Procedures Flashcards
Take Blood Cultures
1- WIPER - Wash hands, introduce, patient permission/procedure explanation, expose, reposition
2 - Prepare - Gloves,
Antisceptic cleaning material (clorhexidine/alcohol)
Tourniquet, Needle, Blood Culture Bottles (aerobic + anaerobic), Gauze, Microbiology request form
3 - Procedure - Re wash hands and apply appropriate protection
Clean skin - 30 seconds allowing a further 30 seconds to dry
Clean bottle tops
Introduce needle to vein and then fill both bottles (aerobic first)
Remove needle and apply gauze + tape
4 - Labelling
Label the patients samples at the bedside and ensure the form is adequately filled in
5 - Wash hands again
i) Risk of transmission through needle stick for HIV, Hep B, Hep C
ii) What to do in case of needlestick/sharps injury
i) HIV - 0.3%
Hep C - 3%
Hep B - 30%
ii) Clean with soap and water
Report to manager and to OT/A&E if out of hours
Have someone consent the patient for viral testing
Baseline bloods for yourself, 3 months and 6 months
Catheter
Wash hands
Ask for patient obs and notes
Assess for pain or discomfort
WIPER - Wash, Introduce, Explain / Permission, Expose, Reposition
Prepare - Catheter 12 fr/ 14 fr (long term/ short term)
Syringe to fill baloon, Instillagel, Gloves x 2 ,
Catheter bag, Swabs, Drape, cleaning solution
Create a sling,
Retract penis
Clean penis with swabs (one per swipe / in to out)
Drape
Change Gloves
Prepare catheter
Handle the penis with one hand + swab
Penis at 90 degrees
Instillagel
Insert catheter
Inflate
Attach urine bag
Wash hands, thank patient, explain post-procedure management
i) What to do if no urine comes out catheter?
ii) Differentials
i) 1) Examine Patient
2) Bladder washout + bladder scan
3) If bladder fills with solution on scan:
- Order renal function tests / FBC/ CLotting/ Group and save / Blood Gas
- Order US KUB / CT if OOH and cannot wait
ii) Differentials:
Pre - Renal (renal hypoperfusion) - Hypovolaemia, Renal Artery Disease, (always suggest ruptured AAA)
Renal - Glomerulonephritis, Interstitial nephritis, Acute Tubular necrosis
Post - Renal - Catheter blocked, Catheter malfunction, Catheter misplacement, Outflow obstruction (stones, tumour, stricture, prostate)
Chest Drain Insertion
WIPER - Wash hands, Introduce, Procedure + Permission, Expose, Reposition (Hand above/behind head)
Consent form + Risks - Explain intention + risks (Failure, Pain, Bleeding, Infection, Damage to other structures - blood vessels, nerves, liver, heart, need to have surgery)
Check - not on anticoagulants, no allergies
Equipment -
Sterile gloves and gown
Cleaning Solution
Drape
LA solution w/without adrenaline + Green/Orange syringe
Gauze, Scalpel + No. 11 blade.
Suture Material - 1 silk
Large haemostat/ Scissors
Spencer clamp x 2
Large bore chest tube 24-30 fr
Tubage + underwater seal
Dressing
Procedure:
Position correctly
Landmark - 5th ICS mid axillary line
Obtain an assistant
Prepare yourself and prep patients.
Clamp both ends of chest drain.
Apply drape.
Lidocaine (by weight) - to skin, periosteum and pleura
Transverse Skin incision just superior to rib
Blunt dissection using haemostat/scissors until pleura is encountered in controlled manner. Spread haemostat widely and withdraw while open.
Insert finger and rotate 360 degrees to check position
Take tube attached to clamp and insert it into incision aiming posteriorly + superiorly for air/ posteriorly and infeirorly for blood
Suture tube in place ensuring attached to underwater seal. Anchor suture just next to tubing along site of incision and then wrap suture around tube to secure before tying again.
Post-procedure-
CXR
Analgaesia
Chest Drain Monitoring
Obs
Document procedure
i) Causes of pneumothorax
ii) What is a large pneumothorax
i) Primary - Spontaneous
Secondary - Underlying lung disorder, Trauma
Iatrogenic - Central Lines, Biopsies, Pacemakers, Barotrauma
ii) >2cm rim of air on CXR
Removal of skin lesion
WIPER
Consent form, Hospital Number, Patient name, DOB
Consent - Risks - Bleeding, Infection, Scar formation, Pain, Re-excision of margins
Equipment -
sterile preparation ( solution, gloves + gown)
Local anaesthetic (1% Lidocain + 1:80,000 adrenaline)
Needle (injecting + drawing up) + Syringe
Marker
Specimen Pot. Histology Form
Suture - Monocryl for subcuticular. Prolene for interrupted.
Dressing
Sharps Bin
Diathermy (precaution)
Excision:
WHO Checklist
Prep Yourself
Clean and Drape
Mark the patient (2mm border for excision, 4mm for SCC, Melanoma dependent on breslow thickness)
Anaesthetise (check drug with examiner beforehand)
Elpitical incision around the marker - 3x1 ratio
Ask about subcutaneous marking stitch
What type of stitch is:
i) Prolene
ii) Vicryl
iii) PDS
iv) silk
i) Prolene - Synthetic, non-braided, non-absorbable suture
ii) Vicryl - synthetic, braided, absorbable suture
iii) PDS - synthetic, non-braided, absorbable suture
iv) SIlk - Natural, braided, non-absorbable suture
i) What is diathermy?
ii) Complications of diathermy
i) High Frequency Alternating Current providing:
localised heat to coagulate or cut tissue
ii) Smoke - carcinogenic
Burns
Fire
Capacitance coupling (if the insulator rests against tissue that has high capacity to store energy/current –> pathway of least resistance becomes the tissue rather than the air) –> leading to burn
i) What does SCC look like histologically?
i) Proliferation of atypical keratinocytes, keratin pearls + invasion of dermis (otherwise is Bowen’s Disease)
Features of LA overdose
Seperately patients can have anaphylaxis
Overdose:
Perioral Tingling
Paraesthesia
Later -> Reduced GCS, Seizures, Arrhythmias ..
Pacemaker precautions
i) Recent pacemaker check
ii) Provision of CPR / Temporary pacing available in theatre
iii) Monoplar to be avoided - if necessary in short bursts with the electrode far away from pacemaker in a direction so current will be guided away from the pacemaker
iv) Bipolar used in short bursts
v) Avoid putting on same side as metal prothesis
i) Specific intraoperative risks for COPD patients
ii) Postoperative risks
iii) Mitigation
i) Splinting of diaphragm due to pneumoperitoneum can reduce TV
ii) Respiratory complicatiosn post-op : T2RF, Atelectasis, Pneumonia, ECOPD
iii) Pre: Smoking Cessation, Discuss HDU bed, CXR, ABG, Spirometry
Intra: Avoid GA, Lower abdominal incision (less chest complications)
Post: - Early Mobilisation after surgery, Chest Physio, Postive Pressure Breathing, Spirometer , Upright posture , Analgaesia (judiciously)
Define:
i) Cleaning
ii) Disinfection
iii) Sterilisation
i) Cleaning- Removal of debris
ii) Disinfection - Reduction of number of microorganisms
iii) Sterilisation - killing of microorganisms
Stopping Warfarin
i) Check Local Guidance and Discuss with haematologist
ii) Stratified into :
Generally only operate if INR <1.4
Low Thromboembolic RIsk:
Stop 5 days pre op
Start when e+d
High Thromboembolic Risk :
Stop 4 days pre op
Provide LMWH cover
Stop LMWH - 12-18 hours pre -op
Restart LMWH 6 hours post op
Stop LMWH when INR is in range again
Very High Risk (Valves):
Unfractionated Heparin Infusion
APTT Checks 6 hourly and stopped 6 hours pre-procedure
Necessary steps to prevent wrong side surgery
Pre - Op:
History + Exam again
Review Notes
Review Imaging
Consent - specify the side
Mark correct side
Op:
WHO CHecklist
Patient ID Confirmation + side confirmation in theatre
Post MI risks of re-infarction
Within 3 weeks - 80%
Within 3 months - 40%
After 6 months - 5%
OCP and surgery?
Stop 4 weeks beforehand due to VTE risk
Metformin before surgery
i) Consider stopping 48 hours before to reduce risk of acidosis.
ii) Monitor BMs as may need a sliding scale
iii) Book 1st
How to prep patients before draping
1) Remove hair - don’t shave
2) Apply skin prep in circular motion from in to out - give enough room to extend incisions + to place drains
3) Dab any pooling of prep to prevent burns
4) Dry edges where drape will be applied
5) apply drape
Talk me through different antiseptics
Chlorhexidene (>4 hours)
Good for bacteria / Viruses
Not good for spores and fungi
Betadine (<4 hours)
Good for bacteria, viruses, fungi and spores
Isopropyl Alcohol
Good for bacteria, viruses, fungi
Not food for spores
Why do we drape
- Creates clean environment
- Provides a barrier from microorganisms
- Keeps clean equipment clean
- Controls fluids
Characteristscs - Durable (Wet/Dry), Resistant to microorganisms, Non - toxic, Flexible, Electrotatic, Breathable, Doesn’t set alight
Examples of sterilisation
Types of chemical sterilisaton substance
Autoclaves - Surgical instruments
Cold/ Chemical - Endoscopes
Gas - Sutures / Eletricals
Ionising - Catheters, Syringes
Formaldehyde, GLutaraldehyde, Ethylene Oxide, Hydrogen Peroxide
NECPOD Classification for intervention
I - Immediate. Life saving.
Ia - Within 6 hours. ORgan or limb saving
II - <24 hours. Appendicitis
III - Days. Stable patients but expedited procedures (soon to obstruct bowel tumours)
IV - Elective
ASA Classification
American society of anaesthesiologist classificaton predicting morbidity/mortality
I - Fit and well
II - Mild Systemic Disease
III - Significant systemic disease but well controlled
IV - Severe systemic disease constant threat to live
V - Expected to die within 24 hours ill with/ without operation
i) Layers incised through midline incision
ii ) Principles of incision
i) Skin
Subcut Fat
SCarper’s Fascia
Line Alba
Transversalis Fascia
Extraperitoneal Fat
Peritoneum
ii) Principles - Good abdominal access, can be extended, muscle fibers split not cut, avoid nerve damage, good closure possibility
Abdominal Incisions
i) Trendelenburg Position
ii) Reverse trendelenburg position
iii) Lithotomy position
iv) Lloyd Davies position
v) Prone
i) Trendelenburg - Supine with head down
ii) Reverse Trendelenburg - Supine with head up
iii) Lithotomy - Legs flexed at hips and knees with ankles in stirrups
iv) Lloyd Davies- legs flexed at hips and knees with ankles in pneumatic stirrups
v) Prone - on stomach
Surgical Wounds:
i) Clean
ii) Clean Contaminated
iii) Contaminated
iv) Dirty
i) Clean - Skin is breached but no other mucosal breach
ii) Clean Contaminated - PLanned mucosal breach with no spillage/contamination
iii) Contaminted - Macroscopic soiling
iv) Dirty - Contamination before surgery (ruptured viscus, peritonitis)
Sutures:
i) Natural
ii) Synthetic
iii) absorbable
iv) non absorbable
v) Multifilament
vi) Monofilament
i) Natural - Silk, Catgut
ii) Synthetic- monocryl, vicryl, prolene, ethilon, PDS
iii) Absorbable - Monocryl, Vicryl, PDS
iv) Non-absorbable - Prolene, Ethilon, Silk
v) Multifilament - Vicryl, Silk, Catgut
vi) Monofilament - Prolene, Ethilon, PDS
What would you use to close:
Skin Laceration
Mass midline
Bowel Anastamosis
Vascular Anastamosis
Drains
Skin Laceration - Prolene/ Ethilon/ Vicryl
Mass midline closure - PDS
Bowel Anastamosis - Vicryl / Staples
Vascular Anastamosis - Prolene
Drains - Silk
Over how much area should the electrode pad for monoplar cover
70 cm squared
Open limb trauma - how to investigate / debride
Initially ATLS - ensure patient is adequately resuscitated
Cannulae - Warmed crystalloid + Broad spectrum antibiotics ( check allergies, cehck trust guideliens) and Tetanus prophylaxis
Debridement:
1. Remove obvious debris with forceps. Use a retractor to remove debris that is not immediately visible
2. Irrigate wound gently (ensure eye protection) with 0.9% Saline. Retract and irrigate further
3, Debride - Excise dead/de-vitalised tissue carefully. If something bleeds it is viable.
Retract and continue the debridement/removal of debris being mindful of neurovascular structures
4. Pack wound with alginate/aquacel/hydrofiber dressings to reduce the dead space and cover with saline impregnated gauze
Options for LA
Immediate:
Lidocaine
Procaine
Prilocaine
Longer Acting:
Bupvicaine
Tetracaine
Hydrocele Surgical options
1. Aspiration
2. Lord’s :
- Scrotal incision
- Drainage of sac
- Minimal/No excision of sac followed by plication of sac walls
3. Jaboulay’s
Anterior Scrotal incision down to tunica vaginalis
Blunt dissect out hydrocele sac
Trocar to drain sac
Excise Sac walls
Suture sac together with interrupted sutures
