Instruments

Question 1

Answer 1

Indications
 Investigate a patient c¯ pyrexia

Features
 Red: anaerobic culture medium
 Blue: aerobic culture medium

Method
 Take blood using ANTT
 Replace needle with a clean one
 Wipe top of bottles c¯ alcohol
 Fill anaerobic (red) bottle first
 Fill in pt. details and send to path lab
 Some hospitals have specific teams that take cultures

Question 2

Answer 2

Catgut Suture
This is catgut suture, which is an example of a natural absorbable suture. Catgut as been replaced my many
of the newer synthetic absorbable materials, however you will still see it being used in the formation of
stomas and circumcisions.

Question 3

Answer 3

Chest Drain Bottle

This is the bottle to which the chest drain is attached.
If you look carefully on these there will be 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 also be used to collected 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.

Indications
 As for chest drain tube

Method
 Fill bottle to prime level c¯ sterile water
 Connect to drain to bottle
 Underwater seal allows one-way flow out of pleural cavity
 May add suction → active drainage

Complications
 Lifting the bottle above the pt can → retrograde flow into chest.
 Complications of chest tube insertion

Question 4

Answer 4

Devers Retractor

This is a type of retractor which is used in open abdominal surgery to allow the surgeon to operate. There are different sizes and types of retractors available, you may frequently be asked to use one during you
clinical training when you are assisting in theatre.

Indications
 Surgical instrument used in open abdominal surgery to retract viscera and ↑ the field of view

Method
 Curved end inserted into abdomen and placed carefully to retract the viscera.
 Can be bent to a suitable shape

Complications
 Damage to skin and internal structures

Question 5

Answer 5

Disposable Rigid Sigmoidoscope

This is a disposable rigid sigmoidoscope, which is 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 e.g. in a case of ulcerative colitis

Indications
 Allows endoscopic examination of the rectum and rectosigmoid junction c¯ possible biopsy.
 Can be used in the outpatient or inpatient setting
 Investigation of
 Rectal bleeding
 Colonic Neoplasia
 IBD

Features
 Graduated plastic tube c¯ an obturator to aid insertion

Method
 For good views a suppository should be given prior to examination
 Consent pt. and explain procedure.
 Examine perineum and perform DRE c¯ pt. in left-lateral position.
 Ensure no obstruction to scope
 Lubricate scope c¯ aquagel and insert into anal canal
 Remove obturator
 Attach light source, bellows and eye piece and insufflate air
 Visualise mucosa as scope withdrawn

Complications
 Perforation
 Mechanical: pushing against bowel wall
 Pneumatic: over-inflation
 Bleeding

Question 6

Answer 6

Drainage Bag

This is a drainage bag which can be connected top either a nasogastric tube or a drain coming out of the abdomen. Drainage relies on gravity so this is an example of a closed passive drainage system.

Question 7

Answer 7

Endotracheal Tube
This is an adult endotracheal tube which is used to provide a definitive airway for patients for example during long operations e.g. laparotomies and during cardiac arrests or trauma. The endotracheal tube is inserted using a laryngoscope, through the laryngeal folds. The end of the tube should lie just above the carina to allow ventilation of both lungs. After inserting the tube a balloon at the end of the tube is inflated with air through the blue side port. Position of the tube is checked by looking for symmetrical rising of the chest on ventilation breath sounds bilaterally and no gurgling over the epigastrium indicating oesophageal intubation. The tube is then tied into place.

Question 8

Answer 8

Feeding NG Tube
This is a feeding nasogastric tube (clinifeed tube) which is used to long term enteral nutrition in patients. It is thin bore and soft making it more comfortable for patients, it is also made of silastic which blocks less often.
After explaining to the patient what you are about to do the tube is inserted into the nostril after it has been lubricated. These tubes come with a wire inside them to aid their introduction, you advance the tube as the
patient swallows. Correct position of the tube is checked by x-raying for the wire. When you are happy with the position of the tube the wire is removed and the feed attached in a sterile manner.

Question 9

Answer 9

Five Percent Dextrose
This is a bag of 5% dextrose, which can be used in conjunction with normal saline to provide the normal daily fluid requirement for a patient.
One litre of 5% dextrose contains 50g of dextrose in 1 litre of water.
It should be remembered that because the sugar in this fluid is metabolised to carbon dioxide and water you
are essentially giving them water

• 25-30 ml/kg/day of water
• 1 mmol/kg/day of potassium, sodium and chloride
• 50-100 g/day of glucose (limit starvation ketosis)

Question 10

Answer 10

Fracture Plate
This is a plate that is used in conjunction with screws to internally fix a bone fracture.

note that in order to properly secure a fracture there needs to be two scrws on either side of the fracture line.

Indications
 Internal fixation of fractures
 This particular type can be used to fix tibial #s

Method
 Requires open reduction
 Plate aligned with orientation of bone
 Screws used to fix plate to bone

Complications
 Relate to #, procedure and the plate
The Plate
 Infection
 Failure
 Malposition of the remodelled fracture

Other Types of Fixation
 POP
 Continuous traction: collar and cuff
 External fixation
 Intramedullary nail
 K wires
 DHS
 Cannulated screws

Question 11

Gelofusin

Answer 11

Gelofusin

This is 500ml of gelofusin which is an example of an artificial colloid solution.
Colloid solutions raise the plasma oncotic pressure and hence expand the intravascular compartment. There are other colloids and some available are natural e.g. albumin and blood. Colloids are useful in cases of
shock e.g. due to sepsis or hypovolaemia

Question 12

Hartman’s Solution

Answer 12

Hartmann Solution
This is an example of a crystalloid solution, which contains sodium, chloride, potassium, calcium, lactate & bicarb. It has a similar composition to the extracellular fluid. It can be used to provide the normal daily fluid requirement of a patient or to supplement the patient for additional loses.
Hartmann’s solution is a favorite solution of anaesthetists and is the fluid advocated to be given initially in trauma in the Advanced Trauma and Life Support (ATLS) guidelines.

Na+ 131mmol, Cl– 111mmol, lactate/HCO3- 29mmol, K+ 5mmol,
and Ca2+ 2mmol per litre of fluid.

• 25-30 ml/kg/day of water
• 1 mmol/kg/day of potassium, sodium and chloride and
• 50-100 g/day of glucose (limit starvation ketosis)

Question 13

Indications, features, method, complications

Answer 13

Hemiarthroplasty Prosthesis
This is a hemiarthoplasty hip prosthesis.
It is used in cases of intracapsular fractures of the neck of femur, as these fractures are prone to avascular
necrosis of the femoral head.

Question 14

Answer 14

Hickman Line
This is a an example of a long term central venous line which is inserted in a similar way to a central line (usually subclavian).
The remnant of the line is tunnelled subcutaneously which decreases the incidence of line infection. These are indicated for longterm parenteral nutrition, longterm intravenous antibiotic therapy and
chemotherapy.

Question 15

Indications, features, methods, comp

Answer 15

Hip Replacement
This is the femoral part of a total hip replacement which articulates with an plastic acetabular cup.
The main indication for a hip replacement is pain from osteoarthtis of the hip.

Question 16

Answer 16

IM Femoral Nail
This is an intramedullary femoral nail which is used to internally fix femoral shaft fractures. Interlocking screws are used to fix the nail. They are usually removed after 12 / 18 months.

Indications
 Form of internal fixation used in the Mx of long-bone #s
 Femur, tibia, humerus

Features
 Titanium or titanium alloy
 Screws insert proximally and distally provide rotational and longitudinal stability
 Curve fits contour of tibia

Dynamisation
 Removal of one or more screws in order to allow collapse
 ↑ loading of fracture site → quicker union

Method
 Inserted under GA
 Nail hammered into medulla of bone
 Screws lock nail in place

Complications of the Prosthesis
 Fracture during nail insertion
 Infection
 Fat embolus
 Delayed or non-union

Question 17

Answer 17

Intravenous Cannula
This is an intravenous cannula which can be used to give intravenous fluids and drugs. If you wish to give fluid quickly the cannula must be short and large bore.

Question 18

Answer 18

Irrigation Urinary Catheter
This is a large bore irrigation type foley urinary catheter which is used to irrigate the bladder of patients at risk
of clot retention e.g. after a TURP.

(three way irrigation foley catheter) -10ml in baloon

Indication
 Irrigate bladder in pts @ risk of clot retention
 E.g. after TURP or in pts c¯ haematuria
Features
 3 ports
 Balloon inflation
 Drainage (middle)
 Irrigation

Question 19

Answer 19

Laparoscopic Port
This is a Laparoscopic post which is used during Laparoscopic procedures e.g. Laparoscopic
cholecystectomy.
These ports allow the surgeon to insert a telescope and instruments in the patient

Indications
 Access the abdomen during laparoscopic surgery
 E.g. lap chole

Features
 Trocar ± sharp blades
 CO2 insufflation port
 Instrument port with rubber flanges

Method
 Small incision made in the abdominal wall
 Either trocar used to enter abdomen or surgical entry is made
 Laparoscope usually inserted @ the umbilicus
 Abdomen inflated c¯ CO2: cheap, soluble, inert gas

Complications
 Visceral trauma on insertion

Question 20

Answer 20

Laryngeal Mask
This is a laryngeal mask airway which can be used to provide an airway during short operations e.g. day cases. It does not protect the airway.

Question 21

Answer 21

Leg Bag
This is a leg bag which is attached to urinary catheter.
The Bag is strapped to the leg of the patient and is indicated for patients who are mobile and have either a
short or long term indwelling urinary catheter.
A man who suffers with incontinence following sphincter damage after multiple TURPs.

Question 22

Answer 22

Mannitol
Mannitol is an osmotic diuretic which can be used to lower raised intracranial pressure or drive the urine
output in a patient with obstructive jaundice to prevent hepato renal syndrome

Indications
 Osmotic diuretic
 Lower intracranial pressure
 ↓ IOP in hyphema

Method
 Given centrally

Complications
 May ↑ ICP in the long-term
 CI in severe cardiac failure and pulmonary oedema

Question 23

Answer 23

Nasopharyngeal AirwayIndications
 Airway adjunct used in pts. with impaired level of consciousness to maintain a patent airway

Method
 Sized according to diameter of pts. little finger
 Inserted into the nasopharynx using a rotational action
 Safety pin and flared end prevents the tube becoming irretrievable.

Complications
 Bleeding: trauma to nasal mucosa
 Intracranial placement

Contraindications
 Absolutely contraindicated in pts. c¯ facial injuries or evidence of basal skull #
 Racoon eyes
 Battles’ Sign: mastoid bruising
 Haemotympanum
 SCF rhinorroea or otorrhoea

Question 24

Answer 24

Needle Holders
These are special forceps designed to hold the needle to allow the surgeon to suture accurately.

Question 25

Answer 25

Normal Saline

Normal (0.9%) Saline. Normal saline is an example of a crystalloid solution which contains 153mmol of NaCl.
It can be used to provide the normal daily fluid requirement for a patient or to replace additional losses e.g.
vomit or diarrhoea

Question 26

Answer 26

Nylon Suture
This an example of a synthetic non absorbable monofilament suture. This suture can be used to close skin wounds.

Question 27

Answer 27

Indications
 Airway adjunct used in pts. with impaired level of consciousness to maintain a patent airway e.g. during extubation

Method
 Sized from incisors to angle of mandible
 Insert upside down and rotated once in the oral cavity

Complications
 Oropharyngeal trauma

 Gagging → vomiting

Question 28

Answer 28

Paediatric Oxygen Mask
This is a paediatric oxygen mask.

Question 29

Answer 29

Proctoscope
This is a proctoscope, it is 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.

Indications
 Investigation and management of pts. c¯ perianal pathology: e.g. haemorrhoids, low rectal Ca
 Examination of the anal canal and lower rectum ± biopsy
 Therapeutic: banding, sclerotherapy

Features
 Obturator to aid insertion
 Attachment for a light source

Method
 Consent pt. and explain procedure.
 Examine perineum and perform DRE c¯ pt. in left-lateral position.
 Lubricate scope c¯ aquagel, attach light source
 Hold in left hand and insert into the rectum.

Complications
 Haemorrhage
 Perforation

Question 30

Answer 30

Ryles NG Tube
This is a Ryles nasogastric tube which is primarily used for draining the stomach but can also be used to insert drug, feed or contrast into the GI. After explaing what you are about to do to the patient , you will require a NG tube which has been in the fridge as it is stiffer, some lubricant, a bladder syringe , a drainage bag, litmus paper and tape. The tip of the NG tube is lubricated and inserted into the nostril of the patient pointing it towards the occiput.
The tube is then advanced as the patient swallows. The correct position of the tube is checked by aspirating gastric contents and checking for acidity on litmus paper, if this is unavailable then air can be inserted to the
tube and the epigastrium auscultated for bubbling. Finally an x ray can be taken to identify the tube, however this is time consuming and often does not show the tube. Once the tube is in the correct position a bag is attached and it is taped to the patients face.

Question 31

Answer 31

Self Retaining Retractor
This is a type of retractor used to hold wounds open e.g. during a hernia repair or an appendicectomy.

Indications
 Used to retract a surgical excision and retain the incision open.
 E.g. in hernia repair or and appendicectomy

Complications
 Compression of nerves of vessels

Question 32

Answer 32

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

Indications
 Injection of haemorrhoids with 5% phenol in almond oil
 Sclerosant

Method
 Consent and explain procedure to pt.
 Pt. placed in left lateral position and syringe used c¯ proctoscope to enable haemorrhoid visualisation
 2ml of phenol is injected above dentate line: insensitive

Complications
Immediate
 Pain if injected below dentate line
 Damage to nearby structures
 Primary haemorrhage
Late
 Prostatitis
 Impotence

Question 33

Answer 33

Silastic Urinary Catheter
This is a drainage type silastic Foley urinary catheter.
Silastic catheters are made of silicone and are more appropriate than latex one for long term catheterization.

Question 34

Answer 34

Single Lumen CVP
Central venous cannulas are inserted in the superior vena can usually via either the internal jugular or subclavian veins. They can be single or triple lumen lines. They are primarily used to measure the central venous pressure. They can also be used for the insertion of drugs e.g. amiodarone, dopamine or chemotherapy.

Question 35

Indications, features, method, complications

Answer 35

Stiff Neck Cervical Collar
This is a stiff neck collar which is used to stabilise the cervical spine in a trauma patient when used in conjunction with 2 sand bags and tape. They are sized by measuring the number of fingers from the clavicle to the angle of the mandible, and this is then compared to the measuring peg on the stiff neck collar.

Indications
 Stabilise the cervical spine in trauma pts.
 Used c¯ two sandbags and tape

Features
 Comes flat packed and must be assembled
 Hole at front allows access to the trachea

Method
 Sized by measuring the number of fingers from the clavicle to the angle of the mandible
 “Key dimension” then compared to the sizing peg on the hard collar.

Complications
 Incorrect placement
 Neck not in neutral alignment
 Chin not flush c¯ end of chin piece

Question 36

Answer 36

Swan Ganz catheter
This is a Swan Ganz catheter which is used to measure the pressures in the heart, the pulmonary artery wedge pressure and can also be used to measure the cardiac output. These are used in the intensive care setting and are typically inserted into a central vein.

Indications
 Flow directed pulmonary artery catheter
 Measure the pulmonary capillary wedge pressure
 Indirect measure of LA filling pressure
 Measure cardiac output
 Used in cardiogenic or septic shock when accurate haemodynamic data is required
 Its use has not been shown to improve outcome

Method
 Used in the intensive care setting
 Inserted into a central vein.

Question 37

Answer 37

Synthetic Absorbale Suture
This is an example of a synthetic absorbable suture which can be used for bowel anastomosis or tying off
vessels

Question 38

Answer 38

Indications
 Used to prevent VTE
 All patients undergoing surgery
 All immobile pts

Method
 Available in different sizes
 Width: widest point of calf
 Length: heel to buttock fold
 Often used in conjunction c¯ LMWH

Complications
 Contraindicated in pts c¯ arterial disease

Question 39

Answer 39

Tracheostomy

This is a temporary tracheostomy; it is an example of a definitive airway as it protects the patients lungs from aspiration. One of the most common occasions you will see a tracheostomy is on a patient being ventilated on the intensive care unit. A tracheostomy allows more efficient ventilation of the patient with a decreased dead space and also allows more effective suctioning of the airways. Tracheostomy can also be used in patients with upper airway obstruction or after laryngeal surgery

Question 40

Answer 40

Triple Lumen CVP
Central venous cannulas are inserted in the superior vena can usually via either the internal jugular or subclavian veins. They can be single or triple lumen lines. They are primarily used to measure the central venous pressure.
They can also be used for the insertion of drugs e.g. amiodarone, dopamine or chemotherapy

Question 41

Answer 41

Tru-cut Needle
This is a trucut biopsy needle which is used to take histological specimens from lesions e.g. breast lumps or liver.
The procedure can be performed under local anaesthetic.

Indications
 Used to take histological specimens from lesions
 Part of triple assessment of breast lumps
 Liver
 Kidney
 Prostate: transrectally

Method
 Consent and explain procedure to pt.
 Anaesthetise area c¯ LA
 Needle advanced under US guidance
 Spring handle is pressed, advancing the specimen tray into the target lesion
 Further pressure fires the surrounding sheath, obtaining a biopsy

Complications
 Bleeding
 Pain
 Cancer seeding

Question 42

Post Op Pyrexia

Answer 42

Early: 0-5d post-op
 Blood transfusion
 Physiological: SIRS from trauma: 0-1d
 Pulmonary atelectasis:24-48hr
 Infection: UTI, superficial thrombophlebitis
 Drug reaction

Delayed: >5d post-op
 Collections
 Pneumonia
 DVT / PE
 Wound infection: 5-7d
 Anastomotic leak: 7d

Examination of Post-Op Febrile Pt.
 Observation chart, notes and drug chart
 Wound
 DRE
 Legs
 Chest
 Lines
 Urine
 Stool

Question 43

Vacutainers

purple, yellow, red, green, blue, grey, black

order

Answer 43

Question 44

Seldinger technique

Answer 44

• Triple lumen central venous catheter
• Angiography
• Chest drain insertion
• Percutaneous endoscopic gastrostomy

Question 45

Answer 45

PICC Line

Question 46

Answer 46

Tessio Catheter

Question 47

Answer 47

Port-a-cath

Question 48

Answer 48

McKintosh Laryngoscope

Question 49

Oxygenation

Options (x5)

Answer 49

Nasal Prongs
 1-4L/min = 24-40% O2

Simple Face Mask
 Variable O2 concentration depending on O2 flow rate

Non-rebreathing Hudson Mask
 Reservoir bag allows delivery of high concentrations of O2.
 60-90% at 10-15L

Venturi Mask
 Uses the Bernoulli Principle
 ↑ speed of flow → ↓ pressure
 Altering O2 flow speed can entrain a known concentration of air for dilution
 Provide precise O2 concentration at high flow rates
 Yellow: 5%
 White: 8%
 Blue: 24%
 Red: 40%
 Green: 60%

CPAP
 Tight fitting mask connected to reservoir or high O2 flow allowing FiO2 ~1.
 Positive pressure is applied continuously to the patient’s airway.
 Benefits
 Recruitment of collapsed lung units
 ↓ shunt → ↑PaO2
 ↑ lung volume → improved compliance → ↓ work of breathing.
 CPAP usually has little effect on PaCO2

Question 50

Ventilations

Types, indications, complications

Answer 50

Types
 Non-invasive: tight-fitting mask
 Invasive: ET or tracheostomy

Indications
 Respiratory failure refractive to less invasive Rx
 At risk airway
 Elective post-op ventilation
 Physiological control (e.g. hyperventilation in ↑ICP)

Complications
 Cardiovascular compromise
 Pneumothorax
 Fluid retention
 VILI
 VAP
 Complications of artificial airway: e.g. tracheal stenosis

Question 51

Types of nutritional supplementation

Answer 51

Question 52

Nutritional supplementation Complications

Answer 52

Complications
 Line-related
 Pneumothorax / haemothorax
 Cardiac arrhythmia
 Line sepsis
 Central venous thrombosis → PE or SVCO
 Feed-related
 Villous atrophy of GIT
 Electrolyte disturbances: e.g. refeeding syndrome
 Hyperglycaemia and reactive hypoglycaemia
 Vitamin and mineral deficiencies

Question 53

Refeeding syndrome

Answer 53

Life-threatening metabolic complication of refeeding via any route after a prolonged period of starvation.

Pathophysiology
 ↓ carbs → catabolic state w ↓insulin, fat and protein catabolism and depletion of intracellular PO4
 Refeeding → ↑ insulin in response to carbs and ↑ cellular PO4 uptake.
 → hypophosphataemia
 Rhabdomyolysis
 Respiratory insufficiency
 Arrhythmias
 Shock
 Seizures

Chemistry
 ↓K, ↓Mg, ↓PO4

At-Risk Patients
 Malignancy
 Anorexia nervosa
 Alcoholism
 GI surgery
 Starvation

Rx
 Identify at-risk pts in advance and liaise c¯ dietician
 Parenteral and oral PO4 supplementation
 Rx complications

Question 54

Preventing DVT

Answer 54

DVT is commonest complication of THR
Peak incidence @ 5-10d post-op

Pre-Op
 Pre-op VTE risk assessment
 TED stockings
 Aggressive optimisation: esp. hydration
 Stop OCP 4wks pre-op

Intra-Op
 Minimise length of surgery
 Use minimal access surgery where possible
 Intermittent pneumatic compression boots

Post-Op
 LMWH
 Early mobilisation
 Good analgesia
 Physio
 Adequate hydration

Question 55

Major Fluids: crystalloids

Answer 55

NS
 0.9% NaCl = 9g/L
 154mM NaCl
 Use: normal daily fluid requirements + replace losses

5% Dextrose
 50g dextrose /L
 Use: normal daily fluid requirements

Dextrose-Saline
 4% dextrose = 40g/L
 0.18% NaCl = 31mM NaCl
 Use: normal daily fluid requirements

Hartmann’s / Ringer’s Lactate
 Na: 131mM
 Cl: 111mM
 K: 5mM
 Ca: 2.2mM
 Lactate / HCO3: 29mM
 Use: Trauma, Burns (Parkland)

Daily Requirements
 3L dex-saline c¯ 20mM K+ in each bag
 1L NS + 2L dex c¯ 20mM K+ in each bag
 Each bag over 8h = 125ml/h

Problems
 Give 1L NS → ~210ml remaining IV
 Give 1L D5W → ~70ml remaining IV
 Acidosis or electrolyte disturbances
 Fluid overload

Question 56

Major Fluids: Colloids

Answer 56

Synthetic
 Gelofusin
 Volplex
 Haemaccel
 Voluven

Natural
 Albumin
 Blood

Use
 Fluid challenge
 Hypovolaemic shock
 Burns: Muir and Barclay

Problems
 Anaphylaxis
 Volume overload

Question 57

Surgical Drains

indications and types

Answer 57

Indications
 Prophylactic
 Prevent fluid accumulation
 Therapeutic
 Drainage of established collections
 Drain a viscus: e.g. bladder
 Collect blood for autotransfusion

Types
Open or Closed
Open
 e.g. corrugated rubber or plastic sheets
 Fluid collects into dressing or stoma bag
Closed
 e.g. chest drains, Robinson or Redivac
 Tube attached to a container

Active or Passive
Active: driven by suction
 e.g. Redivac drain
Passive: no suction, driven by pressure differential
 e.g. Robinson drain

Question 58

Surgical Drains

Removal and complications

Answer 58

Removal
 Remove drain once drainage stopped or <25ml/d
 Perioperative bleeding and haematoma: 24-48hrs
 Intestinal anastomosis: >5d
 T-tube: 6-10d
 T-tube cholangiogram first to ensure distal patency of CBD
 Shortening: removal of drain by 2cm/d to allow tract to heal gradually.

Complications
 May ↑ risk of infection
 Damage may be caused by mechanical pressure or suction.
 May limit pt. mobility

Question 59

Answer 59

Robinsons (simple drain or drain tube)
 Type: closed, passive
 Use: abdominal surgery
 Risk of infection
 Contamination: faeces or pus

Question 60

Answer 60

Redivac
 Type: closed, active
 Use
 Breast surgery: prevent seroma or haematoma
 Thyroid surgery: risk of haematoma

Question 61

Answer 61

Bile Bag
 Type: closed, passive
 Use
 NGT
 T-tube

Question 62

Answer 62

Pemrose Drain
 Type: open, passive
 Use: abdominal surgery

Question 63

Answer 63

Tissue Drain
 Type: open, passive
 Use: large cavities

Question 64

Suture types

Monofil vs braided

Answer 64

Monofilament
 Advantages
 ↓ risk of infection
 ↓ friction in tissues
 Disadvantages
 Harder to handle: stiff and has more memory
 Knots may slip
 Less tensile strength

Braided
 Advantages
 Easier to handle: less memory
 Knots slip less
 Greater tensile strength
 Disadvantage
 ↑ risk of infection
 ↑ friction in tissues

Question 65

suture types

Natural vs synthetic

Answer 65

Question 66

Suture removal times

Answer 66

 Further away from heart = longer time
 Face and neck: 3-5d
 Scalp: 5-7d
 Trunk: 10d
 Arms: 7d
 Legs 10-14d
 Pts. c¯ poor wound healing may need longer

Question 67

Needle types

Answer 67

 Straight: hand-held, used for skin closure
 Curved: require needle-driver
 Diameter
 Fine: GI and vascular surgery
 Medium: general closure
 Heavy: hernia repair
 Tip
 Blunt: abdominal wall closure
 Shape
 J-shaped: abdominal wall closure

Question 68

PR Bleeding differential

Answer 68

Commonest
 Perianal: haemorrhoids, fissure
 Diverticular disease
 Malignancy

Other
 IBD
 Infection
 Upper GI bleed
 Angiodysplasia

Question 69

Advantages and disadvantages of MAS

Answer 69

Advantages of MAS
Smaller Incisions
 ↓ post-op pain
 ↓ risk of wound infection
 Faster post-op recovery
 ↓ hospital stay
 Better cosmesis

May allow better visualisation and access
 Can visualise and operate on pelvic organs in lap appendicectomy.
 Dx and fix contralateral hernia in lap hernia repair.

Disadvantages of MAS
 Different anatomy
 ↓ tactile feedback (can’t feel colon tumours)
 2D view of 3D structures
 Technically challenging and old skills may be lost
 Complications (e.g. haemorrhage) may be harder to Mx
 Expensive

Question 70

Answer 70

Circular Bowel Stapler

Indications
 Rectal anastomosis
 Gastrectomy
 Haemorrhoids
 Rectal prolapse

Features
 Anvil sutured into proximal limb c¯ purse string suture
 Anvil fits into stapler and provides counterpoint for staple insertion.

Complications
 Anastomotic leak

Question 71

Checking the Integrity of an Anastomosis

Answer 71

Intra-operative
 Fill pelvic cavity with saline
 Insufflate rectum c¯ air and look for bubbles in the saline.

Post-operative
 Water-soluble contrast enema

Question 72

Indications for catheterisation

Answer 72

Diagnostic
 Measure urine output
 Sterile urine sample
 Renal tract imaging

Therapeutic
 Urinary retention
 Immobile patients
 Bladder irrigation
 Intermittent decompression of neuropathic bladder

Indications for long term catheterisation

 Chronic bladder outlet obstruction
 Neurogenic bladder c¯ chronic retention
 Complications of incontinence
 Refractory skin breakdown
 Palliative care
 Pt. preference

Question 73

Catheter complications

Answer 73

Early
 Creation of false tract
 Urethral rupture
 Paraphimosis
 Haematuria

Delayed
 Infection
 Blockage

Question 74

Catheter CI

Answer 74

Urethral trauma
 Blood @ urethral meatus
 High-riding prostate
 Scrotal haematoma
 Pelvic fracture

Question 75

Management of non-draining catheter

-TWOC

Answer 75

 Bypassing catheter: consider condom catheter
 Blocked: flush c¯ 20ml sterile 0.9% NS or consider 3- way
 Slipped into prostatic urethra: flushes but won’t drain
 Catheter has perforated the lower tract on insertion and is not in the bladder
 Renal or pre-renal failure

Trial WithOut Catheter

 After 24-72 hrs in AUR
 May be performed as a urology outpt. if retention likely.
 Tamsulosin ↓s risk of retention after TWOC

Question 76

Clean intermittent self catheterisation

(indications)

Answer 76

Alternative to indwelling catheter in CUR
Also useful in pts. who fail to void after TURP

Indications
 Chronic retention
 Neuropathic bladder
 MS
 DM neuropathy
 Spinal trauma

Question 77

Answer 77

Question 78

Answer 78

Suprapubic catheter

Indications
 Urethral injuries
 Urethral obstruction
 BPH
 Ca prostate

Method
 US guided insertion of catheter under LA
 Trocar inserted into catheter and unit advanced through skin.

Complications
 Viscus perforation
 Haemorrhage
 Malignancy seeding

Advantages
 ↓ UTIs
 ↓ stricture formation
 TWOC w/o catheter removal
 Pt. preference: ↑ comfort
 Maintain sexual function

Disadvantages
 More complex: need skills
 Serious complications can occur

CI
 Known or suspected bladder carcinoma
 Undiagnosed haematuria
 Previous lower abdominal surgery
→ adhesion of small bowel to abdo wall

Question 79

Acute Urinary Retention

Clinical features, Ix, Mx

Answer 79

Question 80

Indication, method, comp

Answer 80

JJ or Ureteric stent

Indication
 Relieve ureteric obstruction
 Stones
 Tumours
 May be inserted intra-op during renal Tx

Method
 Retrograde: cystoscopic guidance
 Anterograde: percutaneous

Complications
 Infection
 Blockage
 Displacement / migration

Question 81

Answer 81

Chest drain tube and trocar

Question 82

Total Arthoplasty prosthesis: Indications, features, methods, comp

Answer 82

Question 83

Fat Embolism Syndrome

Presentation/Ix/Mx

Answer 83

Presentation: SOB, petechial rash, confusion
 Typically 24-72h between injury and onset
 Resp: dyspnoea ± chest pain
 Petechial rash: upper anterior trunk, arms, neck
 CNS: headache, confusion, agitation
 Renal: oliguria, haematuria

Ix
 ABG: hypoxia, hypocapnoea
 FBC: ↓ plats, ↓Hb
 CT chest

Mx
 Supportive: O2, volume resuscitation
 Steroids

Question 84

Clearing the C spine

Clinical and radiological

Answer 84

Clinical clearance:

Indication: NEXUS Criteria
 Neurological deficit
 Spinal tenderness in the midline
 Altered consciousness
 Intoxication
 Distracting injury

Method
 Examine for bruising or deformity
 Palpate for deformity and tenderness
 Ensure pain-free active movement

Radiological clearance

Indications
 Pt. doesn’t meet criteria for clinical clearance

Modalities
 Radiograph initially
 Clear if normal radiograph and clinical exam
 CT C-spine if abnormal radiograph or clinical exam

Question 85

Answer 85

Fogarty Embolectomy catheter

Indication
 Mx of acutely ischaemic limb 2O to embolus

Method
 Vascular access gained to femoral artery @ groin.
 Catheter passed distal to embolus
 Balloon is inflated and catheter withdrawn.

Question 86

Renal Biopsy

Indications, CI, Procedure, Complications

Answer 86

Indications
 Unexplained ARF/CRF
 Acute nephritic syndrome
 Unexplained proteinuria / haematuria
 Systemic disease c¯ renal involvement (e.g. SLE)
 Suspected Tx rejection

CI
 Abnormal clotting
 Single kidney (except Tx)
 Small kidneys from CRF (↑ bleeding risk + too late)
 Renal neoplasms

Procedure
 Stop aspirin (1wk) and warfarin (2d) in advance
 Check FBC, clotting and G&S
 US-guided Tru-Cut needle biopsy

Complications
 Macroscopic haematuria in 1%

 Transfusion needed in 0.1%

Question 87

Answer 87

ABG KIT!

Question 88

Answer 88

SUTURE

Question 89

Answer 89

This is a non invasive positive pressure ventilation mask.

I have seen this used on the respiratory ward on a patient with COPD

It can be used to deliver:

CPAP: Continuous positive airway pressure

BiPAP: Bilevel Positive Airway Pressure

CPAP is indicated in patients with T1RF e.g. OSA/acute HF

BiPAP is indicated in patients with T2RF e.g. COPD

Disadvantages: claustrophobia, reduced tollerance by the patinet, emesis and pressure sores.

Full face masks can also be used, this eliminates nasal bridge discomfort as it seals the perimeter of the face where facial contours are smoother and pressure sensitivity is lower