Transcript Document
7
th
Instruments January 2013
Jack Tanaka, Sameer Bahal
Contents
• • • • • Airway Instruments Surgical Instruments Fluids Lines Drains
Airway Instruments
Airway Instruments
Oropharyngeal / Guedel Airway • • • • This is essentially a rigid, curved plastic tube. It is an airway adjunct It 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 mandible to the patient’s mouth. It is inserted upside down into the mouth and rotated downwards when it is past the tongue within the oral cavity.
Airway Instruments
Airway Instruments
Endotracheal Tube • Used to provide a definitive airway for patients. This means a cuff is inflated to prevent aspiration. Used for long operations, (laparotomy) and in cases of inhalation injury, (burns) • Indications: – – – Depressed consciousness Hypoxemia Airway Obstruction
Airway Instruments
Endotracheal Tube • Then check the tube is in the trachea by: – Auscultating: ensure bilateral breath
sounds
– Auscultate over the stomach (epigastric region) to ensure no gurgling (that would indicate oesophageal intubation) – Measure end tidal CO2 tension: since CO2 is produced in the lung, you can confirm that the tube is in the trachea by measuring the end tidal CO2 tension. If the tube is in the oesophagus, then the CO2 gas pattern would be absent.
– Do CXR and look for metallic mark
Airway Instruments
Endotracheal Tube • Complications: – Broken Teeth, lacerations of the tissues of the upper airway, – Intubation of the Oesophagus
Airway Instruments
Tracheostomy Tube • • • • • Definitive airway Tracheostomy = surgical opening into the trachea. Can be temporary or permanent. It involves placing the tracheostomy in between the 2 and 4 th tracheal rings. Usually done in theatre under GA.
Airway Instruments
Tracheostomy Tube • • Indications – Patients who require long term intubation (>2 weeks) – better tolerated than ETT – Severe maxillofacial injury (unable to intubate) – Post-laryngeal surgery (e.g. laryngectomy for malignancy) – Lung disease (e.g. COPD) to reduce dead space and allow effective ventilation – – Obstructive sleep apnoea Upper airway obstruction Complications – Tracheostomy stenosis, – – Infection Blocked tube, – Tracheoesophageal fistula – Surgical emphysema.
Airway Instruments
Airway Instruments
Laryngoscope • A laryngoscope has a handle and a curved blade, usually fitted with a light, it moves the tongue and epiglottis aside in order to inspect the larynx.
Airway Instruments
• It is used to aid insertion of an endotracheal tube or for examination.
Airway Instruments
Laryngeal mask Airway • Sits on top of the larynx and therefore does not intubate the trachea.
Airway Instruments
• It is used to assist a patient with impaired breathing. It can also be used as an airway during short operations e.g. day cases. • It is inserted and then the inflatable cuff over the larynx can be pumped, by pushing air from a syringe, into the blue lumen.
Surgical Instruments
Proctoscope (Gabriel)
Surgical Instruments
• • • • 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.
Surgical Instruments
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
Surgical Instruments
Surgical Instruments
Rigid Sigmoidoscope • • • • • • 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 eg in a case of ulcerative colitis
Surgical Instruments
Surgical Instruments
Trucut Biopsy Needle
Surgical Instruments
• • Used to take histological specimens from lesions – eg breast lumps or liver. The procedure can be performed under local anaesthetic
Surgical Instruments
Sutures • • Sutures Used to hold a wound together in good apposition until such a time as the natural healing process is sufficiently well established to make the support from the suture material unnecessary and redundant
Surgical Instruments
• • • • Alternatives: Staples Steristrips – self adhesive tape, useful for superficial lacerations, useful if there is potential tension on a wound Tissue adhesive – based on cyanoacrylate manometer, wounds need to be clean and tension free
Suture material • Absorbable Synthetic • • Polyglycolic Acid (Dexon) Polyglactin (Vicryl) • • Polydioxone (PDS) Polyglyconate (Maxon)
Surgical Instruments
• Non-Absorbable – Natural • • • Silk Linen Stainless Steel Wire – Synthetic – – – Polyamide (Nylon) Polyester (Dacron) Polypropylene (Prolene)
Surgical Instruments
Needle Holder • These are special forceps • Designed to hold the needle to allow the surgeon to suture accurately
Surgical Instruments
Surgical Instruments
Laparoscopic Port • Used during laparoscopic procedures eg Lap Chole • Ports allow the surgeon to insert telescopes/Cameras/instruments
Surgical Instruments
Surgical Instruments
Dever’s retractor • • Used in open abdominal surgery Allows the surgeon to operate with more space
Surgical Instruments
Surgical Instruments
Self Retaining retractor
Surgical Instruments
• Used to hold wounds open • Eg Hernia repair/appendectomy
Fluids
Hartmanns Solution • Used in Surgery, especially nil by mouth patients
Fluids
Fluids
Dextrose • Dextrose is a solution made of sugar and water
Fluids
Fluids
Saline Crystalloids are an electrolyte solution in water. It can pass through a semi permeable membrane (cell wall).
NaCl saline 0.9% solution is an isotonic fluid as it has similar Na + levels to the extracellular fluid in the body. Saline distributes throughout the ECF (not the ICF like dextrose does). The ECF consists of plasma, interstitial fluid and transcellular fluid (note colloids stay in the plasma). Saline is a good maintenance fluid.
Fluids
Dextrose Saline
1000ml 40g Dextrose Na 30mM K 20mM
Dextrose Saline
1000ml 40g Dextrose Na 30mM K 20mM
Dextrose Saline
1000ml 40g Dextrose Na 30mM K 20mM OR
Normal Saline 5% Dextrose
1000ml 1000ml 50g Dextrose Na 150mM K 20mM K 20mM
5% Dextrose
1000ml 50g Dextrose K 20mM
Fluids
Fluids
Gelofusine This is a colloid. Used in cases of volume loss: eg trauma, molecules cannot pass through semi permeable membrane. Remains in the intravascular space. Useful in increasing Blood Pressure.
Use is controversial.
Natural colloids: albumin Synthetic colloids: Gelofusine and Haemaccel (gelatine based infusions)
Fluids
Lines
Cannulas This is a an IV cannula. It is used to give IV fluids and IV drugs.
If you wish to give the fluid quickly, the cannula must be short and large bore (Poiseuille’s law – flow is proportional to the fourth power of the internal radius of the tube and inversely proportional to the length).
Emergencies (265ml/min)
Generally insert a 18G (green) or higher when giving drugs. Emergency should be brown (14G) which has a flow rate of about 265ml/min. Use antecubital fossae in emergencies. If you cannot get it, use femorals.
Lines
Cannulas
Blue 22G Pink 20G Green 18G White 17G Grey 16G Brown 14G
Lines
Lines
Lines
Triple lumen Central Venous Pressure Catheter • • • Inserted into either the right subclavian vein or internal jugular vein. Used for Central Venous Pressure monitoring and to administer drugs (chemotherapy drugs), taking blood, not good for fluids.
Single or triple lumen
Lines
Triple lumen Central Venous Pressure Catheter • • • • • • • Inserted using Seldinger technique.: Lie patient flat. Infiltrate skin with LA 5ml of lignocaine Assemble the catheter and flush all the lumina Introduce needle and syringe 1cm below the junction of the middle and medial thirds of the clavicle. Aim the needle to the sternal notch and advance. Aspirate as you advance the needle. Once blood enters the syringe, remove the syringe keeping the needle still in its position. Insert the guide wire, remove the needle, feed the dilator over the guide wire, remove dilator, insert central line, remove guide wire Stitch in place, Order CXR to check position and exclude pneumotharax
Lines
Triple lumen Central Venous Pressure Catheter • • • Complications of a central line insertion: Immediate: pneumothorax, haemothorax, damage to adjacent vessels e.g. carotid arteries, primary haemorrhage • • Early: infection (skin commensals), secondary haemorrhage, haematoma formation • • Late: thrombosis, catheter blockage.
Lines
Nasogastric Tube • This is a feeding NG tube. It is used for enteral nutrition in patients. • It has a fine bore and is soft (comfortable for patients), unlike the Ryle’s NG tube which is wide bore. Note the end has a cap (not present in Ryle’s NG tube). It is made from silastic, which tends to block less often.
• Another indication is oesophageal obstruction. • DO NOT use is patients with basal skull fractures, facial trauma or if patient refuses it.
Lines
Lines
Single Lumen Central Venous Catheter
Lines
Lines
Hickmann Line • This is a Hickman line. It is a modified central line that is tunnelled under the skin to make it more secure. It is used as a long term central vascular access device. It is usually inserted into the right subclavian vein. • The Hickmann line is a central line as it is inserted into a central vein (therefore making it a central venous access device). It is used mainly for long term access to the central line. This can be for providing patient with TPN or for taking blood or administering drugs long term. • The line is tunnelled under the skin, therefore you will see subcutaneous swelling under the skin along the path of the catheter (CVP catheters are not tunnelled and they are used for short term only).
Lines
Lines
Lines
Peripherally Inserted Central Catheter (PICC) These lines are inserted into a peripheral vein, usually the cephalic vein in the antecubital fossa and 'unwound' upwards into the subclavian vein/superior vena cava.
They are firmly secured with tape or sutures.
They tend to be used for relatively short-term venous access, e.g. a prolonged course of antibiotics, but can be used for periods of up to several months.
Lines
Swan-Ganz Catheter Inserted into pulmonary artery, this is a diagnostic catheter used to detect heart failure, sepsis, monitor pressures in right atrium, right ventricle and pulmonary artery
Lines
Lines
Tesio Line For Renal Dialysis
Lines
Drains
• • A surgical drain is a tube used to remove pus, blood or other fluids from a wound. Broadly classified as: – Tube Drains – Corrugated Drains • Types of drainage systems – Closed – Open – Passive – Active
Drains
Chest Drain Bottle • Bottle to which the chest drain is attached.
• There is 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 be used to collect air, 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
Drains
Drains
Yates Tissue Drain • • • Row of tubes For big cavity drains It is an open drainage system
Drains
Drains
Vacuum Drain bottle (Redivac) • Used to drain areas where fluid or blood may collect or where the surgery has left a cavity which is closed by the suction from the vacuum drain. • This is an example of an active closed drainage system.