Bed Side Procedures

Dr. Hiwa Omer Ahmed Assistant Professor in General Surgery

Introduction
The ability to insert a urinary catheter .is an essential skill in medicine Catheters are sized in units called French, where one French equals 1/3 of 1 mm. Catheters vary from 12 (small) FR to 48 (large) FR (3.16mm) in size They also come in different varieties including ones without a bladder balloon, and ones with different sized balloons - you should check how much the balloon is made to hold when inflating the !balloon with water

Universal precautions Gloves must be worn while starting the Foley, not only to protect the user, but also to prevent infection in the patient. Trauma protocol calls for all team members to wear gloves, face and eye protection and .gowns

INDICATIONS

Contraindications
Foley catheters are contraindicated in the presence of urethral trauma. Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as .straddle impacts If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of .urethral tear is present One must then perform retrograde urethrography (injecting 20 cc of .(contrast into the urethra

Equipment

Sterile gloves - consider Universal Precautions Sterile drapes Cleansing solution e.g. Savlon Cotton swabs Forceps Sterile water (usually 10 cc) Foley catheter (usually 16-18 French) Syringe (usually 10 cc) Lubricant (water based jelly or xylocaine jelly) Collection bag and tubing

Procedure

Insertion of an urinary catheter in a female

Insertion of an urinary catheter in a male

Complications
The main complications are tissue .trauma and infection After 48 hours of catheterization, most catheters are colonized with bacteria, thus leading to possible .bacteruria and its complications Catheters can also cause renal inflammation, nephro-cystolithiasis, and pyelonephritis if left in .for prolonged periods The alternatives to urethral catheterization include suprapubic catheterization and external condom catheters for longer .durations

Removal of a catheter
Traditionally an indwelling catheter is removed early in the morning so that if micturition does not follow this will be apparent during daytime hours and the catheter can be .replaced When the time comes to remove the catheter, attach a syringe to the orifice to the balloon and draw back on the plunger to suck out the water or saline in the balloon and then gently pull the .catheter out

If the balloon will not empty, try being more gentle with traction on the plunger of the syringe as excessive pressure may have collapsed the tube so that water .will not flow Try instilling another 1 or 2 ml of .water to unblock any adhesions Try wiggling and rotating the catheter whilst pulling the .plunger Cut the catheter a little way outside the urethra.Be careful that the catheter does no retract and disappear into the bladder. It may be necessary to insert a safety pin through it to prevent this and leave the catheter for an hour or two whilst the balloon .slowly empties

If the balloon remains rigid, it may be possible to locate and puncture is by digital examination and use of a prostatic biopsy needle. This is done through the rectum in men and the .vagina in women It may be possible to overinflate the balloon and burst it. If this is done is should be followed by cystoscopy as to ascertain that no pieces are left in .the bladder Ether should not be used. It is said that injecting a small amount of ether into the balloon will destroy the latex but it is probably rather faster than that and causes an explosion. The boiling point of diethyl ether is 34.6º. Therefore, when it is brought up to body temperature it boils with an enormous expansion and increase in pressure. .Ether is very irritant to the bladder

NG TUBE

DIAGNOSTC .1 to drain gastric contents assessment of GI bleeding obtain a specimen of the gastric contents decompress the stomach Administration of radiographic contrast to the GI tract

THERAPUTIC .2 Administration of medication drainage and/or lavage in drug .overdosage or poisoning In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration .MANAGEMENT of GI bleeding NG tubes can also be used for .enteral feeding initially Comatose patients have the potential of vomiting during a NG insertion procedure, thus require protection of the airway prior to placing a NG tube GASTRIC Irrigation before operation

CONTRAINDICATONS
Absolute contraindications
Severe midface trauma Recent nasal surgery

Relative contraindications
Coagulation abnormality Esophageal varices or stricture Recent banding or cautery of esophageal varices Alkaline ingestion

Universal precautions
Gloves must be worn while ;starting an NG if the risk of vomiting is high, the operator should consider face and eye protection as well .as a gown Trauma protocol calls for all team members to wear gloves, face and eye protection and .gowns

PROCEDURE

FLEX THE NECK OF THE PATIWENT

Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the .intervention

Before removal kink the tube

During insertion
if concern exists that the tube is in the incorrect place, ask the patient to speak. If the patient is able to speak, then the nasogastric tube has not passed through .the vocal cords and/or lungs The nasogastric tube may coil in the nasopharynx or oropharynx. If this occurs, or if the tube is difficult to pass in general, try curling the distal end and partially freezing it in a cup of ice so it .temporarily holds its curled shape better Another option (only in patients who are paralyzed) is to place 2-3 fingers through .the patient’s mouth into the oropharynx The fingers are used to guide the .nasogastric tube into the hypopharynx Lifting the thyroid cartilage anterior and upward might open the esophagus and allow passage into the proximal esophagus

VENOUS CUT DOWN

Introduction
Venous cut down is an emergency procedure that is .potentially life saving It is taught in the ATLS (Advanced Trauma Life Support) course, and might often need to be performed by the inexperienced in severely ill trauma patients. It is one of the few modern surgical procedures in which speed is a crucial factor due to the .presence of hypovolemic shock An important drawback is the difficulty in cannulation of the vein. We describe simple modifications in the conventional technique that make the procedure safer and .faster

CONTRAINDICATIONS
Coagulopathy or bleeding diathesis Vein thrombosis Overlying cellulitis

The great saphenous vein at the ankle is commonly used for the procedure; although other sites are also available. After isolation of the vein in the usual manner1, a loop of thread is passed under the vein as shown below The apex of the loop is then .divided

Then Suture the skin Secure the catheter Dress the wound

The complications of venous cut down
are Cellulitis haematoma phlebitis perforation of the posterior wall of the vein venous thrombosis and nerve and arterial

PERITONIAL LAVAGE

INDICATIONS
Blunt trauma to the abdomen is a major component of traumatic injury and can be .deadly Blunt trauma can occur during falls, motor vehicle accidents, or severe blows to the abdomen

Often it is difficult to determine if an intra-abdominal injury has occurred in a .blunt trauma victim In many cases, the decision about when to perform an exploratory .laparotomy surgery is not straightforward The procedure used to determine whether blunt trauma victims require surgery is diagnostic peritoneal lavage .((DPL Using local anesthesia, the surgeon makes a small incision in the abdomen .just below the umbilicus

A catheter is introduced through the incision into the abdomen. Saline is infused into the abdomen through the catheter, and then removed. If blood is present in the saline after removal, it is highly probable that there is a serious intra.abdominal injury

Peripheral intravenous central catheters

Although the lines are placed peripherally, usually in the antecubital or superficial saphenous vein, the distal tip .remains in a large central vein PICC lines areindicated in children who require intermediate-term IV access for prolonged home or hospital therapy, such as those with human immunodeficiency virus (HIV) infection, cystic fibrosis, .osteomylitis, meningitis, or cancer The success of introducing the PICC line is greater if attempts at inserting noncentral peripheral lines are limited. Therefore, PICC placement should be attempted as soon as the need for intermediate.term access is apparent

central lines

Measurement of CVP.1 Central venous access devices .2 (CVADs) are used to deliver larger volumes of irritating solutions, such as antibiotics, blood products, parenteral nutrition media, and sclerosing chemotherapeutic .agents If patients need prolonged IV.3 access, a CVAD is preferred to a .peripheral IV line Central access is also indicated.4 when peripheral access cannot be ;achieved however, in an emergency situation, an intraosseous needle is probably the primary choice according to Pediatric Advanced Life Support .(PALS) guidelines

Umbilical artery catheters and umbilical vein catheters

.Useful in the first few days of life The umbilical vein can be used for access during the first 5-7 days but is rarely used beyond .7 days Both and UACs and UVCs can be used: UAC is used for blood pressure monitoring, and UVC is used for central venous .pressure monitoring

IV THERAPY

Establish or maintain a fluid or electrolyte balance Administer continuous or intermittent medication Administer bolus medication Administer fluid to keep vein open Administer blood or blood components Administer intravenous anesthetics Maintain or correct a patient's nutritional state Administer diagnostic reagents Monitor hemodynamic functions

Prepare the IV fluid Administration set
Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking, and the bag is not expired Select either a Mini/ Micro or Macro drip administration .set and uncoil the tubing .Do Not let the ends of the tubing become contaminated Close the flow regulator (roll the wheel away from the .(end you will attach to the fluid bag Remove the protective covering from the port of the fluid bag and the protective covering from the spike of .the administration set Insert the spike of the administration set into the port of the fluid bag with a quick twist. Do this carefully. Be especially CAREFUL NOT puncture yourself

Perform the Venipuncture
Be sure you have Introduced Yourself to your .Patient and Explained the Procedure Apply a Tourniquet high on the upper arm. It should be tight enough to visibly indent the skin, but not cause the patient discomfort. Have the patient make a FIST several times .in order to maximize venous engorgement Lower the arm to increase vein engorgement. If you cannot easily see a suitable vein, you can sometimes feel them by palpating the arm using your fingers (not your thumb) The vein will feel like an elastic tube that "gives" .under pressure Select the APPROPRIATE vein Wear disposable GLOVES Clean the entry site carefully with the alcohol prep pad

.Allow it to dry Use a circular motion starting with the entry site and extending .outward about 2 inches Using alcohol after betadine will) (negate the effect of the betadine

TRACHEOSTOMY

Definition
Tracheostomy is an operative procedure that creates a surgical airway in the cervical trachea

The trachea is a conduit between the upper airway and .the lungs It delivers moist warm air, and it expels carbon dioxide and .sputum Failure or blockage at any point along that conduit can be corrected most readily by providing access for mechanical ventilators and .suction equipment In the case of upper airway obstruction, tracheostomy provides a path of low .resistance for air exchange

INDICATIONS
To bypass obstruction Neck trauma Subcutaneous emphysema
.

Palpable fractures (eg, mid-face, hyoid, (thyroid, cricoid, mandible, midface Tumor Bilateral vocal cord paralysis Edema
Trauma Burns Infection Anaphylaxis

Indicated to provide a long-term route for mechanical ventilation in cases of respiratory failure (not (enough oxygen in To provide pulmonary toilet Inadequate cough due to chronic pain or weakness Aspiration and the inability to handle secretions. The cuffed tube allows the trachea to be sealed off from the esophagus and its .refluxing contents Prophylaxis (as preparation for extensive head and neck procedures and the convalescent (period

procedure
the patient is continuously monitored by pulse oximeter (oxygen saturation) and .() cardiac rhythmEKG The anesthesiologists usually use a mixture of an intravenous medication and a local anesthetic in order to make the procedure .comfortable for the patient The surgeon makes an incision low in the neck. The trachea is identified in the middle and an opening is created to allow for the new breathing passage (tracheostomy tube) to be inserted below .(the voice box (larynx Newer techniques utilizing special instruments have made it possible to perform this procedure via a percutaneous approach (a less invasive approach using a piercing method rather .(than an open surgical incision

aspiration of and Airway obstruction .(secretions (rare .Bleeding . Damage to thelarynx Infection Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required Scarring of the airway or erosion of the tube .(into the surrounding structures (rare Impaired swallowing and vocal function Scarring of the neck

Cricothyroidotomy

Indications
Intubation is not possible via the oral or nasal route Need to avoid neck manipulation (e.g. basal skull/cervical spine injury or (fracture Severe maxillofacial trauma Oedema of throat tissues preventing .visualisation of the cords (e.g ,anaphylaxis ,angioneurotic oedema (smoke inhalation ,burns Severe oropharyngeal/tracheobronchial haemorrhage Foreign body in upper airway Lack of equipment for endotracheal intubation Technical failure of intubation Severe trismus/clenched teeth Masseter spasm after succinylcholine

This procedure provides a temporary emergency airway in situations where there is obstruction at or above the level of the larynx, such that oral/nasal endotrachealintubation . is impossible Compared to an emergencytracheostomy, it is quicker and easier to perform and .associated with fewer complications It is a relatively quick procedure, taking up .to about 2 minutes to complete In an emergency without access to medical equipment, cricothyroidotomy has even been improvised using a drinking straw and pen-knife. :There are three techniques Needle (Intubation (with purpose-built kits Surgical

Contraindications
vailability of a less invasive means of securing the airway Patients <5 years old (needle technique may be used but formal tracheostomy (is preferred Laryngeal fracture Pre-existing or acute laryngeal pathology Tracheal transection with retraction of trachea into mediastinum Anatomical landmarks obscured by gross haemorrhage/surgical .emphysema etc