cme - common surgical procedure

8/10/2019 Cme - Common surgical Procedure

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Yap Wai Liam

Mentor : Dr Syauqi


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Central Venous Line Insertion

Chest Tube Insertion

Suprapubic Catheter insertionParacentesis


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Indications

Equipments

Procedure

Complications


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- Monitoring of Central venous pressure (CVP) incritically ill patient to quantify fluid balance(Normal Value 5-10 cmH2o, 3-8 mmHg)- for long term IV antibiotics- for long term Parenteral nutrition- Chemotherapy- Plasmapheresis- Need IV access when peripheral venous access isimpossible

- Renal Dialysis


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Central line dressing pack

Sterile gloves/gown

Iodine or chlorhexidine for cleaning

1% or 2% lidocaine Central line (preferably at least a triple-lumen line)

Saline or heparin saline to flush line

Suture (silk- non absorble)

Scalpel blade

21-gauge (green) and 27-gauge (orange) needles

210-ml syringes


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Choose the site of insertion:

-> Long line : Peripherally inserted central

cathether-> Short line: Internal Jugular Vein / SubclavianVein


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A tourniquet is applied to the arm and the area is cleaned and

draped;

Local anaesthetic is injected into the skin near the vein;

A cannula is then inserted into the vein, the needle is removed, and

the tourniquet is released; A wire is inserted through the cannula and further into the vein;

The central line is then passed over the wire into the vein and the

wire is removed

Clean the skin around the line once more, dry, and cover with

occlusive dressings.

Ensure that you can aspirate blood from each lumen of the line, then

flush each lumen with saline or heparin saline.


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Using the finder needle and small syringe withheparinized saline in it, enter the skin at 30 45degree angle, aiming towards the sternal notch, alwayspull back gently on the plunger to create a negativepressure.

When you see a flash and easy withdrawal of darkblood, this indicates entrance into the vein. Steady theneedle and remove the syringe, insert J-tipped guidewire into the needle; if resistance is felt do not force it


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Watch the monitor (if there is cardiac monitor inplaced). Ventricular ectopic indicated placement inRV, guide wire should pull back. Hold the guide wire,remove the needle from the skin. Advance the dilatorover the guide wire with twisting motion. Make a smallnick with blade provided to accommodate dilator.

Remove the dilator and place catheter over the guidewire. Removed the guide wire and flush the line.Suture catheter in place via flange with holes.

Order the CXR stat to evaluate the line placement andcomplication.


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- Landmark approach most widely used is between themedical and lateral heads of the SCM muscle and lateralto carotid artery. Needle point towards ipsilateral nippleat 30 45 degree.

- IJV is a readily compressible vessel. Position the patientin Trendelenburg will increase the size of IJV. Mildrotation of the neck away from the side of IJ insertionwill aid

- Over rotation and over extension can cause the SCMto compress the IJ vein.


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- Palpate the carotid artery, covering the artery

with your fingers. Insert the needle 0.51 cm

laterally to the artery, aiming at a 45angle to

the vertical. In men, aim for the right nipple; inwomen, aim for the iliac crest. Advance slowly,

aspirating all the time, until enter the vein.

- When the needle is in the vein, ensure that you

can reliably aspirate blood. Remove the syringe,keeping the needle very still.


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Insert the wire into the end of the needle, and advance

the wire until at least 30 cm are inserted. The wire should

advance very easily do not force it.

Keeping one hand on the wire at all times, remove the

needle, keeping the wire in place. Make a insertion overthe skin where the wire enters the skin. Insert the dilator

over the wire and push into the skin as far as it will go.

Remove the dilator.


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Insert the central line over the wire. Leave a few

centimeters of the line outside the skin. Withdraw

the wire and immediately clip off the remaining

port.Attach the line to the skin with sutures.

Clean the skin around the line once more, dry,

and cover with occlusive dressings.

Ensure that you can aspirate blood from each

lumen of the line, then flush each lumen with

saline or heparin saline.


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Local site or systemic infection

Arterial puncture

Hematoma

Hemothorax / Pneumothorax Catheter related thrombosis

Air embolism

Catheter tip too deep

Catheter in the wrong vessel


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Indication

Equipments

Procedure

Complications


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- Pneumothorax

- Haemothorax

- Massive pleural effusion

- Empyema- Traumatic Haemapneumothorax

- Post operative procedure


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Sterile gloves and gown

Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol

Sterile drapes

Gauze swabs

A selection of syringes and needles (2125 gauge) Local anaesthetic, e.g. lignocaine (lidocaine) 1% or 2%

Scalpel and blade

Suture

Instrument for blunt dissection (e.g. curved clamp) Chest tube

Connecting tubing

Closed drainage system (including sterile water if underwater seal

being used)


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How to position the patient?

Prop up patient to 45

the arm of the affected side behind the patients head to

expose the axillary area.

Insertion should be in the safety triangle.

anteriorly: lateral border of pectoralis major muscle,

inferior: horizontal level of the nipple/ 4thor 5thICS

posteriorly: mid axillary line


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Chest tube of appropriate size

- Man : 28 32F

- Woman : 28F

- Child : 1228 F

- Infant : 12 16F

- Neonate : 10 12 F


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The arm on the affected side should be abducted andexternally rotated, and place behind the patients head.

Identify the 4thor 5thintercostal space just anterior tomidaxillary line.

Cleaned and draped the area. Administer analgesia over the skin, subcutaneous tissue,

intercostal muscle and pleura. Approximately 4 cm long incision made parallel to the

upper border of the rib below the chosen intercostal space.using blade no. 11 or 10

Use a Kelly clamp to bluntly dissect a tract in thesubcutaneous tissue, intercostal muscle and parietal pleuraand enter into pleural space by intermittently advancingthe closed instrument and opening it.


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Palpate the tract with a finger, make sure the tract ends at theupper border of the rib above the skin incision, to minimized therisks of injury to the nerve and blood vessels of the lower borderof each rib.

Upon entry into the pleural space, a rush of air or fluid shouldoccur. Use a sterile, gloved finger to appreciate the size of thetract and feel for the lung tissue and possible adhesion.

Grasp the proximal end of the chest tube with Kelly clamp andintroduce it through the tract. The distal end of the chest tubeshould always be clamped until it is connected to the drainagedevice.

Release the Kelly clamp and continue to advance the chest tubeposteriorly and superiorly up to 8 10cm. Make sure all thefenestrated holes in the chest tube are inside the thoracic cavity.


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Connect the distal end of the chest tube to the drainagesystem and release the clamp. Look for a respiration-related swing in the fluid level of the water seal device toconfirm intrathoracic placement.

Secure the chest tube to the skin with silk 1-0 using

mattress method or just across the incision site. Fix thedrain with second suture and wrapped tightly around thetube several time to cause slight indentation to preventdislodging the chest tube.

Place petrolatum (Vaseline) gauze over the skin if available.

Dressing over the site and provide enough of paddingbetween the chest tube and chest wall. CXR post insertion of chest tube.


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Improper placement

Bleeding

Hemoperitoneum

Organ penetration Empyema

Injury to the neurovascular bundle in the ICS

Injury to the lung parenchyma


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Indication

Equipments

Procedure

Complications


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SPC is indicated (when transurethral catheterization is contraindicatedor technically not possible) to relieve urinary retention due to followingconditions:

- Urethral injuries

- Urethral obstruction / stricture

- Bladder neck masses

- Benign prostate hyperplasia (BPH)

- Failed urethral catheter

Contraindication:- Lower abdominal incision with likelihood of adhesion

- Pelvic fractures

- Need to rule out bladder cancer in case of clot retention


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Sterile set

Anesthetic solution

Syringe, (10 mL, 60mL)

Needles

Scalpel blade

Percutaneous suprapubic catheter set (Pediatric: 8F,

10F; Adult: 12F, 14F, 16F)Needle obturator

Malecot catheter Connecting tube

Sterile urine bag

Skin tape or nylon suture (3-0)


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Provide adequate parenteral analgesia with or withoutsedation.

Clean and shave if patient is hirsute.

Palpate the distended bladder and mark the insertion site

at the midline and 2 fingers above pubic symphysis.

Apply an antiseptic solution from pubis to umbilicus andapply drapes.

Filled 10 cc syringe with LA and use 25G needle to raise a

skin wheal at the insertion site.

Using the Blade no 11 make 4mm stab incision at theinsertion site with blade facing inferiorly


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Advance the needle while alternating injection andaspiration, until urine enter the syringe. Remove thesyringe and insert the guidewire.

Remove the needle and insert the introducer. Onceintroducer is entered, remove the guidewire and the

trochar. Insert the catheter till the urine flow out and split the

introducer. Inflate the balloon with 5 cc of sterile water for injection. Connect the catheter to the urine bag. And gently withdraw

the catheter to lodge the balloon against the bladder wall. Undrape the patient and clean the skin. Apply dressing

over it.


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Complication :- Gross hematuria is typically a transient condition.

- Postobstruction diuresis monitor i/o and electrolytes

- Bowel perforation and intra abdominal visceralinjuries


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Indication Equipment

Procedure

Complications


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Diagnostic tap is used for the following:

New-onset ascites: Fluid evaluation helps to determine

etiology, differentiate transudate versus exudate, detect

the presence of cancerous cells, or address other

considerations Suspected spontaneous or secondary bacterial peritonitis

Therapeutic tap is used for the following:

Respiratory compromise secondary to ascites

Abdominal pain or pressure secondary to ascites

(including abdominal compartment syndrome)


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Paracentesis kit:

Lidocaine 1%, 5-mL ampule

Syringe, 10 mL and 60mL

Needles,

Blade

Catheter, 8F, over 18 ga7 1/2" needle with 3-way

stopcock, self-sealing valve, and a 5-mL Luer-Lock

syringe

Introducer needle, 20 ga

Tubing set with

Drainage bag or vacuum container

Specimen vials or collection bottles


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Landmark:

2 cm below the umbilicus in the midline (through the

linea alba)

5 cm superior and medial to the anterior superioriliac spines on either side


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Position, clean and drape

Apply local analgesia

Insert the needle directly perpendicular to the selected

skin entry point.

Continuously apply negative pressure to the syringe as

the needle is advanced. Upon entry to the peritoneal

cavity, loss of resistance is felt and ascitic fluid can be

seen filling the syringe


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Advanced the catheter and remove the needle

Connect the catheter to the drainage bag


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Persistent leak from the puncture site

Abdominal wall hematoma

Perforation of bowel

Introduction of infection

Hypotension after a large-volume paracentesis

Dilutional hyponatremia

Hepatorenal syndrome

Major blood vessel laceration Catheter fragment left in the abdominal wall or cavity


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cme - common surgical procedure

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