha (to name a few) are all pyrogenic cytokines that can contribute to a febrile response.

These cytokines act on the preoptic area of the hypothalamus to increase prostaglandin E2 secretion and raises the thermostatic endpoint of the body.  This cascade usually peaks at 48 hours and care should be given to prevent costly and unnecessary infectious work-ups.

 



The Seven W’s of Postop Fever

 

Wind

Atelectasis usually occurs within the first 48 hours due to splinting and incomplete lung expansion secondary to pain following surgery.  It has long been considered the leading cause of postop fever, but has been debunked in the literature for decades now with increased knowledge of the cellular inflammatory cascade.  Decreased breath sounds , SOB, crackles, tachypnea can be indicators for atelectasis and CXR may show dependent, L>R infiltrates.  Treatment should be incentive spirometry and early mobilization to promote expansion.

 

Water

Urinary tract infections (UTI) are the most common postoperative nosocomial infection secondary to the placement of a urinary catheter for surgery.  Risk factors for postoperative UTI are length of catheterization need, female gender, older age, history of diabetes, and previous history of UTIs.  Signs and symptoms can reveal suprapubic pain, CVA tenderness, flank pain, and malodorous, cloudy urine.  Clean catch sample is ideal, but a clean aspirate from an indwelling catheter may be used.  Urinalysis can provide a quick idea if it is infectious are not, specifically looking for positive nitrites and/or leukocyte esterase, or sending for a urine culture and finding > 105 cfu of the offending organism.  Treatment should be removing the catheter (if possible) and tailoring antibiotic therapy to the organism in question.

 

Wound

Surgical site infections (SSI) generally begin to manifest 3-10 after surgery and risk factors for developing are ASA score of 3-5, contaminated or dirty procedure, or an extended length of surgery.  Signs and symptoms of an SSI are increased pain, redness, and swelling at or near the incision.  These can be superficial skin, deep skin, or deep space and ultrasound can help differentiate between cellulitis and focal infection.  Treatment is either antibiotics (for cellulitis) or drainage (for abscess).

 

Walking

Deep venous thrombosis (DVT) can be common in surgical patient (up to 20%) secondary to immobilization and resistance to move due to pain.  To make matters worse, many can be asymptomatic with the exception of the fever.  The incidence is highest 3-5 days after surgery and you should have a low threshold to order a bilateral lower extremity ultrasound.  Treatment for a DVT following surgery can be tricky due to bleeding risk.

 

Wonder Drugs

Medications are the most common, noninfectious cause of fever in patients following surgery.  Timing is variable from immediately after administration to hours, or even days, later.  Most cases are due to antibiotics or heparin and result in only a mild, transient febrile response.  There are 3 life-threatening cause of medication induced fevers that you at least need to think of and rule-out:

  • Serotonin syndrome
  • Malignant hyperthermia
  • Neuroleptic malignant syndrome

 

Withdrawal

Up to 50% of adults over the age of 18 admit to regular alcohol consumption and up to 50% of these patients report withdrawal symptoms when abstinent.  Signs and symptoms of acute withdrawal can begin to manifest 6-72 hours after the last ingestion and range in severity from mild, vague symptoms to florid delirium tremens.  Treatment is aggressive benzodiazepine regimens to abate the symptoms, with a gradual taper while in the hospital.

 

“Wonky” Glands

Though rare, two endocrinologic conditions can cause fever in the postoperative period.  Adrenal insufficiency and thyrotoxicosis can both occur due to disruption of the hypothalamic-pituitary-adrenal/thyroid axis by the inflammatory mediated response of surgery.  Coupled with a patient being NPO prior to surgery, a patient may not be able to take their medications to keep these conditions at bay.  Careful preoperative history will identify these patients prior to surgery and recommendations can be made on which medications can be taken the morning of surgery, or what medications can be given in perioperatively.




Cottage Physician Treatment for Fever

 

Ep-PAINE-nym



Kocher Incision

 

Other Known Aliasesright subcostal incision

 

Definitionoblique incision in the right subcostal area starting 2-5cm below the xiphoid process, running parallel to the ribs, and extending to 2.5cm below the inferior costal margins

 

Image result for kocher incision

 

Clinical Significanceclassic incision used for open cholecystectomy

 

Kocher Maneuver

 

Other Known Aliasesretroperitoneal exposure

 

Definition – maneuver to expose the retroperitoneal structure (pancreas, duodenum, vena cava)

 

Clinical Significancethis maneuver is used for resection of pancreatic head tumors or in trauma with retroperitoneal hemorrhage.  The peritoneum is incised at the right edge of the duodenum and continued in a “C” shaped from superior to inferior.  The duodenum and head of the pancreas is then reflected medially to the left to expose the retroperitoneal structures.

Image result for kocher maneuver exposure

History – Named after Emil Theodor Kocher (1841-1917), a Swiss surgeon who obtained his medical doctorate from the University of Bern in 1865.  He was arguably the most accomplished surgeon of his time and true pioneer in the field of surgery by promoting and advocating the use of aseptic technique, meticulous dissection with attention to minimal blood loss, and implementation of the scientific method in surgery. His “Text-Book of Operative Surgery” was the definitive guide to surgery in the early 1900s.  He received the Nobel Prize in Physiology and Medicine in 1909…the first Swiss citizen and first surgeon to do so.  The practice of modern surgery would certainly not be where it is today without the work of Dr. Kocher and his other notable eponyms are:

 

  • Kocher forceps – hemostatic tooth and groove forceps
  • Kocher’s point – entry point for intrventricular catheter to drain CSF from the cerebral ventricles
  • Kocher-Debre-Semelaigne Syndrome – hypothyroidism in infancy
  • Kocher collar incision – used in thyroid surgery
  • Kocher’s sign – eyelid phenomenon in hyperthyroidism

 

Emil Theodor Kocher.jpg

 


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Kocher T.  Text-Book of Operative Surgery. 1911. https://archive.org/details/textbookofoperat01kochuoft
  7. Gautschi OP, Hildebrandt G. Emil Theodor Kocher (25/8/1841-27/7/1917)–A Swiss (neuro-)surgeon and Nobel Prize winner. British journal of neurosurgery. 2009; 23(3):234-6. [pubmed]
  8. Biography of Theodor Kocher by Nobel Prize Society. https://www.nobelprize.org/nobel_prizes/medicine/laureates/1909/kocher-bio.html

Ep-PAINE-nym



Weitlaner (VIGHT-lahn-er) Retractor

 

Other Known Aliases – Wheatlander, Wheaty

 

DefinitionSelf-retaining retractor

Image result for weitlaner retractor

Clinical SignificanceOne of the more common self-retaining retractors used in surgery.  They have a ratchet locking system and may also be available with jointed hinges.  Primarily used for small to medium incision exposures.

History – Named after Franz Weitlaner (1872-1944), an Austrian physician who received his medical doctorate from Innsbruck Medical University in Austria at the age of 26 in 1898.  He enjoyed a prolific career as as ship surgeon and house physician practicing in St. Poelten and Ottenthal in his homeland.  In 1905, he published an article in the Vienna Clinical Review entitled “Ein Automatischer Wundspreizer” (An Automatic Wound-spreader), which would be the first description of his famous retractor.  They were originally manufactured by Windler Instrument Makers in Berlin in 1912, but Weitlaner never patented his design or received any monetary gains from his invention, only the right to have the instrument named after him.

 

 

 


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Sharma A, Swan KG. Franz Weitlaner: the great spreader of surgery. The Journal of Trauma. 2009; 67(6):1431-4. [pubmed]
  7. Weitlaner F. Ein automatischer Wundspreizer. Wien klin Rundschau. 1905;xix:114.