PROCEDURES AND INVESTIGATIONS IN

SURGERY

PREPARED BY

GROUP 3 & 4

MBBS 2007/2012

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INTRAVENOUS ACCESS

Assess indications and explain procedure to patient/family. A specific surgical consent is not generally obtained.

Indications:·         Access to the peripheral circulation for blood sampling.·         Administration of medication, fluids or nutrition.

Contraindications:1.       Absolute thrombosis2.       Phlebitis or cutaneous infection3.       Relative ipsilateral to mastectomy, dialysis shunts, or distal to an area or

trauma         

Equipment:1.       Alcohol swab2.       Tourniquet3.       Appropriate size catheter4.       Tape or occlusive dressing5.       Filled IV bag and tubing or Heparin trap6.       Anesthetic and topical (EMLA cream) or local (1% Lidocaine, 1cc SQ)    

[OPTIONAL]

Procedure:1.       Site selection will depend on many factors including:  Patient comfort,

accessibility, urgency of IV access, intended use and patient age.  In general, more distal sites should be selected first.  This allows use of a more proximal site if initial attempt is unsuccessful.  Acceptable sites include:  dorsal hand, forearm, antecubital (higher likelihood of position related flow obstruction), foot, lower leg and scalp in children.

2.       Apply a tourniquet proximal under tension.3.       Consider venous dilation; active or passive pumping of an extremity, warm

compress or gravity.  Some advocate a small amount of nitroglycerin ointment.4.       Clean skin with alcohol swab.5.       Apply anesthetic.6.       Stabilize skin by taught traction distally with the non-dominant hand.7.       Puncture skin at a 30º angle, bevel up, just over or parallel to the vein.  Once

blood is seen in the flash chamber, the catheter is advanced over the needle.8.       Remove needle, connect IV tubing or Heparin trap.9.       Apply tape or dressing.  Additional dressing or tape may be used to prevent

removal.

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Complications: Prevention and Management

Complication: Prevention: Management:

Bruising and hematoma: Appropriate technique and catheter size.

Apply direct pressure.

Infection: Aseptic technique. (No acute) 

Fluid extravasation: Assure appropriate catheter function with saline prior to administering medications.

Removal of catheter.

Thrombosis: Adequate fluid administration or Heparin flush.

Remove catheter.

Obstructed IV lines: Adequate fluid administration or Heparin flush.

Aspirate blood if possible, discard, and flush with saline.  If unable to aspirate remove catheter.

Embolism: Prevent air mixture with fluids;, do not allow IV bags to run dry.

Disconnect catheter and allow fluid to fill tubing or aspirate air from a nearby port using a needle

 

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FLUID THERAPY

Indication

Maintenance of intravascular as well as extravascular volume. To correct electrolyte imbalance and dehydration.

The fluid requirement is calculated as follows :

Total requirement: Maintenance + Deficits + On- going losses

For an adult > 2o kg, maintenance is calculated as follows :

60 + ( n- 20 ) ml/kg/hr n = Weight in kg

Deficits = Fluid loss acquired prior to commencement of fluid resuscitation, due to reduced oral intake, vomiting, diarrhoea or 3rd space losses.

On- going losses = Fluid losses on top of normal daily losses, eg loss into 3rd space.

Types of fluids

Two types : Crystalloids and Colloids. Crystalloids can be further classified into hypotonic, isotonic, and hypertonic. Crystalloids basically do not remain in the intravascular space and functions primarily to

replenish the interstitial volume. Colloids, on the other hand, tend to remain in the intravascular space, due to their high

tonicity. Types of Colloids : Human Albumin Solution, Gelatins, Hydroxyethyl starch, Dextran.

Osmolarity and electrolyte contents of crystalloids

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Solution Osm (mOsm/L)

Na Cl K Ca Mg Glucose ( g/L)

Lactate Acetate Maleate

D 5% 278 - - - - 50 -0.9% Saline 308 154 154 - - - -

Dextrose saline

586 154 154 - - 50 -

Hartmann’s 278 131 111 5 2 - 291/5th NS D5 296 30.8 30.8 - - 42.3 -

0.45 % Saline

154 77 77 - - - -

Sterofundin 304 140 127 4 2.5 1 - - 24 5

Dietary Reference Intakes: adequate intakes (AIs) for water

Adult males (>19 years): 3.7 L/day

Adult females (>19 years): 2.7 L/day

An increase or decrease in a patient’s fluid needs is based on a number of factors. Use clinical judgment to adjust fluid estimates as needed.

The following factors can increase fluid requirements:

Fever

Nasogastric tube for suctioning

Fistula wound drains

Diarrhea

Vomiting

Hyperventilation

Respirator

Excessive perspiration

Pressure ulcer (stages II, III, IV)

Circulating air bed for wound-healing treatment

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The following factors can decrease fluid requirements:

Congestive heart failure

Cardiac disease

Renal disease

Dilutional hyponatremia

Edema or ascites

IV DRUGS

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DEFINITION

Refers to the process of giving medication directly into a patient's vein. Methods of administering IV medication may include giving the medication by rapid

injection (push) into the vein using a syringe, giving the medication intermittently over a specific amount of time using an IV secondary line, or giving the medication continuously mixed in the main IV solution.

IV medications are most often given through a peripheral line or saline IV lock, but may also be administered direct IV, through an implanted vascular access port or through a central line.

PURPOSES/INDICATIONS

1. to initiate a rapid systemic response to medication.2. it is easier to control the actual amount of drug delivered to the body by using the IV

method and it is also easier to maintain drug levels in the blood for therapeutic response.

3. IV route for medication administration may be used if the medication to be delivered would be destroyed by digestive enzymes, is poorly absorbed by the tissue, or is painful or irritating when given by intra-muscular (IM) or subcutaneous (SQ) injection.

PRECAUTIONS

1. Proper IV administration should follow the five "rights" of medication administration to avoid medication errors: be sure it is the right patient, the right drug, the right dose, the right time, and the right route before giving any medication.

2. The IV line must be intact before any IV medication can be administered. Some IV medications can cause severe tissue damage if injected into the tissue through an infiltrated IV site.

3. Some IV push medications must be diluted before injection. The health care professional must check the directions for giving the specific drug IV before performing the injection.

COMPLICATIONS

Infection Phlebitis Extravasation Fluid overload Hypothermia Electrolyte imbalance Embolism

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CENTRAL VENOUS LINE MEASUREMENT

Technique and principle of measurement, normal and abnormal values and interpretation.

The procedure is explained to the patient. A verbal consent is obtained from the patient. Then the head of the bed is lowered to a horizontal position. The manometer is zeroed in line with the patient’s mid-axillary line. After the manometer has been zeroed the CVP line is connected to the manometer. The point to which the saline level rises is the CVP reading. Always read at the lower end of the meniscus. The level should swing with inspiration and expiration. After read the CVP, connect the saline line to the CVP so that the CVP line remains patent.

Normal CVP5-10 cmH2O

Increase CVP

Increased intra-thoracic pressure-happen when a patient has been intubated and is being ventilated artificially. Impaired cardiac function (right sided heart failure, tamponade) Hypervolemia-excess amount of IV fluids. Obstruction of the superior vena cava Pulmonary artery stenosis- limit venous outflow and lead to venous congestion cause the CVP to rise Straining, forced exhalation, tension pneumothorax and pleural effusion

Decrease CVP

1. Hypovolaemia is a decrease in circulating volume. (include blood loss and excessive dieresis)2. Reduced intra-thoracic pressure as seen during inspiration

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URINARY CATHETERIZATION

Assess indications.  Note that catheter insertion carries a risk of infection.  A specific surgical consent is not generally obtained.  Explain urethral catheterization (may be intermittent or indwelling).

Indications:·         Diagnostic

         To collect uncontaminated urine specimen         Study anatomy of the urinary tract         Urine output monitoring

·         Therapeutic                                 Acute urinary retention                                 Chronic obstruction causing hydronephrosis                                 Intermittent bladder decompression for neurogenic bladder                                 Chronically bed-ridden patients for hygiene

Contraindications:            1.   Urethral injury                                            

                     Trauma patients with blood at meatus or abnormal prostate location on rectal exam.

 Equipment:1.       Catheter tray.2.       Foley Catheter:                        18 F  Adults                        18 F  Coudé if obstruction at prostrate                           5 – 12 F Children                          5 F feeding tube with tape – infants < 6 months3.       Drainage bag.4.       Transurethral topical Lidocaine jelly (Uro-jet).   [OPTIONAL]

Procedure:1. Consider prophylactic antibiotics: valvular heart disease or acute prostatitis.2. Consider intraurethral anesthetic (Uro-jet).

            3. Position: supine, frogleg or knees flexed.            4. Locate meatus. (Fig. A)

5. Apply antiseptic.6. Gently insert lubricated tube until urine is obtained. (Fig. B)7. Inflate retention balloon slowly with 5cc saline.8. Connect to drainage system.9. Secure tube with tape.                                             

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Figure A Figure B

                       Removal:

·        Deflate retention balloon by aspirating contents with 10cc syringe from side port.

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Complications: Prevention and Management

Complication: Prevention: Management:

Inability to locate urethra:  Proper position. Compress foreskin edema. Use lubricated pediatric vaginal speculum with edematous foreskin.

Vaginal catheterization Position. Discard catheter.Re-attempt with fresh catheter.

Paraphimosis: Properly replace foreskin. Urology consult.

Urethral stricture:   Trial of smaller tube. 

Enlarged prostrate:   Coudé Catheter.

UTI: Aseptic technique.Minimize time Foley remains in.Prophylactic abx as indicated

Change catheterantibiotics

Inability to deflate:   Remove syringe adaptor.Insert guidewire into inflating channel – balloon water should flow out.

·        Withdraw catheter gently, taking care not to splash from tip.   

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NASOGASTRIC TUBE INSERTION

INDICATIONS

Evaluation of upper gastrointestinal (GI) bleed (ie, presence, volume) Aspiration of gastric fluid content Identification of the esophagus and stomach on a chest radiograph Administration of radiographic contrast to the GI tract Gastric decompression, including maintenance of a decompressed state after

endotracheal intubation, often via the oropharynx Relief of symptoms and bowel rest in the setting of small-bowel obstruction Aspiration of gastric content from recent ingestion of toxic material Administration of medication Feeding Bowel irrigation

CONTRAINDICATIONS

Severe midface trauma Recent nasal surgery Coagulation abnormality Esophageal varices or stricture Recent banding or cautery of esophageal varices Alkaline ingestion

COMPLICATIONS

Patient discomfort Generous lubrication, the use of topical anesthetic, and a gentle technique may

reduce the patient’s level of discomfort. Throat irritation may be reduced with administration of anesthetic lozenges

(eg, benzocaine lozenges [Cepacol]) prior to the procedure. Epistaxis may be prevented by generously lubricating the tube tip and using a gentle

technique. Respiratory tree intubation Esophageal perforation

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TYPES OF NASOGASTRIC TUBE

1. The Levin, a flexible, soft rubber or plastic tube with a single lumen and holes at the tip and along the distal side, is typically used for decompression, lavage, or feeding; it's not used for suctioning because it could adhere to and irritate the stomach's mucosal surface.

2. The Salem, which is made of clear, firm plastic, has two lumens; the second, smaller lumen serves as an air vent (also called a sump port or, more commonly, a pigtail). The vent allows atmospheric air to continually flow into the stomach, preventing the tip of the NG tube from adhering to the gut wall, making this tube ideal for use with suction

*both range in size from 12 – 18 F for adults and are 42 – 50 inches long*

TECHNIQUE

1. Explain to patient that you'll gently insert the tube into his stomach. Tell him that he may experience momentary discomfort, such as coughing, gagging, or tearing, but it's essential that he swallow as directed to ease tube insertion.

2. When ready, help patient into a high Fowler's position, supporting his head and shoulders with a pillow.

3. To determine the length required to reach the stomach, extend the end of the tube from the tip of his nose to his earlobe, then down to the xiphoid process. Mark the distance with a piece of tape(The average length for an adult is 22 – 26 inches)

4. Coil the end of the tube around your index finger to produce a flexible curve to ease insertion. Coat approximately four inches of this curved end with a water-soluble lubricant to minimize injury to the nasal passages

5. Instruct the patient to hold his head straight up with his neck slightly hyperextended and facing forward. Grasp the end of the tube above the lubricant. With the curve pointing downward, carefully insert the tube along the floor of the nostril, on the lateral side.

6. Once the tube reaches the nasopharynx, you may meet some resistance. This is the point at which the patient may start to gag or cough. Have him tilt his head forward— unless medically contraindicated. This positioning will close the trachea and make it easier for the tube to pass through the esophagus.

7. When the taped mark reaches the nostril, stop and confirm proper placement in the stomach.

8. To check placement of the tube, inject 10-20 ml of air through the tube and auscultate over the epigastrium.

9. Once placement is confirmed, secure the tube to keep it from becoming dislodged.

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WOUND SUTURE AND DRESSING

PRE-PROCEDURE

1. Assessment Mode of injury: blunt, penetrating, blast Time of injury Type of wound: puncture, laceration, incision, crush, burst, bite Location: proximity to major vessels (potential damage to blood supply for healing),

organs Shape: linear, curved, stellate, Y-shaped, inverted V, etc. Depth and direction: risk to underlying tissues, skin tension lines Potential foreign body: suggestive history, will it be radio-opaque or require USS

location? Potential underlying structural injury: bone fracture, tendon rupture, organ

perforation

2. HaemostasisThis may be spontaneous. However, it may require:

Pressure Elevation Tourniquet Clamp/suture (for arterial bleeders)

3. AnalgesiaDo not forget analgesia; this is not only humane, but facilitates remainder of management.

4. Skin preparation and wound toilet Don't put alcohol or detergents inside the wound. Tap water has been shown to have as low, or lower, infection rates as proprietary

antiseptic solutions. The usual compromise is to use sterile saline. Irrigation:

o This more important where there is high risk of infection.o The aim is to remove foreign matter and bacteria.

Use 50-100 mL/cm saline under pressure (syringe with 25G needle). Also consider debridement of ragged, nonviable skin edges. If necessary you can trim hair, but avoid shaving. Remove foreign bodies, but make sure personnel and equipment to control any

increase in bleeding are at hand.

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Optionso Sutures:

Type: absorbable (e.g. catgut, Dexon®, Vicryl®, polydioxanone (PDS) for deep sutures or sometimes in children (to avoid removal).

Nonabsorbable (e.g. nylon, polypropylene, silk, cotton). Monofilament (less inflammatory response) vs braided(stronger knots)

Needle: generally use a cutting edge rather than tapered end needle.o Staples: favoured by some for scalp wounds. They look horrendous but do a

good job.o If hair is trapped in the wound, it can impair healing, but if you have no other

option you could try tying strands across the wound.

Suggested sizes and durations Child's face: 6'0 monofilament nylon; remove after 3-5 days Other parts of children: 5'0 catgut; deep part absorbs and the top part sloughs off after

10-14 days Adult's face: 5'0 monofilament nylon; remove after 5 days Adult hand: 4'0 nylon; remove after 7 days Adult scalp: 3'0 nylon/silk; remove after 5 days Adult arm/trunk/abdomen: 3'0 nylon/silk; remove after 9-14 days Adult leg: 3'0 nylon; remove after 14 days

SIMPLE WOUND SUTURING

1. Inform patient of the treatment plan, which includes placing one or more sutures. 2. Position the patient in a comfortable position that gives adequate access to the site.3. Prepare the sterile dressing and suturing set.4. Select the appropriate suture and size of the needle according to the suturing site.5. Inject some local anaesthesia ( eg:lidocaine 1%) intradermally to the area that need to be suture.6. Sterile tha area with iodine and drape the area.7. Apply the needle to the needle driver approximately one quarter the distance from the blunt end of the needle.8. The needle should enter the skin with a 1/4-inch bite from the wound edge at a 90-degree angle.9. Release the needle from the needle driver and reach into the wound and grasp the needle with the needle driver and pull it free so that you have enough suture material to enter the opposite side of the wound.10. Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites.11. Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site.12. Release the needle from the needle driver and wrap the suture around the needle driver two times.

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13. Grasp the end of the suture material with the needle driver and pull the two lines across the wound site in opposite direction (this is one throw).14. Do not position the knot directly over the wound edge.15. Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap.16. Cut the ends of the suture 1/4-inch from the knot.17. The remaining sutures are inserted in the same manner.

SIMPLE WOUND DRESSING

1. Don't dress a wound without first cleaning it as well as possible. 2. Once the wound is clean and not bleeding, dab a bit of antiseptic ointment on it to

keep out the germs. Cover the wound lightly with gauze and an adhesive dressing. If body hair gets in the way of an adhesive dressing, you may wrap the extremity loosely with wide roller gauze. Always change dressings every 12 hours.

SUTURE REMOVAL

FACE: 4-5 days. BODY & SCALP: 7 days. SOLES, PALMS, BACK OR OVER JOINTS: 10 days

CENTRAL VENOUS LINE INSERTION

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INDICATIONS

Hemodynamic pressure monitoring

o Central venous pressure (CVP); right-heart filling pressures, surrogate of left-heart filling pressures

o Pulmonary artery catheter insertiono Pulmonary capillary wedge pressure

monitoringo Coronary sinus catheterization for

minimally invasive cardiac surgery

Large-bore intravenous accesso Rapid fluid resuscitation

o Rapid administration of blood replacement therapy

Infusion of therapeutic drugso Vasoactive substanceso Chemotherapyo Hyperalimentationo Other substances that would be too

caustic to the subcutaneous or peripheral vascular spaces

Plasmapheresis, apheresis Renal dialysis Transvenous pacing Aspiration of air embolism

CONTRAINDICATIONS

Absolute Contraindications Patient refusal Infection at the insertion site Anatomical variance at the insertion site Superior vena cava syndrome (except

femoral venous line)

Relative Contraindications Coagulopathy Systemic infection Right-sided ventricular assist device Presence of indwelling catheters or

pacing wires at the insertion site

ANATOMICAL LANDMARKS

Central: subclavian and internal jugular approach

The internal jugular vein follows a line from the inferior aspect of the external acoustic meatus to the medial aspect of the clavicle. It passes deep to the sternocleidomastoid muscle between the two heads and joins the subclavian vein to form the brachiocephalic vein, posterior to the clavicle closest to the sternum.

The subclavian vein is a continuation of the axillary vein draining the arm. It begins at the lateral border of the first rib and ends at the thoracic inlet where it meets the IJV to form the brachiocephalic vein. The SCV passes over the first rib and apical pleura and runs along the underside of the clavicle parallel with the subclavian artery but is separated from the artery at the anterior scalene muscle, with the vein passing over the muscle.

Peripheral :cephalic and femoral approach

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The femoral vein lies within the femoral triangle in the inguinal-femoral area, depicted in the image below. The superior border of the triangle is formed by the inguinal ligament, the medial border by the adductor longus, and the lateral border by the sartorius muscle. The apex of the triangle is formed by the sartorius crossing the adductor longus muscle. The roof of the triangle is composed of the skin, subcutaneous tissue, the cribriform fascia, and the fascia lata. The concave floor is formed of underlying adductor longus, adductor brevis, pectineus, and iliopsoas muscles.

EQUIPMENT

Sterile mask, gloves, and gown Standard monitors, such as pulse oximeter, blood pressure cuff, and ECG When possible, peripheral IV with infusion solution Sterile prep solution (e.g., chlorhexidine) Sterile drapes 5-mL sterile syringe with 25- or 30-gauge needle for local anesthetic infiltration Local anesthetic (usually 1% lidocaine) 22-gauge, 1.5-inch needle 18- or 20-gauge intravenous catheter (over a needle) on a syringe, or 18-gauge hollow-bore

needle Pressure tubing Guidewire No. 11 scalpel blade Central venous catheter with dilator 3.0 suture on cutting needle

INSERTION OF CVL NEEDLE

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Prep and dress the area U sing a 25 gauge needle and 1 cc of lidocaine, anesthetize the spot that you have

marked U sing a 22 gauge needle and more lidocaine, anesthetize the structures deeper to the

spot marked Use the 22 gauge needle (seeker needle) on a 3 cc syringe to locate the vein,

aspirating as the needle is advanced until a flush of blood returns Note the angle and depth of the seeker needle and remove it Use an 18 gauge needle on a 5 cc syringe to follow the path of the seeker needle,

aspirating as the needle is advanced. Entry into the vein is marked by a flush of blood. Stabilizing the needle with the thumb and forefinger, remove the syringe and

immediately occlude the hub of the needle (maintaining a "closed system") Thread the J wire into the 18 gauge needle leaving about half of the wire extruding

from the needle Secure the J wire with a fmgertip and remove the 18 gauge needle over the exposed,

remaining portion of the J wire Make a small cut in the skin adjacent to the entry site of the J wire using a scalpel Thread the silastic dilator over the wire Advance the dilator fully into the chest Remove the dilator while still leaving the J wire in place Remove the hub from the long central catheter Thread the long central catheter over the wire into the vein        Leave 5 to 10 cm of the catheter outside the skin Carefully remove the J wire Attach IV tubing to the catheter Lower the IV bag below the level of the patient to observe for blood return Discontinue the Trendelenberg position Secure the catheter in place using sutures and ties Place an occlusive dressing over the catheter Obtain a STAT post-procedure chest x-ray looking for a pneumothorax or

hemothorax, and looking for the catheter position. The STAT chest x-ray should be obtained whether the procedure is successful or not.

ARTERIAL BLOOD WITHDRAWAL

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Assess indications and explain procedure to patient/family. A specific surgical consent is not generally obtained.

Indications:         To access PH, PO2, PCO2 (note: PO2 may often be obtained by pulse ox).

          Inability to obtain venous sample.

Contraindications:                                                              Skin infection          Relative Bleeding diathesis                                            

Equipment:1.       ABG kit2.       Ice

Procedure:      Choose site for arterial puncture:

1.       Radial- No adjacent nerve or vessels  (Figure 1)      Assess for adequate ulnar artery circulation:      Position wrist in extension      Palpate arterial pulse      Clean skin      Consider subcutaneous Lidocaine      Insert needle at 30º - 40º angle  (See Figure 2)

 In adults with adequate blood pressure, the syringe will “fill itself”; in hypotensive patients or children, the sample will need to be aspirated.

                        Remove needle, apply pressure for 5 mins. or until bleeding is controlled. 

2.       Brachial arterial puncture:            Position elbow in extension            Same technique 3.       Femoral arterial puncture:

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            Position patient supine with hip extended and slightly, externally rotated            Same technique

                                                                                                                                                           

 

Complications: Prevention and Management 

Complication: Prevention: Management:

Hematoma: Assessing the likelihood of   bleeding.

Adequate pressure.

Infection: Aseptic technique. (No acute)

Tendon or Nerve Damage Appropriate positioning (No acute)

RESUSCITATION

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a) Securing airway and airway protection

- Open airway by tilting the head, and lifting jaw (but only if there is no spinal trauma)

- Use close-fitting mask, held in place by thumbs pressing downwardseither side of the mouthpiece; palm against cheeks

b) Equipment and technique for tracheal intubation

i) types of laryngoscope

direct laryngoscope

types of blade

straight – Miller blade

curved – Marcintosh blade

ii) size of endotracheal tubes

female – 8-9

male – 9-11

c) External cardiac compression

- Involves compressive forces over the lower sternum

- With the heal of the hands placed one on top of the other

- Directing the weight of your body through your vertical, straight arms.

- Depth of compression : 4cm

- Rate of compression : 100/min

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d) Intravenous cannulation and fluid administration

e) Resuscitation drug administration

f) Physiological monitoring

i) blood pressure Treatment of shock

ii) pulse rate

iii) oxygen saturation

iv) urine output

Treatment of shock :-

Hypovolaemic shock Septic shock Cardiogenic shock- Lie pt flat : high flow

oxygen ; lift leg to auto transfuse if no IV access

- Repeat fluid infusion 500ml IV rapidly : should see rise in BP

- Take blood and send for FBC, U&E, clotting, cross match

- Take arterial blood gas : estimate Hb, K+, blood gases

- Treat hyperK+- If no improvement in

BP, look for other

- Take blood for culture- Give antibiotic (IV

Cefuroxime 1.5g/6-8h or Gentamicin + antipseudomonal penicillin)

- Give IV fluid (colloid or crystalloid)

- Aim for CVP 8-12 mmHg, MAP >65 mmHg, Urine >35ml/h

- Give high flow oxygen- Give 2.5mg morphine IV- Request 12 lead ecg- Treat arrhytmias- Treat myocardial ischaemic

with 0.1mg GTN, 300mg aspirin

- Auscultate heart sounds and lung fields

- Treat tension pneumothorax, cardiac temponade

- Consider central venous and peripheral arterial monitoring

- Send blood for arterial blood gases, FBC, U&E, clotting, troponin

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causes - Catheterize the patient- Request chest Xray (pulmonary

oedema)- Treat fluid overload with

diuretics : frusemide 40mg IV- Consider transthoracic echo to

exclude pericardial effusion and valvular lesions and access LV function

g) Post resuscitation follow up

Sources :

Oxford handbook of clinical surgery

Oxford handbook of clinical medicine

CHEST TUBE INSERTION

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A chest tube is a flexible plastic tube that is inserted through the side of the chest into the pleural space to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the intrathoracic space.

INDICATIONS

Pneumothorax: accumulation of air in the pleural space Pleural effusion: accumulation of fluid in the pleural space

Chylothorax: a collection of lymphatic fluid in the pleural space Empyema: a pyogenic infection of the pleural space Hemothorax: accumulation of blood in the pleural space Hydrothorax: accumulation of serous fluid in the pleural space

CONTRAINDICATIONS

refractory coagulopathy lack of cooperation by the patient diaphragmatic hernia. scarring in the pleural space (adhesions)

COMPLICATIONS

MINOR

Subcutaneous hematoma or seroma Anxiety, shortness of breath (dyspnea) Cough (after removing large volume of fluid)

MAJOR

H emorrhage Infection Reexpansion pulmonary edema Chest tube clogging Pericardial tamponade Tension pneumothorax

DRAINAGE OF THIRD SPACE

What is third space?

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It is a space or areas in which fluid can collect that is not available in the circulation orThe process of the fluid shift into such spaces. Indications

-         pneumothorax-         pleural effusion-         chylothorax (a collection of lymphatic fluid in the pleural space)-         empyema (collection of pus in pleural space)-         hemothorax

 Complications

-         hemorrhage, hematoma-         infection-         reexpansion pulmonary oedema-         chest tube clogging-         injury to the liver, lung, spleen, & diaphragm

 Maximum Volume of Drainage

-         1.5 L to 2 L  ( to avoid hypovolemic shock due to excessive fluid drainage )-     monitor vital signs (BP, PR, sPO2, RR, Temp) 

Anatomical Landmarks & Technique

-         Free end of the tube is usually attached to an underwater seal, below the level of the chest. This allows the air or fluid to escape from the pleural space, and prevents anything returning to the chest. Alternatively, the tube can be attached to a flutter valve. This allows patients with pneumothorax to remain more mobile.-         "safe zone", a region bordered by: the lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal line superior to the nipple.  More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid axillary line.-         Chest tubes are usually inserted under local anesthesia. The skin over the area of insertion is first cleansed with antiseptic solution, such as iodine, before sterile drapes are placed around the area. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb a small incision is made in the skin and a passage made through the skin and muscle into the chest.-         The tube is placed through this passage. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied to the area. The tube stays in for as long as there is air or fluid to be removed, or risk of air gathering.-         Chest tubes can also be placed using a trocar, which is a pointed metallic bar used to guide the tube through the chest wall. This method is less popular due to an increased risk of iatrogenic lung injury.

ADMINISTRATION OF BLOOD AND BLOOD PRODUCT

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Indication:

Anaemia Major Surgical Operation Trauma resulting in considerable blood loss Cancer patients requiring therapy Women in childbirth and newborn babies in certain cases Patients of hereditary disorders like Haemophilia and Thalassaemia Severe burn victims

Types of blood products:

1. Packed red blood cells

Hemoglobin concentration (g/dL) is used to monitor RBC mass. 1 unit increase Hb by 1-1.5g/dl.

2. Fresh frozen plasma

FFP transfusion is indicated in hemorrhaging patients to replace labile and lost coagulation factors. Clinical circumstances fulfilling this criterion include massive transfusion, cardiopulmonary bypass, extracorporeal pulmonary support techniques, decompensated liver disease, or acute disseminated intravascular coagulation regardless of cause. FFP, in conjunction with vitamin K, is also indicated for excessive warfarinization in circumstances accompanied by life-threatening hemorrhage.

A guideline for initial FFP dosing is 10-15 mL/kg; this typically translates to at least 4 units of FFP to affect a therapeutic response. Efficacy is monitored by laboratory tests of coagulation function, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and the international normalized ratio (INR).

3. Platelets

Platelet transfusion may be beneficial in patients with platelet deficiency or dysfunction. Prophylactic platelet transfusion is indicated in patients with bone marrow failure, no other associated risk factors for bleeding, and platelet counts below 10 X 109/L. If there are associated risk factors, the threshold may be reasonably raised to 20 X 109/L. Patients undergoing invasive procedures should have platelet counts greater than 50 X 109/L. In the hemorrhaging patient, platelet transfusion is indicated when thrombocytopenia is contributing to the bleeding and the platelet count is less than 50 X 109/L. When diffuse microvascular bleeding is present, the platelet count should be maintained above 100 X 109/L while addressing the underlying cause.

Common etiologies to be corrected include, but are not limited to, large volume hemorrhage control failure (solid organ or vascular conduit), hypothermia, acidosis, traumatic brain injury, individual factor deficiencies, and acquired inhibitors of coagulation. The optimal time to measure the effect of platelet transfusion is 1 hour after the completion of the infusion. This timeframe allows one to discern an appropriate increase from ongoing consumption from total destruction due to preformed antibody.

4. Cryoprecipitate

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Transfusion of cryoprecipitate is indicated for fibrinogen deficiency or dysfibrinogenemia in the setting of hemorrhage, invasive procedures, injury, or acute disseminated intravascular coagulation. Fibrinogen levels should be monitored and treatment undertaken for levels less than 100 mg/dL; many clinicians use a higher threshold of 150 mg/dL in patients with active hemorrhage. Cryoprecipitate is generally transfused in aliquots of 10 units. Patients on a massive transfusion protocol and receiving greater than 10 units of FFP generally do not need additional cryoprecipitate, having received an adequate bolus of fibrinogen in the large quantity of FFP.

Normal Values:

Fibrinogen 2–4 g/L

Hct Female 0.36–0.446 fraction of 1

Hct Male 0.4–0.503 fraction of 1

Hemoglobin A 1C 0.053–0.075

Hb Female 121–153 g/L

Hb Male 138–175 g/L

Leukocyte count (WBC) 3.8–9.8 x 109/L

RBC Female 3.5–5 x 1012/L

RBC Male 4.3–5.9 x 1012/L

Mean corpuscular volume (MCV) 80–97.6 fl

Mean corpuscular hemoglobin (MCH) 1.66–2.09 fmol/cell

Mean corpuscular hemoglobin concentrate (MCHC) 20.3–22 mmol/L

Erythrocyte sedimentation rate (ESR) £30 mm/hr

Complications:

Acute (within 24 hours):

Acute hemolytic reactions (ABO/ Rhesus Incompatibility); Anaphylaxis; bacterial contamination; Febrile reaction (HLA antibodies); allergic reaction (urticaria, fever); fluid overload; transfusion related acute lung injury.

Delay:

Infection (Viral, bacterial, protozoal) ; Iron overload; graft-versus-host disease; post-transfusion purpura

NUTRITIONAL SUPPORT IN SURGERY

28

DAILY REQUIREMENT

Calorie : 25-35 Kcal/kg or 105-147 kJ/kg Protein : 1 – 1.5 g/kg

TYPES

Enteral Parenteral

ENTERAL PARENTERALINDICATIONS Long term feeding

Dysphagia Chronic disease

eg:malignancy Malnutrition Sepsis Coma

Preferable for patient who unable to tolerate orally but normal GIT function.

Severe malnutrition Inability to swallow Short bowel syndrome Severe Chron’s disease Prolonged ileus

COMPLICATIONS Vomiting Diarrhea Aspiration Malposition of feeding

tube Feeding intolerance Electrolyte inbalance Constipation

Vitamins and mineral deficiency Cardiac tamponade Pneumothorax/haemothorax Mineral overload Gastrointestinal mucosa atrophy Sepsis Hyperglycemia

METHODS OF ADMINISTRATION

Nasogastric Nasoduodenal Percutenous Endoscopic

Gastrostomy Open gastrostomy Transgastric

jejunostomy Surgical jejunostomy

Peripheral Venous Line Central Venous Line

NUTRITIONAL DISORDER IN SURGICAL PATIENTS

29

STARVATIONo Prolonged fasting for procedures and surgeryo Effect of the disease

METABOLIC EFFECTo Increase catabolism(negative nitrogen balance)o Decrease anabolismo Stress,inflammation

STANDARD PARENTERAL REGIME

Non-protein energy 2200 kcal

Nitrogen 13.5g

Volume 2500ml

Sodium 115mmol

Pottasium 65mmol

Calcium 10mmol

Magnesium 9.5mmol

Phosphate 20mmol

Zinc 0.1mmol

Chloride 113.3mmol

Acetate 135mmol

Adequate vitamins and trace elements

ENTERAL FORMULA

30

TYPES COMMENTSStandard Intact Nutrients Whole protein nitrogen source.

Most products contain ~1.0 kcal/mLProtein varies: most are lactose freeFiber containing or fiber free

Elemental Pre-digested nutrientMost have a low fat content or high percentage of medium chain TGFor severely impaired GI absorption

Fluid Restricted Intact nutrients,calorically dense (2.0 kcal/mL)Renal Intact nutrients,calorically dense (2.0 kcal/mL)

Low phosphorus and low potassiumDisease specific Intact nutrients designed to meet the specific

requirement

WEIGHT GAIN MONITOR

Weight measurement before ,during and after the therapy BMI Fluid balance Plasma protein include albumin Triglycerides Skinfold thickness Waist to hip ratio

REFERENCES

http://courses.washington.edu/hmed665i/Enteral_Feeding_Guidelines.pdf http://www.surgicalcriticalcare.net/Guidelines/nutrition.pdf

SIGMOIDOSCOPY

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- Minimally invasive medical examination of the large intestine from the rectum, to the sigmoid colon.

- 2 types : flexible & rigid. Difference is flexible uses a flexible device, rigid uses a rigid device. - Rigid is never used nowadays. May be useful still in anorectal diseases e.g. PR bleeding and

inflammatory rectal disease.

Indication

1. Screening for colorectal CA2. As an adjunct with barium enema3. Detect bleeding, polyps, fissures, etc.4. In suspected patients of IBD, infectious colitis, diverticulitis, etc.5. Bowel obstruction6. Causes of diarrhea.7. To take a biopsy.

Pre-procedure preparation

1. Introduce self, briefly explain procedure and acquire informed consent (sign form)2. Ask patient if they are on any medication3. Patient must take only clear fluids 12-24 hours before procedure. The night before the

procedure, patient is given laxative and enema.

Procedure

1. Patient is to lie at the left lateral position, with both knees drawn up to chest. (this is not Sim’s position – lie on left lateral side, left leg extended, right leg flexed. Sim’s is for PR examination and enema insertion)

2. Perform a PR examination to check for any blockage and gently dilate the anus.3. Sigmoidoscope is lubricated and gently inserted through the anus rectum sigmoid

colon proximal descending colon4. During this insertion, the bowel is insufflated for better viewing.5. Areas of pathology are viewed during the insertion. When retracting back, also areas are

visualized. Biopsy is taken during this time.

Complications

1. Cramping/bloating of abdomen2. Localized pain3. Bleeding4. Bacteremia5. Bowel perforation

*Complications are rare nowadays.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAM (ERCP)

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INDICATIONS

Always therapeutic but it’s turn to be diagnostic

Biliary obstruction Pancreatic obstruction Evaluation of signs/symptoms suggesting pancreatic malignancy Evaluation of idiopathic pancreatitis Stent placement Balloon dilatation of ductal strictures Tissue sampling from biliary or pancreatic duct Sphincterotomy

COMPLICATIONS

Bleeding Perforation Acute pancreatitis Abscess

Preparation

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home—you will not be allowed to drive because of the sedatives. The physician may give you other special instructions.

OESOPHAGOGASTRODUODENOSCOPY

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An endoscope as used in the field of gastroenterology (the medical study of the stomach and intestines) is a thin, flexible tube that uses a lens or miniature camera to view various areas of the gastrointestinal tract. When the procedure is limited to the examination of the inside of the gastrointestinal tract's upper portion, it is called upper endoscopy or esphagogastroduodenoscopy (EGD). With the endoscope, the esophagus (swallowing tube), stomach, and duodenum (first portion of the small intestine) can be easily examined, and abnormalities frequently treated

INDICATIONS

Diagnostic Unexplained anemia (usually along

with a colonoscopy) Upper gastrointestinal bleeding as

evidenced by hematemesis or melena Persistent dyspepsia in patients over

the age of 40–45 years Heartburn and chronic acid reflux - this

can lead to a precancerous lesion called Barrett's esophagus

Persistent vomiting Dysphagia - difficulty in swallowing Odynophagia - painful swallowing

Therapeutic

Treatment (banding/sclerotherapy) of esophageal varices

Injection therapy (e.g. epinephrine in bleeding lesions)

Cutting off of larger pieces of tissue with a snare device (e.g. polyps, endoscopic mucosal resection)

Application of cautery to tissues Removal of foreign bodies (e.g. food)

that have been ingested Tamponade of bleeding esophageal

varices with a balloon Application of photodynamic therapy

for treatment of esophageal malignancies

Endoscopic drainage of pancreatic pseudocyst

Tightening the lower esophageal sphincter

Dilating or stenting of stenosis or achalasia

Percutaneous endoscopic gastrostomy (feeding tube placement)

PRE PROCEDURE

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Certain medications (such as aspirin   and the anti-inflammatory drugs called NSAIDs) should be discontinued at least seven days before an OGDS to reduce the risk of bleeding

Patients will be asked not to eat or drink anything for at least six to 12 hours before the procedure to ensure that the upper intestinal tract will be empty

Before the procedure, patients may be given a sedative and/or pain medication, usually by intravenous injection.

COMPLICATIONS

Inflammation Aspiration Cardiopulmonary problems Bleeding Perforation

COLONOSCOPY

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A direct visualization of the mucosa and submucosa of the large bowel

Indications

1) Rectal bleed with looser or more frequent stool +/- abdominal pain related to bowel action

2) Iron deficiency anemia

3) Right iliac fossa mass if ultrasound shows colonic origin

4) Change in bowel habit associated with fever or increase inflammatory response

5) Chronic diarrhoea (> 6weeks) after sigmoidoscopy or biopsy negative

6) Follow ups of colorectal cancer and polyps

7) Screening of patients with relevant family history ( colon ca, HNPCC)

8) Assessment of ulcerative colitis or Crohn's Disease

Preparation

Discontinue drugs: warfarin, NSAIDs, and aspirins stopped 1week before

Antibiotic prophylaxis is given in high risk patients only ( prosthetic valve, congenital hert disease, joint replcement, or pulmonary shunts)

Antibiotics used are: gentamycin, vancomycin.

Bowel preparation

To give adequate hydration to the patient during bowel preparation which is done a day before procedure. *Cautions in patients with fluid and electrolyte imbalance.

patient is kept nill by mouth overnight before procedure, except for clear fluids ingestion.

Contraindicated in intestinal obs, perforation, gastric retention, colitis, and toxic megacolon.

Drugs used: macrogols, magnesium citrate, phosphates, or sodium picosulfate with magnesium citrate.

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Anatomical landmark

Rectum length : 12-18cmColonoscope length: 160cm

Visualization of appendix orifice or ileocecal valve confirms visualization of the whole colon

Biopsy technique

-Targeted to are of abnormality-random (exclude microscopic colitis)

Therapeutic

-resection of colonic polyps

Complications

-perforation-haemorrhage-delayed perforation

* to prevent these complications, inject submucosal adrenaline apply tamponade in several minutes or use haemoclips.

Sedation

Benzodiazepine* needs oxygen monitoring and IV access.

BARIUM SWALLOW/FOLLOWTHROUGH/ENEMA

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BARIUMSWALLOW FOLLOW THROUGH ENEMA

Fluoroscopic examination of the pharynx & the esophagus.

Fluroroscopic examination of the small intestine (duodenum to ileocecal junction)

Fluroroscopic examination of the large intestineDouble contrast / air contrast : air is also instilled instead of barium mixture

Indication DysphagiaRegurgitation

Abdominal painDiarrhoeaBleedingPartial obstructionInvestigations of transit time

Lower abdominal painsChanges in bowel habitsPassage of stool containing mucus / bloodVisualizing polyps, diverticula & tumours

Contraindication Pregnant womenPatients with intestinal obstructionPatients with perforated esophagusPatients who are unable to cooperate due to age, mental status, pain etcPatients with unstable vital signs

Pre-test Explain the procedure to the patient & take consentPatient need to fast 8 hours prior to this testPatient need to remove all objects containing metal (i.e jewellery, undergarments)

Explain the procedure to the patient & take consentPatient need to fast 12 hours prior to this testLaxative given 12 hours before this test

Explain the procedure to the patient & take consentPreparation of patient :

- A liquid diet with no dairy products for 24 prior to this test

- Intake of at least 1200 cc of fluids a day prior to the exam

- Stool softeners & laxatives given the evening before & the morning of the test

- NBM after midnight before the day of the test

Patient should be monitored throughout the bowel preparation for fatigue & fluid & electrolyte imbalancePatient need to remove all objects containing metal (i.e jewellery, undergarments)

Procedure Patient is placed in an upright position for the first part of

After the preliminary upper GI series (barium swallow) is complete, the patient

First, put the patient in supine positon and a

38

the procedureThe fluoroscopic screen is placed in front of the patient & the heart, lungs & abdomen can be viewedPatient then take one swallow of thick barium mixture while the videotape is made of the pharyngeal actionWhile the patient continues to drink, films are taken at the esophageal area from variety of anglesThen, patient need to be placed in different positions & drink more of the barium - allows evaluation problem such as gastric refluxTake approximately 30 min to 1 hour

will drink additional barium sulfate, and will be escorted to a waiting area while the barium moves through the small intestines X rays are initially taken at 15-minute intervals until the barium reaches the colon (the only way to be sure the terminal ileum is fully seen is to see the colon or ileocecal valve)The interval may be increased to 30 minutes, or even one hour if the barium passes slowlyThen the radiologist will obtain additional views of the terminal ileum (the most distal segment of the small bowel, just before the colon)This procedure can take from one to four hours.

preliminary film is taken – to verify there is no stool remains in the large intestineThen, patient is turned to the side (Sim’s position) & lubricated rectal tube is insertedThe fluoroscopic screen is placed in front of the patient & the heart, lungs & abdomen can be viewedThen, the barium is allowed to flow slowly into the intestine until the the entire intestine up to ileocecal valve is filled. The flow of barium is observed & periodic films are takenOnce the intestine is filled, the rectal tube is removedThen, assist patient to restroom to expel as much barium as possibleAfter the expulsion, additional film is takenDouble contrast : + air is then instilled in the intestine & additional films takenTake approxiamately 45 min to 75 min

Post-test Resume patient’s diet & medication as taken prior to the testEncourage fluid intakeExplain to the patient that the stools will be white initially and will return to normalAsk the patient to come if the barium is not fully expelled within 2-3 days

Possible findings

AchalasiaEsophageal Ca, Stomach CaEsophageal spasm, ulcers, varicesEsophagitisPolypsStrictures

Hiatal hernia Diverticula Tumors Obstruction Gastroesophageal reflux diseasePulmonary aspiration Inflammation (e.g., ulcers, enteritis, and Crohn's disease).

AppendicitisCarcinomaCrohn’s disease, Ulcerative colitisInflammatory bowel syndromeDiverticulitis, FistulaHircshsprung disease, IntussusceptionPolypsSigmoid torsion, volvulus

Complications Fecal impaction due to retention of barium

Perforation of the colonFecal impaction due to retention of the

Perforation of the colonFluid & electrolyte

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barium imbalanceFecal impaction due to retention of the barium

Reference Manual of laboratory & diagnostic test – Mc Graw Hills

http://www.surgeryencyclopedia.com/St-Wr/Upper-GI-Exam.html

http://www.e-radiography.net/technique/git/bafollowthrough.htm

Manual of laboratory & diagnostic test – Mc Graw Hills

CT SCAN OF HEAD

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INDICATIONS

Contusion/drowsiness which is not improved more than 4 hours New neurological signs GSC <15 presence of any one or more of LOC(loss of consciousness-even upto

5min)/PTA(post or pretraumatic amnesia), vomiting, ENT bleed or CSF leak, fits or seizues,headache.

penetrating head injury or violent mode of injury with or without skull fractures/tense fontanelles

with any of the risk factors-coagulopathy,ch.alcoholism,drugs,epileptic,prev neurosurgery,disabled or elderly or children

NORMAL ANATOMY OF BRAIN

CT SCAN CHEST

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a) Indication:

1. Primary Lung Cancer And Staging Of Metastatic Disease

2. Evaluation Of Solitary Pulmonary Nodule Seen On CXR Or Included On AbdominalCT

3. Mediastinal Pathology (Adenopathy -Lymphoma (For Great Vessel Disease, Early PhaseTumor Imaging) -Great Vessel Disease -Aortic Aneurysm Or Dissection -Widening On CXR

4. Cardiac And Pericardial Disease -Tumor -Inflammation -Pericardial Effusion

5. Pulmonary Infection And Inflammatory Disease - Consolidation (Pneumonia) Routine With IV Contrast - Known Disease Or To Monitor Response To Therapy (e.g.): *Sarcoid *IPF (Interstitial Pulm Fibrosis) *CVD *COPD *Bronchiectasis *Asbestosis *Pneumoconiosis *Cystic Disease *Hypersensitivity Pneumonitis *Infection—Tb, PCP, MAC, etc. - Normal CXR With Symptoms Or Abnormal PFT (To Detect Interstitial Disease)

6. Trauma

7. Rule Out Pulmonary Embolism

8. Lung Cancer Screening

9. Coronary Artery Calcium Detection

b) Colour of structures in CT scan:

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c) CT Scan Contrast Indications

Many CT scans are ordered with contrast.  Here are some common reasons why contrast is given:

History of tumor, cancer, or surgery Looking for infection, inflammation, or cancer Evaluating blood vessels Investigate a finding in a scan done without contrast

d) CT Scan Contrast Contraindications:

- Allergy to contrast media

- Renal Failure

-Pregnancy (also contraindicate in plain CT scan)

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CT SCAN OF ABDOMEN

INDICATIONS

Evaluation of abdominal, flank, or pelvic pain. Evaluation of known or suspected abdominal or pelvic masses or fluid collections. Evaluation of primary or metastatic malignancies. Evaluation of abdominal or pelvic inflammatory processes. Assessment of abnormalities of abdominal or pelvic vascular structures. Evaluation of abdominal or pelvic trauma. Clarification of findings from other imaging studies or laboratory abnormalities. Evaluation of known or suspected congenital abnormalities of abdominal or pelvic

organs. Guidance for interventional or therapeutic procedures within the abdomen or pelvis. Treatment planning for radiation therapy. Noninvasive angiography of the aorta and its branches.

MRI OF THE BRAIN

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INDICATIONS

Look for the causes of headache Help to diagnose a stroke  Help diagnose blood vessels problem eg:aneurysm ,AV malformation Check blood flow or blood clots in the brain.(bleeding) Check symptoms of a known or suspected head injury Check symptoms such as change in consciousness, confusion, or abnormal

movements Look for tumors, infections, an abscess, or conditions of the brain or brain stem, such

as encephalitis or meningitis. Check the eyes, the nerves from the eyes to the brain (optic nerves), the ears, and the

nerves from the ears to the brain (auditory nerves). Look for problems of the pituitary gland.

CONTRAINDICATIONS

Pregnant Having medical devices with metal. This test may not be done if you have:o An intrauterine device (IUD) in place.o Metal parts or clips in the head or eye.o A pacemaker.o An implantable cardioverter-defibrillator (ICD).o Certain types of artificial limbs.o A medicine infusion pump in place. Being unable to lie still during the test.

MICTURATING CYSTOURETHROGRAM

45

INDICATIONS Vesicoureteric reflux in children - Recurrent UTI Urethral stricture Suspected obstructions (eg. Bilateral hydronephrosis) Suspected bladder trauma or rupture Stress incontinence (urine)

CONTRAINDICATIONS Untreated urinary tract infections Hypersensitivity to contrast media Fever within past 24 hours

ANATOMY DEMONSTRATED

CONTRAST MEDIA

Low strength (approx 25% weight/volume) contrast agent i.e. Hypaque 25% urografin 150, suitable volume to fill the bladder, typical 20 ml in an infant to 500 ml in an adult, the contrast media should be warmed to body temperature.

EQUIPMENTNursing-Catheterisation pack - and aseptic procedure pack..Sterile towelsSkin prep./ washSterile lubricantGiving set- Selection of Foley catheters 5 -7 gauge French in infants larger in adults.Drip stand

46

RadiographicFluoroscopy set with spot film or video recording devices.

TECHNIQUE1. The indication is almost exclusively confined to children.

2. The patient lies supine on the x-ray table.

3. Catheterise patient if patient still not catheterized.

4. The contrast media warmed to body temperature is slowly infused through the catheter using a “giving set” into the bladder.

5. Intermittent pulsed fluoroscopy is used to check the filling and for reflux up the ureters.

6. The contrast media reservoir should be no more than 1 metre above the table to limit the pressure.

7. Older children and adults are given a urine receiver but smaller children should be allowed to micturate onto absorbent pads.

8. Adults will find it easier to micturate while standing erect.

An alternative to spot films is to video tape the fluoroscopy.1) Spot films are taken of the bladder, kidneys and ureters to record the normal or abnormal anatomy.

2) When the bladder is considered full or the contrast leaks round the catheter the balloon is deflated and the catheter withdrawn. depending on the age of the patient the patient is asked to micturate into a receiver either erect or supine, suitable privacy and sympathy may be required.

3) Spot films are taken during micturition and any reflux recorded (If the contrast moves into the ureters and back into the kidneys, the radiologist makes the diagnosis of vesicoureteral reflux, and gives the degree of severity a score.). The patient is rotated into the 30 degree left and right anterior obliques to demonstrate the bladder ureteric junctions, to demonstrate the male urethra the left anterior oblique position is adopted with flexion of the right hip and knee to visualise the whole of the male urethra.

4) A final full length abdominal film is taken to visualize the kidneys.

PERCUTANEOUS NEPHROSTOMY

47

: surgical procedure in which the renal pelvis is punctured whilst using imaging as guidance used mainly in the decompression of the renal collecting system providing temporary or permanent drainage of an obstructed urinary system or for establishing diversion of urine flow.

Indications:

1. Temporary urinary diversion associated with urinary obstruction secondary to calculi2. Diversion of urine from the renal collecting system in an attempt to heal fistulas or leaks resulting from traumatic or iatrogenic injury, malignant or inflammatory fistulas, or hemorrhagic cystitis3. Treatment of nondilated obstructive uropathy4. Treatment of urinary tract obstruction related to pregnancy5. Treatment of complications related to renal transplants6. Access for interventions such as direct infusion of substances for dissolving stones; chemotherapy; and antibiotic or antifungal therapy7. Access for other procedures (eg, benign stricture dilatation, antegrade ureteral stent placement, stone retrieval, pyeloureteroscopy, endopyelotomy)8. Decompression of nephric or perinephric fluid collections (eg, abscesses, urinomas)

Contraindications:

1. Bleeding diathesis (most commonly, uncontrollable coagulopathy)2. Uncooperative patient3. Severe hyperkalemia (>7 mEq/L) should be corrected with hemodialysis

before the procedure.

Preprocedure preparation:

48

Informed consent is obtained from the patient, next of kin, or healthcare proxy.

Laboratory studies, including determination of prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet count, BUN and creatinine levels, hematocrit (Hct) and hemoglobin (Hgb) levels, WBC count, and urinalysis and urine culture, are made.

Prophylactic antibiotics are administered 60 minutes before the procedure, especially if pyonephrosis is suspected or if the obstruction is caused by a renal calculus

The patient should receive nothing by mouth (NPO) for 4-8 hours before the procedure, for conscious sedation precautions.

Some have advocated the placement of percutaneous nephrostomy tubes without performing preprocedural coagulation studies, although the authors disagree with this approach unless the situation is an absolute emergency. Because the kidney is highly vascular, needle puncture and tract dilation in a patient with a coagulopathy could result in massive hemorrhage.

Complications:

Major complications with percutaneous nephrostomy tube placement include the following:o Bleedingo Sepsiso Injury to an adjacent organ

Other major complications, though somewhat rare, have been reported to occur in as many as 5% of patients. Complications of percutaneous nephrostomy may include the following:

o Massive hemorrhage requiring transfusion, surgery, or embolization (1-3%)o Pneumothorax (<1%)o Microscopic hematuria (common)o Pain (common)o Urine extravasation (<2%)o Inability to remove the nephrostomy tube because of crystallization around the tube

siteo Death (0.2%)o Sepsis (1.3%)o Catheter dislodgement during the first month (<1%)

Reference: http://emedicine.medscape.com/article/1821504-treatmen

MAMMOGRAM

49

1. Early detection of breast cancer, typically through detection of characteristic masses and/or microcalcifications.

2. Indications: annual screening mammography starting at age 40 (American College of Radiology and the Society of Breast Imaging).

3. Screening mammography: asymptomatic women. angled side-view (mediolateral oblique, MLO) head-to-foot (craniocaudal, CC) view

4. Diagnostic mammography: symptomatic women atero-medial (LM) and medio-lateral (ML) views, exaggerated CC views, magnification views, spot

compression views, and others.  5. False positives: 7%6. False-negative: 8-10%7. If positive:proceed to U/S of breast

Risk of malignancy and care plan by BI-RADS categoryCategory Description Risk of Malignancy Care Plan and Comments

1 Negative 5 in 10,000 Continue annual screening mammography for women 40 years of age or older.

2 Benign finding, noncancerous

5 in 10,000 Continue annual screening mammography for women 40 years of age or older. This category is for cases with a characteristically benign finding (eg, cyst, fibroadenoma).

3 Probably benign finding

<2% Usually, 6-month follow-up mammography is performed. Most category 3 abnormalities are not evaluated with biopsy.

4 Suspicious abnormality

25-50% Most category 4 abnormalities are benign but may require biopsy.

5 Highly suggestive of malignancy

75-99%, depending on how individual radiologists define categories 4 and 5

Classic signs of cancer are seen on the mammogram. All category 5 abnormalities are typically evaluated with biopsy; if the results are benign, repeat biopsy is done to ensure correct sampling.

ULTRASOUND BREAST

50

Ultrasound imaging of the breast produces a picture of the internal structures of the breast. During a breast ultrasound examination the sonographer or physician performing the test may use Doppler techniques to evaluate blood flow or lack of flow in any breast mass. In some cases this may provide additional information as to the cause of the mass. Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck.

Common uses:1. Determining the nature of a breast abnormalityThe primary use of breast ultrasound today is to help diagnose breast abnormalities detected by a physician during a physical exam (such as a lump or bloody or spontaneous clear nippledischarge) and to characterize potential abnormalities seen on mammography. Ultrasound imaging can help to determine if an abnormality is solid (which may be a non-cancerous lump of tissue or a cancerous tumor) or fluid-filled (such as a benign cyst) or both cystic and solid. Ultrasound can also help show additional features of the abnormal area. Doppler ultrasound is used to assess blood supply in breast lesions.

2. Supplemental breast cancer screeningMammography is the only screening tool for breast cancer that is known to reduce deaths due to breast cancer through early detection. Even so, mammograms do not detect all breast cancers. Some breast lesions and abnormalities are not visible or are difficult to interpret on mammograms. In breasts that are dense, meaning there is a lot of glandular tissue and less fat, many cancers can be hard to see on mammography.

Ultrasound can be offered as a screening tool for women who:o are at high risk for breast cancer and unable to tolerate an MRI examination.o are at intermediate risk for breast cancer based on family history, personal history of

breasto cancer, or prior biopsy showing an abnormal result.o have dense breasts.o have silicone breast implants and very little tissue can be included on the

mammogram.o are pregnant or should not to be exposed to x-rays (which is necessary for a

mammogram).

3. Ultrasound-guided breast biopsy When an ultrasound examination reveals a suspicious breast abnormality, a physician may choose to perform an ultrasound-guided biopsy. Because ultrasound provides real-time images, it is often used to guide biopsy procedures.

What can be seen on an ultrasound: Ducts Lobes Muscle layers Cysts Abscess Fibroadenomas Breast masses

Advantages of Ultrasound

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High-contrast images Can image non-palpable masses (lumps that you can't feel) No compression, pain-free No radiation Less expensive than CAT scan or Breast MRI

Disadvantages of Ultrasound Can't image areas deep inside the breast Requires a well-trained and experienced operator Equipment can sometimes have problems May have trouble distinguishing between abnormality and surrounding tissue Cannot show microcalcifications

DOPPLER ULTRASOUND

52

A Doppler ultrasound test uses reflected sound waves to evaluateblood as it flows through a blood vessel. It helps doctors evaluate blood flow through the major arteries and veins of the arms, legs, and neck. It can show blocked or reduced blood flow through narrowing in the major arteries of the neck that could cause a stroke. It also can reveal blood clots in leg veins (deep vein thrombosis, or DVT) that could break loose and block blood flow to the lungs (pulmonary embolism). See pictures of a stroke  and an embolus. During pregnancy, Doppler ultrasound may be used to look at blood flow in an unborn baby (fetus) to check the health of the fetus.

During Doppler ultrasound, a handheld instrument (transducer) is passed lightly over the skin above a blood vessel. The transducer sends and receives sound waves that are amplified through a microphone. The sound waves bounce off solid objects, including blood cells. The movement of blood cells causes a change in pitch of the reflected sound waves (called the Doppler effect). If there is no blood flow, the pitch does not change. Information from the reflected sound waves can be processed by a computer to provide graphs or pictures that represent the flow of blood through the blood vessels. These graphs or pictures can be saved for future review or evaluation

Doppler ultrasound of an artery

Source: http://www.webmd.com/a-to-z-guides/doppler-ultrasound

ANGIOGRAPHY

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Medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins and the heart chambers. Done by injecting a radio-opaque contrast agent into the blood vessel and imaging using X-ray based techniques such as fluoroscopy.

Indication: suspected organic stenosis or occlusions in areas available for reconstructive vascular surgery.

Uses:

Coronary angiography- complication- Cardiac arrhythmias, kidney damage, blood clots (which can cause heart attack or stroke), hypotension and pericardial effusion. Minor complications can include bleeding or bruising at the site where the contrast is injected, blood vessel damage on the route to the heart from the catheter (rare) and allergic reaction to the contrast.[1]

Microangiography-used to visualize tiny blood vessels. Neuro-vascular angiography-to visualise the arterial and venous supply to the brain.

Complication-rare but include stroke, an allergic reaction to the anaesthetic other medication or the contrast medium, blockage or damage to one of the access veins in the leg, or thrombosis and embolism formation. Bleeding or bruising at the site where the contrast is injected are minor complications, delayed bleeding can also occur but is rare.[1]

Peripheral angiography-to identify vessel narrowing in patients with leg claudication or cramps, caused by reduced blood flow down the legs and to the feet; in patients with renal stenosis (which commonly causes high blood pressure) and can be used in the head to find and repair stroke.

Other angiographic uses include the diagnosis of retinal vascular disorders, such as diabetic retinopathy and macular degeneration.

An angiogram is commonly used to check the condition of blood vessels. There are alternatives nowadays to angiography, such as CT scan, MRI scans, nuclear scans, and ultrasound scans, which often produce information as accurate and useful as angiograms.

Angiography may be used if the doctor is considering surgery, because it shows a clear picture of the blood vessels.

Angiography may reveal aneurysms (a bulge on an artery caused by a blood vessel wall becoming weaker).

An angiogram can also be used to give a good view of the carotid artery and its branches in the neck and head. This is generally done to investigate a bleed in the brain (cerebral bleed) or identify the blood supply to a tumour. The angiogram can be used to show if an operation is necessary or possible.

Angiography is used to look at the coronary arteries that send blood to the heart. The test is used to show if the arteries of the heart have narrowed.

Angiography is used to look at the arteries in the legs and kidneys, as well as the aorta (the body's largest artery).

Angiography is used to look at the liver to localise abnormalities, including tumours. This can be particularly useful when planning surgery.

How is angiography done?

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Before taking an X-ray, a liquid dye is injected into the blood vessels. When the test is on the arteries of the heart, the carotid artery, or the major arteries coming from the aorta, the catheter is inserted into the groin or most commonly the arm.

Before a catheter can be inserted into an artery, the surrounding area has to be numbed with a local anaesthetic.

A short, thin wire with a rounded tip is then carefully inserted into the artery using a needle. It is guided with the help of fluoroscopy (X-ray images) to the spot where the dye is needed.

The needle is then removed and a vascular sheath inserted around the wire. A catheter may then be inserted along the guide wire.

When the catheter is in the correct position, the wire is pulled out and dye is inserted through the catheter. The patient may experience a feeling of warmth in the area, but this will disappear after a few seconds.

Now the blood vessels can be checked on a screen, or on a series of rapidly recorded X-rays.

IS ANGIOGRAPHY DANGEROUS?

A small minority of patients are allergic to the liquid dye, mainly due to the iodine content of the dye. Anyone who has previously experienced such reactions should mention this to the doctor.

There is a small risk of the catheter damaging the blood vessels that it was inserted through.

There is a small risk of angiography damaging blood vessels because it passes them. So, in heart (coronary) angiography, it is possible that the angiogram can provoke a stroke, heart attack, either of which occasionally lead to death. The absolute risk of some irreversible damage or death is of the order of 1 in 1000. This risk is clearly always balanced against the risks of not performing a coronary angiogram and not obtaining the data necessary to giving the best treatment.

Cerebral angiography carries a small but significant risk of a serious adverse outcome. Pregnant women should enquire about the risks of the fluoroscopy (X-ray screening)

harming their baby. Patients suffering from severe liver, heart or kidney diseases may be at greater risk,

and should seek advice from the specialist. The risk of X-rays being harmful is very small. Modern X-ray machines are designed

to take high quality pictures using the minimum radiation dose.

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