Airway Instruments
Airway Instruments
Oropharyngeal / Guedel Airway
• This is essentially a rigid, curved
plastic tube. It is an airway adjunct
• It is used to provide an airway for
a patient where there is an
impaired level of consciousness.
• It is sized by measuring the
distance from the angle of the
mandible to the patient’s
mouth.
• It is inserted upside down into the
mouth and rotated downwards
when it is past the tongue within
the oral cavity.
Airway Instruments
Airway Instruments
Endotracheal Tube
• Used to provide a definitive airway for
patients. This means a cuff is inflated
to prevent aspiration. Used for long
operations, (laparotomy) and in cases
of inhalation injury, (burns)
• Indications:
– Depressed consciousness
– Hypoxemia
– Airway Obstruction
Airway Instruments
Endotracheal Tube
• Then check the tube is in the trachea by:
– Auscultating: ensure bilateral breath
sounds
– Auscultate over the stomach (epigastric
region) to ensure no gurgling (that would
indicate oesophageal intubation)
– Measure end tidal CO2 tension: since
CO2 is produced in the lung, you can
confirm that the tube is in the trachea by
measuring the end tidal CO2 tension. If
the tube is in the oesophagus, then the
CO2 gas pattern would be absent.
– Do CXR and look for metallic mark
Airway Instruments
Endotracheal Tube
• Complications:
– Broken Teeth, lacerations of the
tissues of the upper airway,
– Intubation of the Oesophagus
Airway Instruments
Airway Instruments
Tracheostomy Tube
• Definitive airway
• Tracheostomy = surgical
opening into the trachea.
• Can be temporary or
permanent.
• It involves placing the
tracheostomy in between the 2
and 4th tracheal rings.
• Usually done in theatre under
GA.
Airway Instruments
Tracheostomy Tube
• Indications
– Patients who require long term intubation
(>2 weeks) – better tolerated than ETT
– Severe maxillofacial injury (unable to
intubate)
– Post-laryngeal surgery (e.g. laryngectomy
for malignancy)
– Lung disease (e.g. COPD) to reduce dead
space and allow effective ventilation
– Obstructive sleep apnoea
– Upper airway obstruction
• Complications
–
–
–
–
–
Tracheostomy stenosis,
Infection
Blocked tube,
Tracheoesophageal fistula
Surgical emphysema.
Airway Instruments
Airway Instruments
Laryngoscope
• A laryngoscope has a handle and a
curved blade, usually fitted with a
light, it moves the tongue and
epiglottis aside in order to inspect the
larynx.
• It is used to aid insertion of an
endotracheal tube or for examination.
Airway Instruments
Airway Instruments
Laryngeal mask Airway
• Sits on top of the larynx and therefore
does not intubate the trachea.
• It is used to assist a patient with
impaired breathing. It can also be
used as an airway during short
operations e.g. day cases.
• It is inserted and then the inflatable
cuff over the larynx can be pumped,
by pushing air from a syringe, into the
blue lumen.
Surgical Instruments
Surgical Instruments
Proctoscope (Gabriel)
• Used to visualise the anal canal and
lower rectum
• It is also used when injecting or
banding haemorrhoids.
• After explaining the procedure to the
patient, the patient is placed in the
left lateral position and a digital rectal
examination is performed.
• The proctoscope is then attached to a
light source and lubricated prior to its
insertion into the rectum.
Surgical Instruments
Surgical Instruments
Shouldered Syringe
• This a syringe used for the
injection of haemorrhoids with
5% phenol in almond oil.
• The injection is performed in
conjunction with a
proctoscope.
• The injection is performed
above the dentate line as it is
insensitive
Surgical Instruments
Surgical Instruments
Rigid Sigmoidoscope
•
•
•
•
•
•
Used for the inspection of the rectum and
lower sigmoid colon.
After explaining to the patient what you
are about to do, you must attach a light
source and a air pumping device.
The patient is placed in the left lateral
position and a digital rectal examination is
performed.
The sigmoidoscope is then lubricated with
jelly and inserted pointing towards the
umbilicus.
Air is pumped into the rectum to allow
you see the direction of the rectal lumen.
Biopsies can also be taken of rectal
mucosa through the sigmoidoscope eg in
a case of ulcerative colitis
Surgical Instruments
Surgical Instruments
Trucut Biopsy Needle
• Used to take histological
specimens from lesions
– eg breast lumps or liver.
• The procedure can be
performed under local
anaesthetic
Surgical Instruments
Surgical Instruments
Sutures
•
•
Sutures
Used to hold a wound together in
good apposition until such a time as
the natural healing process is
sufficiently well established to make
the support from the suture material
unnecessary and redundant
•
•
•
Alternatives:
Staples
Steristrips – self adhesive tape, useful
for superficial lacerations, useful if
there is potential tension on a wound
Tissue adhesive – based on
cyanoacrylate manometer, wounds
need to be clean and tension free
•
Surgical Instruments
Suture material
• Absorbable
Synthetic
•
•
•
•
Polyglycolic Acid (Dexon)
Polyglactin (Vicryl)
Polydioxone (PDS)
Polyglyconate (Maxon)
• Non-Absorbable
– Natural
• Silk
• Linen
• Stainless Steel Wire
– Synthetic
– Polyamide (Nylon)
– Polyester (Dacron)
– Polypropylene (Prolene)
Surgical Instruments
Surgical Instruments
Needle Holder
•
These are special forceps
•
Designed to hold the needle to allow the
surgeon to suture accurately
Surgical Instruments
Surgical Instruments
Laparoscopic Port
• Used during laparoscopic procedures
eg Lap Chole
• Ports allow the surgeon to insert
telescopes/Cameras/instruments
Surgical Instruments
Surgical Instruments
Dever’s retractor
• Used in open abdominal
surgery
• Allows the surgeon to operate
with more space
Surgical Instruments
Surgical Instruments
Self Retaining retractor
• Used to hold wounds open
• Eg Hernia
repair/appendectomy
Fluids
Fluids
Hartmanns Solution
• Used in Surgery,
especially nil by mouth
patients
Fluids
Fluids
Dextrose
• Dextrose is a solution
made of sugar and
water
Fluids
Fluids
Saline
Crystalloids are an electrolyte solution in
water. It can pass through a semipermeable membrane (cell wall).
NaCl saline 0.9% solution is an isotonic
fluid as it has similar Na+ levels to the
extracellular fluid in the body. Saline
distributes throughout the ECF (not the
ICF like dextrose does). The ECF consists
of plasma, interstitial fluid and
transcellular fluid (note colloids stay in
the plasma). Saline is a good
maintenance fluid.
Fluids
Dextrose
Saline
Dextrose
Saline
Dextrose
Saline
1000ml
1000ml
1000ml
40g Dextrose
40g Dextrose
40g Dextrose
Na 30mM
Na 30mM
Na 30mM
K 20mM
K 20mM
K 20mM
OR
Normal Saline 5% Dextrose
5% Dextrose
1000ml
1000ml
1000ml
50g Dextrose
50g Dextrose
K 20mM
K 20mM
Na 150mM
K 20mM
Fluids
Fluids
Gelofusine
This is a colloid. Used in cases of volume
loss: eg trauma, molecules cannot pass
through semi permeable membrane.
Remains in the intravascular space.
Useful in increasing Blood Pressure.
Use is controversial.
Natural colloids: albumin
Synthetic colloids: Gelofusine and
Haemaccel (gelatine based infusions)
Lines
Lines
Cannulas
This is a an IV cannula. It is used to give IV fluids
and IV drugs.
If you wish to give the fluid quickly, the cannula
must be short and large bore (Poiseuille’s law –
flow is proportional to the fourth power of the
internal radius of the tube and inversely
proportional to the length).
Emergencies (265ml/min)
Generally insert a 18G (green) or higher when
giving drugs. Emergency should be brown (14G)
which has a flow rate of about 265ml/min. Use
antecubital fossae in emergencies. If you cannot
get it, use femorals.
Lines
Cannulas
Blue
22G
Pink
20G
Green 18G
White 17G
Grey
16G
Brown 14G
Lines
Lines
Triple lumen Central Venous Pressure Catheter
• Inserted into either the
right subclavian vein or
internal jugular vein.
• Used for Central Venous
Pressure monitoring and to
administer drugs
(chemotherapy drugs),
taking blood, not good for
fluids.
• Single or triple lumen
Lines
Triple lumen Central Venous Pressure Catheter
•
•
•
•
Inserted using Seldinger technique.:
Lie patient flat. Infiltrate skin with LA 5ml of lignocaine
Assemble the catheter and flush all the lumina
Introduce needle and syringe 1cm below the junction of the
middle and medial thirds of the clavicle. Aim the needle to the
sternal notch and advance. Aspirate as you advance the needle.
• Once blood enters the syringe, remove the syringe keeping the
needle still in its position.
• Insert the guide wire, remove the needle, feed the dilator over
the guide wire, remove dilator, insert central line, remove guide
wire
• Stitch in place, Order CXR to check position and exclude
pneumotharax
Lines
Triple lumen Central Venous Pressure Catheter
• Complications of a central line insertion:
•
• Immediate: pneumothorax, haemothorax, damage to adjacent
vessels e.g. carotid arteries, primary haemorrhage
•
• Early: infection (skin commensals), secondary haemorrhage,
haematoma formation
•
• Late: thrombosis, catheter blockage.
Lines
Lines
Nasogastric Tube
•
This is a feeding NG tube. It is used for
enteral nutrition in patients.
•
It has a fine bore and is soft (comfortable for
patients), unlike the Ryle’s NG tube which is
wide bore. Note the end has a cap (not
present in Ryle’s NG tube). It is made from
silastic, which tends to block less often.
•
Another indication is oesophageal obstruction.
•
DO NOT use is patients with basal skull
fractures, facial trauma or if patient refuses it.
Lines
Lines
Single Lumen Central Venous Catheter
Lines
Lines
Hickmann Line
•
This is a Hickman line. It is a modified central line that is
tunnelled under the skin to make it more secure. It is
used as a long term central vascular access device. It is
usually inserted into the right subclavian vein.
•
The Hickmann line is a central line as it is inserted into a
central vein (therefore making it a central venous access
device). It is used mainly for long term access to the
central line. This can be for providing patient with TPN
or for taking blood or administering drugs long term.
•
The line is tunnelled under the skin, therefore you will
see subcutaneous swelling under the skin along the path
of the catheter (CVP catheters are not tunnelled and
they are used for short term only).
Lines
Lines
Peripherally Inserted Central Catheter (PICC)
These lines are inserted into a
peripheral vein, usually the cephalic
vein in the antecubital fossa and
'unwound' upwards into the
subclavian vein/superior vena cava.
They are firmly secured with tape or
sutures.
They tend to be used for relatively
short-term venous access, e.g. a
prolonged course of antibiotics, but
can be used for periods of up to
several months.
Lines
Lines
Swan-Ganz Catheter
Inserted into
pulmonary artery,
this is a diagnostic
catheter used to
detect heart failure,
sepsis, monitor
pressures in right
atrium, right
ventricle and
pulmonary artery
Lines
Lines
Tesio Line
For Renal Dialysis
Drains
• A surgical drain is a tube
used to remove pus, blood
or other fluids from a
wound.
•Broadly classified as:
– Tube Drains
– Corrugated Drains
• Types
of drainage systems
–Closed
–Open
–Passive
–Active
Drains
Drains
Chest Drain Bottle
•Bottle to which the chest drain is attached.
• There is a line called prime level which is filled
with sterile water.
• The chest drain tubing is connected to a tube
which is under the sterile water and therefore acts
as a water seal.
•After a chest drain has been inserted you can see
bubbling in the water as the air leaves the pleural
space.
•The chest drain bottle can be used to collect air,
blood, fluid and pus from the pleural space.
•The system can be driven by attaching suction to
the top of the bottle making it an example of a
active closed drainage system
Drains
Drains
Yates Tissue Drain
• Row of tubes
• For big cavity drains
• It is an open drainage system
Drains
Drains
Vacuum Drain bottle (Redivac)
•Used to drain areas where fluid or blood
may collect or where the surgery has left
a cavity which is closed by the suction
from the vacuum drain.
•This is an example of an active closed
drainage system.
T-tube
Radioopaque
Q1: Indications:
1 following eradication of C.B.D
2 splint for C.B.D
3 feeding jejunostomy
4 drainage for oesoph. perforation
Q2:Time of removal:
Remove after 10-15 days when there
is no charcot’s triad (pain-jaundicefever)
Q3:Complications:
-Occlusion (blood, biliary mud)
-Dislodgment biliary peritonitis
-Pancreatitis, Cholangitis
Q4:Treatment of complications:
-Reopen and suck bile
-Reoperation
Q5: Contraindication of removal:
-Charcot's triad
-Pain or leakage after clamping
-Abnormal T tube cholangiogram
Q1: Indications:
-control of bleeding esophageal varices
-preparing for endoscopy surgery
Q2: Complications:
-Aspiration pneumonia
-Ulceration, stricture
-Suffocation
-Pressure on nose
-Perforation of esophagus
Q3: Describe
Senkstaken
Tube
-3 lumens
-2 inflatable balloons;
gastric balloon (spherical when inflated)
esophageal balloon (tubular when
inflated), which obliterate varices while
allowing gastric suction and tube
feeding.
Q1: indications: ‫مهم‬
-Drainage of urine in
chronic retention e.g. :SEP
-Monitor urine outflow
-Hemostasis after
prostatectomy
-Peritoneal drainage in
biliary peritonitis
Foley's catheter
Q2: complications:
-False passage
-Bleeding
-Infection
-Rupture urethra
-Obstruction of catheter
Rectal deflation tube
Q1: Indications:
-Drain fluid & blood leakage
after perforation
-After laparotomy for
peritonitis
corrugated rubber
drainage
No more used – highly
complicated
It’s open cystic drain
Describe – uses
Q2: Removal:
After it stops drainage
Q3: Complications:
-Infection
-Incisional hernia
-Bleeding
-Pressure necrosis
-Loss it in drained cavity
Indications:
for varicose vein
surgery
Vein stippler
Allis forceps
Uses:
1- hold tough structures as fascia, sheath , tendon
2- hold duodenum for duodenal closure during gasterectomy
Can hold delicate structure (X)  hold fascia & aponeurosis
Toothed - locked - box - crushed
Artery
Forceps
(mosquito
forceps)
Uses:
1- Hold peritoneum, viscous, soft tissue,
bleeding vessels
2- Facilitate tying of ligature
Babcock
forceps
Uses:
Hold:
1-intestine during resection
2-thyroid gland
3-mesoappendix
4-uterine tube
5-ureter
6-C.B.D
Toothed
forceps
Uses:
*Hold tough layer such
as skin, fascia,
aponeurosis, fat &
muscles
*Give firm grip
Scalpel
Uses:
*Surgical knife used to incise
skin & SC tissue and also
divide major vascular pedicle
after ligation
Intestinal clamp
(non crushing
clamp)
Non crushing – Box
– Locked – Non
toothed
Uses:
* Occlude intestinal lumen to
prevent slippage of contents
&
Control bleeding during
intestinal anastomosis
* Occlude portal vein
* Coapitation of intestine
Kocher’s forceps Uses:
*hold tough structures
Curved –Toothed – screwCrushing
*strap muscles
thyroidectomy
*crush base of appendix
*clamp vascular bands or
omentum
*dissect in tissue planes
Lahey's forceps (right angled clamp)
*Right angle – crushing – long – box
*Used to ligating major vascular pedicles example
superior thyroid pedicle - cystic artery – lumbar vein
(lumber sympathectomy)
Satinsky vena cava clamp (vascular clamp)
*Non crushing – box – locked
*Used to isolate part of wall of IVC to anastomose to
portal vein during portocaval anastomosis
Used to hold renal pedicle to control haemorrhage while
doing partial nephrectomy
Bulldog
Has spring handle
Occlude blood vessel temporary
Used during direct arterial surgery
example anastomosis & grafting
Sponge Forceps


Used to hold gauze
squares or sponge to
“mop up” the surgical site
Jaws are serrated
Transfer Forceps
When sterile, transfer
forceps;
• arrange items on sterile
tray
• transfer items to sterile
field
Needle Holder
• Used to hold and pass a suturing needle through
tissue
• Has groove to hold needle within jaws
Towel Clamp
• Adds weight to drapes and towels to ensure they
stay in place
• Allow exposure of the operative site
Skin Hook
• Flat end is a blunt retractor
• Three-prong end may be sharp to dull
• Used to retract small incisions or secure a skin edge
for suturing
Iris Suture Scissors
• Used to remove sutures
• Blade has beak or hook
to slide under sutures
Sharp/Sharp Scissors
• Used to cut and dissect tissue
• Both blade tips are sharp
Sharp/Blunt Scissors
• Used to cut and dissect fascia and muscle
• One blunt tip and one sharp tip
Nasal Speculum
• Used to spread nostrils
during examination
Vaginal Speculum
• Used during
gynecological exam or
procedure
• Dilates the opening of
the vaginal cavity,
allowing for inspection
of the vagina and cervix
• Facilitates access for
observation and
treatment