DRESSING TROLLEY (General surgery item)-A guide to an emergency room trolley

General surgery

1. DRESSING TROLLEY the surgeons’ armamentarium Dr. Balamurugan G.

2. Shelves Waste Pan Biomedical Waste Bin

3. COMPONENTS Bin containing sterile dressing materials Sterile gloves and drapes Normal Saline, Antiseptic and desloughing agents Local anaesthetic agents Instruments for debridement Suture materials Biomedical waste bin

4. Dressing bin Thin, translucent fabric with a loose open weave, usually made up of cotton GAUZE: (derived from GAZA - region where people used to wear this fabric) Thick layer of absorbent cotton wool between two layers of absorbent gauze. Strip of gauze prepared in roll GAMGEE: (named after Dr. Joseph Sampson Gamgee), Brimingham . ROLLER BANDAGE Acts as a barrier Removes exudates Absorptive dressings Prevents maceration

5. GLOVES DISPOSABLE GLOVES: Made up of NITRILE To remove dressings and other minor procedures STERILE GLOVES: Made up of LATEX Powdered or Powder-free To apply dressings

6. drapes Barrier between the wound field and patient’s own skin flora & and other possible source of microbes Disposable and Reusable woven drapes No difference in reduction of SSI https://www.who.int/gpsc/appendix17.pdf?ua=1 Disposable drapes Reusable drapes

7. MACKINTOSH SHEET James syme invented Copied and patented by Charles Mackintosh Initially used as a raincoat Two layers of high quality rubber High breaking and tearing strength Ideal use: to cover the mattress in dressing room Waterproof ( blood / human excrete spills) Available in blue : red , green : red colors.

8. ADHESIVES White adhesive tape Micropore tape Transpore tape Dynaplast Elastic crepe bandage

9. SOLUTIONS

10. NORMAL SALINE 0.9 gram sodium chloride / 100 ml Na – 154 mEq /L, K – 154 mEq /L Gives moisture Mechanism: “ OSMOTIC DRESSING” When it gets evaporated from dressing, becomes hypertonic from isotonic and fluid from the wound tissues is drawn into dressings Lim JK, Saliba L, Smith MJ, McTavish J, Raine C, Curtin P. Normal saline wound dressing - Is it really normal? British Journal of Plastic Surgery. 2000;53(1):42–5.

11. POVIDONE IODINE Antiseptic BETADINE (brand name); Content: PO ly VI nylpyrroli DONE - IODINE Iodine – bactericidal agent Povidone – carrier molecule Why not only iodine? - Carrier complex releases free- iodine slowly - decreased tissue irritation, less toxicity Effective against Bacteria (+/-), viruses, fungi, sporicidal activity. 10% solution – used in unhealthy wounds and pre-operative skin preparation 5% to 7.5% solution – used to scrub, pre-operatively Preferred in Unhealthy wounds > healthy wounds

12. HYDROGEN PEROXIDE Antiseptic 3-6% solution: Bactericidal (G+ > G-) , some sporicidal activity Mechanism: - Oxidizing agent - ROS generated on degradation oxidizes DNA causing breakage, protein (cytoskeleton), lipid (cell membrane) damage. Hemostasis: activates platelets by stimulating cyclo-oxygenase pathway Desloughing agent Used in chronic wounds till epithelialization is evident Breaks down chromophores – removes blood stain

13. HyPOCHLORITE SOLUTION 5% to 10% Sodium Hypochlorite solution Dakin’s solution – low concentration (0.5%) of sodium hypochlorite Mehanism : NaOCl + H20  HOCl + NaOH Nascent chlorine (Hypochlorous ion) damages cell membrane of bacteria, yeast, fungi “ HOCl produced inside phagosomes by neutrophil digests bacteria and viruses. Disinfectant and bleaching agent Used in chronic unhealthy wounds

14. EUSOL E dinburgh U niversity SOL ution (pH: 7.5 to 8.5) Chrolinated lime (calcium hypochlorite) with boric acid solution Preparation: -12.5 gm of powdered chlorinated lime and 12.5 gm boric acid powder to one litre lukewarm water -Use the filtered solution -Should be used within 15 mins EUSOL Bath: minimum 30 minutes before dressing Mechanism: Same as hypochlorite solution Used in chronic unhealthy wounds De-staining properties

15. Surgical SPIRIT 70% Isopropyl or Ethyl alcohol Methyl violet – Methylated spirit / Denatured spirit Volatile, flammable Topical Antiseptic Mechanism: Denatures cell wall protein Active against Gram positive, Gram negative bacteria, fungi, viruses Used in pre-operative skin preparation, intravenous catheter insertion

16. ETHER Solvent made of Diethyl Ether Colorless , Volatile and inflammable Initially used in anaesthesia Used for surgical debridement Used in cleaning and removing sticky dressings

17. TINCTURE benzoate Tincture means solution in alcohol Benzoin – 80%, alcohol – 10%, others- 10% Pungent solution of Benzoin resin in ethanol Topical adhesive agent Used to provide tackiness and enhance the adhesive property. Stoma, dressings near angle of mouth/eyes

18. SAVLON Brand Name Antiseptics - Cetrimide and Chlorhexidine gluconate Mechanism: Positively charged chlorhexidine reacts with negatively charged cell membrane phospholipids Both bacteriostatic and bactericidal Kills fungi, virus, spores Prevents biofilm formation Kills 99.99% bacteria within 30 seconds Used in pre-operative skin preparation

19. TURPENTINE OIL Dervied from latin –’ terebinthine ’- a tree traditionally used as an antiseptic Used for wounds infested with maggots (myiasis)

20. GLYCERINE Colorless , odorless , viscous liquid Exhibits dehydration effect by osmosis Along with magnesium sulphate (hygroscopic action) Used in non-necrotizing inflammatory conditions – e.g., cellulitis, erysipelas Glycerine soaked gauze pieces – used to reduce oedema on stoma, prolapsed hemorrhoids .

21. LIQUID PARAFFIN An emollient Prevents water loss from skin – keeps skin hydrated Used in dry skin, eczema, ichthyosis, pruritus As an osmotic laxative As a lubricant in rectal examination

22. STERILIUM Rub-in-hand disinfectant Bactericidal, Mycobactericidal, yeasticidal , virucidal Contains 2-propanol, 1-propanol, mecetronium ethyl sulphate

23. OINTMENTS

24. CadOMER 3D lattices of microspherical , polysaccharide beads of cadoxemer iodine with 0.9% elemental iodine loaded into an ointment base of polyethelene glycol and polaxamer . As starch becomes wet, it allows slow and sustained release of iodine into the wound bed Antimicrobial, Desloughing , Exudate control properties Used in highly exuding, infected, chronic wounds

25. debridace Enzymatic debridement Papain – enzyme obtained from ripening fruit of carica papaya, cysteine proteinase. Urea- chaotropic agent Facilitates the action of papain by solubilizing proteins Digests necrotic tissue by liquefying eschar, migrates the viable cells from wound edge into wound cavity. Decreases bacterial burden and exudates Increases granulation tissue formation

26. BETADINE 10% povidone iodine ointment Topical antiseptic Mechanism: as described previously Used in minor skin abrasions, wounds Used in suture line, post-surgery

27. T BACT 2% mupirocin ointment Topical antibiotic – Staphylococcal and Streptococcal Mechanism: inhibits bacterial protein and RNA synthesis Used in superficial skin infections – impetigo, folliculitis Irritates mucous membrane

28. ENZOMAC 2% mupirocin and 2.5% Bromelain Bromelain – cysteine proteinase

29. PLACENTREX 1 gm – 0.1 gm of fresh human placental extract Contains polydeoxy- ribo -nucleotide (major component) Mechanism: promotes epidermal keratinocyte proliferation. Anti-inflammatory, anti-oxidative, anti-platelet, neovascularization properties Bacteriostatic, fungistatic Used in chronic non-healing wound Minimal scar formation

30. REGEN D Recombinant Human Epidermal Growth factor 150 mcg / gram EGF – type of growth factor regulates cell proliferation, migration and differentiation through binding to receptor kinases on target cells Obtained by cloning of EGF polynucleotide which is over-expressed in E.coli Used in diabetic ulcers, venous ulcers, chronic non-healing wounds

31. SILVER SULPHADIAZINE Silver: binds with amino acids, DNA, bacterial cell walls and interferes with respiratory chain. It gets released slowly when in contact with NaCl containing body fluids. Sulphadiazine: Sulphonamide antibiotic, inhibits dihydropteroate synthase, disrupts folic acid metabolism, thereby DNA synthesis Synergistic effect Cerium nitrate: renders the eschar firm, impermeable and adherent to wound bed Gram positive, Gram negative, Pseudomonas aeruginosa, fungi Used in prevention and treatment of infection of burns (II, III) Skin discoloration, esp. in areas exposed to UV light Avoid usage in face, sulfa allergy & pregnancy

32. HYDROheal Amorphous hydrogel with colloidal silver Hydrogel swells up with water yet it retains 3D shape, helps in better drug delivery to targeted sites. Silver – antiseptic Used in chronic, non-healing wounds, bed sores

33. soframycin 1% Framycetin sulphate Topical aminoglycoside Batericidal – inhibits protein synthesis Used in infection of skin, hair, nails, external air Also in superficial burns, scald. Burns over the face

34. LIGNOCAINE 2% lignocaine hydrochloride gel Topical anaesthetic Sodium channel blocker (voltage gated) in cell membrane of neurons Membrane of presynaptic neuron will not depolarize, failure to transmit an action potential – anaesthetic effect Used also as a lubricant – gastric, urinary catheter, endoscopes Used in per-rectal examination,proctoscopic examination Used in combination with other medications in treatment of fissures, hemorrhoids .

35. ANOMETROGYL 7% sucralfate, 1% metronidazole, 4% lignocaine Sucralfate – forms a protective layer in the anal region – prevents irritation, burning sensation Metronidazole – inhibits DNA synthesis, effective against anaerobes, protozoa. Anti-oxidant properties promote wound healing Lignocaine- anaesthetic Used in haemorrhoids, fissure and fistula treatment

36. anobliss Lidocaine 1.5% + Nifedipine 0.3% Nifedipine – calcium channel blocker, relaxes the smooth muscle of internal anal sphincter Lidocaine- anesthetic Used in anal fissures and acute thrombosed hemorrhoids

37. LIGNOCAINE 2% lignocaine hydrochloride +/- 1:100,000 adrenaline solution. Sodium channel blocker, amide drug ; anti- arrythmic Addition of adrenaline – reduces systemic absorption, more volume of infiltration, reduces bleeding due to vasoconstriction Used in regional blocks, local infiltration in minor surgical procedures Lignocaine spray used to anaesthetize the pharynx before endoscopy Maximum dose: 3 mg/kg without adrenaline, 7 mg/kg with adrenaline Avoid adrenaline combination in areas with end-arteries Buffered with sodium bicarbonate – to enhance the effect in abscesses and to reduce pain Action lasts up to an hour

38. BUPIVACAINE 0.5% Bupivacaine hydrochloride Sodium channel blockade Maximum dose: 2 mg/kg without adrenaline, 2.5 mg/kg with adrenaline Action lasts up to 2-3 hours

39. INSTRUMENTS TRAY Surgical blades Toothed dissecting forceps

40. INSTRUMENTS TRAY Surgical scoop Needle holder

41. INSTRUMENTS TRAY Spencer wells hemostat Mayo’s scissors

42. SUTURE MATERIALS

43. THANK YOU