Surgery Instruments for students FINAL copy.pptx

surgery instruments

1. Surgery Instruments Kiko Bridgewater

2. Tables Gastrointestinal Thoracic & Vascular Trauma and Resuscitation Orthopedics & Burns Urology

3. Gastrointestinal Table Stomach & Duodenum NG Tube, Tube Gastrostomy & PEG, Endoscope Large Bowel Flatus tube, Fleet Enema; Metronidazole, Colostomy Bag (& Types of Colostomy), Sigmoidoscope Small Bowel, Appendix & Crohn’s Sutures, Clamps, NG tube, Fluids Hepatobiliary T-tube, Laparoscopic Instruments, Sengstaken Blakemore tube Esophagus Sengstaken Blakemore tube, Mousseau Barbin tube

4. GASTROINTESTINAL TABLE

5. Diathermy Diathermy has a hand control (or foot pad) and a patient adhesive ground plate (patient return electrode) which is typically placed on a large well-perfused muscle, eg. the thigh. Is a device used for heating of the body tissues by the passage of high frequency electrical current which results in coagulation, desiccation or cutting of tissues. Monopolar diathermy is used for both surgical dissection as a bloodless knife and for hemostasis Monopolar Diathermy is not used for circumcision, brain surgery, plastic surgery, and ophthalmology cases because of the danger is coagulation of blood vessels (eg. the dorsal artery of the penis) which may result in ischemia and necrosis of the involved tissues.

6. Diathermy Complications of diathermy include: 1. Mild thermal injury (burns) 2. Damage to adjacent tissues 3.   Increased susceptibility to infection and seromas 4.    Burns at areas of attachment of ECG pads if the grounding plate is not properly attached 5. Damage to ischemic tissues & ischemia. Contraindications – persons with pacemakers.

7. Nasogastric Tube Closed active or passive drain Its uses are diagnostic and therapeutic Diagnostic uses include: diagnosing the presence and amount of blood in the stomach. Therapeutic uses include: decompression of the stomach removal of activated charcoal given to children in acute poisoning nutritional (administration of enteral feeds) administration of drugs

8. Nasogastric (NG) Tube Contraindications: Basal skull fracture as evidenced by CSF otorrhea or rhinorrhea, Battle’s sign (mastoid ecchymosis), or Raccoon eyes (periorbital ecchymosis). CSF is confirmed by the ring sign is by placing a drop of the bloody drainage on a piece of filter paper, and looking for the Ring Sign. This is the appearance of a yellow ring around the periphery of the drop of blood. Facial fractures. The alternative to the nasogastric tube is the orogastric tube which is placed orally using the McGill’s forceps. Complication includes malplacement into the trachea which may result in pulmonary aspiration and abscess.

10. Gastrostomy Tube What is gastrostomy feeding tube placement? Gastrostomy feeding tube placement is a procedure in which the surgeon creates an alternate entrance into the stomach. A tube is placed through the abdominal wall directly into the stomach, bypassing the mouth and esophagus. When done at the time of an operation it is called open gastrostomy tube placement. When performed with the aid of a lighted flexible scope it is called Percutaneous Endoscopic Gastrostomy tube insertion (or PEG).

11. Gastrostomy Tube Gastrostomy feeding may be indicated for patients with a functioning gastrointestinal tract who require long term tube feeding. This includes patients in whom malnutrition already exists, or may result, secondary to: neurologic diseases resulting in an abnormality in swallowing. tumors of the head, neck, or esophagus resulting in an abnormality in swallowing. upper airway diseases/mouth, throat, or neck trauma resulting in an abnormality in swallowing. In addition, some patients who require either chronic supplemental fluids for hydration or chronic gastric decompression are candidates for gastrostomy tube placement.

12. Gastrostomy Tube Gastrostomy tubes allow for decompression of the stomach to prevent vomiting or aspiration pneumonia. What happens during the procedure? Gastrostomy feeding tube placement is done in two basic ways. In the first, open gastrostomy tube placement is generally performed under general anesthesia. This procedure is often done at the time of another major operation in anticipation of postoperative need for emptying (decompressing) the stomach, or for future feeding.

13. Gastrostomy Tube The second way, called percutaneous endoscopic gastrostomy (PEG) tube placement is usually done with IV sedation and a local anesthetic applied to the back of the mouth. The procedure is done with the guidance of an endoscope placed through the patient’s mouth into their stomach. OPEN TECHNIQUE: The gastrostomy tube is placed through a small cut in the abdominal wall and into the stomach. A balloon on the end of the tube is inflated inside the stomach.

14. Gastrostomy Tube Traction is placed on the tube to elevate the stomach against the abdominal wall where it is secured with sutures. Sometimes a second smaller tube is threaded through the stomach tube into the first part of the intestine. This is called a jejunostomy tube and is used to feed or administer medications to patients further down the gastrointestinal tract beyond the stomach. This smaller tube may reduce the risk of regurgitation or reflux of contents into the stomach, esophagus, and lung. Following the tube placement the abdominal wall incision is closed and the patient is taken to the recovery room.

15. Tube Gastrostomy Gastrostomy Tube Care I. Dressing Changes (every 1 to 2 days) a) Clean around tube with hydrogen peroxide. b) Apply antibiotic ointment to skin around tube. c) Dress with gauze pads and tape. d) Position tube so it does not kink. II. Showers - no tub baths. a) Cover dressing with a double layer of plastic wrap and tape edges. b) Remove plastic wrap and change dressing after you shower III. Activities - no specific restrictions.

16. Tube Gastrostomy   IV. Feeding a) Use water to flush the tube after each feeding. b) Use liquid forms of medication if possible. c) Ask your doctor or nurse to provide you with specific information about feedings or medications.   V. Possible problems that can arise with your tube. a) Leakage of feedings around the tube. b) Signs of infection such as swelling, tenderness, redness, or drainage of pus around the tube. c) If the tube falls out completely call immediately. The tube usually can be easily replaced if it is done within 24 hours from the time it fell out. Waiting longer could mean that a separate new tube will have to be placed.

18. Endoscope

19. Endoscope

20. Flatus Tube Large flexible rubber tube Placed into the rectum in patients with sigmoid volvulus and for pseudo-colonic obstruction Requirements: Protective covering Disposable flatus tube and connection tubing Bowl of tepid water (into which the non-lubricated end goes) Lubricant Disposable wipes Disposable gloves Complications: perforation of bowel in patient’s with impaired sensation eg spinally injured patients

21. Fleet Enema Is a phosho-sodium enema Is an osmotically active agent Used for clearing/preparing bowel eg. For left sided bowel resection and anastomosis, IVP or lower GI endoscopy. Complications: Elderly persons can get fluid and electrolyte imbalance, therefore avoid in old patients and those with cardiac and kidney problems

22. Metronidazole 500 mg Antimicrobial agent Is used prophylactically or therapeutically for coverage of anaerobes. Prophylactically it is administered 15 mg/kg IV 30 mins prior to bowel resection / colorectal surgery (maximum dose 1g/dose); then 7.5 mg/kg IV q6h x 2 Ceftriaxone is co-administered for coverage of aerobes (eg. Gram-negatives and gram-positives). Therapeutic doses are used if there is established infection (15 mg/kg IV, then 7.5 mg/kg q6h  maximum = 1g/dose)

23. Colostomy Bag A colostomy is an artificial opening made in the large bowel to divert feces and flatus to the exterior, where it can be collected in an external appliance Types: Temporary vs Permanent Trans-sigmoidal vs Transverse vs Sigmoid

24. Colostomy A temporary (loop) colostomy is most commonly established to defunction an anastomosis after an anterior resection, to prevent fecal peritonitis developing following traumatic injury to the rectum or colon, and to facilitate the operative treatment of a high fistula in ano. Eg. Hartman’s procedure. Most loop colostomies are made in the transverse colon but the sigmoid colon can be suitable.

25. Colostomy A double-barrelled colostomy is another type of temporary colostomy in which the colon is divided so that both ends can be brought separately to the surface, ensuring that the distal segment is completely defunctioned. A permanent (end) colostomy is formed by bringing the distal end of the divided colon to the surface in the left iliac fossa, where it is sutured in place joining the colonic margin to the surrounding skin.

26. Complications of Colostomy Prolapse Retraction Necrosis of the distal end Stenosis of the orifice Colostomy hernia Bleeding (usu from granulomas around the margin of the colostomy) Colostomy diarrhea Many of these complications require revision of the colostomy.

27. Sigmoidoscopy Flexible sigmoidoscopy enables the physician to look at the inside of the large intestine from the rectum through the sigmoid or descending colon. It may be done to find the cause of diarrhea, abdominal pain, or constipation. It may also be done to look for early signs of cancer in the descending colon and rectum. With flexible sigmoidoscopy, the physician can see bleeding, inflammation, abnormal growths, and ulcers in the descending colon and rectum.

28. Sigmoidoscopy If anything unusual is in the rectum or colon, like a polyp or inflamed tissue, the physician can remove a piece of it using instruments inserted into the scope. The physician will send that piece of tissue (biopsy) to the lab for testing. The bowel must be properly prepared by giving an enema and ensuring an empty stomach. Hemorrhage and puncture of the colon are possible complications of sigmoidoscopy.

29. Retractors Langenbach Retractor Morris Body Wall Retractor

30. Sutures: Catgut Plain (Catgut) Suture Natural (causes a greater tissue reaction than vicryl) Absorbable by enzymatic activity Used for approximation of the edges of a surgical wound, blood vessels, fat Maintains its strength for < 7 days Catgut (chromic) Natural (causes a greater tissue reaction than vicryl) Absorbable by enzymatic activity Used for approximating the edges of wounds of the lips, mucous membranes and other tissues that heal slowly. Also used in ophthalmology and in ligature of blood vessels. Maintains its strength for 7-14 days (the chromium coating prolongs strength)

31. Sutures for Small Bowel Silk Natural Non absorbable Multi-filamentous Has memory Is smooth and passes thru the tissues easily Used for bowel anastomosis (outer layer), ligation, scalp and skin approximation in most body tissues, ophthalmology, plastic surgery.

32. IV Fluids for Small bowel Lactated Ringers

33. T-tube Closed, passive drain (attaches to a drainage bag) Comes in different sizes One end inserts into the common bile duct, the opposite end inserts into the common hepatic duct, and the remaining end into the cystic duct Used for drainage of bile in patients with biliary leak after common bile duct exploration Advantages: Decompression of the biliary system; formation of tract for radiologic instrumentation and stone removal

34. T-tube This is a tube placed in the common bile duct with an ascending and descending limb that forms a “T” Drains percutaneously  allows free drainage and passage of small stones. It is usually placed after common bile duct exploration or post cholecystectomy. It is usually removed after 3/52. It may be removed if the bilirubin level does not increase and there are no signs and symptoms of cholangitis after clamping and after a normal T-tube cholangiogram.

35. T-tube After removal of a T-tube the bile duct does not leak bile because a fibrous tract forms around the T-tube prior to removal. The fibrous tract then scleroses down after removal of the T-tube, resulting in a patent and closed bile duct. Complications: Bile Peritonitis\ Obstruction of the tube Displacement of the tube Ascending infection

37. Laparoscopic Surgery Laparoscopic surgery utilizes a high-resolution video camera and a few customized instruments, to allow the surgeon to perform surgery with minimal tissue injury and manipulation. The camera and instruments are inserted thru various ports inserted thru small incisions. Minimally invasive Laparoscopic surgery often results in the following advantages over conventional incisions: Less post operative pain Less complications Shorter recovery period Earlier return to work Smaller incisions Better cosmetic result

38. Laparoscopic Surgery Laparoscopic Cholecystectomy Laparoscopic hernia repairs Laparoscopic colon surgery Laparoscopic gastric fundoplication Laparoscopic spleenectomy Laparoscopic intestinal surgery Laparoscopic Hiatal hernia surgery Surgical weight loss procedures: (VBG) vertical banded gastroplasty Roux-en-Y gastric bypass Laparoscopic appendectomy

39. Sengstaken Blakemore Tube This tube is used for mechanical tamponade of variceal hemorrhage. It consists of 2 balloons and is placed nasally into the stomach. When its position in the stomach has been confirmed radiographically, the distal gastric balloon is inflated with 250 ml of air, drawn tight against the GE junction, and placed on traction. If the gastric balloon alone does not control the hemorrhage, the proximal esophageal balloon is inflated to a pressure of 20 mmHg.

40. Sengstaken Blakemore Tube Balloon tamponade is a temporary measure to control bleeding and can be applied for 12-24 hours. 50% of patients re-bleed after balloon deflation. Risks include esophageal perforation and necrosis of esophageal mucosa from overinflation of the balloon. Other methods of arresting hemorrhage include: Banding Sclerotherapy Transjugular intrahepatic portosystemic shunt (TIPS) Shunt surgery Octreotide/Vasopressin Linton Ballon (has no gastric balloon)

41. Mousseau Barbin Tube Used for palliation in a patient with non-resectable esophageal CA It does not contract, therefore aspiration is a risk when the patient lies down. It lasts for 6-12 months before it becomes occluded

42. THORACIC & VASCULAR

43. Thoracic & Vascular Table Breast Allis forceps, hemostat, Tru-Cut Biopsy needle, Sutures, Drains. Lungs Chest tube, bronchoscope Vascular Fogarty Embolectomy Catheter Dacron Graft, Gore-tex Heparin TED Stockings

44. Breast Surgery: Allis An Allis is used to grasp tissue eg. subcutaneous fascia. Available in short and long sizes.  A "Judd-Allis" holds intestinal tissue; a "heavy Allis" holds breast tissue. Used in hernia repair, breast surgery

45. Hemostat A hemostat is used to clamp small blood vessels or tag sutures.  Its jaws may be straight or curved.  Other names: crile, snap or stat.

46. Core needle biopsy This procedure is similar to fine needle aspiration, but the needle is larger, enabling a larger sample to be obtained. It is performed under local anesthesia and ultrasound or stereotactic mammography is used if the lump cannot be felt. Three to six needle insertions are needed to obtain an adequate sample of tissue. A clicking sound may be heard as the samples are being taken and the patient may feel some pressure, but should not feel pain. The procedure takes a few minutes and no stitches are required.

47. Tru-Cut Biopsy: Core needle biopsy may provide a more accurate analysis and diagnosis than fine needle aspiration because tissue is removed, rather than just cells. This procedure is not accurate in patients with very small or hard lumps. Needle procedures are performed in doctors’ offices, clinics, surgical centers, and hospitals. Informed consent is needed. Complications are rare, but excessive swelling, redness, and bleeding or other drainage can indicate an infection or abnormal bleeding.

48. Breast Biopsy: Types Tru Cut Needle Biopsy Tru Cut Needle Biopsy is also done in the office, usually requires local anesthesia and takes a larger sample of tissue. This needle is more often used for a large palpable mass. Fine Needle Aspiration Fine needle aspiration is probably the most expedient method. It is generally performed in the office, and diagnostic accuracy approaches 100%. The false negative rate is 2-10%. However, a negative result does not exclude cancer.

49. Breast Biopsy: Types Incisional Biopsy Incisional biopsy involves removing only a sample of tissue surgically from a very large mass for diagnostic purposes. This is performed in an operating room. Excisional Biopsy Excisional biopsy is the term used to describe removal of the entire mass. This type of biopsy is performed in an operating room under local or general anesthesia.

50. Sutures for Breast Surgery Catgut for approximating subcutaneous tissues Vicryl repede Synthetic (non-dye) Absorbable Used for skin closure especially when doing a subcuticular stitch. Maintains strength for up to 14 days (strength shorter because there is no dye)

51. Hemovac Drain Is an active closed drain Because it is closed there is less likely to be secondary infection It has a clear, collapsible drum-type reservoir therefore there is the advantage that the fluid collection can be directly observed. There are gradations on the side so that volume can easily be measured. Used for drainage of abdominal abscess cavities, breast abscess cavities, pelvic and others.

52. Penrose Drain Is a floppy cylinder of latex rubber; is flat. Open, passive drain Evacuates fluid by capillary action Uses Breast flap Foot flap Areas in the abdomen where there was an abscess Post thyroidectomy May be used for drainage of the abdominal abscess cavities and esp. after bladder or kidney surgery. Advantages : simple, inexpensive, and promotes the development of a well-established tract within 7-10 days Disadvantages: requires a relatively large skin incision, there is increased risk of infection with use, and is not very effective in emptying a cavity

53. Chest Tube with Trochar Chest Tube Closed active or passive drain It is used for the drainage of blood, fluid, chyle or air from the thoracic cavity, as well as for the restoration of negative pressure in the thoracic cavity and hence re-expansion of the lung.. Attaches to underwater seal which provides negative pressure and collects the drainage fluid. The chest tube is placed in the 5 th ICS Anterior Axillary Line within the triangle of safety. The triangle of safety refers to the area within the mid-axillary line, anterior axillary line, and 5 th ICS.

54. Chest Tube An alternative site includes: the 2 nd ICS MCL (for pneumothorax). The chest tube is removed when it drains <1ml/kg/24hrs or when it stops draining. Thoracotomy is indicated for initial chest drainage of >1500 ml or 3 consecutive hours of >200 ml per hour blood loss. Complications: Hemorrhage from intercostal vessel injury Subcutaneous emphysema Malpositioning into the lung parenchyma, liver, heart. Re-expansion pulmonary edema Obstruction from kinking, clots, tissue debris Dislodgement Infection

55. Placement of Chest Tube The patient is placed in a 30-60 degree reverse Trendelenburg position The site is scrubbed with betadine/alcohol The site is anesthetized with lidocaine A 3-4 cm incision is made over the 5 th – 6 th rib b/w the mid-axillary and anterior axillary line. Use a curved hemostat to puncture thru the intercostal muscles and parietal pleura superior to the rib border. Perform finger exploration to confirm intrapleural placement (feeling for diaphragm and intra-abdominal structures) Insert chest tube along side the finger Place the tube posteriorly and superiorly.

56. Chest Tube To calculate the % pneumothorax, measure the distance b/w the outline of the lung and the chest wall. 1 cm = 10% up to 2.5 cm, then the % increases. It takes 300-500 ml of blood to blunt a costophrenic angle. If a central line is required, always place it on the same side as the injury.

58. Bronchoscope Flexible bronchoscope; passed thru nostril; Allows direct visual examination of the upper airway and tracheobronchial tree, sampling of the respiratory tract secretions and cell, and biopsy of the airway, lung and mediastinal structures Uses: diagnostic and therapeutic Diagnostic: lung neoplasm and staging, assessment of cough & wheeze of unknown origin, evaluation of hemoptysis of unknown origin, identification of etiologic agents in respiratory infections;

59. Bronchoscopy Therapeutic: to remove retained secretions, pus, blood, or foreign body from the tracheobronchial tree, to guide insertion of a nasotracheal or orotracheal tube, and to instill drugs directly to a specific lung area. Requirements: NPO for 4 hrs, Pre-medication with Atropine and codeine, IV access, ECG and intermittent BP monitoring, pulse oximetry, local anaesthesia, and sedation Complications: Respiratory depression from sedatives Hemorrhage (especially if biopsy is performed) Pneumothorax Cardiac arrhythmias Post bronchoscopy fever with no bacteremia

60. Fogarty Embolectomy Catheter Thomas J. Fogarty invented the balloon embolectomy catheter. It is an apparatus for driving an embolus from a blood vessel (usually an artery). It is a long tubular catheter that is inserted deflated into the artery and the balloon at it’s tip is inflated once past the embolus. The catheter is then pulled back while the balloon is still inflated, pulling the clot out of the vessel. Complications: hemorrhage, air embolism, dislodging of the clot  thromboembolism, endothelial damage, infection;

61. Dacron Graft This is a 20 mm woven Dacron graft. It is a synthetic material used to replace or repair blood vessels It is manufactured in either a woven or knitted form. Woven grafts have smaller pores and do not leak as much blood. Dacron grafts are frequently used in aortic and aorto-iliac surgery. Eg. Aneurysm. Venous grafts have a superior result to synthetic grafts when used below the inguinal ligament

62. Dacron Graft Complications: Graft occlusion Graft infection True and false aneurysms at the site of anastomosis Distal embolisation Erosion into adjacent structures e.g. aorto-enteric fistulae

63. Gortef/PTFE Graft PTFE (polytetrafluroethylene)/ Gortef is a synthetic vascular graft. Indications: As a vascular prosthesis for replacement or bypass of diseased vessels in patients suffering occlusive or aneurysmal disease In trauma patients requiring vascular replacement For dialysis access or for other vascular procedures

64. PTFE/ Gortef Contraindications: Should not be used as a patch  leaking Should not be used for CABG or cerebral reconstruction procedures. Complications: Graft occlusion Graft infection True and false aneurysms at the site of anastomosis Distal embolisation Erosion into adjacent structures e.g. aorto-enteric fistulae

65. Heparin Anticoagulant (inhibits formation of clots) Is used for DVT prophylaxis and Rx of DVT and pulmonary embolism It bind to antithrombin III (a protease inhibitor) and enhances (accelerates x1000) its activity (I.e. binding to clotting factor protease enzymes inhibiting them from activating the clotting factors). The prophylactic dose is 5000 U sc bid/tid It is contraindicated in persons who are hypersensitive to the drug, are actively bleeding or who have a bleeding dyscrasia, or post CNS surgery.

66. Heparin Clexane is an alternative to heparin It is low molecular weigh heparin It has smaller molecules and hence is less allergenic than high molecular weight heparin It also has the advantage of less frequent dosing (once daily). Other forms of DVT prophylaxis include: TED Stockings Early Stir up mechanism (early ambulation) Sequential Pneumatic Compression Stocking

67. Heparin: DVT Patients prone to developing DVT: Obese OCP use Long duration surgery Pelvic Surgery Hypovolemia and dehydration during surgery Malignancy (disseminated hematogenously) Hypercoagulable state

68. Thromboembolic Deterent Stockings

69. TRAUMA & RESUSCITATION

70. TRAUMA & RESUSCITATION Hard Cervical Collar 6 Tubes of Resuscitation Laryngoscope & Blade Tracheostomy Intraosseous Infusion needle Oropharyngeal Airway Nasopharyngeal Airway Gardner Wells Tongs Mannitol Steroids Phenytoin

71. Hard Cervical Collar Used for all patients with a history of trauma, especially if C-spine injury is suspected due to: injury above the level of the clavicle, multiple injuries, unconsciousness, neck pain, parasthesias, weakness, paralysis or palpable deformity. The area most injured in the C-spine is C5-C6 because this area is most flexible but least stable. The disadvantage of the hard c-collar is that it is uncomfortable for the patient, and allows for lateral movement of the neck. It must therefore be used with head blocks.

72. C-spine Injury After insuring that the airway, breathing and circulation are secured, it is important to obtain a lateral c-spine x-ray in order to determine whether or not there is injury to the cervical spine. In the x-ray, one looks at 4 special lines: o      The anterior and posterior vertebral bodies o      The base of the transverse process o      The tip of the spinous process These 4 lines should all be straight. Subluxation of 3-3.5 mm is abnormal. Assess for the thickness of the soft tissue anterior to the body. This should not be wider than the body itself.

73. C-spine Injury Initial treatment of C-spine fracture is by application of Gardner-Wells Thongs/Calipers, and administration of steroids (solumedrol). Solumedrol is given 30 mg/kg stat over 15 mins, then 5.4 mg/kg/hr for 24 hours. The purpose for this is to decrease the swelling which may lead to ischemia of the neurons above and below.

74. Steroids High dose methylprednisolone succinate (Solumedrol) is important in the management of spinal injury Dose: 30mg/kg IV STAT over 15 mins followed by: 5.4g/kg/hr IV over 24 hrs and up to 48 hrs. C-spine injury is most likely to occur at C5,C6 (the most flexible portion) In assessing the patient, the anal tone is checked (everything above S2-S5 is intact if normal); A neurological examination should be done each time the patient is moved.

75. Steroids: Spinal Injury Repair: Spinal cord decompression  laminectomy Steel rods Neurogenic Shock – a transient loss of tone  vasodilatation  shock. NB There is hypotension * and bradycardia (expected reflex is tachycardia). Rx: administration of pressor agents Spinal Shock – a transient loss of reflexes and flaccidity NB: Both conditions can coexist. * One should not ascribe hypotension in trauma to neurogenic shock. Hemorrhage should be suspected first.

77. Gardner Wells Tongs This device is used to provide cranio-cervical traction Indications: To reduce cervical spine fractures or dislocations To maintain alignment of reduced spine fractures or dislocations. To immobilize the spine and prevent cord injury The Gardner-Wells tongs will usually be applied by the Neurosurgeon in the ICU using local anaesthetic, although light sedation may be required. A spring loaded pin in one of the handles will indicate the depth of penetration into the skull.

78. Gardner Wells Tongs Protrusion of the pin is 1.0 – 2.0mm into the skull The typical weight for simple cervical immobilisation is 10 lbs. Weight can be progressively added to reduce a fracture/dislocation. The generally accepted maximum weight is 140 lbs!

79. Gardner Wells Tongs Two major complications with the use of Gardner-Wells tongs: Penetration of the inner table of the skull by the pins resulting in damage to the brain and infection Loss of attachment by the pins and abrupt loss of traction A 'hard' cervical collar of the correct size should be kept at the bedside in the event of traction failure Neurological status (motor and sensory function) should be regularly checked while a patient is in traction.

80. 20% Mannitol (Osmitrol) 250 ml This is an osmotic diuretic It is used to reduce elevated ICP and IOP, to treat peripheral edema, and to prevent and treat oliguria. Dose: 0.5-1 g/kg IV (50-100g) over 30-60 minutes 20g in 100 ml = 50g in 250 ml Side Effects include: Hyponatremia and other electrolyte disturbances Pulmonary edema Metabolic acidosis Headache Dehydration Seizures

81. Mannitol Other Methods of Decreasing ICP: Elevation of bed head by 30 degrees Hyperventilation  PaCO2 of 25-30 mmHg Shunt procedure to drain CSF (Ventricular) Craniotomy or Burr Hole Anaesthetic techniques: Lidocaine 100mg IV, Barbiturate coma (Thiopental 3-5 mg/kg IV stat, then 1-2 mg/kg/hr Resection of mass lesion or silent parts of the brain (Rt. frontal lobe, anterior temporal lobe)

82. Phenytoin (Dilantin) Anticonvulsant It modulates neuronal voltage-dependent sodium and potassium channels (raises the seizure threshold). It is given prophylactically for 48 hrs to persons with depressed skull fracture Loading Dose: 750 mg over 30 mins Maintenance: 300mg/day Side effects: gingival hyperplasia, ataxia, nystagmus, tremor; Hepatotoxicity, pancytopenia, arrhythmias.

83. 6 Tubes of Resuscitation Endotracheal Tube Nasogastric Tube Chest Tube Intravenous Catheters Central Venous Catheter Urinary Catheter

84. Endotracheal Tube Uncuffed Endotracheal Tube ·    Pediatric ETT ·    Size 2.0 (premature age) ·   Size 3.0 (newborns up to 2 yrs) ·   Uncuffed because the airways of a child are small, and provide an adequate seal; A cuff can cause irritation à edema à narrowing of the trachea à respiratory embarrassment. ·    The tube is lubricated with sterile water because KY Jelly can also à edema and swelling. ·    Rx for broncho-oedema is racemic epinephrine (aerololized epinephrine) ·    Because there is no cuff, a leak may be audible.

85. ETT Cuffed Endotracheal Tube ·    Internal diameter is in millimeters ·    Parts consist of the bulb, for inflation of the cuff; and a universal adaptor for attachment to the breathing circuit. ·   Indications: 1. Any operation lasting >30 mins 2.    Abdominal, thoracic & intracranial procedures. 3.    All surgeries of the head and neck. 4.    All prone position surgeries.

86. ETT 5.  All full stomach patients:    - Pregnant        - Emergency     - Intestinal Obstruction       - Diabetic 6. Unconscious patients (for airway protection) 7. Evidence of burns to the airway. 8. To provide positive pressure ventilation and PEEP. 9. To free the anesthetist’s hands.

87. ETT     Signs of Correct Placement 1.       Misting of the tube 2.       Normal continuous wave form on the capnogram. 3.       Chest movements. 4.       Bilateral breath sounds on auscultation.   Signs of incorrect placement of the ETT: 1.       Tachycardia 2.       Hypertension 3.       Abdominal Distension 4.       Desaturation

88. ETT Complications: 1.    Sore throat (more in patients with irritable airways eg. smokers, asthmatics) 2.    Failed intubation (adequate oxygenation may be maintained by face-mask). 3.    Oesophageal intubation (must be recognized rapidly, otherwise à fatal) 4.    Endobronchial intubation, recognized by: Unequal chest movements Lack of breath sounds on the left side of chest Low blood oxygen saturations. This is easily remedied by withdrawing the ETT a short distance.

89. Stylet This is an instrument used to facilitate proper placement of the ETT It is placed near the tip, but not past it, otherwise à perforation of trachea on insertion. It ensures that the tip is rigid so that the tube can be easily placed without wavering along its course. Complications: Perforation of the trachea à hemorrhage Perforation of the esophagus

90. Laryngeal Mask Airway (LMA) It is a mask that fits over the larynx It is made of non-latex material It allows provision of positive pressure ventilation without visualization of the vocal cords It does not protect the airway against regurgitation and pulmonary aspiration It requires anesthesia for placement (topical, regional or general)

91. LMA Indications: Surgeries lasting < 30 minutes in which an established airway is needed Difficult intubation To guide ET tube placement It comes in 4 sizes (1-2 for Peds, 3-4 for Adults) It is inserted into the hypopharynx in its anatomical position and then passed onward behind the larynx, sealing the glottic opening, and enabling ventilation after inflation of the cuff. A slight bulging of the tissues over the larynx indicates the mask is properly positioned.

92. LMA Complications: Laryngospasm in a lightly anesthetized airway Mal-placement Injury to surrounding structures Infection Aspiration Contraindications: Full stomach patients Procedures lasting >30 mins Allergy to the material

93. McGill’s Forceps Comes in Adult and Pediatric sizes. It is used to aid the correct placement of the nasotracheal tube. The correct way to hold it is with the edges raised. It grasps the tip of the tube, avoiding the cuff. When one is doing a “blind” intubation and the ETT is not going through, direct laryngoscopy should be done to aid guiding the ETT into place with the forceps.

94. Nasogastric Tube (Ryle’s Tube) Closed active or passive drain It has a radio-opaque line and 4 horizontal lines Its uses are diagnostic and therapeutic Diagnostic uses include: diagnosing the presence and amount of blood in the stomach. Therapeutic uses include: decompression of the stomach removal of activated charcoal given to children in acute poisoning nutritional (administration of enteral feeds) administration of drugs

95. NG Tube Contraindications: Basal skull fracture as evidenced by CSF otorrhea or rhinorrhea, Battle’s sign (mastoid ecchymosis), or Raccoon eyes (periorbital ecchymosis). CSF is confirmed by the ring sign is by placing a drop of the bloody drainage on a piece of filter paper, and looking for the Ring Sign. This is the appearance of a yellow ring around the periphery of the drop of blood. Facial fractures. The alternative to the nasogastric tube is the orogastric tube which is placed orally using the McGill’s forceps. Complication includes malplacement into the trachea which may result in pulmonary aspiration and abscess.

96. Chest Tube/ Tube thoracostomy Closed active or passive drain It is used for the drainage of blood, fluid, chyle or air from the thoracic cavity, as well as for the restoration of negative pressure in the thoracic cavity. Attaches to underwater seal which provides negative pressure and collects the drainage fluid Advantages: permits the evacuation of blood, air, chyle, thus expanding the lung Disadvantages: can infect the thoracic cavity (empyema) The chest tube is placed in the 5 th ICS Anterior Axillary Line within the triangle of safety. The triangle of safety refers to the area within the mid-axillary line, anterior axillary line, and 5 th ICS.

97. Chest Tube/ Tube thoracostomy An alternative site includes: the 2 nd ICS MCL (for pneumothorax). To calculate the % pneumothorax, measure the distance b/w the outline of the lung and the chest wall. 1 cm = 10% up to 2.5 cm, then the % increases. It takes 300-500 ml of blood to blunt a costophrenic angle. If a central line is required, always place it on the same side as the injury. The chest tube is removed when it drains < 1ml/kg/24hrs or when it stops draining. Thoracotomy is indicated for initial chest drainage of >1500 ml or 3 consecutive hours of >200 ml per hour blood loss.

98. Placement of Tube Thoracostomy: Procedure The patient is placed in a 30-60 degree reverse Trendelenburg position The site is scrubbed with betadine/alcohol The site is anesthetized with lidocaine. A 3-4 cm incision is made over the 5 th -6 th rib b/w the mid-axillary and anterior axillary line. Use a curved hemostat to puncture thru the intercostals muscles and parietal pleura superior to the rib border. Perform finger exploration to confirm intrapleural placement (feeling for diaphragm and intrabdominal structures) Insert chest tube along side the finger Place the tube posteriorly and superiorly.

99. Intravenous Catheter

100. Central Venous Catheter A central venous catheter is used to gain access to a central vein for: Monitoring of the central venous pressure Administration of drugs such as chemotherapy, cardioactive drugs, and TPN. Indications: (Dignostic & Therapeutic) Measurement of central venous pressure (diagnostic)      Administration of chemotherapy     Administration of TPN  (this requires a dedicated line )     Hemodialysis   Fluid administration when peripheral line are difficult (9 Fr) Long-term IV catheterization (i.e. >10 days)* * Central lines at all sites should be changed every 3 days .

101. Central Venous Catheter Placement: Seldinger Technique (catheter over a guidewire) : 1.      First localize the vessel is using a small gauge needle. Introduce a thin walled percutaneous entry needle into the vessel. 2.      Pass a guide wire through the needle; advance a portion of the wire guide length into the vessel 3.      Leaving the wire guide in place, advance the needle. 4.      Enlarge the puncture site with a number 11 scalpel blade 5.      With a twisting motion, advance the catheter over the wire guide and into the vessel. 6. After the catheter is in position, remove the guide wire. The catheter is introduced into the Internal jugular, subclavian vein, or femoral vein using an aseptic technique.

102. Central Venous Catheter General Complications of Insertion: Hematoma at the puncture site Air embolism Catheter tip embolism or loss of the guide wire Hemothorax (except for femoral lines) Diaphragmatic paralysis (from phrenic nerve injury) – except for femoral lines Arrhythmias (atrial or ventricular) –except for femoral lines Complications Specific for Subclavian Puncture: Brachial plexus injury Internal mammary artery laceration Pneumothorax Subclavian artery puncture Pulmonary emboli

103. Central Venous Catheter Complications Specific to Internal Jugular: Carotid artery puncture  hematoma, tracheal compression and respiratory embarrassement; or dislodging of an atheromatous plaque  CVA Damage to the trachea or esophagus Complications of the Catheter Itself: Infection Thromboembolism Obstruction Displacement Complications of things put thru it: Hydrothorax Hydromediastinum Hydropericardium Obstruction

104. Central Venous Catheter Open Surgical Exposure Technique ·   Requires an operating theater & general anesthesia. ·   Recommended for: o        Patients with respiratory disease o        Patients on a ventilator o        Patients with severe clotting disorders   Other forms of central venous catheters include: v      Shiley Catheter for dialysis v      Port-a-Cath for chemoRx v      Perma-Cath for dialysis v      Hickman Cath for dialysis

105. Swan Ganz Catheter It is a pulmonary arterial catheter It is used for measurement of: Central venous pressure, Pulmonary artery pressure, Pulmonary capillary wedge pressure, cardiac output, pulmonary vascular resistance, and systemic vascular resistance. Its correct passage and placement by monitoring the changing pressures as the tip moves from one region to another, and by wedging of the catheter in the hilum (on CXR).

106. Swan-Ganz Catheter Indications: Patients with severe cardiopulmonary derangement (eg HF, MI) Hypovolemic shock not responding readily to volume replacement Sepsis with oliguria or hypotenstion Lung disorders at risk for associated myocardial dysfn. Failure of 2 or more organs Procedures in which large volumes are required or large fluid shifts eg abdominal aortic surgery

107. Swan-Ganz Catheter Complications: Same as for central venous catheter Complications unique to Swan-Ganz: Ventricular arrhythmias Ventricular rupture Valvular damage on the right side of the heart Intra-cardiac knotting of catheter Pulmonary infarction induced by permanent wedging of the catheter in the distal pulmonary vascularture Perforation of the pulmonary artery (rare)

108. Urinary Catheter Double lumen urinary catheter Is a closed, passive drain It has 2 lumens, one for drainage and the other for inflation of the bulb which anchor the catheter in the bladder, hence making it self-retaining. Uses: 1. To decompress the urinary bladder, e.g. Acute urinary retention. (a Coude cath is used if this fails) 2. To monitor urinary output intra-op, or in patients in shock. 3. To divert the urine stream in patients who have had an incision & drainage of an abscess of the perineum.

109. Urinary Catheter Contraindications: v      Trauma to the urethra as evidenced by blood in the meatus. v      Pelvic fracture v      A high riding prostate, or boggy mass below the prostate upon digital rectal examination. Urethral tears can be investigated by placing the foley catheter partly in the urethra and instilling 50cc of Urograffin dye as a pelvic x-ray is shot. A retrograde cystourethrogram is created. If there is rupture, then dye will be seen leaking into the surrounding tissues.

110. Laryngoscope & Blade Prevention of the HTN Response to Laryngoscopy: Give deep anesthesia Give 50-100 mcg of fentanyl 2 minutes prior to laryngoscopy Give 50-100 mg of lidocaine 2 minutes prior to laryngoscopy Give a small dose of a short acting beta blocker eg. Esmolol 5-10 mg, immediately before intubation (Avoid in irritable airways)

111. Tracheostomy tube Plastic Cuffed Tracheostomy Tube ·         Cannula - can be outer and inner ·         Obturator is used to clear anything that obstructs the tube. 1.       Eg. crusted blood 2.       Mucous plug 3.       Secretions ·         Inflatable cuff - enough air put into prevent a leak. ·         Flange - for suturing to skin. ·         Strap/Tape - to secure around neck

112. Tracheostomy Indications: 1.       Prolonged intubation > 2/52 2.       Respiratory Toilet (easier suctioning with tracheostomy than ETT) 3.       Trauma to facial bones 4.       During failed oro/naso-tracheal intubation. 5.       Prophylactically in ENT surgery or head surgery. 6.       Upper airway obstruction (esp mechanical obstruction, because oedema can be treated with epinephrine before doing a tracheostomy.)  

113. Tracheostomy Complications: 1.   Hemorrhage 2.   False passage 3.   Pneumothorax Late Complications: Fistula formation

114. Care of Tracheostomy Tube: ·     Dressing - change every 2 hrs or more frequently if it becomes saturated. (NB moist dressings act as a breeding ground for bacteria) ·      Note the type of drainage from drainage from tracheostomy ·     Incision site must be inspected and cleaned with hydrogen peroxide and sterile water with each dressing change. ·      Nitrofurazone ointment is applied if there is any sign of local infection. ·      If the tracheostomy tube has an inner & outer cannula, the inner cannula should be removed every 2-4 hrs for the first 24 hrs, cleaned with a tracheostomy brush, hydrogen peroxide, and sterile water.

115. Care of Tracheostomy NB Always keep a spare tracheostomy tube handy in case the need for it arises. ·     Frequent suctioning (Based on volume & character of patient’s secretions). Suctioning orders should be written as prn orders. Some patients need constant suctioning initially; eg. Fulminant pulmonary edema. However, unnecessary suctioning may lead to undue irritation of the tracheobronchial mucosa and actually cause extensive production of mucus. ·     Tracheostomy tubes should be changed on a regular basis (eg. q7 days). This allows for total inspection of the tracheal stoma and the tube itself.

116. Intraosseous Infusion Needle In children, an intraosseous infusion needle may be sued to instill fluid into the bone marrow cavity. The site selected is 2-3 cm below the tibial tuberosity. The tibia is used because its plate has not closed as yet. The intraosseous infusion needle is driven into the bone marrow cavity in a screwing motion. Bone marrow is aspirated back, and 10cc of saline is instilled. If this flows easily, then the IV fluid is connected.  

117. Intraosseous Infusion Needle Complications of intraosseous infusions: Osteomyelitis Cellulitis Damage to the epiphyseal plate if placed in the wrong location. Injury to muscle Injury to nerves.

118. Oropharyngeal (Guedel) Airway It is a device that is placed into the oral cavity to prevent the tongue from falling back and obstructing the airway It is used in persons who don’t have a gag reflex It is inserted with the tip pointed up, and then rotated 180 degrees pushing the tongue to the side It has a port for allowing suctioning Complications: Can precipitate vomiting in persons with a gag reflex May cause cervical movement  spinal damage in a person with c-spine trauma Can cause elevation of ICP. Injury to oral mucosa or teeth

119. Nasopharyngeal Airway Also called the “trumpet” It is a flexible, soft rubber airway which is placed in the more patent nostril. It can be used without anesthesia It is better tolerated than the oropharyngeal airway Complications: epistaxis

120. Orthopedics & Burns

121. Orthopedics & Burns External Fixation Devices Plaster of Paris, Internal Fixation Devices Intramedullary nail, Richard’s Dynamic Compression Hip Screw, Plates and Screw Traction Devices Skin Traction, Skeletal Traction (Steinmann Pin, Bohler Loop, Pulley & Weight) Replacement Devices Austin Moore Hemi Arthroplasty Bones Femur, Tib/Fib, Hemi-Pelvis

122. Plaster of Paris/Gypsona This is anyhdrous calcium sulphate It is rehydrated in water and applied over under-cast padding to form a hard cast. It’s disadvantages include: Heavy weight (compared to fiberglass) Itching that is not easily accessible Requirement that the cast remains dry

123. Intramedullary Nail ·        This device is used as a means of internal fixation ·         It is suitable for fractures of the long bones especially when the fracture is near the middle of the shaft ·        Bones repaired include: o         Femur o        Tibia o        Humerus o        Ulna?? ·         It has transverse perforations at regular intervals only at the ends to allow the insertion of transfixation (locking) screws through bone and thus afford rigidity and resistance to rotation forces.

124. Intramedullary Nail The rod is inserted into the tibia by splitting the patella tendon fibers and drilling a hole thru the tibial plate, and reaming the rod thru the tibial marrow cavity. ·        The site of insertion for fixation of femoral shaft fractures is the piriform fossa. ·        Advantages: o       ORIF can be done under direct visualization o       The patient can be mobilized sooner. ·        Contraindications: o       Osteomyelitis

125. Acute Specific Complications: ·     Hemorrhage ·     Infection (4-5 th day) ·     Neurovascular injury ·    DVT -80% proximal ·    Failure of fixation 1.   Nail too long or too short 2.   Nail jammed in femur 3.    Failure to get locking screw thru hole in nail ·     # of neck or shaft of femur when placing nail ·      Guide wire driven into knee

126. Longterm Specific Complications Failure of fixation (loosening and migration) Malunion or Nonunion Osteonecrosis Osteomyelitis Heterotopic ossification Post-traumatic arthritis Reflex sympathetic dystrophy

127. Richard Dynamic Compression Hip Screw It is indicated for treatment of intra-trochanteric/pertrochanteric fractures The Richard Classic is specifically indicated for subtrochanteric fractures. It is made up of two parts which can slide in relation to each other but do not allow binding. The 1 st part is a heavy-duty plate which is fixed to the lateral cortex of the femur with cortical screws. The 2 nd part is a rod, which passes up through a slot in the plate into the femoral neck. Its threaded end crosses the fracture line to engage and hold the femoral head.

128. Richard Dynamic Compression Hip Screw As the patient weight-bears on the healing fracture the broken ends of the bone collapse into each other and compress the fracture. The sliding-rod mechanism of the dynamic hip screw allows this to happen without allowing the hip to fall into varus. This prevents the plate breaking at the fracture, or the rod penetrating through into the femoral head and aceabulum

129. Plates & Screws

130. Skin Traction Skin traction can only be done up to 7 lbs or 1/7 – 1/10 body weight.

131. Skeletal Traction Skeletal traction is 1/5 to 1/7 of total body weight. The knee (high tibial) takes up to 30 lbs. The adequacy of skeletal traction is assessed in 48 hours by comparing the lengths of the femurs (from ASIS to tibial tuberosity). Sites for Skeletal Traction: Greater trochanter (for central dislocation of hip) Lower femoral (for femoral #, however may get in the way of an intramedullary pin) High Tibial [most common] – (for femur fractures) Lower Tibial (for tibial fractures) Calcaneum (for some calcaneus fractures)

132. Austin Moor Hemi-Arthroplasty Artificial hip replacement Indications: Elderly persons who fall and fracture their hip (Garden Class 3 & 4 fractures of the neck of the femur) Osteoarthritis Avascular necrosis of the head of the femur eg. sickle cell disease

133. Femur

134. Tibia/Fibula

135. Hemi-Pelvis

136. Orthopedics & Burns 2 Watson Modified Humby Knife (manual dermatome) vs Braune Electric Dermatome Skin Grafts 1% Silver Sulphadiazine Silver Nitrate 0.5% Malfinide Acetate Crystalloid & Colloid Solutions for Resuscitation

137. Watson Modified Humby Knife The humby knife is manually powered and has adjustable rollers that control the thickness of the graft. It can be used to harvest long narrow grafts of split thickness skin from the thigh, arm or abdomen. Once the graft has been harvested the tissue is laid atop the wound and is secured using methods that include skin suture, staples or tape. All areas of the wound should be covered by the grafted skin with adequate fenestrations to allow for fluid escape from beneath the grafted skin.

138. Skin Grafts What must you ensure before taking a skin graft? The donor site must be free of infection. There must be good vascularity. There must be no necrotic tissue present Indications for a skin graft: Burns involving the epidermal appendages (which are necessary for proper wound healing). Large partial thickness burns. Replacement of skin surgically removed because of melanoma, or other purpose. Skin Ulcers.

139. Types Split Thickness Graft Full Thickness Graft ADVANTAGES Heals by 2 nd intention Repeat harvest possible Can be harvested in less than ideal conditions More harvest sites available Does not contract Has better color match DISADVANTAGES Contracts Poor color match Heals by 1 st intention Repeat harvests not possible Requires absolute sterile conditions Limited by number of donor sites Skin Grafts

140. Types SPLIT THICKNESS GRAFT FULL THICKNESS GRAFT HARVEST SITES Buttocks Lateral, posterior and anterior thigh Back (esp. child) Abdomen Scalp Groin Supraclavicular neck Behind the ear Skin Grafts

141. 1% Silver Sulphadiazine Is a topical anti-microbial agent used in the treatment of burns. INDICATIONS: Silver sulphadiazine is a topical antibacterial agent for the prevention of infection in severe burns being particularly effective against Gram-negative organisms such as Pseudomonas aeruginosa and pyocyanea, the most common cause of burn wound infection. Advantages: (i)    inexpensive (ii)    painless to apply (iii)   does not stain tissues (iv)   has broad spectrum activity

142. 1% Silver Sulphadiazine (v) The slow liberation of silver does not cause the rapid and extensive depletion of chloride ion experienced when silver nitrate solutions are used, and thus electrolyte disturbances are minimised. Disadvantages: (i)    C annot be used in persons allergic to sulfur (ii)   D oes not penetrate escar (iii)  D oes not penetrate cartilage (iv) A 3-5 mm thick layer is needed (v) Separation of the eschar may be delayed. (vi) Local skin sensitivity may occur especially when exposed to sunlight.

143. Silver Nitrate It is a topical anti-microbial agent used in the treatment of burns. Disadvantages: (i)    It stains the tissues black and slows healing (ii)   It is painful to apply (iii) It bleaches chloride from the skin, thus can cause hypochlorosis (iv)   Is in liquid for that requires supervision for q2h soaks (time consuming)

144. Malfinide Acetate 0.5% It is a topical antimicrobial agent used in the treatment of burns. Advantages: (i)    penetrates escar well (ii)   penetrates cartilage well (thus can be used on ears and nose) Disadvantages: (i)    It inhibits bicarbonate production  acidosis (ii)   It is not easily available

145. Fluid Resuscitation (Day 1) Parkland Formula: Wt (kg) x %TBSA Burns x 4 = Total fluid for 24 hrs. (Use Lactated Ringers because it is physiologically the closest to plasma). 1 st ½ is given within 8 hrs from the time of the burn. 2 nd half is given over the remaining 16 hrs. Replace any ongoing losses eg. Urine, oozing from the wound, etc. Urine output must be maintained at > 0.5 – 1 ml/kg/hr

146. Fluid Resuscitation (Day 2) Add a colloid solution at 0.3 - 0.5ml / kg / TBSA Burns Colloids are not used on Day 1 because of the acute inflammation that is ongoing which results in widening of the vascular pores  increased leakiness  loss of proteins. By day 2 the pores are not as leaky.

147. Fluids Crystalloids are fluid substances which are able to cross a semi-permeable membrane. It is usually composed of at least one solute and water. They are used for fluid and electrolyte resuscitation in trauma or shocked patient, burns, dehydration secondary to diarrhea/vomiting/ or reduced intake, for maintenance fluids in patients who being kept NPO, as a medium to give drugs which must be diluted. In hemorrhagic shock, for each mL of blood loss, 3-5 mL of crystalloid is given for replacement. If the patient is elderly or has cardiac disease, then replacement is 3ml per 1mL of blood loss. 30-40% of the crystalloid infusion stays in the intravascular space.

148. Fluids Examples of crystalloids include: 0.9% NaCl 1 Liter bag. 5% Dextrose in Water Ringers Lactate D5E48 Complications of administration of crystalloids include: Volume overload Shock from administration of cold fluid DIC secondary to dilution of clotting factors Electrolyte disturbances

149. Colloids: Colloids are fluid substances which are used for fluid replacement therapy. They are used especially in patients who are hypotensive or are hypovolemic. They do not cross semi-permeable membranes easily because their molecules are large. Colloid are given after 2-3 L of crystallid is given, in order to avoid the complications of giving too much fluid. Example of colloids include: Hexastarch (6% Hexose) Dextran Albumin Blood

150. Colloids Complications include: Allergic reactions with Dextran Hexastarch interferes with cross-matching of blood Introduction of infection Thrombophlebitis   The first choice of blood used in trauma is O-negative. The next choice of blood used in trauma is type-specific. But the best choice of blood to be used is cross-matched blood.  

151. Colloids Complications of blood transfusion: Hemolytic transfusion reaction Infections such as Hep B & C, HIV, CMV Iron Overload (250 g of iron per unit)

152. Urology Table

153. Urology Instruments Urethral Dilator/Sound Jake’s Single Lumen Urinary Catheter Double Lumen Foley’s Catheter Triple Lumen Foley’s Catheter Cystoscope Pigtail Ureteral Cathether Double J Stent Ureteral Catheter Non Self-Retatining Ureteral Catheter

154. The Urethra Consists of: Bulbous Urethra Penile Urethra Membranous Urethra Prostatic Urethra The diameter is 22-24 F Commonest reason for

155. Urethral Dilator/Sound The short straight one is for females The long curved end one is for males (it is curved so that it can get over an enlarged prostatic middle lobe) It is used in patients with urethral strictures such as those with prior instrumentation or gonococcal urethritis. The stricture is “dilated up” gradually (over several weeks) There are two numbers (one represents the tip and the other the shaft diameter)

156. Urethral Dilator/Sound Complications: Creation of a false passage (rupture of urethra) Hemorrhage Common Sites of Stricture formation: Bulbous urethra Peno-scrotal junction Membranous urethra Stricture rarely occur in females, and when the do occur, they occur in elderly females at the external uretheral meatus.

157. Jake’s Urinary Catheter Closed, passive drain; It is non-self retaining Used to decompress the urinary bladder during laparoscopic surgery prior to insertion of the umbilical port (hence reducing the likelihood of complications); or to obtain a clean catch specimen (eg. in a patient who is menstruating); or to empty the urinary bladder prior to delivery of the fetus It is less expensive than a Foley’s catheter It is made of red rubber which can cause severe tissue reaction if left in place for long periods of time. (complication)

158. Double Lumen Foley Catheter Is a closed, passive drain; It is self retaining It has 2 lumens, one for drainage and the other for inflation of the bulb which anchor the catheter in the bladder, hence making it self-retaining. Uses: 1. To decompress the urinary bladder, e.g. Acute urinary retention. 2. To monitor urinary output intra-op, or in patients in shock. 3. To divert the urine stream in patients who have had an incision & drainage of an abscess of the perineum.

159. Double Lumen Foley Catheter Contraindications: v      Trauma to the urethra as evidenced by blood in the meatus. v      Pelvic fracture v      A high riding prostate, or boggy mass below the prostate upon digital rectal examination. Urethral tears can be investigated by placing the folley catheter partly in the urethra and instilling 50cc of Urograffin dye as a pelvic x-ray is shot. A retrograde cystourethrogram is created. If there is rupture, then dye will be seen leaking into the surrounding tissues.

160. Triple Lumen Foley Catheter This is a 24 french triple lumen foley catheter (24 F is the external diameter). It is closed passive drain; It is self retaining Has a lumen for inflation of the balloon, one for drainage of the bladder, and the 3 rd for introduction of medication, and introduction of sterile crystalloids (used for irrigation of the bladder. Used in: Patients requiring long-term catheterization Patients undergoing TURP or an other procedure in which significant hemorrhage is expected (a 30cc balloon is required for TURP surgery) Patients with massive hematuria

161. Triple Lumen Urinary Catheter Complications of Placement: Inadequate lubrication of catheter friction trauma  hemorrhage, and eventually stricture formation after healing. Use of an introducer during placement can  false passage If the balloon is inflated while in the urethra, this can  rupture of the urethra and hemorrhage. Complications of the Catheter insitu: Infection Dislodgement Obstruction Stone Formation

162. Triple Lumen Foley Catheter Complications of things put thru the Catheter: TURP Syndrome – Instillation of hypotonic fluids for too long a duration  hyponatremia  seizures A triple Lumen Urinary catheter can be kept insitu for a maximum of 3 months before requiring replacement.

163. Cystoscope A thin, lighted (usually fiber optic) instrument used to look inside the bladder and remove tissue samples ( biopsy ) or small tumors . The indications for cystoscopy include: The evaluation of blood in the urine (hematuria), Evaluation for strictures Removal of stents, Various other reasons, including evaluation of prostate anatomy before consideration of prostate surgery.

164. Cystoscopy: Procedure The flexible cystoscope is connected to water irrigant, and a light source.  Inside the urethra and bladder are viewed thru a lens. The urethra is first entered and inspected, and then the bladder is entered.  The doctor will survey all areas of the bladder and inspect the urine coming out of the ureteral openings.

165. Cystoscopy: Complications Hematuria for a few days or even up to a week or so, and may have a slight bloody urethral discharge.  This is all normal and should improve.  Urethral spasms, or a frequent/urgent need to void.  All this is normal and should also go away soon.  Serious infections or other complications are exceedingly rare after office cystoscopy.

166. Pigtail Ureteral Catheter Closed passive drain Used in percutaneous nephrostomy for drainage if the kidney Complications: Stone formation with prolonged placement Infection Obstruction Displacement

167. Double J Stent Catheter Is a closed passive drain It is self retaining Has a kidney end (that passes into the renal pelvis) and a bladder end It is used to bypass obstruction or after ureteric surgery to stent the ureter. To decompress the kidney to relieve obstruction of the ureter (usually by calculus)

168. Non Self-Retaining Ureteral Catheter Is a non-self-retaining ureteral catheter / stent Is used for: exploring the ureter anterograde pyelography checking for reflux of urine Is placed via a cystoscope

169. Urograffin Radiocontrast Dye Urograffin Radio-Contrast Dye Intravenous, Water soluble contrast dye Used to show the anatomy and function of the kidneys (IVP shows anatomy and function, Retrograde Cysto-urethrogram demonstrates anatomy only) Patients normally experience a metallic taste in the mouth Complications: Allergic reaction if allergic to shell fish

170. Urograffin Radiocontrast Dye Patients having an allergic reaction may appear diaphoretic, short of breath, have wheezing, urticaria. Treatment of the allergic reaction: Stop infusing the contrast Give fluids Administer antihistamines (eg Piriton) Give glucocorticoids (eg. hydrocortisone) If necessary, give subcutaneous epinephrine. Contrast induced nephropathy  renal failure (hence BUN, Creatinine and Electrolytes should be done prior to administration of dye)

171. Urograffin Dye In patients known to have a minor reaction to the dye (eg. Urticaria), antihistamines may be given prior. Alternatively, the patient can be given Ultra-vist which contains low molecular weight iodine which is less allergenic.

172. Self-Retaining Suprapubic Catheter Suprapubic Cystostomy (procedure) Direct puncture of the bladder through the abdominal wall with introduction of a catheter over the needle and guide wire is the method used. Anticholinergics are given to reduce bladder spasticity. Indications: Failure of clean intermittent catheterization Irrigation of the bladder if no 3-way catheters are available Advantages: significantly lower incidences of urinary tract infections than chronic indwelling urethral catheters and even intermittent catheterization.

173. Suprapubic Catheterization Complications: brief haematuria bowel perforation (rarely) increase the incidence bladder stones and possibly kidney stones. Contraindications: bleeding diathesis

174. MISCELLANEOUS

175. Enfamil & SMA Formula

176. Total Parenteral Nutrition Nephro, Criticare HN, & Glucerna Nutritional Supplements TPN is a complete form of nutrition, containing protien, sugar, fat, and added vitamins and minerals as needed for each individual. It is admininstered through an intavenous infusion, usually using a central line. A central line is a special long lasting IV line that goes through a vein directly to the heart.

177. Surgical Stapeler Stainless steel staples used for approximation of skin (eg. Abdominal wall or neck eg post thyroidectomy), and bowel anastomosis. Has the advantages of rapid and technically easier tissue approximation, better cosmetic results, minimal allergic and tissue reactions Disadvantage – higher cost.

178. Nylon Suture Synthetic Non-absorbable Monofilament Used for skin closure , plastic surgery, neurosurgery, ophthalmology, retention, microsurgery (eg. vascular grafts), abdominal fascia and linea alba. Has poor memory, therefore several knots must be made for the suture to hold.