1

BASIC SURGICAL PRACTICE

UNIVERSITY OF MEDICINE AND PHARMACY
FOR THE THIRD YEAR MEDICAL STUDENTS

LIDIA IONESCU
ASSOCIATE PROFESSOR
DEPARTMENT OF SURGERY

GR. T. POPA IASI

INTR ODUC TI ON

1. ASEPSIS AND ANTISEPSIS

Asepsis

This practical guide in surgery is aimed to help you during your medical
training in the different surgical setting such as wards, dressing
rooms, consultation rooms and operative rooms.

A simple definition of asepsis is the absence of any infectious agents.

Surgical asepsis refers to any procedure used to eliminate any
microorganisms.

Easy to read, here you will find when, why and how, different surgical
procedures are applied.

By the process of sterilization it is achieved sterile medical items which are

used during surgical work.

Life in surgery is not comfortable if you are a hesitating and confused

medical student. To get rid of such annoying feelings read the book,
watch carefully what and how the senior surgeons are doing and then
start to practice under supervision.

Aseptic technique means any medical procedure used to prevent

contamination of a person, area or object by microorganisms.
So any surgical work must respect aseptic principles in order to ensure the
safety of the patient and of the surgeon himself.

You will soon realize that what was cloudy has gone.
Sterilization
You will find out in here how to cope with a patient in acute retention of urine
who desperately needs urinary catheterization, how to deal with a
septic wound, what are principles of asepsis and antisepsis upon which
is based the surgical procedures and so on.

Read, watch and practice; this is my advice in your quest to become a

successful doctor.

Sterilization is the process that kills all forms of living matter including
bacteria, viruses and molds with the use of special equipment
employing different physical or chemical agents (moist heat, dry heat,
ethylene oxide gas, gamma irradiation, etc).
The practical criterion of sterility is the failure of microbiological growth to
appear on tests in suitable bacteriologic media.
Sterile is an object or part of the human body without living organisms on
its surface.

Sterilization Procedures

3
1. Moist heat or steam under pressure
This procedure destroys all microbial life through the denaturation and
coagulation of intracellular protein.
The parameters of efficiency are:
- temperature of 140 degree Celsius,
- atmospheric pressure of 2.5

It is particularly useful for heat sensitive or moisture sensitive items such as

lensed instruments, rubber goods, sharp and delicate instruments and for
prepacked commercial medical products such as disposable syringes, suture
materials, drainage tubes, catheters, venflons, needles, etc.
This form of sterilization is dependent on gas concentration, temperature and
exposure time. It is carried out in a pressure vessel (gas autoclave) at slightly
elevated pressure and temperature. Gaseous ethylene oxide as a sterilizing agent
will destroy bacteria, viruses, molds, pathogenic fungi and spores.

- 30 minutes time of sterilization.

Packed item that is outdated, exposed to moisture, dropped on the floor or

punctured is considered contaminated.

The type of moist heat sterilizer commonly used is called autoclave, which is
designed to function rapidly at a high temperature and increased pressure.

4. Radiation sterilization

Moist heat is the most reliable method of sterilizing soft surgical supplies such
as drapes, sheets, gowns, dressings, cotton because of its power of penetration,
microbiologic efficiency, ease of control and economy of time.

This refers to ionizing radiation by cobalt (gamma irradiation). It is currently

used commercially to sterilize disposable hospital supplies such as plastic
syringes, suture materials, etc.

2. Dry heat sterilization

Check the date of expiry written on the pack of the medical items you are going
to use it, sterilized either by ethylene oxide gas or gamma irradiation and if
outdated, do not use it.

This procedure of sterilization is used for items that are spoiled by moisture and
for materials that resist penetration by steam, usually metallic instruments and
glass medical articles.
The process consists of baking the material to be sterilized in a hot-air oven
called Poupinel.
In the absence of moisture, the parameters of efficiency are:

5. Chemical sterilization
This is currently achieved with a 2% aqueous solution glularaldehyde. This
compound is an effective sterilizing agent for surgical, anesthetic catheters or
other heat-sensitive hospital equipment.

- higher temperature (180 degree Celsius)

Either an alkaline solution - Cydex or an acid solution - Sonacide of

glutaraldehyde may be used.

- longer exposure time (1hour) are required.

They equally destroy bacteria, viruses and spores.

3. Ethylene oxide gas sterilization

Cydex is to be used 14 days after its preparation. Before use, the instruments
must be washed up with sterile water.

This is a process that kills bacteria by reacting with the chemical components of
the proteins of the cells.

Disinfection

4
Disinfection of the hospital environment is achieved through the use of
chemical substances to destroy pathogenic infectious agents.
Disinfectant is a chemical substance used to kill organisms on the surface of
inanimate objects such as surgical instruments before sterilization, floors, flush
toilets, etc.
A disinfectant at a low concentration can be used as an antiseptic.
The operating rooms and all the furniture such as operating tables, instrument
tables, lights are cleaned with disinfectants after each operation.
Cleansing with a disinfectant and water of the used surgical instruments is an
essential preliminary to sterilization.
Antisepsis
This refers to the use of chemical substances on skin, mucosa and wounds to
destroy infectious agents.
Surgeons perform the surgical scrub on hands before the operative procedure
with antiseptic solutions.
Also, antiseptic solutions are used carefully for preoperative preparation of the
patients skin in order to create an area of minimal bacterial contamination. This
area is called operative field and in the center of this area will be the surgical
incision of the skin. The margins of the operative field are delineated by sterile
sheets maintained in position by special clips.
A good antiseptic must accomplish the following qualities:
- be effective at low concentration
- have no toxicity for living tissues
- be effective immediately and for a long time
- not staining or having bad smell
- be economic, cost- effective

The most used antiseptics in general surgery are:

Alcohol 70% is a good skin antiseptic that kills bacteria due to its osmotic
properties being capable of penetrating deep into the skin, sebaceous and sweat
glands.
It is not indicated for the treatment of open wounds because it precipitates the
proteins thus facilitating the growth of bacteria underneath.
Iodine 2% is a solution of iodine and alcohol.
It is an efficient antiseptic for the skin; iodine increases the antiseptic power of
the alcohol.
It is very good for skin preparation of the patient in theatre (operative room)
when it is created an operative field.
It may also be used for cleansing vaginal mucosa before gynecological
operations.
Take care of the date of expiry, because outdated solution is toxic for the skin.
Do not use it for skin preparation in the face, scrotum, neo-nates or in allergic
patients.
Do not forget to ask the patient if he is aware of any allergy to iodine. In this
case skin preparation is performed using alcohol 70%.
Betadine
This an aqueous solution of iodine with a good bactericidal action and very well
tolerated by the tissues. It is used for skin preparation preoperatively.
Per-operatively it is used for cleansing bowel cut-ends in entero-colic surgery
and peritoneal lavage in septic operations.
Hydrogen peroxide

5
3% hydrogen peroxide is one of the best antiseptics used for the treatment of the
infected wounds. It has both a good bactericide action and acts as a mechanical
cleanser by removing debris or necrotic tissue due to its foaming effect in
contact with open wound tissues.
It counteracts the foul smell of infected wounds and has a hemostatic action as
well.
Chloramine
This antiseptic is very efficient as it releases chlorine in contact with tissues of
an open wound removing all debris and slough stuff. Therefore it is called "the
chemical scalpel".
Silver nitrate
In a concentration of 1-2 %o it is used as an antiseptic for infected wounds,
especially with Pseudomonas aeruginosa.
In a concentration of 1-2 % it is used for urinary bladder wash outs.
In a concentration of 10-20 % it can cauterize the overgrowth of the granulation
tissue of a wound.
It may also be used in the prophylaxis of neo-nates conjunctivitis.

The surgical scrub is a process of mechanical scrubbing with a chemical

antiseptic solution.
General preparation for surgical scrub includes the following: making sure
fingernails are short and unpolished and removal of all hand jewelry.
The ritual of surgical scrub was imagined by Ignaz Semmelweiss (Wien, 1846)
but it was not accepted into surgical practice until about 1880.
The duration of hands scrubbing varies after the different antiseptic solutions. A
minimum of 4-5 minutes is considered necessary before the first operation and
further on 2 minutes scrub is adequate between next operations scheduled for
the day.
Solutions containing clorhexidine or one of the iodofors appear to be most
effective.
Skin organisms can be divided into two types:
1. Resident flora. This colonizes the skin almost continuously. In normal
healthy adults, the skin is colonized by aerobic and anaerobic bacteria
(acinetobacter, corynebacterium, staphylococcus epidermidis).
These germs are not usually responsible for surgical infections.

Boric acid

The resident flora exists as microcolonies on the skin, often extending deep into
sweat glands, sebaceous glands and hair follicles.

This substance presents as a white powder which can be poured in infected

wounds and it is specially effective against Pseudomonas aeruginosa.

Surgical scrub must take this deep colonization into account.

Iodoform

The most effective agents are those that penetrate deeply and show increasing
residual activity with repeated application (clorhexidine or hexachlorophene).

This substance presents as a yellow, smelly powder, mainly for the dentristy
use, in anaerobes infected cavities.
Surgical scrub
Skin sterilization is not possible; however every effort is made to reduce the
bacterial count of the skin in order to minimize the possibility of microbial
contamination of the surgical wounds.

2. Transient flora. This is composed of a wider variety of organisms.

Their presence, especially on the hands depends on personal hygiene
and environmental circumstances. For example, the hands may
transiently carry Staphylococcus aureus or Proteus mirabilis after
touching the nose or the anus, respectively.

6
In hospitals, doctors hands may become contaminated with microorganisms
after touching patients or secretions infected or colonized with these germs.

Shaving, if required, is performed before the procedure and ideally outside the
operative theatre.

Transient hand carriage of this type of flora is one of the major routes of crossinfection between patients.

The skin preparation removes all transient and resident microorganisms, dirt
and skin oil so that the danger of contamination of the operative field is
minimized.

In the hospital, this transient flora often consists of pathogens resistant to

antibiotics. Therefore pathogenic bacteria on the hands of operarating personnel
at the time of operation must be removed by scrubbing and destroyed by an
antiseptic agent.
Environmental control of the surgical suite
Environmental control of the surgical suite is essential to keep contamination to
a minimum and provide maximum protection for the patient.

After positioning the patient on the operating table, the surgical nurse or the
operator prepares the patient's skin with antiseptic.
The incision line is scrubbed first and the antiseptic is applied to an increasingly
larger area toward the periphery of the field.
Cleansing is vigorously done, employing both chemical and mechanical action.

These factors include:

Particular attention is given to difficult areas such as the umbilicus. After the
skin has been prepared, patient is ready for draping.

- greater room air pressure than in hallway forcing airflow out of the surgical
area,

Draping involves covering patient and surrounding areas with a sterile barrier to
construct a sterile field.

- restricted traffic,

The sterile field

- controlled room temperature of 18-22 degrees Celsius,

The sterile field is the area of the operating room that immediately surrounds
and is especially prepared for the patient.

- controlled humidity of 50%

- air change rate of 18-25 times per hour,
- ultraviolet irradiation following disinfection of the operating room.
The operating room should be considered an isolation zone that may be entered
only by persons wearing clean operating attire which may not be worn
elsewhere.

It is the area around the site of incision. All items needed for the operation are
sterile and used within the sterile field to prevent the transportation of
microorganisms into the open wound.
The sterile field is created by the placement of sterile sheets and towels in a
specific position to maintain the sterility of surface where the operation will be
performed.

Preparation of the patient's skin

The patient and the operating table are covered with sterile sheets so that the site
of incision is exposed, yet isolated.

A wide area of skin around the operative incision is prepared by shaving and
scrubbing.

The sheets are fixed to the patients skin by sterile clips.

Gowning

7
- pick up the sterile gown after scrubbing the hands, being careful to touch only
the inner part.
- hold the inside of the neckband and let the gown unfold keeping the inside part
of the gown towards you.
- with your hands at your shoulder level, insert your arms into the sleeves,
keeping your arms extended.
- the nurse will assist you by pulling the gown over the shoulders and tying it in
the back.
- keep your hands in the air being careful not to touch any unsterile items.
Gloving
- take the left glove from the package by placing the fingers the right hand on
the folded-back cuff, touching only the inner surface of the glove
- insert the left hand into the glove, but do not turn up the cuff
- now take the right glove from the package by slipping gloved left fingers
under the inverted cuff and pull the glove onto the right hand
- the cuffs are now pulled over the sleeves of the gown

Careful attention to these sound principles of sterile technique is mandatory for

the safety of the patient. Once the principles are understood, the need for their
application becomes obvious.
Operating room attire
Regulations for proper attire and conduct in the surgical suite are important
measures in preventing transportation of microorganisms into the
operating room.
All persons who enter restricted areas are required to wear surgical uniform
including cap, facemask, shoe covers.
Street clothes are never worn within restricted areas of surgical suite and
operating attire is never worn outside of operating area. The cap should cover
and contain all the hair.
The mask should cover the mouth and nose and be tied securely. Masks are
handled only by the strings and are discarded after use.

- if a glove becomes contaminated it must be changed immediately.

Sterile gowns and gloves are added to the basic attire for scrubbed team
members.

The following basic principles regarding sterile technique must be mandatory

practiced in the operating room or wherever you do a surgical work:

Gloves are worn to permit the surgeon to handle sterile supplies or tissue of the
operating wound.

- only sterile items are used within a sterile field

MCQ TESTS

- persons who are sterile touch only sterile items, persons who are not sterile
touch only unsterile items

1.1 Asepsis means:

- sterile persons keep within the sterile area; unsterile persons avoid sterile area
- the margins of anything that encloses sterile area is considered unsterile
Destruction of the integrity of microbial barriers results in contamination.

a. the absence of any bacteria,

b. the absence of viruses,
c. decreased amount of the resident flora,
d. decreased amount of transient flora,

8
e. the absence of any living matter.

1.2 A sterile surgical instrument means:

a. a cleansed instrument with normal saline,
b. a cleansed instrument by boiling,
c. an instrument with low content of bacteria,
d. an instrument without any living matter,
e. an instrument cleansed with betadine.
1.3 What do you do if you notice that the urinary catheter you are going to use it
for a patient with acute retention of urine, is outdated:

1.5 What antiseptic is best used for an infected wound with pseudomonas
aeruginosa:
a. normal saline,
b. betadine,
c. alcohol,
d. iodoform,
e. silver nitrate .

a. you use it because there is no time to waste as the patient is in agony,

2. VENUPUNCTURE AND PUTTING UP A DRIP

b. you use it after cleansing it with betadine,

Venupuncture has two major indications: to obtain blood samples for different
tests (for hematology, biochemistry, immunology, bacteriology) and to gain a
peripheral venous access in a patient who needs intravenous fluids and drugs.

c. you ask for another one which is within safety time of expiry,
d. you give the patient some pain killers and postpone the procedure,
e. you use it as it is.
1.4 Chemical sterilization is indicated for:
a. sheets and dressings,
b. metallic instruments,
c. gloves, d. syringes,
d. heat-sensitive surgical equipment,
e. gowns.

The network of superficial veins can be seen on the dorsum of the hand. The
network drains upwards into the lateral cephalic vein and a medial basilica vein.
The cephalic vein crosses the anatomical snuffbox and winds around onto the
anterior aspect of the forearm. It then ascends into the arm and runs along the
lateral border of the biceps. It ends by piercing the deep fascia in the deltopectoral triangle and enters the axillary vein.
The basilica vein can be traced from the dorsum of the hand around the medial
side of the forearm and reaches the anterior aspect just below the elbow. It
pierces the deep fascia at about the middle of the arm. The median cubital vein
links the cephalic and basilic veins in the cubital fossa.
What you need for simple venupuncture:
- a green needle

9
- a syringe of appropriate capacity (don't be caught short using a 10 ml syringe
when you need 20 ml blood)
- an alcohol swab (avoid that when taking blood for alcoholemia)
- a tourniquet

- for peripheral venous access avoid the antecubital fossa and use the forearm
veins below the elbow or posterior aspect of the hand; there is usually a large
prominent vein overlying the back of the distal radius.
- for venupuncture, place the needle on the syringe and insert the needle into the
vein with the bevel of the syringe facing upwards.

- specific sample bottles for the required tests.

- pass the needle with a slight downwards trajectory along the course of the
vein, gently aspirating the syringe once it is below the skin. As soon as you
enter the vein, you will draw back dark venous blood.

What you need for peripheral venous access:

- do not advance the needle any further but continue to aspirate until the syringe
is full.

- a green cannula (venflon)

- adhesive dressing
- a bag of intravenous (i.v.) fluid to administer connected to a giving set, which
you have already "run through"(passing fluid from the bag till the distal part of
the tube connecting to the venflon).
If the cannula is only to be used for intermittent access (e.g i.v. antibiotics every
6 hours, qds), the cannula can be blocked it with a hub till the next use.

-release the tourniquet, apply gentle pressure with a swab over the site of
venupuncture and withdraw the needle.
- ask the patient to continue the pressure over the venupuncture site while you
remove the needle from the syringe and decant the blood into the appropriate
bottles.

To prevent clotting of the cannula, flush it with heparinized saline (100-200

units of heparine in 10ml of saline).

Carefully label the bottles and the correct forms with the patients name and
hospital number. Do not waste your time by mislabeling or misplacing blood in
inappropriate bottles; the lab will not process them and will just throw them
away.

Procedure

For venous access, the technique is the same as that for venupuncture.

- place the tourniquet on the upper arm, midway between elbow and the
shoulder

The cannula can be used immediately for obtaining blood samples; if not
required immediately lock with a hub following a flush through with
heparinized saline.

- examine the posterior aspect of the hand and forearm for sites of maximal
venous engorgement.
- swab the skin at the site of venous access and wait 40 sec. for the alcohol to
dry.
- for venupuncture use either the cephalic or basilica vein in the antecubital
fossa.

In case of immediate i.v. fluid administration, simply connect up the giving set
you have already prepared and gentle start the infusion.
If your infusion causes pain or the region around the vein balloons up then your
drip site is compromised (has tissued).
Stop the drip immediately, place a swab over the cannula entry site and gently
withdraw the cannula. Start all over again.

10
Once successful, tape the cannula and giving set securely and comfortably to
the patients arm.
Problems you might face and solutions
1. Poor veins - place the forearm in a lower position than the body's level
to cause venous dilatation.
2. Fragile veins, particularly in the elderly and patients on chronic steroid
treatment - consider a smaller cannula or use butterfly.
3. Post-procedure bleeding-elevate the patient's arm above the head, this
will cause the veins to collapse and the bleeding stop, in the meanwhile
keep pressure with a swab over the bleeding puncture-site.
4. Thrombophlebitis related with an indwelling cannula - choose another
vein if the patient needs further i.v. fluids and give nonsteroidal
antiinflammatory medication. The pain is troublesome but this
condition never complicates with pulmonary embolism as deep
vein thrombosis does.

c. internal saphenous vein,

d. internal jugular vein,
e. femoral vein.
2.3 What do you do if a patient presents frequent vomitting and canulla related
thromboflebitis and he still needs intravenous antibiotics:
a. keep the canulla till the end of antibiotherapy,
b. keep the canulla and give pain killers,
c. keep the canulla and apply ice bag over the inflammed area.
d. take out the canulla and give antibiotics orally,
e. take out the canulla and insert another canulla into another vein in the
controlateral arm.
2.4 What do you do in a case of post-procedure bleeding:

MCQ tests

a. put the arm of the patient in a lower position,

2.1 For peripheral venous access, what is the best vein to use in an young pcte::

b. elevate the arm and keep pressure over the puncture site for a couple of
minutes, c. take a blood pressure at that arm,

a. external jugular vein,

b. internal saphenous vein,
c. external saphenous vein,

d. give hemostatic drugs,

e. give anticoagulant drugs.

d. a vein in the antecubital fossa,

2.5 The following statements about canulla-related thrombophlebitis are true

EXCEPT ONE:

e. a vein in the forearm or dorsum of the hand.

a. the patient presents local pain at the site of canulla,

2.2 For simple venupuncture you should use:

b. the skin over the entry site of the canulla is red,

a. the most visible vein of the forearm,

c. the redness extends along the traject of the vein,

b. external jugular vein,

d. the migration of a thrombus from a superficial thrombophlebitis can result in

pulmonary embolism,

11
e. a superficial thrombophlebitis can never complicates with pulmonary
embolism.
Allen test
3. ARTERIAL PUNCTURE
Hold the patient's hand up and palpate the radial and ulnaris arteries at the wrist.

Arterial puncture is indicated in critically ill patients for arterial blood gas
measurements (ABGs).
This is an important investigation which gives us a clue about acid-base
imbalance.
What you need for arterial puncture:
- a green needle
- a special syringe of 2 ml containing 100 units of heparine
- alcohol swab and a blind syringe hub
When the femoral artery is used for puncture, lay the patient supine on the bed.
In fat patients, ask your assistant to retract the abdominal apron to display the
groin.
Femoral artery enters the thigh by passing behind the inguinal ligament, as a
continuation of the external iliac artery. Here it lies midway between the
anterior superior iliac spine and the symphisis pubis. Its pulsations are easily
felt.
The femoral vein leaves the thigh by passing behind the inguinal ligament
medial to the pulsating femoral artery.
When the radial artery is used for puncture perform firstly the Allen test to
establish the competence of the radial and ulnar arteries in the supplying the
hand.
The pulsations of the radial artery can easily be felt anterior to the distal third of
the radius. Here, it lies just beneath the skin and fascia lateral to the tendon of
flexor carpi ulnari.

Occlude both with pressure and ask the patient to clench and open the hand
several times.
The hand becomes blanched. Release pressure on the ulnar artery and watch a
blush appearing rapidly over the hand, demonstrating the patency of the ulnar
artery.
Repeat with the radial artery. Patency of both arteries is required before
proceeding.
Procedure - femoral artery puncture
Locate the femoral pulse at the mid-inguinal point (middle between the anterior
superior iliac spine and symphysis pubis)
Place the index and third finger of your non-dominant hand either side of the
pulse and press to fix the artery.
Pass your needle between these two fingers, vertical downwards through the
artery, so transfixing it.
Gentle withdraw the needle and as it passes back through lumen of the artery,
the arterial pressure will cause bright blood to fill the syringe.
Remove the needle and get your assistant to press on arterial puncture site for at
least 5 min.
Ensure that there is no air bubble trapped within the syringe and seal the syringe
immediately with the blind hub.
Transfer the arterial sample on ice directly to the lab.
Needle puncture is used to measure ABCs while an indwelling cannula can be
used both for blood sampling and for BP monitoring in intensive care unit.

12

Arterial blood gasses- normal values

Respiratory acidosis

Ph= 7.35- 7.45

This occurs when alveolar ventilation is insufficient to excrete metabolically

produced C02.

PCO2= 35-45mm Hg

Causes:

PO2=90-110mm Hg
HCO3= 22-27 mmol/l
Base excess= -3 to +3
Acid-base homeostasis represents an equilibrium between the concentration of
H+, PO2 and HCO3. In clinical practice, H+ concentration is expressed as Ph.
Acidosis and alkalosis describe processes that cause the accumulation of acid or
alkali, respectively.
Acid-base imbalance
Imbalance
1. Respiratory

atelectasis and sputum retention

massive pulmonary embolism

respiratory center depression - drugs (morphine)

neuromuscular disorders - myasthenia gravis

cardio-pulmonary arrest.

Chronic respiratory acidosis may occur in pulmonary disease such as chronic

emphysema and bronchitis.

Ph

initial change

compensatory

low

high PCO2

high HCO3

The diagnosis of acute respiratory acidosis usually is evident from the clinical
situation, especially if respiration is obvious depressed. Appropriate therapy is
correction of the underlying disorder.

high

low PCO2

low HCO3

Definitions of the medical terms used in text

acidosis
2. Respiratory
alkalosis
3. Metabolic

low

low HCO3

low PCO2

Pulmonary emphysema means an increase in the size of the air space in the
lungs distal to the terminal bronchioles. Subcutaneous emphysema means the
presence of air or gas in subcutaneous tissues (usually following a chest trauma
or gas forming soft tissue infections)

high

high HCO3

high PCO2

Pulmonary atelectasis means collapse of the lung

acidosis
4. Metabolic
alkalosis

Pulmonary embolism means blocking of the pulmonary artery usually by a clot.

Myasthenia gravis is a neuro-muscular disorder due to the presence of
antibodies against acetylcholine receptors at the neuromuscular junction.

13
Anemia is reduction of the number of red cells and quantity of hemoglobin in
the blood.
Respiratory alkalosis
Metabolic acidosis
This is the result of acute or chronic hyperventilation.
This results from the accumulation of acids, reduction of renal acid excretion or
loss of alkali.

Causes:
-

acute hypoxia, due to pneumonia, pneumothorax, pulmonary edema

Causes

chronic hypoxia, due to cyanotic heart diseases, anemia

- increased acid production

respiratory center stimulation caused by anxiety, fever, Gram negative

sepsis

- ketoacidosis (diabetes, alcoholism, starvation)

excessive ventilation in the mechanically ventilated patient.

- lactic acidosis (critically ill patient)

- toxic ingestion (salicylates, methanol)
- renal failure
Definitions of the medical terms used in text
Pneumonia is inflammation of the lungs with exudation and consolidation.
Pneumothorax is presence of air in the pleural space, usually as a result of
chest trauma.

- loss of alkali (diarrhea)

Treatment must be directed primarily to the underlying cause.
Bicarbonate therapy should be considered in patients with moderate to severe
metabolic acidosis, depending on the etiology.

Pulmonary edema is diffuse extra-vascular accumulation of fluid in the

pulmonary tissues and air spaces due to change in hydrostatic forces in the
capillaries or to increased capillary permeability; the clinical sign is dyspnea.

Metabolic alkalosis

Edema in general is an abnormal accumulation of fluid in intercellular spaces

of the body.

- diuretic therapy

Hypoxia is reduction of oxygen supply to a tissue below physiological levels

despite adequate perfusion of the tissue by blood.
Hypoxemia means deficient oxygenation of the blood.
Cyanosis means a bluish discoloration of skin and mucous membranes due to
excessive concentration of reduced hemoglobin in the blood.

The most common causes of metabolic alkalosis in the surgical patient include:

- acid loss through gastro-intestinal secretions (frequent vomiting), as happens

in pyloric stenosis.
- exogenous administration of HCO3 or HCO3 precursors (citrate in blood).
Medical terms definition
Pyloric stenosis is a clinical condition in which there is an obstruction (tumour,
chronic ulcer healed by excessive fibrosis) at the level of pylorus.

14
Pyloric ulcer (peptic ulcer) lack of substance in the parietal layers of pyloric
region, due to the action of the acid gastric juice.
3.3 In what clinical condition may appear metabolic acidosis:
Under normal circumstances, the excess in bicarbonates is excreted rapidly in
the urine.

a. respiratory center depression,

Consequently, maintenance of metabolic alkalosis requires an impairment in

renal HCO3 excretion, most commonly due to volume and chloride depletion.
Replenishment of Cl corrects the metabolic alkalosis (normal saline).

b. severe myasthenia gravis,

Treatment principles in metabolic alkalosis include identifying and removing

underlying causes.

d. cardiopulmonary arrest,

Initial therapy should include the correction of volume deficits (with normal
saline) and hypokalemia.
Patients with vomiting and nasogastric suctioning may also benefit from H2receptor antagonists or other acid-suppressing drugs.MCQ tests

c. diabetic ketoacidosis,

e. pulmonary edema
3.4 Metabolic alkalosis may happen in:
a. pneumonia,
b. pulmonary embolism,

3.1 Massive pulmonary embolism induces:

c. cardiac arrest,

a. respiratory acidosis,

d. pyloric stenosis,

b. respiratory alkalosis,

e. acute hypoxia

c. metabolic acidosis,

3.5 Metabolic alkalosis may happen due to:

d. metabolic alkalosis,

a. severe infection with high fever,

e. none.

b. acid loss due to frequent vomiting,

3.2 Acute hypoxia induces:

c. severe bleeding,

a. metabolic alkalosis,

d. pulmonary hyperventilation,

b. metabolic acidosis,

e. acute hypoxia.

c. respiratory acidosis,
d. respiratory alkalosis,
e. none.

15
Paralytic ileus is a non-functioning bowel without any mechanical obstruction
(e.g. of mechanical obstruction- obstructing tumour, bowel kinking due to
adhesions or fibrous bands) resulting in abdominal distension.
4. PASSING A NASOGASTRIC TUBE
Nasogastric tubes are used in a variety of clinical conditions:

What you need for passing a naso-gastric tube.

- to allow fluid in excess to escape from a distended stomach (pyloric stenosis,

high small bowel obstruction)

- a suitably decent sized nasogastric tube

- a pair of gloves

- to instill fluid for gastric lavage ( preparation of the stomach for upper
endoscopy)
- to instill feeding solutions into the stomach, indicated in a patient in coma or
in prolonged mechanically ventilated patient).
Nasogastric tubes are either single lumen (Levin) or double lumen (sump tube).
Most NG tubes have a radioopaque stripe that can be identified easily on CXR/
plain abdominal X ray, giving us informations about the position of the tube
within the digestive tract.
Indications:

- a lubricating jelly and lignocaine throat spray

- a syringe.
Procedure
The NG tube is inserted at the bedside.
Provide local anesthesia with lignocaine throat spray, if necessary.
Grease the end of the tube with the lubricating jelly and pass it into the patients
nostril and then horizontally along the floor of the nasal cavity.
Tilt the patients head slightly forwards and ask him to swallow. The tip of the
tube should now enter the pharynx.

postoperative gastric decompression

persistent paralytic ileus

small bowel obstruction

As you continue to advance the tube it should engage the hypo-pharynx and
with the swallowing action, enter the esophagus.

enteral nutrition

Continue to advance the tube until more than 60 cm of tube has been passed.

gastric lavage (preparation for upper digestive endoscopy)

Check the position of the tube by:

administration of medication.

- aspirating gastric contents which should be acid when tested with litmus paper.

Medical term definition

- ascultation of the stomach while your assistant injects air down the tube, you
should hear air bubbling (typical rumbling sound of the air entering the fluid
stomach).

16
- a CXR or abdominal X ray can be obtained to confirm correct placement, but
usually this is unnecessary.

Peritonitis - inflammation of the peritoneum which may be due to chemical

irritation (gastric acid from a perforated peptic ulcer) or bacterial invasion.

The tube should be flushed with 30 ml of saline or water every 4 hours to

maintain patency.

Gastro-esophageal reflux means the ascending of the gastric content into the
esophagus due to lower esophageal sphincter incompetence.

Sump tube (double lumen tube) can be connected to low intermittent suction ( a
patent air port prevents tube adherence to the stomach wall) or can be left to
gravity drainage or capped off.

Esophagitis - inflammation of the esophageal mucosa due to chemical irritation

(gastric acid or bile reflux).

To prevent injury to the gastric mucosa, single-lumen tube should not be

connected to continuous suction.
The NG tube is removed with gentle traction.
Problems you might face and solutions
1. Patient wont swallow- try again while at the same time the patient is
swallowing sips of water.
2. Meet resistance in the esophagus- give up, this tube needs to be passed under
radiological control.
3. Anxious patient - explain the procedure and reassure that procedure is for his
benefit and you need his cooperation.
Complications
Perforation of the esophagus, stomach or duodenum is rare may result in
mediastinitis or peritonitis.

Aspiration pneumonitis - inflammation of the lungs due to aspiration of gastric

content into the respiratory tree.
MCQ TESTS
4.1 The following indications of the nasogastric tube are correct EXCEPT ONE:
a. decompression of the stomach,
b. aspirating pneumonitis,
c. gastric lavage,
d. instilling the feeding solutions,
e. small bowel obstruction.
4.2 The length of a nasogastric tube must be:
a. 20 cm,
b. 25 cm,

The tube prevents closure of the lower gastroesophageal sphincter and might
lead to gastroesophageal reflux, esophagitis, esophageal stricture or bronchial
aspiration of gastric contents inducing aspiration pneumonitis.

c. 30 cm,

Medical terms definitions

e. 35 cm.

Mediastinitis - inflammation of the mediastinum (life-threatening medical

condition)

4.3 The following statements regarding passing a nasogastric tube are correct
EXCEPT ONE:

d. more than 60 cm,

a. the tube is passed through a nostril,

17
b. the patient must cooperate by swallowing in order to engage the tube into
the esophagus,

The male urethra is about 20 cm in length from the bladder to the external
meatus on the glans penis.

c. the tube has reached the stomach when gastric content can be aspirated into a
syringe,

It is divided into three parts: prostatic, membranous and penile.

d. the nasogastric tubes are always passed through the mouth,

e. the naso-gastric tube can be used for feeding.
4.4 The feeding nasogastric tube can be used :

The prostatic urethra lies within the prostate and is the widest and the most
dilatable portion of the urethra.
The membranous urethra lies within the urogenital diaphragm surrounded by
the sphincter urethrae muscle. It is the least dilatable portion of the urethra.

a. in a patient with prolonged mechanical ventilation,

The penile urethra is enclosed in the bulb and the corpus spongiosum of the
penis.

b. in a patient with esophageal perforation,

The external meatus is the narrowest part of the entire urethra.

c. in a patient with reflux esophagitis,

The part of the urethra that lies within the glans penis is dilated to form the
fossa terminalis (navicular fossa).

d. in a patient with aspirating pneumonitis,

e. in a patient with complete esophageal obstruction.

Female urethra

a. pyloric stenosis,

The female urethra is about 4 cm long. It extends from the neck of the bladder
to the vestibule, where it opens about 2.5 cm below the clitoris. It transverses
the sphincter urethrae and lies immediately in front of the vagina.

b. duodenal obstruction,

The anatomy you should remember before passing an urinary catheter in men.

c. small bowel obstruction,

1. the external orifice at the glans penis is the narrowest part of the entire
urethra

4.5 Passing a nasogastric tube is not indicated in:

d. gastro-esophageal reflux,
e. gastric lavage.

5. URETHRAL CATHETERIZATION
Anatomy
Male urethra

2. within the glans the urethra dilates to form the fossa terminalis
3. near the posterior end of the fossa, a fold of mucous membrane projects into
the lumen from the roof.
4. the membranous part of the urethra is narrow and fixed
5. the prostatic part of the urethra is the widest and most dilatable part of the
urethra

18
6. by holding the penis upward, the S-shaped curve of the urethra is converted
into a J-shaped curve.
Indications:
-monitoring urinary output (critically ill patient and perioperatively)
- acute retention of urine

5. When the catheter has advanced to the junction of the penile and
membranous urethra at the level of the external sphincter, bring the penis down
to lie horizontally while you advance the catheter through the prostatic urethra.
6. When urine begins to flow, inflate the balloon of the catheter.
7. Connect up the catheter to a collecting bag.

- urinary incontinence
- facilitation of abdominal surgical procedure (particularly pelvic operations).
What you need for urethral catheterization:
-

a Foley catheter (size 12-16 F)

a syringe with saline already drawn up

a sterile catheter pack containing drapes, kidney dish, cotton balls,

swabs, pots, plastic forceps, antiseptic cleansing, lignocaine jelly and
an urinary collecting system

a relaxed and reassured patient.

Procedure
1. With the patient supine on the bed, clean the genital area (glans with external
urethral meatus). In a man retract foreskin (prepuce) unless he is circumcised, to
display external urethral meatus. In a woman, ask her to open her legs,
supporting her knees placing the soles of her feet together. With the fingers of
your left hand gently lift and retract the labia to expose the urethral meatus.
Clean the area with an appropriate antiseptic.
2. Gently inject the urethra with sterile lignocaine jelly.
3. In a man lift up the penis and hold it in a vertical position.
4. Begin to pass the catheter. Do not force it if you encounter any resistance, this
may be a stricture and will only damage the urethra further and may create a
false passage.

Problems you might face and solutions

1. Unable to pass the catheter- do not keep on trying to pass it yourself, call for
help; there may be a stricture or false passage and these require an expert.
2. The catheter passed but no urine comes out- the tip of the catheter may be
smeared with lubricating jelly, gently inject 10 ml of normal saline up the
catheter. Urine should then flow back.
If nothing happens, either you are in a false passage or the patient is anuric. Do
not inflate the balloon and call for help.
3. When decompressing a grossly distended bladder following chronic
retention of urine which aggravates into acute retention of urine, let the
urine out slowly by intermittently clamping the catheter. Release 200300 ml of urine every 30 min as rapid decompression may result in
hemorrhage from the bladder mucosa. The effect is macroscopic
hematuria.
4. These patients can have an increased dieresis over the next 48-72 hours
after the back pressure is taken off the kidney, therefore they can
become dehydrated if the urinary losses are not compensated.
The urethra is an extremely sensitive structure and catheterization is an
uncomfortable procedure; so take your time, explain to the patient what you are
going to do and for what reason, ask him to stay relaxed as you will use plenty
of local anesthetic lubricating jelly.
Always use as small a catheter as will be effective.

19
If difficulties arise, you must try a smaller gauge catheter or perform a suprapubic catheterization.
You must never use force.
It takes only a second to damage a urethra, but to the patient this may mean a
lifetime of micturition difficulties, repeated instrumentation of urethra and
hospitalizations.
Perform this procedure only in a sterile fashion, so any part of the catheter that
passes into the urethra must be and remain sterile.

Failure to deflate the balloon of the catheter

Occasionally you may face with the problem of a Foley catheter that cannot be
removed. The cause of this is almost invariably a failure of the Foley balloon to
deflate, despite attempts to withdraw the water from the balloon.

If by chance you compromised the sterility of the catheter, discard it and ask for
another sterile catheter.
The blocked catheter
5. Urethral catheters, unfortunately, do frequently become blocked. The
problem occurs commonly in two different circumstances: the long
term indwelling catheter that becomes blocked by accumulated debris
and the postoperative TURP (transurethral resection of prostate) when
the catheter becomes blocked by blood clot or by loose prostatic or
bladder tissue.
The following steps may be helpful in overcoming the problem:
Check that the catheter is indeed blocked.
Check the site of the blockage; usually this is at the eye of the catheter within
the bladder but occasionally blockage owing to clots can occur at the junction of
the urine bag and its tube.

One of the following procedures may be effective:

- the balloon can become soften if 5 ml of liquid paraffin is introduced into it
via the inflating channel.
- pass a stylet wire along the inflating channel of the catheter until reaches the
balloon. A sharp forward movement and the balloon will be pierced.
- locate the balloon within the bladder by rectal palpation, then introduce into
the bladder a long thin needle (lumbar puncture needle) under local anesthetic
suprapubically and guiding it with the other hand on the balloon, thus bursting it
and allowing the catheter to be withdrawn.
Suprapubic catheterization
This procedure is an alternative to evacuate an overdistended urinary bladder
when urethral catheterization is not feasible for any reason.

If the blockage seems to be in the catheter, check that the catheter is correctly
placed in the bladder. The balloon should lie in the bladder and not in the
prostatic cavity. Try to wash out any clots that have accumulated with a 60 ml
bladder syringe with normal saline.

Sterile technique is essential.

If this maneuver fails, the catheter will probably have to be changed. Catheter
changing should not be undertaken lightly.

For this procedure the bladder must be distended so a clinical diagnosis of

retention of urine must be done correctly. If you are in doubt ask for an

Suprapubic catheter is prepacked and each pack contains specific instructions

for use.

20
ultrasound examination of the pelvis to confirm the clinical diagnosis of acute
retention of urine.

-drugs: anticholinergics, smooth muscle relaxants.

Procedure
1. Clean the suprapubic skin and select a point 5 cm above the pubic symphysis
and in the mid-line.
2. Use lignocaine 1% in a 10 ml syringe with a green needle and slowly inject
the substance in the skin, subcutaneous tissue, fascia and properitoneal fat.

Urethral stricture
Urethral strictures follow damage or destruction of the urethal mucosa.

3. When the needle is completely buried and all the local anesthetic has been
expelled, withdraw the plunger, you should obtain urine.
If you do, make a small incision in the skin and rectus sheath with a knife blade
and proceed with the technique of introducing the catheter according to the
instructions contained in the pack

The common causes

traumatic: catheterization, prostatectomy, direct injuries
inflammatory: gonorrhoea, meatal ulceration.

If urine is not obtained, stop and ask for help.

Acute retention of urine is the sudden inability to micturate in the presence of a
painful distended bladder.
The causes of retention of urine
1. Mechanical
- in the lumen of the urethra: tumour, blood clot, stones
- in the wall of the bladder or urethra: rupture of the urethra, urethral stricture,
tumour, prostatic enlargement (benign or malignant)
- outside the wall: fecal impaction, paraphimosis
2. Neurogenic
-postoperative retention
-spinal cord injuries
-hysteria

Medical terms definitions

Urinary incontinence means inability to control the voiding of urine.
Anuria means complete suppression of urine formation by the kidney.
Oliguria means diminished urine secretion by the kidney.
MCQ TESTS
5.1 The widest part of the male urethra is at the level of:
a. external orifice,
b. fossa terminalis,
c. membranous urethra,
d. prostatic urethra,
e. junction between urethra and urinary bladder

21
5.2 The indications of urinary catheterization are the following EXCEPT ONE:

d. rupture of the urethra,

a. acute retention of urine,

e. prostatic enlargement.

b. urinary tract infection,

c. urinary incontinence,
d. monitoring the urine output in critically ill patient,
e. perioperative in pelvic surgery.
5.3 Anuria is:
a. complete suppression of urine formation by the kidneys,
b. diminished urine secretion by the kidneys,
c. inability to control the voiding of urine,
d. the presence of blood in the urine,
e. the presence of pus in the urine.
5.4 What is the most serious complication of the urinary catheterization:
a. urinary tract infection,

6. ASPIRATION OF A PLEURAL EFFUSION OR CHEST ASPIRATION

OR THORACOCENTESIS
Chest aspiration is required when there is fluid in the pleural cavity. That is
invariably pathological and therefore removal the fluid is necessary for
diagnostic or therapeutic purposes.
The fluid removed may be examined to determine if it is transudate (low protein
content) or an exudate (high protein content).
It should also be examined for the presence of cells, if malignant disease is
suspected, or bacteria if infection is to be proved.
Therapeutic removal of fluid, in significant amounts, may assist ventilation and
allow the lung to re-expand.

b. local pain,

If infection is present, the drainage of the infected fluid may in itself be

therapeutic.

c. unbearable sensation to micturate,

When repeated thoracocenteses are necessary, chest drainage is more effective.

d. renal colic,

Risks of the procedure

e. create a false passage resulting in an urethral stricture.

If an effusion is present and is not infected, then introducing a needle can also
introduce infection and this risk should be balanced against the benefits.

5.5 The mechanical causes of the acute retention of urine are EXCEPT ONE:
a. urethral tumour,
b. urethral stones,
c. spinal cord injury,

Coagulopathy is a relative contraindication due to bleeding risk.

If positive pressure ventilation is required then using a needle to remove fluid
carries the risk of damage to the visceral pleura therefore there is potential risk
of a pneumothorax; the alveolar pressure is considerably higher than

22
spontaneous breathing and the combination of a small hole and positive
pressure may result in a large leak-analogous to a puncture in the inner tube of a
tyre.
The size of the effusion, as determined by X-ray and clinical judgement, should
indicate the site of puncture.
What you need for chest aspiration:
- sterile gloves
- chest aspiration pack containing a sterile dressing pack, a large syringe, a long
wide bore needle, a 3-way-tap and a large jug.

jug. Take about 1 l of the effusion at each sitting, no more 9 l (re-expansion of

the lung that occurs when the fluid is removed can result in pulmonary edema.
6. When finished, place a waterproof dressing over the site and check the result
by chest X ray.
Problems
1. Dry tap- may be an organized empyema, get help
2. Pneumothorax-the drainage tube is the best option

- local anesthetic (10 ml of 1% lignocaine)

3. Unexpectedly very bloody aspirate-you have punctured an intercostals

vessel. Keep the patient on quarter hourly observation for the next 3-4
hours and repeat CXR at this time.

- specimen bottles for biochemistry, microbiology and cytology

4. Re-expansion pulmonary edema

- one assistant.
Position of the patient

MCQ TESTS

Seated and leaned over a bedside table with the hands on the table.

6.1 What might be the risk of thoracocentesis in a positive pressure ventilated

patient: a. septic risk,

Procedure
1. After the image of a chest X ray or after the guidance of an ultrasound of the
chest fluid, the site of puncture is established.

b. pneumothorax,
c. excessive coughing,

2. Infiltrate the site of chest drainage with local anesthetic 1% lignocaine to

obtain a numbed area. Usually the site of puncture is in an intercostal space
from 6 to 8 in the midaxillary or posterior axillary line.

d. pneumonia,

3. Mount the 3-way-tap onto the syringe and attach the needle to the 3-way-tap.

6.2 What means a high protein content of the pleural effusion:

4. Gently insert the needle through the anesthetized skin and slide the needle
over the superior margin of the rib into the pleural space so avoiding the
neurovascular bundle.

a. exudates,

5. Aspirate the effusion, taking samples of the first aspirate for laboratory
investigation. As the syringe fills, empty the contents via the 3-way-tap into the

e. atelectasis.

b. transudate,
c. hemothorax,
d. pneumothorax,

23
e. chylothorax.
6.3 What is the position of the patient when you want to do a left chest
aspiration: a. decubitus position,
b. procubitus position,
c. on the left lateral side,
d. Trendelenburg position,
e. seated and leaned over a bedside table.
6.4 Where is the best site for chest aspiration:
a. second intercostal space,
b. third intercostal space,

This is the technique by which air or fluid can be drained from the chest and is
useful in a variety of clinical conditions.
Indications
This technique is used in any situation when either air or fluid present in the
pleural space is likely to cause respiratory failure.
Note that a small effusion or small pneumothorax is often managed effectively
with careful observation alone and chest drainage is not always necessary.
From a diagnostic viewpoint, when dealing with either chest trauma or
postoperative thoracic surgery, chest drainage is useful in evaluating the rate of
hemorrhage and monitoring the pleural drainage.
Contraindications
1. Coagulopathy necessitates special care to avoid bleeding.

th

c. 7 intercostal space, inferior margin of the rib, in the posterior axillary line,

2. The risk of infecting the pleural space should always be considered.

th

d. 7 intercostals space, over the superior margin of the rib in the posterior
axillary line,
e. 10th intercostal space in the anterior axillary line.
6.5 How can you assess the best site for chest aspiration:
a. ascultation of the chest,
b. percussion of the chest,

Technique
In general, a no. 22-24 Fr chest tube directed apically is used for pneumothorax
and a no. 32-36 Fr tube directed basally is used for the evacuation of
hemothorax or a dependent effusion.
Position the patient in lateral position with the affected side exposed, the arm
must be abducted.

c. observation of the respiratory movements,

Ask a CXR to check the position of the diaphragm so as to avoid introducing

the drain subdiaphragmatically and to document the chest injuries.

d. palpation of the chest,

Clean the area thoroughly and drape.

e. chest X ray or ultrasound of the lower thorax in seated position

Find the sixth intercostal space in the midaxillary line infiltrate local anesthetic
solution. The skin, intercostal muscles and the parietal pleura which is
particularly sensitive, must all be infiltrated.

7. CHEST DRAINAGE OR TUBE THORACOSTOMY

Make an incision in the skin parallel to the rib over the 6th intercostals space.
The incision should be large enough for the chest drain to pass through.

24
Avoiding the lower margin of the 6th, where the neurovascular bundle runs, use
a pair of forceps or scissors for blunt dissection through the intercostals muscles
to the pleural and push the forceps through into the pleural space.
Alternatively, introduce a short trocar through the chest wall, through which the
drain can be placed.
Advance the intercostals tube into the pleura and use your finger to direct it in
the required direction-upwards or posteriorly.

of the drain can result in air escaping from the pleura into the tissues.
Check that the tubing is not kinked or obstructed.
Medical term definitions
Arterial aneurysm is a sac formed by localized dilatation of an artery.
Pleural empyema is accumulation of pus in the pleural space.

Close each side of the incision around the tube and secure the tube in situ.

Hemothorax is accumulation of blood in the pleural space usually

following a chest trauma.

Attach the tube to an underwater sealed drain. Check to see that water in the
tube moves with ventilation. It should swing.

Pneumothorax is accumulation of air in the pleural space usually following

a chest trauma.

Ask for a check CXR to confirm the position of the drainage chest tube.

Underwater seal drainage

A chest drain, if left open, can equalize the pleural pressure with the
atmosphere.

Complications
1. The low placement of chest tubes may result in injury to
intraperitoneal structures such as the liver or spleen.
2.

Parenchymal lung injuries and cardiac contusion or perforation

can occur with overzealous advancement of the tube into the pleural
space.

The lung, not held by the negative intrapleural pressure, will collapse.
During inspiration, while the patient is breathing spontaneously air will be
entrained; therefore in a spontaneously breathing patient, a valve which will let
air out during expiration but not allow it back in is required. This can be
achieved with an underwater seal drain.

3. Other complications include: subcutaneous emphysema, re-expansion

pulmonary edema, esophageal perforation, intercostal artery aneurysm.

The principle is simple. A length of tubing connects the chest drain to a sealed
bottle containing fluid. The end of the tube is immersed in the fluid and an air
vent allows air to pass out bottle.

4. Sepsis is a potential problem in any invasive procedure and this is a

route by which the pleural space can become infected and an empyema
can develop.

For air to escape from the chest, it must pass through the tube and out through
the fluid. The height of the fluid in the tube, where it is immersed, is the
hydrostatic pressure (5 cm H2O) which must be overcome.

5. Tube blockage can occur if there is bleeding into the chest and it may
be necessary to insert further drains to facilitate drainage.

For drainage of air a simple underwater seal can be used.

6. Surgical emphysema develops when there is a leak through the parietal

pleura but not through the skin. Any blockage or increase in resistence

If fluid is to be drained then the level in bottle will rise and there will be an
increased resistance to drainage.

25
A second bottle can be added so that the patient drains into an empty bottle
which acts as a fluid trap; this is then connected to an underwater seal drain. Air
cannot be entrained past the seal but fluid can drain easily.

e. 4th intercostals space, midaxillary line.

Removal of chest drain

a. drainage of a small hemothorax,

A chest drain should only be left in situ for as long as it serves a purpose.

b. drainage of a small pneumothorax,

However, in intensive care unit, special attention should be given as positive

pressure ventilation will tend to potentiate leaks.

c. drainage of a small hemopneumothorax,

If drainage of air, blood or fluid has stopped then the need for the drain is no
longer apparent and the tube can be removed.
A more cautious approach is to clamp the drain for 24 hours and if no air is seen
on CXR, then it can be removed.

7.3 What is the indication for chest drainage tube:

d. pain relief after a rib fracture,

e. drainage of a hemo or pneumothorax which induces respiratory
embarrasment.
7.4 Chest drainage tube requires:
a. a gravitational drainage,

MCQ TESTS
7.1 The following complications might appear after chest drainage EXCEPT
ONE: a. diaphragmatic perforation in low insertion of the tube,

b. an open drainage,
c. closed drainage,
d. underwater sealed drainage,

b. injury to the intercostals vessels,

e. suction drainage.

c. empyema of the pleural space,

7.5 What might happen if the chest drainage tube is not connected to an
underwater sealed drainage:

d. subcutaneous emphysema,
e. aspiration pneumonitis.
7.2 Where is the best entry site for the chest drainage tube:
a. 2nd intercostal space, anterior axillary line,
b. first intercostals space, anterior axillary line,
c. 10th intercostals space, anterior axillary line,
d. 6th intercostal space, midaxillary line,

a. hemothorax,
b. pneumothorax,
c. chest pain,
d. pleural empyema,
e. aspiration pnumonitis.

26
8. INTERCOSTAL NERVE BLOCK

a 20 ml syringe and a green needle

Anatomy

20 ml of 1% marcaine

The upper edge of the ribs is thick, rounded and smooth while the lower thinner
edge has a subcostal groove. The outer lip of this groove is the insertion site of
the external intercostal muscle, as the internal intercostal muscle is inserted on
the inner lip.

dressing pack and topical skin antiseptic.

The intercostal nerve emerges from the intervertebral foramen and gives off a
posterior branch. It then passes into the space and gives three further branches,
the collateral branch and the anterior and lateral cutaneous branches. The
collateral branch supplies the intercostal muscles, rib periosteum and parietal
pleura.
The anterior cutaneous branch supplies the skin over the front the thorax or in
the case of the lower intercostals, the upper abdomen and associated muscles.
The lateral cutaneous branch arises from the main nerve in the mid-axillary line
and supplies the skin over the lateral chest wall.

Position of the patient

Seated with the chest leaned forwards
Preparation of the skin
Use iodine over the back of the chest including the rib avobe and rib below the
broken ribs
Procedure
1. Palpate the intercostal spaces assessing the lower margin where the
intercostal bundle is located
2. Pass the needle of the syringe containing the local anesthetic under the rib.

Indications

3. Aspirate and if no blood or air is drawn back, then infiltrate 3-5 ml.

Indications include analgesia both in emergency and in elective postoperative

situations.

4. Repeat the procedure at the sites above and below the broken rib.
5. Ask for a check CXR to exclude a pneumothorax.

In the emergency situation, the pain resulted from fractured ribs can be
alleviated.

Problems

These are extremely painful and may inhibit chest wall movements making
normal breathing difficult.

If you draw blood or air, slowly withdraw the needle several millimeters and
aspirate again

Intercostal blocks can efficiently alleviate the pain associated both with normal
movement and interventions such as chest physiotherapy.

Ask the patient before procedure if he is aware of any allergy to the local
anesthetic

Operative procedures, such as inserting chest drains, are made more tolerable by
intercostal block.

If the patient is not aware, do a skin test for allergy.

What you need for intercostal block:

-

sterile gloves

MCQ TESTS
8.1 Why it is so important to relieve the pain in rib fractures:

27
a. just for patients comfort,

d. clavicular fracture,

b. to improve the pulse rate,

e. rib fracture in sedated and intubated patient.

c. to improve chest movements, ventilation and bronchial clearance by an

efficient coughing,

8.5 What is the most important symptom or sign in a broken rib:

d. to improve the blood pressure,

e. to allow decubitus position while sleeping.
8.2 What substance is used for intercostal block:
a. paracetamol,
b. aspirine,
c. lignocaine 1%,
d. morphine,
e. pethidine.

a. local pain,
b. local bruising,
c. local hematoma,
d. fever,
e. tachycardia
9. PARACENTESIS ABDOMINIS OR PERITONEAL ASPIRATION
This technique involves the removal of fluid from the peritoneal cavity.
It is performed both as a diagnostic or therapeutic procedure.

a. in front of the rib,

In diagnostic procedure, the fluid sample obtained may indicate the nature of
the problem, while the removal of large volumes of fluid from the abdominal
cavity may alleviate abdominal discomfort even respiratory discomfort as
happens in tension ascitis in patients with cirrhosis.

b. behind the rib,

Indications

c. attached to the visceral pleura,

Aspiration of a small volume of peritoneal fluid for diagnostic purpose is a

simple, quick and useful procedure. The initial macroscopical examination of
the fluid is important for the diagnosis - for example blood aspirated from
peritoneum may confirm clinical judgement in the casualty department of
hemoperitoneum (absence of blood does not exclude the possibility of
intraperitoneal bleeding).

8.3 Where is located intercostal nerve:

d. inferior margin of the rib,

e. superior margin of the rib.
8.4 What is the indication of intercostal block:

b. rib fracture,

Therapeutic paracentesis can be used to alleviate the problems associated with

severe abdominal distension. These include general discomfort, indigestion and
respiratory embarrasment due to splinting of the diaphragm.

c. scapular fracture,

Contraindications

a. sternal fracture,

28
Coagulopathy, pregnancy and abdominal scarring may all make the procedure
hazardous.

3. After local anesthesia done, advance the needle through the skin into
the peritoneum, aspirating as the needle advances.

Avoid this procedure if there is gaseous distension of the bowel either clinically
or on abdominal X-ray.

4. Once in the peritoneum, fluid should be aspirated easily.

What you need for peritoneal aspiration:

-

minor dressing pack

antiseptic

local anesthetic (1% lignocaine)

green needle for a diagnostic tap.

60 ml syringe, green needle and a three way tap if for therapeutic tap.

specimen bottles for biochemistry, microbiology, cytology.

Position of the patient

5. If you are draining ascitis, connect the needle to a collecting tube and
bag.
If following a severe trauma, you draw back blood, you have the diagnosis of
hemoperitoneum.
Withdraw the needle and dress the wound.
In the presence of infection, the protein content of peritoneal aspirate raises
(exudates) and there is a marked increase in neutrophils on cytological
examination.
In frank peritonitis a turbid fluid may be aspirated and microorganisms may be
seen on Gram Stain and culture.

Supine position with a slight tilt to the left

In acute pancreatitis, the amylase concentration of the peritoneal fluid can be

very high.

Preparation

Complications

Percuss the abdomen usually in the left iliac fossa for dullness.
Clean the skin with bethadine.
Infiltrate the site of the tap down to, including the peritoneum, with local
anesthetic.
Technique

1. Damage to the inferior epigastric vessels is seen as a rapidly

accumulating hematoma- ice bag and observation.
2. Puncture of the bladder should not occur if the bladder empty.
3. Puncture of the bowel is unusual but may result in contamination of the
otherwise sterile ascites.
4. Infection of ascitis if the aseptic technique is not used.

1. Ensure that the bladder is empty. Check by palpation and percussion.

2. Select a site in the iliac fossa, one-third of the way between the anterior
superior iliac spine and the umbilicus. Avoid the inferior epigastric
vessels.

MCQ TESTS
9.1 What anatomical topographic region is chosen for an abdominal tap:

29
a. epigastrium,

c. acute pancreatitis,

b. right hypochondrium,

d. bowel infarction,

c. right iliac fossa,

e. acute appendicitis.

d. left iliac fossa,

9.5 Choose a contraindication of the paracentesis from the following clinical

conditions:

e. hypogastrium.

a. hemophilia,
b. severe abdominal pain,
9.2 What anatomical structure should be preserved during an abdominal
aspiration: a. rectus abdominis sheath,

c. high fever,

b. inferior epigastric vessels,

d. peritonitis,

c. external oblique fascia,

e. acute pancreatitis.

d. internal oblique muscle,

10. PERITONEAL LAVAGE

e. parietal peritoneum.

Peritoneal lavage is a method for washing out the peritoneal cavity either for
diagnostic or therapeutic purposes.

9.3 What complications might appear during paracentesis, EXCEPT ONE:

Indications
a. injury of the inferior epigastric vessels,
b. injury to the distended urinary bladder,
c. injury of the left ureter,

Clinical conditions where there may be intraabdominal hemorrhage or visceral

injury not readily diagnosable by the usual clinical means.

d. puncture of the small bowel,

Usually in a politrauma patient with a significant head injury the usual signs of
intraabdominal bleeding can either be absent or dangerously misleading.
Guarding may be absent.

e. infection of ascitis if aseptic technique is not used.

Bear in mind that spinal injury can also produce misleading clinical signs.

9.4 In which clinical condition the level of amylase in the peritoneal fluid is
very high:

Peritoneal lavage should indicate if intraabdominal bleeding is present.

a. peritonitis,

Failure to diagnose intraabdominal bleeding promptly in the multiple trauma

patient can be disastrous.

b. bowel obstruction,

Medical term definition

30
Politrauma means multiple injuries but at least one is life-threatening.
Technique
The commonly used site for insertion is in the midline about 5 cm below the
umbilicus.
Ensure that the patients bladder is empty and pass urinary catheter if necessary.
Clean and drape the lower abdomen
Infiltrate the local anesthetic into the skin and down into the linea alba.
With a scalpel make a small incision in the skin.
Either blunt dissection or direct placement of a trocar can be used.
Advance this perpendicular to the skin and push quite hard, there will be a
definite
loss of resistence as the trocar perforates the peritoneum.
Withdraw the trocar onto the catheter and gently advance the catheter into right
or left paracolic gutter.
If blood readily pours through the catheter and then continous, a lavage is
unnecessary as laparotomy is indicated.
If not, attach a 500 ml bag of saline to a giving set and run in - it should run
easily.
When the bag is empty, drop it below the level of the patient and fluid should
run back.
Interpretation can be difficult, but thick, heavily bloodstained fluid is indicative
for intraaabdominal hemorrhage.
Laparotomy should be done straight forward.
Cellular indications for laparotomy are: RBC more than 100, 000/mm3, WBC
more than 500/mm3 , Gram stain shows bacteria.

If the clinical signs indicate a laparotomy then it is pointless performing a

lavage.
Complications
1. Coagulopathy may result in bleeding from the puncture.
2. Scarring of the lower abdomen may suggest tethering of the bowel or
adhesions that highly increase the risk of bowel perforation.
3. If the patient has an ileus with distended bowel there is a similar risk.
4. A full bladder needs to be emptied prior to insertion of peritoneal
catheter as bladder puncture is a common problem.
5. Bowel perforation can be difficult to diagnose but failure to drain
adequately or an offensive smell with the fluid that does come back
should suggest the possibility of a perforated bowel and a surgical
opinion should be sought.
MCQ TESTS
10.1 Where is the entry site of the catheter for peritoneal lavage:
a. linea alba, 5 cm below the xiphisternum,
b. linea alba, 5 cm below the umbilicus,
c. 5 cm above the anterior superior iliac spine,
d. 5 cm lateral to the umbilicus,
e. 5 cm above the umbilicus.
10.2 The following clinical conditions are contraindications for peritoneal
lavage EXCEPT ONE:
a. pregnancy,
b. hemophilia,
c. bowel adhesions,

31
d. politrauma patient in coma,

e. fluid ressuscitation.

e. overdistended urinary bladder.

10.3 What is the indication for peritoneal lavage from the following clinical
situations:

11. BALLOON TAMPONADE FOR ESOPHAGEAL VARICEAL

BLEEDING

a. politrauma patient with a high suspicion of visceral injury not readily

diagnosable by the usual clinical means,

Blakemore tube

b. when abdominal aspiration reveals frank blood,

c. when abdominal paracentesis reveals pus,
d. when abdominal tap reveals turbid foul smelling fluid,
e. when abdominal tap reveals urine in a trauma patient.

10.4 What do you do if peritoneal lavage is negative but the patient presents the
signs of severe internal bleeding:
a. wait and see,
b. blood transfusion,
c. urgent laparotomy,
d. ask for a CT scan of the abdomen,
e. monitor blood pressure.
10.5 What do you recommand if peritoneal lavage reveals fecal peritonitis:
a. give antibiotics,
b. give painkillers,
c. give blood transfusion,
d. exploratory laparotomy,

This tube is essentially designed for applying pressure to esophageal varices and
thereby tamponading the vessels in cirrhotic patients who present hematemesis
due to rupture of the esophageal varices.
It is a large triple lumen device with two balloons. Two lumens supply the
balloons: one for the stomach and the other for the esophagus while the third
lumen is used to drain the stomach content.
The principle involved is that the tube is introduced and then the stomach
balloon is inflated with a volume of 250ml of normal saline. It is then pulled
back tight against the gastro-esophageal junction. This ensures that the sausage
shaped esophageal balloon is positioned in the esophagus and this can be
subsequently inflated to press on the varices and stop the bleeding.
Anatomy
The esophagus extends from the cricoids cartilage (C6) to the gastro-esophageal
junction (T10) a distance of about 25 cm in an adult.
In the thorax it lies posteriorly and slightly to the left so that the left bronchus
passes anteriorly.
At the level of T10 it passes anterior to the descending aorta and pierces the
diaphragm.
At the lower end of the esophagus there is the anastomosis of the portal and
systemic venous system.
Medical terms definitions
Esophageal varices - dilated submucosal esophageal veins due to portal
hypertension as happens in cirrhotic patients.

32
Cirrhosis - interstitial inflammation of the liver.

Technique

Portal hypertension - abnormally increased pressure in the portal circulation.

In view of the potential complications this should be done in intensive care unit.

Hematemesis - vomiting digested blood.

The combination of upper gastrointestinal bleeding and the effort to swallow a

large tube is likely to result in vomiting and may compromise the airway.

Hemostasis - arrest of bleeding

Spleno - renal shunt means a surgical connection between the portal and
systemic venous circulation

In a distressed and uncooperative patient elective intubation may facilitate safe

placement and a quiet ventilated patient will not tend to retch and aggravate the
bleeding.

Bradicardia - slowing of the pulse rate to less than 60.

In other circumstances, tube placement can be done when the patient is awake.

Hiatus hernia - protrusion of the upper part of the stomach into the chest
through the hiatus orifice.

Under no circumstances should such a patient be sedated to facilitate tube

placement without airway protection, nor should this be performed if there is
impairment consciousness.

Indications
This technique is useful for tamponading varices of the lower esophagus and the
gastro-esophageal junction.
It is a device by which bleeding can be controlled while the patient is
resuscitated or until definitive management of the varices can be carried out
such as injection of the vasoconstrictors or sclerosing agents of the esophageal
veins.
In appropriate patients surgery to lower the portal venous pressure by portosystemic shunt (spleno-renal shunt) may be other alternative.
Practically, the use of these tubes rarely solves the problem but does facilitate
control of the situation until definitive measures can be used.
Contraindications
A relative contraindication is the presence of a significant hiatus hernia.
In other situations however, as it is a technique with a high morbidity and very
uncomfortable for the patient, there should be careful consideration of
alternatives prior to placing the tube.

In awake patient, cooperation is essential.

Technique
Place the patient in a comfortable position. If the patient is vomiting then the
lateral decubitus is the safest position to use. The risk of vomiting and aspiration
is high.
1. Check that suction is readily available.
2. Check the balloons on the tube by inflating them and assess the volume
required for each. Test the patency of the lumens.
3. Use a local anesthetic for oro-pharynx. Advance the tube orally.
4. Ask the patient to swallow. It is often easier to place the larger tubes
than the smaller naso-gastric tubes as they are likely to curl up in the
pharynx.
5. Insert more than 30 cm and check the position by injecting air and
ascultating over the stomach.

33
6. Inflate the gastric balloon (250ml NS). There should be no resistance.
If there is resistance, the balloon is either in the esophagus or in the
duodenum.

4. Occasionally the traction, especially if it is a weighted system, can result in

migration of the tube into the hypopharynx resulting in partial or complete
airway obstruction.

7. Pull the tube back until it lodges firmly at the gastro-esophageal

junction. Excessive force will cause damage.

5. Prolonged use with pressure on the esophageal mucosa can cause mucosal
necrosis and ulceration. To avoid this, the esophageal balloon can be deflated
for a few minutes every 6 hours but this may precipitate bleeding.

8. Inflate the esophageal balloon with 100 ml NS. During inflation watch
for any signs of respiratory embarrassment or complaints of pain.
Cardiac arrhythmias occasionally occur as the esophageal balloon is
inflated.
9. Apply traction to the tube. A weight of 300 g can be used. The easiest
method is to use a bag of saline as 1 ml is 1 g.
10. At 24 hours deflate the esophageal balloon and remove the traction to
assess hemostasis. In case of rebleeding, the balloon can be reinflated
for a further 12-24 hours but surgical intervention becomes
increasingly likely.
11. If there is no bleeding, leave the esophageal balloon deflated but leave
the tube in place. Deflate the gastric balloon and remove 24 hours later
if no bleeding has occurred.
Complications
1. The tube generally is uncomfortable for the patient. There might be recurrent
hemorrhage after balloon deflation.
2. Serious complications related to use of the tube might include esophageal
perforation, ischemic necrosis of the esophagus due to overinflation of the
esophageal balloon or tracheobronchial aspiration of the gastric content.
3. Inflation of the gastric balloon in the lower esophagus or in an unidentified
hiatus hernia can result in rupture of the esophagus as can overinflation of the
esophageal balloon.
These complications can be avoided by ensuring there is no resistance to
inflation of the gastric balloon, the x-ray position is correct and traction on the
tube is not excessive.

MCQ TESTS
11.1 In what condition may appear esophageal varices:
a. cirrhosis with portal hypertension,
b. gastro-esophageal reflux,
c. esophagitis,
d. hepatic cyst,
e. hypertension.
11.2 What is the most important clinical sign for ruptured esophageal varices:
a. high systolic blood pressure,
b. hematemesis,
c. bradicardia,
d. low hourly urinary output,
e. biliary vomiting.
11.3 The complications of passing a Blakemore tube are EXCEPT ONE:
a. esophageal perforation,
b. ischemic necrosis of the esophagus,

34
c. pneumothorax,
d. esophageal ulceration,
e. tracheo bronchial aspiration of the gastric content.
11.4 The following statements about the technique are true EXCEPT ONE:
a. advance the tube orally,
b. insert more than 30 cm and check the position by injecting air and ascultating
over the stomach,
c. inflate the gastric balloon with 250ml normal saline,
d. pull the tube back, after inflating the gastric balloon until it lodges firmly at
the gastro-esophageal junction,

The indications for placement and the management are specific for each type of
tube.
Gastrointestinal tubes
Indications
1. Gastric tubes are used to provide enteral nutrition for a period of time
till the oral way becomes feasible, e.g. patients in prolonged coma,
patients unable to swallow as happens in the severe forms of
myasthenia gravis.
2. Gastric tubes are used to decompress the overdistended stomach as
happens in pyloric stenosis.

e. inflate the esophageal balloon till the patient complains of chest pain.

3. Gastric tubes are used in preparing a patient with hematemesis for

endoscopic examination in order to find out the bleeding digestive
lesion such as a peptic ulcer or ulcerated gastric tumour.

11.5 For safety, this procedure should be performed:

4. Gastric tubes are used to evacuate the gastric content in patients with
upper bowel obstruction or paralytic ileus from severe forms of acute
pancreatitis.

a. in the ward after taking a blood pressure,

5. Nasojejunal tube is indicated for administration of enteral nutrition,

administration of medications and decompression of small bowel.

b. in the outpatient after taking the pulse rate,

c. at home by paramedics,
d. at radiological department to check by a chest X ray the position of the
esophageal tube,
e. in intensive care unit under cardio-vascular monitoring.

12. SURGICAL TUBES AND DRAINS

They are used in a variety of settings to allow fluid to escape from or to instill
fluid or feeding solutions into one of the body cavity.

Feeding-type naso-jejunal tube can be placed under fluoroscopic guidance in the

distal duodenum or proximal jejunum; most tubes come with a flexible wire
stylet that can aid in negociating into the duodenum. The stylet is removed after
placement.
The tube should be flushed with 20-30 ml of saline or water every 4-6 hours to
maintain patency.
If the tube becomes blocked, instillation of several ml of carbonated soda into
the tube can remove the blockage.
Naso jejunal feeding tubes can be placed during operation with the assistance of
the anesthetist who can introduce through the nose the tube and push it till the

35
surgeon can take it over and place it in the jejunum, e.g. during a total
gastrectomy with eso-jejunal anastomosis.

After the tract through the abdominal wall has healed for at least 1 week, most
gastrostomy tubes can be replaced if there is a leak or malfunction of the tube.

The naso-jejunal feeding tube can be removed at the bedside when no longer
needed.

If the gastrostomy tube no longer is needed it can be removed with gentle

traction and a small gauze bandage can be placed over the exit site until the
drainage subsides. Most gastrostomy sites will close off within 2-4 weeks.

Complications
Complications are related to incorrect placement.
1. Perforation of the esophagus, stomach, duodenum, jejunum is rare but
might lead to development of septic mediastinitis in case of esophageal
perforation and peritonitis in case of gastric or duodenal perforation.
2. Long standing naso-gastric tube may facilitate a gastro-esophageal
reflux due to maintained open cardia with potential complication of
stenosing esophagitis.
2. Gastrostomy tubes
Gastrostomy tubes enter the stomach through the anterior abdominal wall, so
they are usually placed surgically under local anesthesia or general anesthesia.
Indications
A gastrostomy tube might be indicated for nutrition ar administration of
medication in a patient with complete dysphagia, usually due to an unresectable
carcinoma of the esophagus that obstructs the lumen.
Types of tubes
Tubes designed specifically for use as a gastrostomy tube are available with
balloon tips or mushrooms tips and have a single lumen.
Management
The gastrostomy tube can be placed: operatively through a small laparotomy,
laparoscopically or percutaneous under endoscopic guidance (PGA)
The gastrostomy tube can be placed to gravity drainage or can capped off and
used only as needed. The exit site should be cleansed daily.

Medical terms definitions

Gastrostomy - opening of the anterior stomach wall to the abdominal skin for
enteral nutrition when oral way is not feasible (e.g. obstructive esophageal
cancer).
Gastrotomy cutting of the gastric wall during surgery
Gastrectomy- resection of the stomach (total resection is total gastrectomy,
partial resection is partial gastrectomy).

Jejunostomy tube
They are placed into the jejunum through the anterior abdominal wall. These are
indicated for administration of medication and enteral feeding, when it is not
possible to perform a gastrostomy (tumours of the stomach and duodenum or
previous gastric surgery).
A jejunostomy tube can be placed at laparotomy or laparoscopically.
The tube can be secured in the jejunum with only a purse-string suture or with a
segment of the catheter tunneled within the jejunum.
The tube should be flushed with 20-30 ml of water or saline every 4-6 hours to
maintain patency.

36
Complications

1. A leak at the site of insertion into the bile duct.

They are related to incorrect placement.

2. Rarely, the catheter can break off when it is removed.

1. Peritonitis might result from perforation of the bowel.

Rectal tubes

2. Obstruction might develop due to bowel loop rotation around the

jejunostomy tube or from partial occlusion of the bowel lumen by a
tunneled tube.

Rectal tubes are placed into the rectum to drain flatus and soft feces.

Blakemore tubes
They are used in patients with hemorrhage from gastroesophageal varices.

Rectal tube can be connected to gravity drainage.

The tube should not be used for more than a week to prevent pressure necrosis
of the anus.
Urinary catheters

Although the Blakemore tube is used infrequently because of the success of

endoscopic sclerotherapy, this can be a life-saving treatment in some patients.

They are used to evacuate urine from the urinary bladder.

T-tubes or Kehr tubes

Types of urinary catheters are: Foley, Nelaton, Thieman catheters, single lumen,
double lumen.

T-tubes are T-shaped tubes surgically inserted into the common bile duct and
exteriorized through the anterior abdominal wall.

Thoracostomy tubes

Indications

They are used to evacuate fluid from the pleural space which may induce
repiratory embarracement.

A T-tube is indicated to divert biliary flow and to prevent complete biliary

obstruction for patients after common bile duct exploration, after liver
transplantation with primary bile duct anastomoses and for certain patients
requiring biliary diversion.
Management
The T-tube is placed operatively and initially is left to gravity drainage in a
bottle with antiseptic located on the floor at the bedside. The tube can be capped
off subsequently when there is no obstruction and no further need for biliary
diversion.
If there is no evidence of biliary obstruction, the T-tube can be removed with
gentle traction 2-6 weeks after operation with a check cholangiogram to
document the biliary patency.
Complications

A chest X ray should confirm the presence and the amount of the pleural
effusion before procedure.
The procedure is described previously.
Surgical drains
Surgical drains are used in a variety of settings to allow fluid to escape from a
particular body cavity.
The indication for placement and drainage management is specific for each type
of drain.

37
Selection of the most appropriate tube or drain for a particular situation is based
on type, viscosity and volume of fluid to be evacuated.

The closed nature of this drainage decreases the risk of introducing infection
into the body cavity being drained.

Types of surgical drains

The output from the drain and the quality of the drainage fluid should be
monitored frequently.

1. Open drains
They are used to establish a tract between a body cavity and skin surface. They
are used as a wick.
Drainage is facilitated by placing the drain in a dependent position of the cavity
to be drained.
For example, dependent position of the peritoneal cavity is Douglas pouch.
In generalized peritonitis, to place the drainage tubes in the Douglas pouch is
not enough. Surgical tubes must also be placed under the diaphragm to avoid
aspiration due to respiratory movements, of the peritoneal fluid from dependent
position up till under the diaphragm. The formation of a sub-phrenic abscess is
in such way prevented
To prevent retraction of the drain into the wound, the drainage tube is fixed to
the skin using a non-absorbable suture or a large safety pin is placed through the
drain above the skin.
The drain is covered by thick dressing to absorb the drainage fluid or an ostomy
appliance bag can be placed over the drain to collect drainage.
2. Closed drains
They are tubes connecting a body cavity to a sealed reservoir.
Closed drains are used to drain serous or bloody fluid from dissection sites or
from around intraperitoneal anastomoses.
The goal of these drains is to facilitate coaptation of adjacent tissues and to
prevent accumulation of serum and the development of a hematoma.
When placed in the peritoneal cavity, closed drains are surrounded by omentum
and other tissues producing a controlled sinus tract.

Closed drains are removed when the drainage has decreased to an acceptable
level.
3. Closed suction drains
A low intensity suction can be applied to these tubes in order to facilitate the
draining of large volumes of fluid (most frequently digestive fluids).
They also promote closure of dead spaces allowing a better approximation of
tissue surfaces (e.g. following mastectomy with axillary limphadenectomy).
4.Sump drains
They are large caliber, two lumen tubes that provide both irrigation and
aspiration. These drains generally are placed operatively and are used most
commonly to drain intraabdominal spaces.
Complications
1. The presence of a drain does not guarantee that an abscess or other
collection will not reform.
2. The foreign body reaction can isolate a drain from adjacent tissues,
preventing blood, pus or other fluid from having access to the lumen.
3. Drains and the tissues that they transverse can be colonized by
microorganisms from outside. Open drains increase the risk of
infection. Avoiding bacterial contamination requires careful wound
care at the drain's exit site.
4. A drain should not be regarded as a substitute
for hemostasis. Hematomas are likely to develop despite drainage if
hemostasis is not adequate.

38
5. A rigid drain may erode through the wall of a blood vessel or a hollow
intestinal structure. This complication can be minimized by using soft
drains and removing drains early.

12.3 Feeding jejunostomy tube is indicated in:

6. Excessive suction on a tube can also cause necrosis of nearby

structures. Intermittent low-level suction is safer.

b. ileal bowel obstruction,

Removal
Drains should be removed when they have accomplished their purpose:
-

when the risk of anastomotic leakage has passed,

when a drainage tube is used for postoperative fluid collection (blood,

serum, lymph) and it may be removed when no further drainage
occurs.

a. gastric cancer,

c. bowel infarction,
d. colonic cancer,
e. rectal cancer.
12.4 Kehr tube is used for:
a. external drainage of the bile from the common bile duct,
b. external drainage of the pancreatic juice,

MCQ TESTS

c. drainage of the gastric juice,

12.1 Naso-gastric tube is indicated in the following conditions EXCEPT ONE:

d. drainage of the duodenal content,

a. gastric decompression,

e. drainage of the bile from the gall bladder.

b. feeding in coma patient,

12.5 The dependent position of the peritoneal cavity where a surgical drainage
should be placed is represented by:

c. preparation of the stomach for gastric endoscopy,

d. gastric lavage,
e. esophagitis.
12.2 Feeding gastrostomy tube is indicated in:
a. esophageal cancer with complete dysphagia,
b. gastric cancer,

a. Douglas pouch,
b. paracolic region,
c. paraduodenal region,
d. under transverse mesocolon,
e. gastro-hepatic region.

c. pyloric stenosis,
d. duodenal tumour,
e. duodenal ulcer.

13. STOMA CARE

Indications and general principles of stomas

39
The etimology of stoma comes from greek word stomata meaning mouthlike
opening, particularly an incised opening which is kept open for different
purposes.
Examples of stomas:
1. Colostomy- opening of the colon onto the abdominal skin for fecal
drainage.
2. Ileostomy- opening of the ileum onto the abdominal skin for ileal
drainage.

This is necessary when there is no distal bowel segment remaining after

resection or, for some reason, the bowel cannot be rejoined.
A left colostomy is required after abdominal-perineal resection of the low rectal
or anal canal tumour.
An ileostomy is required after excision of the whole colon and rectum
(panproctocolectomy), unless a pelvic reservoir is constructed (an ileum pouch
anastomozed to the anus). The usual indications are inflammatory bowel disease
(mainly ulcerative colitis) or familial polyposis coli.

3. Gastrostomy- opening of the stomach onto the abdominal skin for

feeding.

Permanent stomas must be carefully sited to facilitate long-term management.

They are usually below the belt line. Permanent colostomies are usually
fashioned in the left iliac fossa and ileostomies in the right iliac fossa.

4. Jejunostomy- opening of the jejunum onto the abdominal skin for

feeding.

Temporary stomas

5. Tracheostomy- opening of the trachea onto the neck skin for breathing.

A stoma is often required temporarily to divert the fecal stream away from a
more distal part of the bowel. When the distal bowel problem has resolved, the
colostomy is closed.

It is often necessary to divert the fecal stream onto the anterior abdominal wall
via a colostomy.
The effluent is collected in a removable plastic bag attached by adhesive to the
abdominal skin around stoma.
Stomas are named according to the part of the bowel opening onto the
abdominal wall: ileostomy or colostomy.
The majority of stomas are performed in cancer surgery, although they are
sometimes necessary in inflammatory bowel disease, sigmoid diverticulitis
disease and sigmoid volvulus.
Stomas may be permanent( for the entire life) or temporary.
Wherever possible, the need for a stoma should be anticipated before operation
and discussed with the patient.
Permanent stomas

Indications for temporary stomas

A colostomy may be created as an emergency measure to relieve complete distal
large bowel obstruction causing proximal dilatation. The obstructive lesion may
be removed at the same operation or later as an elective procedure.
A stoma may be used to protect a more distal anastomosis which is at particular
risk of leakage or breakdown.
Common examples are:
1. A technically difficult low anastomosis when there is a risk of
anastomotic breakdown or fistula;
2. An anastomosis performed after resection of an obstructing lesion
when distention may compromise the blood supply and again the risk
of anastomotic leakage is likely;

40
3. Emergency resection involving unprepared bowel (solid feces in the
lumen) or elective surgery where the bowel has not been adequately
cleared.
4. A temporary colostomy may be used to rest a more distal segment of
bowel involved in an inflammatory process such as a pericolic abscess,
acute Chrons disease or a colo-vesical or colo-vaginal fistula.

Sigmoid volvulus - torsion of sigmoid colon, causing obstruction.

Sigmoid diverticulosis - the presence of diverticula in the sigmoid colon in the
absence of inflammation.
Diverticula - pouches or sacs created by herniation of the mucous membrane
through a defect in the muscular coat.

Types of stoma

Sigmoid diverticulitis- inflammed diverticula in the sigmoid colon.

Colonic stomas are designed with the bowel mucosa lying flush with the skin.

Abdomino - perineal resection of the rectum is a surgical procedure indicated in

low rectal cancer or anal cancer when rectum and anus together with the anal
sphincter is removed, the fecal stream being diverted out through a permanent
and terminal left colostomy, sited in the left iliac fossa.

Small bowel stomas are fashioned with a spout of bowel protruding about 5
cm to ensure that the irritant small bowel contents enter the ileostomy appliance
directly rather than flowing onto the skin.
1. Loop stoma or lateral stoma
This type of stoma is designed so that both the proximal and distal segments of
bowel drain onto the skin surface. A loop of bowel is brought through a single
skin incision and held above the skin surface by a bridge of plastic or a glass
rod.
An incision is made in the side of exteriorized loop which opens both proximal
and distal loops.
Weeks or months later, the bowel incision is closed and the loop dropped back
into the abdomen. This is a temporary stoma.
2. Double stoma
The bowel ends are completely divided. Both proximal and distal ends are
brought separately to the skin surface to drain into separate appliances.
3. Terminal stoma or single end stoma
This is a permanent stoma, fashioned after pan-proctocolectomy or removal of
the rectum and anal sphincter (abdomino-perineal resection).
Medical terms definitions

Panproctocolectomy is a surgical procedure indicated in ulcerative colitis

when the entire dideased colon and rectum is removed and digestive content is
diverted out through a terminal ileostomy sited in the right iliac fossa.

Complications of stomas and solutions

1. Badly fitting stoma: where scarring has led to irregular skin and the
stomas do not fit properly, this can often be dealt with by filling up the
crevices with some sort of gum.
2. Stoma leakage- different types of gums can be used. Persistent leakage
between skin and appliance causes skin erosion and patient distress.
Sometimes may require resiting operation.
3. Prolapsed stoma- this can be a real problem and often requires
refashioning of stoma.
4. Parastomal hernia- due to abdominal weakness. It requires resiting of
stoma. Do not forget that you can examine a colostomy exactly as you
would an anal canal, including doing a digital examination.

41
5. Obstruction of stoma due to edema or fecal impaction - relieved by
exploration with a gloved finger and sometimes glycerine suppositories
or softening enemas.

e. right iliac fossa.

6. Retraction of a spout ileostomy- requires reoperation and fashioning

of a new ileostomy.

a. right hypochondrium,

MCQ TESTS
13.1 The following are complications of a stoma EXCEPT ONE:
a. prolapsed stoma,
b. stoma incontinence,
c. parastomal hernia,
d. retraction of stoma ,
e. stoma obstruction.
13.2 A colostomy is performed in the following clinical conditions EXCEPT
ONE: a. low rectal tumour,
b. anal tumour,

13.4 The common site for an ilieostomy is:

b. right iliac fossa,

c. left iliac fossa,
d. hypogastrium,
e. epigastrium.
13.5 The adequate treatment of prolapsed left colostoma is:
a. painkillers,
b. ileostomy,
c. transverse colostomy,
d. refashioning stoma,
e. none.

c. ileal tumour,
d. recto-sigmoid tumour complicated with pericolic abscess,
e. obstructive rectosigmoid tumour.
13.3 The common site for a colostomy is:
a. right hypochondrium,
b. epigastrium,
c. hypogastrium,
d. left iliac fossa,

14. PRINCIPLES OF HEMOSTASIS

Bleeding is an inevitable part of surgery.
Blood loss should be minimized because bleeding obscures the operative field
and the loss has to be made up later.
1. Clipping and ligation
Ligation is obligatory when large vessels are divided. In order to minimize
hemorrhage any vessels are generally occluded by pressure alone, the forceps
being left on for one minute or two. Larger vessels require to be ligated or

42
tied off with a thread. Care should therefore be taken as much possible to
clamp the vessel alone, without taking up adjacent tissue.
For the "tying off of bleeding points close cooperation between surgeon and
assistant is required. The surgeon passes the ligature material around the
forceps; the assistant holds the forceps depressing the handle and elevating the
point as much possible, so that the tissue which is clamped becomes encircled
by the ligature.
Just as the surgeon is tightening the first hitch of the knot, the assistant slowly
releases the forceps.
If the forceps is released suddenly the tissue is liable to slip out of the grasp of
the ligature.
If the end of the bleeding vessel cannot be grasped by hemostat forceps, a suture
can be used to encircle to vessel and its surrounding tissues; this technique often
described as "under-running" and it is particularly useful for a bleeding vessel,
e.g. the bleeding vessel in the base of a peptic ulcer.
2. Diathermy
Diathermy achieves hemostasis by local intravascular coagulation using a
particular electrical waveform. Enough heat is also produced to burn the tissues.
Diathermy is useless for large vessels which should be ligated.
Monopolar diathermy is the most widely used for routine hemostasis but there is
wide dispersion of the coagulating and heating effects, making it unsuitable for
use near the nerves and other delicate structures.
Bipolar diathermy is mainly used for fine surgery and requires accurate
grasping of the bleeding vessel. Its main advantages are minimal tissue damage
at the point of coagulation and its safety in relation to nearby nerves, vascular
structures and cardiac pacemakers.
3. Tourniquet and exsanguinations
This technique is used in surgery of the limbs and digits where a bloodless field
is particularly desirable. For the whole limb, a pneumatic tourniquet is placed
proximaly around the limb. The limb is exsanguinated by elevation and spiral

application of a rubber bandage (Esmark) from the periphery; the tourniquet is

then inflated. Upper limb tourniquets must not be left inflated for more than 30
min and lower limb tourniquets for more than one hour to avoid the risk of
necrosis.
4. Pressure
Pressure is an useful way of controlling bleeding until platelet aggregation,
reactive vasoconstriction and blood coagulation take over.
It can be used for emergency control of severe arterial or venous bleeding but is
equally useful for controlling diffuse small-vessel bleeding from a large raw
area (liver bed after cholecystectomy).
Pressure is usually applied with gauze swabs which must be kept in position for
at least 10 min.
5. Local hemostatic agents
For intractable bleeding which is not amenable to ligature, diathermy or suture,
various resorbable packing materials can be left in position to encourage
hemostasis.
Local hemostatic agents can be helpfull in the intraoperative control of
bleeding from needle holes, vascular suture lines areas of extensive tissue
dissection.
These agents speed hemostasis by providing a matrix thrombus formation. The
types of these agents are: gelatine sponge, surgicel, collagen sponge, tachosyl.
MCQ TESTS
14.1 What is the best way to obtain hemostasis of cut small vessels during
surgery:
a. local pressure,
b. tourniquet,
c. bipolar diathery,

43
d. monopolar diathermy,
e. local hemostatic agents
14.2 What is the best way to obtain hemostatis for large vessels during surgery:
a. local pressure,
b. ligature,
c. monopolar diathermu,
d. bipolar diathermy,

14.5 What is the best way to obtain hemostasis in a patient with a pace maker,
requiring a cholecystectomy:
a. local pressure,
b. ligature,
c. monopolar diathermy,
d. bipolar diathermy,
e. suture.

e. local hemostatic agents.

14.3 What is the best way to control diffuse small vessels bleeding from a raw
area (liver bed after cholecystectomy):
a. local pressure and packing with resorbable hemostatic materials,
b. clipping,
c. ligation,

15. TYPES OF SUTURE MATERIAL

Various types of suture are available, the most important distinction being
between absorbable and non-absorbable materials.
The group can be subdivided into monofilament and polyfilament (braided)
materials. The choice of suture material depends upon the task at hand, the
handling qualities and personal preference.

d. ask the anesthetist to lower blood pressure,

e. ask the anesthetist to give vit. K to the patient.

Characteristics of absorbable sutures

14.4 The following are the ways of surgical hemostasis EXCEPT ONE:

Suture

a. clipping,

Polyglactic acid
(Vicryl)

Effective strength
3 weeks

Absorbtion
3 months

Use
mucosa/muscle

b. ligature,
c. monopolar diathery,
d. bipolar diathermy,
e. controlled lowering of the blood pressure during surgery.

Polyglicolic acid
(Dexon)

3 weeks

4 months

44
Polydiaxone

2 months

6 months

(PDS)

The strength of absorbable sutures declines at a predictable rate for each type of
material, although the suture material remains in the wound for a much longer
period.

Polygliconate

Absorbable sutures are often used in the skin to avoid the need for removal;
typical applications are minor skin operation, surgery in children, circumcisions
and vasectomies.

2 months

6 months

(Maxon)

Non-absorbable sutures retain their strength indefinitly. They are used where the
repair will take a long time to reach full strength (abdominal wall closure) and
for the hernia repair or incisional hernia repair.
Non-absorbable sutures are widely used for skin closure; synthetic
monofilament sutures give the best cosmetic result and are most easily and
painlessly removed.
Natural versus synthetic materials

Characteristics of nonabsorbable sutures

Trade name
Silk

Tissue reactivity
high

Handling

Application

excellent

vessels ligation

Should be avoided in areas prone to infection due to high capillary

Polyester

minimal

good

fascia/skin

Nylon

minimal

good

fascia/skin

Catgut has been used as a suture and ligature material since before Roman
times. It consists of collagen and is actually made from the dried small bowel
submucosa of sheep.
Catgut is still widely used material.
Many surgeons believe that silk has the best handling and knotting properties of
any material but it provokes a strong inflammatory response exceeded only by
linen.
Linen thread is now unpopular, being used mainly for ligation of blood vessels.

Requires 5 throws for knot security

Natural materials are cheap.
Polypropilene

minimal

good

fascia/skin

Novafil

minimal

good

skin

none

poor

bone

Steel

The main advantages of synthetic suture materials are that they provoke little or
no inflammatory reaction and that they can be designed to meet specific
requirements of absorbability, duration of strength and handling.
Monofilament versus polyfilament sutures

Absorbable versus non-absorbable materials

45
Monofilament materials have an extremely smooth surface and can be pulled
through the tissues with minimal friction; this makes them easier to insert and
remove then polyfilament braided materials.

On the other hand, monofilament materials are stiff, springy and more difficult
to knot. Braided materials have the best handling qualities, but their interstices
provide a heaven for bacteria. They tend to act as a wick drawing infected
material in. This problem is partly overcome by the application of surface
coating.

Needles with an eye require suture material to be threaded by hand, so that

needles can be re-used.
"Atraumatic" needles with suture material already attach (swaged into the end);
there is no double thickness of suture material to cause extradrag and trauma as
it is pulled through the tissues, and the suture material does not detach from the
needle during use.

Knots

Types of suture needles

Requirement- security without strangulation

A vast range of needles have been designed for various different demands of
general and specialist surgery.

Different types of knots

Method of use

2. Two half-hitches placed in the same direction form a granny knot which is
not secure.

Hand - held needles; routine use for skin suturing of straight needles.
Instrument - held needles; necessary for deeper access.

1. Two half- hitches placed in the opposite directions from a square or reef
knot. The square knot is simple, reliable and secure.

3. Multiple knots are required to provide a safe knot with monofilament nylon;
this gives additional security and allows the ends to be cut very short.

Straight - skin suturing

4. Surgeons knot is used where a combination of tissue tension and slick suture
material leads to loosening of the first throw, in this case a double first knot or
surgeons knot is required for safety.

Curved - used for most purposes

There are two types of throw: using the index finger or using the middle finger.

Tissue penetration characteristics

Choose the correct first throw.

Round bodied - used for soft tissues: gut, fat.

If the short end of the thread is away you, use the index finger.

Cutting needles, triangular on cross-section are used for tough tissues, fascia,
skin.

If the short end is towards you, use the middle finger.

Shape of needle

Ensure your knot is secure but not strangulate the tissues.

Means of attachment of suture to needle

46
The reef knot is generally secure with braided materials. It is not so with
monofilament material. Therefore achieve security by using extra throws or by
tying a surgeons knot.

Skin sutures should be removed as soon as the wound is strong enough to

remain intact without support. In the abdomen this takes about 7 days, while in
the face and neck - 4 days.

Methods of skin suturing

Sutures should remain in place if there is any danger of wound separation.

The objective of skin suturing is to approximate the cut edges so they will
rapidly heal, leaving a minimal scar. Edges to be apposed should have been cut
in a clean line and at right angles to the skin surface; ragged and angled edges
should be trimmed.

For removal of the suture, pick up with a forceps one cut end and pull to expose
a part of the stitch from the skin and then cut flush with the tissue surface so
that the exposed length of the suture, which is potentially infected, does not
have to pass through the tissues.

The cut edges should be able to be brought neatly together and without tension,
otherwise the wound may break down or the scar slowly stretches, giving an
ugly result.

MCQ TESTS

The needle should be made to pass perpendicularly through the skin in order
that inversion of the edges may be avoided and the stitches should be tied with
only sufficient tightness to bring the skin edges together without constriction.
Too tight stitches cause ischemia of the tissue and result in delayed healing.
Skin closure techniques
1. Simple interrupted suture
2. Vertical mattress sutures used for closure of most large wounds. Good skin
apposition but tend to leave wide stitch scars.
3. Continous overhand suture, or simple running stitch.
4. Continous blanket suture, or running locked stitch
5. Subcuticular- used for cosmetic appearance
6. Horizontal mattress suture
7. Closure of skin wound by means of Michel clips.

15.1 Absorbable sutures are often used to avoid the need for removal, EXCEPT
ONE:
a. Minor skin operations,
b. Surgery in kids,
c. Circumcisions,
d. Vasectomies,
e. Hernia repair.
15.2 The main advantage of synthetic suture materials is:
a. They provoke a little or no inflammatory reaction,
b. Good handling,
c. Good absorbability,
d. Optimal duration of strength,
e. Provoke an intense inflammatory reaction.
15.3 What is true about monofilament materials:

Suture removal

a. They have an irregular surface,

47
b. They can be pulled through the tissue with minimal friction,
c. They have the best handling qualities,
d. They are easy to knot,
e. They can draw infected material in.

In order to realize the maximum potential of any surgical instrument, it will

need to be handled correctly and carefully.
Take every opportunity to practice handling.
The basic principles of all instrument handling include:
- safety
- economy of movement
- relaxed handling

15.4 What is true about braided materials:

a. They have bad handling qualities,
b. They have smooth surface,
c. They tend to act as a wick drawing infected material in,
d. Less friction when pulled through the tissue then monofilament suture
materials, e. They are stiff and springy.
15.5 What technique of skin suture is the most used for cosmetic appearance:
a. simple interrupted suture,
b. Vertical mattress sutures,
c. Simple running stitch,
d. Running locked stitch,
e. Subcuticular stitch.

- avoidance of awkward movements.

The scalpel
Handle with care as the blades are very sharp. Practice attaching and detaching
the blade using a hemostat and never handle the blade directly.
For making a routine skin incision hold the scalpel in a similar manner to a table
knife, with your index finger guiding the blade. Keep the knife horizontal and
draw the whole length of the sharp blade, not just the point over the tissues.
For fine work the scalpel may be held like a pen, often steadying the hand by
using the little finger as a fulcrum.
Always pass the scalpel in a kidney dish. Never pass the scalpel point-first
across the table.
Scissors
Insert the thumb and ring fingers into the rings of the scissors that just the distal
phalanges are within the rings. Any further advancement of the fingers will lead
to clumsy handling and difficulty in extricating the fingers at speed.

16. SURGICAL INSTRUMENTS

Use the index finger to steady the scissors by placing it over joint.

Instrument handling

When one, cutting tissues or sutures especially at depth it often helps to steady
the scissors over the fingers of the other hand.

48
Cut with the tips of the scissors for accuracy rather than using the crutch which
will run the risk of damaging tissues beyond the item being divided and will
also diminish accuracy.
Dissecting forceps
Hold gently between thumb and ring fingers, the middle finger playing the
pivotal role.

Hold the needles in the tip of the jaws about two-thirds of the way along the
circumference, never at its very delicate point.
Select the needle-holder carefully. For delicate, fine suturing use a fine shorthandled needle-holder and an appropriate needle.
Suturing at depth requires a long-handled needle-holder.
Most needle-holders incorporate a ratchet lock.

Two main types of forceps are available, toothed for tougher tissue such as
fascia or skin, and non-toothed (atraumatic) for delicate tissues such as bowel
and vessels. Never crush tissues with the forceps but use them to hold
manipulate tissues with great care and gentleness.

MCQ TESTS

Haemostats (artery forceps)

16.1 What is not accepted about surgical instrument handling:

Hold haemostats in a similar manner to scissors.

a. Safety handling,

Place on vessels using the tips of the jaws (the grip lessens towards the joint of
the instrument).

b. Manipulation by hand of sharp instruments,

Secure position using the ratchet lock. Learn to release the hemostat using either
hand. For the right hand hold the forceps as normally then gently further
compress the handles and separate them in a plane at right angles to the plane of
action of the joint.
Control the forceps during this manoevre to prevent them from springing open
in an uncontrolled manner.
For the left hand, hold the forceps use the thumb and index finger grasping the
distal ring and the ring finger resting on the undersurface of the near ring and
gently compress the handles and separate them again at right angles to the plane
of action taking care to control the forceps as you do so.

c. Economy of movements,
d. Relaxed handling,
e. Avoidance of awkward movements.

16.2 How is correctly held a dissecting forceps:

a. Between thumb and index finger,
b. Between thumb and medius finger,
c. Between thumb and ring finger,
d. Between thumb and little finger,

Needle holder
Grasp the needle holders in a similar manner to scissors.

e. Between index and ring finger.

49
16.3 How is correctly hold a scalpel for a fine skin incision:
a. Like a knife table,

17. PREOPERATIVE CARE

b. Between thumb and ring finger,

Operations should be carried out under optimal conditions to ensure the best
possible result for the patient.

c. Between thumb and medius finger,

d. Between thumb and litlle finger,
e. Like a pen.

Preperative investigations: which tests and why?

Cardiovascular system
An ECG will diagnose ischemic heart disease and dysrhytmias.

16.4 How is correctly hold a scalpel for a routine skin incision:

a. Like a knife table,

The incidence of "silent ischemia" is significant and ischemic heart disease is

associated with many other pathological conditions such as cerebrovascular
disease, hypertension, diabetes.

b. Like a pen,
c. Between thumb and index finger,
d. Between thumb and ring finger,
e. Between thumb and little finger.

16.5 What is the use of an anatomical forceps:

a. Grasping aponeurosis,
b. Grasping skin,
c. Grasping delicate tissues,
d. Retracting the tissues,
e. Cutting.

A preoperative ECG on all patients over the age of 40 is recommended.

Under the age of 40, an ECG should be carried out in the following conditions:
-

history of chest pains, palpitations,

shortness of breath on exertion,

sudden fainting

hypertension

history of heart disease

strong family history of heart disease

heavy smoker

Respiratory system
If the patient is normally fit but has a cough or cold, it is customary to postpone
surgery until he is better. This is because general anesthesia causes some

50
atelectasis (alveolar collapse), which in the presence of co-existing upper
airway infection may lead to bronchopneumonia.
If the surgical condition is life threatening then it cannot be deferred. In this
situation it is necessary to optimize the perioperative state using antibiotics,
oxygen, bronchodilators and chest physiotherapy.
Routine chest-x-ray is often a pointless exercise.
It is of value if there is a history of previous pulmonary disease or physical
signs indicate significant pathology.
All investigations must be justified by an expectation that the result could be
abnormal.

Serum sodium is rarely abnormal unless there is a serious underlying metabolic

disturbance (severe dehydration or water overload, Addison's disease, Conn's
syndrome).
Serum urea and creatinine measure renal function. Serum glucose should be
measured in all patients.
Make sure that all the following are cheked and right:
-

correct patient

right operation on the right side which usually must be marked (right
or left).

consent form

Preoperative investigations are not a screening exercise for the general

population.

instructions to nurses

Blood

the site of the incision should be shaved

Ensure that the patient is not anemic.

preop. diet: nil orally for patient from midnight on day before surgery.

Do a blood hemoglobin estimation and full blood count before even minor
surgery.

passage of nasogastric tube in Gl surgery

bowel preparation in bowel surgery

urinary catheter if needed

prophylactic antibiotics.

If the patient is anemic postpone an elective procedure until it is investigated

and corrected.
If an emergency operation is necessary, correct the anemia by transfusion of
whole blood or packed cells.
Exclude blood disease and bleeding tendencies, especially if the patient is
jaundiced or has liver disease. Vitamin K injections 1 mg, 8 hourly, may be
required to correct abnormal prothrombine time.

Inform:
- laboratory for frozen section

For all major surgery, ensure that blood has been cross-matched and retained.

- anesthetist for specific problems

Electrolytes

- physician for diabetes, thyroid problems, cardiac problems

Abnormal serum potassium frightens anaesthetists. Hyper or hypokalemia

predisposes to cardiac arrhythmias and reduction in miocardial contractility.

Nutrition in surgical patient

51
Malnutrition is linked to postoperative morbidity and mortality. There is a
reduced resistance to infection and poor wound healing.
These complications are observed in patients undergoing radiotherapy or
chemotherapy, in diabetes, older patients and those who are immunodeppressed
or on long-term steroids.

- radio/chemotherapy for cancers.

Routes for nutritional support
If GI tract is available, use it.
1.

Oral route: food preparations and supplements can be given if

swallowing is possible and GI tract is functioning.

2.

Enteral route: NG tubes, gastrostomy feeding tube, jejunostomy tube

in patients with functioning small bowel.

Examine and weigh the patient.

Is there evidence of weight loss: loose skin fold, gaunt appearance.
Ask how the weight loss came about: recurrent vomiting, pain on eating,
diarrhea, loss of apetite. Loss of 10% is accepted as evidence of malnutrition.

Start by continuously infusing at 25 ml/h, gradually increasing to 100 ml/h.

Body mass index is calculated G (Kg) over height square in cm (G/H2)

3.

Parenteral route:

Normal weight

peripheral vein feeding is useful in the short term. Patients with

malnutrition for malignant disease may benefit from preoperative
nutrition of this kind.

total parenteral nutrition via a central vein is indicated when other

methods of feeding are either impossible or unsuitable.

20-25

Overweight

25-30

Obesity grade II 30-40

Obesity grade III 40-70
Benefits of nutritional support:
- immune competence increases
- wound and anastomotic healing improve when albumin levels approach
normality.

Most patients require about 2500 Kcal daily and more in severe burns or sepsis.
Carbohydrate as glucose and fat are used energy sources. Nitrogen requirements
are about1l0g /24h except in hypermetabolic states when 25-30 g/day may be
required. Maintain a separate peripheral line to correct fluid and electrolyte
losses or administer drugs.

- survival from surgical complications is more likely.

Indications for nutritional support:
- preoperatively in malnourished patients
- exacerbations of inflammatory bowel disease
- sepsis and major surgical complications
- extensive burns or trauma

Disorders of water and electrolyte balance

Water balance

intake (ml)

Water as fluid

1200 ml

Water in food
Oxidation

urine1000 ml

300 ml

output (ml)
1500 ml
lungs-500 ml
sweat- 500 ml

52
TOTAL

2500 ml

2500 ml

ECG- T wave flattening

Potassium excess

Water depletion

More than 7.5 mmol/l leads to muscle paralysis, cardiac arrhythmias with
peaked T waves on ECG.

Mild water depletion is when the deficit is 2 l.

Simptoms and signs: thirst, oliguria, dry tongue.
Moderate water depletion when the deficit is 3 l.

In surgical patients it is associated with acute renal failure, massive tissue

distruction (crush or burns injuries) when K leaks out of yhe traumatized
tissues.

Simptoms and signs: weakness and tachycardia

Treatment: 50 g glucose+15 U insulin given as rapid infusion+100 ml of 8.4%

sodium bicarbonate+ 20 ml calcium gluconate 10% over 5 min.

Severe water deficit is when the deficit is 4 l.

If it fails then dialysis is advisable.

Simptoms and signs: low BP, high urea, hypernatriemia.

MCQ TESTS

Water excess

17.1 The benefits of nutritional support, preoperatively when major surgery is

planned, are EXCEPT ONE:

Simptoms and signs: headache, confusion, convulsions.

Natrium depletion
This is due to water overload.
Symptoms and signs: fainting, postural hypotension, oliguria.
Severe hyponatriemia: shock, severe hypotension, high urea, low Na, confusion,
coma.

a. immune competence increases,

b. less postoperative pain,
c. wound healing improves when albumin levels approach normality,
d. anastomotic healing improves,
e. survival from surgical complications is more likely.

Natrium excess

17.2 When should not nutritional support be used:

The interstitial compartment expands leading to clinical edema.

a. preoperatively in malnourished patients,

Potassium depletion

b. sepsis and major surgical complications,

This is due to depleting diuretics, pyloric stenosis.

c. old patients undergoing a cholecystectomy,

Symptoms and signs: weakness, anorexia, ileus, cardiac arrhythmias.

d. extensive burns or trauma,

53
e. radio/chemotherapy for cancers.
17.3 Symptoms and signs of water depletion are EXCEPT ONE:
a. oliguria,
b. hyponatriemia,
c. low blood pressure,
d. hypernatriemia,
e. high urea.
17.4 Symptoms and signs of potassium depletion are, EXCEPT ONE:
a. weakness,
b. anorexia,
c. ileus,
d. on ECG, peaked T wave,
e. on ECG- T wave flattening.

Gastrointestinal problems
1. Paralytic ileus
After abdominal surgery normal bowel sounds disappear about 48 hours usually
returning on the third or fourth day.
Postoperative ileus is due to paralysis of the myenteric plexus and is of two
types: intestinal ileus (the commonest) and acute gastric dilatation.
Ileus will also occur following peritonitis, abdominal trauma and
immobilization. It may be prolonged in hypoproteinemic and hypokaliemic
patients.
Symptoms
-

abdominal distension and vomiting,

absent bowel sounds.

Intestinal ileus usually settles with appropriate treatment.

Acute gastric dilatation is an emergency.

17.5 What is not true about symptoms and signs of potassium excess:

A nasogastric tube must be passed immediately to prevent inhalation of gastric

content, hypovolemia or gastric rupture.

a. T wave flattening on ECG,

A nasogastric tube will empty the stomach of fluid and gas.

b. muscle paralysis,

Maintain continous aspiration.

c. cardiac arrhythmias,

Ensure adequate hydration by infusion and maintain the electrolyte balance.

d. peaked T waves on ECG,

Ileus persisting more than 5-7 days, institute total parenteral nutrition(TPN).

e. Potassium of 7.5 mmol/l

18. POSTOPERATIVE COMPLICATIONS

2. Nausea and vomiting

These are common symptoms in surgical patients. They may be the result of
anaesthetic agents, analgesics, cytotoxic drugs, intestinal ileus and mechanical
obstruction.
Treatment

54
Ensure nil orally for 6 hours before surgery.
Exclude mechanical causes and ileus. Give central antiemetics.

Medical terms definition

When persistent, pass a NG tube, correct hydration and electrolyte disturbances.

Paralytic ileus- non functioning, non obstructive, distended small bowe.,

3. Diarrhea

Acute gastric dilatation- overdistended stomach

Diarrhea may occur following an ileus or in association with continuing sepsis.

Analgesics- pain killers drugs

It may also follow specific procedures such ileo-anal anastomosis, truncal

vagotomy and hemicolectomies.

Cytotoxic drugs- medication used in oncology to kill cancer cells but may affect
and normal cells.

Also remember the possibility of infection, pseudomembranous colitis is easily

forgotten.

Antiemetics- medication against nausea

Treatment

Sepsis is defined as a documented or suspected infection with one or more of

the following:

Identify the cause:

General variables:

rectal and US to exclude pelvic abscess

stool culture to exclude an infectious diarrhea

abdominal X ray for obstructive lesions.

Replace lost fluids and give antiperistalitic drugs (codeine phosphate, lomotil).
4. Constipation

Fever >38.3C
Hypothermia <36C
Heart rate >90 min
Tachypnea
Altered mental status
Significant edema
Hyperglycemia (plasma glucose >120 mg/dL) in the absence of
diabetes

It is commonly encountered after elective surgery, particularly in the elderly.

Treatment
Ensure adequate hydration.
Limit the use of constipating analgesics after the first two days.
Ensure adequate dietary fibers.
Suppositories or enemas may be indicated but nevertheless a rectal examination
should not be forgotten.

Inflammatory variables:
- Leukocytosis (WBC count >12,000 L1)
- Leukopenia (WBC count <4000 L1)
- Plasma C-reactive protein >2 SD above the normal value
- Plasma procalcitonin >2 SD above the normal value

55
Severe sepsis is defined as sepsis associated with organ dysfunction,
hypoperfusion or hypotension.
Organ dysfunction variables:
- Arterial hypoxemia
- Acute oliguria
- Creatinine > 2.0 mg/dL
- Coagulation abnormalities (INR >1.5 or aPTT >60 secs)
- Thrombocytopenia (platelet count <100,000
- Hyperbilirubinemia (plasma total bilirubin > 2.0 mg/dL or 35 mmol/L)
Tissue perfusion variables:
- Hyperlactatemia (>2 mmol/L)
Hemodynamic variables:
Arterial hypotension (SBP <90 mm Hg)

Venous blood is darker in color and flows steadily.

Hemicolectomy resection of the right or left half of the large bowel( colon)

Clinical features

Truncal vagotomy- transection of the trunk of the vagus nerve

There may be visible blood loss into a drainage bottle or to the bedclothes. The
patient is restless, cold and clammy with an increasing pulse rate. There is
pallor, sighing, gasping respiration and thirst.

Pseudomembranous colitis acute inflammation of the colonic mucosa

following a period of antibio-therapy that destroys the normal colonic flora,
inducing the overgrowth of the anaerobic bacteria Clostridium difficile. Health
care workers must wash the hands adequately to prevent outbreaks of
epidemics. Oral vancomycin or parenteral metronidazol, 3-5 days will resolve
this infection.
Antiperistaltic drugs - medication that slows the peristaltic movements of the
bowel.

There can be massive blood loss if it is from the large vessel.

Types
a. primary hemorrhage occurs during surgery and continues.
b. reactionary hemorrhage occurs in the first 24 hours. It may result from the
slipping of a ligature or the removal of primary clot as a result of coughing or
increasing postoperative blood pressure.
c. secondary hemorrhage is due to infection. It occurs about 7-14 days after
operation.

Pulse and blood pressure should be recorded every 15-30 min. The trend of
pulse and BP is the key to blood loss.
Treatment
-

raise the legs, establish an iv infusion

apply pressure to obvious external bleeding points

replace lost blood volume with colloids fluid (voluven, hemaccel or

dextran 70) until whole blood is available.

arrange for the patient to return to theatre if necessary (to ligate

bleeding source).

carry out a coagulation screen, clotting factors may be replaced with

fresh frozen plasma

measure urine volume.

Elective surgery refers to non-emergent operative procedure

Postoperative hemorrhage
Bleeding after surgery may be arterial or venous.
Arterial blood is bright red and spurts in time with the pulse.

56
Wound infection
Wound infection remains one of the most common complications in the surgical
patient despite advances in aseptic surgical practice and after decades of
progresses in antibiotic therapy.
It is related to the type of surgery carried out, depending whether the surgical
procedure is classified as clean, potentially contaminated, contaminated or dirty.
Classification of operative procedure based on degree of microbial
contamination:
1.

2.

3.

4.

Clean procedure is considered when the operation is elective, not

emergent, non-traumatic, the wound is primarily closed, when there is
no acute inflammation and no break in technique and respiratory,
gastrointestinal, biliary and genitourinary tracts was not entered. (E.g.
heart surgery, hernia repair, thyroidectomy).
Intraoperative hypothermia is likely to cause a reduction in peripheral
circulation, which may increase tissue hypoxia and make the wound
more susceptible to infection, even if contamination levels are low.
Clean-contaminated procedure is considered when the procedure is
urgent or there is an opening of respiratory, gastrointestinal, biliary or
genitourinary tract with minimal spillage (e.g. appendectomy) or minor
technique break.
Contaminated procedure is considered when during operation there
was a gross spillage from gastrointestinal tract or entry into biliary or
genitourinary tract in the presence of infected bile or urine, or there
was a major break in technique.
Dirty procedure refers to operations for abscesses.

Before the routine use of prophylactic antibiotics infection rates were 1-2% or
less for clean wounds, 6-9% for clean-contaminated wounds, 13-20% for
contaminated wounds and about 40% for dirty wounds.
Preventive techniques of surgical site infection
Skin preparation: The skin is colonised by various types of bacteria, mainly
Staphylococcus aureus. The main source of wound contamination was found to

be the skin of the patient. For this reason, preoperative preparation should be
performed
Shaving: It is now recognised that shaving damages the skin and that the risk of
infection increases with the length of time between shaving and surgery.
If shaving is essential, it should be performed as close to the time of surgery as
possible.
Surgical site infection- classification
1.

Superficial surgical site infections:

Occur within 30 days of procedure

Involve the skin and subcutaneous tissue

purulent drainage from the incision

organisms isolated from culture of fluid or tissue from the incision

signs or symptoms of infection - pain or tenderness, localised swelling,

redness or heat

The following are not considered superficial SSIs:

-

stitch abscesses (minimal inflammation and discharge confined to the

points of suture penetration)
infected burn wounds

2.

Deep surgical site infections:

Occur within 30 days of procedure

Involve deep soft tissues( fascia, muscles)

Purulent drainage from incision

Symptoms and signs of acute infection, fever above 38 degree Celsius

57
- evidence of preop. Congestive cardiac failure
Severity of a wound infection:
-

minor infection if there is discharge without cellulitis or deep tissue

destruction,
major infection if the discharge of pus is associated with tissue
breakdown, partial or total dehiscence of the deep fascial layers of the
wound, or if systemic illness is present.

Risk factors of wound infection:

- intraoperative hypotension
- angina pectoris, especially at rest
- myocardial infarction in the last 6 months.

Advice for surgeons:

-

elective procedures should be deferred for at least 6 months. Before 3

months more then 35% will reinfarct, after 3 months 15% and after 6
months only 4%.

reduced immunity and drugs (steroids)

Preoperative anticoagulatants and antiplatelet drugs may be of value

tissue hypoxia

give appropriate medical treatment to patients with angina or

congestive cardiac failure.

hematoma formation,

diabetes, poor nutrition,

Treatment:
- antibiotics are indicated when there is cellulitis or immunodeficiency.
- suture should be removed
- release pus if present by opening the wound to provide adequate drainage.

Surgery and myocardial infarction

Surgery increases the risk of peri- or postoperative myocardial infarction.
In previously asymptomatic patient over 50 years the incidence is around 0,5 %.
If the patient has had a previous infarct incidence increases almost 40 folds with
a mortality of 7o% and a recurrence rate of 50 %.
Adverse factors
- preoperative hypertension

In patients who need emergency surgery, the risk of surgery is justifiable.

Deep venous thrombosis
DVT is highest in patients over 40 years old who undergo major surgery.
Postoperative increase in platelets coupled with venous endothelial trauma and
stasis all contribute (Virchows triad). If no prophylaxis is given, 30% of
surgical patients will develop DVT and 0,1-0,2% will die from pulmonary
thrombo-embolism (PTE).
High risk factors:
-

Pelvic surgery

Hip replacement surgery

Malignant disease

Contraceptive pills

58
-

Previous history of DVT ot PTE

Older patients as the increase of DVT is almost liniar with advancing

age.

Other factors: obesity, diabetes mellitus, polycythemia, varicose veins,

cardiac and respiratory disease.

Clinical diagnosis:
-

pyrexia at 7-8 days postoperatively is often the first sign. It may be

associated with pain, swelling of the leg and rise in skin temperature.

Hommans sign present: pain in the calf on forced flexion of foot.

Treatment

- Dextran 70: started on induction of anaesthetic, repeat thereafter if

necessary.
- Alternative agents: aspirin, clopidrogel (plavix).
MCQ TESTS
18.1 Nausea and vomiting as complications of postoperative period might NOT
be due to:
a. anaesthetic agents,
b. analgesics,
c. constipation,
d. intestinal ileus,

Low molecular weight heparine for 10 days, enoxaparine (clexane) - 1 mg/Kg

twice daily or nadroparin ( fraxiparine) 0,1 ml/10 Kg twice daily.

e. mechanical obstruction.

Not necessary to monitor coagulation during LMWH treatment.

18.2 What is NOT a clinical feature regarding a patient with postoperative

bleeding:

After 8 days, associate to LMWH, oral anticoagulant such as warfarin 1 tb of 2

mg for two days then carry on with warfarine only for 6 months.

a. the patient is restless, cold and clammy,

The dose of warfarine is trimmed after the prothrombine time.

b. decreasing pulse rate,

Prevention

c. increasing pulse rate,

Identify the high risk patient

d. pallor,

Methods of prevention:

e. sighing.

- mechanical: use of elastic stockings and intermittent peroperative pneumatic

calf compression.

18.3 What is NOT a risk factor for wound infection as a postoperative

complication:

- medication:

a. hematoma formation,

- low dose LMWH: subcutaneous, 200u/kg 12 hours preop. then 8 or

12 hourly until mobile.

b. clean surgery,
c. diabetes,

59
d. poor nutrition,
e. reduced immunity and drugs (steroids).
18.4 What is the best thing to do in grossly infected postoperative wound:
a. applying ice bag,

19. WOUND CARE

b. change dressings three times daily,

Disruption of tissue integrity, whether surgical or traumatic, stimulates a series

of celullar and morphologic events that can result in spontaneous wound
closure.

c. suture removed to release pus,

d. antipiretics,
e. pain killers.
18.5 What is NOT a high risk factor for deep venous thrombosis as
postoperative complication:
a. pelvic surgery,
b. malignant disease,
c. contraceptive pills,
d. previous history of deep venous thrombosis or pulmonary thrombembolism,
e. young patient with a body mass index of 20.

Impairment of normal healing, especially by infection, is a major source of

surgical morbidity, Processes of wound healing.
1. Epithelization - begins within 12 hours from injury, is the process by which
surface covering of the wound is restored by a combination of cell migration
and multiplication. When an area is denuded of epithelium the marginal cells
divide migrate across the bare area.
2. Proliferation of fibroblasts begins at approximately the fourthday. Fibroblasts
migrate into the wound, proliferate and produce extracelullar matrix including
collagen. Budding of new capillaries from existing venules produces a red,
beefy surface called granulation tissue.
3. Maturation of the wound starts during the third week and is characterized by
an increase in wound strength without an increase in the amount of collagen.
Strength is gained by collagen remodelling with an increase in cross-linking and
improved collagen alignment along lines of tension. The increase in tensile
strength plateaus after 1 year at 70-80% of intact skin.
The slope of the maturation curve is steepest during the first 6-8 weeks.
Contraction is an important clinical feature in open wounds.
After 2-3 days, myofibroblasts appear, causing the wound ins to move toward
each other, significantly reducing the wound area.

60
The first step in wound care is to cleanse the wound and surrounding skin in
preparation for examination and closure.
In general, wounds cannot be cleansed adequately without appropriate
anesthesia.
The most common method for local anesthesia is infiltration of the wound edges
with 1% lignocaine.
Different ways of wound healing
1.

2.

3.

Primary intention wound healing refers to closure of wellapproximated tissues (the wound edges are brought together, apposed,
and then held in place by mechanical means: adhesive strips, staples or
sutures).
Secondary intention wound healing refers to wounds left open, because
of the presence of infection, excessive trauma or skin loss, and the
wound edges come together naturally by means of granulation and
contraction.
Delayed primary closure refers to approximation of wound edges after
initial open treatment. Bacterial counts in contaminated open wounds
are reduced after 4-5 days. Wound edges are brought together at about
4-5 days, before granulation tissue is visible.

Clean the surrounding skin. Standard aseptic surgical technique is used.

Gross contaminants such as dirt or grease should be removed.
1.

Antimicrobial agents are appropriate for the surrounding skin but are cytotoxic.
Irrigation with normal saline is the safest and most effective method of
removing bacteria from the wound.
2.

The patient must be examined for other injuries that may not be immediately
apparent.
Neurologic and vascular integrity should be assessed distal to the site of injury.
The neurologic examination must be performed prior to infiltration of anesthetic
agents.
1.

Wound cleansing

Hemostasis

This is accomplished initially by elevation or direct pressure or both. Once the

wound site is prepared, bleeding from large vessels can be controlled by suture
ligation. For isolated capillary bleeding diathermy can be used.
3.

Wound exploration is important for identifying foreign bodies and

disruption of underlying structures. The extent and depth of injury
should be assessed.

4.

Debridement is used to remove necrotic tissue or tissue containing

gross contamination not cleared by irrigation.

Emergency wound care

History and physical examination

Wound irrigation

Debriding healthy tissue at the wound margins can permit more accurate
approximation of tissue layers.
In this way, wound edges that are irregular, jagged or necrotic can be
approximated.
Wounds closure

61
The decision to close a wound depends on a clinical judgment of the degree of
contamination present.

This infection is characterized by spasm of the voluntary muscles and may

quickly evolve to respiratory arrest.

Wounds that are clearly infected on presentation should be left open for delayed
closure or healing by second intention.
After 4-6 hours from injury, a wound has a high risk of contamination.
A judgment must be made after assessment of the mechanism of injury, the
presence of contamining material or a subjacent fracture, the appearance and the
location of the wound.

Tetanus-prone wounds are:

- deep, old wounds

Antibiotics prophylaxis
- wounds contaminated by soil, feces, rust
In the uninfected minor soft-tissue wound, most studies demonstrate no
advantage in administering prophylactic antibiotics.
A few specific exceptions include patients with cardiac valve disease or
prostheses and orthopedic prostheses.
Antibiotics are also indicated for high-risk wounds (old, deep, devitalized) or in
the compromised host.
Contaminated wounds usually can be managed with debridement and allowed to
close by secondary intention without the use antibiotics.
Indications for antibiotic use include clinically infected wounds or heavy
contamination with feces, saliva or vaginal secretions.
Antibiotic use does not allow closure of a wound that would otherwise be left
open.
A possible exception is the contaminated wound in the highly vascular skin of
the head and face; such a wound is closed immediately owing to cosmetic
consideration:
Tetanus infection
Tetanus is caused by a toxin produced by the anaerobic organism Clostridium
tetani.

- missile, crush, burn or frostbite wounds

- wounds characterized by devitalized or denervated tissue
- wounds caused by animal or human bite
Tetanus prophylaxis
Active immunization with tetanus toxoid injections is given in the
recommended schedule resulting in a protective titer within 30 days. This is
usually done in infancy with DTP shots or during military induction. A booster
every 10 years is recommended.
Prophylaxis at the time of injury
Any person with a penetrating injury must receive tetanus prophylaxis if
previous immunization cannot be documented.
A previously immunized person should be given a booster dose if none has been
given within the past 5 years.
A patient with a clean injury who has never been immunized should be given
the first of three immunizing doses, but it is important that the patient receives
the subsequent two doses.

62
A patient with a dirty wound who has never been immunized should be given
passive immunization with human tetanus immune globuline intramuscularly.
The protection period has a half-life of 1 month.
The first dose of tetanus toxoid may be given at the same time but should be
given at a separate intramuscular site.
Adequate debridement of devitalized tissue and removal of all foreign debris are
also essential.
The value of antibiotics, particularly penicillin, for the prophylaxis of tetanusprone wounds is unproven. However, for patients who have a suspected
Clostridium tetani infection or extensive necrosis, prophylactic penicillin should
be given in high doses.
Bites
1. Dog and cat bites
Most patients are children who present with a single bite.
The most frequent complication is infection.
Most wound infections result from the organisms inoculated deep into the
wound.
Infected dog bites often are polimicrobial.
Local care - dog bites tend to tear and crush, whereas cat bites usually result in
small puncture wounds.
X-rays should be obtained for bites to the hand or fingers to rule out fracture or
osteomyelitis.
The general principles of wound cleansing and debridement must be applied.
Bite puncture wounds should not be closed. However, it is safe to close most cat
and dog lacerations if they can be cleansed adequately. Closed wounds need to
be inspected daily.

Infected hand wounds are best left open for delayed closure.
2.

Human bites

Patients with human bites often delay seeking treatment, which increases the
risk of infection. Common presentation includes:
3. a true bite with puncture wounds, lacerations or tissue avulsion
4. hand laceration from striking another person's mouth
5. unintentional bites of the lip or tongue during a fall or seizure
Infected foot ulcers
Lower extremity ulcers may be caused by diabetes, arterial insufficiency and
venous stasis.
Venous stasis ulcers are common, tend to occur on the medial ankle and are
surrounded by firmly edematous, hyperpigmented skin.
Ischemic ulcers occur around the lateral maleolus.
The surrounding skin usually is thin and shiny and may exhibit cyanosis or
dependent rubor. Peripheral pulses are diminished or absent.
Diabetic foot ulcers are associated with neuropathy and typically are located on
the plantar surface over the metatarsal heads or the heel.
Etiology
1. Peripheral neuropathy contributes to the development of foot ulcers in two
ways. The lack of pain from trauma, foreign bodies or ill-fitting footwear allows
the progression of tissue breakdown and infection without the patients being
aware.
2. Ischemia
Vascular insufficiency contributes to the pathogenesis of foot ulcers associated
with diabetes in up to 60% of cases. If there is proximal atherosclerotic

63
obstruction, appropriate intervention to either revascularize the distal leg or to
allow healing after amputation may be indicated.
3. Poor leukocyte function in diabetics may impair wound healing and the
immune response to infection.

Dressings
Function of dressings
Dressings serve the following functions:

Examination

-protection from trauma

Assess the extent and severity of the wound.

- immobilization

The peripheral circulation should be assessed by examination of the peripheral

pulses or capillary refill.

- compression

Note the level of sensory loss, if any.

Plantar ulcers extending to a metatarsal head, leaving exposed cartilage is
typical of so called mal perforans ulcer.

- absorbtion of drainage
- protection from bacterial contamination
- esthetics.

Osteomyelitis in the phalanx or metatarsal is common.

Examine web spaces for mycotic infection, which can lead to skin fissures that
provide a portal of entry for bacteria.
Uninfected wounds are treated by debridement and dressing.

In open wounds, dressings can also aid in debridement.

In surgically closed wounds, dressings should be left in place 48-72 hours until
epithelization occurs; however they should be removed sooner if saturated by
blood or serum and immediately if infection is suspected.

Careful trimming of calluses and nails is helpful.

Revascularization may improve circulation. Close follow-up is essential.
Infected wounds
Infections are polimicrobial and can include aerobic cocci, bacilli and
anaerobes. Patients should be hospitalized and treated with broad spectrum
intravenous antibiotics.
Non viable tissue should be completely debrided and abscesses should be
drained.

Dressing material for open wounds

Gauze packing
Gauze packing permits drainage while providing some degree debridement.
Dry-to-dry and wet-to-wet dressings provide gentler debridement and are less
painful.

Absolute non-weight bearing is crucial for healing.

Dressings, however do not substitute for surgical debridement of large amounts

of necrotic or contaminated tissue.

Control blood sugar repeatedly.

Hydrocolloids.

64
These occlusive, adhesive wafers (Duoderm
ConvaTec) provide a moist environment for shallow wounds with light exudate.
They can be left in place for 3-5 days and may be used under compression.
Hydrogels.
These water-or glycerin-based gels are used in deep wounds to maintain
hydration and facilitate debridement.
Alginates (Kaltostat, Calgon) are highly absorbant, used in wounds with heavy
exudate. They form a gel as they absorb drainage.

d. irrigation with iodine 50%,

e. irrigation with iodine 80%.
19.3 What is the best management for clearly infected wound on presentation:
a. leave it open for delayed closure or healing by second intention,
b. suture with separate stitches,
c. suture with a simple running stitch,
d. suture with running locked stitch,
e. apply Michel clips
19.4 Diabetic skin ulcers are most commonly localized on:
a. lateral aspect of the thigh,

MCQ TESTS

b. lateral aspect of the calf,

19.1What is NOT a process of wound healing:

c. popliteal fossa,

a. epithelization,

d. plantar region,

b. proliferation of fibroblasts,

e. anterior aspect of the foot.

c. development of new capillaries,

19.5 Dressings serve the following functions, EXCEPT ONE:

d. collagen laydown,

a. protection from trauma,

e. bleeding.

b. pain relief,

19.2 What is the safest and most effective method of removing bacteria from the
wound:

c. immobilization,

a. irrigation with normal saline,

b. irrigation with iodine 20%,
c. irrigation with alcohol,

d. absorbtion of drainage,
e. protection from bacterial contamination.

65
20. TRANSFUSION THERAPY IN SURGERY
Blood components
1.

Whole blood is collected in an anticoagulant preservative solution and

is stored at 4 degrees Celsius for up to 42 days.

The most common solutions are citrate phosphate dextrose and adenosine
dextrose saline.
Banked blood undergoes several changes during storage:
-red blood cells progressively lose their viability. For example, if blood is
transfused after it has been stored for 28 days only 25% of its red cells will still
be viable 60 days after the transfusion.
-oxygen transport is also reduced because of a decreased in cellular 2, 3diphosphoglycerate; this shifts the oxygen-hemoglobin dissociation curve to the
left.
-clotting factors V and VIII rapidly deteriorate in banked blood, and platelets do
not remain active past 24 hours.
- changes in chemistry also take place; the pH of stored blood gradually
decreases, reaching about 6.7 after 4 weeks of storage.
- potassium concentration may be 25-30 mEq/1 at this time.
- amonia also steadily rises.
Probably the only indication for the transfusion of whole blood is hypovolemia
secondary to acute hemorrhage.
Fresh whole blood (not more than 24 hours old) would be ideal for this purpose,
since platelets and clotting factors would still be active and many of the adverse
biochemical effects of stored blood would be avoided.
Generally, whole blood is infrequently used. Transfusion is based on replacing
the needed components of whole blood.

2.

Packed red blood cells are prepared by removing the plasma, leaving a
hematocrit of 70%.

Packed cells are indicated for most transfusions in which the goal is to increase
the patients oxygen-carrying capacity.
Packed cells present less volume and a lower electrolyte load for the patient
than whole blood.
Packed cells should be used for the management of most patients who requires
restoration of red cells mass and who are not actively bleeding.
3. Fresh frozen plasma contains all of the coagulation factors lacking in banked
whole blood, including factors V and VIII.
It is used to replace clotting factors during massive transfusion of packed red
cells or to correct the factor abnormalities found in conditions such as liver
disease or disseminated intravascular coagulation.
4. Cryoprecipitate, a plasma derivative, contains high concentrations of factor
VIII and fibrinogen along with smaller amounts of other factors. It is used in
hemophilia.
5. Specific factor concentrates provide replacement therapy for inherited
deficiency states: several commercial products are available.
6. Albumin is available in 5% and 25% concentrations. It is used as a volume
expander.
Unlike all of the above components, albumin is free from infectious risk.
Complications of transfusions
1. Disease transmision
- hepatitis is estimated to occur about 2% of transfusions although most cases
are asymptomatic. The incidence is higher with factor concentrates. Effective
screening can detect hepatitis B surface antigen.
Post-transfusion hepatitis is now due to non A non-B hepatitis.

66
Approximately 70-80 % of post-transfusion hepatitis can now be identified with
a new test for antibodies to hepatitis. The risk post-transfusion hepatitis should
fall to less than 0,5 %.
-

acquired immune deficiency syndrome (AIDS) is a severe defect in the

immune system, which leave its victim susceptible to opportunistic
infections and rare neoplasms such as Kaposis sarcoma.

This disease may be transmitted via blood obtained from affected individuals.
Screening tests can detect the antibody response against the virus; however,
there is a period of time early in the course of the infection when AIDScontaminated blood can escape detection.
Other disease such as syphilis, brucellosis, malaria and cytomegalovirus can
also be transmitted in transfused blood.

2. Immediate transfusion reactions

- allergic reactions are the commonest type, occurring in up to 2% of
transfusions. Fever, chills, urticaria and itching typically occur after at least half
of a unit of blood or packed cells is transfused. Respiratory symptoms such as
wheezing or stridor occur in severe cases.
An antihistamine will control the minor symptoms. Adrenaline and steroids are
reserved for more serious cases. If the reaction is typically allergic and responds
to treatment, it is not necessary to stop transfusion. However if there is concern
about a hemolytic reaction, the transfusion is stopped immediately.
Fever is caused by antigens on white cells or platelets to which the patient is
sensitive.
Antipyretics are given to reduce the fever.
-

hemolytic reactions are fulminant reactions usually due to the

transfusion of cross-match incompatible blood because of errors in
cross-matching, typing, labeling or patient identification.

Typically, early reactions appear after only 50-100 ml of blood has been given.
The patient may develop fever and chills with complaints of chest, back or flank
pain and dyspnea.
-

hypotension and shock may also occur.

The transfusion is immediately stopped when any patient is suspected of having

a hemolytic reaction.
The remaining transfusion blood and fresh sample of the patients blood are sent
to the laboratory for retyping and crossmatching.
Urine and serum should also be sent for free hemoglobin. A Foley urinary
catheter is inserted and dieresis is established rapidly by giving 25 g of manitol
and infusing lactated Ringers solution at a rate that should ensure a urine
output of at least 100ml/h.
Sodium bicarbonate may also be given to alkalinize the urine and help prevent
tubular damage.
Delayed hemolytic reactions are considered to be anamnestic responses to prior
transfusions or pregnancies. They cause hemolysis and jaundice that appear
several days after the transfusion.
Complications of massive transfusions of banked blood.
Rapid transfusion within 12 hours of an amount of stored blood equal to or
greater than the patient's blood volume can lead to problems, due primarily to
the changes that occur in stored blood.
-

Decreased oxygen-carrying capacity: because the 2,3 DPG level

gradually falls in stored blood, the hemoglobin affinity for oxygen
increases so that oxygen release to the tissues is less efficient.

Coagulation defects: these result from a dilutional effect since whole

blood stored longer than 24 hours has virtually no platelets and no
factor V or factor VIII activity. Platelets and fresh frozen plasma must
be given in addition to banked blood.

67
-

Hypothermia: this rapidly develops if several units of blood are

transfused without being warmed. Arrhythmias will commonly occur
at body temperatures of 30 degrees Celsius. During a transfusion, the
blood must be warmed up near body temperature. The container of
blood should never be warmed.

Remember, blood transfusion is the same like organ transplantation and is the
most frequently performed transplant procedure. As much care must be taken
with cross-matching as it is taken with tissue typing for transplantation.

Metabolic effects:

Related to the amount of blood needed, operative procedures can be divided

into three categories:

- hyperkalemia: because the extracellular K concentration rises in

banked red cells, rapid administration of large amounts of old stored blood can
cause transiently dangerous hyperkalemia.
Therefore, when massive transfusions are required, blood less than 2-3 days old
should be preferentially used or at least alternated with older blood to minimize
this problem.
- acidosis and citrate toxicity; normally, citric acid (from transfused
blood) and lactic acid (from poorly perfused tissue) are rapidly metabolized.

Request for blood

1. Blood transfusion is invariable needed: abdominal aortic aneurism,

pancreatectomy, colectomy, total gastrectomy.
2. Blood transfusion is occasional needed: partial gastrectomy,
mastectomy
3. Blood transfusion is rare: colostomy, laparotomy

However, in the hypovolemic patient or the patient in shock with reduced

hepatic blood flow, this will be slowed and severe acidosis can occur.

To make sure that the blood is readily available when required, send blood for
grouping and cross-matching 48 hours before operation with the appropriate
request: please cross-match 3 units of blood for a splenectomy on the 5th of
December.

Alkalinization is not routinely advisable and should be used synergistically with

hypothermia and low 2.3-DPG levels to decrease the delivery of oxygen to the
tissues.

A request form for blood should contain the patient's full name, age, hospital
number, ward number, diagnosis, theatre number, the name of surgeon who is
going to perform the operation.

Also it can lower the level of ionized calcium. A low level of ionized calcium
has a detrimental effect on myocardial performance.

The safest patient to transfuse is the patient with a negative antibody screen who
has never been transfused or had pregnancy.

The hypothermic patients heart is very sensitive to the calcium ion.

Transfusion reactions in such patients, except for the major ABO

incompatibility, are rare.

Giving calcium gluconate 1g/l of blood is probably safe, but ideally,

replacement should be guided by direct measurement of ionized calcium.

The recommended procedure in a patient needing urgent transfusion should be:

- respiratory insufficiency- degenerating platelets and white cells in stored

blood can microembolize and when large amounts of banked blood are
transfused, pulmonary damage and respiratory insufficiency may occur.
This complication is partially prevented by transfusing the blood through a
micropore filter.

warn the blood bank

insert an iv. cannula and use it to take blood samples for grouping and
cross-match.

send the sample to the blood bank with the request form.

68

Depending on the degree of urgency, ask for:

-

0 Rh negative blood in extreme emergency only

grouped but not cross-matched blood, only in great urgency (5-10min)

grouped and simple cross-matched blood (15 min).

fully cross-matched group (1-1, 5 h )

In the meantime, use a plasma volume expander such as plasma protein solution
or plasma substitute (dextran, gelofusin, rheomacrodex).
Blood transfusion also stimulates an immune response (humoral and cellular) in
the recipient which may explain its beneficial effect in renal transplant but its
possible adverse effect in cancer recurrence.
It is probable that the plasma components of whole blood initiate an adverse
immunological reaction.
Medical terms definition
Hypovolemia means low blood volume. "Hypo" means low, "vol" is for volume,
and "emia" refers to blood. Symptoms : cold hands and feet, increased heart
rate, and weakness.
Hepatitis- inflammation of the liver
Kaposi sarcoma is a cancer that causes patches of abnormal tissue to grow
under the skin, in the lining of the mouth, nose, and throat or in other organs.
Syphilis is a chronic infectious disease caused by a spirochete (Treponema
pallidum), transmitted by direct contact, usually in sexual intercourse.
Brucellosis Brucellosis is a bacterial disease caused by members of the
Brucella genus. Symptoms of the disease include intermittent fever, sweating,
chills, aches, and mental depression

Malaria is an infectious disease characterized by cycles of chills, fever, and

sweating, caused by a protozoan of the genus Plasmodium in red blood cells,
which is transmitted to humans by the bite of an infected female anopheles
mosquito.
Urticaria is a vascular reaction of the upper dermis marked by transient
appearance of slightly elevated patches (wheals) which are redder or paler than
the surrounding skin and often attended by severe itching; the exciting cause
may be certain foods or drugs, infection, or emotional stress.
Wheezing means breathe with difficulty, producing a hoarse whistling sound.
Stridor means a noisy breathing in general, and to refer specifically to a highpitched crowing sound associated with respiratory infection, and airway
obstruction.
Hemolytic transfusion reaction is a serious problem that occurs after a patient
receives a transfusion of blood. The red blood cells that were given to the
patient are destroyed by the patient's immune system.
Antipyretics - medication against fever.
Dyspnea - shortness of breath (air hunger).
Jaundice or icterus - yellowish discoloration of the whites of the eyes, skin, and
mucous membranes caused by deposition of bile salts in these tissues.
Abdominal aorta aneurism - saccular dilation of the abdominal aorta
Pancreatectomy- resection of pancreas
Colectomy- resection of the colon
Mastectomy- excision of the mammary gland
Splenectomy- excision of the spleen
Laparotomy- operative procedure of opening of the peritoneal cavity

69
c. transmission of acquired immune deficiency syndrome,
d. allergic reactions,
MCQ TESTS

e. hemolytic reactions.

20.1 Banked blood undergoes several changes during storage, EXCEPT ONE,
a. red blood cells progressively lose their viability,
b. clotting factors V and VIII rapidly deteriorate in banked blood, and platelets
do not remain active past 24 hours,

20.4 Complications of massive transfusions of banked blood are, EXCEPT

ONE: a. hypothermia if several units of blood are transfused without being
warmed,
b. hyperkalemia,

c. oxygen transport is also reduced because of a decreased in cellular 2, 3diphosphoglycerate,

c. hypokalemia,

d. pH of stored blood gradually increases,

d. acidosis,

e. potassium concentration may be 25-30 mEq/l.

e. respiratory insufficiency.

20.2 The only indication for the transfusion of whole blood is:

20.5 In what type of surgery, blood transfusion is invariable needed:

a. hypovolemia secondary to acute hemorrhage,

a. total gastrectomy,

b. hematemesis,

b. partial gastrectomy,

c. melena,

c. mastectomy,

d. rectal bleeding,

d. colostomy,

e. frequent epistaxis.

e. laparotomy

20.3 What are the complications of transfusion, EXCEPT ONE:

MCQ TESTS- ANSWERS

a. transmission of hepatitis,

1.1- e

b. transmission of actynomicosis,

2.1- e
6.1- b

3.1- a

4.1- b

5.1- d

70
1.2- d

2.2- a

3.2- a

4.2- d

5.2-

6.2- a
1.3- c

2.3- e

3.3- c

4.3- d

5.3- a

3.4- d

4.4- a

5.4-

3.5- b

4.5- d

5.5-

9.1- d

10.1- b

11.1- a

9.2- b

10.2- d

11.2- b

9.3- c

10.3- a

11.3- c

9.4- c

10.4- c

11.4- e

9.5- a

10.5- d

11.5- e

6.3- e
1.4- d

2.4- b
6.4- d

1.5- e

2.5- d
6.5- e

7.1- e

8.1- b
12.1- e

7.2- d

8.2- c
12.2- a

7.3- e

8.3- d
12.3- a

7.4- d

8.4- b
12.4- a

7.5-b

8.5- a
12.5- a

13.1- b

14.1- c

15.1- e

16.1- b

17.1- b

13.2- c

14.2- b

15.2- a

16.2- c

17.2- c

13.3- d

14.3- a

15.3- b

16.3- e

17.3- b

13.4- b

14.4- e

15.4- c

16.4- a

17.4- d

13.5- d

14.5- d

15.5- e

16.5- c

17.5- a

18.1- c

19.1- e

20.1- d

18.2- b

19.2- a

20.2- a

18.3- c

19.3- a

20.3- b

18.4- c

19.4- d

20.4- c

18.5- e

19.5- b

20.5- a