Instruments 7 th January 2013 Jack Tanaka, Sameer Bahal

Instruments7th January 2013

Jack Tanaka, Sameer Bahal

Contents

• Airway Instruments• Surgical Instruments• Fluids• Lines• Drains

Airway Instruments

Airway Instruments

• 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.

Oropharyngeal / Guedel Airway

Airway Instruments

Airway Instruments

• 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

Endotracheal Tube

Airway Instruments

• 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

Endotracheal Tube

Airway Instruments

• Complications:– Broken Teeth, lacerations of the

tissues of the upper airway, – Intubation of the Oesophagus

Endotracheal Tube

Airway Instruments

Airway Instruments

• Definitive airway • Tracheostomy = surgical

opening into the trachea. • Can be temporary or

permanent. • It involves placing the

tracheostomy in between the 2 and 4th tracheal rings.

• Usually done in theatre under GA.

Tracheostomy Tube

Airway Instruments

• 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.

Tracheostomy Tube

Airway Instruments

Airway Instruments

• 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.

• It is used to aid insertion of an endotracheal tube or for examination.

Laryngoscope

Airway Instruments

Airway Instruments

• Sits on top of the larynx and therefore does not intubate the trachea.

• 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.

Laryngeal mask Airway

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.

Proctoscope (Gabriel)



•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

Shouldered Syringe



• 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

Rigid Sigmoidoscope



• Used to take histological specimens from lesions – eg breast lumps or liver.

• The procedure can be performed under local anaesthetic

Trucut Biopsy Needle



• 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

• 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

Sutures


• Absorbable Synthetic

• Polyglycolic Acid (Dexon)• Polyglactin (Vicryl)• Polydioxone (PDS)• Polyglyconate (Maxon)

Suture material

• Non-Absorbable – Natural

• Silk• Linen• Stainless Steel Wire

– Synthetic – Polyamide (Nylon)– Polyester (Dacron)– Polypropylene (Prolene)



• These are special forceps

• Designed to hold the needle to allow the surgeon to suture accurately

Needle Holder



• Used during laparoscopic procedures eg Lap Chole

• Ports allow the surgeon to insert telescopes/Cameras/instruments

Laparoscopic Port



•Used in open abdominal surgery•Allows the surgeon to operate with more space

Dever’s retractor



• Used to hold wounds open

• Eg Hernia repair/appendectomy

Self Retaining retractor

Fluids

Fluids

• Used in Surgery, especially nil by mouth patients

Hartmanns Solution

Fluids

Fluids

• Dextrose is a solution made of sugar and water

Dextrose

Fluids

FluidsSaline

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

Dextrose Saline

Dextrose Saline

1000ml 1000ml 1000ml

40g Dextrose 40g Dextrose 40g Dextrose

Na 30mM Na 30mM Na 30mM

K 20mM K 20mM K 20mM

Normal Saline 5% Dextrose 5% Dextrose

1000ml 1000ml 1000ml

50g Dextrose 50g Dextrose

Na 150mM

K 20mM K 20mM K 20mM

OR

Fluids

FluidsGelofusine

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)

Lines

Lines

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.

Cannulas

Lines

Blue 22G Pink 20G Green 18G White 17G Grey 16G Brown 14G

Cannulas

Lines

Lines

• 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

Triple lumen Central Venous Pressure Catheter

Lines

• 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

• 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

LinesNasogastric 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

LinesSingle Lumen Central Venous Catheter

Lines

LinesHickmann 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

LinesPeripherally 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

LinesSwan-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

LinesTesio Line

For Renal Dialysis

Drains

• Types of drainage systems

–Closed–Open–Passive–Active

• A surgical drain is a tube used to remove pus, blood or other fluids from a wound.

•Broadly classified as:– Tube Drains– Corrugated Drains

Drains

Drains

•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

Chest Drain Bottle

Drains

Drains

• Row of tubes• For big cavity drains• It is an open drainage system

Yates Tissue Drain

Drains

Drains

•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.

Vacuum Drain bottle (Redivac)

Thank You

Documents

Instruments 7 th January 2013 Jack Tanaka, Sameer Bahal