Transcript Document 7516666

‫یکی از مسایلی که بیمارستانها و مراکز‬
‫درمانی با آن روبرو هستند جلوگیری از‬
‫صدمات پوستی در طول و بعد از جراحی‬
‫است‬
‫‪Pressure Ulcer, Bedsore, Trophic Ulcers, Ischemic Ulcer‬‬
‫)‪1‬‬
‫‪Burn-Like Ulcer‬‬
‫)‪2‬‬
‫عوامل مستعد کننده صدمات پوستی ‪‬‬
‫طوالنی بودن مدت بی تحرکی بیمار‬
‫کاهش گردش خون در حین بی هوشی‬
‫وضعیت عمومی بیمار قبل از جراحی‬
‫نتیجه ‪PU‬در واقع سوختگی از تماس با منبع انرژی ناشی می شود و حال آنکه‬
‫تشدید فشار آزاد نشده است‬
‫زخم فشاری ساعاتی پس از جراحی تا حداکثر هفت روز بعد از جراحی‬
‫سوختگیها آسیبهای بافتی هستند که بالفاصله پس از اتمام جراحی قابل مشاهده‬
‫میباشند‬
‫عوامل سوختگی ‪‬‬
‫منابع شیمیایی‬
‫منابع الکتریکی‬
‫منابع گرمایی‬
‫عوامل سوختگی محدود به موارد فوق نیست پس در صورت آسیب دیدگی‬
‫وسایلی که درحین جراحی امکان ایجاد این نوع آسیب ها را دارند‬
‫باید کلیه‬
‫مورد بررسی قرار گیرند‬
P.U
‫در بافتهایی دیده میشوند که پوشاننده برجستگی های‬
‫استخوانی بیمار هستند‬
1. Ischium
8. Elbow
2. Sacrum
9. Pretibial crest
3. Trochlear
10. Spinous Process
4. Heel
11. Occiput
5. Malleous
12. Chin
6. Knee
13.Scapula
7. Iliac crest
 Whereas pressure ulcers in adults predominantly
appear on the lower body (sacrum, ischium, and
heels), they are more common on the upper body of
children (occiput and ears)
‫در انواع ‪PU‬میزان بروز و وقوع‬
‫جراحی ها‬
‫انواع جراحی‬
‫میزان بروز‬
‫میزان وقوع‬
‫قلبی‬
‫‪۱۷-۲۹/۵‬‬
‫عروقی‬
‫‪۹/۸-۱۷/۳‬‬
‫ستون فقرات ‪ ،‬شکمی‬
‫ارتوپدی‬
‫‪۷‬‬
‫‪۳۶‬‬
‫‪۱۵-۲۶‬‬
‫ارتوپدی در سالمندان‬
‫‪۶۶‬‬
‫عمومی ‪ ،‬قفسه سینه‬
‫‪۲۷/۷‬‬
‫‪۶/۵‬‬
‫‪۷‬‬
‫سر و گردن‬
‫‪۱۰‬‬
‫اعصاب‬
‫‪۵/۲‬‬
‫در صورتی که زمان جراحی افزایش یابد‬
‫وقوع و میزان بروز افزایش می یابد‬
‫زمان جراحی‬
‫میزان بروز‬
‫‪ ۳-۴‬ساعت‬
‫‪۵/۸-۶‬‬
‫‪ ۴-۵‬ساعت‬
‫‪۸/۹‬‬
‫‪ ۶-۵‬ساعت‬
‫‪۹/۹‬‬
‫بیش از ‪ ۶‬ساعت‬
‫‪۹/۹‬‬
‫بیش از ‪ ۷‬ساعت‬
‫‪۱۳/۲‬‬
Electrical Safety
Principles
 Electricity is the flow of electrons
 Direct Current-electrons flow in 1 direction
 Alternating Current-electrons switch directions at regular
intervals
 Capacitance
 The ability of a capacitor to store a charge.
Principles
Principles
Application: Electrical Shock
 If electrical systems are not properly wired, persons
can be subjected to electric shock.
Application: Electrical Shock
 People become injured and death occurs when voltage
pushes electrons through the human body, particularly
through the heart.
 Damage from electrical current is due to disruption of
normal electrical function of cells
or
dissipation of
electrical energy into human bodies (increased temp>burn).
 Macroshock-large amount of current flow that can
cause harm or death
 Microshock-small amounts of current flow. Dangerous
only to electrically susceptible patients
Application: Electrical Shock
 DC-is less dangerous
 AC-is more dangerous
 High frequency current have low
penetration and does not
tissue
excite contractile cells
 Low frequency current penetrates more
Application: Electrical Shock
 What levels of current (mA) is dangerous?
 Remember 1,10,100 macro/100 micro
 <1 mA = imperceptable to touch
 10 mA skeletal muscle shock (you can let go)
 V Fib can be induced by:
 100 mA of macroshock
 100 μA (microamperes)of microshock current
Application: Electrical Shock
 THE MAX LEAKAGE
ALLOWED IN OR
EQUIPMENT IS 10 μA
(microamperes)
Grounding
 Electrical Power Grounding can exist in two forms
 GROUNDED
 UNGROUNDED
The National Electrical Code of the National Fire Protection
Association (NFPA * ) defines electrical ground as a
conducting connection, intentional or accidental, between
an electrical circuit or equipment and earth or as a
connection to some conducting body that serves in place of
the earth.
Grounding
 Think about your
house:
 2 prong outlets = no
ground
 3 prong outlets =
grounded
 Modern homes have a
ground to reduce
amount of shock
Grounded Power
Grounded Electrocution
Why is equipment grounded?
 Stray
Capacitance/Capacitive
Coupling:
 Remember all equipment
leaks a small amount of
current
 All OR equipment has 3
prong plug
Ungrounding
 The OR has many
perils that make
grounding impracticle.
 Saline puddles
 Power cords w/ tears in
their insulation (colored
part of cord)
 Numerous electronic
devices that  risk
Ungrounding
 This is where the questions are derived:
 OR uses ungrounded power that is derived from
Grounded utilities
 ISOLATION TRANSFORMER is the answer…
Isolated and Ungrounded
 Electrical contacts with “ground” can cause injury if they
occur in two different locations such that a circuit is
completed and permits a large flow of current through
“ground.” One strategy for ensuring safety is to isolate all
electric power sources from “ground,” thus making it
impossible for “ground” to be used as a path for injurious or
damaging currents.
 Traditionally, implementation of this strategy in the operating
room has been accomplished by means of isolation
transformers, which usually take the form of large wall
panels that have outlets and meters. The term isolation
transformer comes from the fact that power output is
isolated from the electrical ground.
Ungrounding: Isolated Power
 Power source does not have a ground, the equipment
is grounded
 Isolated Power System provides protection from
Macroshock.
 Faulty equipment plugged into an isolated power
system does not present a shock hazard.
Ungrounded Safety
LIM (Line Isolation Monitor)
 Alarm is activated if 2mA-5mA of current is detected.
Line Isolation Monitor
electrosurgery
 Most concerns with electrical safety in the operating room
arise from the use of electrosurgical units because they are
capable of causing electrical shock, burns, explosions,
arrhythmias, and disturbances in pacemaker functioning.
 During electrosurgery, high currents enter the patient
through a small-area surface electrode at the tip of the
cutting tool. The combination of high resistance (R), which is
attributable to the small area, and high current (I) causes
local tissue heating proportional to I2R, which produces
cutting or coagulation. The tip of the electrode is also
designed to produce lower current densities (low I2R) at
points farther than a few millimeters from the electrode tip.
electrosurgery
 When electrosurgery is in use, a grounding pad should be
used that connects the patient to the ground connection
provided on the electrosurgery machine.
 The grounding pad should be well gelled and placed in
contact with the patient across a large area.
 The grounding pad should be inspected during lengthy
operations and gelled again or replaced if necessary.
 The electrosurgical grounding pad should be placed as near
the operative site as reasonably possible and as far as
possible from any pacemaker wires and ECG wires.
 When grounding pads are removed, the underlying skin
should be inspected for burns.
Electrocautery
Electrocautery with Poor
Contact
Unipolar Electrosurgery
In unipolar electrosurgery, the more common of the two, the
electric current that enters the patient through one electrode
travels throughout the body and is collected outside the
surgical field by a large, wide-area, well-jelled grounding pad
(i.e., the dispersive electrode).
Skin burns can occur if the grounding pad is dry (i.e., most of
the conducting gel is gone) or is otherwise in poor contact with
the patient.
Electrical burns have also occurred at the site of ECG leads
when the grounding pad was defective and the leads became
an alternative path for returning high-frequency electrosurgery
currents
Unipolar Electrosurgery
 Some body locations are never safe for unipolar
electrosurgery. This situation is encountered frequently
during neurosurgery and in patients with implanted
cardiac pacemakers.
 The solution is bipolar electrosurgery.
Bipolar Electrosurgery
 Bipolar surgery is performed by two pencil-point
electrodes arranged at the tips of a forceps
 Bipolar devices are required when electrosurgery is
performed on an ovary or a fallopian tube
 Several cases of fatal bowel injury have occurred after
female sterilization with unipolar devices
Safe Practice
 The anesthesiologist should go through the checklists
relevant to every case, just as the pilot and the copilot
of a commercial airplane do for air travel
 Years ago the word “vigilance” was used more
commonly to describe how anesthesiologists’ eyes and
mind are repeatedly and systematically scanning
everything in the operating room
 “Vigilance” is now used more appropriately to describe
the virtues of sophisticated electronic monitors and
alarms in the operating room