BASIC WARD PROCEDURES

Noopur S. Sawarkar

TOPICS TO BE COVERED
1.

ROUTES OF INJECTIONS IV CANNULATIONS DRAINS OXYGEN THERAPY DRESSINGS CATHETERIZATION AIRWAY BLOOD TRANSFUSION BANDAGES

2.

3.

4.

5.

6.

7.

8.

9.

ROUTES OF INJECTIONS

Routes of injections Intramuscular Subcutaneous Intradermal Intravenous injections

INTRAMUSCULAR INJECTIONS

Deltoid (Arm)
1. To find this site you will form an imaginary box on the upper arm. 2. Find the knobby top of the arm (Acromion process). 3. The top border of the box is two finger widths down from the Acromion process. 4. The bottom border is an imaginary line

running from the crease of the armpit,

from front to back.

Medicines

Dexamethasone sodium phosphate(8mg) Tetanus toxoid 0.5 ml Diclofenac sodium 75mg

Tramadol hydrochloride
Paracetamol 150 mg Streptomycin Chlorpheniramine maleate 10 mg Hydrocortisone sodium succinate 100 mg Deriphyline (theophylline + etiophylline)

LEG (VASTUS LATERALIS) SITE FOR IM INJECTION

1.

To find the thigh injection site, you will be making an imaginary box on your upper leg. Find the groin. One hand's width below the groin becomes the upper border of the box.

2. Find the top of knee. One hand's width above the top of the knee becomes the lower border of the box.

3. The center of the top to your leg comes the left border of box.
4. center of the side of your leg becomes the right border of box. 5. The best areas to use for injection is in the middle of this imaginary box. The sites are marked with X's. 6. Stretch the skin to make it tight. 7. Insert needle at a right angle to the skin (90 degree) straight in. 8. You may give up to 2 ml. (cc) of fluid into the site

BUTTOCK (GLUTEUS MEDIUS) SITE FOR IM INJECTION

1. Find the trochanter . It is the knobby top portion of the long bone in your upper leg (femur). It is the size

of a golf ball.
2. Find the posterior iliac crest. Many people have "dimples "over this bone. The nurse will help you find the bone landmarks.

3. Draw an imaginary line between the two bones.

4. After locating the center of the imaginary line, find a point one inch toward your head. This is where (X) you will put the needle in.

5. Stretch the skin tight.

6. Hold the syringe like a pencil or dart. Insert the needle at right angle to your skin (90 degree). 7. Give up to 3 ml. (cc) of fluid in this site.

SUBCUTANEOUS INJECTIONS

Locating injection sites

Subcutaneous injections can be given in the arms, legs, or abdomen

SUBCUTANEOUS INJECTIONS

These injections are given because there is little blood flow to fatty tissue, and the injected medication is generally absorbed more slowly, sometimes over 24 hours.

Some medications that can be injected subcutaneously are growth hormone, insulin, epinephrine, and other substances. MEDICINES - Insulin - Heparin - Inj. Adrenaline(0.2-0.5 ml) in Acute Bronchial Asthma

INJECTION ON THE SIDE OF THE FOREARM

INJECTION ON THE SIDE OF THE FOREARM

INJECTION IN FRONT OF THE THIGH

INJECTION ON THE ABDOMEN

INTRADERMAL INJECTIONS
0.1 ML solution is injected and the injection is very painful Avoid visible vein.

Stretch the skin , keep the needle parallel to it keeping the bevel of the needle up . Push the needle and inject .
Repeated intradermal injections lead to desensitization Site forearm(anteriorly) Deltoid Below scapula

INTRAVENOUS CANNULATION

CANNULA

ACCESS:INTRAVENOUS CANNULATION

Peripheral venous cannulation One of the most common invasive procedures carried in the hospital

INDICATIONS

Intravenous fluids Intravenous drugs Blood or blood products Intravenous radiopaque contrast or sedation

Prophylactic use in unstable patients or those undergoing

procedures

CONTRAINDICATIONS
Absolute

Inflammation or infection of the underlying skin at proposed cannula site

Arteriovenous fistula in arm

Lymphoedema on side of proposed upper limb cannulation

Relative

Bleeding tendency Veins of the forearm(elbow or wrist) in those with renal failure who may require AV fistula formation in the future

ANATOMY OF VEINS
Veins consist of three layers:

Tunica adventitia

Tunica media
Tunica intima

CANNULA SIZES AND USES

Colour Blue Size 22G Flow rate 36ml/min 2.2l/hr 61ml/min 3.7l/hr 90ml/min 5.4l/hr 140ml/min 6.2l/hr Use Elderly patients with small fragile veins Iv maintenance fluids,drugs Blood products Rapid infusion of fluids or drugs

Pink Green

20G 18G 17G

Grey
Brown/orange

16G
14G

200ml/min 12l/hr
300ml/min 18l/hr

Rapid infusion of blood products

Unstable patients, emergency situations

SITE OF CANNULATION

Factors on which site of cannulation depends

Patient comfort Size of cannula required Size , mobility and fragility of the patients veins

Distal cephalic vein known as housemans vein Veins in the antecubital fossa
Large Easy to cannulate DisadvantagesObstruction of flow through the cannula tends to occur if the elbow is flexed

Back of the hand or lower arm is selected

AdvantagesUnlikely to kink Easily inspected and accessed

PROCEDURE

Position the patient with arm resting on a pillow Apply a tourniquet to the upper arm (palpate the radial pulse) Clench and unclench the fist

Palpate and feel for full and bouncy pulse

The site of vein bifurcation is ideal Clean the area with an 2%chlorhexidine gluconate in 70% Isopropyl alcohol Hold the skin taut Hold the cannula at 10 degree to 30 degree angle to the skin and in the direction of vein ,gently advance the cannula through the skin and into the vein Once flashback is seen , lower the cannula Watch for second flashback after withdrawal of needle Slowly advance the cannula by holding the wings only Remove the tourniquet Occlude the vein proximal to the tip of the cannula Secure the cannula safely Flush the cannula via the injection port with .5 ml 0.9%saline

Document the procedure

POTENTIAL COMPLICATIONS
Early complications

Possibly hit the valve Catastrophic changes when artery is cannulated accidentally Arterial cannulation more likely in overweigh patients Needle stick injuries Phlebitis of veins Systemic sepsis Cannula site infection Thromboembolism Extravasation is a common problem

Late complications

All cannulas should be removed after 72 hours , regardless or whether or not beyond this.

Cannula no longer in use should be removed as soon as possible to prevent complications

ACCESS :CENTRAL VENOUS

Three sites:

Internal jugular vein Subclavian vein Femoral vein

IV FLUIDS
Intravenous (IV) fluids
Delivered directly into the bloodstream via a vein Includes
Solutions Medications Blood

Rapid effect

FUNCTIONS
Replacement
Electrolytes Fluids

KVO fluids
Keep Vein Open Maintain an IV line

Maintenance
Fluid balance Electrolyte balance

Therapeutic
Delivers medication to patient

In abbreviations for IV solutions:

-Letters identify components -Numbers identify concentration Eg.NS(Letters) 0.9%(Numbers)

IV Solutions
IV CONCENTRATIONS
Choice of solution is based on patient requirements

Isotonic
-Do not affect fluid balance of cells and tissues
D5W, NS, LR

Hypotonic
-Move fluid into surrounding cells and tissues -Restore proper fluid level in cells and tissues -Used to correct dehydration 0.45% NS, 0.3% NS

HYPERTONIC
-Draw fluid from cells and tissues into blood stream -Used to correct severe fluid shifts (burns) 3% Saline

Patients with normal electrolyte levels are likely to receive isotonic solutions. Patients with high electrolyte levels will receive hypotonic solutions. Patients with low electrolyte levels will receive hypertonic solutions

Before combining any medications, electrolytes, or nutrients with an IV solution, be sure the components are compatible.

COMPATIBILTY SOLUTIONS
INCOMPATIBLE MEDICATIONS AND SOLUTIONS

Ampicillin Cefotaxime sodium Diazepam Dopamine HCl Penicillin Penicillin

D5W Sodium bicarbonate Potassium chloride Sodium bicarbonate Heparin Vitamin B complex

Sodium bicarbonate
Tetracycline

Lactated Ringers
Calcium chloride

Roller clamp

Injection ports
Drip chamber

EQUIPMENT
TUBING

Macrodrip
Larger drops in drip chamber Infusion rates of 80 mL/h or more

Microdrip Smaller drops in drip chamber Infusion rates less than 80 mL/h and KVO Pediatric and critical care IVs

Macrodrip
Larger drops Drop factors: 10 gtt/mL, 15 gtt/mL, or 20 gtt/mL

Microdrip tubing
Smaller drops Drop factor: 60 gtt/mL

Drains

Prophylactic drain-to prevent accumulation of fluid or blood Therapeutic drain-to promote escape of fluids already accumulated

COTTON GAUZE Acts as a drain by capillary action in the fabric which absorbs fluid Once it becomes saturated it plugs rather than as a drain Hence should be changed twice daily or every 24 hours Uses To pack the cavity

RED RUBBER CORRUGATED DRAIN

Drainage takes place around the grooves of the drain so blockage is less likely
Used when there is minimal amount of discharge

Secured with sutures and is left in place for three to five days

PREOP VIEW
Patient with squamous cell carcinoma of left buccal mucosa ulcerating into the skin of cheek. Markings for resection and reconstruction have been made.

Early postoperative view. There is a No. 8 sized infant feeding tube to drain the dead space between the paddles and a suction drain for the neck. Note that the donor area is primarily closed. The patient has nasogastric tube feeding for 5 days after surgery.

{
Bipaddled submental artery flap Ramkumar , International Journal of Oral and Maxillofacial Surgery Volume 41, Issue 4, April 2012, Pages 458460

FOLEYS CATHETER AS A DRAIN

{
Foleys catheter inserted to the base of the tongue
The immediate lifesaving management of maxillofacial, life-threatening haemorrhages due to IED and/or shrapnel injuries: When hazard is in hesitation, not in the action Sabri T. Shuker , Consultant MaxillofacialSurgery (Formerly Head of Department of Oral and MaxillofacialSurgery), Baghdad Medical City, Baghdad, Iraq

Patient after partial mandibulectomy with alloplastic (titanium) implant extruding a year after surgery. Note granulation tissue and purulent drainage.

Jackson-Pratt drain

- In draining branchial cleft cyst

- Extension of dental abscesses to distant areas of the head and neck

{
The Acute Orbit: Etiology, Diagnosis, and TherapyJournal of Oral and Maxillofacial Surgery Volume 64, Issue 1 , Pages 87-93, January 2006

REMOVAL OF DRAIN

The prophylactically placed drain remove the drain as soon as drainage has subsided (48 hours) Therapeutic drain removed gradually to close the drainage tract prevent pocket formation Corrugated rubber drain should be removed after 3 days or after cessation of discharge

Pathway of a through-andthrough drain of the submandibular space.

Note that the drain passes deep to the medial surface of the mandible, below the attachment of the mylohyoid muscle.

Adapted from Flynn TR.31

AIRWAY

INTRODUCTION

A fundamental responsibility of anaesthesia providers is to maintain a patent airway. The airway passage has a rigid posterior wall and a collapsible anterior wall consisting of the tongue and epiglottis. Under anaesthesia the tongue & epiglottis falls back into the posterior pharynx occluding the airway. The purpose of airway is to lift the tongue & epiglottis away from the posterior pharyngeal wall & maintain a patent airway.

TERMINOLOGY :
Artificial airway - any device that aims to maintain oral or nasal air passages. It may be

Simple supraglottic device such as oropharyngeal or nasopharyngeal airways. These may not be sufficient to maintain the patency of airway on their own & may require pts jaw to be supported as well. Augmented supraglottic device such as LMA & airway management device Infraglottic devices such as Endotracheal tubes,tracheostomy tubes, jet ventilation catheters

AIRWAY MANOEUVRES
These manoeuvres are designed to displace the tongue anteriorly , bringing it forward out of the pharynx and clearing the airway.

INDICATIONS

An obstructed or blocked airway To assist in ventilation of an unconscious patient Prepare for or to assist in advanced airway maneuvers

CONTRAINDICATIONS
Patients who have actual cervical spine injury should not have a head tilt /chin lift as this may exacerbate their injuries : a jaw thrust should be applied as an alternative

PROCEDURE
Sniffing the morning air position

JAW THRUST
-Place the fingers of both the sides under the corresponding side of the mandible , at the angle of the jaw - Lift the mandible forwards , opening the airway (avoid moving the patients head)

AIRWAY ADJUNCTS
- Use of airway adjuncts can assist in obtaining or maintaining an unobstructed,open airway.

Oropharyngeal airway
- An oropharyngeal (OP) airway is designed to hold the tongue away from the posterior pharynx ; this allows the passage of both through the device itself and around it

INDICATIONS

Maintaining an airway opened by a head tilt /chin lift or jaw thrust As an alternative method of opening an obstructed airway when airway maneuvers have failed As a bite block to protect an endotracheal tube

CONTRAINDICATIONS
-Patients must be unconscious to tolerate an OP airway -Inserting An Airway in a semiconscious patient may stimulate the gag reflex causing them to vomit , leading to further airway compromise and potential aspiration

Size
-A correctly sized airway will extend from the corner of the patients mouth(incisors) to the angle of the mandible
-Improper sizing can cause bleeding of the airway and obstruction of the glottis .

The American National Standard specifies that the size of oral airways be designated by a no. i.e the length in cms.
size colour length(cm)
3.5 4.5 5.5 6.5 7.5 8.5 9.5 10.5

000 00 0 1 2 3 4 5

Violet Blue Black White Green Orange Red Yellow

DESCRIPTION
- It extends from lips to pharynx, fitting between tongue & posterior pharyngeal wall. Made up of elastomeric or plastic materials. Parts are Flange : it is at buccal end to prevent it from moving deeper into mouth & may also serve to fix airway in place. Bite Portion : it is straight & fits between teeth & gums.. Curved portion(body) : extends backwards to correspond the shape of tongue & contour of the hard palate. Tip portion :at the base of the tongue allowing air passage through and around the airway .

Guedel Airway -Most frequently used airway & has large flange & reinforced bite portion with tubular channel for air exchange & suctioning.

Cuffed Oro-Pharyngeal Airway

It is Guedel`s Airway with an inflatable cuff designed to seal the oropharynx. It has an integral bite block & a 15mm connector for attachment of the breathing circuit. The cuff is inflated with air to displace the base of tongue & form a low pressure seal with the pharynx & provide an open airway.

Patil-Syracuse Endoscopic Airway

Patil-Syracuse Endoscopic Airway It was designed to aid fiber-optic intubation. It is made of aluminium.

It has lateral channels & a central groove on the lingual surface to allow passage of fiberscope. A slit in distal end allows fiberscope to be manipulated in anteroposterior direction but limits lateral movements.

Berman Intubating Airway

-It is tubular along its entire length. It is open on 1 side so that it can be split & removed from around a tracheal tube. It can be used as an oral airway or as an aid to fiberoptic or blind orotracheal intubation

Williams Airway Intubator

Designed for blind tracheal intubation & can also be used for fiberoptic intubation or as an oral airway. It is available in 2 sizes #9 & #10 which will admit upto 8 & 8.5 mm tracheal tube respectively. The proximal half is cylindrical while distal half is open on lingual surface.

PROCEDURES

Pharyngeal & laryngeal reflexes should be depressed before an airway is inserted to avoid coughing & laryngospasm. Selecting the correct size is important. Correct size is estimated by holding the airway next to pts mouth & the tip should be at the angle of mandible.

The best criteria for proper size & position is unobstructed gas exchange

Oral airway may be inserted in 2 ways Open the patients mouth (if an assistant is available let them do a jaw thrust) Insert the airway upside down , with the curvature towards the tongue and the tip towards the tongue (convex surface) and the tip towards the hard palate When the airway reaches the back of the tongue , rotate the device 180degree so the tip faces downwards Ensure the patients tongue / lips are not caught between the airway and the teeth Reassess the patients airway for patency

NASOPHARYNGEAL AIRWAY (nasal trumpet/ nasal airway)

It is designed to hold the tongue from posterior pharynx The NP airway consists of the flange , the shaft and the bevel

INDICATIONS

Maintaining an airway opened by a head tilt /chin lift or jaw thrust procedure

As an alternative method of opening an obstructed airway when airway maneuvers have failed

Better tolerated than OP airways in semi-conscious patients

Excellent for use in patients unable to open their mouths

As a means to facilitate the bronchial suction

Contraindications

Known base of skull fracture Commonly causes nose bleeds so should be avoided in those patients known to have bleeding tendencies (e.g. on warfarin)

SIZES
Patient Size of NP(diameter)

Average-height female
Average height -male Large male

6
7 8

NP airways were trditionally sized choosing a diameter which closest matched that of the patients little finger
The diameter of nasal airway should be the same as needed to insert the tracheal tube (0.5-1.0mm smaller than oral tracheal tube).

PROCEDURE

Apply a water based lubricant Insert the NP airway into the right nostril first The bevel should be on the medial side of the nasopharyngeal airway The NP airway should be inserted at 90 degree of the patients forehead and should pass with minimal resistance towards the patients occiput Rolling the nasopharyngeal tube with your fingers from side to side as you exert downward pressure may make insertion easier

If resistance then try the other nostril

Reassess the patients airway for patency

Complications

Airway obstruction Epistaxis Ulceration & Necrosis Dental Damage

CNS trauma
Laryngospasm & Coughing. Aspiration or Swallowing of part or all of the airway. Latex Allergy Gastric distension.

Bag-valve -mask

A simple airway maneuvers or a use of an adjunct to open the airway

will allow them to breathe spontaneously .if this is the case high flow
oxygen (15L/minute)should be administered via a mask with nonrebreathe reservoir

If they are not breathing sufficiently it is necessary to ventilate the

patient .the most convenient method to achieve this is with a bagvalve mask with reservoir.

It is the device which allows administration of gases to the patient from breathing system without introducing any apparatus to the patients mouth.

A face mask can be made up of black rubber, clear plastics, elastomeric material or combination of these. Parts of the face mask Body: constitutes the main part of the mask Transparent body allows observation of moisture, vomitus , secretions etc . Seal : Comes in contact with the face.Two types are available Pad or cushion inflated with air Flap flexible extension of the body

Connector ( orifice/ collar ) : Opposite to the seal Thickened fitting of 22 mm ID Ring with hooks helps in strapping the mask

1.

Anatomical mask :

-Can be moulded to conform to the anatomy of face . -Has slightly malleable rubber body, a sharp notch for the nose and a curved chin section.

2. Rendell-baker-soucek(RBS) mask Designed for paediatric patients < than 10 yrs It has triangular body and low dead space Used in tracheostomy and acromegaly patients

Size

Age group

Dead space

0 1 2 3

preterm infant 1 to 3 years 4 to 10 years

3 cu.mm 4 cu.mm 8 cu.mm 12 cu.mm

Scented mask :

Scent incorporated into the mask by manufacturer or anaesthesia provider Added for better acceptability and pleasant experience during induction Disadvantage- ethyl alcohol in some flavors may affect accuracy of gas monitors

One Hand Method

the thumb & index finger of left hand are placed on mask body on opposite sides of connector push downward to prevent leak. The remaining 3 fingers are placed on the mandible such that middle finger is applied to the mentum, ring finger on body of mandible & little finger at angle of mandible to give jaw thrust anteriorly

Two Handed Method

As it requires both hands, a 2nd person is necessary for assisted or controlled ventilation. Here thumbs are placed on either side of body of masks, index fingers are placed under the angles of jaw, mandible is lifted & head is extended. If a leak is present, downward pressure on mask can be increased by anesthesiologists chin on the mask elbow

Two Handed Jaw Thrust

1 person stands at head end of pt & performs jaw thrust with his left hand at angle of left mandible while his right hand compresses the reservoir bag.

The 2nd person stands at pts shoulder facing 1st person. This persons Rt hand covers the Lt hand of the 1st person & the Lt hand achieves Rt sided Jaw thrust & mask seal.

Claw Hand Technique

It is useful for children undergoing short duration

procedures.

The Anesthesiologists stands at the side of bed facing the child. The face mask is applied to face by using the Rt hand with the palmar surface facing upwards. The ring & middle finger are placed under the angle of jaw & the index finger & thumb encircle the body of mask.

Squeeze the chamber at the rate of 10-12 breathes a minute . Ensure adequate ventilation by bilateral chest movement and fogging of the face mask on expiration

Advantages

It is useful for children undergoing short duration procedures.

The Anesthesiologists stands at the side of bed facing the child. The face mask is applied to face by using the Rt hand with the palmar surface facing upwards. The ring & middle finger are placed under the angle of jaw & the index finger & thumb encircle the body of mask.

Disadvantages

Anesthesiologist`s hands are tied up Higher fresh gas flows are often needed. During remote anesthesia, airway access is difficult ( CT & MRI). Often more episodes of oxygen desaturation & require more intraoperative airway manipulations

Complications

Skin problems- dermatitis, pressure necrosis. Nerve injury. Eye injury conjunctival chemosis, eyelid edema & corneal injuries. Gastric Inflation Latex allergy Lack of co-relation between arterial & end tidal CO2. Environmental Pollution with anesthetic gases Jaw Pain & User fatigue.

Laryngeal mask airway

-The laryngeal mask airway has an important role in advanced airway management . It is recommended for use in patients requiring advanced life support and is relatively easily inserted by a non-specialists.

INDICATIONS

A first line airway management device with limited airway management device

In unconscious patient who requires assisted ventilation in the absence of the ability to provide a definitive airway
As an alternative to oropharyngeal and nasopharyngeal airways (more suitable for prolonged ventilation) Emergency airway management at a cardiorespiratory arrest . As an alternative to ET tube .

CONTRAINDICATIONS

When a definitive airway is required High risk anesthetics Patient with fluctuating consciousness level (intact gag reflex is a contraindication due to risk of introducing vomiting ). Unconscious patients unable to open mouth (e.g. trismus) Patients requiring high airway pressure to ventilate (e.g. heavily pregnant , obese , asthmatic

Laryngeal mask airway

Airway connector
Valve

Airway tube

Cuff

Sizes

LMA size
1 1.5 2 2.5

Type

Weight
under 5 kg 5 to 10 kg 10 to 20 kg 20 to 30 kg

Inflation volume
4 ml 7 ml 10 ml 14 ml

3 4 5

Small adult Normal adult Large adult

30-50 kg 50-70 kg 70 kg +

20 ml 30 ml 40 ml

Generally, the size 4 LMA will be suitable for most adult female patients, and the size 5 LMA for adult males up to 100 kg. The new size 6 is intended for adult patients over 100 kg.

Size 3 is a pediatric size The larger the size used, the lower the intracuff pressure needed to obtain an adequate seal.

It is better to use a large size with small inflation volumes than a small size excessively inflated.

Always have a larger and smaller size LMA immediately available.

Preparation of the Laryngeal Mask Airway for clinical use.

Ensure laryngeal mask airway has been previously sterilized. Check cuff and valve. Lubricate the LMA with jelly or other sterile surgical lubricant. Evacuate all air from cuff, preferably using the LMA deflator

Use the optional cuff deflation device to remove all air from the LMA cuff prior to insertion

Step #2: -Press mask tip upwards against the hard palate to flatten it out and advance the mask into the pharynx using the index finger. (CAUTION: Be sure to carefully "fit" the deflated LMA tip into the convexity of the hard palate as this is the KEY to successful insertion.) -Press mask tip upwards against the hard palate to flatten it out and advance the mask into the pharynx using the index finger.

With neck flexed and head extended, press the laryngeal mask airway into the posterior pharyngeal wall using the index finger.

-Complete the insertion by exerting cephalad pressure by the nondominant hand prior to removing the index finger.

- Inflate laryngeal mask airway and secure in place with tape -Connect the LMA to means of ventilation

-Auscultate for lung sounds and the absence of epigastric sounds.

-Insert an oral airway as a bite block.

-Secure the LMA with tape or ribbon .

PHLEBOTOMY

Phlebotomy from Greek words, phlebo, relates to vein as, tomy, relates to cutting.

Opening a vein to collect blood

Cultures should be drawn before administration of antibiotics, if possible

MATERIALS

Chlorhexidine swabs (1-2 packages) Alcohol swabs Blood culture bottles (2 bottles per set) 2 syringes (adult: 20 cc, paediatric: 5 cc) 2 needles (adult: 22 gauge or preferably larger butterfly or standard needle; pediatric: 25 or 23 gauge butterfly or standard needle) Gloves (sterile &nonsterile) Tourniquet Sterile gauze pad Adhesive strip or tape Self-sticking patient labels Plastic zip lock specimen bags

INDICATIONS

Profile testing e.g. urea , electrolytes , liver function testing Monitoring of hormones , therapeutic drugs Toxicology

Venesection
Sampling according to research protocols(ensure that you have consent)

CONTRAINDICATIONS

Infection at the site of access e.g. cellulitis

Bleeding tendenciese.g. on warfarin Thrombophlebitis Taking sampling from drip arm(stop the infusion and wait for atleast 2 minutes

before sampling).

Points of access

Median Cubital Veins Cephalic Veins The Basilic Vein Dorsal Hand Veins Foot Veins

Blood collection bottles

Bottle lid colour Tube contents Tests

Purple

EDTA

Full blood count , ESR, Malaria, crossmatch and group

Biochemistry testing

Gold

Clotting accelerator and separation gel

Light blue
Red Grey Green Royal blue

Trisodium citrate
Clotting accelerator Sodium fluoride Lithium heparin Sodium heparin

Coagulation testing
Serology , vitamin B12 , folate Glucose Ammonia Trace elements

Red top

Additive

None

Mode of action

Blood clots, and the serum is separated by centrifugation

Uses

Chemistries, Immunology and Serology, Blood Bank (Crossmatch)

Gold top

Additive

None

Mode of actions

Serum separator tube (SST) contains a gel at the bottom to separate blood from serum on centrifugation

Uses

Chemistries, Immunology and Serology

Light green top

Additives

Plasma Separating Tube (PST) with Lithium heparin

Mode of action

Anticoagulates with lithium heparin; Plasma is separated with PST gel at the bottom of the tube

Uses

Chemistries

PURPLE TOP

ADDITIVE

EDTA

FORMS CALCIUM SALTS TO FORM CALCIUM

Hematology (CBC) and Blood Bank (Crossmatch); requires full draw - invert 8 times to prevent clotting and platelet clumping

LIGHT BLUE TOP

SODIUM CITRATE

FORMS CALCIUM SALTS TO REMOVE CALCIUM

Coagulation tests (protime and prothrombin time), FULL draw required

Green top

Sodium heparin or lithium heparin

Inactivates thrombin and thromboplastin

For lithium level, use sodium heparin For ammonia level, use sodium or lithium heparin

Grey top

Sodium fluoride and potassium oxalate

Antiglycolytic agents preserves glucose upto 5 days

Glucoses, requires full draw (may cause hemolysis if short draw)

PINK TOP

Potassium EDTA

FORMS CALCIUM SALTS

MOLECULAR /VIRAL LOAD TESTING

METHODS FOR BLOOD COLLECTION

Vacutainer system Needle and syringe

Vacutainer system

One of the safest means Consists of a cylindrical clear plastic collecting device , known as tube holder which is attached to either a multisampling needle or a butterfly needle and luer adaptor Vacutainer blood bottles are loaded onto the luer adaptor within the tube holder , the vacuum present causes blood to flow directly from the vein and into the bottle

Advantages
It is safest

Disadvantages
While loading the different blood collection tubes whilst keeping the needle still within the vein requires some practice .

Method

A minimum of 10 ml of blood is taken

through venipuncture and injected into two or more "blood bottles" with specific media for aerobic and anaerobic organisms.

The blood is collected using clean technique. This requires that both the tops of the culture bottles and the venipuncture site of the patient are cleaned prior to collection with alcohol swabs containing 2% Chlorhexidine and 70% isopropyl alcohol.

The area of skin is cleaned with a disinfectant, or an alcohol swab as the persistent presence of skin commensals in blood cultures could indicate endocarditis but they are most often found as contaminants

The vein is anchored and the needle is inserted

The vacutainer tube is depressed into the needle to begin drawing blood

Additional vacutainer tubes can be utilized. Determine what tests are ordered and what tubes will be necessary BEFORE you begin to draw blood.

When the final tube is being drawn, release the tourniquet. Then remove the tube, and remove the needle

After the needle is removed from the vein, apply firm pressure over the site to achieve haemostasis.

Apply a bandage to the area

Preparation of Cap before Injecting Blood

Prep the rubber cap of the blood culture bottles with an alcohol pad in a circular motion. Allow the alcohol to dry.

Mix

-Gently rotate the bottles to mix the blood & the broth (do not shake vigorously)

Needle and syringe

Traditional method for phlebotomy

It is simply a needle (21G-green) attached to a syringe .

OPEN METHOD

16=Transparent 18 =Yellow 19=Brown 20=Violet 21=Green

22=Black 23=Sky blue 24=Red 25=Dark Blue 26=Orange

Macrosample collection

Superficial veins of the foot

Procedure

Wear gloves and apron Attempt venepuncture in the non-dominant arm Place the tourniquet above the antecubital fossa

Ideally, tourniquet should not be kept on for more than one minute
Leave at least for 20 sec. for to veins to fill and meanwhile do repetitive fist actions bouncy vein is more easier and successful rather than thready vein Wipe the skin carefully with a antiseptic wipe working in circles from centre outwards Using the needle with vacutainer system or syringe , insert the bevel upwards , passing through the skin and into the vein Attach the collecting bottles Loosen the tourniquet Withdraw the needle and place a cotton ball over the access site . Secure with the tape If blood collected in bottles then transfer it to bottles Label the bottles

Complications

Infection at the puncture site

Clean the skin with an antiseptic wipe

Hematoma
Gentle pressure for 1-2 minutes after the procedure and release the torniquet before removing the needle. Advise the patient to keep their arm straight

Pain
A local anesthetic cream applied to the skin

BLOOD CULTURE
-A blood culture is a laboratory test in which blood is injected into bottles with culture media to determine whether microorganisms have invaded the patients bloodstream.

Need for blood culture

No microbiological test is more essential to the clinician than the blood culture. The finding of pathogenic microorganisms in a patients bloodstream is of great importance in terms of

diagnosis, prognosis, and therapy.

- L. Barth Reller, Clin. Infect. Diseases, 1996

Blood transfusion
INTRODUCTION

Blood transfusion is defined as the process of receiving blood products into ones circulation intravenously .
This is usually done as a life saving maneuver to replace blood cells or blood products lost through severe bleeding, during surgery when severe blood loss occurs or to increase the blood count in an anaemic patient.

Bloodtransfusionsinvolvestheuseofwholeblood,redbloodcells,w hitebloodcells,plasma,clottingfactorsandplatelets.

WHOLE BLOOD TRANSFUSION

Stored between +2 and +6 degrees centigrade in a blood and refrigerator. Transfusion should be started within 30 minutes of removal from the refrigerator and completed within 4 hours of commencement because changes in the composition may occur due to red cell metabolism.

Indications

Red cell replacement in acute blood loss with hypovolemia Exchange transfusion

Contraindications

Chronic anaemia Incipient cardiac failure

PACKED RED BLOOD CELLS

One unit of packed red cells is approx.330ml and has a hematocrit of 50-70%.

They are stored in a sag-m(saline-adenine-glucosemannitol)solution to increase their shelf life to 5 weeks at 26 degrees centigrade

Indicated in replacement of red cells in anaemic patients and also used with crystalloid and colloid solutions in acute blood loss conditions

Safe blood transfusion procedures

The blood pack should always be inspected for signs of deterioration on arrival and before transfusion if not used immediately.

Discolouration of the blood pack and any signs of leakage indicate contamination and could cause a severe fatal reaction if transfused.

Warmed blood is most commonly required in large volume rapid transfusions & exchange transfusion in infants.

Intravenous cannulations for blood transfusion can be done from

Cephalic vein Basilic vein Forearm veins Great Saphenous veins

URINARY CATHETERIZATION
Catheterization of the urinary bladder is the insertion of a
hollow tube through the urethra into the bladder for removing urine. It is an aseptic procedure for which sterile equipment is required.

PURPOSE
a. Relieve urinary retention.

b. Obtain a sterile urine specimen from a female patient.

c. Measure residual urine. d. Empty the bladder before, during, or after surgery. e. Allows accurate measurement of urine output.

SIZES

Number 14 Fr.(french) and 16 Fr. are used for female adults. Number 20 Fr. and 22 Fr. are usually used for male adults.

TYPES
Intermittent Catheter -An intermittent catheter is used to drain the bladder for short periods (5-10 minutes). It may be inserted by the patient.

Retention/Indwelling Catheter

- This type of catheter is placed into

the bladder and secured there for a

period of time.

POSITION

Position the female patient in a dorsal recumbent position with the knees flexed and the feet about two feet apart. Cover the upper body and each leg. Place the catheter set between the female patient's legs.
Position a male patient in a supine position. Drape the patient so that only the area around the penis is exposed. Place the catheter set next to the legs of the male patient.

Grasp the patient's penis between your thumb and forefinger of your nondominant hand.

Retract the foreskin of an uncircumcised male.

The gloved hand that has touched the patient is now contaminated.

PROCEDURE-Hold the penis at a 90-degree angle. Advance the catheter into the patient's urinary meatus. You may encounter resistance at the prostatic sphincter. (1) Pause and allow the sphincter to relax. (2) Lower the penis and continue to advance the catheter.
NOTE: Never force the catheter to advance. Discontinue the procedure if the catheter will not advance or the patient has unusual discomfort. Get assistance from the charge nurse or physician.

3.When the catheter has passed through the prostatic sphincter into the bladder, urine will start to flow. Gently insert until 1 to 2 inches beyond where urine is noted 4. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)

5. Gently pull catheter until inflation balloon is snug against bladder neck
6. Connect catheter to drainage system

7.Anchor the catheter tubing to the lateral abdomen with tape, without tension on tubing 8.Place drainage bag below level of bladder 9.Evaluate catheter function and amount, color, odor, and quality of urine

CATHETERIZATION IN FEMALES PROCEDURE1.

Place the thumb and forefinger of your nondominant hand between the labia minora, spread and separate upward. The gloved hand that has touched the patient is now contaminated.
Using the forceps, pick up a cotton ball saturated with antiseptic solution. Use one cotton ball for each stroke. Swab from above the meatus downward toward the rectum. Keeping the labia separated, cleanse each side of the meatus in the same downward manner Do not go back over any previously cleansed area. Deposit each cotton ball into the disposal bag. After the last cotton ball is used, deposit the forceps into the bag as well.

2.

3.

4.

5.Continue to hold the labium apart after cleansing. Insert the lubricated catheter into the female patient's urinary meatus.
6. Angle the catheter upward as it is advanced. If the catheter will not advance, instruct the patient to inhale and exhale slowly. This may relax the sphincter muscle. Do not force the catheter. 7. When urine starts to flow, insert the catheter approximately one inch further. Place the cup under the stream of flowing urine to obtain a sterile specimen if required.

8. Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size) 9.Gently pull catheter until inflation balloon is snug against bladder neck 10.Connect catheter to drainage system.

RYLES TUBE FEEDING

Steps Place the patient in semi to high fowlers position or a lateral if patient cannot be propped up in order to prevent gastric discomfort or regurgitation of feed.

Aspirate stomach contents gently with 50ml syringe and with test with blue litmus paper to conform the position of the tube and note the residual amount. If the tube is in the stomach the blue litmus paper change red.

Observe the nature of aspirate for color, volume and presence of blood to exclude the malabsorption of previous feed and review feeding regime if necessary. Attach funnel / Syringe to the tube and hold it to the side, at the level of the patients forehead ,If the syringe is held too high, it increases the pressure at which the fluid enters the stomach.

Fill the funnel/ syringe with the prescribed feed, allowing it to flow in by gravity. Observe the patient during feed to detect any adverse reaction to the feeding. Record the type and amount of feed and water given. Nasogastric tubes are changed weekly or when necessary Conclude feed with water to keep the lumen of tube feeding.

WOUND MANAGEMENT

- The accepted interval from injury to wound closure is up to

6 hours for wounds to the extremities and up to 24 hours for

face and scalp wounds is the golden period for repair

wound preparation (debridement,cleansing, etc.)

dress with saline soaked fine mesh gauze follow up in 72-96 hours for debridement repeat cleansing and closure if no evidence of infection

WOUND ASSESSMENT
Examine for: amount of tissue destruction degree of contamination damage to underlying structures

WOUND PREPARATION

WOUND PREPARATION ANESTHESIA

Topical

Solution or paste EMLA

Local

Direct infiltration 1% lidocaine with or without epinephrine Bupivacaine or sensoricaine for longer acting anesthesia

Regional Block

Local infiltration proximally in order to avoid tissue disruption Smaller amount of anesthesia required

Wound Preparation Hemostasis

Direct PressureUsually best choice Ligatures Use a tourniquet

Chemicals Epinephrine
Gelfoam Oxycel Actifoam

Cautery

FOREIGN BODY REMOVAL

Suspect with point tenderness

Visual inspection (to the apex)

Imaging -Glass, metal, gravel fragments >1mm should be

visible on plain radiographs

-Organic substances and plastics are usually radiolucent

Always discuss and document possibility of retained

foreign body

HAIR REMOVAL

Shaving Increases risk of infection X 10 !

Clip Hair with Scissors

Matt Hair with Ointment

Never shave eyebrows( may not regrow )

CLEANING

High pressure irrigation (Normal Saline)

100-300 ml with continued irrigation

At least 8 psi force to the wound the irrigation fluid

dislodges foreign bodies, contaminants, and bacteria.

A simple device setup 30-60 ml syringe

SAVLON

1:1000 SOLUTION Cleaning and disinfecting of postoperative wounds

1:30 (aqueous solution ) Cleaning and disinfecting of physically dirty wound where an extra detergent is required 1:30 in 70% alcohol solution Skin disinfection (preoperative and other invasive procedures)

SPIRIT

Contains 70% isopropyl alcohol Disinfection of skin before intramuscular and intravenous injections

Removal of iodine in preparation of skin for operation Cleaning the stitched wound Cleaning the skin of the surrounding ulcer and open wounds Used along with the other disinfectants , such as iodine spirit and cetavlon spirit , for painting the parts before operation .

HYDROGEN PEROXIDE

2-3% volume hydrogen peroxide It is not an antiseptic but a cleaning agent It destroys anaerobic organisms Whenever there is capillary oozing used as a hemostatic solution (e.g. incision and drainage) It produces frothing and brings out debris from the depth of the wound

Betadine

Povidone-iodine 5% and 10% topical solutions

Surgical scrub (7.5%)

Mouthwash Ointment

Combination of POVIDONE -IODINE(PVP-I)

An effective and useful germicide High dilutions are active in destroying organisms within 15 secoonds Antibiotic and antiseptic action Immediate action-nonselective Used for irrigation of wound(subcutaneous)

DEBRIDEMENT

Removes devitalized tissue

Creates sharp wound edge

Excision with elliptical shape Respect skin lines

OXYGEN THERAPY
O2 DELIVERY SYSTEMS:
1.Low flow or variable performance systems. 2.High flow fixed performance systems

NASAL PRONGS
-

The prongs protrude 1cm into nares. Well tolerated. Less interference in day to day activities. Useless in mouth breathers. No reservoir system. FiO2 unpredictable.

Simple O2 masks:
-

Covers the nose & mouth. 4-6 lit/min.

0.4 -0.6 FiO2

Feeling of suffocation. Interference with daily activities. FiO2 unpredictable. Displacement at nights.

Mask with reservoir bags:

-Polymask with 2 chambers. -High FiOP2 with 5-6 lits of O2.

O2 CYLINDER

HAZARDS OF O2 THERAPY
1.Drying of mucous membrane. 2.Depression of ventilation in COPD. 3.Reversal of compensatory hypoxic vasoconstriction. 4.Atelectasis due to absorption collapse. 5.O2 toxicity.

O2 TOXICITY

Pulmonary oxygen toxicity (Lorrain-Smith effect):

-100%O2 given for 12 hours or more. -80% O2 for more than 24hrs. -60%O2 more than 36hrs.

Symptoms: substernal pain, irresistible cough,

dyspnoea.

BANDAGES

1. 2. 3. 4. 5. 6.

Bartons bandage Eye bandage

Ear bandage
Head bandage Triangular bandage Cravat bandage

BARREL/BARTONS BANDAGE

1.The middle of the bandage is placed under the jaw, well back just in front of the angle; then a simple knot is tied over the vertex of the skull .

2.Using both hands, open the knot so that the front loop comes in front of the forehead and the back portion under the occiput

3.The two ends are then taken and upward tension is exerted, and by a slight adjustment the two running hitches are made to occupy a position slightly above and in front of the ear.

4.The two ends are then tied in a reef knot on the top of the head.

Use
-bandage is used to support the fractured mandible and head injury

THE BARREL BANDAGE FOR FRACTURES OF THE JAW BY W. KELSEY FRY, M.C., M1.R.C.S., L.D.S. Dec. 2, 1939 BARREL BANDAGE FOR FRACTURE OF JAW British Medical i
Journal page no 1086

Ear bandage
-To keep the dressing in position after mastoid surgery

Eye bandage
-To support eye dressings

HEAD BANDAGES

1.Wrap the first tail horizontally around the head, ensure the tail covers the dressing

2. Hold the first tail in place and wrap the second tail the opposite direction, covering the dressing

3.Tie a nonslip knot and secure the tails at the side of the head, making sure they DO NOT cover the eyes or ears

4.Apply a dressing to a wound on the top of the head

5. Wrap one tail down under the chin , up in front of the ear, over the dressing, and in front of the other ear.

6. Wrap the remaining tail under the chin in the opposite direction and up the side of the face to meet the first tail

7. Cross the tails , bringing one around the forehead (above the eyebrows) and the other around the back of the head (at the base of the skull) to a point just above and in front of the opposite ear, and tie them using a nonslip knot

TRIANGULAR BANDAGE
1.

Turn the base (longest side) of the bandage up and center its base on center of the forehead, letting the point (apex) fall on the back of the neck (Figure A). Take the ends behind the head and cross the ends over the apex. Take them over the forehead and tie them (Figure B). Tuck the apex behind the crossed part of the bandage and/or secure it with a safety pin, if available

2.

3.

4.

CRAVAT BANDAGE
1.

Place the middle of the bandage over the dressing (Figure A). Cross the two ends of the bandage in opposite directions completely around the head (Figure B). Tie the ends over the dressing

2.

3.

REFERENCES

ABC of practical procedures- Tim Nutbeam and Ron Daniels Moore KL , Dalley AF(1999) Clinically Oriented Anatomy , 4th Edition . Lippincott Williams , Philadelphia American College Of Surgeons (2008) Advanced Trauma Life Support :Student Manual , 8th Edition Jerry A. Dorsh and Susan E. Dorsh Understanding Anaesthesia Equipment, 5th Edition,

THANK YOU