Instruments Flashcards
Indications
Investigate a patient c¯ pyrexia
Features
Red: anaerobic culture medium
Blue: aerobic culture medium
Method
Take blood using ANTT
Replace needle with a clean one
Wipe top of bottles c¯ alcohol
Fill anaerobic (red) bottle first
Fill in pt. details and send to path lab
Some hospitals have specific teams that take cultures
Catgut Suture
This is catgut suture, which is an example of a natural absorbable suture. Catgut as been replaced my many
of the newer synthetic absorbable materials, however you will still see it being used in the formation of
stomas and circumcisions.
Chest Drain Bottle
This is the bottle to which the chest drain is attached.
If you look carefully on these there will be a line called prime level which is filled with sterile water. The chest drain tubing is connected to a tube which is under the sterile water and therefore acts as a water seal. After a chest drain has been inserted you can see bubbling in the water as the air leaves the pleural space. The chest drain bottle can also be used to collected blood, fluid and pus from the pleural space. The system can be driven by attaching suction to the top of the bottle making it an example of a active closed drainage system.
Indications
As for chest drain tube
Method
Fill bottle to prime level c¯ sterile water
Connect to drain to bottle
Underwater seal allows one-way flow out of pleural cavity
May add suction → active drainage
Complications
Lifting the bottle above the pt can → retrograde flow into chest.
Complications of chest tube insertion
Devers Retractor
This is a type of retractor which is used in open abdominal surgery to allow the surgeon to operate. There are different sizes and types of retractors available, you may frequently be asked to use one during you
clinical training when you are assisting in theatre.
Indications
Surgical instrument used in open abdominal surgery to retract viscera and ↑ the field of view
Method
Curved end inserted into abdomen and placed carefully to retract the viscera.
Can be bent to a suitable shape
Complications
Damage to skin and internal structures
Disposable Rigid Sigmoidoscope
This is a disposable rigid sigmoidoscope, which is used for the inspection of the rectum and lower sigmoid colon. After explaining to the patient what you are about to do, you must attach a light source and a air pumping
device. The patient is placed in the left lateral position and a digital rectal examination is performed. The sigmoidoscope is then lubricated with jelly and inserted pointing towards the umbilicus. Air is pumped into
the rectum to allow you see the direction of the rectal lumen.
Biopsies can also be taken of rectal mucosa through the sigmoidoscope e.g. in a case of ulcerative colitis
Indications
Allows endoscopic examination of the rectum and rectosigmoid junction c¯ possible biopsy.
Can be used in the outpatient or inpatient setting
Investigation of
Rectal bleeding
Colonic Neoplasia
IBD
Features
Graduated plastic tube c¯ an obturator to aid insertion
Method
For good views a suppository should be given prior to examination
Consent pt. and explain procedure.
Examine perineum and perform DRE c¯ pt. in left-lateral position.
Ensure no obstruction to scope
Lubricate scope c¯ aquagel and insert into anal canal
Remove obturator
Attach light source, bellows and eye piece and insufflate air
Visualise mucosa as scope withdrawn
Complications
Perforation
Mechanical: pushing against bowel wall
Pneumatic: over-inflation
Bleeding
Drainage Bag
This is a drainage bag which can be connected top either a nasogastric tube or a drain coming out of the abdomen. Drainage relies on gravity so this is an example of a closed passive drainage system.
Endotracheal Tube
This is an adult endotracheal tube which is used to provide a definitive airway for patients for example during long operations e.g. laparotomies and during cardiac arrests or trauma. The endotracheal tube is inserted using a laryngoscope, through the laryngeal folds. The end of the tube should lie just above the carina to allow ventilation of both lungs. After inserting the tube a balloon at the end of the tube is inflated with air through the blue side port. Position of the tube is checked by looking for symmetrical rising of the chest on ventilation breath sounds bilaterally and no gurgling over the epigastrium indicating oesophageal intubation. The tube is then tied into place.
Feeding NG Tube
This is a feeding nasogastric tube (clinifeed tube) which is used to long term enteral nutrition in patients. It is thin bore and soft making it more comfortable for patients, it is also made of silastic which blocks less often.
After explaining to the patient what you are about to do the tube is inserted into the nostril after it has been lubricated. These tubes come with a wire inside them to aid their introduction, you advance the tube as the
patient swallows. Correct position of the tube is checked by x-raying for the wire. When you are happy with the position of the tube the wire is removed and the feed attached in a sterile manner.
Five Percent Dextrose
This is a bag of 5% dextrose, which can be used in conjunction with normal saline to provide the normal daily fluid requirement for a patient.
One litre of 5% dextrose contains 50g of dextrose in 1 litre of water.
It should be remembered that because the sugar in this fluid is metabolised to carbon dioxide and water you
are essentially giving them water
- 25-30 ml/kg/day of water
- 1 mmol/kg/day of potassium, sodium and chloride
- 50-100 g/day of glucose (limit starvation ketosis)
Fracture Plate
This is a plate that is used in conjunction with screws to internally fix a bone fracture.
note that in order to properly secure a fracture there needs to be two scrws on either side of the fracture line.
Indications
Internal fixation of fractures
This particular type can be used to fix tibial #s
Method
Requires open reduction
Plate aligned with orientation of bone
Screws used to fix plate to bone
Complications
Relate to #, procedure and the plate
The Plate
Infection
Failure
Malposition of the remodelled fracture
Other Types of Fixation
POP
Continuous traction: collar and cuff
External fixation
Intramedullary nail
K wires
DHS
Cannulated screws
Gelofusin
Gelofusin
This is 500ml of gelofusin which is an example of an artificial colloid solution.
Colloid solutions raise the plasma oncotic pressure and hence expand the intravascular compartment. There are other colloids and some available are natural e.g. albumin and blood. Colloids are useful in cases of
shock e.g. due to sepsis or hypovolaemia
Hartman’s Solution
Hartmann Solution
This is an example of a crystalloid solution, which contains sodium, chloride, potassium, calcium, lactate & bicarb. It has a similar composition to the extracellular fluid. It can be used to provide the normal daily fluid requirement of a patient or to supplement the patient for additional loses.
Hartmann’s solution is a favorite solution of anaesthetists and is the fluid advocated to be given initially in trauma in the Advanced Trauma and Life Support (ATLS) guidelines.
Na+ 131mmol, Cl– 111mmol, lactate/HCO3- 29mmol, K+ 5mmol,
and Ca2+ 2mmol per litre of fluid.
- 25-30 ml/kg/day of water
- 1 mmol/kg/day of potassium, sodium and chloride and
- 50-100 g/day of glucose (limit starvation ketosis)
Indications, features, method, complications
Hemiarthroplasty Prosthesis
This is a hemiarthoplasty hip prosthesis.
It is used in cases of intracapsular fractures of the neck of femur, as these fractures are prone to avascular
necrosis of the femoral head.
Hickman Line
This is a an example of a long term central venous line which is inserted in a similar way to a central line (usually subclavian).
The remnant of the line is tunnelled subcutaneously which decreases the incidence of line infection. These are indicated for longterm parenteral nutrition, longterm intravenous antibiotic therapy and
chemotherapy.
Indications, features, methods, comp
Hip Replacement
This is the femoral part of a total hip replacement which articulates with an plastic acetabular cup.
The main indication for a hip replacement is pain from osteoarthtis of the hip.
IM Femoral Nail
This is an intramedullary femoral nail which is used to internally fix femoral shaft fractures. Interlocking screws are used to fix the nail. They are usually removed after 12 / 18 months.
Indications
Form of internal fixation used in the Mx of long-bone #s
Femur, tibia, humerus
Features
Titanium or titanium alloy
Screws insert proximally and distally provide rotational and longitudinal stability
Curve fits contour of tibia
Dynamisation
Removal of one or more screws in order to allow collapse
↑ loading of fracture site → quicker union
Method
Inserted under GA
Nail hammered into medulla of bone
Screws lock nail in place
Complications of the Prosthesis
Fracture during nail insertion
Infection
Fat embolus
Delayed or non-union
Intravenous Cannula
This is an intravenous cannula which can be used to give intravenous fluids and drugs. If you wish to give fluid quickly the cannula must be short and large bore.
Irrigation Urinary Catheter
This is a large bore irrigation type foley urinary catheter which is used to irrigate the bladder of patients at risk
of clot retention e.g. after a TURP.
(three way irrigation foley catheter) -10ml in baloon
Indication
Irrigate bladder in pts @ risk of clot retention
E.g. after TURP or in pts c¯ haematuria
Features
3 ports
Balloon inflation
Drainage (middle)
Irrigation
Laparoscopic Port
This is a Laparoscopic post which is used during Laparoscopic procedures e.g. Laparoscopic
cholecystectomy.
These ports allow the surgeon to insert a telescope and instruments in the patient
Indications
Access the abdomen during laparoscopic surgery
E.g. lap chole
Features
Trocar ± sharp blades
CO2 insufflation port
Instrument port with rubber flanges
Method
Small incision made in the abdominal wall
Either trocar used to enter abdomen or surgical entry is made
Laparoscope usually inserted @ the umbilicus
Abdomen inflated c¯ CO2: cheap, soluble, inert gas
Complications
Visceral trauma on insertion
Laryngeal Mask
This is a laryngeal mask airway which can be used to provide an airway during short operations e.g. day cases. It does not protect the airway.
Leg Bag
This is a leg bag which is attached to urinary catheter.
The Bag is strapped to the leg of the patient and is indicated for patients who are mobile and have either a
short or long term indwelling urinary catheter.
A man who suffers with incontinence following sphincter damage after multiple TURPs.
Mannitol
Mannitol is an osmotic diuretic which can be used to lower raised intracranial pressure or drive the urine
output in a patient with obstructive jaundice to prevent hepato renal syndrome
Indications
Osmotic diuretic
Lower intracranial pressure
↓ IOP in hyphema
Method
Given centrally
Complications
May ↑ ICP in the long-term
CI in severe cardiac failure and pulmonary oedema
Nasopharyngeal AirwayIndications
Airway adjunct used in pts. with impaired level of consciousness to maintain a patent airway
Method
Sized according to diameter of pts. little finger
Inserted into the nasopharynx using a rotational action
Safety pin and flared end prevents the tube becoming irretrievable.
Complications
Bleeding: trauma to nasal mucosa
Intracranial placement
Contraindications
Absolutely contraindicated in pts. c¯ facial injuries or evidence of basal skull #
Racoon eyes
Battles’ Sign: mastoid bruising
Haemotympanum
SCF rhinorroea or otorrhoea
Needle Holders
These are special forceps designed to hold the needle to allow the surgeon to suture accurately.
Normal Saline
Normal (0.9%) Saline. Normal saline is an example of a crystalloid solution which contains 153mmol of NaCl.
It can be used to provide the normal daily fluid requirement for a patient or to replace additional losses e.g.
vomit or diarrhoea
Nylon Suture
This an example of a synthetic non absorbable monofilament suture. This suture can be used to close skin wounds.
Indications
Airway adjunct used in pts. with impaired level of consciousness to maintain a patent airway e.g. during extubation
Method
Sized from incisors to angle of mandible
Insert upside down and rotated once in the oral cavity
Complications
Oropharyngeal trauma
Gagging → vomiting
Paediatric Oxygen Mask
This is a paediatric oxygen mask.
Proctoscope
This is a proctoscope, it is used to visualise the anal canal and lower rectum, it is also used when injecting or banding haemorrhoids. After explaining the procedure to the patient, the patient is placed in the left lateral position and a digital rectal examination is performed. The proctoscope is then attached to a light source and lubricated prior to its insertion into the rectum.
Indications
Investigation and management of pts. c¯ perianal pathology: e.g. haemorrhoids, low rectal Ca
Examination of the anal canal and lower rectum ± biopsy
Therapeutic: banding, sclerotherapy
Features
Obturator to aid insertion
Attachment for a light source
Method
Consent pt. and explain procedure.
Examine perineum and perform DRE c¯ pt. in left-lateral position.
Lubricate scope c¯ aquagel, attach light source
Hold in left hand and insert into the rectum.
Complications
Haemorrhage
Perforation
Ryles NG Tube
This is a Ryles nasogastric tube which is primarily used for draining the stomach but can also be used to insert drug, feed or contrast into the GI. After explaing what you are about to do to the patient , you will require a NG tube which has been in the fridge as it is stiffer, some lubricant, a bladder syringe , a drainage bag, litmus paper and tape. The tip of the NG tube is lubricated and inserted into the nostril of the patient pointing it towards the occiput.
The tube is then advanced as the patient swallows. The correct position of the tube is checked by aspirating gastric contents and checking for acidity on litmus paper, if this is unavailable then air can be inserted to the
tube and the epigastrium auscultated for bubbling. Finally an x ray can be taken to identify the tube, however this is time consuming and often does not show the tube. Once the tube is in the correct position a bag is attached and it is taped to the patients face.
Self Retaining Retractor
This is a type of retractor used to hold wounds open e.g. during a hernia repair or an appendicectomy.
Indications
Used to retract a surgical excision and retain the incision open.
E.g. in hernia repair or and appendicectomy
Complications
Compression of nerves of vessels
Shouldered Syringe
This a syringe used for the injection of haemorrhoids with 5% phenol in almond oil.
The injection is performed in conjunction with a proctoscope. The injection is performed above the dentate
line as it is insensitive
Indications
Injection of haemorrhoids with 5% phenol in almond oil
Sclerosant
Method
Consent and explain procedure to pt.
Pt. placed in left lateral position and syringe used c¯ proctoscope to enable haemorrhoid visualisation
2ml of phenol is injected above dentate line: insensitive
Complications
Immediate
Pain if injected below dentate line
Damage to nearby structures
Primary haemorrhage
Late
Prostatitis
Impotence
Silastic Urinary Catheter
This is a drainage type silastic Foley urinary catheter.
Silastic catheters are made of silicone and are more appropriate than latex one for long term catheterization.
Single Lumen CVP
Central venous cannulas are inserted in the superior vena can usually via either the internal jugular or subclavian veins. They can be single or triple lumen lines. They are primarily used to measure the central venous pressure. They can also be used for the insertion of drugs e.g. amiodarone, dopamine or chemotherapy.
Indications, features, method, complications
Stiff Neck Cervical Collar
This is a stiff neck collar which is used to stabilise the cervical spine in a trauma patient when used in conjunction with 2 sand bags and tape. They are sized by measuring the number of fingers from the clavicle to the angle of the mandible, and this is then compared to the measuring peg on the stiff neck collar.
Indications
Stabilise the cervical spine in trauma pts.
Used c¯ two sandbags and tape
Features
Comes flat packed and must be assembled
Hole at front allows access to the trachea
Method
Sized by measuring the number of fingers from the clavicle to the angle of the mandible
“Key dimension” then compared to the sizing peg on the hard collar.
Complications
Incorrect placement
Neck not in neutral alignment
Chin not flush c¯ end of chin piece
Swan Ganz catheter
This is a Swan Ganz catheter which is used to measure the pressures in the heart, the pulmonary artery wedge pressure and can also be used to measure the cardiac output. These are used in the intensive care setting and are typically inserted into a central vein.
Indications
Flow directed pulmonary artery catheter
Measure the pulmonary capillary wedge pressure
Indirect measure of LA filling pressure
Measure cardiac output
Used in cardiogenic or septic shock when accurate haemodynamic data is required
Its use has not been shown to improve outcome
Method
Used in the intensive care setting
Inserted into a central vein.
Synthetic Absorbale Suture
This is an example of a synthetic absorbable suture which can be used for bowel anastomosis or tying off
vessels
Indications
Used to prevent VTE
All patients undergoing surgery
All immobile pts
Method
Available in different sizes
Width: widest point of calf
Length: heel to buttock fold
Often used in conjunction c¯ LMWH
Complications
Contraindicated in pts c¯ arterial disease
Tracheostomy
This is a temporary tracheostomy; it is an example of a definitive airway as it protects the patients lungs from aspiration. One of the most common occasions you will see a tracheostomy is on a patient being ventilated on the intensive care unit. A tracheostomy allows more efficient ventilation of the patient with a decreased dead space and also allows more effective suctioning of the airways. Tracheostomy can also be used in patients with upper airway obstruction or after laryngeal surgery
Triple Lumen CVP
Central venous cannulas are inserted in the superior vena can usually via either the internal jugular or subclavian veins. They can be single or triple lumen lines. They are primarily used to measure the central venous pressure.
They can also be used for the insertion of drugs e.g. amiodarone, dopamine or chemotherapy
Tru-cut Needle
This is a trucut biopsy needle which is used to take histological specimens from lesions e.g. breast lumps or liver.
The procedure can be performed under local anaesthetic.
Indications
Used to take histological specimens from lesions
Part of triple assessment of breast lumps
Liver
Kidney
Prostate: transrectally
Method
Consent and explain procedure to pt.
Anaesthetise area c¯ LA
Needle advanced under US guidance
Spring handle is pressed, advancing the specimen tray into the target lesion
Further pressure fires the surrounding sheath, obtaining a biopsy
Complications
Bleeding
Pain
Cancer seeding
Post Op Pyrexia
Early: 0-5d post-op
Blood transfusion
Physiological: SIRS from trauma: 0-1d
Pulmonary atelectasis:24-48hr
Infection: UTI, superficial thrombophlebitis
Drug reaction
Delayed: >5d post-op
Collections
Pneumonia
DVT / PE
Wound infection: 5-7d
Anastomotic leak: 7d
Examination of Post-Op Febrile Pt.
Observation chart, notes and drug chart
Wound
DRE
Legs
Chest
Lines
Urine
Stool
Vacutainers
purple, yellow, red, green, blue, grey, black
order
Seldinger technique
- Triple lumen central venous catheter
- Angiography
- Chest drain insertion
- Percutaneous endoscopic gastrostomy
PICC Line
Tessio Catheter
Port-a-cath
McKintosh Laryngoscope
Oxygenation
Options (x5)
Nasal Prongs
1-4L/min = 24-40% O2
Simple Face Mask
Variable O2 concentration depending on O2 flow rate
Non-rebreathing Hudson Mask
Reservoir bag allows delivery of high concentrations of O2.
60-90% at 10-15L
Venturi Mask
Uses the Bernoulli Principle
↑ speed of flow → ↓ pressure
Altering O2 flow speed can entrain a known concentration of air for dilution
Provide precise O2 concentration at high flow rates
Yellow: 5%
White: 8%
Blue: 24%
Red: 40%
Green: 60%
CPAP
Tight fitting mask connected to reservoir or high O2 flow allowing FiO2 ~1.
Positive pressure is applied continuously to the patient’s airway.
Benefits
Recruitment of collapsed lung units
↓ shunt → ↑PaO2
↑ lung volume → improved compliance → ↓ work of breathing.
CPAP usually has little effect on PaCO2
Ventilations
Types, indications, complications
Types
Non-invasive: tight-fitting mask
Invasive: ET or tracheostomy
Indications
Respiratory failure refractive to less invasive Rx
At risk airway
Elective post-op ventilation
Physiological control (e.g. hyperventilation in ↑ICP)
Complications
Cardiovascular compromise
Pneumothorax
Fluid retention
VILI
VAP
Complications of artificial airway: e.g. tracheal stenosis
Types of nutritional supplementation
Nutritional supplementation Complications
Complications
Line-related
Pneumothorax / haemothorax
Cardiac arrhythmia
Line sepsis
Central venous thrombosis → PE or SVCO
Feed-related
Villous atrophy of GIT
Electrolyte disturbances: e.g. refeeding syndrome
Hyperglycaemia and reactive hypoglycaemia
Vitamin and mineral deficiencies
Refeeding syndrome
Life-threatening metabolic complication of refeeding via any route after a prolonged period of starvation.
Pathophysiology
↓ carbs → catabolic state w ↓insulin, fat and protein catabolism and depletion of intracellular PO4
Refeeding → ↑ insulin in response to carbs and ↑ cellular PO4 uptake.
→ hypophosphataemia
Rhabdomyolysis
Respiratory insufficiency
Arrhythmias
Shock
Seizures
Chemistry
↓K, ↓Mg, ↓PO4
At-Risk Patients
Malignancy
Anorexia nervosa
Alcoholism
GI surgery
Starvation
Rx
Identify at-risk pts in advance and liaise c¯ dietician
Parenteral and oral PO4 supplementation
Rx complications
Preventing DVT
DVT is commonest complication of THR
Peak incidence @ 5-10d post-op
Pre-Op
Pre-op VTE risk assessment
TED stockings
Aggressive optimisation: esp. hydration
Stop OCP 4wks pre-op
Intra-Op
Minimise length of surgery
Use minimal access surgery where possible
Intermittent pneumatic compression boots
Post-Op
LMWH
Early mobilisation
Good analgesia
Physio
Adequate hydration
Major Fluids: crystalloids
NS
0.9% NaCl = 9g/L
154mM NaCl
Use: normal daily fluid requirements + replace losses
5% Dextrose
50g dextrose /L
Use: normal daily fluid requirements
Dextrose-Saline
4% dextrose = 40g/L
0.18% NaCl = 31mM NaCl
Use: normal daily fluid requirements
Hartmann’s / Ringer’s Lactate
Na: 131mM
Cl: 111mM
K: 5mM
Ca: 2.2mM
Lactate / HCO3: 29mM
Use: Trauma, Burns (Parkland)
Daily Requirements
3L dex-saline c¯ 20mM K+ in each bag
1L NS + 2L dex c¯ 20mM K+ in each bag
Each bag over 8h = 125ml/h
Problems
Give 1L NS → ~210ml remaining IV
Give 1L D5W → ~70ml remaining IV
Acidosis or electrolyte disturbances
Fluid overload
Major Fluids: Colloids
Synthetic
Gelofusin
Volplex
Haemaccel
Voluven
Natural
Albumin
Blood
Use
Fluid challenge
Hypovolaemic shock
Burns: Muir and Barclay
Problems
Anaphylaxis
Volume overload
Surgical Drains
indications and types
Indications
Prophylactic
Prevent fluid accumulation
Therapeutic
Drainage of established collections
Drain a viscus: e.g. bladder
Collect blood for autotransfusion
Types
Open or Closed
Open
e.g. corrugated rubber or plastic sheets
Fluid collects into dressing or stoma bag
Closed
e.g. chest drains, Robinson or Redivac
Tube attached to a container
Active or Passive
Active: driven by suction
e.g. Redivac drain
Passive: no suction, driven by pressure differential
e.g. Robinson drain
Surgical Drains
Removal and complications
Removal
Remove drain once drainage stopped or <25ml/d
Perioperative bleeding and haematoma: 24-48hrs
Intestinal anastomosis: >5d
T-tube: 6-10d
T-tube cholangiogram first to ensure distal patency of CBD
Shortening: removal of drain by 2cm/d to allow tract to heal gradually.
Complications
May ↑ risk of infection
Damage may be caused by mechanical pressure or suction.
May limit pt. mobility
Robinsons (simple drain or drain tube)
Type: closed, passive
Use: abdominal surgery
Risk of infection
Contamination: faeces or pus
Redivac
Type: closed, active
Use
Breast surgery: prevent seroma or haematoma
Thyroid surgery: risk of haematoma
Bile Bag
Type: closed, passive
Use
NGT
T-tube
Pemrose Drain
Type: open, passive
Use: abdominal surgery
Tissue Drain
Type: open, passive
Use: large cavities
Suture types
Monofil vs braided
Monofilament
Advantages
↓ risk of infection
↓ friction in tissues
Disadvantages
Harder to handle: stiff and has more memory
Knots may slip
Less tensile strength
Braided
Advantages
Easier to handle: less memory
Knots slip less
Greater tensile strength
Disadvantage
↑ risk of infection
↑ friction in tissues
suture types
Natural vs synthetic
Suture removal times
Further away from heart = longer time
Face and neck: 3-5d
Scalp: 5-7d
Trunk: 10d
Arms: 7d
Legs 10-14d
Pts. c¯ poor wound healing may need longer
Needle types
Straight: hand-held, used for skin closure
Curved: require needle-driver
Diameter
Fine: GI and vascular surgery
Medium: general closure
Heavy: hernia repair
Tip
Blunt: abdominal wall closure
Shape
J-shaped: abdominal wall closure
PR Bleeding differential
Commonest
Perianal: haemorrhoids, fissure
Diverticular disease
Malignancy
Other
IBD
Infection
Upper GI bleed
Angiodysplasia
Advantages and disadvantages of MAS
Advantages of MAS
Smaller Incisions
↓ post-op pain
↓ risk of wound infection
Faster post-op recovery
↓ hospital stay
Better cosmesis
May allow better visualisation and access
Can visualise and operate on pelvic organs in lap appendicectomy.
Dx and fix contralateral hernia in lap hernia repair.
Disadvantages of MAS
Different anatomy
↓ tactile feedback (can’t feel colon tumours)
2D view of 3D structures
Technically challenging and old skills may be lost
Complications (e.g. haemorrhage) may be harder to Mx
Expensive
Circular Bowel Stapler
Indications
Rectal anastomosis
Gastrectomy
Haemorrhoids
Rectal prolapse
Features
Anvil sutured into proximal limb c¯ purse string suture
Anvil fits into stapler and provides counterpoint for staple insertion.
Complications
Anastomotic leak
Checking the Integrity of an Anastomosis
Intra-operative
Fill pelvic cavity with saline
Insufflate rectum c¯ air and look for bubbles in the saline.
Post-operative
Water-soluble contrast enema
Indications for catheterisation
Diagnostic
Measure urine output
Sterile urine sample
Renal tract imaging
Therapeutic
Urinary retention
Immobile patients
Bladder irrigation
Intermittent decompression of neuropathic bladder
Indications for long term catheterisation
Chronic bladder outlet obstruction
Neurogenic bladder c¯ chronic retention
Complications of incontinence
Refractory skin breakdown
Palliative care
Pt. preference
Catheter complications
Early
Creation of false tract
Urethral rupture
Paraphimosis
Haematuria
Delayed
Infection
Blockage
Catheter CI
Urethral trauma
Blood @ urethral meatus
High-riding prostate
Scrotal haematoma
Pelvic fracture
Management of non-draining catheter
-TWOC
Bypassing catheter: consider condom catheter
Blocked: flush c¯ 20ml sterile 0.9% NS or consider 3- way
Slipped into prostatic urethra: flushes but won’t drain
Catheter has perforated the lower tract on insertion and is not in the bladder
Renal or pre-renal failure
Trial WithOut Catheter
After 24-72 hrs in AUR
May be performed as a urology outpt. if retention likely.
Tamsulosin ↓s risk of retention after TWOC
Clean intermittent self catheterisation
(indications)
Alternative to indwelling catheter in CUR
Also useful in pts. who fail to void after TURP
Indications
Chronic retention
Neuropathic bladder
MS
DM neuropathy
Spinal trauma
Suprapubic catheter
Indications
Urethral injuries
Urethral obstruction
BPH
Ca prostate
Method
US guided insertion of catheter under LA
Trocar inserted into catheter and unit advanced through skin.
Complications
Viscus perforation
Haemorrhage
Malignancy seeding
Advantages
↓ UTIs
↓ stricture formation
TWOC w/o catheter removal
Pt. preference: ↑ comfort
Maintain sexual function
Disadvantages
More complex: need skills
Serious complications can occur
CI
Known or suspected bladder carcinoma
Undiagnosed haematuria
Previous lower abdominal surgery
→ adhesion of small bowel to abdo wall
Acute Urinary Retention
Clinical features, Ix, Mx
Indication, method, comp
JJ or Ureteric stent
Indication
Relieve ureteric obstruction
Stones
Tumours
May be inserted intra-op during renal Tx
Method
Retrograde: cystoscopic guidance
Anterograde: percutaneous
Complications
Infection
Blockage
Displacement / migration
Chest drain tube and trocar
Total Arthoplasty prosthesis: Indications, features, methods, comp
Fat Embolism Syndrome
Presentation/Ix/Mx
Presentation: SOB, petechial rash, confusion
Typically 24-72h between injury and onset
Resp: dyspnoea ± chest pain
Petechial rash: upper anterior trunk, arms, neck
CNS: headache, confusion, agitation
Renal: oliguria, haematuria
Ix
ABG: hypoxia, hypocapnoea
FBC: ↓ plats, ↓Hb
CT chest
Mx
Supportive: O2, volume resuscitation
Steroids
Clearing the C spine
Clinical and radiological
Clinical clearance:
Indication: NEXUS Criteria
Neurological deficit
Spinal tenderness in the midline
Altered consciousness
Intoxication
Distracting injury
Method
Examine for bruising or deformity
Palpate for deformity and tenderness
Ensure pain-free active movement
Radiological clearance
Indications
Pt. doesn’t meet criteria for clinical clearance
Modalities
Radiograph initially
Clear if normal radiograph and clinical exam
CT C-spine if abnormal radiograph or clinical exam
Fogarty Embolectomy catheter
Indication
Mx of acutely ischaemic limb 2O to embolus
Method
Vascular access gained to femoral artery @ groin.
Catheter passed distal to embolus
Balloon is inflated and catheter withdrawn.
Renal Biopsy
Indications, CI, Procedure, Complications
Indications
Unexplained ARF/CRF
Acute nephritic syndrome
Unexplained proteinuria / haematuria
Systemic disease c¯ renal involvement (e.g. SLE)
Suspected Tx rejection
CI
Abnormal clotting
Single kidney (except Tx)
Small kidneys from CRF (↑ bleeding risk + too late)
Renal neoplasms
Procedure
Stop aspirin (1wk) and warfarin (2d) in advance
Check FBC, clotting and G&S
US-guided Tru-Cut needle biopsy
Complications
Macroscopic haematuria in 1%
Transfusion needed in 0.1%
ABG KIT!
SUTURE
This is a non invasive positive pressure ventilation mask.
I have seen this used on the respiratory ward on a patient with COPD
It can be used to deliver:
CPAP: Continuous positive airway pressure
BiPAP: Bilevel Positive Airway Pressure
CPAP is indicated in patients with T1RF e.g. OSA/acute HF
BiPAP is indicated in patients with T2RF e.g. COPD
Disadvantages: claustrophobia, reduced tollerance by the patinet, emesis and pressure sores.
Full face masks can also be used, this eliminates nasal bridge discomfort as it seals the perimeter of the face where facial contours are smoother and pressure sensitivity is lower
