common surgical procedures

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Basic Clinical Procedures Chapter 2 43
01
3 Introduce yourself to the patient and explain what you
are going to do and why.
4 Attach the tourniquet to the upper arm of the patient
and ask them to open and close their hand.
5 Select a vein; usually the antecubital fossa is the best.
Also make sure you are not taking blood from an arm that
has an intravenous drip running into it.
6 Assemble the vacutainers.
7 Swab the selected vein with the alcohol swab.
8 Warn the patient you are about to start and insert the
needle at 30° to the skin.
9 Insert a bottle into the vacutainer barrel; if the needle is
in the vein, the bottle will fill with blood. If not, adjust the
needle.
10 Fill all the bottles required.
11 Remove tourniquet.
12 Place cottonwool ball over needle and withdraw it
rom the skin; the patient should apply pressure for 5 min.
13 Dispose of sharps.
14 Label bottles fully with name, hospital number, date of
birth and date of sample. Place them with the completed
forms in a bag for transfer to the laboratory.
15 Apply a small plaster to the patient’s arm.
Insertion of an intravenous cannula
Equipment

Intravenous cannula (for sizes refer below):
blue, 22G (very small)
pink, 20G (small)
green, 18G (average)
grey, 16G (large)
brown, 14G (very large)
Blood collection tubes (Vacutainer system)
Correct order of draw
(as recommended by the National Committee for Clinical Laboratory Standards,
1991 Guidelines Reference H3A3)
• Blood culture (Bacteriology)
• Plain or serum (no additives)
• Coagulation profiles
• Other additive tubes, e.g. EDTA, lithium heparin, glucose
Forms calcium salts to
remove calcium
EDTA liquid Haematology (FBC) and blood
bank (crossmatch): gently invert
bottle after filling to prevent
clotting and platelet clumping
Forms calcium salts to
remove calcium
Sodium citrate Coagulation tests (INR), full
draw required
Anticoagulates with
lithium heparin; plasma is
separated with PST gel at
the bottom of the tube
Plasma separating
tube (PST) with
lithium heparin
Chemistries
Serum separator tube
(SST) contains a gel at the
bottom to separate blood
from serum on
centrifugation
None Chemistries, Immunology and
Serology
Blood clots, and the serum
is separated by
centrifugation
None Chemistries, Immunology and
Serology, some blood bank
profiles
Antiglycolytic agent
preserves glucose for up to
five days
Sodium fluoride
and potassium
oxalate
For glucose levels
Forms calcium salts to
remove calcium
Sodium citrate
(buffered)
Erythrocyte Sedimentation Rate
(ESR)
44 Part 1 Clinical Skills and Investigations
01

Tourniquet

Saline flush or intravenous fluid with giving set

Securing dressing

Sharps bin
Procedure
1 Gather your equipment, introduce yourself to the
patient and explain what you are about to do.
2 Apply a tourniquet to upper arm and ask the patient to
open and close their hand.
3 Select a vein that is palpable and straight; if the cannula
is for long-term use, it is best situated away from joints,
e.g. lower forearm cephalic vein. In an emergency, select a
large-bore cannula in an antecubital fossa vein.
4 Take the cannula, remove the sheath, open the wings
and introduce the needle into the vein at 30° to the skin.
Once the needle is in the vein there will be a visible flash-
back in the barrel of the needle.
5 Slide the cannula into the vein over the needle while
removing the needle.
6 Remove the tourniquet, remove the needle and put
white cap on the end of the cannula.
7 Dispose of sharps.
8 Apply a dressing to the cannula.
9 Flush the cannula with saline.
10 Eliminate any air bubbles from the giving set of the
intravenous fluid and then attach it to the cannula.
11 Set infusion rate and note time infusion started.
Venous cut-down
If emergency intravenous access is required and no other
sites are available, then a venous cut-down can be per-
formed. The most consistent and easily accessible large
vein is the long saphenous vein; alternative sites include
the antecubital fossa and the wrist. Aseptic technique
should be used.
1 Infiltrate the skin with local anaesthetic.
2 A transverse incision is made 1 cm above and anterior
to the medial malleolus.
3 The vein is gently dissected out; to control the vein, two
ligatures are passed under it.
4 The distal ligature is tied; the other is left untied until a
cannula is inserted.
5 A large-bore cannula is inserted through the skin and
into the vein; the proximal ligature is then tied to keep the
cannula in place.
6 The skin is closed and the cannula secured with a fur-
ther suture and a dressing.
Central venous cannulation
Access to the central veins is a common requirement in
modern practice and is important for:

measurement of central venous pressure;

infusion of irritant drugs, e.g. amiodarone, dopamine,
streptokinase;

infusion of parenteral nutrition;

measurement of pulmonary artery wedge pressure;

infusion of chemotherapeutic agents;

placement of pacing wires.
It is important to note that although fluids can obviously
be given through a central line, it is not the method of
choice if fluid needs to be infused quickly as central lines
tend to be long and thin.
Central venous access may be required for a short
period of time or for longer-term therapy such as chemo-
therapy. If long-term central venous access is required,
then a tunnelled central line should be inserted (e.g.
Hickman line). Non-tunnelled central lines are changed
every 7 days to minimize infection.
Insertion of the central line
In general, most clinicians approach the central veins
from either above or below the clavicle (Fig. 2.9). In the
supraclavicular approach the preferred vein to cannulate
is the right internal jugular vein because it is easily access-
ible, has a straight path to the right atrium and possible
injury to the thoracic duct is eliminated. Also, with the
supraclavicular approach there is less risk of damaging
the pleural cap and causing a pneumothorax. Hence it
should be the method of choice for the less experienced
practitioner.
The infraclavicular or subclavian approach tends to be
used by more experienced practitioners. However, there is
an increased risk of pneumothorax and should not be
used in patients with clotting abnormalities as it is difficult
to stem bleeding from the subclavian vein if haemorrhage
occurs. Nevertheless, this approach makes nursing care of
the central line easier and is more comfortable for the patient.
Figure 2.9 Insertion of a central venous cannula: internal
jugular approach.
Basic Clinical Procedures Chapter 2 45
01
Equipment

Central line set:
central venous catheter cannulation needles
syringes scalpel blade
introducing wire track dilator

Saline

Local anaesthetic

Suture material

Antiseptic

Transparent dressing

Giving set

Sterile pack

Sterile gloves
Procedure
1 You will need an assistant for this procedure to pass you
items while you are sterile; the maintenance of sterility is
extremely important, especially when placing lines on the
ward.
2 Explain the procedure to the patient.
3 Remove the pillows from under the head and tilt the
patient 30° head down. Some patients may not tolerate
this, especially those in heart failure.
4 Place a bag of fluids under the right shoulder to bring
the vessels forward.
5 Expose the area and turn the patient’s head to the left.
6 Scrub and don sterile gloves. With patient in position
paint the area where you are going to insert the central line
with antiseptic.
7 Inject local anaesthetic into the skin and deeper tissues
at the cannulation site.
internal jugular approach (Fig. 2.9)
The right internal jugular vein runs from the base of the
skull anterolaterally in the carotid sheath below the ster-
nomastoid muscle to meet the innominate vein and
thence into the superior vena cava. The vein can be
approached either high or low. In the high approach, the
landmark for cannulation is half distance along a line
between the sternal head of the clavicle and the mastoid,
and lateral to the sternomastoid muscle. Enter the skin
with a needle connected to a syringe with saline. Advance
the needle deep to the sternomastoid and point towards
the suprasternal notch until you freely aspirate blood. In
the low approach to the vein, the landmark is the tri-
angle formed by the sternal and clavicular heads of the
sternomastoid; the vein lies between them.
subclavian approach (Fig. 2.10)
In this approach, the entry point of the needle should be
3 cm below the midpoint of the clavicle, with the needle
angled towards the jugular notch. Occasionally, the needle
may abut against the clavicular periosteum; this will be
painful, so it is important to anaesthetize down to the clav-
Figure 2.10 Insertion of a central venous cannula: subclavian
approach.
icle. If the clavicle is encountered, then gentle downward
pressure should be applied to the needle to help it enter
the vein.
seldinger technique
The Seldinger technique is common to whichever method
of insertion is used. After the vein has been cannulated,
a flexible wire with a leading J end is inserted into the
needle and fed through the vein towards the right atrium.
Electrocardiographic monitoring helps gauge whether the
wire has been inserted too far and is impinging on the
myocardium. When the wire has been placed, the needle is
removed over the top of it. The track formed by the wire is
then dilated by making a small incision over the wire and
placing a dilating device over it. The central venous
catheter is then fed into the vein over the wire; the wire is
removed through the cannula.
The cannula is aspirated and flushed with saline to
check it is working, is sutured in place and a transparent
dressing applied, and a giving set attached to the line.
Once the patient has received a chest X-ray to check posi-
tion and exclude a pneumothorax, the line can then be
used. The complications of central line insertion are
shown in the box below.
Complications of central line insertion
Immediate
Haemorrhage
Misplacement
Pneumothorax
Early
Infection
Blockage
Late
Scarring
Myocardial damage
46 Part 1 Clinical Skills and Investigations
01
Measuring central venous pressure (Fig. 2.11)
Monitoring of central venous pressure (CVP) is com-
monly required in patients who need intensive fluid
management or who may have circulatory failure. The
CVP can be measured using a transducer or a water mano-
meter. It is essential that you are competent at measuring
the CVP, commonly performed in the ward using a
manometer.
A giving set, three-way tap and manometer are attached
to the central venous catheter. The manometer is attached
to a drip stand that has a scale in centimetres and a side
arm with a spirit level. The CVP must be referred to the
level of the right atrium; this is called the zero point and
must be the same for all subsequent readings. With the
patient lying flat, the zero point is indicated by aligning the
spirit level with the sternal angle; alternatively the point
where this level crosses the midaxillary line can be used.
The zero point should be marked on the scale with a per-
manent marker.
To measure the CVP the manometer is primed with
fluid from a reservoir bag, the zero point is set and the
manometer levelled. The three-way tap is then opened
to allow fluid to run into the patient. The fluid level fluctu-
ates with the respiratory cycle, but will settle around a
point that is recorded as the CVP. A normal CVP is
approximately 5 cm H
2
O. If the patient is hypovolaemic,
right atrial pressure will be lower thereby allowing
more fluid from the manometer to run into the heart,
leading to low or even negative CVP values. When there
is heart failure the opposite occurs and the CVP remains
high.
Arterial blood gas sampling
Femoral artery
Equipment

Arterial blood gas syringe with heparin

Alcohol swab

Swab

1% lidocaine local anaesthetic

Syringe and blue needle for anaesthetic
Procedure
1 The patient should be supine with the groin and leg
extended and slightly abducted.
2 Locate the femoral artery, halfway between the anterior
superior iliac spine and pubic symphysis, 2 cm below the
inguinal ligament.
3 Clean the skin directly over the artery with an alcohol
swab.
4 Raise a bleb of local anaesthetic.
5 Fix the artery between two fingers while inserting hep-
arinized syringe and needle at 90° to skin.
6 Slowly advance the needle until there is free flow into
syringe.
7 Withdraw needle and apply pressure for 5 min.
8 Cap the syringe and place in ice if immediate analysis is
not possible.
Radial artery
Equipment

Arterial blood gas syringe with heparin

Alcohol swab

Swab

1% lidocaine local anaesthetic

Syringe and blue needle for anaesthetic
Procedure
1 Before the procedure perform the Allen test.
2 Occlude both ulnar and radial arteries digitally and
allow the veins to drain all the blood.
3 Release the ulnar artery while keeping the radial artery
compressed.
4 Hand colour should return in less than 5 s, indicating
that there is sufficient collateral blood flow from the ulnar
artery.
Figure 2.11 Measurement of central venous pressure using a
manometer.
Basic Clinical Procedures Chapter 2 47
01
5 If the patient fails the Allen test, radial artery sampl-
ing should not be attempted. If the test is successful,
place patient in supine position with wrist and thumb
extended.
6 Place a rolled-up hand towel under the dorsal surface of
the wrist.
7 Palpate the radial artery.
8 Clean the skin proximal to the wrist joint.
9 Using a 25G needle, raise a small bleb of local anaes-
thetic at the proposed entry site.
10 Insert the needle of a heparin-coated 2-mL syringe at
60–90° through the skin, ensuring avoidance of air in the
syringe.
11 Palpate the radial artery proximally, using it to guide
direction of the needle.
12 Arterial blood pressure will fill the syringe automatically.
13 Withdraw the needle and apply pressure for 5 min.
Cap the syringe and place in ice if immediate analysis is
not possible.
Nasogastric tubes
Tubes inserted into the stomach via the nose are used for
either drainage or feeding. The most commonly used
nasogastric tubes are of the drainage type, are made of
plastic and are called Ryle’s tubes. Tubes used for feed-
ing, which are likely to be in place for a longer period
of time, are thinner and made of silicon, which is softer
and hence more comfortable for the patient and blocks
less readily.
It is very important to remember that passage of a
nasogastric tube is contraindicated in patients with a head
injury because of the risk of passing the tube through a
fractured cribriform plate into the brain. If drainage of the
stomach is required, an orogastric tube can be passed.
Insertion of a drainage tube
Equipment

Nasogastric tube made stiffer by storing in refrigerator

Lubricating jelly

Bladder syringe

Drainage bag

Securing tape

Litmus paper
Procedure
1 Explain to the patient that the procedure is not particu-
larly pleasant and insertion of the tube may cause them to
retch.
2 Inspect the nose for any obvious deformities.
3 Lubricate the tube.
4 Insert the tube into nostril pointing towards the occiput
(Fig. 2.12).
5 Ask the patient to swallow, and as they do advance the
tube.
6 To check the tube is in the stomach aspirate contents
and test for acidity with litmus. Alternatively instil 30 mL
of air with the bladder syringe and auscultate the epigas-
trium for bubbling.
7 Secure the tube to the nose and attach a drainage
bag.
Insertion of a feeding tube
Insertion of a feeding tube is similar to that described
above, except that feeding tubes have a wire within
them as they have insufficient rigidity for insertion into
the stomach. An X-ray is taken of the epigastrium to
check the position of the wire. When in the correct
position the wire is removed, leaving the feeding tube
in place.
Figure 2.12 Insertion of a nasogastric
tube.

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