10. • Approach:
– Peripheral – Cephalic / basilic /brachial
vein
– IJV – Between 2 heads of SCM muscle
– Subclavian - 1 – 2cm below the
junction of middle and medial third of
the clavicle
• Equipments:
– Central venous catheter (long line) set
– Manometer set
– Accessory : Dressing set, syringe, hep
saline
11. Peripheral approach
position: supine
Place tourniquet & choose a vein
Clean and drape
Infiltrate LA around entry point
Puncture at entry point using introducer needle
into the vein while gently withdrawing the plunger
of the syringe
12. When theres venous blood backflow, remove the
needle
Insert the catheter+guide wire through the needle
into the vein
Split the protective catheter sheath.
Remove the guidewire.
Measure length using the guidewire and pull the
catheter back using the measurement
Flush with hep saline & apply flavine dressing
CXR
14. 2. Nasogastric tube insertion
Indications:
• GI decompression
• Gastric lavage
• Enteral feeding
• Prevention of aspiration
Contraindications:
• Recent esophageal/gastric surgery
• Base of skull fracture
• Severe facial trauma
15. Equipment:
NG tube 8,10
Accessory : Gel, syringe, gauze, stethoscope, glass of
water
Length:
Measure: tip of nose to earlobe to midpoint between
xiphisternum and umbilicus
16. procedure
• Position : sit up straight
• Lubricate the NGT with gel
• Insert through the nasal opening until the tip
hits pts throat - swallow sips of water
• Advanced the NGT gently while asking the
patient to keep swallowing until desired length
• Secure with tape
17. Confirm position:
• Inject air while auscultate the stomach and
compare with lung
• Aspirate gastric content
• CXR
22. For female patients
Expose labia minora
Clean with povidone and drape
Put sterile lignocaine onto catheter
Use forceps to hold the catheter
and gently advance the catheter
into urethral orifice until bifurcation
Note the urine backflow and
inflate the balloon with 10ml
sterile water, attach catheter to
the bag
23. For male patients
•Expose genital area
•Clean with povidone and drape
•Hold penis upward
•Put sterile lignocaine into urethra
•Use forceps to hold the catheter and
gently advance the catheter vertically
downward
•Lower the penis horizontally, advance the catheter
until bifurcation
•Note the urine backflow and inflate the balloon with
10ml sterile water, attach catheter to the bag
25. 4. Endotracheal intubation
Indications
Airway management during
resuscitation
General anaesthesia
Respiratory failure
Airway obstruction
Multiple trauma, head injury and
abnormal mental status
Inhalation injury with erythema/edema of
the vocal cords
27. Equipment
Endotracheal tube (7-9), laryngoscope handle
and blade, 10cc syringe, suction, ambubag
Medication
Midazolam-morphine 2.5, 5 ,10 mg IV
Esmeron - 0.6-1.2 mg/kg IV
Scoline – 0.3-1.1 mg/kg IV
28. procedure
Ventilate pt before attempting
procedure(100% O2)
Check the light and et tube cuff
Position pts head tilt and jaw lift
After adequate ventilation, insert
laryngoscope with left hand
use the blade to push the tounge to pts left
Advance the blade until epiglottis visualized,
29. place the blade anterior to epiglottis and
lift anteriorly to visualize vocal cords
(Gentle pressure to cricoid cartilage
helps visualizitaion)
30. Insert the et tube with right hand while
maintain visualization of the chords
Suction to clear the airway
Inflate the cuff with 10cc syringe
Check chest movement and auscultate both
lungs to compare
Secure with tape
32. 5.Toilet and suturing
Indications
All wounds need some kind of toilet.
Contraindications to a radical toilet
are signs of established infection, such as a
foul discharge, lymphangitis, lymphadenitis, or
fever.
33. Equipment
T&S set, blade or scalpel, suture, plenty of sterile
water, syringe 10cc,50 cc, lignocaine 2% injection
34. procedure
Assess the wound: depth, foreign body, sign
of infection, active bleeding, necrotic tissue,
underlying structural injury (bone fracture,
tendon injury, organ perforation)
Hemostasis
Skin preparation and wound toilet
Clean surrounding skin with povidone
Give adequate local anaesthesia
Irrigation with copious amount of saline
Remove foreign body and necrotic tissue
Debride ragged, nonviable skin edges.
35. Closure
Timing
Primary closure: immediate closure for
simple wounds <12 hours old (24 hours on
face), with opposable edges.
Delayed primary closure: if there is high risk
of infection, give prophylactic antibiotics and
close after approximately 4 days if no
infection.
36. Sutures
type: absorbable for deep sutures or
sometimes in children. Nonabsorbable more
common
Face- 5/0, Limb - 4/0, Scalp - 3/0
Interrupted for most, interlocking suture
at scalp
42. 1
• Position : 45 degree with UL
abducted
• Clean and drape
• Administer LA
2
• Make 2-3cm incision at the safety
triangle
• Blunt dissection intercostals muscles
until pleura
• Sweep finger inside chest to avoid
adhesion
3
• Deepen the incision aiming above
the rib by using the artery forcep
(skin, subcutaneous fat, ICS &
parietal pleura)
43. 4
• Insert chest tube without the trocar
using forcep with the distal end clamp
• Advance the tube until 8-10cm
5
• Attach the tube to the underwater
sealed.
• Release the clamp to see fluctuation
fluid and bubbling
6
• Suture and anchor
• CXR
45. 7. Paracentesis
Indications:
• Diagnostic
• Therapeutic – relief of respiratory
compromise, abdominal pain or
discomfort
Contraindications:
• Coagulopathy
• Pregnancy
• Infected skin at entry site
46. Equipment
Branula, 3 way connector, drain bag
Accessory : Dressing set, syringe, LA,
gauze
Insertion point
Percuss for shifting dullness, 2-3 fingers
breath below at the level of umbilicus at right
or left iliac fossa
47.
48. 1
• Position : Lying supine
• Area clean and drape
• Infiltrate LA
2
• Introduce branula into abdominal
cavity while aspirating with Z tracking
method until the straw colour fluid
seen
• Draw fluid for diagnostic purposes or
connect branula to drainage bag
about 2litres
3
• If >2L are drained out, may need to
replace fluid to prevent hypovolaemic
shock
• Withdraw and apply dressing post
tap
57. 9. Hemorrhoid banding
• A procedure in which elastic bands are applied onto
an internal hemorrhoid above the dentate line to cut
off its blood supply
• Hemorrhoidal banding is successful in two thirds to
three quarters of all individuals with first and second
degree hemorrhoids.
• Equipment
– Rubber Band, Ligator, Proctoscope, Suction
58. Press trigger, release and apply
rubber band onto hemorrhoid base
Firm suction applied on hemorrhoid
Visualise internal hemorrhoid above
the dentate line
Proctoscope inserted
Position as we do per rectal
examination -LLP
59. Take home messages
Invasive bedside procedure is contraindicated in
coagulopathy
Insertion of CVL must be accompanied with SpO2
and cardiac monitoring
Secure NG tube but don’t apply pressure to ala of
nose
No touch technique in urethral catheterization –
use forceps
60. TAKE HOME MESSAGES
Give adequate ventilation before attempting
intubation to minimize hypoxia
Adequate toilet of wound will minimize risk of
infection and foreign body reaction
Open method and without trochar before entering
the chest tube at safety triangle is preferred
SPC should be inserted with a palpable bladder
pointing towards pelvis
Dentate line should be identified during hemorrhoidal
banding and apply ligator above dentate line
61. REFERENCES
• Oxford Handbook of Clinical Surgery 4th Ed 2012
• British Thoracic Society Guidelines
• Journals.lww.com/anaesthesiology
• Medscape
• Surgery On Call 4th Ed
MOA: altering membrane sodium permeability resulting in a block to the transmission of impulses along the nerve fibre
Agents : Lidocaine & Bupivacaine less common be used Prilocaine
Max doses: 4mg/kg
Neurological: drowsiness, slurred speech, numbness of the tongue or mouth, convulsions & coma
CVS: early tachycardia, , hypertension, late bradycardia, hypotension, cardiac arrythmias, and cardiac arrest
Common ones From head to toe
Consent, preparation
Aseptic
Wash hand, wear gown and sterile glvoes
Assemble the instrument and flush
CVP – require strict input/output charting
aggressive hydration to prevent fluid overload or AKI
E.g: Acute pancreatitis, ascending cholangitis, major GI surgery or patients with underlying heart failure or renal failure
Size: 45/70cm
Bleeding : rupture the vessels / artery puncture
Air embolus :
Pneumothorax – sudden gush of air aspirated – confirm clinically and CXR
Malpositioning – too deep or high
Dysarrthmias -
GI decompression: obstruction, ileus, postoperative, pancreatitis
Gastric lavage : UGIB or to drain alleged ingestion of poison
Enteral feeding : unable to swallow
Prevention of aspiration : stroke or neuro d/o affecting swallowing
C/I : may go intracranially
May cause perforate or puncture the op site
Pneumothorax
Massive pleural effusion
Empyema
Post operative procedures : thoracotomy, cardiac surgery, esophageal surgery
Pleurodesis : chronic, reccurent pneumothorax or effusion
Child : 16-20F
Average size adult :24-32F
Large size adult : 36-40F
Branula 14-16g
Grade I - bleeding without prolapse.
Grade II - prolapse with spontaneous reduction.
Grade III - prolapse with manual reduction.
Grade IV - incarcerated, irreducible prolapse.
.
