Decompressive craniectomy ppts and latest 380 published articles

Decompressive craniectomy

Management of head injury
http://peds.stanford.edu/

Management of Acute Ischemic Stroke
Carlos S. Kase, M.D.
http://portal.mah.harvard.edu/

Overview of Head Injury Management
Eldad J. Hadar, M.D.
https://www.med.unc.edu

Focus Of Neurocritical Care
Andrew M. Luks, MD
https://catalyst.uw.edu

Rapid Neurologic Assessment
Linda Self
http://www.atu.edu/

Management of Severe Traumatic Brain Injury: A Diagnosis & Treatment Protocol
Scott Weingart, MD
https://www.uic.edu/

Traumatic Brain Injury
Dayna Ryan
http://homepages.umflint.edu/

Traumatic Brain Injury in children
Marc D. Berg, M.D.
https://streaming.biocom.arizona.edu/

Traumatic Brain Injury Pediatric Intensive Care Unit
https://medicine.stonybrookmedicine.edu/

Advanced Emergency Trauma Course
Patrick Carter, MD ∙ Daniel Wachter, MD ∙ Rockefeller Oteng, MD ∙ Carl Seger, MD
http://open.umich.edu/

Latest 380 published articles on  Decompressive craniectomy

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Coronary Artery Bypass Grafting (CABG) ppts and latest 500 published articles

Coronary Artery Bypass Grafting (CABG)

Algorithmic Port Placement for Robot-assisted CABG
Pierre Dupont
http://web.mit.edu/

Cardiac Surgery
https://isol.abtech.edu/

Comparative Effectiveness of Percutaneous Coronary Interventions and Coronary Artery Bypass Grafting for Coronary Artery Disease
Dena Bravata, MD, MS and Mark Hlatky, MD
http://fsi-media.stanford.edu/

Is Coronary Artery Bypass Surgery Really Better than Coronary Stents? A look at the risks and benefits
Sarah Smith, Advisor: Dr. Grimes
http://www.uky.edu/

Acute Coronary Syndrome
Charles Shoalmire, MSN, RN, ACNP-BC
https://www.texarkanacollege.edu/

Ischemic Heart Disease and Myocardial Infarction
http://www.brown.edu/

Cardiovascular System
http://sp.myconcorde.edu 

Inflammatory Disorders of the Heart
http://www.austincc.edu

Women and heart disease:  What’s new?
Dennis Cheek, RN, PhD, FAHA; Melissa Sherrod, RN; and Jennifer Tester
http://www.ecmc.edu/

Coronary Atherosclerosis
Wala’a Fathi, Abed Al Fatah Hassan
http://scholar.najah.edu 


Latest 500 Published articles of CABG

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Adenoidectomy Ppts and details of 45 Published articles

Adenoidectomy is surgical removal of the adenoids for reasons which include impaired breathing through the nose, chronic infections, or recurrent earache.

Tonsillitis, Tonsillectomy, and Adenoidectomy
Mary Talley Dorn, M.D., Norman R. Friedman, M.D
http://www2.utmb.edu/

Tonsillitis, Tonsillectomy and Adenoidectomy
Steven T. Wright, M.D., Ronald Deskin, M.D.
http://www.utmb.edu/

Special Situations in Management of Tonsil and Adenoid Disorders
http://www.utmb.edu/

Tonsillectomy & Adenoidectomy See Exemplar Provided
http://faculty.nwfsc.edu/

Tubes and Tonsils
Lawrence M. Simon, M.D.
http://www.medschool.lsuhsc.edu/

Ear Tubes
http://www.medschool.lsuhsc.edu

Otitis Media With Effusion
Steven Feinberg MD
http://www.ent.uci.edu/

Pediatric Sleep Apnea
SRI KIRAN CHENNUPATI, MD
http://www.uphs.upenn.edu/

Pediatric Turbinate Hypertrophy
Nina L. Shapiro, MD
http://headandnecksurgery.ucla.edu

Otitis
John H. Isaacs, M.D.
http://www.mgm.ufl.edu/

Otitis Media
http://www.clas.ufl.edu

Interferences with Ventilation Objectives
http://www.mccc.edu/

Treatment of Pediatric Upper Respiratory Infections
Stanley E. Grogg, DO, FACOP
http://www.healthsciences.okstate.edu

The Tonsils and Adenoids in Pediatric Patients
Gordon Shields, MD, Ronald Deskin, MD
http://www.utmb.edu


45 Published articles on Adenoidectomy

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Fractures ppt adn 381 free access articles

Trauma Emergencies
http://web.uaccb.edu

Findings in Child Abuse
Reena Desai
http://radiology.med.sc.edu

Ribs & Sternum
http://occonline.occ.cccd.edu

Chest Trauma Lecture
Rose Bianchi, RN, DNSc.
http://online.santarosa.edu

Chest Injuries
http://www.uwec.edu

Respiratory Disorders: Pleural and Thoracic Injury
http://www.austincc.edu

Children with Injuries: Accident or Child Abuse?
Kristine Ruggiero
http://w3.salemstate.edu

Chest, Abdomen, and Pelvic Injuries
http://www.ivcc.edu

Geriatric Trauma
http://elearning.najah.edu

Pediatric Upper Extremity Fractures
Manish Shah, MD
http://www.bcm.edu

Radiology of Child Abuse
Kristy Rollins
http://radiology.med.sc.edu

Surgical Resident Research
http://www.mc.uky.edu

Rib Fractures
Brandy Lay & Amanda Bradshaw
http://at.uwa.edu

Chest, Abdominal, and Pelvic Injuries Chest Injuries
http://coefaculty.valdosta.edu

Thoracic Trauma
http://www.coe.uga.edu

Thoracic Trauma
Dave Lloyd, MD
http://faculty.plattsburgh.edu

Pleural and Thoracic Injury
http://www.austincc.edu

Upper Extremity Trauma
http://www.unmc.edu

Injuries to the Chest, Abdomen, and Genitalia
http://faculty.sgc.edu

Abuse & Imaging Peds & Geriatrics
http://www.elcamino.edu

Injuries to the Thorax and Abdomen
Amber Giacomazzi MS, ATC
http://staffwww.fullcoll.edu

Injuries to the Thorax and Abdomen
http://www.canyons.edu

Injuries and Evaluation Techniques for Thoracic Region
http://wweb.uta.edu

381 free access published articles on fractures

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Arthroplasty Ppts and Publications

Anesthesia for Total Hip and Knee Arthroplasty
Nigel E. Sharrock, MB, ChB
http://www.hss.edu/

Knee Arthroplasty Degeneration of Knee
http://wings.buffalo.edu

Hip Arthroplasty
http://wings.buffalo.edu

Replacement Arthroplasty Focused on The Knee
http://www.ele.uri.edu

Total Hip Arthroplasty
By: Erik Walder
http://www.ele.uri.edu/

Hip Arthroplasty
Chris Oser
http://www.uky.edu

Arthroplasty: Joint reconstruction
http://www.austincc.edu

Total Hip Arthroplasty
Jared Patenaude
http://schools.nashua.edu

Hip and Knee Reconstruction
https://www.mc.vanderbilt.edu

Orthopedic Surgery and Venous Thrombosis: Relationship to Antiphospholipid Antibodies?
Natalia Yazigi MD, Joseph Mazza MD, Hong Liang PhD, Mark Earll MD, William Hocking MD, James Burmester PhD, Steven Yale MD
https://www.fammed.wisc.edu

Osteoarthritis
http://appliedexerciselab.tamu.edu

Anesthesia for Orthopedic Surgery
DENNIS STEVENS CRNA,MSN,ARNP
http://chua2.fiu.edu

Joint Replacements
http://www.biomed.drexel.edu

X-ray after your ‘ream and run’ joint replacement
Winston J Warme, M.D.
http://faculty.washington.edu

New Drugs & Delivery Techniques
Keith B. Thomasset, PharmD, BCPS
http://www.bu.edu

Knee replacement surgery
http://www.udel.edu

Hand and Upper Extremity
Skip Brown, OTR,CHT, Peggy Haase, OTR,CHT, Joanna Hearington, RN, Dana Moulton, OT CHT, Lisa Perrone,OTR,CHT, Pam Harrell, OTR,CHT
http://www.mc.vanderbilt.edu


Latest 400 Published articles on anthroplasty

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Skin grafting

Moh's Surgery and Reconstruction
Shashidhar S. Reddy MD, MPH, Karen Calhoun MD
http://www.utmb.edu

Wound Healing and Burns
Reuben Bueno, M.D.
http://www.siumed.edu

Wound Healing, Burn Injuries & Plastic Surgery
http://courses.phhp.ufl.edu

Improving Perfusion of Synthetic Skin
Jordan S. Pober and Jeffrey S. Schechner
http://medicine.yale.edu

Tissue Engineering of the Skin
Connor Walsh
http://www.ele.uri.edu

Burn Emergencies
Heather Hartney RN
http://open.umich.edu

Biochemical Engineering
Dr. Christine Kelly
http://www.lcs.syr.edu

Burns
http://www.esd.uga.edu

Loxosceles Reclusa
http://hematology.im.wustl.edu/

Radiological Emergencies
http://www.science.sjsu.edu

Skin Procedures
Wanda T. Ziemba
http://medschool2.ucsf.edu

Solid Organ Transplantation
Ronald H. Kerman, PhD
http://www.uth.tmc.edu

Biomaterials and Material Testing
http://vubme.vuse.vanderbilt.edu

Vitiligo
http://www.chem.uwec.edu

Calcific Uremic Arteriolopathy ‘Calciphylaxis’
David Shure
http://medicine.med.nyu.edu

Reconstruction of the Oral Cavity
Michael Underbrink, M.D., Anna Pou, M.D.
http://www.utmb.edu/otoref

Management of Clients with Integumentary Problems
http://www.mac.edu

Principles of Wound Healing
R. Edward Newsome, MD
http://tulane.edu 2009-2010.ppt

Latest 600 Published articles on skin grafting

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Sleeve Gastrectomy

Changes in Physiology with Increasing Fat Mass
Dara P. Schuster, MD, FACE
Projected obesity trends to 2025
https://carmenwiki.osu.edu/

Perioperative Care of the Bariatric Patient
Mark Kadowaki, MD, FACS
http://www.etsu.edu

Obesity Weight Loss Management
http://www.medschool.lsuhsc.edu

Behavior Intervention for Bariatric Surgery Patients
http://www.prefer.pitt.edu

Laparoscopic Adjustable Banding in Severely Obese Adolescents: A Randomized Trial
Daniel DeUgarte, MD
http://assessment.crump.ucla.edu

Weight Loss Surgery
http://www.ecu.edu

Obesity: Medical and Surgical Management
John Varras, M.D.
http://www.medicine.nevada.edu

Bariatric Surgery: an effective treatment for combating obesity?
Kristen Huselid
http://wwwwin.cord.edu

Weight Sensitivity Training
http://portal.mah.harvard.edu


513 Published articles on Sleeve Gastrectomy

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Pelvic reconstructive surgery

Vaginal Procedures
Vaginal Procedures.ppt

Elective (Primary) Cesarean Section: Two Very Different Viewpoints?
Kenneth Griffis, MD, Urogynecology & Reconstructive Pelvic Surgery
Elective (Primary) Cesarean Section.ppt

Patient Positioning In the Operating Room
Patient Positioning In the Operating Room.ppt

Urinary Incontinence and Pelvic Organ Prolapse
Urinary Incontinence and Pelvic Organ Prolapse.ppt

Urogynecology and Reconstructive Pelvic Surgery
Urogynecology and Reconstructive Pelvic Surgery.ppt

Procedures Advanced Format: Abdominoperineal Resection
Procedures Advanced Format.ppt

Androgen Insensitivity Syndrome (AIS)
Alice Mann, Maureen O’Brien, Elizabeth Rueckert
Androgen Insensitivity Syndrome.ppt

Suture Selection
Sutures.ppt

Evaluation and Treatment of Urinary Incontinence and Prolapse
Prolapse.ppt

Introduction to Residency in Obstetrics and Gynecology
Shelly Holmström, MD
Residency in Obstetrics and Gynecology.ppt

What to do if surgery fails?
Kimberly Kenton M.D., M.S., Associate Professor
Female Pelvic Medicine & Reconstructive Surgery
What to do if surgery fails?.ppt

Published articles

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Hernias

Inguinal  Hernia Repair Past, Present Future
Magdy  Giurgius MD
Inguinal  Hernia Repair Past, Present & Future.ppt

Hernia
Elizabeth Travis and Michael Snyder
Hernia.ppt

Inguinal  hernia
Karen  Brasel, MD, MPH
Herniainguinal.pps

Abdominal  Pain/Abdominal Mass
Melissa  L. Hughes, Scott  Q. Nguyen, M.D.
AbdMass-AbdPain.pps

Traditional  Hernia Repair
Traditional  Hernia Repair.ppt

Hernia
Hernia.ppt

Ventral  Incisional Hernias – Etiology  and Repair Options 
Levi  Procter, MD
Ventral  Incisional Hernias.ppt

Abdominal  Wall Hernia
Sharfi  Sarker, MD
Hernia.ppt

Hernia
Hernia.ppt

Paraesophageal  Hernia Repair Utilizing Acellular Dermal Matrix
Randal L. Croshaw,  MD, Stephen A. Fann, MD, James M.  Nottingham, MD, FACS
Hernia Repair.ppt

Clinical  Correlation: Abdominal Wall Hernias
Richard  E. Burney, MD
Hernia.ppt

Congenital  Diaphragmatic Hernia
Jeff Wu
Hernia.ppt

Diaphragmatic  Hernias
Maureen Austin, Kimberly Novak
DiaphragmaticHernias.ppt

Hernias
Hernias.ppt

Clinical Correlations:  Hernias
Clinical Correlations.ppt

Open  Inguinal & Ventral Hernia Repair
Andrew  Gassman
Open  Inguinal & Ventral Hernia Repair.ppt

Abdominal Wall Hernias
John Morton, M.D.
Abdominal Wall Hernias.ppt
Latest 500 Published articles free access

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Bariatric surgery - weight-loss surgery and 50 free published articles

Bariatric Surgery
Anaďse  Ikama etal
Bariatricsurgeryppt.ppt

Bariatric Surgery
Tracy Ann Rydel,  MD
RydelBariatric.ppt

Weight Loss Surgery:  The First Step Toward a More Healthy Life
Pre-operative Medications, Post-operative Medications
Weight Loss Surgery.ppt

The Family  Physician’s Role in Managing the Bariatric Surgery Patient
B. Wayne Blount,  M.D., MPH
Managing the Bariatric Surgery.ppt

Medical Nutrition Therapy for Bariatric Surgery
Rebecca  Scheeler
Medical Nutrition Therapy for Bariatric Surgery.ppt

Weight  Loss Surgery - informational Materials
Weight  Loss Surgery.ppt

Anesthesia  for Bariatric Surgery
By:  Vladimir Melnikov MD
Anesthesia  for Bariatric Surgery.ppt

Bariatric Surgery: An Overview
Andrea Cherrington
Bariatric Surgery: An Overview.ppt

Revisional  Bariatric Surgery Indications and potential benefits.
William  Bakhos,MD
Revisional  Bariatric Surgery.ppt

Complications  and Benefits of Bariatric  Surgery
Tracy Robinson
Complications  and Benefits of Bariatric  Surgery.ppt

Gastric Surgery  for Severe Obesity
David L.  Gee, PhD
Gastric Surgery  for Severe Obesity.PPT

Binge  Eating Behavior in Post Bariatric Surgery  Patients
Lowisa  Dohrmund
Post Bariatric Surgery.ppt

Nutrition Practice  Standards for Bariatric Surgery
Dana Eiesland,  RD, LDN
Nutrition Practice  Standards for Bariatric Surgery .ppt

Male Obesity  and Semen Analysis Parameters
Joseph Petty, MD, Samuel Prien, PhD, Amantia Kennedy, MSIV, Sami Jabara, MD
Male Obesity  and Semen Analysis Parameters.ppt

Unintended consequences of bariatric surgery – the changing face of a familiar disease
Andrea Braun MD, Thomas S. Huddle MD
Unintended consequences of bariatric surgery.ppt
Free 50 Published scholarly articles on Bariatric surgery

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Knee/ Hip Arthroplasty ppt Presentations

Anesthesia for Total Hip and Knee Arthroplasty by Nigel E. Sharrock, MB, ChB, Hospital for Special Surgery, New York
http://www.hss.edu/files/Anesthesia-for-Total-Hip-and-Knee.ppt

Knee Arthroplasty By Simranjit Rekhi
http://www.ele.uri.edu/Courses/ele282/S10/SimranjitR_1.ppt

Total Hip & Knee Arthroplasty & Rehabilitation Implications:  Past, Present, & Future
by Celia Pechak, PT, MPH, PhD
http://www.uthct.edu/files/ppt/rehab_totalhip.ppt

Joint Replacements
http://www.biomed.drexel.edu/new04/content/academics/CourseMaterials/BMES641_2005FALL/Lecture8.ppt

Joint Replacement
http://www.austincc.edu/cmorse/2410/hipknee/hipknee.PPT

Post-op “cold foot”
http://www.uth.tmc.edu/anes/Assets/powerpoint/Post-op-cold-foot.pps

The Knee Joint
By: Aggie Brockie, Krystal Gantner, Angie Gauer, Krista Gooding, Laura Marchwinski, Tracy Mueller, Matt Schlueter, Jenn Summers
http://accweb.itr.maryville.edu/kbruzzini/Gross%20Anatomy%20S06/Knee%20Joint.ppt

Nursing Management Musculoskeletal Trauma and Orthopedic Surgery
http://nah.southtexascollege.edu/ADN/assets/docs/maila/Chapter_063.ppt

Hip Arthroplasty by Chris Oser
http://www.uky.edu/~hadleyr/PA2009/Oser.ppt

Rehabilitation After Hip Surgery Total Hip Arthroplasty
http://www.sahs.utmb.edu/programs/ot/Courses/Spring/2003/hip%20rehab%20week%208%20presentation.ppt

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Surgical Emergencies in the Newborn

Surgical Emergencies in the Newborn
University of North Carolina at Chapel Hill
Pediatric Surgery Division
Patty Lange

Emergencies
* Types
o Airway/Respiratory
o Intestinal Obstruction
o Intestinal Perforation
* Signs
o Respiratory distress
o Abdominal distension
o Peritonitis
o Pneumoperitoneum

Airway/Respiratory
* Neck Masses
* Thoracic masses/pulmonary lesions

Cystic Hygroma
* Multiloculated cystic spaces lined by endothelial cells
* Incidence about 1 in 12,000 births
* Complications
* Treatment
* Postnatal overdistension of one or more lobes of histologically normal lung
* Location

Congenital Lobar Emphysema
* Diagnosis
* Treatment

Congenital Cystic Adenomatous Malformation (CCAM)
* Mass of cysts lined by ciliated cuboidal or columnar pseudostratified epithelium
* Three types
* More common on the left side, 2% bilateral

CCAM
* Diagnosis
* Treatment
Congenital Diaphragmatic Hernia
* Intro
* DX
* Treatment
Tracheoesophageal Fistula and Esophageal Atresia
Intestinal Obstruction
Anatomic Differentiation
* Upper GI
* Lower GI
Anatomic Differentiation
Urgency to Treat
* Emergencies
* Further workup
Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation/Volvulus
* Hirschsprung’s
* Presentation

NEC Treatment
* Medical
* Surgical indications
NEC Outcomes
* Overall survival ~ 80%, improving in LBW
* In pts w/perforation, 65% perioperative mortality, no perf--30% mortality
* 25% of Survivors develop stricture
* 6% pts have recurrent NEC
* Postop NEC--Myelomeningocele, Gastroschisis--45-65% mortality

Pneumatosis
Pneumoperitoneum
NEC--Abd Distension/Erythema
Necrotic Segment Ileum
Resection
Specimen--Ileocecectomy
Ileostomy
Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation
* Hirschsprung’s

Duodenal Atresia
* Incidence--1 in 5,000 to 10,000 live births
* 75% of stenoses and 40% of atresias are found in Duodenum
* Multiple atresias in 15% of cases
* 50% pts are LBW and premature
* Polyhydramnios in 75%
* Bilious emesis usually present
* Associated Anomalies

Duodenal Atresia Diagnosis
* Radiographs
* Workup of potential associated anomalies
“Double Bubble”
Duodenal Atresia Treatment
* Nasogastric decompression, hydration
* Surgery
Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation
* Hirschsprung’s

Small Bowel Atresia
* Jejunal is most common, about 1 per 2,000 live births
* Atresia due to in-utero occlusion of all or part of the blood supply to the bowel
* Classification--Types I-IV
* Presents w/bilious emesis, abd distension, failure to pass meconium (70%)

Intestinal Atresia Classification
* Associated Anomalies
o other atresias
o Hirschsprung’s
o Biliary atresia
o polysplenia syndrome (situs inversus, cardiac anomalies, atresias)
o CF (10%)

Atresia--Diagnosis and Treatment
* Plain films show dilated loops small bowel
* Contrast enema shows small unused colon
* UGI/SBFT shows failure of contrast to pass beyond atretic point
* Treatment is surgical

Common Disorders
* NEC
* Duodenal Atresia
* Small Bowel Atresia
* Malrotation/Volvulus
* Hirschsprung’s

Malrotation
* 1 per 6,000 live births
* can be asymptomatic throughout life
* Usually presents in first 6 months of life
* 18% children w/short gut had malrotation with volvulus
* Etiology
o physiologic umbilical hernia--4th wk gestation
o Reduction of hernia 10th - 12th wks of gestation

Normal Embryology
Malrotation Classification
* Nonrotation
* Abn Rotation of Duodenojejunal limb
* Abn rotation of Cecocolic limb

Abnormal Rotation/Fixation
Malrotation Diagnosis
* Varying symptoms from very mild to catastrophic
* **Bilious emesis is Volvulus until proven otherwise**
* Bilious emesis, bloody diarrhea, abd distension, lethargy, shock
* UGI shows abnormal position of Duodenum
o if Volvulus, see “bird’s beak” in duodenum

Malrotation UGI
Intraop Volvulus
Bowel Necrosis--Volvulus
Malrotation--Treatment
* Surgical--Ladd’s Procedure
Common Disorders
Hirschsprung’s Disease
* Migratory failure of neural crest cells
* Incidence 1 in 5,000 live births, males affected 4:1 over females
* 90% of pts w/H’sprung’s fail to pass meconium in first 24-48 hrs
* Abd distension, bilious emesis, obstructive enterocolitis
Hirschsprung’s Diagnosis
* Barium Enema
* Anorectal Manometry
* Rectal Biopsy

Transition Zone on BE
Hirschsprung’s Treatment
Pull-Through Procedure
Summary
* BILIOUS EMESIS IS VOLVULUS UNTIL PROVEN OTHERWISE
* Signs of surgical emergency
o free air, abd wall cellulitis, fixed loop on xray, rapid distension, peritonitis, clinical deterioration
* History and plain films will guide sequence of additional studies
* Remember associated anomalies

Surgical Emergencies in the Newborn.ppt

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Pediatric Minimally Invasive Surgery

Pediatric Minimally Invasive Surgery
By:Joseph A. Iocono, M.D.
Assistant Professor
Division of Pediatric Surgery
University of Kentucky
Children’s Hospital

Large Operations with Tiny Incisions
Lap Hirschsprung’s pull through 8 weeks post-op pull through

MIS-Advantages
* Cosmesis
+ open operations often leave large, unsightly incisions
+ with some laparoscopic instruments smaller than 2mm in size, it is often difficult to see incisions postoperatively
* Analgesia
o Smaller incisions associated with less pain, lower analgesic use, and quicker recovery.
+ few controlled studies in children, especially in youngest patients
* Adhesions
o several studies suggest the formation of fewer intra-abdominal adhesions after laparoscopic procedures
+ reduces the risk of future postoperative bowel obstructions
+ possibly reduces postoperative pain
* Decreased Ileus
+ Nissen, Appendectomy, Pyloromyotomy, Bowel resection, Spleen
+ Real or perceived?

Pediatric Surgery and MIS
Pediatric Surgeons—already “in the business”
o Small incisions--small scars
o Preemptive anesthesia--decreased pain med needs
o Short hospital stays
o Laparoscopic Cholecystectomy
o Laparoscopic Pyloromyotomy
o First true pediatric MIS procedure
o Laparoscopic appendectomy
o Laparoscopic Nissen Fundoplication
o Laparoscopic Splenectomy

MIS—What’s So Great?
* Why Bother?
o Additional expense
o Prolonged procedures
o Lack of tactile evaluation
o Loss of depth perception
o Complications specific to MIS
“After an advanced MIS case, the patient goes home and the surgeon goes to the ICU”
* Expense
* Length of Procedures
From Curiosity to Standard of Care—How?
o Procedure Driven
o Patient (parent) Driven
o Technology Driven
o Physician Driven
o Care Driven --“re-think” care

Technology – Smaller and Better
Ligation Monopolar Bipolar, harmonic
Instruments 10 mm 3 mm (disposable) (reusable)

Technology
MIS – Indications
* General Indications
* New procedures Developed rapidly
Partial list of described MIS procedures in Children
Achalasia (1) Adhesive Small Bowel Obstruction
Adrenal Tumors (1) Appendicitis (25)
Biliary Atresia Cholelithiasis (5)
Chronic Abdominal Pain (2) Chronic Constipation (ACE procedure) (5)
Crohn’s Disease (2) Diaphragmatic Hernia (1)
Duodenal Atresia Empyema
Gastroesophageal Reflux (25) Gastrostomy Tube Placement (20)
Hirschsprung’s Disease (2) Benign Kidney Disease
Lung tumor (4) Malrotation (1)
Meckel’s Diverticulum Mediastinal Pathology (1)
Ovarian Torsion and Cysts (2) Pancreatic Pseudocyst
Pectus Excavatum (4) Placement of VP Shunt
Pyloromyotomy (32) Recurrent Pneumothorax (1)
Splenic Pathology (5) Tracheoesophageal Fistula
Undescended Testicle (6) Ulcerative Colitis (1)
Urinary Reflux Inguinal Hernia (recurrent) (1)
Patent ductus arteriosus Peritoneal Dialysis access

MIS in Pediatric Surgery
* Indications
* Procedure
* Complications
* Changes in Care
* Controversies
* Cholecystectomy
* Nissen Fundoplication
* Appendectomy
* Splenectomy
* Intestinal Resection
* VATS
* Inguinal Hernias
* Pyloromyotomy
* Hirschsprung’s Pull Through
* Ladd’s Procedure
* Pectus Excavatum- Nuss Procedure
* Congenital Diaphragmatic Hernia

Cholecystectomy--1991

* Indications
* Procedure
* Complications
* Changes to Care
* Controversies
* Gold Standard
* Complications
* Changes to Care
* Controversies

Port size/use
1. 5mm--camera
2. 3mm--liver retractor
3. 5mm--dissection (G-tube)
4. 3mm--dissection
5. 3mm---retraction (optional)

Appendectomy--1992
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Splenectomy--1998
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Intestinal Resection
* Indications
* Procedure- 2 ways
* Complications
* Changes to Care
* Controversies
Optional Incisions
Thoracoscopy-VATS
* Indications
o Empyema Blebs
o Wedge Biopsy Anterior Spine
o Mediastinal cysts Thymectomy
* Procedure
o 3 ports, low pressure CO2
* Complications
o Conversion rate high
* Changes to Care
o Insufflation better
o Faster recovery
o Start chemo earlier
* Controversies
o Ability to “feel’ lung.

Inguinal Hernias
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Pyloromyotomy-1991
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Pull-through for Hirschsprung’s--1995
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Ladd’s Procedure for Malrotation--1997
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Nuss Procedure for Pectus Excavatum --1995
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies
o Need for scope?

Diaphragmatic Hernia
* Indications
* Procedure
* Complications
* Changes to Care
* Controversies

Pediatric Minimally Invasive Surgery
* Conclusions
o Surgeon must decide whether a minimally invasive approach is the safest and most appropriate procedure.
o Must convert to an open procedure at any time that the risks are greater than those of the open technique.
o Must increase his/her repertoire of MIS cases as skills improve.
o Must stay informed about new techniques, tools, and indications and complete CME in order to gain needed training.

Teaching Minimally Invasive Surgery
* Education
* Solution--basic skills need to be mastered

Who gets MIS Procedures and
When do I refer to Pediatric Surgery?
* Who?
* When?
* How?

Future Directions
* Limitations of current MIS technology
* Solution---daVinci operative system
* Ready for Pediatric MIS? Yes Infant MIS? Not quite

Final Thoughts
“Five years ago it would have been unthinkable that an [entire] issue of Seminars in Pediatric Surgery would be discussing intracorporeal anastomoses after intestinal resections and laparoscopic pull-through for high imperforate anus. Yes it is likely that we are only in the infancy of the development of laparoscopic surgery in our patients…Several pediatric surgeons are involved with experimentation and development with robotic surgery…Certainly, it will make intestinal anastomoses easier and make [more complicated] procedures such as portoenterostomy [Kasai procedure] more feasible.”

Pediatric Minimally Invasive Surgery.ppt

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video for amputation surgery

video for amputation surgery

5 Levels of amputation surgical video :

* transfemoral
* knee disarticulation
* transtibial
* partial calcanectomy
* transmetatarsal

http://www.ampsurg.org/html/amplevels.html

Read more...

Surgical Preparation and Instrument Care

Surgical Preparation and Instrument Care

Sanitation, Disinfection and Sterilization

Learning Outcomes
After this section is completed you should be able to:
List the classes of pathogenic organisms in order of their resistance to destruction
Differentiate between sanitation, disinfection and sterilization
List the different ways that microbial control methods destroy or inhibit pathogenic organisms

After this section is completed you should be able to:
List the five categories of physical methods of microbial control
Name and describe the physical methods of microbial control
Identify the level of microbial control achieved with each of the physical methods
State an example of the application of each of the physical methods of microbial control

List the properties of the “ideal chemical agent” for microbial control
Name and describe the classes of microbial control chemicals
Identify the level of microbial control achieved by the chemical classes

List the advantages and disadvantages of the autoclave in animal care facilities
Explain the function of the autoclave
Compare and contrast the different autoclaves

Describe the preparation of each of the following for processing in the autoclave: linen packs, pouch packs, hard goods, liquids and contaminated objects
List the guidelines for loading the autoclave chamber
Compare the three different autoclave cycles

List and define the five methods of quality control for sterilization
List and define the two methods of quality control for disinfection

Section Outline
Levels of microbial resistance
Degrees of microbial control
How microbial control methods work
Methods of microbial control
Autoclave
Quality control for sterilization and disinfection

Overarching Principle
The objective in sanitation, sterilization and disinfection is to control microorganisms, or pathogens, in the environment, thus protecting patients and staff from contamination and disease, and thereby promoting optimal healing and wellness.

The Ever Present Danger
Improper application of the methods of sanitation, sterilization and disinfection can lead to microbial resistance and increase the risk of nosocomial infection

Levels of Microbial Resistance
Pathogens
Microorganisms that cause disease
Viruses
Bacteria
Fungi
Protozoan
Prions
Different classes of pathogens vary in their resistance to destruction by chemical methods

Protozoan Cysts
Bacterial Spores
Non-enveloped virus
TB organisms
Enveloped viruses
Fungi
Vegetative bacteria


Most Resistant
Least Resistant
Levels of Microbial Resistance
Microbial control
Is achieved by using methods of sanitation, disinfection and sterilization
Microbial control
Done to a degree that is practical, efficient and cost effective

Levels of Microbial Resistance
Sterility is used only when necessary

In many situations sanitation and disinfection create acceptable levels of microbial control

Degrees of Microbial Control
Sterilization is the elimination of all life from an object
Complete microbial control
Asepsis is a condition in which no living organisms are present
Free of infection or infectious material

Degrees of Microbial Control
Sanitation: The state of being clean and conducive to health.

Disinfection: To cleanse so as to destroy or prevent the growth of disease-carrying microorganisms

Degrees of Microbial Control
Disinfection, sanitation and cleaning remove most microorganisms
Most disinfectants are microbiocidal
Microbes are killed
Some disinfectants are bacteriostatic
Microbial growth is inhibited

Degrees of Microbial Control
Disinfectants can be classified according to their spectrum of activity
Bacteriocidal
Bacteriostatic
Sporocidal
Virucidal
Fungicidal

How Microbial Control Methods Work
Mode of Action
Different physical and chemical methods destroy or inhibit microbes in several ways
Damage cell walls or membranes
Interfere with cell enzyme activity or metabolism
Destroy microbial cell contents through oxidation, hydrolysis, reduction, coagulation, protein denaturation or the formation of salts

Efficacy of Microbial Control
The effectiveness of all microbial control methods depends on the following factors:
Time
Most methods have minimum effective exposure times
Temperature
Most methods are more effective as temperature increases

Efficacy of Microbial Control
The effectiveness of all microbial control methods depends on the following factors:
Concentration and Preparation
Chemical methods require appropriate concentrations of agent
Disinfectants may be adversely affected by mixing with other chemicals
Organisms
Type, number and stage of growth of target organisms

Efficacy of Microbial Control
The effectiveness of all microbial control methods depends on the following factors:
Surface
Physical and chemical properties of the surface to be treated may interfere with the method’s activity
Some surfaces are damaged by some methods

Efficacy of Microbial Control
The effectiveness of all microbial control methods depends on the following factors:
Organic debris or other soils
Will dilute, render ineffective or interfere with many control methods
Method of application
Items may be sprayed, swabbed or immersed in disinfectants
Cotton and some synthetic materials may reduce chemical activity

Methods of Microbial Control
Physical Methods
Chemical Methods

Physical Methods
Dry Heat
Oxidation
Moist Heat
Denatures microbial protein
Radiation
Damages cell enzyme systems and DNA
Filtration
Traps organisms that are too large to pass through the filter
Ultrasonic Vibration
Coagulates proteins and damages cell walls

Dry Heat
Incineration
Material or object is exposed to a hot fire
Object must become red hot as in the inoculation loops used in microbiology
Used to dispose of tissue or carcasses
Efficacy: complete sterilization

Dry Heat
Hot Air Oven
Sterility requires 1 hour of exposure @ 170° C(340° F)
Powders and non-aqueous liquids like paraffin or Vaseline
Used in some animal care facilities and useful in domestic applications (e.g. the kitchen oven)
Efficacy: complete sterilization

Dry Heat
Drying
Most organisms require humidity to survive and grow
More commonly used to prevent spoiling and preserve foodstuffs (e.g. raisins)
Efficacy: incomplete sterilization

Moist Heat
Hot Water
Used to clean and sanitize surfaces
Addition of detergents increases efficacy by emulsifying oils and suspending soils so they are rinsed away
Efficacy: incomplete sterilization

Moist Heat
Boiling
Requires 3 hours of boiling to achieve complete sterilization
Boiling for 10 minutes will destroy vegetative bacteria and viruses but not spores
Addition of 2% calcium carbonate or sodium carbonate will inhibit rust and increase efficacy
Useful for field work
Efficacy: may be complete sterilization

Moist Heat
Steam
Similar to boiling because the temperature is the same
Exposure to steam for 90 minutes kills vegetative bacteria but not spores
Efficacy: incomplete sterilization

Moist Heat
Steam under pressure
Pressure increases the boiling point such that the temperature of the water becomes much higher that 100° C (212° F)
The autoclave utilizes steam under pressure to achieve sterilization
This is the most efficient and inexpensive method of sterilization for routine use
Efficacy: complete sterilization

Radiation
Ultraviolet (UV)
Low energy UV radiation is a sterilant when items are placed at a close range
UV radiation has no penetrating ability
Used to sterilize rooms
Very irritating to eyes
Efficacy: may be complete sterilization

Radiation
Gamma radiation
Ionizing radiation produced from a Cobalt 60 source
Good penetrating ability in solids and liquids
Used extensively in commercial preparation of pharmaceuticals, biological products and disposable plastics
Efficacy: complete sterilization

Filtration
Fluid filtration
Forced through a filter with either positive or negative pressure
Filter is most commonly a synthetic screen filter with micropore openings
Used to sterilize culture media, buffers and pharmaceuticals
Pore size of 0.45µm removes most bacteria
Microplasmas and viruses require 0.01µm to 0.1µm
May be used in conjunction with a pre-filter
Efficacy: can be complete sterilization

Filtration
Air filtration
Examples of usage: surgical masks, laboratory animal cages and air duct filters
Fibrous filters made of various paper products are effective for removing particles from air
Efficacy is influenced by air velocity, relative humidity and electrostatic charge
Efficacy: can be complete sterilization

Filtration
Air filtration
HEPA: high efficiency particle absorption filters are 99.97% to 99.997% effective in removing particles with diameters greater that 0.3µm

Filtration
Air filtration
Surgical masks
Designed to protect the patient from the surgeon, not the surgeon from the patient
Special masks are available that are designed to protect personnel from animal pathogens
Masks must fit snugly, stay dry and be changed every 3 to 4 hours to remain effective

Ultrasonic Vibration
Cavitation
High frequency sound waves passed through a solution create thousands of cavitation “bubbles”
Bubbles contain a vacuum; as they implode or collapse, debris is physically removed from objects
Effective as an instrument cleaner
Efficacy: incomplete sterility

Chemical Methods
Many chemicals are available to sterilize, disinfect or sanitize
None is the “ideal” agent
Chemicals penetrate cell walls and react with cell components in various ways to destroy or inhibit growth
Many chemicals are disinfectants with varying levels of efficacy
Some are sterilants

Chemical Methods

Bacteria Viruses

Level Vegetative Acid-fast Spores Lipophilic Hydrophilic

High + + + + +

Medium + + 0 + +/-

Low + 0 0 +/- 0

Examples:

High: Aldehydes, VPHP, Chlorine-dioxide

Medium: Alcohols, Phenols, 7th generation Quats

Low: Quats

Ethylene oxide

Aldehydes

Vapor phase H2O2

Halogens

Phenols

7th generation quaternary

Alcohols

Chlorhexidine

Old generation quaternary

High-cidal

Activity

Low-cidal

Activity

Chemical Methods
Ideal chemical agent
Broad spectrum of activity
Does not stain or damage surfaces
Stable after application
Effective in a short time
Nonirritating and nontoxic to surfaces and tissues
Inexpensive and easy to store and use
Not affected by organic debris or other soil
Effective at any temperature
Nontoxic, nonpyrogenic and nonantigenic
Possesses residual and cumulative action

Chemical Methods
Soaps
Detergents
Quaternary ammonium compounds
Phenols
Aldehydes
Halogens
Chlorine and chlorine releasing compounds
Alcohols
Peroxygen compounds
Ethylene Oxide

Chemical Methods
Soaps
Anionic cleaning agent made from natural oils
Ineffective in hard water
Does not mix well with quats and decreases the effectiveness of halogens
Is not antimicrobial
Minimal disinfectant activity

Chemical Methods
Detergents
Synthetic soaps
Anionic, cationic or nonionic; anionic combined with cationic will lead to neutralization of both
Most are basic; a few are acidic
Emulsify grease and suspend particles in solution
May contain wetting agents

Chemical Methods
Quaternary Ammonium Compounds
Quats: Centrimide, benzalkonium chloride, Zephiran, Quatsyl-D, Germiphene
Effective against gm+ and gm- microorganisms and enveloped viruses
Low toxicity and generally nonirritating
Prolonged contact irritates epithelial tissues

Chemical Methods
Quaternary Ammonium Compounds
Inactivated by organic material, soap, hard water and cellulose fibers
Reduced efficacy in presence of organic debris, soap, detergents and hard water
Ineffective sporocide and fungicide
Bacteria not destroyed may clump together; those inside the clump are protected
Dissolves lipids in cell walls and cell membranes

Chemical Methods
Quaternary Ammonium Compounds
Organically substituted ammonium compounds
More effective in basic pH
Cationic detergent
Deodorizes


Chemical Methods
Phenols
Active against gm+ bacteria and enveloped viruses
Developed from phenol or carbolic acid
Synthetic phenols are prepared in soap solutions that are nontoxic and nonirritating
Prolonged contact may lead to skin lesions

Chemical Methods
Phenols
Toxic to cats because cats lack the inherent enzymes needed to detoxify the compound
May be toxic to rodents and rabbits
Not inactivated by organic matter, soap or hard water
Activity decreased by quats

Chemical Methods
Aldehydes
Active against gm+ and gm-, most acid fast bacteria, bacterial spores, most viruses and fungi
Considered to be a sterilant but may require prolonged contact

Chemical Methods
Aldehydes
Gluteraldehyde (Cidex)
Noncorrosive
Supplied as an acid, activated by adding sodium bicarbonate
Good for plastics, rubber, lenses in “cold sterilization”
Not inactivated by organic material or hard water
Irritating to respiratory tract and skin

Chemical Methods
Aldehydes
Formaldehyde (Formicide)
Aqueous solution 37% to 40% (w/v) formaldehyde
May be diluted with water or alcohol
Irritating to tissues and respiratory tract
A vapor phase surface disinfectant that slowly yields formaldehyde

Chemical Methods
Aldehydes
Biguanide (e.g. chlorhexidine gluconate [Hibitane, Precyde])
Active against gm+, most gm-, some lipophilic viruses and fungi
Efficient disinfectant, used mostly as an antiseptic
Some reduction of activity in presence of hard water and organic material
Immediate, cumulative and residual activity
Precipitates to an inactive form when mixed with a saline solution
Used as a surgical scrub and hand wash
Low toxicity

Chemical Methods
Halogens
Chlorine, iodine, fluorine and bromine
Active against gm+ and gm-, acid fast, all viruses and fungi
Iodine most common
Chlorine and chlorine releasing compounds

Chemical Methods
Halogens
Iodine
Used in solution with water or alcohol
Iodophors: iodine plus carrier molecule that acts to release iodine over time
Surgical scrub (Betadine): iodophor plus detergent
Tinctures and solutions: iodines and iodophors w/o detergent
Nonstaining and nonirritating
Inactivated by organic material
Aqueous forms are staining, irritating and corrosive to metals, especially if used undiluted

Chemical Methods
Halogens
Chlorine and chlorine releasing compounds (e.g. chlorine gas, chlorine dioxide)
Commonly available as sodium hypochlorite
Least expensive and most effective chemical disinfectant
Available chlorine equals oxidizing ability
Damages fabrics, corrosive to metals
Inactivated by organic debris
May require several minutes of contact to be effective
Skin and mucous membrane irritant if not diluted properly or rinsed well

Chemical Methods
Alcohols
Ethyl alcohol, isopropyl alcohol, methyl alcohol
Active against gm+ and gm- bacteria and enveloped viruses
Most effective when diluted to 60% to 70% (isopropyl), 705 to 80% (ethyl)

Chemical Methods
Alcohols
Used as a solvent for other disinfectants and antiseptics
Most commonly used skin antiseptic
Low cost and low toxicity

Chemical Methods
Alcohols
Irritating to tissues and painful on open wounds
Repeated use dries skin
Forms coagulum in presence of tissue fluid
Consists of a layer of tissue fluid whose proteins have been denatured by alcohol
Facilitates survival of bacteria under the coagulum
Fogs lenses, hardens plastics and dissolves some cements

Chemical Methods
Alcohols
Inactivated by organic debris
Ineffective after evaporation
Defatting agent

Chemical Methods
Peroxygen compounds (e.g. Peracetic acid)
Active against gm+ and gm-, acid-fast, fungi.
No virucidal activity
Classified as a sterilant but may not kill pinworm eggs

Chemical Methods
Peroxygen compounds (e.g. Peracetic acid)
Oxidizing agent
Reacts with cellular debris to release oxygen
Kills anaerobes
Applied as a 2% solution for 30 minutes at 80% humidity
Explosive and can damage iron, steel and rubber
Irritating to healthy tissues

Chemical Methods
Ethylene Oxide
Active against gm+ and gm-, lipophilic and hydrophilic viruses, fungi and bacterial spores
Classified as a sterilant
Effective sterilant for heat labile objects

Chemical Methods
Ethylene Oxide
EO is a colorless nearly odorless gas that diffuses and penetrates rapidly
Flammable and explosive
Toxic, carcinogenic and irritating to tissue

Chemical Methods
Ethylene Oxide
Used in a chamber with a vacuum
May be mixed with CO2, ether or freon
Used at temperatures of 21° to 60° C (70° to 140° F)
Works quicker at higher temperatures
Exposure times of 1 to 18 hours
Requires minimum relative humidity of 30% (40% is optimum
Items must be clean and dry and can be wrapped muslin, polyethylene, polypropylene or polyvinyl
Sterilized items must be ventilated in a designated area for 24 to 48 hours to dissipate residual EO

Autoclave
Advantages
Consistently achieves complete sterility
Inexpensive and easy to operate
Safe for most surgical instruments and equipment, drapes and gowns, suture materials, sponges and some plastics and rubbers
Safe for patients and personnel
Established protocols and quality control indicators are easy to access

Autoclave
Disadvantages
Staff may overestimate the ability of the autoclave
Sterility depends on saturated steam of the appropriate temperature having contact with all objects within the unit for a sufficient length of time
Requires a thorough understanding of techniques to ensure that the above occurs

Autoclave
Function
Heat is the killing agent
Steam is the vector that supplies the heat and promotes penetration of the heat
Pressure is the means to create adequately heated steam

Autoclave
Function
Complete sterilization of most items is achieved after 9 to 15 minutes exposure to 121° C (250° F)
Steam at sea level is 100° C (212° F) as pressure is increased the temperature of the steam increases
The minimum effective pressure of the autoclave is 15 pounds per square inch which provides steam at 121° C (250° F)
Many autoclaves attain 35 psi which creates steam temperature of 135° C (275° F)

Autoclave
Function
Exposure times must allow penetration and exposure of all surfaces to 121°C (250° F) steam
Exposure time is decreased by increasing pressure, which increases steam temperature

Steam Sterilization Temperature/
Pressure Chart

Temperature

Pressure(psi) °C °F Time(mins)

0 100 212 360

15 121 250 9-15

20 125 257 6.5

25 130 266 2.5

35 133 272 1

Autoclave
Types
Gravity displacement autoclave
Prevacuum autoclave

Autoclave
Types
Gravity displacement
Water is heated in a chamber
Continued heating creates pressure
Steam displaces air within the chamber forcing it out through a vent
Cycle timing begins when the temperature reaches at least 121°C

Autoclave
Types
Gravity displacement
After sufficient exposure time, steam is exhausted through a vent back into a reservoir
Air that has been sterilized within the jacket and then filtered is admitted back into the chamber to replace the exhausting steam
If the chamber is loaded improperly or there is insufficient steam, there will be air pockets remaining in the chamber that will interfere with steam penetration and result in non-sterile areas
The load must be dried within the autoclave

Autoclave
Types
Prevacuum
Usually a much larger and more costly machine
Equipped with a boiler to generate steam and a vacuum system
Air is taken out of the loaded chamber by means of the vacuum system
Steam at 121°C or more is introduced into the chamber
The steam immediately fills the chamber to eliminate the vacuum
Exposure time begins immediately
At completion of the cycle steam is vacuumed and replaced by hot, dry sterile air
Air pockets are eliminated and processing times are reduced due to the vacuum

Autoclave
Operation
Preparation of the load
Loading the chamber
Autoclave cycles

Autoclave
Operation
Preparation of the load
Linen packs
Pouch packs
Hard goods
Liquids
Contaminated objects

Autoclave
Linen packs
All instruments in packs are scrupulously cleaned and rinsed in de-ionized water
Instruments are disassembled and ratchets are left closed and unlocked
Appropriate lines are in good repair and freshly laundered
Disposable linens are not reused

Autoclave
Linen packs
A chemical sterilization indicator is included in every pack
Chemical sterilization indicators provide verification that the inside of the pack was exposed to appropriate sterilization temperatures for the appropriate length of time

Autoclave
Linen packs
The pack is wrapped using at least two layers of material
The shelf life of the sterilized pack varies with the type of the outer wrapping
Pack is sealed with autoclave tape and labeled with the date, contents and operator
Autoclave tape provides verification that the outside of the pack was exposed to appropriate sterilization temperatures

Autoclave

SHELF LIFE

Wrapper Shelf-life

Dbl wrapped two layer muslin 4 wk

Dbl wrapped two layer muslin 6 mo

heat sealed in dust covers

after sterilization

Dbl wrapped two layer muslin 2 mo

tape sealed in dust covers

after sterilization

Dbl wrapped non-woven barrier 6 mo

materials (paper)

Paper/plastic peel pouches, heat sealed 1 year

Plastic-peel pouches, heat sealed 1 year

Autoclave
Linen packs
Pack should not exceed 30 X 30 X 50 cm (12 X 12 X 20 inches) in size
Pack should not exceed 5.5 kg (12 lb) in weight
Pack should not exceed 115 kg/m3 in density

Autoclave
Pouch packs
Used for single instruments, sponges, etc.
Previous guidelines apply
Pouches are heat sealed or ends are rolled and securely taped with autoclave tape
Labeled as above

Autoclave
Hard goods
Stainless steel or other hard instruments, trays, bowls, laboratory cages and other equipment may be autoclaved without wrapping
Must be physically clean and rinsed in de-ionized water
Syringes and plungers are separated before autoclaving

Autoclave
Liquids
Contained in Pyrex flasks 3 times larger than contents require
Cover loosely with applied lid or paraffin film, or place a needle through the stopper to allow air exchange
Sterility of liquids processed in the autoclave is in question
Removing liquids from the chamber is hazardous to personnel

Autoclave
Contaminated objects
Used before disposal to decontaminate syringes, culture plates, etc., that contain biohazardous waste
Place objects in a container appropriate for disposal
Special autoclavable biohazard bags are available

Autoclave
Chamber loading
Must allow free circulation of steam
Use perforated or wire mesh shelves
Linen packs have 2.5cm to 7.5cm space between
Place multiple packs on edge instead of stacking
Paper/plastic pouches are placed in specially designed baskets that support them on edge with the paper side of each package facing the plastic side of the adjacent package
Solid bowls or basins are placed upside down or on edge
Mixed loads (hard goods and wrapped goods) have wrapped goods on upper shelf

Autoclave
Autoclave cycles
Wrapped goods
Hard goods
Liquids

Autoclave
Autoclave cycles
Wrapped goods
Has “dry” cycle that allows wrapped packs to dry
Used for most surgical packs

Autoclave
Autoclave cycles
Hard goods
Has no dry cycle
Used for trays, bowls, cages, etc. that will not be maintained in a sterile condition
Also used for flash autoclaving to quickly sterilize instruments that are needed immediately

Autoclave
Autoclave cycles
Liquids
Exhausts steam more slowly than other cycles
Used for liquids that would be forced from containers during a faster exhaust cycle

Quality Control
The effectiveness of any method of microbial control must be monitored regularly
Verification of the effectiveness of microbial control should be performed at least monthly

Quality Control
Methods
Recording thermometer
Thermocouple
Chemical indicator
Biological testing
Bowie Dick test
Surface sampling
Serology

Quality Control
Methods
Recording thermometer
Displays the temperature of the autoclave chamber
Operator observes for correct temperature during cycle
Some autoclaves are equipped with printed tape of chamber temperatures during cycle

Quality Control
Methods
Thermocouple
Used in steam and dry heat sterilization chambers
Temperature sensors are placed in the part of a test pack that is most inaccessible to steam penetration

Quality Control
Methods
Chemical indicator
Paper strips impregnated with sensitive chemicals change color when conditions of sterility are met
Used with autoclaves and ethylene oxide systems
Placed deep inside packs before sterilization

Quality Control
Methods
Biological testing
Bacterial spores are exposed to autoclave or ethylene oxide and then cultured
Recommended method for verification of proper autoclave operation in veterinary clinics

Quality Control
Methods
Bowie Dick test
Tests pre-vacuumed autoclaves for complete removal of air and uniform steam penetration
Uses a pack of uniform dimensions with a cross of autoclave tape in the center

Quality Control
Methods
Surface sampling
Surface to be tested is swabbed with a sterile applicator and transferred to a suitable media plate for growth
Surface or item is rinsed with a sterile solution, which is examined for contamination
“Contact plate” of media is touched to the surface and incubated
Recommended method for ensuring proper disinfection of surgical suites in veterinary clinics

Quality Control
Methods
Serology
The presence of viruses in the environment is monitored by serological testing of animals to determine the presence of antibodies
Animals maintained for this purpose are referred to as sentinel animals

Surgical Preparation and Instrument Care.ppt

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Double Layered Urethrovesical Anastomosis

Double Layered Urethrovesical Anastomosis during Robotic Radical Prostatectomy

A novel technique of double layered urethrovesical anastomosis during robotic radical prostatectomy and report early continence results with our initial experience.

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Neurology & NeuroSurgery Grand Rounds 2005 videos

Neurology & NeuroSurgery Grand Rounds videos - 2005
from University of Arizona

December 16, 2005 NEUROLOGY	Benefits & Risks of Immunomodulation in Multiple Sclerosis Therapy Olaf Stüve, MD Assistant Professor Department of Neurology, University of Texas, Southwest Medical Center at Dallas Disclosure: Nothing to disclose.
December 9, 2005 NEUROLOGY	GRAND ROUNDS NOT AVAILABLE AT REQUEST OF PRESENTER Amir Akhter , MD, Assistant Professor, Clinical Neurology, VA Hospital
December 2, 2005 NEUROSURGERY	Management of Malignant Skull Base Tumors Involving the Carotid Artery Iman Feiz-Erfan, MD Neurosurgery Resident, Barrow Neurological Institute, St Joseph's Hospital and Medical Center Phoenix, Az Disclosure: Nothing to disclose.
October 21, 2005 NEUROLOGY	Lysosomal Storage Disorders Tim Miller, M.D. Neurosurgery Resident UA College of Medicine, Dept. of Neurosurgery Disclosure: Presenter is a consultant for Genzyone.
October 14, 2005 NEUROLOGY	Neurotube 2005 A. Lee Dellon, MD, Professor of Plastic Surgery and Neurosurgery, John Hopkins University Baltimore, Maryland, The University of Arizona Disclosure: Presenter has relationship with commercial products or devices included in discussion.
October 7, 2005 NEUROSURGERY	Surgical Treatment of the Peripheral Entrapment Neuropathy of the Lower Extremities: 158 consecutive surgical cases Juan Valdivia-Valdivia, M.D. Neurosurgery Resident UA College of Medicine, Dept. of Neurosurgery Disclosure: Nothing to disclose.
September 30, 2005 NEUROLOGY	Drug-Induced Movement Disorders Holly Shill, M.D. Director, Muhammad Ali Parkinson Research Center, Barrow Neurological Institute Disclosure: Presentation will include discussion of unlabeled/investigational drug use.
September 23, 2005 NEUROLOGY	Telemedicine and it's use in Acute Stroke: The Stroke DOC Clinical Trial Brett Meyer, M.D. Assistant Professor, Neurology; USCD Stroke Center San Diego, CA Disclosure: Nothing to disclose.
September 16, 2005 NEUROLOGY	Neurologic Treatment of Status Epilepticus Yu-Tze Ng, MD, FRACP; UA Asst. Professor, Clinical Pediatrics & Neurology; Pediatric Neurologist/Epileptologist, Division of Child Neurology, Children's Health Center, Barrow Neurologic Institute Disclosure: Presenter in on the speakers bureau for Novartis, GSK, Ortho-McNeil, and Cyberonics
September 9, 2005 NEUROLOGY	Tourette Syndrome: An Integrative Approach SLIDES Evan S. Trost, MD; Troon Family and Preventative Care, PLLC Disclosure: Nothing to disclose.
September 2, 2005 NEUROSURGERY	Stereotactic Radiotherapy of Central Nervous System and Head and Neck Lesions using a Conformal Intensity Modulated Radiotherapy System: The PEACOCK System Mario Ammirati, MD Adjunct Professor, Center for Biotechnology, College of Science and Technology, Temple University, Philadelphia, PA Disclosure: Nothing to disclose.
August 26, 2005 NEUROLOGY	The Search for Neuroprotection in Parkinson's Disease Richard B. Dewey, Jr., MD Associate of Professor of Neurology, Department of Neurology The University of Texas Southwestern Medical Center at Dallas Disclosure: Nothing to disclose.
August 19, 2005 NEUROLOGY	Physicians, Stress and Optimal Performance: How to Perform Optimally in Today's Healthcare Environment Larry G. Oñate, M.D. House Staff Counselor,The University of Arizona College of Medicine, Chair, UMC Physician Well-being Committee Disclosure: Nothing to disclose.
August 12, 2005 NEUROLOGY	Health Consequences of Sleep Disordered Breathing Stuart F. Quan, M.D. Professor, Medicine, Anesthesiology, Public Health; Director, Sleep Disorders Center, The University of Arizona Disclosure: Nothing to disclose.
August 5, 2005 NEUROSURGERY	Lower Extremity Nerve Pathology Jerome K. Steck, D.P.M UA Clinical Assist. Professor, Surgery Institute for Plastic Surgery and Peripheral Nerve Surgery, Foot & Ankle Institute of Arizona. Disclosure: Nothing to disclose.
July 29, 2005 NEUROLOGY	Epilepsy and Depression David M. Labiner, M.D. Professor of Neurology, Pharmacy Practice & Science. Disclosure: Nothing to disclose.
July 22, 2005 NEUROLOGY	Temporolimbic Epilepsy and Behavior SLIDES Geoffrey L. Ahern, M.D., PhD Professor of Neurology, Psychology, and Psychiatry. Director, Behavioral Neuroscience & Alzheimer's Clinic, The University of Arizona Health Sciences Center Disclosure: Nothing to disclose.
July 15, 2005 NEUROLOGY	The Hospitalists in Neurology SLIDES Marc Malkoff, M.D. Director Neurocritical and Neurovascular Service, Barrow Neurological Institute Disclosure: Nothing to disclose.
July 8, 2005 NEUROSURGERY	Safety and Effectiveness of Cortical Stimulation in Patients with Hemiparetic Stroke, The Baker Study Martin E. Weinand, M.D. Disclosure: Nothing to disclose.
July 1, 2005 NEUROLOGY	Systemic Thrombolysis for Stroke Andrei V. Alexandrov , M.D. Assoc. Professor, Director, Cerebrovascular Ultrasound, Dept. of Neurology, University of Texas, Houston Disclosure: Presenter recieves grant/research support. Presenter is a consultant for IMARX and is on the speakers' bureau for Genentech.
June 24, 2005 NEUROLOGY	Neuronal Migration Disorders Dinesh Talwar , M.D. Pediatric Neurology Associates Disclosure: Nothing to disclose.
June 17, 2005 NEUROLOGY	Does Prolonged Status Epilepticus Produce a Model of Temporal Lobe Epilepsy with Hippocampal Sclerosis? Hemant Kudrimoti, M.D., Ph.D. Assistant Professor, Department of Neurology, The University of Arizona Disclosure: Nothing to disclose.
June 10, 2005 NEUROLOGY	Disturbing Sleep: Dreams, Violence and REM Behavior Disorder Pedram Navab, D.O. Neurology Resident, The University of Arizona Disclosure: Nothing to disclose.
June 3, 2005 NEUROSURGERY	Not available due to privacy concerns
May 27, 2005 NEUROLOGY	Technical Advances in the Treatment of Brain Tumors Baldassarre 'Dino' Stea, M.D., Ph.D. Disclosure: Nothing to disclose
May 20, 2005 NEUROLOGY	Cortico-Hippocampal Interactions and Memory Consolidation: Insights From Neural Ensemble Recording and Immediate-Early Gene Activation Studies Bruce L. McNaughton Ph.D. Disclosure: Nothing to disclose
May 13, 2005 NEUROLOGY	Cancelled
May 6, 2005 NEUROSURGERY	Hyperglycemia During Acute Cerebral Infarction: Does it Matter?/New Concept in the Neurovascular Unit Askiel Bruno, M.D./ Gregory del Zoppo, M.D.
April 29, 2005 NEUROLOGY	A Deadly Cross-Talk Between Mitochondria and Nuclei in Neuronal Apoptosis & Neurogeneration Seong-Woon Yu, Ph.D. Disclosure: Nothing to disclose
April 22, 2005 NEUROLOGY	Dr. Alzheimer Goes Molecular: Recent Developments in Diagnosis and Treatment Earl Zimmerman, M.D. Disclsoure: Presenter recieves grant/research support from Pfizer, General Electric. He is on the speakers bureau for Pfizer, Forest Labs and Novartis
April 8, 2005 NEUROLOGY	The Physiology of Emotion: A Non-Human Primitive Model Katalin Gothard, M.D. Disclosure: Nothing to disclose
April 1, 2005 NEUROSURGERY	Dynamic Cerebral Blood Flow Phillip Carter, M.D. Disclosure: Presenter has relationship with commercial products or devices included in discussion.
March 18, 2005 NEUROLOGY	Automatic Tracking of Body Movement, Gait & Gestures Jay Nunamaker, M.D. Disclosure: Nothing to disclose.
March 4, 2005 NEUROSURGERY	Advances in Endovascular Neurosurgery Eric Eskioglu, M.D. Disclosure: Presentation includes discussion of unlabeled or investigational drug use.
February 25, 2005 NEUROLOGY	Genetic Disorders and Epilepsy David King-Stephans, M.D. Disclosure: Presenter is on the speakers bureau for UCB Pharma, Novartis , and GlaxoSmithKline
February 11, 2005 NEUROLOGY	Recent Advances in Vestibular Testing Terry D. Fife, M.D. Disclosure: Presenter has a financial interest, arrangement or affiliation with GlaxoSmithKline.
February 4, 2005 NEUROSURGERY	Localizing and False Localizing Signs in Neurosurgery Patients Charles W. Needham, M.D. Disclosure: Nothing to disclose
January 21, 2005 NEUROLOGY	Treatment of Ischemic Stroke Adhan Qureshi, M.D. Disclosure: Presenter has a financial interest, arrangement or affiliation with corporate organizations.
December 3, 2004 NEUROSURGERY	Arachnoid Cysts: To Treat or Not to Treat and How to Treat When Treating David H. Shafron, M.D. Disclosure: Nothing to disclose.

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