Images and Instruments Flashcards
What are the complications of cannula?
Exstravasation Haematoma Phlebitis Thrombosis Systemic infection
What is a the description of the a central venous catheter (central line)?
A catheter which is inserted into either the jugular vein, subclavian vein or femoral vein
How long a central venous catheter used for?
3 days (it is short term)
What are the indications for a central venous catheter? (7)
- Central administration of medication
- Vasopressors
- Inotropes
- Total parenteral nutrition
- Chemotherapy
- Access for extracorporeal circuit - renal replacement therapy
- Monitoring central venous pressure
Describe a tunnelled central line
Catheter inserted into the subclavian through a subcutaneous tunnel
What are the other names for a tunnelled central line
Hickman line
Tesio line
What are the indications for a tunnelled central line? (6)
- IV administration of medication
- Antibiotics
- Chemotherapy
- Regular vascular access
- Renal replacement therapy
- Blood sampling
What does PICC line stand for?
Peripherally inserted central catheter
How long can a tunnelled central line be used?
Long term - months to years
Describe a peripherally inserted central catheter
inserted into the basilic or cephalic veins with the tip sitting into the superior vena cava
How long can a PICC line be used for?
Medium term - weeks to months
What are the indications for a PICC line? (4)
- IV administration of medication
- Antibiotics
- Chemotherapy
- Poor peripheral access
What are the immediate complications of central venous access? (6)
- Haemorrhage
- Pneumothorax
- Arterial puncture
- Arrhythmias
- Cardiac tamponade
- Air embolism
What are the delated complications of central venous access? (6)
- Venous stenosis
- Thrombosis
- Erosion of vessel
- Line fracture
- Catheter colonisation
- Line related sepsis
Describe a chest drain
A drain which is inserted into the triangle of safety for drainage of pleural space via a tube
How is the position of a chest drain confirmed?
CXR
What are the indications for chest drain?
- Pneumothorax
- Pleural effusion
- Traumatic haemopneumothorax - wide bore
- Post -surgical (cardiac, thoracic, oesophagus)
What are the borders of the triangle of safety
Lateral edge of pec major
Lateral edge of latissimus dorsi
5th ICS
Apex of axilla
Why do you insert it above the rib?
To avoid the neurovascular bundle
What are the complications of Chest drains?
Insertion related:
- Damage to nearby structures (intercostal artery, solid organ)
- Subcutaneous emphysema
- Pneumothorax
Position related:
- Obstruction
- Kinking
- Dislodged
- Re-expansion pulmonary oedema
Infection
- Wound infection
- Pneumonia
- Empyema
Describe chest drain bottle
Bottle filled with sterile water with drainage tube submerged
Creates an underwater seal and one-way valve
Where should a chest drain bottle be position?
Below the patient and kept upright
What does the swinging represent in the chest drain bottle? (state what up and down represents)
Movement of the water column with the respiratory cycle
Up in inspiration and down in expiration
What does the bubbling represent in the chest drain bottle?
Bubbling = air leaving the pleural cavity
Stops when all air is expelled
Describe surgical drains
Tubes inserted into the surgical field to allow decompression of fluid or air
What are the indications for surgical drains?
- Drainage of a potential space post-surgery
- Removal of harmful fluid - e.g. blood, pus, bile
- Detection of bleeding or leakage - e.g. anastomosis
Multiple uses in upper GI, orthopaedic, cardiothoracic, plastic, breast, head and neck surgery
What is the difference between open and closed surgical drains?
Open drains (e.g. corrugated or rubber) connect to the external environment Closed drains connect via tubing to a drain bottle
What are open drains used for?
Superficial wounds but increase the risk of infection
What is the difference between active and passive surgical drains?
Active drains maintained under negative pressure, improves wound closure
Passive drains use gravity
Where in the body are passive drains preferred and why?
In the abdomen because there is less risk of visceral perforation
What are the complications of surgical drains?
- Ascending infection (more common with open or passive systems)
- Foreign body reaction (fibrosis or granulation)
- Migration
- Obstruction/kinking
- Fistulation
Describe nasogastric feeding tube
A tube which goes in through the nostril, down the oesophagus into the stomach with aid of a guidewire to give stiffness to the tube
- Narrow bore nasogastric tube (<9 Fr)
How is the position of NG tube confirmed?
pH aspirate (<4.5) or CXR
What are the indications for Nasogastric feeding tube?
- Short/medium term feeding (max 4-6 weeks) in patients with a functional GI tract
- Administration of drugs/contrast in an unsafe swallow
What is a Ryles tube?
A wide bore tube (16-18 Fr) nasogastric tube - no guidewire is needed
What are the indications for a Ryles NG tube?
Gastric decompression (in bowel obstruction, ileus, post-surgical)
What is the benefit of having thicker walls in a Ryles NG tube?
Prevent tube collapse during aspiration of gastric contents
What 4 questions can you ask to make sure the position of the NG tube is correct when looking at the CXR?
- Does the tube path follow the oesophagus/avoid the contours of the bronchi?
- Does the tube clearly bisect the carina or the bronchi?
- Does it cross the diaphragm in the midline?
- Is the tip clearly visible below the left hemi-diaphragm?
What are the complications of nasogastric tubes?
Pulmonary
- Aspiration pneumonia (incorrect position)
- Pneumothorax
GI
- Malposition in the GI tract
- Obstruction/knotting/kinking
- Reflux oesophagitiis
- Gastritis
- Visceral perforation (rare)
What is post-pyloric feeding?
When the NG tube is passed through the pylorus and rests in the jejunum
How do you insert a post -pyloric tube?
Using endoscopic or fluoroscopic means
and this is also used to confirm it is in the right place
What are the indications of Post-pyloric feeding?
- Gastroparesis e.g. in critical illness, diabetes, neurological (MS, Parkinson’s)
- Gastric outlet obstruction e.g. peptic ulcer disease, malignancy
- Recurrent aspiration
- Pancreatitis (less stimulation of pancreas)
Describe urinary catheter
A catheter inserted into the urethra to the bladder into the bladder for drainage of urine
What are the 3 types of urinary catheter?
- Foleys catheter
- Long-term catheter
- Three-way catheter
What are the typical sizes of urinary catheter?
14-16 Ch
How long can Foleys be used for vs Long term?
Foleys - 28 days
Long term - more than 6 weeks
What is a Foleys catheter vs a long term catheter made from?
Foleys = latex (yellow)
Long term = silicone (transparent)
What does the curved tip of a catheter help with?
To aid insertion past an enlarged prostate
What are the indications of a urinary catheter?
- Urinary retention
- Measurement of urine output in acute illness
- During abdominal/pelvic surgery
- Neurogenic bladder
- Immobility
- End of life care
- Urinary incontinence
- Sacaral or perineal ulceration
Describe a 3 way catheter
A urinary catheter with a third port to allow for bladder irrigation and prevent clot formation
What are the indications of a 3 way catheter?
Visible haematuria with clots
Post-bladder/prostate surgery
What are the immediate/early complications of urinary catheterisation?
- Urethral trauma
- allergic reaction to material
- Balloon rupture
- Obstruction
- Bypass leakage
- Bladder perforation (rare)
What are the delayed complications of urinary catheterisation?
- Bacteriuria/UTI – do not treat if asymptomatic
- Pyelonephritis
- Urethral stricture
- Bladder stones
Describe a catheter drainage bag
Collection of urine
Has a port to empty the bag/sample the urine
Describe a Urometer
A catheter bag and collection chamber
- it allows for accurate recording of the urine output
Describe a rigid sigmoidoscope
A scope inserted into the anus used to insect the rectum and lower sigmoid colon in an outpatient setting
What position does the patient need to be to use the rigid sigmoidoscope?
Left lateral position with knees flexed
What should occur before a rigid sigmoidoscope is carried out?
A DRE to assess the rectal contents
What is the maximum length of the sigmoidoscope inserted?
15-20cm
What is a complication of using a rigid sigmoidoscope?
Pain and Rectal discomfort - very common
Describe a proctoscope
Used to visualise the anal canal and lower rectum
What extra feature can you use a proctoscope for?
Injecting (sclerotherapy) or banding haemarrhoids
What extra feature can you use a rigid sigmoidoscope for?
Biopsy of the rectal mucosa e.g. in UC
Describe a stoma bag
A stoma bag is a prosthetic medical device that provides a means for the collection of waste (faeces, flatus or urine) from a surgically diverted bowel.
How can you prevent wind inflation and smell with a stoma bag?
some stoma bags ahve a filter which can release the wind
Some have a deodorising component
What are the complications of stoma bags?
Adhesive can cause irritation (stomal dermatitis)
It can become displaced
Describe a Scalpel
A scalpel is made up of a blade and handle
The blade is single use and disposable whilst the handle is reusable or disposable
Scalpels are numbered based on shape
State the numbers of scalpels and what they are used for
10 - ‘traditional blade’ - large cutting curve for skin incisions
11 - pointed apex for puncturing movements
15 - smaller cutting surface for more delicate control
Describe sutures
Used for wound closure and approximation of tissue
All sutures cause a tissue foreign body reaction
Ideally sterile, easy to handle, low risk of infection and cheap
What are the types of Sutures?
Absorbable (broken down by hydrolysis or enzymatic degradation) - Vicryl, Monocryl, PDS
Non-absorbable - Nylon , Prolene, silk, steel
Monofilament
Braided (multifilament)
Compare and contrast monofilament and multifilament
Monofilament: less trauma and tissue reaction, lower risk of infection
Multifilament: Easier to handle and retain knots, increased risk of infection
Over what features are sutures chosen?
Diameter (larger number of ‘0’s = smaller diameter)
tissue strength
duration of closure
When do you use absorbable sutures?
Deep or rapid healing tissues e.g. bowel/biliary/urinary anastamoses
When do you use non-absorbable sutures?
Used for permanent support and slower healing tissues e.g. vascular
anastomoses, tendon, fascia
When do you use monofilament sutures?
Used for superficial wound closure (less tissue reaction)
Describe a Laparoscopic trocar
- Used to create entry ports in laparoscopic procedures
- Initial entry carries the highest risk of visceral perforation
- Several described techniques (Veress needle, Hasson technique)
- Extra care taken at extremes of BMI and previous laparotomy
At what point would you insert the other ports when using a laparoscopic trocar?
Once pneumoperitoneum is established
What gas do you use with lapascopic procedures and why?
Carbon dioxide - it is inert, highly soluble in blood and tissues and rapidly cleared by expiration
Describe diathermy
High frequency current driven by an electric generator
Current can be delivered as a continuous waveform for cutting
tissue or intermittent waveform for coagulation of small vessels
What are the two types of diathermy?
Monopolar-
Current flows between pen and electrode bad through the patient
Bipolar -
Both electrodes mounted on the forceps
Used when tissue can be grabbed from two sides
Describe the two types of hip prosthesis
Hemiarthroplasty
- Single component
- Used for intracapsular NOF fractures in co-morbid patients with poor
functional reserve
Total hip replacement
- Two components (femoral and acetabular)
- Used for intracapsular NOF fractures in healthier and more active patients
What are the complications of a Hip prosthesis?
Dislocation Osteolysis Metal sensitivity Nerve injury Chronic pain
Describe oropharyngeal airway
- First-line airway adjunct
- Lifts tongue of posterior pharyngeal
wall - Sized by measuring the from incisors
to the angle of the mandible - Inserted into the mouth upside down,
and rotated within the oral cavity
(except in children)
What are the complications of oropharyngeal airways?
Vomiting
Aspiration if the
gag reflex is present
Describe a nasopharyngeal airway
Inserted horizontally into nostril
Sized by patient height (6 for female, 7 for
male)
When is nasopharyngeal airway used?
In patients with decreased
consciousness but intact gag reflex
What are the complications of nasopharyngeal airway?
Ulceration
Epistaxis
When should nasopharyngeal airway be avoided?
In severe head or maxillofacial trauma (esp if signs of basal skull fracture)
Describe a Laryngeal mask airway
Supraglottic airway devic e
What is the difference between an iGel and Laryngeal mask airway?
- iGels contain a thermoplastic elastomer (styrene) that moulds to perilaryngeal framework with patient temperature
- The tip extends into the oesophageal opening, has its own gastric channel to allow the passing of NG tube into the stomach for gastric emptying
- The iGel also seals off the oropharyngeal opening from the larynx, preventing aspiration
Describe an endotracheal tube?
Inserted through the mouth with the aid of a laryngoscope
so that the end of the tube lies above the carina
Cuff is inflated to secure the airway and prevent gastric
aspiration
How do you confirm the position of an endotracheal tube?
Definitive airway
Symmetrical
chest expansion and breath sounds (alternatively, a chest
x-ray can confirm its placement, CO2 monitor, or
aspiration)
What are the two definitive airways?
Endotracheal tube
Tracheostomy
Describe tracheostomy tube
Definitive airway
Inserted below the glottis (surgical or percutaneous access)
What are the advantages of a tracheostomy vs endotracheal intubation?
Reduced dead space
Improved oral hygiene
Reduced sedation
What are the indications for tracheostomy?
Weaning of mechanical ventilation
Severe maxillofacial trauma
What are the complications of intubation?
Early
- Cant intubate, cant ventilate
- Trauma
- Bleeding
- Cuff perforation
- Endobronchial intubation
Delayed
Tracheal necrosis
Tracheal stensois
What are the complications of intubation?
Early
- Cant intubate, cant ventilate
- Trauma
- Bleeding
- Cuff perforation
- Endobronchial intubation
Delayed
Tracheal necrosis
Tracheal stensois
What is the stepwise progression for airway management?
Airway manoeuvres
Airway adjuncts
Supraglottic devices
Definitive airway
What are the features of a definitive airway?
Infraglottic (crosses the cords)
Secure (cuffed)
Prevents aspiration of gastric contents
Can deliver max concentrations of o2
What are the indications for intubation?
- Decreased consciousness and loss of airway reflexes (GCS <8)
- failure to protect against aspiration - Failure to oxygenate (T1RF)
- Respiratory pathologu, ARDS, pulmonary oedema - Failure to ventilate (T2RF)
- Tiring patient (life threatening) - Failure to maintain airway patency
- Upper aiway obstruction
- Angioedema
- Facial/upper airway trauma
What are the indications for intubation?
- Decreased consciousness and loss of airway reflexes (GCS <8)
- failure to protect against aspiration - Failure to oxygenate (T1RF)
- Respiratory pathologu, ARDS, pulmonary oedema - Failure to ventilate (T2RF)
- Tiring patient (life threatening) - Failure to maintain airway patency
- Upper aiway obstruction
- Angioedema
- Facial/upper airway trauma
Describe a laryngoscope
- A device used in conjunction with an endotracheal tube for intubation
- It has its own light source which aids visualisation of the laryngeal folds
- used in the left hand, with the right hand guiding the tube down
Describe nasal cannulae
First line device for oxygen therapy
Can deliver 25-35% FiO2
Mix 4L/min of oxygen
What are the indications for Nasal cannula?
Mild hypoxia
Used for long term oxygen therapy
What are the complications of nasal cannula?
necrosis
ulceration
Describe face mask
- Used for moderate hypoxia (<90% o2 sats)
- Can deliver up to 10L/min
- FiO2 25-60%
Describe a non-rebreathe mask
A fask mask combined with a bag and valve Can deliver up to 15L/min O2 FiO2 80-85% First line in acutely unwell patients Aim target sats 94-98%
Describe a venturi mask
Multiple valves of different colours allow controlled FiO2
Uses the venturi effect to entrain air into the mask
The flow rate is selected, giving a specific FiO2
What is the indication for a venturi mask?
Used when there is a risk of T2RF and CO2 retention e..g. COPD
What is the stepwise action plan for delivering o2 therapy?
- Nasal cannula
- Face mask (and venturi)
- Non-rebreathe mask
- High flow nasal cannula
- Non-invasive ventilation
- Mechanical ventilation
Described TED stockings
Graduated compressionn (maximum distally) Often used in conjunction with LMWH
What are the indications of TED stockings?
- Used in patients undergoing surgery those 2. pts who are immobile for DVT prophylaxis
What are the contraindications of TED stockings?
- Severe peripheral vascular disease
2. Severe skin breakdown e.g. ulceration, infection
Describe intermittent pneumatic compression
Inflatable sleeves that are wrapped around the calves
Inflated one side at a time at regular intervals
They reduce venous stasis and the risk of VTE
What are the indications of Intermittent pneumatic compression?
- Mechanical thromboprophylaxis
- Post-abdominal /orhorpaedic surgery
- Post-stroke
What are the contraindications of intermittent pneumatic compression?
Severe peripheral vascular disease
severe skin breakdown e.g. ulceration, infection
