Instruments

Question 1

Answer 1

Absorbable Sutures

Absorbable sutures are broken down by physiological processes such as enzymatic degradation and hydrolysis.

Patient clinical status can affect the rate of absorption, e.g. sepsis.

Monocryl – monofilament, increased throws for stable knot (9).

Vicryl – polyfilament, less throws (3) but has increased fraying issues and local tissue inflammation.

Tensile strength of sutures rely on diameter of thread.

Question 2

Answer 2

Arterial Blood Gas Syringe
Arterial Blood Gas samples are a useful adjunct in the acute environment. They are a version of point-of-care testing (POCT) and therefore you can attain immediate results.

Key areas tested with the blood test include:

pH – acidosis/alkalosis

pO2 and pCO2 – identification of respiratory failure (arterial)

Bicarbonate – renal and compensation of acidosis/alkalosis

Lactate – poor perfusion

Hb – anaemia

Na+/K+ quick testing of electrolytes – handy in monitoring and treatment of hyperkalaemia.

Question 3

Answer 3

Blood Bottles
Blood bottles are colour coded to use for different tests.

Purple – contains EDTA. Used for haematology.
Pink – contains EDTA. Used for group and save and crossmatch.
Blue – contains buffered sodium citrate. Used for coagulation screening.
Yellow/gold – known as SST. Contains silica particles and serum separating gel. Used for a variety of tests that require separated serum for analysis, including immunology, microbiology, biochemistry, endocrinology, toxicology, oncology, U+E and liver function.
Grey – contains sodium fluoride and potassium oxalate. Used for glucose and lactate tests.
Red – contains silica particles. Used for sensitive tests including toxicology, drug levels, antibodies, hormones and bacterial and viral serology.
Dark green – contains sodium heparin. Used for ammonia, renin, aldosterone and insulin tests.
Light green – Known as PST. Contains lithium heparin and a plasma separator gel. Used for routine biochemistry.
Rust Top- Viral Immunology.

Question 4

Answer 4

Blood Culture Bottles
These are two blood culture bottles, one for aerobic bacteria (blue top) and one for anaerobic bacteria (purple top). The blood is injected in a sterile manner into the bottles using a different needle from the one the blood was drawn with.

Blood cultures are a useful investigation in a case of pyrexia or suspected systemic sepsis.

Remember, fill the aerobic bottle first if you are using a vacutainer.

Note – You need to take blood cultures via peripheral venepuncture.

Question 5

Answer 5

Blood Glucose Monitoring Kit
To test real-time capillary blood glucose levels.

Diabetic patients will use capillary blood glucose (CBGs) levels to help guide insulin dosing.

CBGs are also important in diabetic crises, such as DKA, non-ketotic hyperglycaemia, hypoglycaemia and reduced GCS.

CBG monitoring forms a key element to ALS and ATLS protocols. (Don’t ever forget glucose!)

Question 6

Answer 6

Breast Implants
These are breast implants. They come in many shapes and sizes to suit different body habitus. They can be round or anatomical shaped. Made from Silicone. Used for breast augmentation and breast reconstruction after mastectomy. Also in gender reassignment.

They last for about 10-15 years on average. Over time they degrade and can rupture.

There is a very rare risk of ALCL – Anaplastic Large-Cell Lymphoma – a recently described complication.

Complications: Rupture, Infection, Capsular contracture, Erosion, through the skin, Migration, ALCL.

Question 7

Answer 7

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.

Question 8

Answer 8

Catheter Bag
A catheter bag includes a flexible tube used to empty the bladder and collect urine in a drainage bag.

They can either be inserted through the tube that carries urine out of the bladder (urethral catheter) or through a small opening made in lower abdomen (suprapubic catheter).

Question 9

Answer 9

Central Line Insertion Pack
Seldinger central line kits include a 3-5 lumen cannula, guide wire, dilator, scalpel, and introducer needle.

Central venous catheters are placed often into the subclavian or internal jugular veins via ultrasound. They are useful in the delivery of medications/fluids that may be harmful orally or peripherally. Blood tests and central venous pressures can also be obtained.

Key indications include: parenteral nutrition, emergency venous access, fluid resuscitation, infusion of irritant drugs, vasopressors, inotropes.

Complications on insertion include: pneumothorax, sepsis, thrombosis and misplacement.

Question 10

Answer 10

Chest Drain Bottle
The are multiple drainage systems that can be used once a chest drain has been inserted.

Passive drainage – underwater seal which employs a positive expiratory pressure and gravity to drain the pleural space. This helps recreate a negative pressure in the pleural space. 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.

Question 11

Answer 11

CSF Manometer
CSF Manometers are key in the identification of opening pressures and represent Intracranial Pressure during Lumbar Puncture.

Measurement is in cm H2O.

Current accepted opening pressures (normal) are 10-18 cm H2O if patient is lying on their side, 20-30 cm H2O when sat up

Question 12

Answer 12

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.

Question 13

Answer 13

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

Question 14

Answer 14

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.

Question 15

Answer 15

Endotracheal Tube with Tape and Syringe
An endotracheal tube is a definitive airway.

Used commonly in trauma cases, surgery with general anaesthetic and in patients with a GCS <8.

The tube is inserted into the trachea via the oropharynx using a laryngoscope and Eschmann Tracheal Tube Introducer (ETTI – or otherwise known as the bougie). Usually performed by an anaesthetist.

It is connected to oxygen and ensures adequate oxygen/CO2 gaseous exchange.

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 tape secures the tube in the airway whilst balloon inflation maintains position and protects airway from aspiration.

Complications include (but not exhaustive) inappropriate placing (oesophageal), injury to larynx, pneumothorax, atelectasis and infection.

What is this used for?
Used as a definitive airway to provide oxygen and inhaled gases to the lungs for patients whom…
* Require protection against aspiration
* Are unable to ventilate and/or oxygenate
* Are unable to maintain airway patency

 
How do you use this instrument?
First, identify and select the appropriate size tube prior- the different sizes refer to the internal diameter in millimeters).
Next, with your patient lying on the bed, adjust them to the “sniffing the morning air” position. This can be achieved by inserting a pillow underneath the shoulders to allow the head to be elevated relative to the rest of the body. The goal of this first step is to provide a line of sight to the vocal cords to enable easier passage for the endotracheal tube.
Oxygenate the patient with a mask and administer the general anaesthetic (e.g. propofol) as the patient should ideally not be awake for this procedure. Now continue to ventilate the patient while proceeding to perform the two-finger chin lift/jaw thrust to open the patient’s airway. Confirmation of successful ventilation will be observed with symmetrical chest wall rising, and end-tidal carbon dioxide return.
Open the patient’s mouth and insert the laryngoscope, pushing the tongue aside and lifting the epiglottis. The goal of this maneuvre is to create an unobstructed line of sight to the vocal cords.
Now, insert the endotracheal tube until the balloon cuff is no longer in sight (i.e. the balloon cuff should be below the vocal cords). Inflate the balloon cuff. Remove the laryngoscope and connect the end of the endotracheal tube to the ventilator. Successful endotracheal intubation will be confirmed by return of symmetric chest wall rising and end-tidal carbon dioxide with respiratory cycles.
Secure the tube to the patient’s mouth with tape and re-commence mechanical ventilation.

What are the possible complications of using this instrument?
* Leaving in situ may cause infection.
* Inserting incorrectly may cause bleeding of vessels
* Damage to surrounding structures, e.g. perforation of the oropharynx, hoarseness of voice denoting vocal cord injury, damage to teeth/lips

 

Question 16

Answer 16

Epidural Insertion Pack
An epidural insertion pack contains:

Touhy/Epidural needle – Touhy type needle is provided with clear depth marking for accurate insertion depth reading.
Epidural catheter- It is specially designed for short term and long term anaesthesia and pain relief.
Epidural catheter adapter – This catheter adapter is for safe and secure attachment to the catheter for convenience of the procedure

Question 17

Answer 17

Faeces Sample Pot
Stool samples enable the identification of pathogens that are infecting the gut. Ideally, Bristol stool chart 5,6 and 7 warrant samples.

Tests that can be used to identify cause of symptoms include:

MCS – takes up to 4 days for result.

Rotavirus/Adenovirus/Norovirus – same day result

Glutamine Dehydrogenase (GDH) (C.diff)

C.Diff Toxin test only performed if GDH is positive

C.Difficile ribotyping results take up to 2 weeks

Microscopy for Ova, Cysts and parasites – 4 days

Helicobacter antigen testing – up to a week

Question 18

Answer 18

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.

Question 19

Answer 19

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.

Question 20

Answer 20

Fluid Giving Set
Regularly used on wards to give IV fluids, administration of IV medications including antibiotics and blood products.

Question 21

Answer 21

Forceps
Two common types of forceps include non-toothed (top) and toothed (bottom).

These are often known as Ramsay Forceps (dissecting forceps). They are used to grasp edges of tissue and the general rule is that toothed should only be used for Skin.

Once in peritoneal cavity, the general rule is that only non-toothed should be used.

Grasp these forceps between thumb and fore-finger in a pincer grip.

Question 22

Answer 22

Fracture Plate
This is a plate that is used in conjunction with screws to internally fix a bone fracture.

Question 23

Answer 23

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.

Question 24

Answer 24

Hartmann/Plasmalyte Solution
This is an example of a crystalloid solution, which contains sodium, chloride, bicarbonate and lactate.

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 favourite solution of anaesthetists and is the fluid advocated to be given initially in trauma in the Advanced Trauma and Life Support (ATLS) guidelines.

Question 25

Answer 25

Hemiarthroplasty This is a hemiarthoplasty hip prosthesis. It is used in cases of intracapsular fractures of the neck of femur avascular necrosis of the femoral head is a common complication.

Question 26

Answer 26

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 long-term parenteral nutrition, long-term intravenous antibiotic therapy and chemotherapy.

Question 27

Answer 27

Hip Replacement A total hip replacement consists of two distinct parts: The femoral stem with femoral head The polyethylene acetabular cup that is inserted into the acetabulum. Total hip replacements are often used to replace a hip joint, for instance in severe osteoarthritis. Complications with THRs include DVTs, infection and dislocation (2%).

Question 28

Answer 28

Histology Specimen Pot Histology specimen pots are routinely used in surgery. Biopsies, resected tumours etc can be placed here and set in formalin. They form a part of the WHO Surgical Safety Checklist. There is a distinct prompt in the “Sign Out” section to make sure histology specimens are correctly labelled.

Question 29

Answer 29

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.

Question 30

Answer 30

Instillagel Instillagel is a sterile gel containing a local anaesthetic and lubricant gel. It is used for male and female catheterisation.

Question 31

Answer 31

Intravenous Cannula & Octopus Multiple different cannula systems are available: The newer – premade dual lumen cannula systems requires no saline preparation and allows the user to take blood samples directly post insertion. Lumens will then need to be flushed to prevent clot formation. Old systems may require a pre-flushed octopus as an adjunct. Cannulae come in different sizes, 22G (Blue) and 20G (Pink) are common on wards. 16G (Grey) are common in fluid resus and trauma. If you wish to give fluid quickly the cannula must be short and large bore.

Question 32

Answer 32

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.

Question 33

Answer 33

Laryngoscope A laryngoscope is used to aid intubation, visualisation of larynx to aid diagnosis of vocal problems and strictures. There are multiple different forms of blades – curved (Macintosh) as seen in the picture. Straight blades (Miller) are also used. Inexperienced users of laryngoscopes can cause severe harm to the patient including mild soft tissue injury, laryngeal and pharyngeal scarring, ulceration and abscess formation. What is this used for? For direct visualisation of the larynx and hypopharynx. Laryngoscopes may also be used to facilitate the insertion of endotracheal tubes How do you use this instrument? First, correctly position the patient in the “sniffing the morning air” position. This can be achieved by inserting a pillow underneath the shoulders to allow the head to be elevated relative to the rest of the body. The goal of this first step is to provide a clear line of sight to the larynx. Next, open the patient’s mouth and insert the laryngoscope (with the light switched on!) through the right side of the mouth and sweep the patient’s tongue to the left. Advance the scope carefully and anteriorly to move the epiglottis. This will provide a clear line of sight of the patient’s vocal cords. What are the possible complications of using this instrument? * Bleeding * Damage to surrounding structures, e.g. perforation of the oropharynx, damage to teeth/lips, vocal cord damage * Sore throat

Question 34

Answer 34

Laryngeal Mask & Airway Adjuncts iGels and laryngeal mask airways (LMA) are supraglottic airway devices that are used as a step prior to intubation. They are very good for elective procedures, cardiac arrests and prehospital airway management. They have benefits that include reduced trauma to the oropharynx (seen with intubation) and therefore can be used to reduce hospital stays in elective patients. iGels contain a thermoplastic elastomer (styrene) that moulds to perilaryngeal framework with patient temperature. The device 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. iGel can also be used as conduit for intubation. Insert with number facing towards you when behind the patient. LMAs are also an excellent choice of airway management, however they do not eliminate aspiration risk. Inflation of the device can also cause pressure lesions and nerve palsies. What is this used for? Used as a supraglottic airway that may be used pre-operatively to maintain a patent airway during administration of anaesthesia. It may also be used in emergency scenarios as a temporary bridge to intubation. How do you use this instrument? First, ensure that the cuff is fully deflated by connecting to a syringe and drawing any air out. Next, apply lubricant to the back of the device ensuring that gel is not applied to the front as this could obstruct the airway lumen. Now, adjust the patient to lying flat in the “sniffing the morning air position” (which by inserting a pillow underneath the shoulders to allow the head to be elevated relative to the rest of the body). With their mouth open, insert the laryngeal mask airway with the airway lumen facing the caudal direction. Continue to insert the until the device reaches the supraglottic area. Next, inflate the cuff and attach the end of the laryngeal mask airway to a ventilation device. To confirm correct insertion, observe symmetrical chest when providing mechanical ventilation. What are the possible complications of using this instrument? * Damage to surrounding structures, e.g. abrasion of pharyngeal tissues * Bleeding * Stomach insufflation

Question 35

Answer 35

Leg Bag This is a leg bag which is attached to a 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.

Question 36

Answer 36

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.

Question 37

Answer 37

Monopolar Diathermy Handle Monopolar diathermy is used for coagulation and dissection of tissue during open or laparoscopic surgery.

Question 38

Answer 38

Nasal Cannulae Nasal cannula are commonly used mode of oxygen delivery both in hospital and in the community. It is widely used to carry 1-3L of oxygen per minute (can be upto 5L/min). This delivers between 28-44% of oxygen. These cannulae differ from high-flow therapy (NIV). Common issues are nasal sores and epistaxis, therefore patients are encouraged to apply water-based creams to moisturise. Nasal cannulae What is this used for? Supplemental oxygen therapy delivering up to 24-30% oxygen at flow rate of between 1 and 4 litres per minute. It may be used acutely when attending to patients with saturations below the expected threshold percentages. How do you use this instrument? Insert the prongs into the patient’s nostrils and drape the cannula behind the patient’s ears before using the slider to reduce cable slack. Connect the end of the cannula to an oxygen delivery device. What are the possible complications of using this instrument? * Oxygen is flammable

Question 39

Answer 39

Nasal Speculum Thudichum Nasal Speculum is designed to open and expand the nasal cavity.

Question 40

Answer 40

Nasopharyngeal Airway This is a nasopharyngeal airway which is inserted into the nose using a rotational action. It is used to provide an airway in people with a decreased level of consciousness or decreased gag reflex. The diameter tube should be sized against the patients own little finger distal phalanx. A safety pin is placed in the end of the tube to prevent it being inhaled. What is this used for? Used as an airway adjunct during management of an upper airway obstruction. It works by stooping the tongue from covering the epiglottis to provide a patent upper airway. The added benefit of a nasopharyngeal airway is that it is better tolerated in awake patients, compared with the oropharyngeal airway adjunct. How do you use this instrument? First, select the appropriate size device by measuring the tip of the device at the angle of the mandible and the flange to border with the patient’s nostril. With patient lying or sitting upright, apply lubricant to the tip of the nasopharyngeal airway and insert the device through the patient’s nostril ensuring that the curvature of the tube is orientated towards the caudal side. Direct the airway through the floor of the nose towards the oropharynx. What are the possible complications of using this instrument? * Leaving in situ may cause infection. * Damage to surrounding structures, e.g. epistaxis, retropharyngeal laceration. * Without prior confirmation that patient has not had a basillar skull fracture, insertion of nasopharyngeal airway may result in intracranial placement

Question 41

Answer 41

Nebuliser Mask + Chamber Nebuliser mask and chamber can be used to administer all commonly prescribed bronchodilators for respiratory conditions. Aerosol drug effectiveness depends on the quality of its delivery to the lungs. What is this used for? Used to deliver liquid medication to the lungs by inhalation. Used in spontaneously breathing patients. How do you use this instrument? First pour the medicine into the medicine cup and attach the top piece to the medicine cup before connecting to the mask. Next, connect the tubing to the medicine cup. After the compressor machine has been connected to the end of the tubing and the mask has been placed on the patient, the patient may breathe normally through the mask to allow administration of nebulized medications. What are the possible complications of using this instrument? * A poorly fitting mask, especially if oversized, may disrupt ability to see properly * Infection if nebuliser pieces are not cleaned thoroughly

Question 42

Answer 42

Needle Holders These are special forceps designed to hold the needle to allow the surgeon to suture accurately.

Question 43

Answer 43

Neurology Kit Neurology kit includes: 1x 128Hz tuning fork (vibration for joints) 1x 512Hx tuning fork (Weber’s and Rinne’s) Neurotips for blunt/sharp sensation in sensory examination Orange stick – to test Babinski reflexes (plantar reflex) Tendon hammer – reflexes. Other aids may include: Snellen chert, ophthalmoscope and tongue depressor.

Question 44

Answer 44

Non-Absorbable Sutures Ethilon (nylon) is monofilament – therefore requires 9 throws to maintain a strong knot over time. Prolene is another example of non-absorbable suture. Both ethilon and prolene have high tensile strength and low-reactivity. However, ethilon knots are more likely to loosen over time. Therefore usually limited to percutaneous closure. Non-absorbable sutures are used in longer-term tissue approximation: Percutaneous wound closure Bowel anastomosis (Prolene) Vascular anastomosis (Prolene)

Question 45

Answer 45

Non-Rebreather Mask A non-rebreather mask (NRB) is used to assist in the delivery of oxygen therapy. It requires that the patient can breathe unassisted. The non-rebreather mask covers both the nose and mouth of the patient and attaches with the use of an elastic cord around the patient’s head. The NRB has an attached reservoir bag, that connects to an external oxygen tank or Bulk Oxygen Supply system. The flow rate is 10-15 litres/minute and it can deliver up to 90% oxygen concentration. What is this used for? Used to deliver 85-90% high flow rates of oxygen up to 15 Litres per minute. This device is used for acutely unwell patients. Used in spontaneously breathing patients. How do you use this instrument? Ensure that the reservoir bag is securely attached to the mask. Connect the mask to a flow meter via oxygen tubing with appropriate flow rate of FiO2. Allow the reservoir bag to inflate before placing the mask over the patient’s face to administer oxygen What are the possible complications of using this instrument? * Dry mouth and nose * Oxygen toxicity is administered excessively * Retrolental fibroplasia if mask is not placed carefully

Question 46

Answer 46

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.

Question 47

Answer 47

Nylon Suture This an example of a synthetic non absorbable monofilament suture. This suture can be used to close skin wounds.

Question 48

Answer 48

Oropharyngeal Airway This is used to provide an airway for a patient where there is an impaired level of consciousness. It is sized by measuring the distance from the angle of the mouth to the angle of the jaw. It is inserted into the mouth upside down and rotated within the oral cavity. It is inserted the correct way up in children. What is this used for? Used as an airway adjunct during management of an upper airway obstruction. It works by stoping the tongue from covering the epiglottis to provide a patent upper airway. For example, this device may be used in unconscious patients with an absent gag reflex in whom their tongue covers their epiglottis, creating an upper airway obstruction. How do you use this instrument? First, select the appropriate size device by measuring the tip of the device at the angle of the mandible and the flange to border with the patient’s lips. Next, with the patient lying flat, open the patient’s mouth and gently insert the oropharyngeal airway with the tip of the device pointing in the patient’s cephalic direction, and then rotate it 180 degrees as you progress it further to the back of the oropharynx What are the possible complications of using this instrument? * Damage to surrounding structures, e.g. hard and soft palate, dentition. * Laryngospasm may occur if an inappropriately sized device is inserted

Question 49

Answer 49

Paediatric Oxygen Mask This is a paediatric oxygen mask.

Question 50

Answer 50

PICC Line A commonly used IV access option is the peripheral IV central catheter, or PICC line, which shares features of both central and peripheral venous access. PICC lines are suitable for long-term vascular access for blood sampling, chemotherapy administration, and infusion of hyperosmolar solutions such as those used for total parenteral nutrition. A PICC line is composed of a thin tube of biocompatible material and an attachment hub that is inserted percutaneously into peripheral veins and advanced into a large central vein.

Question 51

Answer 51

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.

Question 52

Answer 52

Scalpel There are two types of scalpels: disposable (on top) and non-disposable (below). The blade of the non-disposable scalpel must be changed. Surgical blades, or scalpels, are used for cutting skin and tissue during surgical procedures. There are different types of blades specific to the type of procedure. Surgical blades vary by size and shape. The number of the blade indicates the blade size and shape e.g. 10, 11, 12, 15, 22.

Question 53

Answer 53

Seldinger Chest Drain Insertion Pack Chest drain seldinger can come in a variety of forms, (Rocket, Portex etc) These can be used on the wards and in outpatients to insert chest drains. Indications include: Pneumothorax (in ventilated patient, tension pneumothorax after needle relief, persistent pneumothorax or large spontaneous pneumothorax); symptomatic malignant pleural effusions; empyema, traumatic haemothorax.

Question 54

Answer 54

Specimen Swabs Sterile specimen swabs are used routinely in MRSA screening (nasopharyngeal and rectal). Bluetop Transwab Amies are to recover aerobes, anaerobes and fastidious organisms. These swabs are excellent to aid gram stains. They are also used to take specimens from wounds, skin, urogenitalia and throat.

Question 55

Answer 55

Spinal Needles There are two types of spinal needle. Traumatic needles are cutting needles (top picture). These are related with higher risk of post-LP headaches (35%), severe headaches that may require blood patching to help treat the symptoms and additional hospital visits for pain. Pencil-point (atraumatic) needles are blunt tipped, allowing for blunt dissection of the anatomy rather than cutting. It is now the needle of choice for LP (not for epidural) as they have significantly the incidence of post-LP headaches reduced (relative risk of 0.4 compared to traumatic) and backache.

Question 56

Answer 56

Stoma Bags A stoma bag is a prosthetic medical device that provides a means for the collection of waste from a surgically diverted bowel. Pouching systems are most commonly associated with colostomies, ileal conduits and ileostomies.

Question 57

Answer 57

Surgical Chest Drain Surgical Chest Drains (thoracostomy) are used as an emergency procedure. They differ from seldinger chest drains which can be inserted by trained physicians. Sizing is measured in French (Ch) – smaller calibre drains used for pneumothorax, larger calibres needed for haemothorax, effusion and empyema. Indications include: Pneumothorax, Malignant Pleural Effusion, Empyema, Traumatic pneumothorax or haemothorax, peri-operative. ATLS guidelines should be followed in emergencies.

Question 58

Answer 58

Ryles NG Tool This is a Ryles nasogastric tube which is primarily used for decompression (drip and suck) in bowel obstruction, but can also be used to insert drugs or contrast into the GI tract. After explaining 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 and pH dipstick. The correct position of the tube is checked by aspirating gastric contents and checking for acidity on pH dipstick, 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. Once the tube is in the correct position a bag is attached and it is taped to the patients face.

Question 59

Answer 59

Self-Inflatable Bag-Valve-Mask Very useful in delivering high levels of oxygen even at low-flow rates. Can deliver 100% oxygen with flows above 10L/min. What is this used for? Used for ventilation in patients who may present with… * hypercapnic/hypoxic respiratory failure * apnoea * patients undergoing anaesthesia for elective surgery procedures How do you use this instrument? After selecting the appropriate sized mask, connect the self inflating bag-valve to the mask. Now, adjust the patient to a “sniffing the morning air” position. Place the mask over the patient’s mouth and apply a jaw thrust manoeuvre whilst simultaneously applying pressure on the mask to create a tight seal and open airway. To confirm that the mask is secure over the patient’s face, compress the bag and observe for symmetrical chest rising What are the possible complications of using this instrument? * Dry mouth and nose * May fail if patient has upper airway obstruction that requires intubation * Gastric insufflation leading to vomiting * Barotrauma from excessive lung inflation - Breathing

Question 60

Answer 60

Self Retaining Retractor This is a type of retractor used to hold wounds open e.g. during a hernia repair or an appendicectomy.

Question 61

Answer 61

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.

Question 62

Answer 62

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.

Question 63

Answer 63

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.

Question 64

Answer 64

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 (Triple Immobilisation). 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.

Question 65

Answer 65

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.

Question 66

Answer 66

Synthetic Absorbale Suture This is an example of a synthetic absorbable suture which can be used for bowel anastomosis or tying off vessels.

Question 67

Answer 67

TEDS Stocking This is a thromboembolic deterrent stocking which should be used in all patients undergoing surgery and those who are immobile to help prevent deep vein thromboses. They are available in different sizes and are used in conjunction with low dose subcutaneous heparin. They are contraindicated in patients with arterial disease of the lower limb.

Question 68

Answer 68

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. What is this used for? May be used in an emergency setting to bypass acute airway obstruction or in the context of severe facial or cervical trauma that contraindicates nasal airway insertion. Tracheostomy tubes may also be used in elective scenarios for several causes, including: * Prolonged ventilator dependence * Definitive treatment for obstructive sleep apnoea, refractory to other treatments * Neuromuscular disease * Chronic aspiration * Subglottic stenosis The ‘cuffed’ element of the tracheostomy tube enables the tracheostomy tube to be used for ventilation and reduces risk of aspiration contents. Fenestrations in the tracheostomy tube enables airflow to the vocal cords thus allowing the patient to speak. Patients with unfenestrated tracheostomy tubes will have difficulty producing speech.   How do you use this instrument? First, perform a cricothyrotomy making an incision in the midline anterior neck at the level of the cricothyroid membrane. Insert the tracheostomy tube through the guide wire using a dilator. Remove the dilator and guide wire but maintain the position of the tracheostomy tube. If you are using an unfenestrated and cuffed tracheostomy tube, the balloon may now be inflated prior to ventilation. To confirm that there is established access to the trachea, symmetrical chest rising may be observed when connected to mechanical ventilation. What are the possible complications of using this instrument? * Leaving in situ may cause infection, e.g. cellulitis of the skin at the insertion site * Acute obstruction of the tracheostomy tube due to blood or mucus * Pressure necrosis due to over-inflation of the cuff * Fistula formation, e.g. tracheoesophageal fistula

Question 69

Answer 69

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.

Question 70

Answer 70

Trucut 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.

Question 71

Answer 71

Urinary Catheter Catheter sizes are measured in French (Ch). A 14Ch is a common starting point for catheters. The larger the Ch, the greater the diameter. The three common types of urinary catheters include: Foleys Catheter (centre) – short term up to 28 days catheter. Made usually of latex Long-term Catheter (left) – up to 3 months made usually of silicone Three-way catheter (right) – used in cases of haematuria for bladder washout and irrigation. Larger Ch required due to containing 3 lumens.

Question 72

Answer 72

Urine Dip + Universal Sterile Container Urine dipstick testing is very useful in the acute clinical environment and in primary care. Key elements assessed in urine dipstick testing are blood (microscopic/macroscopic haematuria), protein (renal disease), nitrites (active infection), and leukocytes (inflammatory processes), glucose (diabetes), ketones (DKA), bilirubin and urobilinogen (haemolysis and liver pathology) Positive tests for Nitrites and Leukocytes should be sent for urine MCS Positive blood and protein should be sent for Urine Protein:Creatinine Ratio.

Question 73

Answer 73

Urometer Drainage Bag The urometer drainage bag allows monitoring of urine collection as it is designed with a clear graduation scheme. It reflects the accurate amount of urinary output per hour. It is used during surgery, postoperatively and to monitor fluid status.

Question 74

Answer 74

Venturi Mask Venturi masks are often using in COPD, where it is important not to over-oxygenate the patient. It delivers 24-60% oxygen. The flow rate varies depending on the colour. The correct flow rate to use with each colour it is shown on mask, along with the percentage of oxygen delivered. Types: –BLUE = 2-4L/min = 24% O2 –WHITE = 4-6L/min = 28% O2 –YELLOW = 8-10L/min = 35% O2 –RED = 10-12L/min = 40% O2 –GREEN = 12-15L/min = 60% O2 Venturi mask What is this used for? A high flow oxygen therapy device delivering 24-60% oxygen. The different coloured attachments deliver different percentages of oxygen with varying flow rates as depicted below. Used in spontaneously breathing patients. These devices are particularly useful for Chronic Obstructive Pulmonary Disease (COPD) patients, and patients with asthma too. * BLUE – 24% O2 - 2-4 Litres per minute * WHITE – 28% O2 - 4-6 Litres per minute * YELLOW – 35% O2 - 8-10 Litres per minute * RED – 40% O2 - 10-12 Litres per minute * GREEN – 60% O2 - 12-15 Litres per minute How do you use this instrument? Connect the Venturi piece to the patient’s face mask and oxygen tubing. Ensure that the oxygen tube is connected to a flow meter and the appropriate flow rate of FiO2. What are the possible complications of using this instrument? * Pressure necrosis of skin from tightening of mask to patient’s face * Oxygen-induced hypoventilation may occur in patients with chronic hypoxia and hypercapnia

Question 75

Answer 75

20ml syringe What is this used for? For drawing and flushing liquids. A 20ml syringe may also be used to draw air which can be used for inflating and deflating cuffs How do you use this instrument? Apply pressure on the plunger and use the graduation markings to deliver/draw fluid or gas, as appropriate What are the possible complications of using this instrument? * Potential needlestick injury if connected to a needle

Question 76

Answer 76

Tube ties What is this used for? Used to securely fasten airway instruments to the patient whilst ensuring that they do not become bothersome to the patient either, e.g. oropharyngeal airways, tracheostomy. How do you use this instrument? Tie a secure knot around the inserted tube and secure with tape off-centre to reduce the inconvenience caused to the patient What are the possible complications of using this instrument? * Nil

Question 77

Answer 77

Oxygen tubing What is this used for? Used as an adjunct to connect oxygen delivery devices to flow meters or ventilators How do you use this instrument? Click the tube into place on either end ensuring that there are no leaks What are the possible complications of using this instrument? * Trip hazard due to cable slack