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-cysto-
lithiasis, 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