Surgical Instruments and Drains PDF

Surgical Instruments and Drains
By Ramarno Forrester
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Ramarno Forrester MBBS 2K12 Table of Contents
Table of Contents
Biopsy Instruments ................................................................................................................................. 4
Core Needle......................................................................................................................................... 4
Drains ..................................................................................................................................................... 6
Haemovac_Drain ................................................................................................................................. 6
Jackson Pratt Drain .............................................................................................................................. 7
J-Vac Drain .......... 7
Penrose Drain ...................................................................................................................................... 7
Corrugated Drain ................................................................................................................................. 7
Cigarette Drain .................................................................................................................................... 8
Sump Drain .......................................................................................................................................... 8
Pigtail Catheter .................................................................................................................................... 8
Cadiovascular System ........................................................................................................................... 10
Dacron Graft ...................................................................................................................................... 10
Fogathy Embolectomy Catheter ......................................................................................................... 11
Type chapter title (level 2) .....................................................................................................................
Respiratory System ............................................................................................................................... 13
Chest tube .............................................................................................................................................
Incentive Spirometer ......................................................................................................................... 13
Rigid Bronchoscope ........................................................................................................................... 13
Mediastinoscope ............................................................................................................................... 16
Gastrointestinal System ........................................................................................................................ 19
Rigid Oesophagoscpe ......................................................................................................................... 19
Nasogastric Tube ............................................................................................................................... 20
Self Expanding Metal Stent ................................................................................................................ 23
Mousseau Barbin Tube ...................................................................................................................... 23
T-tube................................................................................................................................................ 24
Laparoscopic Trocar and Port............................................................................................................. 25
Laparoscopic Grasper ........................................................................................................................ 28
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Stoma Bag ......................................................................................................................................... 28
Sigmoidoscope .................................................................................................................................. 30
Proctopscope..................................................................................................................................... 32
Fatus Tube ......................................................................................................................................... 32
Urinary System ..................................................................................................................................... 33
Urinary Catheters .............................................................................................................................. 33
Urethral Bougie ................................................................................................................................. 37
Malecot and Pezzer Catheters ........................................................................................................... 39
Cystoscope ........................................................................................................................................ 40
Ureteric Catheter ............................................................................................................................... 40
Anaesthesia instruments ...................................................................................................................... 42
Suction Catheter ................................................................................................................................ 42
Face Mask.......................................................................................................................................... 42
Oropharyngeal Tube .......................................................................................................................... 42
Endotracheal Tube............................................................................................................................. 43
Magill’s Forceps ................................................................................................................................. 46
Larygoscope ...................................................................................................................................... 47
Tracheostomy Tube ........................................................................................................................... 48
Central Venous Catheter ........................................................................................................................
Fluids, Electrolytes and Nutrients ......................................................................................................... 55
Orthopedic Instruments........................................................................................................................ 59
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Biopsy instruments
Core needle
Identify: This is a core needle
Describe:
It has a plastic handle with a graduated

sliding bar and an inner needle.
Indications
To biopsy breast lumps or other masses

with or without ultrasound guidance
Procedure
1. Informed consent
2. It is a sterile procedure so aseptic measures must be taken.
3. Clean the area and apply local anaesthesisa
4. Use a blade to nick the area above the mass
5. Insert the metal tubing with the needle covered
6. With the handle stable pull the sliding bar backwards to expose the needle then push it forward
to obtain the biopsy specimen.
7. Withdraw the metal tubing and remove the tissue you collected. You may repeat twice.
Questions
1. What other methods of biopsy are there?
a. Incisional, excisional, fine needle aspiration and cytology
2. What information can you get from a core needle biopsy?
a. It gives information on histology showing if there are lymphovascular infiltration along with
cytology to show (whether there is malignancy or not) and the level of differentiation. It also
tells about oestrogen receptor status the presence of HER 2 receptors. You can also attain
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the progesterone receptor status.
3. What are the levels in birads classification?
a. The BI-RADS assessment (for breast imaging based on microcalcification and spikulation)
categories are:
0- incomplete,
1- normal tissue
2-benign findings,
3-probably benign,
4-suspicious abnormality,
5-highly suspicious of malignancy,
6-known biopsy with proven malignancy.
4. If the cytology comes back birads 4 or 5 but your mammographic findings suggest malignancy
what you you do?
a. Do an excisional biopsy.
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Drains
Classification
Drain
s
Closed
Open
Active Passive Active Passive
Haemovac NGT SUMP drain Penrose drain
Jackson pratt Urinary catheter Cigarette drain
J-vac Chest tube not Corrugated drain

on suction
Chest tube on T-tube
suction
Pigtail catheter
Haemovac drain
Identify: This is a haemovac drain
Classify: This is a closed active drain
Describe
It has 2 ports and a reservoir bag with gradients to measure volume.

One port is to drain the fluid and the other is to deflate the bag.
Indications
1. Thyroidectomy
2. Neck sugery
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3. Breast surgery to drain lymphatic fluid (seroma)
4. Lymphatic surgery
5. Groin surgery
Advantage
It is closed so it reduces the risks of infection and the suction mechanism helps in its prophylactic uses in
preventing excessive fluid collection post surgery.
Disadvantage
Its resoivoir bag limits its use in draining massive secretions.
Jackson-Pratt drain J- Vac drain
Penrose drain
Identify: This is a penrose drain
Classify: It is an open passive drain
Describe: Flabby latex tube
Indications
1. For prophylaxis against fluid build up within a wound
2. Abdominal fluid collection
3. After a foot flap
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4. It can also be used to drain cerebrospinal fluid to treat a hydrocephalus patient.
Disadvantage
Open so high risk of infection
Questions
1. What physical principle does this drain use?
a. Capillary action - The movement of a liquid along the surface of a (solid tube) due to the
adhesive properties of the liquid.
2. How long should a drain be left in place for?
a. For serous fluid 3-5 days
b. For wounds 1-5 days
c. For bowel anastamosis 5-7 days
d. For T-tube 10 days when a fibrous tract has formed
Corrugated drain
Identify: This is a corrugated drain
Classify: It is an open passive drain
Describe: It consists of a flat flabby material with

corrugated channels
Indications:
1. Drain a wound
2. Drain abscess
Cigarette Drain
Penrose with a gauze
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Sump Drain
Identify: This is a Sump drain
Classify: It is an open active drain
Describe:
It has a long outer tank with distal perforations and a

proximal end that communicates with the environment.
There is an inner tube with a distal opening and a
proximal port for connection to suction..
Indications
1. To drain abdominal fluid collection.
2. To drain abscess
It does not cause any any bowel trauma on suction since the outer tank communicates with the
environment and equalises the negative pressure from inner tube thus the bowel will not adhere to the
tube. Fluid drains into the tank and is sucked into the inner tube.
Sump means a tank!
Pig tail Catheter
Identify: This is a pigtail catheter
Classify: It is a closed passive drain
Describe: It consists of kink resistant soft-polyurethane material with a distal curled tip and a proximal
port for connection to a resevoir bag. There is a obturator that can be used to allow uncurling of the tail
for placement and removal.
Indictions
1. Used to drain pancreatic abscess/ pseudocyst
2. Used to drain liver abscess
3. In percutaneous nephrostomy to drain kidney and is placed under ultrasound or CT guidance
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Complications:
1. Stone formation with prolonged placement
2. Infection
3. Obstruction
4. Displacement
Condom catheter
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Ramarno Forrester MBBS 2K12 10 Table of Contents
Cardiovascular System
Dacron graft
Identify: This is a dacron graft
Describe: It is at threaded tube with a longitudinal radiopaue line.
Indications:
Bypass in peripheral arterial disease above the knee
Contraindications
Poor run in, run off or a large occlusion.
Procedure: Refer to text
Complications:
 Infection
 Thrombosis
 Psuedo-aneurysms
 Leaking of around graft
Questions
1. Can you use it below the knee.
a. No, because it has a very high failure rate there.
2. What other methods of bipass are there?
a. Autologous such as the saphenous vein and the cephalic vein. If the cephalic vein is used
then it could be a reversve one or an anatomical one with valvulotomy using a valvulotome.
Remember that the sphenous vein has valves that prevent caudal flow of blood. So in order
for it to be used in arterial bipass you either have to reverse it or rupture the valves.
3. How can you prevent thrombosis that is likely to develop in the graft.
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a. By placing the patient on heparin and warfarin initially and then maintaining the patient on
antiplatelets.
Fogathy Embolectomy catheter
Identify: This is a fogathy catheter
Describe: It is a long tubular instrument with a distal bulb that is inflatable

and a proximal port fot attachement of a syringe
Indications
1. Extraction of arterial emboli in acute arterial occlusion
2. Can also used to remove stones from the urinary tract and the
common bile duct.
Procedure
1. Attain informed consent
2. Gather instruments
3. Sterile procedure so aseptic measure must be taken
4. Clean area with betadine and allow it to dry
5. Incise skin and bluntly dissect down to artery (femoral artery in lower limb)
6. Make a small transverse incision on the artery (careful not to cut the artery in two!)
7. Introduce the catheter and with radiological guidance pass it distal to the embolus
8. Inflate the bulb after it has safely passed the occlusion
9. Remove the catheter
10. It may take several attempts before the clot may be removed
11. Repair and suture the artery, soft tissue and skin.
Complications
1. Massive haemorrhage and transection of artery
2. Distal migration of embolus
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3. Damage to endothelium of vessel (less likely)
Sengstaken Blakemore Tube
Identify: This is a senstaknen Blakmore tube
Describe:
It consists of a plastic tube with 2 proximal ports that inflate

the two distal balloons
Indications:
1. Tamponade of variceal hemorrhage
2. Massive post-partum bleed
Procedure:
It consists of 2 balloons and is placed nasally into the

stomach. When its position in the stomach has been confirmed radiographically, the distal gastric
balloon is inflated with 250 ml of air, drawn tight against the GE junction, and placed on traction. If the
gastric balloon alone does not control the hemorrhage, the proximal esophageal balloon is inflated to a
pressure of 20 mmHgBalloon tamponade is a temporary measure to control bleeding and can be applied
for 12-24 hours.
Complications:
Risks include esophageal perforation and necrosis of esophageal mucosa from overinflation of the
balloon.
Questions:
1. What are other methods of arresting haemorrhage?
a. Other methods of arresting hemorrhage include:
i. Banding
ii. Sclerotherapy
iii. Transjugular intrahepatic portosystemic shunt (TIPS)
iv. Shunt surgery
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v. Octreotide/Vasopressin
vi. Linton Ballon (has no gastric balloon)
2. Is this a definitive management?
a. No 50% of patients re-bleed after balloon deflation.
Respiratory system
Incentive Spirometer
Identify: This is an incentive

spirometer
Describe: It consists of a
graduated cylinder with an free
floatation device inside. A tube
with a mouthpiece is attached to
the cylinder.
Indications:
1. Post op atelectasis
2. Patients with pneumothorax or hemothorax
(It promotes re-expansion of the lung so anybody with a lung collapse can benefit from it)
Procedure:
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1. Sit on the edge of your bed if possible, or sit up as far as you can in bed.
2. Hold the incentive spirometer in an upright position.
3. Place the mouthpiece in your mouth and seal your lips tightly around it.
4. Breathe in slowly and as deeply as possible, raising the yellow piston toward the top of the
column. The yellow coach indicator should be in the blue outlined area.
5. Hold your breath as long as possible (for at least five seconds). Allow the piston to fall to the
bottom of the column.
6. Rest for a few seconds and repeat Steps one to five at least 10 times every hour when you are
awake.
7. Position the yellow indicator on the left side of the spirometer to show your best effort. Use the
indicator as a goal to work toward during each repetition.
8. After each set of 10 deep breaths, practice coughing to be sure your lungs are clear. If you have
an incision, support your incision when coughing by placing a pillow firmly against it.
9. Once you are able to get out of bed, walk in the hallway and cough well. You may stop using the
incentive spirometer unless otherwise instructed by your health care provider.
Thoracostomy (Chest) Tube with under water seal
Identify: This is a chest tube
Classify: It is a closed passive drain that may be converted to an active system by application o a suction
system.
Describe: It consists of a plastic tube attached to a bottle with an under-water seal. The bottle has to
ports. On port attaches to the thoracostomy tube and the other commmunicates with the environment
or may be attached to suction.
Indications:
Therapeutic
1. Pneumothorax: accumulation of air in the pleural space
2. Chylothorax: a collection of lymphatic fluid in the pleural space
3. Empyema: a pyogenic infection of the pleural space
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4. Haemothorax: accumulation of blood in the pleural space
5. Hydrothorax: accumulation of serous fluid in the pleural space
Conraindications
1. Refractory coagulopathy
2. Lack of cooperation by the patient,
3. Diaphragmatic hernia.
Don’t list the contraindications unless asked
Procedure
2. The skin over the area of insertion is first cleansed with antiseptic solution, such as iodine,
then sterile drapes are placed around the area
3. Identify the 4th or 5th intercostal space between the anterior axillary line and the posterior
axillary line
4. The local anesthetic is injected into the skin and down to the muscle, and after the area is numb
5. A small incision is made in the skin just above the inferior rib
6. A curved artery forceps is used to bluntly dissect down to the pleura
7. Use the index finger to explore the area
8. The tube is placed through this passage with the aid of the forceps guided by your finger
upwards and posteriorly.
9. Once the tube is in place it is sutured to the skin to prevent it falling out and a dressing applied
to the area.
a. Apply a suture to close part o the wound on one side of the tube. Ensure that a
sufficient amount of suture is left
b. After making 3 knots, wrap both ends of the suture around the tube a few times
c. With the ends of the sutures, make 3 knots
10. Once the drain is in place, a chest radiograph will be taken to check the location of the drain.
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Footnote
British Thoracic Society recommends the tube is inserted in an area described as the "safe zone", a region bordered by: the
lateral border of pectoralis major, a horizontal line inferior to the axilla, the anterior border of latissimus dorsi and a horizontal
line superior to the nipple. More specifically, the tube is inserted into the 5th intercostal space slightly anterior to the mid
axillary line. This is to avoid the long thoracic nerve at the mid-axillary region and the vascular and muscular anterior chest wall.
Complications
Immediate- Major complications are hemorrhage, mal-placement into lung, perforation of the diaphragm
or liver
Early - Chest tube clogging or leaking, infection
Late - Re-expansion pulmonary edema.
Removing the chest tube
1. Cut suture
2. Ask patient to expire & hold breath
3. Rapidly remove chest tube
4. Draw purse string suture tight (if used)
5. Place gauze covered by tape over wound
6. Obtain CXR
Questions
1. Why do you go above the inferior rib?
a. To avoid the neurovascular bundles that run bellow the ribs.
2. Which phase of respiration does fluid come out of the pleural space?
a. On expiration when a positive pressure is created.
3. When do you remove a chest tube?

a. When there is clinical and radiological evidence of lung re-expansion
b. When there is less than 50-100 ml of blood drainage per day.
4. What is the function of the under-water seal

a. Protects the pleural space by:
i. Permitting egress of fluids and air
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ii. Prevents re-entry of air
iii. Maintains negative intrapleural pressure.
5. How would you apply suction?

a. By attaching the first tube (reservoir) to another tube that has the underwater seal. That
tube is attached to a third tube with three ports. One port attaches to the first tube,
another attaches to suction and the last communicates with the environment.
6. How would you apply suction if you only have bottles with two ports?
a. The second bottle would have a port that communicates with the environment and
another that attaches to a connecter. The first tube would have would have a port that
attaches to the thoracostomy tube and another that attaches to the connector. The
connector attaches to suction.
7. Why is the triple port tube necessary in order to apply suction?
a. It is important to ensure that no more than 20 cm water of suction is applied in order to
avoid barotrauma to the lungs.
8. Can the chest tube be used in airplanes
a. No because air would start to go into the chest on inspiration due to the
decreased environmental pressure.
9. What would you do if you had to carry a patient in an airplane?
a. Attach a Heimlich flutter bag or a glove with one finger cut to act as a flutter
bag.
Rigid Bronchoscope
Identify: This is a rigid bronchoscope
Describe: It is metallic with a handle and two ports for air introduction/suction and visualization. Some
have a port for light too. The shaft is relatively short compared to an oesophagoscope and is fenestrated
at the end to facilitate ventilation.
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Indications
1. Diagnostic
a. Biopsy of lung tumour
b. Suspicion of foreign body
c. Massive Haemoptysis >600 mL of blood in

24 hours
d. Unexplained + ve sputum.
e. Pulmonary mass on CXR esp. children.
f. Recurrent/ Unresolved pneumonia
g. Persistent atelectasis - (remove mucus plug)
h. Diffuse lung disease
i. Malignant pleural effusion
j. Brochioalveolar lavage
2. Therapeutic
a. Foreign body removal
b. Difficult intubation
c. Laser resection of tumors or benign tracheal and bronchial strictures
d. Stent insertion to palliate extrinsic compression of the tracheobronchial lumen from

either malignant or benign disease processes
e. Lobar atelectasis
f. Stricture dilation
g. Lung abscess
Contraindications:
a. Small airways.
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b. Severe medical problems contraindicating anaesthesia.
Procedure
Bronchoscopy can be performed in a special room designated for such procedures, operating
room, intensive care unit, or other location with resources for the management of airway emergencies.
The patient will often be given antianxiety and antisecretory medications (to prevent oral secretions
from obstructing the view), generally atropine, and sometimes an analgesic such as morphine. During
the procedure, sedatives such as midazolam or propofol may be used. A local anesthetic is often given
to anesthetise the mucous membranes of thepharynx, larynx, and trachea. The patient is monitored
during the procedure with periodic blood pressure checks, continuous ECG monitoring of the heart,
and pulse oximetry.
A flexible bronchoscope is inserted with the patient in a sitting or supine position. Once the
bronchoscope is inserted into the upper airway, the vocal cords are inspected. The instrument is
advanced to the trachea and further down into the bronchial system and each area is inspected as the
bronchoscope passes. If an abnormality is discovered, it may be sampled, using a brush, a needle, or
forceps. Specimen of lung tissue (transbronchial biopsy) may be sampled using a real-time x-
ray (fluoroscopy). Flexible bronchoscopy can also be performed on intubated patients, such as patients
in intensive care. In this case, the instrument is inserted through an adapter connected to the tracheal
tube.
Rigid bronchoscopy is performed under general anesthesia. Rigid bronchoscopes are too large to allow
parallel placement of other devices in the trachea; therefore the anesthesia apparatus is connected to
the bronchoscope and the patient is ventilated through the bronchoscope.
Complications
1. Anaesthesia and premedication
a. Respiratory depression/ Arrest
b. Transient hypotension
c. Seizures
d. Syncopy
e. Larygospasm
2. TECHNICAL
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a. Bronchospasm
b. Haemorrhage
c. Laryngospasm
3. BIOPSY
a. Haemorhage
b. Perforation/pnemothorax
Questions
1. What are the lengths and internal diameters?
a. Length adults 40 cm
Paed ?cm
b. Internal diameter 7-8 mm in adults
3 mm in paed.
2. How do you differentiate a rigid bronchoscope and an oesophagoscope
a. One can differentiate a rigid bronchoscope from oesophagoscope. It has 2 holes at tip of
bronchoscope to allow air so can ventilate the patient!
3. What is the flexible bronchoscope composed of
a. Flexible bronchoscope composed of
a. Bronchoscope
b. Suction port
c. Light carrier fitting in bronchoscope
d. Light cable
e. Light source
f. The fibreoptic technology has 1 light
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source can flex 180 0.
i. Can go 80 degrees posteriorly to look up at Right upper lobe bronchus

unlike rigid.
4. What is the purpose of biopsy?
a. The purpose of staging is to confirm any N2 nodes. If involved, cannot operate / excise the
tumour.
5. Are the diameters of the flexible and the rigid bronchoscope the same?
a. No the bronchoscope is larger and thus can remove larger foreign body.
6. How is biopsy collected in the flexible bronchoscope
a. Biopsy is connected to suction.
7. If the patient has haemoptysis which method is better
a. If patient has excessive Haemoptysis, do rigid

bronchoscopy.
One biopsies the node revealed from CT Scan
Facilitates drug + therapeutic intervention at 4th or 5th order bronchial level.
Mediastinoscope
Identify: This is a mediastinoscope
Describe
The mediastinoscope has a light and a lens for viewing

and may also have a tool to remove tissue.
Indications
Mediastinoscopy is often used for obtaining biopsy samples of lymph nodes for staging of lung cancer or
for diagnosing other conditions affecting structures in the mediastinum such as sarcoidosis or lymphoma
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Contraindications
1. Absolute
a. Aneurysm
b. Superior vena cava obstruction
2. Relative
a. Previous mediastinum surgery (because of scarring that

eliminates the plane of disection)
b. Precious thoracostomy
Procedure
1. Obtain informed consent
2. It is done under general anaesthesia.
3. An incision approximately 1 cm is made above the suprasternal notch of the sternum.
4. Dissection is carried out down to the pretracheal space and down to the carina.
5. A scope (mediastinoscope) is then advanced into the created tunnel which provides a view of
the mediastinum.
6. The scope may provide direct visualization or may be attached to a video monitor.
7. Mediastinoscopy provides access to mediastinal lymph node levels 2, 4, and 7.
8. Biopsy specinmens are taken (aspirate before you biopsys)
Complications
1. Complications related to general anesthesia
2. Bleeding – On occasion further surgery may be required to control bleeding
3. A pneumothorax
4. Persistent hoarseness if the nerve to the vocal cords is damaged during the procedure
5. Infections
Serious complications are uncommon following a mediastinoscopy
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Questions
1. What are the contents of the mediastinum?
a. The contents of the mediastinum include the heart and its large blood
vessels, trachea, esophagus, and bronchi.
2. How do you classify lung cancers?
3. How does each present?
4. What is the management of a patient with positive lymph nodes?
Gastrointestinal System
Rigid Oesophagoscpe
Identify: This is a rgid oesophagoscope
Describe: It is a metal tube with a handle and relatively long

(compared to a bronchoscope) shaft with no distal
fenestrations. It has two proximal ports for suction and
visualization
Indications
1. Diagnostic
a. Tumour in prox. 1/3 & mid. 1/3 oesophagus
b. Aetiology of upper GI bleeding
c. Assess oesophagitis
d. Diagnose GERD Assess caustic injury
e. Confirm hiatal hernia
f. Investigate atypical chest pain
2. Therapeutic
b. Stricture dilatation
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c. Sclerotherapy
The ones in red are the more likely indications say those only unless they ask for more
Questions
1. What are the most common foreign bodies removed

from an adult and a child?
a. The most common foreign body is from a child

and it is coin. In adults its fish bone.
2. What are the advantage and disadvantage of the rigid

over the flexible oesophagoscope.
a. The advantage over the flexible is that it can retrieve odjects while the flexible cannot. The
disadvantage is that you have to do it under
general anaesthesia.
3. What happens if the object peforates the oesophagus

and how do you manage it?
a. If foreign body perforates the oesophagus then

there is a risk for mediastinitis which is managed
by keeping the patient npo give antibiotics. If
small it will heal by itself.
b. For large perforation do thoracotomy and bypass.
i. To allow drainage of saliva bring the oesophagus up to the skin then give antibiotics.
Later use a piece of the pericardium and patch the oesophagus
ii. To test for oesophageal perforation give water soluble contrast (gastrgaoffin
swallow), lateral chest x-ray - pneumomediastinum
Nasogastric tube
Identify: This is a nasogastric tube
Classification: It is a closed passive drain
Describe: It is a graduated non-collapsible tube with distal

fenestrations, an atraumatic tip and a proximal port for
connection to reservoir bag.
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Indications:
1. Diagnostic
a. To identify an upper GI bleed
b. To identify an intrathoracic stomach as in a ruptured diaphragm or hiatal hernia
c. To administer gastrograffin
d. To diagnose oesophageal atresia in neonates
2. Therapeutic
a. To decompress and rest the bowel in bowel obstruction, burns, acute cholecystitis and acute
pancreatitis
b. For gastric lavage in poisoning
c. As a feeding tube
d. To administer medication
Two things up and two down
Contraindications
1. Absolute
a. Basal skull fracture
b. Mid-face fracture
c. Recent nasal surgery
2. Relative
a. Coagulation abnormality
b. Oesophageal varices or stricture
c. Recent banding or cautery of the oesophageal varices
d. Alkaline ingestion
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Procedure
1. Informed consent- explain benefit vs risk, indications and ascertain historical contraindications.
Warn about discomfort during passing the tube
2. Examine the patient's nostril for septal deviation. To determine which nostril is more patent, ask
the patient to occlude each nostril and breathe through the other.
3. Instill 10 mL of viscous lidocaine 2% (for oral use) down the more patent nostril with the head
tilted backwards and ask the patient to sniff and swallow to anesthetize the nasal and
oropharyngeal mucosa.
4. Estimate the length of insertion by measuring the distance from the tip of the nose, around the
ear, and down to zyphisternum.
5. Position the patient sitting upright with the neck partially flexed.
6. Lubricate the distal tip of the nasogastric tube.
7. Have suction ready or at least a bowl for them to spit in
8. Gently insert the nasogastric tube along the floor of the nose and advance it parallel to the nasal
floor (ie, directly perpendicular to the patient's head, not angled up into the nose) until it
reaches the back of the nasopharynx, where resistance will be met (10-20 cm).
9. Ask the patient to swallow.
10. Stop advancing and completely withdraw the nasogastric tube if, at any time, the patient
experiences respiratory distress, is unable to speak, has significant nasal hemorrhage, or if the
tube meets significant resistance.
11. Verify proper placement of the nasogastric tube by auscultating a rush of air over the stomach
using 20 mL of air.
12. Tape the nasogastric tube to the nose to secure.
Complications
1. Pressure necrosis of ala of nose if secured too tightly
2. Epistaxis
3. Sinusitis
4. Otitis media
5. Incompetent lower esophageal sphincter
6. Respiratory tree intubation (rare and unlikely)
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7. Esophageal perforation (rare and unlikely)
Questions
1. What are indications for removing the tube
a. Subjective - must feel comfortable and complain of hunger (recall pts w/ NGT are NPO),
even better if in conjunction n with passage of flatus or stool
b. Objective - nil stomach distension on inspection or no succusion splash or distal

obstruction on examination
c. Drainage- minimal drainage less than 100ml (recall stomach produce about 2.5 L
fluid/day so if drainage is even 500ml/ day it means 2L emptied into bowel
2. What is meant by a succession splash?
a. Succussion splash is a sloshing sound heard through the stethoscope during sudden
movement of the patient on abdominal auscultation. It reflects the presence of gas and
fluid in an obstructed organ.
3. What must you do when removing the tube?
a. When removing the drain the main complication to worry about is spilling the tube
contents into the lower airway therefore you kink the tube and quickly remove it.
Self-expanding Metal Stent
Mousseau Barbin Tube
Identify: This is a moussea barbin tube
Describe: It is a tappering non-collapsible orange tube with

a distal rat-tail end that has fenestration and a relatively
thick funnel-shaped proximal end
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Indication
Patients with non-resectable oesophageal cancer as a palliative management for dysphagia
Contraindication
Upper 1/3 oesophageal cancer because it will press on airway
Complications
1. Immediate- Haemorrhage and damage to viscus
2. Early- Wound infection, ischaemia, risk of aspiration since non-collapsible
3. Late- Prolapse, herniation, stomal stenosis, migration of tube
Procedure
1. Informed consent
2. Done under general anaesthesia
3. Laparotomy and gastrostomy done
4. Cannulate the oesophagus with NGT
5. Attach silk strings to Mosseau- Barbin tube and anaesthesist pulls back up NGT.
6. Surgeon while holding its string, pulls tube until it sits in pocket of Ca.
7. In- situ, the funnel shaped proximal end is secured above cancer. Tube distally is cut off.
8. Anchor to anterior stomach wall with 2-0 (secondary) knots of non-abs., synthetic suture.
Follow-up considerations
1. Patients are allowed to consume only liquids
2. No solid food because the cone and the distal end of the tube are narrow.
a. Non – compliance  blockage of tube.
It becomes occluded in 6-12 months.
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T-tube
Identify: This is a t-tube
Describe: It is a ‘T’ shape latex drain with horizontal and vertical limbs that are
placed in the common bile duct and a long leading end for attachment to a
reservoir bag.
Indications: Post common bile duct exploaration in patients with choledocolithiasis it allows for
drainage of any retained stones and for a fibrous to form leading to a re-establishhment of the integrity
of the bile duct.
After removal of a T-tube the bile duct does not leak bile because a fibrous tract forms around the T-
tube prior to removal. The fibrous tract then scleroses down after removal of the T-tube, resulting in a
patent and closed bile duct.
Complications:
1. Obstruction of the tube
2. Displacement of the tube
3. Ascending infection
4. Stricture – now found to cause strictures even though it was once thought that they were put to
prevent strictures
5. Bile Peritonitis
Questions
1. Why use a T-tube and not just anastamose the common bile duct?
a. Because the pressure developed when the sphinture is closed would lead to failure of the
anastamosis and bile peritonitis.
2. How long is the t tube left in place?
a. For 10 days.
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3. What should be performed before removal?
a. You should do a cholangiogram to exclude any retained stones.
4. If there is a retained stone how can yo remove it?
a. By using a dormier basket
5. What is the better alternative to t tube?
a. Choledochojejunostomy.
Laparoscopic trocar and port
Identify: This is a laparoscopic trocar and port
Describe: It consists of an inner trocar with may or may

not have a blade and an outer port
Indications:
1. Therapeutic
In any laparascopic surgery such as:
a. Cholecystectomy
b. Inguinal hernia repair
c. Prostatectomy
d. Kidney surgery
e. Gynaecological surgery (hysterectomy, salpingo-oopherectomy, endometriosis extractions)
2. Diagnostic
a. Ectopic pregnancy
b. Pelvic inflammatory disease
c. Endometriosis
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Contraindications:
Sever respiratory distress
Procedure:
2. Establish general anaesthesia
3. Clean and drape the area
4. Put four ports in as describe in the questions below
5. Disect out and ligate the cystic duct
6. Desect the gallbladder and remove it through the umbilical port
Your really don’t need to describe the laparascopic procedure unless asked.
Complications:
These complications are those of laparoscopic cholecystectomy
1. Complications of anaesthesia
2. Complications similar to laparotomy
3. Increased risk of damage to the liver, common hepatic duct and duodenum
4. Air embolism
Questions
1. Describe the ports used in laparascopic Cholecystectomy
a. A 10 mm port at umbilicus that goes through fascia. It is the port used to insulflate CO2,
house the camera initially and to remove the gallbladder. It is the largest port and the
only on that a fascial incision has been made.
b. A 5 mm port at the epigastrium. This is the second port. When the CO2 of about 10-12
mmHg (not more than 15 mmHg) has insuflated the abdomen through the first port the
camera is placed and the trocar used to go through the abdominal layers with good
intra-abdominal vision. This is the operating port. Towards the end of the surgery when
the gallbladder is being removed it will house the camera.
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c. A 5 mm port in the lower portion of the RUQ. This port grasps the fundus of the gall
bladder and brings it up to the inferior liver edge pushing the liver cephalad.
d. A 5 mm port above the 3rd port ond inferior to the costal margin. This port grasps
hartman’s pouch and pulls it down to expose Calot’s triangle.
2. How do you identify Calot’s triangle?
a. Calot’s triangle is bordered by the common hepatic duct midially, the liver superiorly and
the cystic duct laterally.
3. What is the importance of identifying Calot’s triangle?
a. To identiy and ligate the cystic artery prior to removing the gallbladder.
4. Why is the gallbladder collected through the umbilical port as opposed to through the ports in
the RUQ.
a. The umbilical port is the the only port with a fascial incision so it is the only area that
can potentially herniate. Ifone tries to remove the ‘large’ gallbladder through the other
ports the they most likely would be unsuccessful as the ports are only 0.5 cm thick. If
the gallbladder cannot fit throught the umbilical port all that is needed is for a larger
fascial opening to be made at the umbilicus to remove the gall bladder. If a fascial
incision was made at the other ports then the patient would now have two incision sites
that can herniate.
5. Why do you not not want to go over 15 mmHg CO2?
a. Even though abdominal compartment syndrome may not occur untill the pressure is 25
mmHg, remember that the pressure waxes and wanes and that the pressure at a given
second may be several mmHg above what is shown. Additionally above 15 mmHg there
is no overtly increased advantage of visualization because at that pressure there is
enough space to see and operate.
6. Why is CO2 used?
a. It has the advantages of being enert, easily absorded from the abdomen,it is cheap and
relatively readily available.
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7. What is the advantage of using the umbilical port?
a. It is less vascular so it will bleed less and it is done along the natural curve of the
umbilicus good cosmesis
8. What is the advantage of laparascopy?
a. Decreased recovery time and post-op hospital stay (less handling of the bowel less pain
and haemorrhage)
b. Better cosmesis
c. Decreased risk of incisional herias and infection
Laparoscopic grasper
Identify: This is a laparoscopic grasper
Describe: It consists of a handle and and inulated long shaft
Indications: As noted above
Contraindications: As noted above
Procedure: As noted above
Complacations: As noted above
Stoma bag
Identify: This is a colostomy bag
Describe: It consists of a reservoire bag with an opening to put over the ostomy site.
There is an adhesive potion for attachment of the bag and a vent for filtering air (some
don’t). Some have gradients at portfor you to cut to a suitable size.
Indications
1. Temperary divesion of stool in the case of an anastomotic leak
2. Decompress the bowel
3. Terminalizing
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a. After bowel resection
b. After damage to the anal sphincture
4. Controlled drainage of enterocutaneous fistula
Complications
1. Intra-op: Bowel perforation, damage to adjacent structures and peritonitis
2. Early post-op: Bowel strangulation, colostomy diarrhea, excoriation of the skin, and retration of
colostomy
3. Late: Prolapse, sticture, obstruction, bleeding (usually from granulomas around the margin of
the colostomy) parastomal hernia if the ring it’s brought through is too slack
Care for colostomy
1. Keep area clean
2. Change bag daily
Questions
1. What are the types of colostomies?
a. Loop, end and double barrel.
2. What are the anatomical divisions of ostomies?
a. Ileostomy and colostomy
3. What are the functional divisions of colostomies?
a. Divertions – eg. When you want to allow a primary anastamosis to heal , in perianal sepsis
and during radiation treatment for anal tumours
b. Decompress/Defunctioning – in obstruction when there is increased risk for caecal rupture
c. Terminalization – AP resection and hartman’s
4. What measures can you take if there is skin excoriation?
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a. Use zinc oxide on the skin which acts as a mechanical barrier.
Sigmoidoscope
Identify: This is a rigid sigmoidoscope
Describe: It is a metallic hollow instrument with a graduated shaft, flang and three proximal ports for
insufflation air, light source and for visualization. The latter port has a trap door.
Indications:
1. Diagnostic
a. Biopsy of a lesion
b. Evaluation rectum
c. Bright red blood per rectum
2. Therapeutic:
b. Deflating volvulus
c. Sclerotherapy/ rubber band ligation for haemorrhoids
Complications
Perforation
Procedure
2. The bowel must be properly prepared by giving an enema and ensuring an empty stomach.
4. Place the patient in the left lateral position with the knees and hips flexed
5. Perform a digital rectal examination looking for skin tags and feeling the anal mucosal for any
masses.
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6. Lubricate the shaft of the instrument
7. Introduce 4 cm of the shaft aiming towards the umbilicus. Turn 90 degress posterior and now
visualize as you advance. You can insulflate with air to help visualization.
8. Do not pass the rectosimoid junction because it is highly likely that you will perforate the bowel
9. Remove the instrument while you continue to visualize the rectal mucosa
Questions
1. How long are the anus and rectum?
a. Four-5 and 15 cm respectively.
2. How long is the rigid sigmoidoscope?
a. It is 25 cm long.
3. What are the advantages and disadvantages of the rigid over the flexible sigmoidoscope?
a. It is straight so it allows measurement of depth but it does not visualize the sigmoid colon.
4. How far can the sigmoidoscope go?
a. It is 65 cm long and can go up to the splenic flexure.
5. What is the difference between the plastic and metal sigmoidoscope?
a. One is reusable and the other is not
6. What important thing should you tell the patient before they leave
a. That if they feel unwell, experience pain, adominal distension, fever or see severe bleed per
rectum they should come the hospital as soon as possible as these may be symptoms of a
perforation.
Proctoscope
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Identify: This is a proctoscope
Describe: It is a metal instrument with a handle, a short shaft

and and obturator to assist in introduction. Some have a port
for attachment to a light source.
Indications
To visualize anus for any pathology
Procedure
1. obtain informed consent and gather instruments
2. Place the patient in the left lateral position with the hips and knees flexed
3. Perform a digital rectal examination to identify skin tags and to feel the rectal mucosa for any
masses.
4. Lubricate the shaft and insert it into the anus
Flatus tube
Urinary System
Urinary Catheters
Single use urinary catheter/ Jakes catheter
Identify: This is a Jakes catheter
Describe: It consists of a latex tube with an atraumatic tip and single

port for collection of urine
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Indications
Therapeutic
1. For self catheterization in persons with spinal injury and neurogenic bladder with urinary
retention
2. To empty the bladder prior to delivery in a pregnant patient
Diagnostic
1. To obtain a clean catch specimen
Contraindications: Refer to 2-way catheter
Complications
1. It is made of red rubber which can cause severe tissue reaction if left in place for long periods of
time.
2. Others are in 2-way catheter
Indwelling Two-way Foley catheter
Identify: This is a two-way foley cathter
Describe: It consists of a latex tube with an atraumatic tip, a distal inflatable bulb and 2 proximal ports:
one port is for the collection of urine and another for inflating the bulb.
Indictions
1. Diagnostic
a. Monituring resuscitation, renal function and hydration status
b. Catheter specimen for C/S
c. To do micturating cystourethrogram
d. Diagnose haematuria
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2. Therapeutic
a. Acute urinary retention
b. Decompress the bladder in BPH patients
c. Tamponade of epistaxis
d. Dilate/ rippen the cervix
3. Other less common indictions
a. Tamponade a bullet wound
b. Tamponade vascular damage
c. Chest tube in pediatric population
d. Drain abdominal abcesses
e. Nephrostomy tube
f. Administer chemotherapy to the bladder
g. Cholecystostomy tube – drain thhe gall bladder if too inflammed for surgery
Contraindications
Meatal haemorrhage assosociated with a high ridding prostate and perineal haematoma which are
indicative of a laceration to the urethra.
Complications
1. Urinary tract infection
2. Septic shock (give gentamycin before instrumentation if history of urinary retention)
3. Stricture
4. Damage to membranous urethra and causing fistula formation
5. Damage bladder wall
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Procedure
1. Informed consent
3. Sterile procedure so asceptic measures are taken
4. The penis is held in the penile grip with the non dominant had while the dominant hand cleans
the glands penis with savlon
5. Three ml of KY gel is placed into the urethra using a syringe
6. The catheter is then placed into the urethra down to the bifucation
7. You inflate the bulb with 10-15 ml of sterile water and not normal saline.
a. If you use normal saline it will crystalize in about a day and it would not be possible to
deflate the bulb or remove the catheter. In that case you would have to rupture the
bulb percutaneously with ultrasound guidance. If ultrasound is not available you will
have to do a suprapubic cystostomy and cut the bulb. If air is used ther could be in
explosive burse that could theoreticaly damage the bowel. If fluid is there will be and
implosion.
Questions
1. How do you conver Ffrench to mm?
a. To convert ffrench to mm divide ffrench by pie.
2. If a patient with a very distended bladder is catheterized and then afterwards they become
diaphoretic, tachycardic and tachypnoeic how would you manage this patient?
a. They patient is in urosepsis. The long stasis caused more bacterial prolypheration and
subsequent catheterization inevitably caused some amount of epithelial damage leading to
systemic liberation of baceteria and thus sepsis. Threat this with gentamycin antibiotics and
fluid resuscitation because of risk of shock.
3. What do you do if the catheter fails to pass in a BPH patient?
a. If there is failure to pass a catheter then use a larger one ie if you are using an (18 ffrench
use 20 next). If that fails do a suprapubic catheterization.
4. Would you dilate this patient with a urethral dilator.
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a. Do not attempt a urethral dilation.
5. What if a stricture is present? What is the management?
a. If stricture is present then do an optical internal urethrotomy OIU

(cystostope done with blade to cut the strictures)
b. Definitive management is urethroplasty using buccal mucosa or vaginal epithelium.
Triple-way catheter
Describe: This is a 24 french triple lumen foley catheter (24 F is the external diameter).
Describe: It consists of a latex tube with an atraumatic tip, a distal inflatable bulb and 3 proximal ports:
one port is for the collection of urine, one for irrigation and another for inflating the bulb.
Indications
1. Irrigation of the bladder in cases of haemturia and clots
2. Administer medication such as chemotherapy for bladder cancer
3. Patients requiring long-term catheterization
4. Patients undergoing TURP or an other procedure in which significant hemorrhage is expected (a

30cc balloon is required for TURP surgery)
Complications
1. Complications of Placement:
a. Inadequate lubrication of catheter friction trauma  hemorrhage, and eventually

stricture formation after healing.
b. Use of an introducer during placement can  false passage
c. If the balloon is inflated while in the urethra, this can  rupture of the urethra and
hemorrhage.
2. Complications of the Catheter insitu:
a. Infection
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b. Dislodgement
c. Obstruction  stasis  Stone Formation
3. Complications of things put thru the Catheter:
a. TURP Syndrome – Instillation of hypotonic fluids for too long a duration 

hyponatremia  seizures
A triple Lumen Urinary catheter can be kept insitu for a maximum of 3 months before requiring
replacement.
Urethral Bougie
Identify: This is a urethral bougie
Describe: It is a metalic instrument with a flat straight

handle and a curved tip. The top number (26in this case) is
the diametre of the tip in Ffrench and the bottom number
(30 in this case) is the diametre of the shaft also in Ffrench. To convert Ffrench to mm divide by pie
(22/7 or 3.14)
Indications:
a. Strictures
b. Urethral calebration
Note well – It should only be used by a urologist! You should never attempt to use a bougie!
Contraindications
2. Urinary stasis
3. Urethral rupture
4. Active urethritis or infection
Complications
1. Urosepsis from damage to uroepithelium and seeding of the blood with gram negative
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organisms
2. Perforation of the urethra
Procedure
2. Sterile procedure so aseptic measures should be taken
3. Clean the glands and the shaft of the penis
4. Introduce 3 cc of KY jelly into the external meatus
5. Introduce the dilator with the tip pointing caudally
6. When you reach the bulbous urethra turn it cephallad
Questions
1. What are the different types of dilators?
a. They are Clutton which is violin shaped and Lister which has a
round tip
2. What is used in females?
a. Yes there is one for the females too! The female urethra is only 4cm
long and straight so the use a relatively straight bougie called Hegar
dilator.
3. How do you manage urosepsis?
a. Fluids for the septic shock that will ensue in 20 mins and antibiotics.
4. What are the causes of stricture formation?
a. Catheterization or other instrumentation, infections (such as gonococcal, Chlamydia,

Mycoplasma, TB), or after trauma (to the perineal region)
b. Post – Gonococcal urethral strictures affect the bulbar urethra. Mcq – this would most likely
be the cause in a young otherwise health man.
5. Ideally and definitively how should strictures be treated?
a. Optical internal urethrotomy (OIU)or uroplasty with buccal or vaginal epithelium.
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Malecot and Pezzer catheters
Malecot Pezzar Catheter
Identify:These are malecot and pezzer catheters
Classify: They are closed passive drains
Describe: The malecot has a batwing tip and a proximal port for attachment
to a resouvoire bag. The Pezzer catheter has a mushroom shaped tip with a
proxima/l port for attachment to a resovouire bag.
Indications
1. Suprapubic cystostomy
2. Gastrostomy
3. Pelvic drain
Suprapubic cystostomy
Procedure
1. Informed consent
2. Gather instrument
3. Sterile procedure so aseptic measures taken
4. Give general anaesthesia or spinal anaesthesia (mcq)
5. Clean the area
6. A make a 5-6 cm vertical incision on abdomen wall at mid line and 2 finger breadth above the
pubic symphisis.
7. Cut skin,superficial fascia, linea alba and split the transverses abdominus muscle, and
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peritonium is separated by blunt dissection.
8. Check the bladder by aspirating the urine with syringe or by looking vesicular plexus.
9. Give two stitches, make an incision and insert the malecot catheter and stitch the layers by
layers and done.
Cystoscope
Identify: This is a rigid cystoscope
Describe: It has an instrument port along with a light source connection and two fluid ports on each
side. The is a long shaft with a bebelled tip.
Indications:
1. Diagnostic
a. Bladder biopsy
b. Haematuria
c. Bladder diverticuli
d. Retrograde pyelogram study
2. Therapeutic
a. Stent replacement (to relieve ureteric obstruction)
b. Chemotherapy for bladder cancer
c. Retrieve bladder calculi
Ureteric Catheter (double j-stent)
Identify: This is a ureteric catheter
Describe: It is a long thin tubular latex instument
Indications:
1. To decompress a kidney (eg. hydroneprosis)
2. Facilitate a retrograde pyelogram (outlines pelvi-calyceal system)
Procedure:
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1. Do cystoscopy
2. Introduce the guide wire (one end is floppy and the othe end is thick)
a. Use the floppy end of the DJ stent becase it is less traumatic
3. X-ray guidance allows confirmation of placement
4. Seldinger (i.e. pass stent over guide wire into ureteric orifice.)
Questions
1. What is the difference betwwen a retrograde pyelogram and an IVP?
a. The retrograde pyelogram is retrograde and the IVP is anterograde with regards to the
urinary tract
2. What should you do before you read either the IVP or the retrograde pyelogram.
a. Ask for the KUB (the plain film)
Anaesthesia
Suction catheter
Identify: This is a suction catheter
Describe: It consists of a proximal port for connection to suction, an

occlusible osteum, a long tube with a distal bevelled tip and fenestration.
Indications: To remove fluid collection in the pharynx
Procedure:
Informed consent placed the bevelled tip into pharynx then occlude the
osteum at the proximal end while you retract the tube.
Face Mask
Identify: This is a black/transparent face mask
Describe: It consists of a hollow latex rim with a 22 mm

orifice and metallic breathing hooks for attachment of
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stirups to hold the mask in place
Indications:
1. Respiratory failure
a. Failure of ventilation
b. Failure of oxygenation
2. Failed intubation or prior to intubation
Procedure:
Hold mask in left hand with downward pressure through thumb and index finger. Other fingers grasp
the mandible and extend atlanto-occipital joint (preventing tongue from slipping backwards) Remember
that you are standing behind the patient.
Questions
1. What is the disadvantage of the black mask.
a. It does not allow you to see any secretions

or vomitus so you cannot suction it and the
patient may aspirate.
2. What is the instrument to your right?
a. It is a bag valve mask.
Oropharyngeal tube
Identify: This is an oropharyngeal tube
Describe: It is a flat tubular non- collapsible instrument with a curved tip, a

hard bite block and a flange.
Indications
Resucitation of an unconscious patient to prevent the tongue and epiglottis

from falling back and occluding the airway
Precedure:
1. Informed consent (generally not possible since it is not placed in the conscious patient)
2. Insert into the mouth with the tube pointing cephalad then turn 180 degrees once in
oropharynx
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a. In children it may be placed in the anatomical position, ie. You don’t have to turn it.
Endotracheal Tube
Identify: This is an endotracheal tube
Describe: It consists of a curved tube of internal diameter x mm, an

Inflatable cuff to provide an air-tight seal, Pilot balloon attached to ETT
by an inflating tube (Valve prevents air loss), a beveled tip that aids direct
visualization and insertion through vocal cords, murphy’s eye to  risk of
complete tubal occlusion, connector (connects to ventilator or airbag)
and a radio-opaque line to allow direct visualization on CXR.
The proximal port connects to the breathing system and has a 15 mm outer diameter (British Standard).
Indications
1. Patients at risk for aspiration ( to secure and protect their airway & prevent Mendelson
syndrome)
2. Unconscious/ emergency pts.
3. Patient wiith absent gag reflex
4. Comatosed pts.
For GA ( Major surgical procedures- head + neck+ body cavities)
Resp. Support ( Note :NOT SUITABLE for long term use)
Admin. of medication
Procedure
1. Informed consent
2. Inflate the cuff to see if the is any leak; if none the deflate it
3. Hold the laryngoscope in the left hand with the blade pointing down
4. Hold the endotracheal tube in the right hand with the tip pointing up
5. Place the patient in the sniffing morning air position
6. You should be standing at the head of the bed
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7. Sweep the tongue to the left with the curved blade of the laryngoscope and place the tip in the
valecula
8. Adjust until the true vocal cords are visible
9. Slide the laryngoscope under the grooved side of the blade through the vocal cords (till the black
line is below the cords)
10. Inflate the cuff (ensure that the cuff passed the vocal cords before you inflate)
Confirmation of correct placement
1. Direct visualization during placement
2. Misting of the tube
3. Five point auscultation (2 on each side of the chest and one over the epigastrium)
4. Symmetrical rise and fall of the chest
5. Capnograph shows appropriate wave form (5 successive wave forms)
Complications
During Insertion
1. Airway trauma, (haemorrhage, Tooth, tongue, sore throat, dislocated mandible,)
2. Malposition (oesophageal or endobronchial)
3. Physiologic reflexes (hypertension
4. Tachycardia
5. Intracranial and intraocular hypertension
Late
1. Irritate vocal cord
Following extubation
1. Airway trauma
2. Edema and stenosis (glottic, sublglottic or tracheal)
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3. Hoarseness (vocal cord granuloma, paralysis)
4. Laryngospasm
Questions
1. Why is the cuff inflatable?
a. To prevent leakage of anaesthetic agent (gas).
b. Prevents aspiration of secretions.
2. Why do children less than 8 not need the cuffed endotracheal tube?
a. The subglottic region is the narrowest portion of their larynx which thus acts as a seal.
Adults do not have a narrowing of larynx
3. What are the numbers at the side for?
a. ID internal diameter and OD eternal diameter
4. What do you do if after placement you find that there is

asymmetrical rise and fall of the chest?
a. A main-stem bronchus may have been intubated (ie. The tube went too far down). I would
simply pull the tube back a little
5. What are the drug you can give via the tube?
a. Naloxone
b. Atropine
c. Salbutamol
d. Adrenaline
e. Lidocaine
6. What are the advantages of the tracheostomy tube over the endotracheal tube?
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a. ETT facilitates positive pressure ventilation
b. Can be left in for long periods
c. More oxygen can be delivered & quicker
d. It reduces the dead space by half. ( Normally dead space = 150 ml)
e. Can be used in procedures with upper airway obstruction
 laryngeal obstruction
 impaired laryngeal reflex.
7. How do you determine the appropriate size?
a. Internal diameter :
Men 8.0- 9.0 mm
Women 7.5- 8.5 mm
b. LENGTH:
Men 22 – 24 cm
Women 20 – 22 cm
For kids - Predicted Size Uncuffed Tube = (Age / 4) + 4

Predicted Size Cuffed Tube = (Age / 4) + 3
Up to age 12.
8. If you have difficulty passing the tube which instrument could you use to help you?
a. Put a metal stylet into the tube.
9. What are the instruments on the right?
a. A south and north bound endotracheal tube. The south bound tube is
used in nasal surgeries and the north bound in dental sugeries.
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Magill’s forceps
Identify: This is a Magill’s forceps
Describe: It has a long handle and an obtuse angled tip
Indications
1. Assist introduction of endotracheal tube (nasal

intubation)
2. Removal of foreign bodies. Use only if you can see the foreign body
3. Grasp tongue to move tongue aside
4. Assisting tube placement
Laryngoscope
Identify: This is a laryngoscope
Describe: It has a grooved curved (McIntosh ) or

straight (Magill) blade a light source and a handle
which is gripped and contains the batteries
Indications
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Placing an endotracheal tube
Procedure
As describe in endotracheal tube
Questions
1. Why would a Magill bladed laryngoscope be used?
a. In neonates or children because the epiglottis is floppy and if

the blade were placed in the valecula then the epiglottis would
just hang down and block the view of the vocal cords. The
magill blade covers the tongue and epiglottis and pulls them up
negating the above problem in kids.
However in exam, you will more likely see a laryngoscope with

a McIntosh blade ( used for adults).
2. Where is the vallecula?
a. It is a space between the epiglottis and the base of the tongue.
3. Describe the exact positioning of the patients head?
a. Moderate head elevation
b. Flexion of cervical spine
c. Extension of atlanto- occipital joint
d. Long axis of oral cavity, larynx and trachea lie almost in a straight line
4. How would you intubate a patient with suspected C-spine injury?
a. Anterior jaw thrust with the neck kept stable.
Tracheostomy tube
Identify: This is a tracheostomy tube
Describe: It consists of an inflatable bulb and wings for attachment

of a securing cord and two ports for inflating the bulb and
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ventilation. There are also an inner tube and an obturator.
Indications
1. Therapeutic
a. Foreign body that cannot be dislodged with Heimlich and basic cardiac life support (BCLS)
maneuvers
b. To provide a long-term route for mechanical ventilation in cases of respiratory failure
c. To provide pulmonary toilet
d. Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord
paralysis)
e. Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone, or
great vessels.
f. Subcutaneous emphysema
g. Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of the
midface and mandible)
h. To bypass obstruction – Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
2. Prophylactic
 Post-laryngectomy
 Extensve head to neck injuries
 Edema - Trauma, Burns, Infection, Anaphylaxis
Procedure
Tracheostomy
Tracheostomy should be performed, whenever possible as an elective procedure, with an endotracheal

tube in place. Adequate suction, lighting and oxygen should be available. The operation
is ideally performed in the Main Operating Theatre. Test the competence of the valve to the
tracheostomy tube's bulb
1. Informed consent
2. Position the unconscious or anesthetized patient supine with the neck extended and the
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shoulders elevated on a small roll
a. The awake patient does not tolerate this; therefore, the procedure is performed with
the patient in a sitting or semi-recumbent position
b. Overextension of the neck should be avoided because it further narrows the airway;
additionally, overextension can lead to placement of the tracheostomy too low (toward
the carina) and too close to the innominate artery (especially in the very mobile
pediatric trachea)
3. Infiltrate lidocaine (1%) with 1:200,000 parts epinephrine
4. Make an incision with size 15 blade 2cm below the cricoid cartilage or midway between the
sternal notch and the cricoid cartilage.
5. Bluntly dissect through the platysma until the midline raphe between the strap muscles is
identified.
a. Palpate the inferior limit of the field to assess the proximity of the innominate artery.
Cauterize or ligate aberrant anterior jugular veins and smaller vessels
b. Midline dissection is essential for hemostasis and avoidance of paratracheal structures
6. The strap muscles are separated and retracted laterally, exposing the pretracheal fascia and the
thyroid isthmus. The lateral retraction also serves to stabilize the trachea in the midline.
7. Elevate the isthmus off the trachea with a hemostat and divide it.
8. When preparations for transfer of circuitry tubes are complete, deflate the endotracheal tube
balloon and enter the trachea.
a. Absolute hemostasis before this point obviates the threat that blood could enter the
trachea and exacerbate the cough reflex
9. Secure the cricoid with a hook and elevate it superiorly facilitating control of the tracheal entry.
10. After the trachea is entered, suction secretions and blood out of the lumen and slowly withdraw
the endotracheal tube to a point just proximal to the opening
11. Replace the lateral retractors into the trachea and insert the previously tested tracheostomy
tube
12. After the airway is confirmed intact based on carbon dioxide return and bilateral breath sounds,
secure the tracheostomy tube to the skin with 4-0 permanent sutures
13. Attach a tracheostomy collar with the head flexed to avoid unnecessary slack in the collar
14. To avoid the risk of subcutaneous emphysema and subsequent pneumomediastinum, the skin is
not closed
15. Place a sponge soaked with iodine or petrolatum gauze between the skin and the flange for 24
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hours to deflect infection and anxiety about minor oozing of the skin edge.
Complications of tracheostomy
1. Perioperative Complications
a. Haemorrhage from the anterior jugular veins, inferior thyroid veins, brachiocephalic
veins and rarely thyroidea ima artery
b. Injury to the recurrent laryngeal nerve
c. Injury to the oesophagus with the creation of a tracheo- oesophageal fistula
d. Injury to thoracic duct leading to a chylous fistula
e. Pneumothorax
f. Massive surgical emphysema
g. Apnoea in the patient who has had long-standing upper airway obstruction
2. Early complications
a. Obstruction to the tracheostomy tube
3. Late Complications
a. Granulation tissue formation in the trachea
b. Tracheal stenosis
c. Erosion into the innominate artery
d. Tracheo- cutaneous fistula
e. Keloid formation at the tracheostomy site
General instructions and follow-up care after tracheostomy
The surgeons will monitor the healing for several days after the tracheostomy. Usually, the initial tube
that was placed at the time of surgery will be changed to a new tube sometime between 10 and 14 days
following surgery, depending on the specific circumstances. Subsequent tube changes are usually
managed by the treating physician or nursing staff.
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Questions
1. How would you perform a cricothyroidotmy
a. Informed consent (If possible)
b. The patient's neck is extended and stabilized
c. Palpate for the cricoid cartilage approximately 2-3 cm below the thyroid notch
d. A 1-cm horizontal incision is made just above the superior border of the cricoid (this
avoids the vessels that run under the inferior border, in the same manner as the
intercostal neurovascular bundles) to expose the cricothyroid membrane, which is then
punctured in the midline
e. The blade must be directed inferiorly to avoid trauma to the true vocal cords
f. Care is taken not to extend this puncture through the back wall of the larynx and into the
esophagus
g. Insert a blunt instrument (eg, knife handle) into the incision and rotate it perpendicularly
to widen the incision to accommodate a small cannula
2. What size cuff should be used for males and females?
a. In adult patients, size 8.5 or 9 mm Portex tube is generally adequate for males. While in
females size 7.5 -8 mm should be selected. Alternate sizes should readily be available
should there be difficulty in inserting the tube.
3. Why is the tube cuffed?
a. Cuffed tubes allow positive pressure ventilation and prevent aspiration. If the cuff is not
necessary for those reasons, it should not be used because it irritates the trachea and
provokes and trap secretions, even when deflated. Even modern low-pressure cuffs
should be deflated regularly (qid) to prevent pressure necrosis. Standard fenestrations
are rarely in the right place; if flush with the tracheal wall, they instead cause irritation
and granulation and should not be used.
Central venous catheter
Identify: This is a central venous catheter
Describe: The set consists of a needle, syringe,

guidwire, dilator and the central venus pressure
cathter.
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Indications
1. Therapeutic
b. Total parenteral nutrition
c. Drugs that are prone to cause phlebitis in peripheral veins (caustic), such as:
 Calcium chloride
 Chemotherapy
 Hypertonic saline
 Potassium chloride
 Amiodarone
 Vasopressors (e.g. epinephrine, dopamine)
d. Massive fluid resucscitation
e. Long term venous canulation
f. Dialysis
2. Diagnostic
a. Monitoring of the central venous pressure (CVP) in acutely ill patients to quantify fluid
balance Normal CVP is 10cm H2O
Contraindications
1. Locals infection
Procedure
Sites are : Subclavian vein cephalic vein basilic vein femoral vein internal jugular vein
Subclavian vein: Betweem the medial 1/3 and lateral 2/3 gioing towards the sternoclavicular joint
Internal jugular: Between the two heads of the sternocleidomastoid going towards the contalateral
nipple
1. Obtain infromed consent explaininng the indication and complications
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3. Aceptic technique
4. Clean patient with betadine and allow it to dry
5. Drap the patient and put them in the trendelenburg
6. The skin is cleaned, and local anesthetic applied if required.
7. The location of the vein is then identified by landmarks or with the use of a small ultrasound
device ideally but the landmarks above may be used.
8. A hollow needle is advanced through the skin until blood is aspirated; the color of the blood and
the rate of its flow help distinguish it from arterial blood
9. The line is then inserted using the Seldinger technique: a blunt guidewire is passed through the
needle, then the needle is removed.
10. A dilating device may be passed over the guidewire to slightly enlarge the tract
11. Finally, the central line itself is then passed over the guidewire, which is then removed.
12. All the lumens of the line are aspirated (to ensure that they are all positioned inside the vein)
and flushed.
13. The catheter is usually held in place by a suture or staple and an occlusive dressing.
14. Regular flushing with saline or a heparin-containing solution keeps the line patent and
prevents thrombosis.
15. Certain lines are impregnated with antibiotics, silver-containing substances (specifically silver
sulfadiazine) and/or chlorhexidine to reduce infection risk.
Ultrasound probably now represents the gold standard for central venous access and skills, within North
American and Europe, with landmark techniques are diminishing.
For jugular and subclavian lines, a chest X-ray is typically performed afterwards to confirm that the line is
positioned inside the superior vena cava and, in the case of insertion through the subclavian vein, that
no pneumothorax was caused as a complication.
Complications
1. Immediate:
a. Arterial cannulation
b. Perforation of a vessel
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c. Arrhythmia (SA node stimulation)
d. Pneumothorax
e. Recurrent laryngeal nerve
f. Guide wire migration
2. Intermediate to late:
a. Infection (if suspected take catheter out and send tip for culture and sensitivity)
b. Haematoma
Arrhythmias may occur during the insertion process when the wire comes in contact with
the endocardium. It typically resolves when the wire is pulled back.
Catheter tip embolism is not common anymore due to the seldinger technique. It occurred more
commonly in the older technique.
THIOPENTAL
SODIUM
500 mg vial
Rapid Sequence Induction especially
for Status Epilepticus
Proximal IV access; running NS drip;
CM, resus-ready;
Diluted to 20 ml NS; given 2 - 4 mls
every 30 seconds; until induction
Atropine
Identify: This is a 1 mg ampule of atropine
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Classify: It is an anticholinergic drug (parasympatholytic).
Mode of action: It is a competitive antagonist for themuscarinic acetylcholine receptor types M1, M2,
M3, M4 and M5.
Indications:
Symptomatic bradycardia - 0.5 to 1 mg IV push, may repeat every 3 to 5 minutes up to a total dose of
3 mg (maximum 0.04 mg/kg)
Asystole/ PEA - 1 mg bolus repeated rapidly up to 3 mg maximum
Cholinergic crisis (organophosphate and mushroom poisoning) - 1 - 2 mg every 2 - 5 mins

until respiratory secretions dry, and HR > 100; start infusion titrate to effect
second-degree heart block Mobitz Type 1 (Wenckebach block)
Contraindications:
In patients pre-disposed to narrow angle glaucoma.
Procedure
Side effects:
ventricular fibrillation, supraventricular or ventricular tachycardia, dizziness, nausea, blurred vision, loss
of balance, dilated pupils, photophobia, dry mouth and potentially extreme confusion,
dissociative hallucinations and excitation especially amongst the elderly. These latter effects are because
atropine is able to cross the blood-brain barrier. Because of the hallucinogenicproperties, some have
used the drug recreationally, though this is potentially dangerous and often unpleasant.
A common mnemonic used to describe the physiologic manifestations of atropine overdose is: as per
Jon Blinkey "hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter". [9] These
associations reflect the specific changes of warm, dry skin from decreased sweating, blurry vision,
decreased sweating/lacrimation, vasodilation, and central nervous system effects
on muscarinic receptors, type 4 and 5. This set of symptoms is known as anticholinergic toxidrome, and
may also be caused by other drugs with anticholinergic effects, such
asdiphenhydramine, phenothiazine antipsychotics and benztropine.
Questions
1. How do the organophosphates cause cholinergic crisis and what are the symptoms
a. By inhibiting the anticholinesterases
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b. Atropine is given as a treatment for Sludge (salivation, lacrimation, urination,
diaphoresis, gastrointestinal motility, emesis) symptoms caused by organophosphate
poisoning.
c. Another mnemonic is DUMBBELSS, which stands for diarrhea, urination, miosis,

bradycardia, bronchoconstriction, excitation (as of muscle in the form of fasciculations
and CNS), lacrimation, salivation, and sweating (only sympathetic innervation using Musc
receptors).
2. What are the muscarinic receptors
a. M1 – Secretion by salivary glands, other exocrine glands and stomach
b. M2 – reduce contractile forces of atrium, reduce conduction velocity of AV node
c. M3 – smooth muscle contraction, Increase intracellular calcium in vascular endothelium

increased endocrine and gland secretions, e.g. salivary glands and stomach, eye
accommodation, vasodilation induce emesis
d. M4 – Cns
e. M5 - Cns
Identify: This is epinephrin
Classify: It is a
Mode of action:
Indications
Contraindications
Side effects
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Fluids, electrolytes and Nutrients
Intravenous fluids
Crystalloids Colloids
Hypotonic Isotonic Hypertonic Natural Synthetic
5% dectrose 0.9% Saline 3% saline Whole blood Gelafusin

in water
5% dextrose 5% dextrose Packed cells Dextran
0.45% Saline in 0.45% 40:70
in 0.2% saline
saline Plasma
Pentastarch
Lactated 5% dextrose and
Platelets
Ringers in normal Hetastarch
saline Albumin
Gel
Hartman Synthetic
Plasma
10% albumin
Solution dextrose
Hypotonic Crystalloids
5% dextrose water
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Identify: This 500ml of 5% dextrose water
Classify: It is a hypotonic crystalloid
Describe: It consists of 25g of dextrose in 500 ml of distilled water
Indications:
1. As a regular adjunct in fluid resuscitation
2. In diabetic patients pre-op
a. Prefer to be slightly hyperglycemic than hypoglycemic because it is easier to correct the

former and it prevents the adverse effects of hypoglycemia such as coma….
3. Burns
a. Protein sparing by giving carbohydrate
b. Prevent negative nitrogen balance
Contraindications:
1. Patients with head trauma
2. Shock
3. Haemorrhage
4. In the first 24 hours of a burn injury
Questions
1. How many calories are in 500mls of 5% D/W?
a. 100 Kcal
100 ml of 5%D/W contains 5g dextrose.
in 500ml,  25g dextrose.
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 25g dextrose= 100Kcal
Recall 1g CHO = 4 Kcal
25g CHO = 100Kcal
The caloric value is minimal , thus not used for surgical nutrition.
2. Why is 5% dectrose water so hypotonic?
a. Because the dextrose is rapidly metabolized by the liver leaving free water which rapidly
equilibrates through all fluid compartments.
Isotonic crystalloid
Normal saline
Identify: This is 500ml of normal saline
Classify: It is an isotonic crystalloid
Describe: It consists of 0.9% ( 77mEq ) sodium chloride in 500 ml of distilled water
Indications
1. As a normal adjunct in fluid management
2. To replace ongoing losses or fluid deficits
Questions
1. What is the normal distribution of water in the body.
a. For a 70 kg man the total bodily fluid is 42 L (60% of body weight). Of this 2/3 is
intracellular and 1/3 extracellular (14L). Of the extracellular fluid 1/3 is intravascular the
rest are interstitial.
2. How much of the NS will remain intravascular?
a. 1/3
3. What is the normal urine output per hour and per day?
a. 05-1 ml/ kg/ hour
b. 1500 ml/day
4. How do you calculate maintenance fluids?
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a. The first 10 kg is multiplied by 100
b. The 2nd 10 kg is multiplied by 50
c. Each subsequent kg is multiplied by 20
5. Which fluid do you give to replace fluid deficits?
a. NS
6. How do you classify dehydration?
a. Adults
i. Mild – 5%
ii. Moderate – 10%
iii. Severe – 15%
b. Infants less than 2 years
i. Mild – 3%
ii. Moderate – 6%
iii. Severe – 9%
7. If a patient is dehydrated and weak what are you going to do?
a. Bolus 2L of NS
8. How do you resuscitate in dehydration?
a. 10× weight in kg × % dehydration
b. Give first ½ in 8 hrs and the next ½ in 16 hrs
9. How do you replace blood loss
a. Blood 1:1
b. Colloid 2:1
c. Crystalloid (isotonic) 3 - 4:1
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Lactated Ringers
Identify: This is 500 ml of lactated ringers
Describe: it contains
1. 130 mEq of sodium ion = 130 mmol/L

2. 109 mEq of chloride ion = 109 mmol/L
3. 28 mEq of lactate = 28 mmol/L
4. 4 mEq of potassium ion = 4 mmol/L
5. 3 mEq of calcium ion = 1.5 mmol/L
Lactated Ringers has an osmolarity of 273 Osm/L
Generally, the sodium, chloride, potassium and lactate come from NaCl (sodium chloride),
NaC3H5O3 (sodium lactate), CaCl2 (calcium chloride), and KCl (potassium chloride).
Although its pH is 6.5, it is an alkalizing solution.
Indications
1. First 24 hours of a burn injury
2. To replace fluid loss
Lactated Ringer's solution is used because the by-products of lactate metabolism in the liver
counteract acidosis, which is a chemical imbalance that occurs with acute fluid loss or renal failure. [7]
Lactated Ringer's solution is not suitable for maintenance therapy because the sodium content (130
mEq/L) is considered too high, particularly for children, and the potassium content (4 mEq/L) is too low,
in view of electrolyte daily requirement.
Hartmans solution
Identify: This is 500 ml of hartman’s solution
Describe: It contains in a liter
1. 131 mEq of sodium ion = 131 mmol/L.

2. 111 mEq of chloride ion = 111 mmol/L.
3. 29 mEq of lactate = 29 mmol/L.
4. 5 mEq of potassium ion = 5 mmol/L.
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5. 4 mEq of calcium ion = 2 mmol/L .
Generally, the sodium, chloride, potassium and lactate come from NaCl (sodium chloride),
NaC3H5O3 (sodium lactate), CaCl2 (calcium chloride), and KCl (potassium chloride).
Potassium chloride (KCl)
Identify: This is a bottle contain 40 meq of potassium chloride
Describe:
20% KCl sol’n or > 40mEq / 15 mls for IV fluid administration
Considerations:
Ensure pt. Has adequate urine output.
INDICATIONS:
Potassium deficiency from
1. Excess vomiting
2. Diarrhoea
3. Ketoacidotic pt ( Tx c.10U insulin+? 15Meq KCl)
4. NPO Pt. ( usually needed for > 6 days)
Procedure
Pass a urinary catheter to ensure that the patient is passing urine at 0.5-1 ml/kg/day
Calculate the potassium requirements 0.5-1 mEq/ Kg in 24hrs
Give 10 meq in alternating isotonic solutions at a rate of no more than 10 meq
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Hypernatraemia
 Water deficit > solute deficit
1. Comatose, debilitated patients
2. Excess insensible losses
3. Diabetes insipidus
4. Tube feedings without adequate water
 Symptoms
1. Lethargy
2. Coma
3. ? Tremors, seizures
 Correction
1. Replace with free water, unless hypotensive
2. ? Hypotonic saline
3. NOT 0.9% NaCl, unless in shock!!
desired Na+
Total H2O deficit (L) = total body water x ( 1 - )
serum Na+
Hyponatraemia
 Solute loss > water loss
1. GI losses
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2. Excessive diuretic therapy
3. Profuse sweating
4. Burns
5. Sequestration
 Fluid overload
1. Post op surgery water retention
2. Iatrogenic
3. Fluid restriction
4. Diuretic therapy
Treatment
Na+ requirement (mmol) = total body water x (desired Na+ - serum Na+ )
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TPN Constituents
I’m too tired. Just read this. They are going to give you a bag of 10% or 20% Dextrose that is used for
TPN. You will know it’s TPN because the bag is very long.
Parenteral nutrition is by definition given IV.
Partial parenteral nutrition supplies only part of daily nutritional requirements, supplementing oral
intake. Many hospitalized patients are given dextrose or amino acid solutions by this method.
Total parenteral nutrition (TPN) supplies all daily nutritional requirements. TPN can be used in the
hospital or at home. Because TPN solutions are concentrated and can cause thrombosis of peripheral
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veins, a central venous catheter is usually required.
Parenteral nutrition should not be used routinely in patients with an intact GI tract. Compared with
enteral nutrition, it causes more complications, does not preserve GI tract structure and function as
well, and is more expensive.
Indications:
TPN may be the only feasible option for patients who do not have a functioning GI tract or who have
disorders requiring complete bowel rest, such as the following:
1. Some stages of Crohn's disease or ulcerative colitis

2. Bowel obstruction
3. Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea regardless of its
cause)
4. Short bowel syndrome due to surgery
Nutritional content:
TPN requires
1. water (30 to 40 mL/kg/day)

2. energy (30 to 60 kcal/kg/day, depending on energy expenditure)(30-40 kcal/kg/day at
UWI )
3. amino acids (1 to 2.0 g/kg/day, depending on the degree of catabolism)
4. essential fatty acids, vitamins, and minerals (see Table 3: Nutritional Support: Basic
Adult Daily Requirements for Total Parenteral Nutrition )
5. Vitamin suppliments
Children who need TPN may have different fluid requirements and need more energy (up to 120
kcal/kg/day) and amino acids (up to 2.5 or 3.5 g/kg/day).
Basic TPN solutions are prepared using sterile techniques, usually in liter batches according to standard
formulas. Normally, 2 L/day of the standard solution is needed. Solutions may be modified based on
laboratory results, underlying disorders, hypermetabolism, or other factors.
Most calories are supplied as carbohydrate. Typically, about 4 to 5 mg/kg/day of dextrose is given.
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Standard solutions contain up to about 25% dextrose, but the amount and concentration depend on
other factors, such as metabolic needs and the proportion of caloric needs that are supplied by lipids.
Commercially available lipid emulsions are often added to supply essential fatty acids and triglycerides;
20 to 30% of total calories are usually supplied as lipids. However, withholding lipids and their calories
may help obese patients mobilize endogenous fat stores, increasing insulin sensitivity.
Glucose
Glucose provides the major energy source of parenteral nutrition. Although any concentration of
glucose may be selected, certain concentrations provide for easier calculations and sufficient calories
when employed with common infusion rates. Glucose provides 4 kcal/gm. Strictly speaking, glucose in
PN solutions is hydrated and thus provides only 3.4 kcal/gm of actual hydrated weight. To simplify
calculations, however, glucose is commonly estimated to provide its actual 4 kcal/gm. Thus, a 10%
glucose or dexstrose solution supplies 40 kcal/100ml or 0.4 kcal/ml. A 20% glucose solution provides 0.8
kcal/ml.
For PN solutions infused via peripheral vein, glucose concentration should not exceed 12.5%. Higher
concentrations of glucose produce PN solutions of sufficiently high osmolarity that venous endothelium
may be damaged, resulting in venous thrombosis and sclerosis.
For PN solutions infused via central vein, the high venous flow rate rapidly dissipates the high
osmolarity. Although a 20% glucose concentration is standard, concentrations as high as 40% can be
employed if required by fluid restrictions.
NB: one liter of 10% dextrose has 400 Kcal, 500 ml of 5% has 100 Kcal. Just swat this.
Amino Acids
Since protein is needed for tissue synthesis and repair, amino acids are not routinely used for basic
energy requirements. Dextrose and lipids are typically used to provide a patient's energy needs.
The amino acids regarded as essential for humans

are phenylalanine, valine, threonine, tryptophan, isoleucine, methionine, leucine,lysine, and histidine
Micronutrient requirements
Electrolytes
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Initial electrolyte doses in a PN order must be individualized for each patient. Starting doses of
electrolytes should be at maintenance levels and evaluated daily during initial startup of PN therapy.
As the patient demonstrates tolerance and as electrolyte needs stabilize, less frequent monitoring
may be performed.
Electrolyte requirements
Usual adult range Infants/children
Sodium 60 to 200 mEq/day 2 to 4 mEq/kg/day
Potassium 60 to 200 mEq/day 2 to 4 mEq/kg/day
Magnesium 8 to 40 mEq/day 0.25 to 0.5 mEq/kg/day
Calcium 10 to 30 mEq/day 0.5 to 3 mEq/kg/day
Phosphorus 10 to 40 mMol/day 0.5 to 2 mMol/kg/day
As needed to
Chloride maintain acid-base Same as adults
balance
As needed to
Acetate maintain acid-base Same as adults
balance
Vitamins
Pediatric mulivitamin dosage

Manufacturer AMA
Weight (kg) Dose (ml) Weight (kg) Dose
<1 1.5 < 2.5 2 ml/kg
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1-3 3.25 >2.5 5 ml
>3 5
Occasionally, a patient will need to be treated with a therapeutic dose of a vitamin. Since long term
patients are susceptible to developing vitamin deficiencies, they are more like to require vitamin
therapy.
Trace elements
Trace elements are metabolic cofactors essential for the proper functioning of several enzyme
systems. Suggested daily intake for parenteral trace minerals is presented below. As with vitamins,
long-term PN is more likely to be associated with deficiencies, therefore, additional trace mineral
supplementation may be required in these patients.
Daily trace mineral requirements
Adults Peds < 5 years Peds 5 - 12 years
Copper 300 to 500 mcg 20 mcg/kg 200 to 500 mcg
Manganese 60 to 100 mcg 2 to 10 mcg/kg 50 to 100 mcg
Zinc 2.5 to 5 mg 0.1 mg/kg 2 to 5 mg
0.14 to 0.2
Chromium 10 to 15 mcg 5 to 15 mcg
mcg/kg
Selenium 60 mcg 2 to 3 mcg/kg 30 to 40 mcg
Molybdenum As needed 0.25 mcg/kg As needed
Iodine As needed 1 mcg/kg As needed
Iron As needed As needed As needed

Trace mineral administration should be decreased or withheld in patients with impaired ability to
excrete them. In patients with renal impairment, selenium, chromium, and molybdenum may be
omitted. In patients with severe hepatic disease, manganese and copper may be withheld.
Intravenous Lipid
Intravenous lipid provides essential fatty acids and supplemental calories. Intralipid is the standard
commercial form of intravenous lipid.
They form the starting point for the creation of longer and more desaturated fatty acids, which are also
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referred to as long-chain polyunsaturated fatty acids (LC-PUFA):
1. ω-3 fatty acids:

a) eicosapentaenoic acid or EPA (20:5)
b) docosahexaenoic acid or DHA (22:6)
2. ω-6 fatty acids:
a) gamma-linolenic acid or GLA (18:3)
b) dihomo-gamma-linolenic acid or DGLA (20:3)
c) arachidonic acid or AA (20:4)
ω-9 fatty acids are not essential in humans, because humans generally possess all the enzymes required
for their synthesis.
Solutions:
Many solutions are commonly used. Electrolytes can be added to meet the patient's needs.
Solutions vary depending on other disorders present and patient age, as for the following:
 For renal insufficiency not being treated with dialysis or for liver failure: Reduced protein
content and a high percentage of essential amino acids
 For heart or kidney failure: Limited volume (liquid) intake
 For respiratory failure: A lipid emulsion that provides most of nonprotein calories to minimize
CO2 production by carbohydrate metabolism
 For neonates: Lower dextrose concentrations (17 to 18%)
Beginning TPN administration:
Because the central venous catheter needs to remain in place for a long time, strict sterile technique
must be used during insertion and maintenance. The TPN line should not be used for any other purpose.
External tubing should be changed every 24 h with the first bag of the day. In-line filters have not been
shown to decrease complications. Dressings should be kept sterile and are usually changed every 48 h
using strict sterile techniques. If TPN is given outside the hospital, patients must be taught to recognize
symptoms of infection, and qualified home nursing must be arranged.
The solution is started slowly at 50% of the calculated requirements, using 5% dextrose to make up the
balance of fluid requirements. Energy and nitrogen should be given simultaneously. The amount of
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regular insulin given (added directly to the TPN solution) depends on the plasma glucose level; if the
level is normal and the final solution contains 25% dextrose, the usual starting dose is 5 to 10 units of
regular insulin/L of TPN fluid.
Monitoring:
Progress should be followed on a flowchart. An interdisciplinary nutrition team, if available, should

monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for
inpatients). Plasma glucose should be monitored every 6 h until patients and glucose levels become
stable. Fluid intake and output should be monitored continuously. When patients become stable, blood
tests can be done much less often.
Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or
retinol-binding protein), prothrombin time, plasma and urine osmolality, and Ca, Mg, and phosphate
should be measured twice/wk. Changes in transthyretin and retinol-binding protein reflect overall
clinical status rather than nutritional status alone. If possible, blood tests should not be done during
glucose infusion.
Complications:
About 5 to 10% of patients have complications related to central venous access.
Catheter-related sepsis occurs in about ≥ 50% of patients. Glucose abnormalities (hyperglycemia or

hypoglycemia) or liver dysfunction occurs in > 90% of patients.
1. Glucose abnormalities are common. Hyperglycemia can be avoided by monitoring plasma

glucose often, adjusting the insulin dose in the TPN solution and giving subcutaneous insulin as
needed. Hypoglycemia can be precipitated by suddenly stopping constant concentrated
dextrose infusions. Treatment depends on the degree of hypoglycemia. Short-term
hypoglycemia may be reversed with 50% dextrose IV; more prolonged hypoglycemia may
require infusion of 5 or 10% dextrose for 24 h before resuming TPN via the central venous
catheter.
2. Hepatic complications include liver dysfunction, painful hepatomegaly, and hyperammonemia.
They can develop at any age but are most common among infants, particularly premature ones
(whose liver is immature).
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a. Liver dysfunction may be transient, evidenced by increased transaminases, bilirubin, and
alkaline phosphatase; it commonly occurs when TPN is started. Delayed or persistent
elevations may result from excess amino acids. Pathogenesis is unknown, but
cholestasis and inflammation may contribute. Progressive fibrosis occasionally develops.
Reducing protein delivery may help.
b. Painful hepatomegaly suggests fat accumulation; carbohydrate delivery should be
reduced.
c. Hyperammonemia can develop in infants, causing lethargy, twitching, and generalized
seizures.Arginine supplementation at 0.5 to 1.0 mmol/kg/day can correct it. If infants
develop any hepatic complication, limiting amino acids to 1.0 g/kg/day may be
necessary.
3. Abnormalities of serum electrolytes and minerals should be corrected by modifying

subsequent infusions or, if correction is urgently required, by beginning appropriate peripheral
vein infusions. Vitamin and mineral deficiencies are rare when solutions are given correctly.
Elevated BUN may reflect dehydration, which can be corrected by giving free water as 5%
dextrose via a peripheral vein.
4. Volume overload (suggested by > 1 kg/day weight gain) may occur when patients have high
daily energy requirements and thus require large fluid volumes.
5. Metabolic bone disease, or bone demineralization (osteoporosis or osteomalacia), develops in

some patients given TPN for > 3 mo. The mechanism is unknown. Advanced disease can cause
severe periarticular, lower-extremity, and back pain. Temporarily or permanently stopping TPN
is the only known treatment.
6. Adverse reactions to lipid emulsions (eg, dyspnea, cutaneous allergic reactions, nausea,
headache, back pain, sweating, dizziness) are uncommon but may occur early, particularly if
lipids are given at > 1.0 kcal/kg/h. Temporary hyperlipidemia may occur, particularly in patients
with kidney or liver failure; treatment is usually not required. Delayed adverse reactions to lipid
emulsions include hepatomegaly, mild elevation of liver enzymes, splenomegaly,
thrombocytopenia, leukopenia, and, especially in premature infants with respiratory distress
syndrome, pulmonary function abnormalities. Temporarily or permanently slowing or stopping
lipid emulsion infusion may prevent or minimize these adverse reactions.
7. Gallbladder complications include cholelithiasis, gallbladder sludge, and cholecystitis. These

complications can be caused or worsened by prolonged gallbladder stasis. Stimulating
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contraction by providing about 20 to 30% of calories as fat and stopping glucose infusion several
hours a day is helpful. Oral or enteral intake also helps. Treatment withmetronidazole,
ursodeoxycholic acid, phenobarbital, or cholecystokinin helps some patients with cholestasis
Sutures
Absorbable vs nonabsorbable sutures
Absorbable sutures provide temporary wound support, until the wound heals well enough to withstand
normal stress. Absorption occurs by enzymatic degradation in natural materials and by hydrolysis in
synthetic materials. Hydrolysis causes less tissue reaction than enzymatic degradation.
The first stage of absorption has a linear rate, lasting for several days to weeks. The second stage is
characterized by loss of suture mass and overlaps the first stage. Loss of suture mass occurs as a result
of leukocytic cellular responses that remove cellular debris and suture material from the line of tissue
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approximation. Chemical treatments, such as chromic salts, lengthen the absorption time.
Importantly, note that loss of tensile strength and the rate of absorption are separate phenomena. The
surgeon must recognize that accelerated absorption may occur in patients with fever, infection, or
protein deficiency, and this may lead to an excessively rapid decline in tensile strength. Accelerated
absorption may also occur in a body cavity that is moist or filled with fluid or if sutures become wet or
moist during handling before implantation.
Natrual absorbable vs Synthetic absorbable
Natural fiber absorbable sutures have several distinct disadvantages. First, these natural fiber
absorbable sutures have a tendency to fray during knot construction. Second, there is considerably
more variability in their retention of tensile strength than is found with the synthetic absorbable
sutures.
Absorbable synthetic sutures are composed of chemical polymers that are absorbed by hydrolysis and
cause a lesser degree of tissue reaction following placement.
Monofilament vs multifilament sutures
Monofilament suture is made of a single strand; this structure is relatively more resistant to harboring
microorganisms. The monofilament suture also exhibits less resistance to passage through tissue than
the multifilament suture. However, great care must be taken in handling and tying the monofilament
suture, because crushing or crimping of this suture can nick or weaken the suture and lead to
undesirable and premature suture failure.
Multifilament suture is composed of several filaments twisted or braided together; these materials are
less stiff but have a higher coefficient of friction. Multifilament suture generally has greater tensile
strength and better pliability and flexibility than monofilament suture, and this type of suture handles
and ties well. However, because multifilament materials have increased capillarity (ie, the extent to
which absorbed fluid is transferred along the suture), the increased absorption of fluid may act as a tract
for the introduction of pathogens, which increases the risk for wound infection and dehiscence.
In addition, because the individual filaments of a multifilament suture are braided together, an
increased coefficient of friction is created when the suture is passed through tissue. Multifilament
sutures are often treated with special coatings to allow tissue passage to occur more easily and to
reduce subsequent tissue damage.
Natural Absorbable sutures
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Catgut suture is a type of surgical suture that is naturally degraded by the body's own
proteolytic enzymes. Absorption is complete by 90 days, and full tensile strength remains for at least 7
days. This eventual disintegration makes it good for use in rapidly-healing tissues and in internal
structures that cannot be re-accessed for suture removal.
Catgut suture has high knot-pull tensile strength and good knot security due to special excellent
handling features. It is used for all surgical procedures including general closure, ophthalmic,
orthopedics, obstetrics/gynecology and gastrointestinal surgery. It is absorbed faster in patients with
cancer, anemia, and malnutrition. It also absorbed faster when used in the mouth and in the vagina, due
to the presence of microorganisms.
Catgut suture is made by twisting together strands of purified collagen taken from
the serosal or submucosal layer of the small intestineof healthy ruminants (cattle, sheep, goats) or
from beef tendon.[2] The natural plain thread is precision ground in order to achieve
amonofilament character and treated with a glycerol-containing solution. The suture is sterilized
with ethylene oxide gas.
Chromic cat gut is treated with chromium salt, which slows down the absorption rate (90 d). Tensile
strength is maintained for 10-14 days. Tissue reaction is due to the noncollagenous material present in
these sutures. Also, patient factors affect rates of absorption and make tensile strength somewhat
unpredictable. Salthouse and colleagues demonstrated that the mechanism by which chromic surgical
gut reabsorbs is the result of sequential attacks by lysosomal enzymes. [3]
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Natural non-absorbable sutures
1. Surgical silk
2. Surgical cotton
3. Surgical steel
1. Mersilk Suture
Surgical silk suture is made of raw silk spun by silkworms. The suture may be coated with beeswax or
silicone. Many surgeons consider silk suture the standard of performance (superior handling
characteristics). Although classified as a nonabsorbable material, silk suture becomes absorbed by
proteolysis and is often undetectable in the wound site by 2 years. Tensile strength decreases with
moisture absorption and is lost by 1 year. The problem with silk suture is the acute inflammatory
reaction triggered by this material. Host reaction leads to encapsulation by fibrous connective tissue.
2. Cotton
Surgical cotton suture is made of twisted, long, staple cotton fibers. Tensile strength is 50% within 6
months and 30-40% by 2 years. Surgical cotton is nonabsorbable and becomes encapsulated within body
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tissues.
3. Surgical steel suture
Surgical steel suture is made of stainless steel (iron-chromium-nickel-molybdenum alloy) as a

monofilament and twisted multifilament. This suture can be made with flexibility, fine size, and the
absence of toxic elements. Surgical steel demonstrates high tensile strength with little loss over time
and low tissue reactivity. The material also holds knots well.
Synthetic Absorbable sutures
1. Polyglactin 910 (Vicryl)

2. Poliglecaprone 25 (Monocryl)
3. Polydioxanone (PDS II)
4. Maxon
1. Vicryl Suture
Polyglactin 910 (Vicryl) synthetic suture is a braided multifilament suture coated with a copolymer of
lactide and glycolide (polyglactin 370). The water-repelling quality of lactide slows loss of tensile
strength, and the bulkiness of lactide leads to rapid absorption of suture mass once tensile strength is
lost. The suture is also coated with calcium stearate, which permits easy tissue passage, precise knot
placement, and smooth tie-down. Tensile strength is approximately 65% at 14 days postimplantation.
Absorption is minimal for 40 days and complete in 56-70 days. These sutures cause only minimal tissue
reaction. Vicryl sutures are used in general soft-tissue approximation and vessel ligation. Another similar
suture material is made from polyglycolic acid and coated with Polycaprolate (Dexon II). This material
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has a similar tensile strength and absorption profile.
2. Monocryl Suture
Poliglecaprone 25 (Monocryl) synthetic suture is a monofilament suture that is a copolymer of glycolide

and e-caprolactone. The suture has superior pliability, leading to ease in handling and tying. Tensile
strength is high initially, 50-60% at 7 days, and is lost at 21 days. Absorption is complete at 91-119 days.
Poliglecaprone 25 sutures are used for subcuticular closure and soft-tissue approximations and ligations.
3. PDS Suture
Polydioxanone (PDS II) is a polyester monofilament suture made of polydioxanone. This suture provides
extended wound support and elicits only a slight tissue reaction. Tensile strength is 70% at 14 days and
25% at 42 days. Wound support remains for up to 6 weeks. Absorption is minimal for the first 90 days
and essentially complete within 6 months. This material has a low affinity for microorganisms (like other
monofilament sutures). PDS II suture is used for soft-tissue approximation, especially in pediatric,
cardiovascular, gynecologic, ophthalmic, plastic, and digestive (colonic) situations.
Another similar, new synthetic absorbable suture material is made from polytrimethylene carbonate
(Maxon). This material has a similar tensile strength and absorption profile.
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Synthetic non-absorbable Sutures
1. Nylon
2. Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated])
3. Polypropylene (Prolene)
1. Nylon
Nylon suture is a polyamide polymer suture material available in monofilament (Ethilon/Monosof) and
braided (Nurolon/Surgilon) forms. The elasticity of this material makes it useful in retention and skin
closure. Nylon is quite pliable, especially when moist. Of note, a premoistened form is available for
cosmetic plastic surgery. The braided forms are coated with silicone. Nylon suture has good handling
characteristics, although its memory tends to return the material to its original straight form. Nylon has
81% tensile strength at 1 year, 72% at 2 years, and 66% at 11 years. The material is stronger than silk
suture and elicits minimal acute inflammatory reaction. Nylon is hydrolyzed slowly, but remaining suture
material is stable at 2 years, due to gradual encapsulation by fibrous connective tissue.
2. Polyester
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Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]) suture material is formed
from polyester, a polymer of polyethylene terephthalate. The multifilament braided suture also comes
coated with polybutilate (Ethibond) or silicone (Ti-cron). The coating reduces friction for ease of tissue
passage and improved suture pliability and tie-down. The suture elicits minimal tissue reaction and lasts
indefinitely in the body. Polyester fiber sutures are stronger than natural fibers and do not weaken with
moistening. The material provides precise consistent suture tension and retains tensile strength. This
suture is commonly used for vessel anastomosis and the placement of prosthetic materials.
3. Prolene
Polypropylene (Prolene) is a monofilament suture that is an isostatic crystalline stereoisomer of a linear

propylene polymer, permitting little or no saturation. The material does not adhere to tissues and is
useful as a pull-out suture (eg, subcuticular closure). Polypropylene also holds knots better than other
monofilament synthetic materials. This material is biologically inert and elicits minimal tissue reaction.
Prolene is not subject to degradation or weakening and maintains tensile strength for up to 2 years. This
material is useful in contaminated and infected wounds, minimizing later sinus formation and suture
extrusion.
Suture size
From smallest to largest
10-0 Typically used in the most delicate surgeries. Common in both Ophthalmic (eye)
9-0 surgery and for repairing small damaged nerves often due to lacerations in the
8-0 hand.
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7-0 Used for repairing small vessels and arteries or for delicate facial plastic surgery.
6-0 Common for use in vascular graft sewing such a carotid endarterectomy.
5-0 Used for larger vessel repair such as an Abdominal Aortic Aneurysm or
4-0 skin closure.
3-0 Skin closure when there is a lot of tension on the tissue, closure of muscle layers
2-0 or repair of bowel in general surgery.
0 For closing of the fascia layer in abdominal surgery, the joint capsule in knee and
1 hip surgery or deep layers in back surgery.
2 For repair of tendons or other high tension structures in large orthopedic

5 surgeries.
Orthopedics
Rigid Cervical Collar
Identify: This is a rigid cervical collar
Describe: It consists of posterior and anterior portions that are held

together by an adhesive strap. It also has a por for management of a
tracheostomy
Indications
Suspected C-spine injury (multiple trauma)
Confirm C-spine injury
Pain relief
Procedure
Assistant puts on manual in line stabilization
Place posterior portion on from the side then place the anterior portion on next
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Soft cervical collar
For psychologic support (comfort)
Esmarch Band
Identify: This is an esmarch band
Describe: Simply as roll of broad latex
Indications
Torniquet in orthopedic procedure
Contraindications
Sickle cell patients !!!!!!!!!!!!!
Procedure
Informed consent
Apply wrap around limb from distal to proximal
Release the distal and attach to proximal
Advantages
Cheap
Disadvantages
The applied pressure is not known (remember that you should not apply more than 100 mmHg above
systolic blood pressure
Questions
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What happens when the it is left on too long?
Torniquet palsey and Neuropraxia.
How soon after does neuropraxia recover?
24-48 hrs
How does the nerve grow back?
Wallerian regeneration
What are the types of nerve injuries?
Neurotemesis, axonomesis, neuropraxia
Pneumatic torniquet
Identify: This is a pnuematic

torniquet
Describe: It has a cuff and a

guage
Indications
As a torniquet in limb Sugery
Biers block
Intravenous Regional Anaesthesia (IVRA) of the Arm (Bier's Block)
Introduction
This is a unique regional LA technique as it relies on the nerves being blocked via the venous system.
Exactly how this occurs is not known but it is presumed that the LA gains access to the nerve roots by
back diffusion from the veins. The technique involves total isolation and drainage of the venous network
in the arm using an Esmarch bandage and tourniquet. The former empties the veins whilst the latter
prevents further influx of blood. The veins are then filled with LA and within minutes the arm below the
tourniquet is analgesic and relaxed. It is suitable for most superficial surgery of the arm and for bony
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manipulations, e.g. following a Colles fracture of the wrist.
Technique
It cannot be emphasised enough that this block must NOT, under any circumstances, be undertaken
without having full resuscitation facilities and expertise at hand. It should be noted that, if the dose of
local anaesthetic injected i.v. for the procedure should gain rapid access into the systemic circulation,
toxic side effects will be produced, ranging from convulsions to a state of general anaesthesia with
respiratory and cardiovascular depression .
The patient should lie supine and comfortably, with the affected arm supported by a side board. A
suitable tourniquet (type used for orthopaedic surgery of the arm, or a specially devised double cuff
tourniquet) is put round the affected arm over cotton wool padding, and carefully secured to prevent
accidental deflation or detachment.
A 21 or 23G Y-canR is then inserted into a vein of the dorsum of the hand. If this
location interferes with surgery or is inconvenient, it may be inserted into any other
superficial vein of the arm as distally as possible. The arm is raised vertically for
three minutes to reduce the volume of blood contained within the venous
compartment. A similar cannula is inserted into the other arm so that an open vein
is available during the procedure for the injection of adjuvant drugs such as opioids
and benzodiazepines as well as drugs for the treatment of toxicity (see later).
If the lesion to be treated surgically is not painful, the Esmarch rubber bandage is
tightly applied round the whole limb, starting distally, draining the blood away into
the general circulation. If the bandage cannot be applied, the brachial artery may be compressed with
the fingers (without obstructing venous return) for 30 seconds while keeping the arm upright. The
proximal tourniquet cuff is then inflated rapidly to a pressure about 50 mmHg above the patients
systolic B.P. and maintained throughout the procedure. The pressure in the tourniquet must be carefully
observed throughout the whole procedure and not allowed to fall.
With the tourniquet inflated, 40 ml of 0.5% lignocaine or prilocaine (up to 3 mg.kg-1) is then injected
very slowly through the cannula with the arm horizontal, watching for signs of venous . If veins appear
distended, the rate of injection must be reduced or stopped, because pressures may be generated
within the venous system sufficient to cause leakage of anaesthetic into the general circulation.
Paraesthesiae are soon felt by the patient, and within 5-10 minutes a complete sensory and motor block
should ensue, lasting for as long as the tourniquet is applied (up to 1 hour). If a double cuffed tourniquet
is used, the proximal cuff is first inflated. When analgesia of the arm is established, the distal cuff (lying
on anaesthetised skin) is inflated to the same pressure and the proximal one deflated. This usually
relieves the discomfort associated with the pressure of the cuff.
The tourniquet must not be let down for at least 15 minutes after the injection of the local anaesthetic.
This time interval ensures that enough anaesthetic has diffused out of the vascular compartment, such
that the amount entering the circulation as a 'bolus' is not sufficient to cause toxic effects.
Advantages
The only expertise required is ability to cannulate the vein and a rigorous technique
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Extremely high (> 95%) success rate, higher than any other block
Disadvantages
Not suitable for deep operations as analgesia is not sufficiently intense
Tips of fingers are often missed, an additional ring block may then be necessary (vide infra)
The tourniquet may become extremely uncomfortable and thus limit the duration of surgery (using
a second tourniquet together with the judicious use of adjuvant drugs may overcome this problem)
Surgical time is limited to about 1 hour due to the tourniquet, which must not be released during the
procedure
Postoperative analgesia is extremely short lived
Complications
Should the tourniquet be accidentally deflated less than 25-30 minutes after injection of lignocaine, the
patient must be closely monitored for side effects; paraesthesiae of the tongue and lips is usually the
first symptom of systemic overdose.
Should an epileptiform fit occur, 10 mg of diazepam should be injected intravenously through the Y-can
in the opposite hand, and 100% oxygen given through a facemask until the convulsion is over. The dose
of diazepam may be repeated twice if necessary, but it must be remembered that it will potentiate the
respiratory depression caused by lignocaine. An intravenous infusion should be set up in the 'free' arm.
The first toxic symptom may be loss of consciousness. If respiratory depression occurs (also following a
convulsion) manual ventilation with 100% oxygen must be started immediately and monitoring of pulse,
blood pressure and ECG instituted. The P-Q interval of the ECG is likely to be prolonged, the heart rate
slow, and the blood pressure low. If systolic pressure is below 60 mmHg, 3-5 mg boluses of ephedrine
may be given intravenously (up to 30 mg total). If the blood pressure is unrecordable (no pulses felt in
the carotids) external cardiac massage must be started.
Other features of toxicity are arrhythmia, metallic taste in the back of the mouth.
Austin Moore Prosthesis Hemiarthoplasty
Identify: This is an Austin Moore hemiarthoplasty

prosthesis
Describe: Metalic head and Shaft with 2 holes to

aid in fixation The diameter of the head ranges
from 37 – 58
Indications
Elderly (>65) persons with infracapsular fractures
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who are not expected to ambulate a lot (ie. Not very active)
Contraindications
Relatively contraindicated in young patients because it only last 10 years
Questions
What is the major complication of neck of femur fracture
Avascular necrosis
How do you classify neck of femur fractures
Gardener’s Classification
How does the fumur get its blood supply
Anatomy:
Blood supply to the neck of femour

- extracapsular arterieal ring at the base of the femoral neck;
- formed posteriorly by large branch of medial femoral
circumflex artery MFCA
- formed anteriorly by smaller branches of lateral femoral
circumflex artery LFCA;
- superior & inferior gluteal artery have minor contributions;
- ascending cervical branches
- these give rise to retinacular arteries;
- gives rise to subsynovial intra articular ring
- artery of ligamentum teres;
- derived from obturator or MFCA;
- inadequate to supply femoral head with displaced fractures;
- forms the medial epiphyseal vessels;
- only small & variable amount of the femoral head is nourished by artery of ligamentum teres;
- Changes w/ Age:
- even after closure of epiphyseal plate, there is minimal astomosis between epiphyseal and
metaphyseal circulations;
- in the adult, greatest portion of blood supply to head of femur is derived from vessels on posterior
superior surface of femoral neck;
- Femoral Neck Frx:

- frx disrupts intraosseous cervical vessels;
- portion of the neck that is intracapsular has essentially no cambium layer in its fibrous covering to
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participate in peripheral callus formation;
- hence, healing is dependent on endosteal union alone;
- femoral head nutrition is then dependent on remaining retinacular vessels, & supply from the
ligamentum teres;
- position acheived at reduction is significant factor in development of avascular necrosis:
- in frx of hip, valgus reduction may end up kinking of lateral epiphyseal vessels & tethering
of medial epiphyseal vessels in ligamentum teres;
- valgus and rotatory malposition may result in AVN;
What is the cause of the fracture in the young and the old?
Fall from standing or some other minor fall (osteoporosis) for elderly and MVA for the young
What is the clinical presentation presentation?
Externally rotated shortened limb with antalgic gait
What other bones are prone to AVN?
Scaphoid, tallus and humeral head.
What medical conditions predispose you to AVN?
Steroid therapy and Sickle cell
If a patient has severe cardiopulmonary problems and atherosclerosis and presents with a hip fracture
would you do surgery and why?
Yes because there is a 100% chance that this patient will die from a complication of being bed ridden so
in this case the risk of conservative management out-weighs the risk of surgery
What are the complications of being bedridden?
These include pressure ulcers (most common), deep vein thrombosis leading to a pulmonary embolism,
Pneumonia, urinary tract infection, urinary calculi, osteopenia with associated hypercalcaemia.
If a 25 year old sickler presents with AVN, how would you manage this patient
Revascularization surgery which is now offered at UHWI where a portion of vascularized fibula is taken
and microvascular surgery performed. There are also new total hip replacement available soon that can
last up to 50 years. You would not use a hemiarthroplasty because it will only last 10 years and even
shorter with an active individual. Arthodesis is another option, but it should be a last resort and only a
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temporary procedure.
To check the diameter of the femoral head on an x-ray measure the head and subtract 1/6 of the
diamtre (x-ray magnifies the the stuctures)
Lorenzo Stuff
1st GENERATION NAIL : KUNTSCHER NAIL (K- nail )
Definition: An intramedullary nail which is hollow and of clover leaf section .
MOA: 3 point fixation
STRUCTURE:
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Its structure allows the nail to negotiate canal when been put in.
10mm(widest) x 38 mm ( long)
Stability is gained by 3 points of K- nail in contact with femur.
However there is no rotational control or stability of K- nail, thus not used @ lower 1/3
femur # because femur @ distal 1/3 flares.
*Ensure the hole is at the top when K- nail is placed because it is for removal!
Put the hook there & bash it out!
USE:
Internal fixation of # of long bones – particularly shaft of femur ( proximal and middle 1/3),tibia,
humerus, & ulna.
K- Nail functions to maintain length & alignment.
CONTRAINDICATIONS :
1. Comminuted #
2. Oblique #
3. Lower 1/3 femur #
PASSAGE OF NAIL:
Can be anterograde (doesn’t disturb fracture site) or Retrograde (needs fluoroscopy—for AP and Lat
views)
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-Lateral incision made over trochanteric region # site
- Long guide wire is introduced
- Ream the dip of greater trochanter.
- Pass down the shaft – impt. To check
The intramedullary nail is then threaded over the guidewire . & reduce # & hammer
nail & leave 1 cm nail sticking out & close wound.
- Why does it have a hole at one end? So that a hook can be used to pull it out.
- Removal aided by rectangular hole at upper end.
Always give a 5 cm interference fit!
Description:
-Light, hollow
Clover leaf , cross- section
-Rectangular opening at one end placed proximally ( aids removal when # site unite)
-Shape prevents rotation, more stable.
30. 2nd GENERATION NAIL : AO NAIL

 Similar to K- nail but is curved. The AO nail addressed the problem of the curvature of the femur
 Also has a 3 point- fixation.
 Can be locked at the top , hollow, clover leaf in cross – section.
 However, it cannot prevent rotation & maintain limb length.
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RD
31. 3 GENERATION NAIL: AO LOCKED NAIL
It has holes for screws at the top & bottom.
Pass guide – wire from top & ream over guide wire until hit cortex.
 achieve certain size ( recall : In canal,  cancellous bone, want to erode

medullary bone ). Can lock it @ top & bottom,  locked nail.
It maintains limb length & rotational control.
USE:
It can be used for : femur shaft #
Lower 1/3 femur #+prox femur+ oblique, communuted
Adv.: Don’t have to open # site , thus prevents  risk of infection.
Disadv: fluoroscopy view (10X more expensive than K-knail)
32. AUSTIN – MOORE PROSTHESIS = hemiarthroplasty

- It is used for displaced intracapsular #
- Remove head of femur & put it into shaft & it will articulate with acetabulum.
- Its head is very shiny to reduce friction.
- The holes in it are for bone grafting, bone will heal onto either side of proximal femur.
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- The hook @ top is for removal & bash it out.
Problems:
1.Will get wearing of hip jt. Esp. of acetabulum,  good for the elderly with  movement.Not good for
60 year old unless movement is very limited.
3. Socket jt. Dislocation.

4. Can have rxn of metal. A portion of the transition zone distal to metal portion is weakened,
likely to # distally if  fall.
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33. DHS ( dynamic hip screw)
Structure: 1. Screw placed into head +neck of femur [center] 2. Barrel + plate which holds the
screws. The back of the screw is flutedso that screw driver can fit. Screw is threaded for a locking
screw to lock and compress the # site.
Dynamic becazit’s movable. It allows for collapse of fracture siteallows for dynamization to a
stable position
Indications
Extracapsular #s,
Inter trachanteric #s
Sometimes subtrocanteric #s
Pass a guide wire up neck of femur to head. Ream over wire & create core. Pass screw over guide –
wire into head of femur until it fits alongside bone.
When  collapse over # site, sliding mechanism prevents screw from entering pelvis.
 sliding = safety device
34. TOTAL HIP ARTHROPLASTY PROSTHESIS
Structure
1. Acetabular component: can be made of polyehtyline

2. Femoral component: has a head + neck+ stem+callor. Can be made of metal alloy, highly
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polished to decrease friction
Total hip arthroplasty is used for : arthritis (1. osteo, 2. rheumatoid).
Very active pt. with intracapsular NOF #

AVN
Tumor
Total hip arthroplasty lasts 10 –15 years
Complications
1. Femoral fractures!!!!!
2. DVT (right after Sx) + PE
3. Dislocationprosthesis has a small head in
relation to it’s native head
4. Damate to neurovascular structs around
5. Damageto the acetabellum and intra-abdominal org.
IL 1, IL 6 stimulates osteoclastic activity  loosening of bone
35. RUSH ROD
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 Intra-medullary device.
Used in Mx of # of forearm bones i.e. (radius, ulna) + humerus + ? filula)
 Has a hole at one end.

 Only maintains alignment of #, prevent displacement .
 For simple transverse #
 Not good for unstable # eg. Oblique #
 Does not give rotational stability.
 No need to use rush rod by itself.
 Does not give stability to be used on its own.
 Needs cast.
 Hook lies subcutaneously , facilitates removal.
36. K- WIRE ( KERSCHNER WIRE)

Used in reduction of Bennet’s # (# at base of 1 st metacarpal with involvement of carpometacarpal joint.
It can occur from a direct violent force as in boxing).
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 Looks like a long, slim Steinmann pin but may or may not have 2 pointed ends
37. STEINMANN PIN
 4mm diameter steel pin

 2 pointed ends ( or 1 pointed/ 1 blunted end)
 Threaded or unthreaded The choice depends on :
Surgeon’s preference
Density of bone
Force to be applied
A. Threaded Fully or partialgood drainage+more stability. For sk mus traction. To fish out bone
fragments.
Low torque used as high torque cazes burningthermal necrosis, inc risk of infection
B. Smooth Steinman pinless risk of infection + less traumato tissue when putting it in. More
easily displaced
Smooth is stronger however
Page
Where sited?
 Distal femur
 Proximal 1/3 tibia
 Distal tibia
 Calcaneous- occasionally
PURPOSE:
Application of skeletal traction ( along with devices –Bohter Brain frame)
Thomas splint
Hamilton Russel traction
Note : Need for counter- traction (elevate the foot of the bed)
INDICATIONS:
1. Primarily the long bone # of the lower limb

2. Particularly beneficial for:
 Unstable #
 Comminuted #
 SUFE
WHY?
Provides both longitudinal force and provides rotational stability.
# Management
-Pain relief (  muscle spasm)
-Overcome xs. M. tone )
-’n of #
-Stabilisation of reduction.(promotes healing
Page
Prevents soft tissue damage)
PLACEMENT:
Explain procedure to patient
Aseptic technique
Local anaesthesia – soft tissue ---> periosteum
Proximal tibia insertion :- 2.5 cm distal and posterior to tibial tuberosity)
COMPLICATION:
1. Displacement of pin
2. Damage to neurovascular structure (Common peroneal N. injury***)
3. Infection—osteomyelitis—get a rim of sequestrum (unique)
EXTERNAL FIXATORPIN
Threading is at the end. This is part of a full device. DO NOT confuse with partially threaded Steinman
pinthe treadings are in the centre!
38. PLASTER OF PARIS:

 Hemi- hydrated calcium sulphate
Page
PROPERTIES:
 Addition of H2O --> Particles of water incorporated into crystalline lattice of CaSO4.1/2 H2O.
 Its immersion in H2O is ceased when there are no more bubbling, i.e. until all air spaces are
saturated.
 RESULT: Powder --> Solid ( rock hard mass)
NB. Exothermic rxn , process reversible ( degrade plaster by soaking it in H 2O)
ADV: DISADV.
Low cost Poor H2O resistance
Excellent moulding Poor radiolucency
Multiple uses Heavy
V. low allergenicity
 hospitalization Risk of burns (esp if not padded properly)
Can be used as a splint (backslab)
Used to immobilize jts
In newborn, main concern is that it must be well padded to prevent pressure necrosis.
Page
Discharge instructions to mother:
1. Keep cast dry
2. Look out for signs of ischemia such as: inconsolable child, child stamping limb, or squeezing limb.
USES:
1. # + dislocations of bones / joints.
2. Correction of congenital /Acquired deformities
3. Injuries of M., tendons, fascias, ligaments.
4. Protection of vascular or N. repairs.
5. Application around amputation stump ( speeds up stump maturation + early prosthesis)
6. Replica for which prosthesis can be fashioned
7. Prevention of progressive deformity( e.g. cerebral palsy)
COMPLICATIONS
Bone/Jt. Skin Nerves Vessel
 Osteoporosis - Plaster burns N. palsy A. injury
 Joint stiffness - Contact dermatitis e.g. Common peroneal
- Pressure sores N.
ADVISE Pt.:
1. Elevate limb
2. Move toes/ fingers frequently
3. Avoid H2O
4. Avoid scratching
Page
SEEK MEDICAL ATTENTION IF:
1. Pain is not reduced by analgesia

2. Change in colour of digits
3. Tightness / loss of sensation
COMPLICATIONS:
IMMEDIATE EARLY LATE
1. Allergy 1. Compt. Syndrome 1. Diffuse

2. Burns Osteoporosis
2. Pruritus 2. Stiff jts.
3. Primary necrosis
4. Rash /excoriation of
skin
5. N. damage
6. M. atrophy
NOTE: Lateral condyle of femur prevents lateral displacement of patella.
Page
HaloThoracic Vest
has an adjustable velco strap
Halo vest immobilization uses pins to affix the halo

apparatus to the skull. Special care is required to
maintain the pin sites and keep the vest
connections tight. Tightening the halo pins to 6-
in/lbs of torque at 24-hours and one-week after
application is associated with the least pin site
complications.
Indications
Used for high C-spine #s eg. C1-C2. Gives rigid

fixation bypreventing head from turning
Complications
 damage to neurovascular structure

 Infection: Pin site infectioncellulitis,
osteomyelitis, and more rarely, brain abscess
 Difficulty sleeping
 Enter cranium thru unknown fractures of the skull [unknown #s sustain fr the injury
 Immobilizes skin-fixes eyes open
 Muscle spasm
CERVICAL ORTHOSES
Soft Collar
Design: nonrigid, made of firm foam covered by

cotton and fastened posteriorly with Velcro.
Provides minimal restriction of cervical movement.
Indications:
 Cervical spondylosis,
 cervical strains.
 Allows soft tissue rest,
 provides warmth to muscles +
reminds pts to avoid neck motions
Page
Contraindications: any condition where cervical motion is restrictedfractures + ligamentous injuries
Rigid Collars
Design: vinyl-covered, foam padded collar with adjustable height

and ventilated. Uses the hook and pile closure. Semi rigid
support provides mild restriction of sagital plane
motion without restriction of rotation and side
bending
Indications: Used for soft tissue injury,

emergent
Philadelphia Collars
Design: 2-piece
plastazote foam collar
with Velcro fasteners.
Includes ventilation,
molded chin support,
occipital support. Tracheostomy style available.
Page
Indications: Stable cervical spine injuries, Emergent immobilization of C-injuries, postsurgical
immobilization,
Contraindications: pts that cant tolerate press over the chin, occiput, or upper sterum
Skin Traction Kit
The skin can only take about

5kg traction in an adult. If
more than this force is
required to obtain on maintain
a reduction Skeletal traction
must be used.
Avoid skeletal traction in

children - growth plates can
easily be damaged by skeletal
pins
Indications for Skin Traction
 Children (esp < 12 kgrecall Gallows splinting)

 Temporary traction - only a few days e.g. Preoperative
 Small force required to maintain reduction <5 kg
Contraindications
 Force required > 5kg

 Skin damage(ulcer/skin dz) or sepsis in area
 Allergies to Elastoplast (Zinc)
Complications:
 Distal Oedema
 Compartment syndrome
 Shearing of skin if too much wght
 Vascular obstruction
 Peroneal nerve palsy
Page
Intramedullary Rods: Nancy Nails
Structure: the ends are beveled for easier passage,

most are titanium or allo
Indications: used
 Pediatric (4-14 yrs., <140 lbs.) upper & lower

extremity long bone fractures*
 Adult upper extremity long bone
fractures eg.radial and ulnar fractures*
 Metacarpal, Metatarsal and Phalangeal
Fractures (ø1mm)
Used esp for short spiral + obliquenot used for

communuted.
Disadvantages
 Doesn’t control shortening

 Angulation can occur becaz it’s malleable
 Height energy can overcome the 3 point fixation and rotation can result
Antibiotic Beads(gentamycin or tobramycin)
Indications:
 Tx of ostemyelitis for sequestrum

 Open fracture that has high
contamination
 Occupies spaceesp if an ostetomy is
done/for infected wounds
Advantage:
 A single string can last for 6 wkshigh local [

] + low systemic [ ] + slow release of meds
Complications
 Nidus for infection—if anitibiotics is used

up
 Allergies
 The beads may migrate(as muscle moves)
Total Knee Prothesis
Page
Components:
1. Femur prosthesis—metal
2. Tibeal Prosthesis—Poly ethyl plastic
3. Posterior stabilizer
Indications
 Surgical management of pts with severe osteoarthritis (to relieve pain***)**

 Tumor of distal fem ur or prox tibiawhere resection is needed
 Surgical mnx of severe RA
Contraindications
 Absolute
 Knee sepsis
 extensor mechanism dysfunction,
 severe vascular disease,
 The presence of a well-functioning knee arthrodesis.
Imaging Studies needed for Total knee replacement
 Standing AP view
 Lateral view
 Patellofemoral (skyline) view (see image
below)

Total knee arthroplasty. Skyline view of the patellofemoral joint

demonstrating lateral and medial osteophytes and lateral subluxation of
the patella.
 Long leg radiographs to assess malalignment - Helpful for preoperative planning

 Standing radiographs with the knee in extension or in 45 degrees of flexion (Rosenberg view) - Can
improve the sensitivity of detection of cartilage degeneration
Page
External Fixator devise
Indications
 Open fracture***: in which the wound can be left

open for inspection and dressing. Also for wound
healing, neurovascular status, viability of skin flaps,
and tense muscle compartments.
 To correct limb lengthening and correct angular
deformities***
 Unstable Joints: provides stability across the joint in a
dislocation.***
 Comminuted & Unstable fractures. *
 Fractures of pelvis.*
 Fractures associated with injuries of nerve & blood vessel.*
 Infected fractures.(eg. osteomyelitis) *
 Non-united fractures where the dead fragments can
be excised and combine with elongation in normal
shaft.
NB. External fixation is most successful in superficial

bones e.g. tibial shaft. Avoid it in deeper bones e.g. the
femur or humerus - here the chance of pin tract sepsis is
greater.
A. Adv:
 Early patient mobilization is allowed. With rigid fixation the limb can be moved and positioned
without fear of loss of fracture position. In stable, uncomminuted fractures early ambulation is
usually possible; this may not be the case if these fractures are treated by traction or casting
 Insertion can be performed with the patient under local anesthesia, if necessary(where general
anaesthesia is contraindicated
B. Disadv:
1. The equipment is expensive.

2. The frame can be cumbersome, and the patient may reject it for aesthetic reasons.
3. Fracture through pin tracts may occur
Complications of applications of the device
 Neurovascular damage
 Fracture of the bone
 Pin tract Infection
 Ankle Stiffness—fixing muscles with pin—
muscle fibrosis/tendon rupture
Page
 Compartment Syndrome
 Mal-alignment
Page
Antibiotic beads Bone Reamer
Nail nipper Plaster cast breaker Plaster cast separator
Page
Kuntshner nail driver Kuntschner extraction hook Kuntschn
Page

Surgical Instruments and Drains PDF

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Surgical Instruments and Drains PDF

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Surgical Instruments and Drains

Identify: This is a core needle

It has a plastic handle with a graduated

To biopsy breast lumps or other masses

2. It is a sterile procedure so aseptic measures must be taken.

3. Clean the area and apply local anaesthesisa

4. Use a blade to nick the area above the mass

5. Insert the metal tubing with the needle covered

1. What other methods of biopsy are there?

a. Incisional, excisional, fine needle aspiration and cytology

2. What information can you get from a core needle biopsy?

3. What are the levels in birads classification?

5-highly suspicious of malignancy,

6-known biopsy with proven malignancy.

Active Passive Active Passive

Haemovac NGT SUMP drain Penrose drain

Jackson pratt Urinary catheter Cigarette drain

J-vac Chest tube not Corrugated drain

Identify: This is a haemovac drain

Classify: This is a closed active drain

It has 2 ports and a reservoir bag with gradients to measure volume.

Its resoivoir bag limits its use in draining massive secretions.

Jackson-Pratt drain J- Vac drain

Identify: This is a penrose drain

Classify: It is an open passive drain

Describe: Flabby latex tube

1. For prophylaxis against fluid build up within a wound

2. Abdominal fluid collection

3. After a foot flap

Open so high risk of infection

1. What physical principle does this drain use?

2. How long should a drain be left in place for?

a. For serous fluid 3-5 days

b. For wounds 1-5 days

c. For bowel anastamosis 5-7 days

d. For T-tube 10 days when a fibrous tract has formed

Identify: This is a corrugated drain

Classify: It is an open passive drain

Describe: It consists of a flat flabby material with

Penrose with a gauze

Identify: This is a Sump drain

Classify: It is an open active drain

It has a long outer tank with distal perforations and a

1. To drain abdominal fluid collection.

Sump means a tank!

Pig tail Catheter

Identify: This is a pigtail catheter

Classify: It is a closed passive drain

1. Used to drain pancreatic abscess/ pseudocyst

2. Used to drain liver abscess

3. In percutaneous nephrostomy to drain kidney and is placed under ultrasound or CT guidance

1. Stone formation with prolonged placement

Identify: This is a dacron graft

Describe: It is at threaded tube with a longitudinal radiopaue line.

Bypass in peripheral arterial disease above the knee

Poor run in, run off or a large occlusion.

Procedure: Refer to text

 Leaking of around graft

1. Can you use it below the knee.

a. No, because it has a very high failure rate there.

2. What other methods of bipass are there?

Fogathy Embolectomy catheter