Fundamentals of Operative Surgery

Fundamentals of
Operative Surgery
Fundamentals of
Operative Surgery
Rajendra Singh Sewta

MS FAIS DHHM DMLS
Smt Shanti Devi Memorial Sewta Hospital
Abohar (Punjab), India
and
Professor of Surgery
Homeopathic Medical College
Abohar (Punjab), India
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Fundamentals of Operative Surgery

© 2009, Jaypee Brothers Medical Publishers (P) Ltd
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording,
or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original.
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will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 2009

ISBN 978-81-8448-573-8
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, Sector 60, Noida
To my Beloved Ones
Mother and Father
Preface
This manual has been a true labor of love. My untold time, effort and
expertise contributed to this project. I had tried my best to touch with
the fundamentals. The manual is written in notebook style; with liberal
use of headings to facilitate the use of manual as a quick reference tool.
It is liberally illustrated with the drawings that significantly enhance
the text. There is comprehensive coverage of routine procedures in
operation theater from the understanding of the equipment and its
working. There is an extensive description of the management of
patients undergoing the operative procedures. The manual is little larger
than was originally intended, but it is an advantage to the reader as
information is thorough, comprehensive and at the fingertips in an easy
language. These features made the manual an excellent companion and
quick reference tool regarding operative surgery. This manual is the
most useful for all Surgeons, Residents, Paramedical Staff, Nursing,
Homeopathy, Ayurvedic, General Practitioners and Operation Theater
Technicians. I will be highly thankful for your valuable comments and
suggestions.
Innumerable individuals deserve my profound thanks. I will name
just a few here. My family, my mother Smt Shanti Devi, brother Ram
Krishan, sister Sulochana, my wife Rita and my loving son Raghav and
daughter Raveena. My special thanks goes to my wife Rita Sewta for
her unanswering support.
I am thankful to Shri Jitendar P Vij (Chairman and Managing
Director), Mr Tarun Duneja (Director–Publishing), and the Editorial
Board of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi.
I must also thank my colleagues Dr Mangat Badal (Prof of Hindi)
and Dr NL Verma (Ophthalmologist) who continuously encouraged
and normally boosted me up to keep my writing on. I am very much
thankful to Mr Anil Seemar Dharampura and Executive Engineer
Mr Bhanaj Lal Arya for their unlimited support.
Finally, I wish to give thanks to my friend Mr Sunil Upneja who is
actually not a typist but typed this manuscript, he is a Faculty Member
in BEd College, Abohar.
Rajendra Singh Sewta
Contents
1. Sterile Precautions and Operation Theater Safety .................... 1

2. Consent ............................................................................................ 10
3. Position of Patient for Surgery and Examination .................... 16
4. Antiseptic Solutions ...................................................................... 21
5. Dressing Material and Bandage .................................................. 28
6. Wound Care, Suturing and Topical Agents .............................. 40
7. Electrosurgery (Diathermy) ......................................................... 50
8. Sterilization ..................................................................................... 61
9. Anesthesia ....................................................................................... 85
10. Intravenous Cannulation ............................................................ 114
11. Nasogastric Tube Insertion and Catheterization ................... 124
12. Operative Notes ........................................................................... 133
13. Care of Instruments ..................................................................... 135
14. Drains ............................................................................................. 139
15. Preoperative Management of Specific Problem in
Surgical Patients ........................................................................... 143
16. Intestinal Stomas ......................................................................... 160
17. Preoperative Care ......................................................................... 171
18. Incisions ......................................................................................... 180
19. Assisting at Operations .............................................................. 188
20. Postoperative Care ....................................................................... 202
21. Postoperative Fluid Therapy ..................................................... 207
22. Postoperative Complications ..................................................... 211
23. Cryosurgery .................................................................................. 215
24. Application of Plaster and Splints ............................................ 217
x Fundamentals of Operative Surgery
25. Oxygen Therapy ........................................................................... 226
26. Emergency Drugs ......................................................................... 236
27. Blood Transfusion ....................................................................... 259
28. Plasma Volume Expanders ......................................................... 276
29. Intravenous Fluids ....................................................................... 283
30. Human Immunodeficiency Virus (HIV) ................................. 293
31. Anaphylactic Shock ..................................................................... 300
32. Endoscopy ..................................................................................... 304
Bibliography ............................................................................................. 317
Index ......................................................................................................... 319
Sterile Precautions and
1 Operation Theater Safety
ENVIRONMENT OF OPERATION THEATER

The environment of operation theater must be free from any
microorganism. It should provide safe and comfortable environment
for the patient as well theater personnel.
• It should be away from the other areas.
• The floor should have a smooth surface for easy washing and
cleaning.
• Any wire running across the floor should be avoided.
• It should be in noise free place.
• Movement in the operation theater must be kept minimum.
• To maintain the sterilization of operation theater, it should be kept
closed.
FUMIGATION OF OPERATION THEATER
Fig. 1.1: Fumigation of operation theater

2 Fundamentals of Operative Surgery
Fumigation is a process of disinfection by exposure to the fumes of
vaporized germicides.
Formalin (Formaldehyde) is commonly used agent to sterilize the
OT and wards. It is very irritant to eye, mucus membrane and skin.
That's why it is neutralized with the ammonia. The exposure period is
3 to 6 hours. After fumigation all the doors must be kept closed. Then it
is used for the operation. Our main aim is to give a sterilized
environment to the patient. By this process all the articles which we
use in OT are also sterilized by this method.
OPERATION THEATER SET UP

• Floor of OT should be mopped up with 1% hypochlorite solution.
• OT should be near to surgical wards and the main lifts or ramp.
• It should be within easy access of the trauma and emergency ward
and radiology department.
• OT should have a double door entrance and double door exit into
the clean corridor.
• There should be a separate store for OT to keep sutures, dressings,
needles and other articles used in surgery.
• There should be a separate space to keep the dirty drapes, linen,
instruments and waste products at the end of the procedure.
• All the doors should be well sealed for proper fumigation of OT.
• OT must have an adequate power points, emergency electricity,
piped gases, etc
• Cardiac resuscitation equipment (DC, shock, defibrillator ) must be
readily available.
• The temperature should range between 19°C and 22°C with
humidity of 45 to 55%.
• OT table should be adjustable with all the working parts and
compatible to C-arm.
• Cushion of OT table should be easy to clean and in good repair.
• There should be ceiling light and should be adjustable, sealed and
cleaned with a facility of light handles so that surgeon and scrub
team can adjust it.
Scrub Room
• This room opens into the OT with two doors one leading to OT and
one to the corridor.
• Sink with taps can be manipulated with the elbow and soap holders
can be manipulated by foot pedals or by elbow.
• There must be brushes for cleaning finger nails.
Sterile Precautions and Operation Theater Safety 3
• Removal of personal clothing-remove your own clothes and wear
gowns or OT dress in changing room.
Masks and Caps

Purpose of masks: Masks are usually used to prevent the spread of
respiratory microorganism. The oropharynx is also a source of bacteria
(about 36 bacteria are emitted for 100 spoken words). The use of mask
has been shown to decrease the number of bacteria. These are also
important for staff protection to avoid cross infection.
Mouth and nose should be covered with the masks. Tie the strings
at the back of the head. It should be worn before scrubbing and it should
be worn in the scrub room before entry to the OT. Masks should be
discarded when it is damp or wet. It should be so thin to take breathing
comfortably. Before wearing the masks and caps (sterilized) wash the
hand thoroughly. Head cap should also be worn to prevent falling of
hair, dust from the head. Female staff should wear scarf to cover all the
scalp hairs.
Scrubbing
• After wearing the cap and mask, scrub the hands and forearm up to
the elbow.
• Brushes should be used for cleaning fingernails.
• Nails should be short to avoid microorganism to reside there.
• Remove all jewellery, e.g. rings, rings with stone.
• Scrub-up time—5 minutes for first case and 2 minutes for next are
with chlorhexidine soap or povidone-iodine soap (scrub) is essential.
The technique should include thorough washing of the hands to
the elbow with removal of the hands to the elbow with removal of
the soap in the direction hand to elbow. Repeat the procedure for
thorough cleanliness. Wash interdigital spaces thoroughly and each
finger separately.
• Drying is again essential. Dry the forearm and hands with sterilized
towel again in the direction hand to elbow then discard the towel.
Gowning (To Wear Gown)

• Design of the gown should be with long sleeves long skirt and high
neck to cover all the clothes of wearer.
• Hold the gown at the inside of gown's neck and open the knot, and
unfold the gown not allow the gown to touch floor or other
equipments in the OT.
• Now slide your hands down in the sleeves of gown.
• Ask the assistant/nurse to tie the strings after overlapping the gown
at the back as much as possible.
Gloves (Gloving)
Gloves are already folded at its sleeves. For the first glove of left hand,
hold the left hand glove with right hand by its folded cuff, do not touch
outside of the glove. Slide your left hand in the gloves and wear it to
cover up to sleeve of gown by keeping the cuff folded. Now wear the
right hand glove, use left hand (worn glove) hold the right hand glove
by inserting the gloved finger under the folded cuff, do not touch outer
side of folded glove, slide over the hand and unfold it without touching
inner side of a glove. Now unfold the left glove cuff by using inner side
of folded cuff and pull over the sleeve of gown.
PREOPERATIVE PREPARATION OF PATIENT

i. Preoperative bath: Preoperative bath should be given to every
patient (if possible)—it definitely reduce the incidence of infection.
ii. Preoperative hospital stay: A short preoperative hospital stay is also
important, it reduces the chance of infection (hospital acquired
infection). As well as acclimatize the patient. Long preoperative
stay should be avoided.
iii. Shaving: The trauma of shaving undoubtedly results in lacerations
to the skin that can increase the infection rate. It is preferably to
do just before the operation (chances of infection are less). It is
preferable to use either clipper or ideally depilation cream but it
is expensive.
iv. Transport: There should be a separate trolley for OT and ward.
One should be for inside use and one should be of outside use.
v. Remove the personal clothing: Preferably it is good to change the
clothing of patient and ask to wear sterilize gown or OT patients
dress.
vi. Jewellary: Jewellary, rings and all the other ornaments worn in legs,
toes should be removed and should be handed over to patients
close relatives.
vii. Check the check list before you receive the patient in OT from
ward sister.
viii. Finger nails should be cleaned and free from any nail polish for
applying pulse oxymeter electrode and for color watching of nail
bed.
ix. Patient bladder must be empty before operation theater entry or
put a Foley catheter.
THE PATIENT IN THE OT
Position of the Patient
• Patient’s trolley (if shifted by trolley) should be positioned close to
the OT table and height should be adjusted.
• Transfer the patient very carefully preferably by using 'patient slide'
to avoid lifting at an awkward angle.
• Patient's leg should be supported to avoid undue pressure on the
calf.
• Optimum position is achieved for surgeons in such height so that
surgeon’s hand movements should be free over the patient.
• The airway and IV drip lines should be protected.
• Head should be well protected to avoid hyperextension of neck.
• If strips are used, must be securely anchored to the table.
• Make a required position that must be appropriate according to the
site which surgery is to be performed.
Protection of Nerves
• This is especially important for a thin patient, chances of nerve
compression are more because of less fat.
• In the Lloyd Davis Stirrups-protect the lateral peroneal nerve. These
must be well padded so that there is no direct contact with metal.
• If the arms are placed on an arm board, protect the ulnar nerve at
the elbow.
• In case of breast operation when arm is placed above the head,
shoulder is supported posteriorly to prevent traction on brachial
plexus.
• In patients with neck problem—patient should wear a protective
cervical collar.
• If patient is having lumber disk problem when Lithotomy position
is required, position should be carefully considered.
• In case of thyroid surgery, tracheostomy in which hyperextension
of cervical spine is required—head must be supported.
• In case of major orthopedic surgery or pelvic surgery to prevent
DVT (deep vein thrombosis)—calves should be well protected
against pressure by whatever means is chosen—stockings or
pneumatic compression. For this subcutaneous heparin is also used
additionally.
Painting and Scrubbing the Operative Site

• The skin of the operation site should be thoroughly scrubbed with
povidone iodine detergent. This will clean and degrease the skin
and removes all the microbes. It must be dried off completely.
• The area like axilla, umbilicus, perineum should be cleaned
completely with extra care as these are the site of harboring microbes.
Vagina and perineal area should be cleaned with chlorhexidine and
cetrimide solution.
• Area must be dried off completely otherwise there is danger of burn
with the use of electrosurgery (diathermy).
Drapping of the Patient

Drapping of the patient should be adequate. Cover all the area except
the endotracheal tube side and the site of incision according to operation.
During Procedure
• All the instruments should be kept in an order to avoid unnecessary
time to find them.
• Instruments must be handled in such a way as to avoid injury to the
patient and staff.
• Instruments should not be left on drapes where they can directly
injure the patient.
• Contaminated instruments, swabs, pads should be discarded.
• Before starting the procedure counting of instruments, pads, swabs,
needle is must.
• Before closure of body cavities, incised organ or joints spaces-count
all the articles.
• Nothing should be removed from OT until the incision is closed
and till scrub nurse tells that all is correct.
• Particular care should be taken when there is a changeover of staff
(in case of prolonged procedure or fatigue of staff) change over nurse
must know each and all about the extent of surgery and all the
equipments and articles being used and their count.
• Staff in the OT including surgeons should be in good health with no
upper respiratory tract infection and there should not be any septic
lesions.
• Talking and movements during procedure should be minimum.
• Assistant should not lean on patients as this may cause compression
of chest/abdomen and may cause damage, bruising or neuropraxia.
• Use of tourniquet, if used the pressure and time should be checked
and noted when it was applied.
• Anesthetist or OT assistant (circulator) should remind the surgeon
about the “tourniquet” time.
Electrosurgery (Diathermy)
Better term is diathermy than electrocautery. In diathermy high
frequency alternating current is passed through the body tissue that
liberates heat.
In Monopolar—current passes through the patient and complete the
circuit through the patient's plate of diathermy. In this there is single
point in the hand.
In Bipolar—the two blades of the forceps are in hand and tissue is
grasped between the blades.
Coagulation and cutting of tissue depends on the power setting,
size of electrode, time and tissue type.
Precautions
• Staff must know the details of diathermy.
• Power should be checked before using.
• It should not be used when ether is used.
• Patient’s plate must be accurately placed, it should not touch the
metal objects such as parts of OT table and IV stand, etc.
• Conductor, e.g. wrapped with wet cloth or jelly is used over the
plate which is in contact with the patient.
• Diathermy and its parts (accessories) foot pedals, plugs leads and
sockets should be checked regularly that all are OK.
• Mode of diathermy monopolar, bipolar or under water cutting
should be checked and selected before to use and correct setting to
be used should be checked.
• Skin is checked after removal of plate.
If it is not working then look for:
1. Its connection
2. Faulty electrodes
3. Contact of plate
• If there is pacemaker—use of diathermy may affect the
pacemaker.
• It is always safer to use a “Bipolar” circuit when possible.
For Endosurgery
• Insulation of the instruments should be checked regularly.
• Always use in a low power setting. Use low voltage.
• Use intermittent rather than continuous.
• Do not use when electrode is in contact with other metallic
instruments.
When Image Intensifier Television (IITV) is Used
• All staff should wear a good quality of lead apron.
• Pregnant staff must not be in OT.
• Sterility must not be compromised.
Specimens
• Specimen removed in operation should be kept in a separate bowl.
• It should always be shown to the patient's relative.
• It is a duty of attending staff to keep in 10% formalin solution in a
container, seal it and label it.
Care of Instruments after Operation

• All the washable instruments must be rinsed with cold water (hot
water cause blood to clot) and washed thoroughly under running
water with brush mainly at the ratchet or joints of instruments.
• All the plug points rechecked for their disconnection.
• Delicate instruments like camera, light cord, diathermy wire,
electrodes, scope should be handed over very first to other
responsible assistant. He/she will clean, dry and will keep in the
respective place.
Care of Linen
• Soiled linen should not be placed or thrown on the floor.
• Linen soiled with urine, stool should be washed with cold water
and remove all the stain.
• If stains are not removed by cold water then use stain remover.
• Blood stains are removed by rinsing in cold water, because blood
contains protein. Heat (hot water) coagulates the protein, so never
use hot water to remove blood stains.
• If blood is dry, apply hydrogen peroxide and wash with cold water.
• When dye stains the linen—wet the cloth and bleaches them in
sunlight, chlorine water.
Care of OT Table Mattress and Pillows

• OT table mattresses should be covered with Macintosh to prevent
staining after the procedure. Macintosh is washed thoroughly.
• Similarly pillow which is used during the procedure for positioning
can be of plastic cover otherwise small Macintosh can be used as a
protection against staining by discharge and expirations.
• If table is stained by blood, should be washed immediately after the
procedure, and clean with 1% hypochlorite solution.
TRANSFER OF THE PATIENT TO RECOVERY ROOM
• Recovery room is usually designed very close to the OT.
• In this room—adequate monitoring equipments are necessary like—
suction machine, oxygen with mask, all emergency medicine, pulse
oxymetry, etc.
Management of Patients in Recovery Room

• The patient airway should be regularly checked.
• Monitor oxygen saturation more than 95%.
• Breathing should be normal.
• Temperature should be normal.
• Pulse, BP, and respiration rate should be regularly recorded in chart.
• Pain relief is mandatory.
• Check the pressure areas.
• IV cannula should be at hand and fit well.
• Any medicine given should be recorded with time.
• If central venous line is present this should be handled in a strict
aseptic way and clearly labeled.
• All tubes and catheter should be cared and should be properly fixed.
• Before sending the patient in ward, patient must be fully awake
with all the verbal response.
• Pulse, BP, respiration and temperature should be normal.
• The effect of muscle relaxants must be completely reversed. Patient
should be able to cough, lift the head and protrude the tongue.
• Dressing (incision site) should be rechecked and if there is bleeding,
inform the doctor and redress it after achieving homeostasis.
• Anti-emetic drugs should be given if needed.
• Take a green signal from anesthetist before sending to ward.
• Urine output, amount of drain, nasogastric aspiration should be
recorded.
TRANSFER OF THE PATIENT TO THE WARD

• If any special instructions should be told to the ward staff.
• All postoperative instructions record must be complete.
• All the OT notes including anesthetic record must be complete.
• Patient should be comfortable and well positioned on the trolley.
2 Consent
INTRODUCTION
The concept of consent comes from the ethical issue of respect for
individual integrity as well as self determination.
In the words of Mr. Justice Cardozo
Every human being of adult years and sound mind has a right to determine
what should be done with his body and the surgeon who performs operations
without his patient’s consent commits assault for which he is liable in danger.
TYPES OF CONSENT
Informal Consent
In surgical practice, obtain informal consent before the commencement
of the treatment. Patients need to be given appropriate and accurate
information about:
a. Their condition and the reasons why it warrants surgery.
b. What type of surgery is proposed.
c. The expected side effects of the proposed surgery.
d. The unexpected hazards of the proposed surgery.
e. Any alternative and potentially successful treatments for their
condition other than the proposed surgery.
f. The consequences of no treatment at all.
Written material (consent) in the potential preferred language should
be provided to supplement verbal communication. Avoid overly
technical language in descriptions and explanations. Surgeon have a
legal as well as moral, obligation to obtain consent for treatment based
on appropriate levels of information. Surgeons have a legal obligation
to give the conscious and competent patient sufficient information in
broad terms about the surgical treatment being proposed and why.
Consent 11
Expressed Consent
Expressed consent may be in oral or written form. It should be obtained,
for example, when the treatment is likely to be more than mildly painful,
when it carries appreciable risk or when it will result in diminishing of
a bodily function.
Expressed consent in written form should be obtained for surgical
operations and invasive investigation procedure. It is prudent to obtain
written consent, as narcotic or anesthetic agents can significantly affect
the patient’s level of consciousness during the treatment.
It is important to note that even an expressed consent for examination
is negated by improper motive of the doctor since such consent is falsely
obtained.
Implied Consent
This is when the patient implies his agreement to the procedure to be
done. This includes history taking, conducting a physical examination
or an investigation and administration of drugs by any route. The
consent is implied by the patient’s reaction to the request, for example,
answering questions, taking off the clothes and holding out the arm
for the needle. Usually not much explanation is given to him. Care must
be taken, however with the examination of the females it is better to
have a witness present during explanation and when conducting an
examination.
VALID CONSENT
Consent consists of three related aspects, i.e.
i. Voluntariness, ii. Capacity, iii. Knowledge
Voluntariness
Patients should give consent completely voluntarily without any
coercion either from the doctor or any third party (e.g. relatives).
Consent obtained with compulsion either by the action or the doctor or
other is no consent at all. One needs to keep in mind that initiatives to
the treatment may not be of the patient herself and she may be coerced
by relatives into giving consent. Here the doctors have to ensure
voluntariness of the consent.
Capacity to Consent
The patient should be in a position to understand the nature and
implications of the proposed treatment, including its consequences. In
this regard the law requires following special considerations.
Age of Consent
In our country only a person who is a major by law, i.e. above the age
of 18 can give valid consent for the treatment. Hence, any person who
is a minor, cannot legally give consent.
The concept of a “mature minor’, i.e. a minor who is mature enough
to understand the implications of his or her treatment though well
established in some western countries is not routinely recognized in
our country. It is also important for a doctor to remember that even
though a minor may represent himself/herself as a major even then
the onus of finding out whether the patient is minor or not is not the
physician.
Mental Incapacity
It is well accepted that a person should be mentally capable to give
consent for his or her own treatment. This implies that patients who
are mentally retarded or mentally incapable due to any disease, process
may not be capable of giving their own consent. In such cases consent
from the legal guardian is essential.
Patients under the influence of alcohol or drugs as well as patients
suffering from extreme pain form a separate category; validity of
consent in such situations is liable to be questioned.
Knowledge
It includes:
i. Nature of the diagnosis
ii. Nature of treatment planned
iii. Foreseeable risk involved in the treatment
iv. Prognosis if treatment is not carried out
v. Any alternative therapy available
It is duty of a doctor to disclose all these points to the patients so
that patients may exercise their right to self determination about the
proposed course of treatment.
When questioned specifically by a patient about the risk involved
in a particular treatment proposed, the doctor’s/nurse’s duty is to
answer both truthfully and as fully as the patient/relative requires.
Consent in Emergency
Generally, it is essential to obtain consent before any treatment is
administered. However, there is an important exception to the rule. In
case of emergency a patient may be unable to give consent, in such
cases a substitute decision maker, if readily available, should be
Consent 13
approached. If however such a person is not on the scene, then it is
duty of the doctor to do what is immediately necessary without waiting
for consent.
For the doctor to declare any clinical situation to be an emergency,
for which consent is not required there should be demonstrable
imminent threat to the life or health of the patient.
There must be an undoubted necessity to proceed at that time. Under
such emergency situations, the treatment should be limited to those
steps which are necessary to deal with, imminent threat to life, limb or
health.
If the circumstances are such that the urgency might be questioned
later, arranging a second medical consent of the patient for operation
of appendicitis and hence was held negligent.
Refusal of Treatment
The patient has a right to control over his or her body. Hence, any
treatment without consent of the patient is actionable.
Any competent adult is entitled to reject any specific treatment
offered to him, even if the decision may entail risk, as serious as death,
and may appear wrong in the eyes of the medical profession. This
concept has been rigorously followed by the western law courts in recent
times.
Reasons for Consent

Consent can be for:
• History taking
• Physical examination
• Investigation – Invasive or non-invasive
• Treatment
• Participation in research
Participation in Research
The information given should be more detailed in case of research
activity. Medical research shares the same aims as therapy with one
vital difference. The patient who participates in the research may not
benefit personally and may be inconvenienced and even harmed. The
Royal College of Physicians recommends an information sheet, time to
reflect and in most cases a written consent. All committee, which consists
of professional and lay members (usually a member from medical
profession, one from the general public and an administrator). The
committee’s consent must be obtained first.
He is also ethical to note what motivates a patient to participate.
This can be:
• As a philanthropic gesture
• Direct financial inducements
• A desire to oblige the doctors
• The hope of obtaining the latest treatment.
MEDICOLEGAL CONSIDERATIONS
There are two types of claim to damage against a medical practitioner.
Negligence
The common law of tort to trespass to the person (battery). In legal
terms tort means an international or reckless untainful application of
force to another person.
Both negligence and battery are likely to be considered when there
is any question as to whether or not a valid consent has been given by
the patient to medical treatment.
If battery were applied indiscriminately, it would give rise to a claim
to damage in a massive number of cases as it theoretically covers
injections, surgery or manipulations done without consent of the patient.
For this reason courts have been reluctant to apply it in many instances,
particularly when it has been seen as a device to avoid the difficulty in
sustaining an action of negligence-based on failure to communicate
proper information to a patient.
There are three types of situations in which the question of consent
generally arises.
Where there is no consent at all.
Where consent is obtained by fraud and misinterpretation.
Where there is informed consent.
In the absence of consent almost all treatment – medical and surgical
of an adult is unlawful however beneficial it might be. Not all cases in
which no consent is given will amount battery.
Where a great emergency that could not be anticipated arises, it is
better to put consent altogether out of the care and to rule that it is
surgeons duty to act in order to save the life or preserve the health of
the patient. For example, when operating for a hernia and it is found
that it contains a non-viable testes and oviduct is undertaken without
consent.
Patients are also unable to give any form of consent because of
physical or mental conditions or age. If the physical condition on
admission is precarious, all attempts to save life without consent should
be attempted. The situation is more complicated in for example
Consent 15
Jehnovates witnesses carrying written statements of the unwillingness
to receive blood and its products. A next of kin is better consented before
taking actions.
For the mentally incompetent or those under 16 year, consent is
obtained from the next of kin, guardian or parent. A special case is
when parents oppose administering contraception to a girl under
16 years. In most cases she can give a valid consent.
Here the valid consent.
Here there can be no battery but difficulty may arise as to whether
the fit was given proper and sufficient information on which to have
the consent. A patient need only be informed in broad terms of the
treatment to give a valid consent. Sufficient to negate any battery but it
may be negligent to inform to the patient the risks of the treatment.
The detail in which the risks should be obtained is a matter of expert
medical opinion in any given case.
CONCLUSION
In general the patients sign a consent form to the effect that the nature
and purpose of the operation has been explained to them and this is
extended to such alternative or further operation and anesthesia has
been found necessary during the course of the operation. Patient is an
individual. Any encroachment affecting body integrity needs his
consent. This principle cannot be violated by anyone and health
professional is no exception.
Position of Patient for
3 Surgery and Examination
Position of patient should be comfort to the patient, surgeons and

anesthetist. Correct position is essential for a good access for surgery.
Now modern operation tables have different adjustments for different
positions of patient's for surgery and examine the patient.
It is essential to ensure:
1. Patients safety,
2. Anesthesia technique,
3. Monitoring the patient, and
4. Proper position for the intravenous line.
Precautions
1. Pressures on the nerves and bony points must be avoided and these
sites must be well padded to avoid pressure on them.
2. Proper support to patient is given on side tilt with belts, to avoid
falling.
3. At the end of the operation the pressure points should be checked
to ensure any damage.
Positions
Different positions are shown in Figs 3.1 to 3.7:
Fig. 3.1: Lloyd-Davis position. Avoid localized pressure on the arms

Position of Patient for Surgery and Examination 17
Fig. 3.2: Patient in the lithotomy position. Be very careful with elderly patients, particularly
if there is any abnormality of the hip joints. Protect the hands from the posts
Fig. 3.3: Patient in the lateral position. The lower knee is flexed, the upper knee and calf are
cushioned, the upper arm is supported and the operating table can be broken in the center
Knee-Chest Position
Prone-posture, patient rest on knee, elbow and chest with face on one
side. It is suitable position for rectal examination.
Sims Position (Lateral recumbent)

Patient lying on left side with the left arm on the side and right arm on
the head and buttocks on the end of table, lower leg is straight and
upper leg is folded at knee joint. It is for rectal examination (for
Proctoscopy).
Mayo-Robson Position
Patient is in supine position, a thick pad is under the right loin causing
marked lordosis in this region. It is for operation on the gallbladder
and bile duct.
Prone Position
Lying face down (whole body is reversed). It is for spine operations
and pilonidal sinus.
Fig. 3.4: Patients in the different position
Fowler’s Position
The patient lying down by raising the head of bed from 2 to 2.5 feet in
order to ensure better dependent drainage after an abdominal operation
and for chest physiotherapy after major abdominal operations.
Position of Patient for Surgery and Examination 19
Fig. 3.5: Trendelenburg position. The patient’s shoulders must be

adequately padded and supported
Fig. 3.6: Bent knee position for meniscectomy.

The thigh pad should not exert pressure in the pepilleal fossa
Fig. 3.7: Fracture table position for hip fracture surgery.

Padding removed for clarity
Lithotomy Position
The patient is lying on the back with buttocks at the end of operating
table. The hips and knee fully flexed with feet strapped in the support
of legging. It is for vaginal and ano-rectal surgery.
Supine Position
Patient is lying on back with upper limb on the side of body or on arm
rest used for most of the operations.
Trendelenburg's Position (Head down)

Same as in supine position but head side is down 45° so that the pelvis
is higher than the head. It is suitable for operation in the pelvis and for
shock.
Kidney Position
In this it is lateral (right or left) position in which upper arm is supported
by a special (Carter Braine's) arm support. Lower arm is flexed, upper
leg straight and one pillow is placed between the legs. Kidney area is
elevated by kidney bridge to extend the region. Pelvis and chest are
supported by a support. This is used for operations on thorax, kidney,
ureter and hip.
Anatomical Position
Standing (erect) position of the body with the face directed forwards
the arms of the side and palms of hands looking forward.
Neck Position
Supine position but a pillow or sand bag is placed under the shoulder
to extend the neck. Head is well supported and on head ring. It is used
for neck operations especially thyroid surgery and tracheostomy.
Supine Hip Position

In supine position in which lower part of table is removed and feet are
secured on foot pieces and traction is applied both legs are abducted.
Padded support is at perineum. Used for nailing of a femur neck
fracture.
4 Antiseptic Solutions
ANTISEPTIC AGENT
It is a chemical agent which either kills the microorganisms or inhibit
their growth.
Asepsis
It is a process by which environment of the patient is protected from
contact with infective organisms.
These antiseptic solutions are used for disinfecting the instruments,
equipments and for dressing of wound and in operation.
The commonly used solutions are:
1. Povidone iodine
2. Weak iodine
3. Hydrogen peroxide
4. Savlon
5. Surgical spirit
6. Acrifilavine
7. Mercurochrome
8. Gention violet
9. Silver nitrate
10. Potassium permangnate
11. Cetrimide
12. Turpentine
13. Tincture benzoin
14. Lysol
15. Eusol
16. Glycerine Magsulf solution
POVIDONE-IODINE
It is available in — Solution (5 to 10%)
— Scrub (7.5 %)
— Mouth gargles
— Ointment
— Vaginal Pessaries
It is also available in combination with Metronidazole compound.
Properties
• It is very effective against most of the bacteria, viruses, protozoa
and fungi.
• Iodine content has irritating property and can stain the tissue. It can
be allergic to skin, mucous membrane. This undesirable effect of
iodine could be eliminated by combining it with polyvinyl-
pyrrolidine. When this is combined with iodine a complex is formed
which is very less irritant and can be used without sensitivity test. It
kills the microorganisms within seconds.
Uses
• Widely used as surface disinfectant preoperative painting of the skin
– Apply double coat and wait for two minutes, surgical spirit is
applied over it, (spirit increases the penetration power of iodine).
Wipe off the extra iodine.
• Used for wound and ulcer dressing.
• It is used for scrubbing the part of body before operation.
• It is used for mouth gargles.
• It is used for irrigation or toileting the urinary bladder, wound,
peritoneal cavity, thoracic cavity, abscess cavity, etc.
WEAK IODINE SOLUTION

It contains:
• Tincture iodine
• Alcohol
Precautions
• It may cause allergy to skin, if there is sign of any reaction, wipe off
it with spirit or normal saline.
Antiseptic Solutions 23
Properties and Uses
• It kills most of the microbes within two minutes.
• It is one of the best preparation for preoperative painting of the
skin.
• It should be wiped off with surgical spirit after two minutes of
painting.
HYDROGEN PEROXIDE (H2O2)

Properties and Uses
• It releases nascent oxygen or free oxygen radical which is highly
bactericidal for anaerobic organism.
• It produces frothing and dissolves the debris or slough, thus when
applied in dirty wound or abscess cavity it brings out the debris
from the depth of the wound.
• It also produces heat, thus prevents the capillary oozing. It is helpful
in capillary oozing in case of incision and drainage.
• It is commonly used in diluted form for cleaning ear, nose, throat or
mouth wash.
• It is commonly used to remove the blood-stains from cloths, linen,
stapler, tubings, etc.
SAVLON (HOSPITAL CONCENTRATE)

It contains:
• Chlorhexidine gluconate
• Cetrimide
• Isopropyl alcohol
It is yellow in color. It is germicidal and detergent also. It is used in
different concentration for different purposes.
Uses
1:100 concentration solution (means 10 ml made up to one liter with
water)
• To store the previously sterilized instruments.
• To clean and disinfect the instruments.
• To clean postoperative wound.
• To clean the vagina and perianal region in delivery, vaginal
operations and anorectal surgery.
• For scrubbing.
• Used in case of burn for aseptic purposes.
1:30 conc. solution (35 ml made up to one liter of water)
• To clean dirty wounds.
• To clean and disinfect the catheters and rubber appliances.
1:30 conc. in 70 % alcohol (35 ml savlon + 200 ml sterile water, made
up to one liter with 95% alcohol).
• For skin disinfection.
• To disinfect the surgical instruments in an emergency situation
(immerse for two minutes)
• To keep the clinical thermometer.
• To keep the cheatle forceps.
SURGICAL SPIRIT
Optimum concentration is 70% alcohol.
Uses
Instruments which is required in emergency at the spot can be dipped
in it and can be used.
Other uses of spirit are:
• It is used to remove povidone iodine from skin in operation.
• To clean the skin for IV, IM, SC, intradermal injection.
• To clean the stitched wound.
• To clean the surrounding skin of a wound, ulcer, etc.
• It is used along with povidone iodine in skin preparation for
operation as it increases the penetration of iodine solution.
• To clean the hands before sterile dressings.
ACRIFLAVINE
• It is available in the form of crystals.
• Solution of 0.5 to 2% is made with sterile water.
• It is yellow in color.
Properties and Uses

• It is mild antiseptic.
• It has an astringent property, thus used on oozing ulcers.
(Astringent—an agent that causes contraction of the tissues, arrest
of the secretion or control the minute bleeding).
• It is used to dress the wound in open fracture case before applying
POP slab.
• It is quite effective in wound dressing suspecting infected with gram-
negative bacteria.
MERCUROCHROME
• It is available in crystal form.
• Its solution is made 0.5 to 2% with sterile water.
Properties and Uses

• It has also an astringent property, thus, it can be applied on oozing
wounds and hypergranulated wound.
• It can be used for bed sore dressing.
Precautions
It should not be applied on healthy granulating wound as it damage
the granulation tissue.
Disadvantage
It stains the floor of ulcer, so the progress of healing becomes difficult
to judge.
GENTION VIOLET
It is violet in color. It is used in 1:100 or 1:1000 concentration.
Properties and Uses

• It decreases the discharge from oozing ulcers by coagulating it.
• It is very useful in dressing of copious mucopurulant discharge and
make the ulcer dry.
Disadvantage
Only disadvantage is it stains the floor of ulcer, so the progress of healing
becomes difficult to judge.
SILVER NITRATE (AgNO3)

It is used in 1:100 to 1:10000 concentration.
Properties and Uses

• It is kept in dark and tinted glass bottle because on exposure to light
it gets destroyed.
• It is used for dressing of burn and wound of hypergranulation.
• It can be used for bladder irrigation in case of hematurea as it has
cauterizing effect.
• It is expensive, but very useful.
POTASSIUM PERMANGANATE (KMnO4)
Properties and Uses
• It acts as an antiseptic.
• It is available in crystal form, when even a very small crystal is put
in water it readily mixed and gives red color.
• It has oxidizing property. It is used in 1:5000 to 1:10000 concentration
in sterile water.
• It is used for urinary bladder irrigation and bladder wash.
• It is used for gastric lavage in certain cases of poisoning.
• It is used as mouth gargles.
CETRIMIDE
It contains: Cetrimide and rectified spirit
It is pinkish in color.
Its main use is as a scolicidal agent. In the operation of hydatid cyst
after enucleating the cyst, it is filled with this to destroy the scolices.
Precautions
It should not be used in open wounds and burn dressing because of its
irritant property due to spirit content.
TURPENTINE
Properties and Uses
• It is available in oil form. Its main use in surgery is to kill the maggots
from the wound and ear.
• It can be used to remove zinc of sticky plaster.
• It may be used to rupture the balloon of catheter (as it dissolve the
plastic and rubber).
TINCTURE BENZOIN
It is very good antiseptic solution. It is mainly used to seal the puncture
site, e.g. abdominocentesis, pleural tap, lumbar puncture site, etc.
LYSOL
Properties
It is a concentrated solution of erosol. It is used in diluted form usually
1:100 in sterile water. It is quite irritant so instruments which are
immersed, should be rinsed with sterile water or normal saline before
use.
Use
It is used for sterilization of sharp instruments like scissors, knives,
needles, etc.
EDINBURGH UNIVERSITY SOLUTION (EUSOL)

It contains:
• Boric acid 1.25 gm.
• Bleaching powder (chlorinated lime) – 1.25 gm.
• Sterile water up to 100 ml.
Properties and Uses

• It releases nascent chlorine, which separates the slough from infected
wound or ulcer.
• It creates acidic pH, therefore, it is very useful in the dressing of
wound which is infected with pseudomonas bacteria, by this way it
arrest the growth of this bacteria.
Precautions
It becomes inactive after 24 hours so freshly prepared solution should
be used, discard the solution after 24 hours.
GLYCERINE MAGSULF SOLUTION

It is composed of magnesium sulphate (MgSO4) and glycerine.
Properties and Uses

It is hygroscopic (capable of readily absorbing and retaining moisture),
thus, used to reduce edema in case of:
• Cellulitis
• Paraphimosis
• Prolapsed thrombosed piles.
by applying it locally.
Dressing Material and
5 Bandage
Dressing material and bandage are used for care of the wound. Some
of them are:
1. Cotton
2. Gauze
3. Surgical pads
4. Laparotomy pads
5. Packing roll
6. Swab
7. Peanut
8. Bandage
9. Elastocrepe bandage
10. Multitailed abdominal bandage or abdominal binder
11. Esmarch's bandage
12. Head or scalp bandage
13. Eye bandage
14. Ear bandage
15. Barrel bandage
16. Scrotal bandage
17. T-bandage
COTTON
Cotton is bleached to white, clean and defatted (bypassing it through
10% KOH solution) so that it can absorb the discharge and stain can be
seen early and easily. Ideally surgical cotton sinks in water within 10
seconds.
It is available in sterile rolls.
Dressing Material and Bandage 29
GAUZE
Gauze is woven cloth with 16 × 16 fibers or 8 × 8 fiber per square inch.
This configuration is ideal for dressing, for making gauze rolls, surgical
pads, peanuts and sling.
SURGICAL PADS
These are made in different size. These are used for dressing of a wound
or ulcer or burn cases. Cotton is wrapped in the gauze piece for soakage
of wound. Small size of pads for small wound/ulcer. Large size of pads
for dressing of burns and large ulcers. These are available in pre-
sterilized packets but it is costly.
LAPAROTOMY PADS
These are made up to keep the surgical field clean and dry. Usually
suitable or optimum size is 6” × 4” or 5” × 3”. These are made by
multilayer gauze is sewn with a long tail at one corner so that during
abdominal surgery it may not be left in the cavity.
PACKING ROLL
These are multilayered ribbon of gauze. It is used to pack a cavity.
SWABS
Swabs are made of cotton or gauze pieces, used to clean the skin for 1V
1M, SC, IV injection and for painting the part before surgery and for
swabbing the deep cavity.
PEANUT
It is made with gauze which is used for blunt dissection, e.g. near the
neurovascular structure, hernial sac. This is for blunt dissection.
BANDAGING TECHNIQUES (FIGS 5.1 TO 5.4)
Fig. 5.1: Bandage to thumb of hand—spica

Fig. 5.2: Bandage to elbow—spica
Fig. 5.3: A reverse spiral turn

Fig. 5.4: Adhesive strapping to ankle
These are made from gauze which are soft, porous and light.
Available in different sizes 1”, 2”, 4”, 6”, 8” for dressing of a wound.
Sizes are chosen according to the size of part to which it is to be applied.
It is used:
• To keep the dressing in place.
• To support the limb as a sling.
• To prevent wound contamination.
• Used in POP plaster applications.
ELASTOCREPE BANDAGE (FIG. 5.5)

These are used where
pressure bandage is
required or to reduce
edema. It provides
constant, firm, desired
and uniform pressure.
It is stretchable. It does
not inhibit blood circu-
lation. It is available in
different sizes. It is
pinkish in color and
with two safety pins
with a marking on it. Fig. 5.5: Varicose vein—Elastocrepe bandage
It should be cleaned with cold water and soap. Do not iron it. Roll it
without any wrinkle. By frequent washing it loses elasticity.
How it is Applied?
• First apply some lubricant like any oil or vaseline over the part.
• Wrap a thin layer of cotton over the part to prevent excessive
pressure.
• Apply it by starting from distant most part of limb, first give two
spiral turns to fix it then with uniform and desired pressure by
keeping 2/3 overlapping or just cover the marking on it, gradually
go up to proximal part. Apply a clip or adhesive tap, normally 2 LPS
pressure is given.
It is indicated in:
1. The treatment of varicose vein, varicose ulcer.
2. Postoperatively—operation of varicose vein or varicose ulcer.
3. The treatment of sprain.
4. The treatment of pain in the joint.
5. The treatment of inflamed swollen soft tissue injury of limb.
6. The treatment of un-displaced fracture, hair line fracture of a limb.
7. The treatment of lymphoedema.
8. After closed reduction, nailing of a fracture of limb bones.
9. Postoperatively to prevent hematoma formation, e.g. mastectomy.
MULTITAILED ABDOMINAL BANDAGE

(ABDOMINAL BINDER) (FIGS 5.6 TO 5.10)
Fig. 5.6: Tongue and slot adhesive strapping for abdomen
Fig. 5.7: Abdominal corset using adhesive strapping

Fig. 5.8: Interlocking cut-outs in adhesive strapping on abdomen
Fig. 5.9: Many-tailed abdominal binder
Fig. 5.10: Multitailed abdominal bandage

It is made of simple cotton cloth with strips which are overlapping.
It is used after exploratory laparotomy where there are chances of
wound dehiscence. When patient coughs or strains it prevent the burst
abdomen.
This is tied around the abdomen in such a way that each strip overlap
each other for two-third of the width. It should be started from below
upwards then lastly tied or fix it with pins.
ESMARCH’S BANDAGE
• It is a strip of long rubber tourniquet.
• It is used for bloodless field.
• It is also used when Bier's block is injected in a limb.
How it is Applied?
First elevate the limb to drain the blood. Then bandage is applied tightly
from the finger tips to the level desired for surgery. Now pneumatic
cuff is inflated 20 to 30 mmHg above the systolic blood pressure. After
inflating the cuff, bandage is removed.
Now limb becomes white and waxy and cool.
Precaution
1. Pressure should not be more than 20 to 30 mmHg.
2. Time should be noted when it is applied. Maximum permissible
time for lower limb is 30 to 45 minutes and for upper limb 45 to
60 minutes.
HEAD OR SCALP BANDAGE (FIG. 5.11)

It is applied in case of scalp injury and after neurological operation
over a stitched wound.
How it is Applied?
• Take two bandage or single long bandage which is rolled on both
ends.
• Keep small cotton behind the ear to prevent compression of ear
pinna.
• To fix the bandage take two turns around the head.
• Now pass the bandage over the center of the head by keeping one
end below it to prevent its slippage.
• Take reverse turn going back and turn by another end of bandage.
• Pass it over and over till entire head is covered. Secure it with
adhesive tape or pins.
Fig. 5.11: Head bandage
EYE BANDAGE (FIG. 5.12)

It is used to support eye dressings.
How it is Applied?
• Take two turns around the head above the affected eye.
• Then take it towards the occiput and pass it below the ear on the
effected side over the dressing.
• Take 3 to 4 turn like this way by covering the dressing placed over
the eye.
• Lastly take two turns around the head same as was taken initially.
• Secure it over the forehead by adhesive tap.
Fig. 5.12: Eye bandage

EAR BANDAGE (FIG. 5.13)
It is also known as mastoid bandage because it is done to keep the
dressing in position after mastoid surgery.
Fig. 5.13: Ear bandage
How it is Applied?
Take two turns around the head to fix it. Now take the bandage over
the dressing and turn downwards to the occipital region and go above
the ear on the normal side. Take 3 to 4 turns in such a way that on
every turn it come on the effected side to cover the bandage.
Complete the dressing by two turns around the head. Apply
adhesive tap to fix it.
BARREL BANDAGE (FIG. 5.14)

This dressing is used to support the fracture of mandible.
Fig. 5.14: Barrel bandage

SCROTAL BANDAGE (FIG. 5.15)
Fig. 5.15: Scrotal bandage
It is used to:
i. Keep the dressing in place after scrotal surgery, e.g. operation on
scrotum, varicose operation, hydrocele, testis operation, cord
operation, testicular biopsy.
ii. To give a support to scrotum in case of
• Cellulitis
• Orchitis
• Epididymo-orchitis
In this way by elevating the scrotum it decreases the congestion
edema (due to antigravity drainage of blood and lymph). It prevents
unusual movement of scrotum thus reduces pain also.
How it is Applied?
• Tie a sling to waist.
• Clean the scrotum, perineum and penis.
• Take long bandage first tie on the sling and by lifting the scrotum
take a turn from below upwards and around overlapping 2/3 of
previous turn and continue till it covers the scrotum and then fix it.
• Take the penis out from the bandage.
• Tightness of waist sling should be checked which causes discomfort
to the patient.
• It should be changed daily to clean the scrotal area.
• Readymade scrotal bandages are also available of cotton cloth with
multiple holes and stretchable elastic with a passage for the penis.
T-BANDAGE (FIG. 5.16)
It is used to keep the dressing in position, e.g. after operation of ano-
rectal region like hemorrhoids, fissure, fistula, scrotal surgery.
Fig. 5.16: T-bandage
How it is Applied?
Take a piece of 6” bandage which can be tied over the waist. Take a
long piece of bandage turn it around the center of waist sling.
Tie waist sling first. Then bring both ends of bandage over the
dressing and tie on the waist sling.
STUMP DRESSING (FIG. 5.17)
Fig. 5.17: Bandage to an above-knee stump of an amputated limb

OTHER TYPES OF BANDAGES
1. Dynaplast
2. Micropore/Primapore
3. Medicated bandaid
These are used:
1. To fix the dressing.
2. To fix oxygen cannula, Ryel's tube, cannula, scalp vein set, catheter,
drain, endotracheal tube.
3. To maintain position during operation, e.g. kidney position, pilonidal
sinus.
Precautions
1. These are quite sticky, when it is removed it may pluck the hair and
causes pain and harm to the patient so area should be shaved where
it is to be applied.
2. Area should be dry otherwise it may not stick over it.
3. Care should be taken. Do not encircle the extremity otherwise it
may hamper the blood circulation.
4. Adhesive tapes should never be applied over the raw area.
5. Watch for the allergic reaction like redness, vesicles as it is
impregnated with zinc oxide which may be allergic to any individual.
Primapore/micropore are used in these individuals as these are
specially made by adhesive paper which is less irritant.
6. When it is to be removed, it should be removed by pulling it towards
the wound with counter pressure on the skin.
7. If it is quite sticky or causing more pain while removing it apply
acetone on either end.
TRANSPARENT DRESSING (TEGADERM)

It is impervious to liquid and bacteria to prevent further contamination.
It is transparent so wound or central line, cannula site extravasation,
soakage can be checked without disturbing the dressing. It is less allergic
and easy to remove. But it is costly.
STERI-STRIP
These can be used to approximate the edges of superficial linear cut
wounds. It is edges of superficial linear cut wounds. It is a time saving
device and very useful when you do not want to stitch the wound
especially in case of children.
Wound Care, Suturing
6 and Topical Agents
DEFINITIONS
Some common definitions regarding wound.
Wound
Wound is defined as an injury or traumatism to any tissues of the body,
caused by mechanical violence with or without a solution of continuity.
A surgical incision is also a wound.
Ulcer
An ulcer is a break in the continuity of the covering epithelium—skin
or mucous membrane. It may either follow molecular death of the
surface epithelium or its traumatic removal.
Slough
It is a piece of dead tissue separated from the living structure, e.g. skin,
muscle, tendon fascia.
Necrosis (G. Nekrosis means Death)

The pathologic death of one or more cells or a portion of tissue or organ
resulting from irreversible damage, the most frequent visible alterations
are nuclear or it is a molecular death of the cells or tissue.
Gangrene
Necrosis due to obstruction of blood supply, may be localized to a small
area or involve the entire extremity. It may be dry or wet. It is usually
superadded by putrefactive bacterial infection.
Wound Care, Suturing and Topical Agents 41
Granulation Tissue
It is vascular connective tissue, forming granular projections on the
surface of a healing wound, ulcer or inflamed tissue surface. It comprises
grown capillaries, fibroblast and collagen fibers. It is flat, rosy pink in
color without any slough with minimum serous discharge. It bleeds
while rubbing with gauze piece.
Hypergranulation Tissue
It is an excessive granulation tissue and which has grown above the
level of surrounding skin surface. It is also known as "proud flesh".
Scab/Crust
It is formed by dried discharge or coagulation of blood, serum, pus or
combination of these on the surface of an ulcer wound.
TYPES OF WOUND
Two types of wound:
1. Open wounds
2. Closed wounds
Open Wounds
These are of five types:
Incised Wound
It is caused by sharp instruments like knife, glass, razor blade. There is
a clean and sharp cut. There is no crushing and bruising. It bleeds more.
Lacerated Wound
This is caused by blunt objects or by animal bites, machinery, etc. There
is crushing and tearing of the tissues. Edges of wound are rough and
jagged. There may be skin or tissue loss.
Stab Wound or Punctured Wound

It is caused by pointed and sharp objects like knife. Wound is deeper
than its breadth. Wound of entry may be small.
Penetrating Wound
These are caused by gunshot, missiles. There is almost always entry
and exit wound.
Degloving or Abrasion
It is due to scrapping by vehicle accidents. There is loss of superficial
layers of skin or subcutaneous tissue may be roll off and exposing the
deeper tissue and even bone.
Closed Wounds
Skin is intact, there is no loss of continuity of skin but there is soft tissue
injury.
Bruise/Contusion
It is caused by blunt object. Skin becomes bluish and there is swelling
of the part. There is underlying tissue injury.
Hematoma
It is also caused by blunt object. This is due to rupture or tear in the
large vessels.
TREATMENT OF WOUND
1. Wash hands thoroughly before the procedure and rinse your hands
with spirit.
2. Always wear gloves while dealing with open wounds.
3. Clean the wound: Clean the wound thoroughly with hydrogen -
peroxide and normal saline. If there is any foreign body, it should
be removed gently.
4. Clean the surrounding skin: Always clean the surrounding skin of
wound with antiseptic solution. If area is hairy, is should be
shaved.
5. Local or general anesthesia: Anesthesia is quite necessary. According
to need it may be given.
6. Debridment of wound: Debridment means—removal of all the dead
devitalized tissues. Remove dead or damaged tissue. Clean
thoroughly with normal saline. Wash the wound with antiseptic
solution.
7. Repair and closure of the wound: The crushed edges, should be
trimmed with knife. If there is any bleeder it should be ligated
with chromic catgut. Any tear in muscle, tenden or nerves should
be repaired. Then close the wound by approximating the skin
without tension.
8. Dressing: Always put some sterile gauze pieces or cotton pad for
soakage, then apply bandage.
9. POP slab: If wound is on the limbs especially the joints and
immobilization is required. POP slab is applied after proper
suturing and dressing of the wound.
10. Leaving the wound open: Wound should be left open, i.e. without
primary closure when there is anyone of following condition:
i. When there is doubt in the viability of tissues.
ii. Infected or grossly contaminated wound.
iii. Abdominal cavity wound.
iv. With extensive muscle loss.
CARE OF INFECTED WOUND

If there is no signs of systemic infection, wound infection can be
controlled by simple local mechanical washing and local application of
antibiotics.
1. For slough (dead tissue) should be excised thoroughly.
2. If there is collection of pus pockets of pus the loculi should be broken
and all pus should be drained out.
3. Deep slough can be removed by using EUSOL or hydrogen peroxide.
Other desloughing agents are:
– One percent zinc sulphate solution dressing
– Debrisan granules
– Alum
4. Wound should be thoroughly cleaned with normal saline and then
local antibiotic is applied.
5. Dressing should be changed daily or twice a day according to the
severity of infection.
SUTURING
The wounds are sutured in different manner. There are different types
of suturing technique.
Types
Continuous
i. Simple
ii. Blanket (locked)
iii. Subcuticular
iv. Purse-string
Interrupted
i. Simple
ii. Mattress
iii. Tension
Continuous Suture
These can be carried out rapidly. These have very few knots.
Disadvantage: In case of collection, you have to remove the entire stitch.
Simple Continuous Stitch

These are used to close the:
• Peritoneum
• Rectus sheath
• Intestinal anastomosis
Blanket Stitch
This is a type of continuous suture, but in every loop of stitch it is locked.
It is used to approximate the skin edges especially scalp skin as it achieve
homeostasis from the edges of skin.
Subcuticular Stitch
In this type of suture only dermis is taken in the stitch. It is used in
1. Children operations
2. Wound of face
It gives a better cosmetic result.
In this non-absorbable sutures are used, the tail or both ends are left
outside the wound for removal.
Purse-string Stitch
In this the bites are taken in round or circle and when tied at one point
it closes like a ladies purse, thus it is called purse string stitch. It is used
to:
• Bury the stump of appendix in caecal wall.
• Fix the catheter in cavity, e.g. feeding jejunostomy, cholecystostomy,
caecostomy, etc.
Interrupted Sutures
Simple Suture
In this type of suture, edges are approximated by taking single-single
stitches individually tied. These are used for
i. Skin closure
ii. When there is doubt of collection, because it is possible to remove
one of the stitches and collection can be removed, without
disturbing other stitches.
Fig. 6.1: Method repairing a disrupted abdominal wound by

means of through and thorugh mattress stitches of strong,
stainless steel wire or nylon. The stitches are made to pass
through all layers of the abdominal wall about 2.5 cm from the
wound edge, and are passed through pieces of rubber tubing to
prevent them from cutting into the skin. A few additional matters
are inserted to coat aponeuroses and skin
Fig. 6.2: Removal of sutures

In this type of suture, individual stitches are tied simply. It is most
commonly used sutures for wound closure.
Mattress Stitches
This type of suture is used when there are chances of inversion of wound
edges. After taking simple stitch again with same needle and thread
suture is taken from edges, i.e. vertical mattress and when again stitches
are taken with the same level is horizontal mattress stitch, then it is
tied on one side. With this type of suture we get eversion of the edges
and definitely will be strong than simple.
Tension Stitches
These sutures are used to prevent wound dehiscence. Bites are taken
deep and quite away from the wound and passed through a plastic
tube and tied. Plastic tubing prevents it to cut through.
METHOD OF STITCH REMOVAL

1. Stitch line should be cleaned thoroughly with surgical spirit.
2. Hold or pick-up the free end of the knot with toothed forceps and
lift the suture.
3. Pass the blade of stitch cutting suture under the lifted end and cut it
away from the knot and near the skin.
4. Pull the cut suture from the other end in such a way that exposed
portion should not travel through the suture tract to avoid any
chance of infection.
TOPICAL AGENTS
These are used to dress a wound or ulcer. These are available in lotion,
cream, ointment, powder and medicated sterile gauze.
Ointment
These are mixture of greases and fat with or without antimicrobial agent.
It prevents evaporation and heat loss from wound. These are helpful
in chronic conditions to soften the crust. These are not used in acute
conditions where free removal of exudates and cooling are needed.
It does not spread easily over the wound because of lack of water
content.
Cream
These are emulsions either of oil in water (cosmic cream) or water in oil
(as medicine) cold cream—a cooling effect is obtained when water
evaporates.
Water-in-oil cream—do not mix with serous discharge and it spreads
over wound easily due to its water content.
Lotion
It is a pharmacopial preparation in liquid form.
COMMON TOPICAL AGENTS

Povidone-Iodine
It is available in lotion, cream, powder and scrub form. It is effective
against most of the bacteria. The application is painful due to its irritant
effect on wounds. That's why it is not used in superficial burn where
pain is more.
Silver Sulfadiazine
It is available as one percent cream. It is effective against most of the
bacteria. It is the best choice in topical agent for dressing of deep burn
and heavily contaminated superficial burns. It softens the eschar. It
increases the growth of granulation tissue. Once healthy granulation
tissue has come up its dressing should be stopped.
Framycetin Sulphate
• It is available in one percent cream or powder.
• It is effective against most of the bacteria.
• It does not cause any irritation to wound.
Combination of Neomycin, Polymyxin and Bacitracin

• It is available in ointment or powder form.
• It is effective mainly against gram-positive bacteria. It is frequently
used in dressing of superficial wound and superficial burns, e.g.
face wound.
Gentamicin
• It is used as 0.1% cream, ointment or drops. It is used where gram-
negative bacterial infection is suspected.
• It is absorbed systemically that’s why it should be avoided in large
or extensive wound as its side effect due to systemic absorption
(ototoxic and nephrotoxic).
Nitrofurazone
• It is available in ointment or cream.
• It is effective against most of the bacteria. Application is painful
due to its irritant effect.
• It is not in common use because of its disadvantages like:
– It is an irritant.
– It is not effective against pseudomonas infection.
– Eschar penetration is very limited.
– On prolonged use fungal growth may develop.
Hydrogen Peroxide (H2O2)

It has certain advantages:
1. It releases nascent oxygen, thus destroys anaerobic organism.
2. It produces frothing and brings out debris from the depth of the
wound.
3. It produces heat, thus helps in preventing capillary oozing.
It is used for cleaning wounds, boils, any cavity, abscess cavity,
mouth wash, ear syringing and used to remove blood-stains on clothes.
Magsulf Glycerine Solution

It is a hygroscopic, it absorb the water from the surface. Thus, used to
reduce edema in
i. Cellulitis
ii. Paraphimosis
iii. Prolapsed thrombosed piles
Ichthammol
It is used to reduce edema.
MEDICATED DRESSINGS
There is a gauze piece which is impregnated with topical agents and
available in sterilized pack.
Tulle Dressing
Gauze is impregnated with polymyxin sulphate, bacitracin and
neomycin.
• It is a sterilized (by gamma radiation) packing.
• It is a prepared dressing, used to dress an infected wound or ulcer
or bed sore.
Bactigras
Gauze is impregnated with soft paraffin and chlorhexidine. Use same
as above.
Central Gel Formula (CGF) Dressing

It is hydrocolloid occlusive dressing. It is used for pressure sore, ulcer,
abrasion and burn dressing.
Calcium, Sodium Alginate Dressing

It is used for oozing wound, burn, ulcer, gangrenous growth, nasal
and dental bleeding. It is natural hemostatic wound dressing.
Ulcer or Wound Covering

Opsite, biobrane, trancyte, integra these provides a moisture barrier
and decrease the wound pain. It also accelerates wound healing.
Integra
It provides a complete closure of wound and leaves a dermal equivalent.
Advantages
• Promotes rapid healing.
• It is in well sterilized pack, thus decreases the risk of contamination.
• No need to change the dressing often.
• It is easily removable and does not cause damage to the newly
formed granulation tissue while removing it.
• No hypersensitivity.
• Well accepted by the patient.
Electrosurgery
7 (Diathermy)
Diathermy is a greek word. Dia means through, thermo means heat.

Electrocautery—involves the applications of direct current flowing in
one direction. Electrocautery is a closed circuit DC device in which
current is passed through an exposed wire offering resistance to the
current. In surgical diathermy a high frequency alternating current is
passed through the body tissue.
Thus, term 'electrocautery' should not be used to described electro-
surgery.
The electrosurgical circuit consist of four primary parts—
(i) electrosurgical generators, (ii) active electrode, (iii) patient, and
(iv) return electrode.
PRINCIPLES OF ELECTRICITY
An electric circuit is any pathway that allows the uninterrupted flow
of electrons. Electrical current is the flow of electricity in a given circuit
over a constant period of time and is measured in amperes (A) current
Fig. 7.1: Electric circuit

Electrosurgery (Diathermy) 51
Fig. 7.2: Electric equipment
can be supplied either as direct current (DC) with constant positive

and negative terminals or as alternating current (AC) with constantly
reversing poles. Voltage is a measurement of the force that propels the
current and is related to the difference in potential energy between
two terminals. The resistance is the tendency of any component to DC
circuit. The equipment of this tendency in AC circuit is known as
impedance.
TISSUE EFFECTS BY ELECTROSURGERY

Cutting
Cutting current has a low voltage. This is achieved with a constant
waveform of low voltage. Once the current is applied the current is
actively flowing during the entire application. In this technique, the tip
of electrode is held just slightly off the surface of the tissue. It produces
an intense heat, vaporizing water, exploding the cells in the immediate
vicinity of the current. Thus, cutting occurs with minimum coagulation
production and minimum hemostasis. A combination of coagulation
and cutting can be produced by setting the electrosurgical generators,
to blend. Blended current is used for: (i) TUR of prostate, bladder tumor,
bladder neck (ii) excision of neoplastic tissue anywhere.
Coagulation
Coagulation current do not produce a constant waveform. Enough heat
is produced to disrupt the normal cellular architecture because cells
are not constantly vaporized, heat produced is enough to denature the
cellular protein. This accounts for the formation of a coagulation that
allows sealing of smaller blood vessels and control of local bleeding.
Fulguration
Tissue is coagulated and charred over wide area. This is achieved by
an intermittent waveform of high voltage producing less heat. This
results in the disruption of normal cellular protein to form a coagulum
and char the tissue forming a black eschar at the site of operation. The
benefit of using this cutting current is less voltage is needed, an
important during laproscopic surgery.
Desiccation
This occurs when the electrode is in direct contact with tissue. Less
heat is generated and no cutting action occurs. A relatively low power
setting is used, resulting in limited area of tissue ablation with
coagulation. Desiccation is achieved most efficiently with the cutting
current. The cells dry out and form a coagulation rather than vaporize
and explode.
Variables Affecting Tissue Effect

Power setting and the waveform effect, the results of the current
application. Any change in the circuit that influence the impedance of
the system with influence the tissue affect. These include: (i) the size of
the electrode, (ii) position of the electrode, (iii) type of tissue, (iv) the
formation of eschar, and (v) time.
The smaller the electrode, higher the current concentration. The
longer the generator is activated the more heat is produced. The greater
the heat, it will travel to adjust tissue, i.e. thermal spread. Eschar is
high in resistant to current. Electrodes should be kept clean and free of
eschar.
TYPES OF CIRCUIT
There are two types of circuit.
Monopolar Circuit
The active electrode is the surgical site. The patient return electrode is
on the patient's body (the plate). This current passes through the patient
as it completes the circuit from the active to the patient return electrode.
If the patient were not to connected in some way either to a negative
terminal or to ground, no current would flow as there would be no
way to complete the circuit.
Figs 7.3A and B: (A) In monopolar electrosurgery, current from an electrosurgical generator
passes from an active electrode (the “Bovie” tip) through the patient to a return electrode of
greater area, (B) In bipolar electrosurgery, the active and return electrodes are in the handpiece,
and current only flows through the surgical site
Bipolar Circuit
In this the two blades of the forcep perform these two functions, i.e.
active and return electrodes, thus only the tissue grasped is included in
the electrical circuit. No patient return electrode is needed.
Precautions
Following precautions should be taken while diathermy is used:
1. All OT staff must know whole about the diathermy.
2. The alarm system, generator and equipment should be checked
regularly.
3. It should never be used in the presence of ether or cyclopropane
should be kept atleast 50 cm from the anesthetic machine.
4. Surgical spirit must be dried before diathermy is used.
5. Do not use the top of the generator as a table. Fluids can enter in the
generator.
CAUSES OF DIATHERMY INJURY
1. Incorrect application of patients plate.
2. Careless technique.
3. The patient touching earth, metal objects, part of OT table, IV stand,
etc.
Safety Measures
1. Diathermy machine and all its accessories must be checked and need
to be serviced regularly.
2. The foot plates should be checked, it should be completely sealed.
3. Monopolar or bipolar should be selected prior to use and correct
setting should be checked because when monopolar diathermy is
used cutting and fulguration involve higher power current than
coagulation, these are not applicable to bipolar. That’s why
coagulation and cutting levels are correctly set before its use.
4. Insulation of the instruments should be checked regularly.
5. Patient should be protected from metal like OT table metal, OT table
accessories, IV stand, etc.
6. Patients' plate should be in proper position and it should not touch
any metal point.
7. Skin should be checked after removal of the plate.
8. Live electrode is always placed in the quiver and never on the drapes
or on the tray.
9. Always place ECG electrodes as far as away from the site of surgery
as possible.
If diathermy is not working look for:

1. Its all connections.
2. Loose active electrodes.
3. Poor contact of plate.
4. Faulty or disconnected cable.
5. Setting of electric generator.
6. Plugs, sockets and power supply.
Patient Plate Electrode

The patient plate electrode is also known as return electrode or simply
patient plate. It should be fully in contact with the patient over the
entire plate area. Conductive jellies help in maintaining this condition.
However, this condition is necessary to be fulfilled during the entire
operative procedure.
Patient plate covered with wet cloth is not recommended for surgical
procedure more than 30 minutes time period. The cloth gets dry after
this time and creates resistive path for current to flow, which can lead
to the burn under the plate.
Avoid any contact of the plate with grounded objects like OT table,
IV stand, etc.
Placement of Plate
Certain body sites are generally considered unsuitable for placing the
patients plate, e.g. bony protuberances, hairy areas, limbs with restricted
blood flow, scar tissue. It should be placed under the buttocks, thigh,
shoulders or anywhere that can ensure an adequate contact area.
Patients plate should be placed near to the site of surgery. It should
have maximum contact with the patient's body. The connecting cord
must be securely connected towards the instrument end. This cord
should never be pulled either during the use or during storage. Lift the
patient to remove the plate or to place the plate.
Foot Switch
There are two types of foot switch one is monopolar and another is
bipolar. Connect the monopolar footswitch to perform monopolar
cutting and coagulation functions. If bipolar electrosurgery is required
then connect bipolar function. It should be under the control of operating
surgeon. These foot switch must be covered by plastic transparent cover
to keep it dry and clean and to prevent any spillage of fluids or blood
during operations. Foot switch is provided with two paddles. Yellow
for cutting or blend current and blue for coagulation current. Hand
switch is also provided with cutting/ blend and coagulation current to
be switched by yellow and blue button on it.
Different Modes of Current

1. Coagulation current is divided in two types. Fulguration is used
where arcing of the coagulation current is required from a distance
in operations like TURP and bladder resection where fulguration
plays an important role.
2. Cutting is provided with three types of current. Pure, blend 1 and
blend 2.
a. Pure cutting gives sharp cutting. A knife in a butter effect is
usually loved by urosurgeons.
b. Blend 1, a modulated waveform type current is used where
cutting with controlled bleeding is used.
c. Blend 2, current with additional percentage of coagulation when
used for cutting purpose gives absolutely bloodless cutting.
3. Monopolar accessories are provided with specially electrodes like
straight knife, ball and needle.
a. Straight knife electrode is used both for cutting and coagulation
by changing the face of blade.
b. Ball electrode is used for desiccation, i.e. contact coagulation
normally used in gynecology.
c. Needle electrode is used for sharp cutting. Cutting with needle
electrode requires less setting compare to straight knife electrode.
4. Bipolar activation is provided with independent bipolar activator.
In bipolar, tissue is grasped in between the bipolar forcep and
cauterized the tissue.
Patient with Pacemaker

Diathermy may affect the pacemaker. Modern pacemaker are also
sensitive to possible interference during electrosurgery but have an
inbuilt safeguard so that any interference is in building rather
stimulating.
It is always safer to use a bipolar circuit when possible.
Metallic Prosthesis
With a monopolar circuit, patient plate should be sited well away from
the prosthesis, e.g. in orthopedic surgery where generally prosthesis
are used.
Safe Sue of Diathermy in Minimal Invasive Surgery

Several safety concerns are unique to MIS, have a limited and tight
environment in which operations occur. One danger is that of direct
coupling between the electrode and other conductive instruments,
which lead to tissue damage. When coagulation is used with high
voltage current, there is risk of breakdown in the insulation resulting
into tissue damage of adjacent tissue. This damage can be reduced by
using low voltage current. A capacitor may be created between the
active surgical instrument electrode and the metal cannula. A capacitor
by a dielectric. The conductive electrode separated from either a metal
cannula or the abdominal wall can induce capacitance in either of these
structures.
The electric field between these two conductors allows a current to
be induced in the second conductor (metal cannula). It is reduced but
not eliminated by the use of plastic cannula safety measures:
1. Check insulation thoroughly and regularly.
2. Use a low power setting.
3. Use a low voltage when possible.
4. Use intermittent rather than continuous.
5. Do not activate when the electrode is in contact with other metallic
instrument.
ARGON BEAM COAGULATION

Argon is an inert gas that is easily ionized by the application of an
electric current. The current arcs along the pathway of ionized gas,
which is heavier than both oxygen and nitrogen and thereby displaces
air. Once the current arrives at the tissue, it produces its coagulating
effect in the same manner as conventional diathermy. Argon beam
coagulation devices can operate only in two modes: (i) pin point
coagulation and (ii) spray coagulation.
It does not cut even the most delicate tissue.
Advantages
• It allows use of the coagulation mode without contact of the
electrode. This prevents buildup of eschar, which diminishes
electrode efficiency on the electrode tip.
• There is decreased smoke and thus odor is also reduced.
• There is decreased tissue loss and reduced tissue damage.
• There is less danger of ignition by instrument as argon gas is
delivered at room temperature.
• Beam coagulation improves coagulation and reduces blood loss and
the risk of rebleeding.
Disadvantages
• It cannot be used to produce a cutting effect in the same manner as
other types of diathermy.
• Its nozzle for gas delivery can become clogged, which reduces its
efficiency.
• If it is used for a prolonged period of time it may overheat and may
cause inadvertent damage.
Use
It is especially useful for procedures in which the surgeon needs to
rapidly and efficiently coagulate a wide area of tissue. It is especially
suitable to dissecting very vascular tissue and organs, e.g. liver.
ULTRASONIC DEVICES
These are totally different from electrosurgery (diathermy). By this there
are two most prominent devices which produces ultrasonic vibrations
in which mechanical energy is converted into energy for surgery.
These are:
Fig. 7.4: Harmonic Scalpel Generator 300
i. Ultrasonic scalpels and clamps

ii. Cavitational Ultrasonic Surgical Aspiration (CUSA)
Ultrasonic Scalpels and Clamps

In these instruments electric energy from a power source is transformed
into ultrasonic vibrations by a transducer. This transducer expands and
contracts in response to electrical current at a frequency of up to 55,500
cycles/second. The blade tip vibrates through an amplitude of around
200 micrometer. As the blade tip vibrates, it produces cellular friction
and denatures proteins. These denatured proteins form a coagulation,
which allows sealing of blood vessels. By this way temperatures reaches
between 50° and 100°C. In conventional diathermy temperature reaches
between 150° and 400°C. Thus, using this device, tissue can be dissected
without burning or oxidizing tissues and eschar. When it is used for
clamp, energy is transferred to the tissue through the active blade under
applied force, which minimizes the lateral spread. The monitor of the
blades induces cavitation along the cell surfaces, whereby low pressure
causes cell fluids to vaporize and rupture.
Advantages
• It can be used while operating deep and tight spaces with least
damage to adjacent structures. This makes such instruments
especially suitable for MIS.
• There is no risk of current inadvertently arcing to adjacent structures.
• There is no neuromuscular stimulation, since no current passes
through the patient.
• Coagulation occurs at much lower temperature than conventional
diathermy.
• Lateral thermal tissue damage is negligible.
• There is no eschar formation on the blade and less smoke is
produced.
• It can be safely used in patient having pacemaker.
Disadvantages
• It is quite expensive instrument.
• Maintenance is also expensive.
• Electrosurgery can be applied throughout an operation, while
ultrasonic scalpels are typically used for more controlled dissection
around the site of interest.
CAVITATIONAL ULTRASONIC SURGICAL

ASPIRATION (CUSA)
It works on almost same principle as ultrasonic scalpels. In this there is
a handpiece in which current passes through a coil and induces a
magnetic field which in turn results in a vibration. These vibrations are
magnified over the length of the handipiece. The oscillating tip, when
brought into contact with tissue, causes fragmentation of tissue leading
to cellular disruption. This high-frequency vibration produces heat,
which is reduced via a closed, recalculating cooling water system. This
maintains the temperature of the tip around 40°C.
There is an another function of this system is suction (aspiration as
its name implied). As tissue is fragmented, debris is carried away by
aspiration. For irrigation sterilized water or saline is fed through tubing
to the handpiece, where it irrigates the surgical site. Which is removed
by the vacuum pump (which is attached in the same system). Suction
pulls irrigation fluid, fragmented tissue and debris through the distal
tip of handpiece.
Uses
1. CUSA system have their primary application in situations where
fragmentation emulsification and aspiration debris or other tissue
are desirable.
2. In general surgery its primary application is in liver resection where
it can disrupt only parenchyma and leaves major vasculature and
biliary ducts intact.
Limitations CUSA
Since it provides minimum hemostasis thus it is not versatile in general
surgery as diathermy or ultrasonic scalpel.
LASER
It is very sophisticated instrument. It should be used in designated OT
by fully trained staff. Protective eye wear is must at all times of its use.
Care with the direction of the laser beam is critical to safe use. There
should be no reflective or inflammable fixtures or furnishings must be
present in the OT. With all these any many more limitations. It is not
useful in general surgical practice. It is more useful in dermatology
and ophthalmology practice.
8 Sterilization
DEFINITIONS
Antiseptic Agents
These are chemical agent which either kills the pathogenic organism or
inhibit their growth.
Asepsis
It is a process by which environment of the patient is protected from
contact with infective organisms.
Bacteremia
Presence of viable bacteria in the blood.
Septicemia
Systemic manifestations of infection caused by multiplication of micro-
organisms in circulating blood.
Toxemia
Clinical syndrome caused by toxic substances in the blood.
Slough
It is a piece of dead soft tissue.
Antiseptic
A substance that has antimicrobial activity and that can be safely applied
to living tissue.
Bacteria
Minute unicellular organisms. This term is usually applied to the
vegetative (growing) forms.
Bacteriostat
An agent that will prevent bacterial growth but does not necessarily
kill the bacteria. Bacteriostatic action is reversible; when the agent is
removed the bacterial will resume normal growth.
Bioburden (Bioload, microbial load)

The number and types of viable organisms with which an object is
contaminated.
Biological Indicator
A sterilization process monitoring device consisting of a standardized,
viable population of microorganisms (usually bacterial spores) of high
resistance to the mode of sterilization being monitored. Subsequent
growth or failure of the microorganisms to grow under suitable condi-
tions indicates whether or not conditions were adequate to achieve
sterilization.
Chemical Indicator
Chemical indicator (chemical monitor, sterilizer control, chemical
control device): A sterilization process monitoring device designed to
respond with a characteristic chemical change to one or more process
parameters of a sterilization cycle.
Chemosterilizer (Chemical sterilant)

A chemical used for the purpose of destroying all forms of microbiologic
life, including bacterial spores.
Cleaning
Removal of visible extraneous material from objects.
Contamination
The state of actually or potentially having been in contact with
microorganisms.
Decontamination
This term has a number of definitions. Simply
a. The reduction of microbial contamination to an acceptable level.
Sterilization 63
b. Any process that eliminates harmful substances. A decontamination
procedure can range from sterilization to simple cleaning.
Disinfectant
A chemical germicide that is formulated to be used solely on inanimate
objects. Disinfectants can be divided into those with labels that claim
tuberculocidal activity and those with no claim for tuberculocidal
activity.
Disinfection
It is a process of destruction of pathogenic microorganisms or their
toxins or vactors or any substance or to inhibit their growth and vital
activity.
It does not affect spore states of an organism.
The destruction of many, but not all, microorganisms on inanimate
objects. A classification that includes three levels of disinfection:
a. High-level disinfection.
b. Intermediate-level disinfection.
c. Low-level disinfection.
Disposable
A device intended for single use or single patient use.
Fungicide
An agent that kills fungi.
Germicide
An agent that destroys microorganisms.
Mechanical Control (Physical) Monitors

Sterilizer components that gauge and record time, temperature,
humidity, or pressure during a sterilization cycle.
Microbiocidal Process
A process designed to provide an appropriate level of microbial lethality
(kill). Depending on the level of decontamination, this process may be
sanitization, disinfection, or sterilization.
Microbiocide
An agent that kills all organisms.
Nosocomial
Pertaining to health care facility.
Sanitization
The process of reducing the number of microbial contaminations to a
safe or relatively safe level. The term is generally used in connection
with cleaning.
Sanitizer
A low-level disinfectant with no claim for tuberculocidal activity.
Spore
It is a normal resting stage in the life cycle of certain bacteria.
Sterilant/Disinfection
Term applied to a germicide that is capable of sterilization of high-
level disinfection.
Sterile/Sterility
The state of being free from all living microorganisms. Sterility is usually
described in terms of the probability that a microorganism will survive
treatment.
Sterilization
Destruction of all viable forms of microorganisms.
Viricide
An agent that kills viruses.
Pasteurization
Pasteurization is a high-level disinfection process, although this is
inconsistent because of its inability to reliably kill spores and viruses.
Pasteurization has been used for breathing tubes, reservoir bags,
tracheal tubes, face masks, airways, laryngoscope blades, and ventilators
bellows. It may produce tubings as clean as those of a disposable
breathing system.
The main advantage of this method is that the lower temperature is
less damaging to equipment. There are no toxic fumes or residues. It is
simple, inexpensive, and reliable. The main disadvantage is that the
Sterilization 65
treated equipment is wet and must still be dried and packaged, during
which it may again become contaminated.
METHODS OF STERILIZATION
i. Physical methods
ii. Chemical methods
Physical Methods
Autoclaving
Means sterilization is done by steam under pressure. Saturated steam
has a better penetrating power. Machine used is – Autoclave.
In autoclave, water boils and by its vapor, pressure increases inside
a closed vessel, when steam comes into contact with a water surface, it
condenses into water and gives up its latent heat to that surface when
steam is held in a closed container, it is compressed and the temperature
rises above the boiling point. The steam under pressure is able to
penetrates the porours material quickly. Steam is first introduced into
the outer chamber until the desired temperature is reached. Then it
turns into the inner chamber where articles are kept for sterilization.
Initially, when air enters into the inner chamber, it comes out forcibly
through the valve. It is kept flowing into the inner chamber till the
desired temperature is reached. Now note the desired temperature,
pressure and time, door closed and secured. Once the intended
temperature is reached, the duration of sterilization is set. The air needs
to be removed from the sterilizer. When continuous jet of steam comes
out it means air is removed. As steam enters the chamber, it enters the
loaded sterilizer and gives up its latent heat. Then outlet of steam is
closed. After completion of the procedure, allow the pressure to come
at zero level and temperature around 100°C, only then the door is
opened.
Autoclaving is extremely effective because the saturated steam
rapidly transfers heat to materials.
Temperature
Water boils at 100oC. When it is boiled within a closed vessel at increased
pressure, with the steam temperature exceeds 100oC. The increase in
temperature depends on the pressure of the autoclave. It is the moist
heat at a suitable temperature, as regulated by the pressure in the
chamber, that brings about sterilization.
Control measures: To determine the efficacy of sterilization, spores of
Bacillus–Stearo thermophilus are used as a test organism which is killed
at 120°C in 12 minutes. The paper stripes are available which is
impregnated with 106 spores of this organism and placed in an envelope.
These are placed in different parts of load and after sterilization these
stripes are checked in a suitable media to check the efficacy of
sterilization. Biological monitors should be used at least once a week.
Chemical indicators: A chemical indicator is a sterilization process
monitoring device, designed to respond to one or more of the physical
conditions (temperature time, or pressure) within the sterilization
chamber. They are a more practical means of detecting local conditions
within the load than biological indicators. A chemical indicator should
be attached to every package that goes through a sterilization cycle.
Autoclave labels: Labels are available. It has two parts one is white to
write the details of articles in the drum and second part is green in
color. Green part turns to dark gray or black when sterilization is
complete. This label is applied on the autoclave drum.
Required time, temperature and pressure:
Temperature — 120°C
Pressure — 15 PSI (Ponds per square inch)
Time — 20 to 45 minutes
Unwrapped: Metal instruments, syringes, powdered rubber gloves
packed in linen— 20 minutes.
Wrapped: Metal instruments, trays, threads, nylon, silk, cotton and
metal wires— 30 minutes.
Linen, towels, gowns, dressing gauge, cotton, bandage, etc.—
45 minutes.
While autoclaving following points must be remembered:
1. Equipment to be sterilized is first cleaned and then packed in
muslin, linen, or paper. The steam easily penetrates these materials.
2. The air in the autoclave must be displaced by steam.
3. Materials inside the drums must be packed loosely and should be
in vertical direction because tight packing decrease the penetration
power of steam and movement of steam is in vertical direction.
4. There should be sufficient number and size of perforators (holes)
on the side of drum for adequate entry of steam.
5. The materials linen, gowns, bandage that take a long-time for
sterilization should be kept in upper part since steam penetration
starts earlier in the upper part then in the lower part.
Sterilization 67
6. The article should be left in the autoclave for a time after the
procedure is over to make them dry.
7. All the valves and seals must be checked regularly. It is adjusted in
such a way that the steam escapes from it when the pressure inside
reaches about 17 PSI and closes when it falls to 15 PSI.
Actual time starts when the pressure and temperature reaches at 15 PSI
and 120°C respectively.
Uses
For sterilization of:
1. Surgical metal instruments.
2. Glass syringes and needles.
3. Gowns, linen, towel bandages, cotton, gauze.
4. Cap, masks.
5. Silk, cotton, nylon.
6. Reusable gloves
7. Abdominal packing, laparotomy pads or sponges.
Autoclave are available in:
• Vertical
• Horizontal
Single drum or two drum of different sizes of drums.
Advantages and disadvantages: Autoclaving can kill all bacteria, spores
and viruses. Advantages include speed, good penetration, economic,
easy to use, absence of toxic products or residues, and reliability. It
allows the interior of wrapped packet to be sterilized.
The principal disadvantage of autoclaving is that heat sensitive
materials are damaged. Autoclaving can cause blunting of cutting edges,
corrosion of metal surfaces, and shortened life of electronic components.
Hot Air Oven

In this sterilization is by dry heat.
• Temperature: 160°C
• Time for sterilization is: One hour.
Articles which can be sterilized are:
• Glassware
• Forceps
• Scissor
• Syringes
• Scalpels
• Liquid paraffin
• Fat
• Grease
• Dusting powder, etc.
Following points must be kept in mind while using oven for
sterilization:
1. All the articles must be perfectly dry before placing in the oven.
2. Oven should be cool down before the door is opened, atleast it takes
two hours to cool down.
3. Oven should not be overloaded.
4. All the articles should be arranged in such a manner that there should
be free air circulation for perfect sterilization.
Boiling (Moist Heat)

Boiling the instruments in water at 100°C for 20 minutes, kills most of
the microorganisms. This is for disinfection of instruments (not
sterilizing).
Advantages
• It is quite simple method for disinfection.
• It is quite economical also.
Disadvantages
• It does not kill the spores, certain bacteria and certain viruses.
• It is not suitable for sharp instruments, as sharpness is damaged by
repeated boiling.
While boiling following points must be kept in mind:
1. Instruments should be fully dipped in water.
2. When boiling in process do not put the instruments in boiling
water as sudden change in temperature may cause cracks in
instruments.
3. Sharp instruments should not be sterilized by this method as
sharpness is damaged by this process.
4. Keep the containers lid closed.
5. All the instruments should be clean and free from organic material
before putting in water.
6. Water which is used should be free from salt otherwise corrosion of
instruments may result.
7. The glassware should be wrapped in linen before putting in
container because during the process of boiling by movements it
may break.
8. Water should be changed after each boil.
Sterilization 69
Sterilizer
Sterilizer is used for this process because it is especially designed for
this. It contains a perforating tray that can be moved by pressing a
handle fitted on outer side. This tray remains in the water. This tray
should be covered by gauze or water. When instruments are to be taken
out press the handle so that it comes out from the surface of water and
instruments are picked up by cheatle forceps.
Filtration
Certain liquids which are not sterilized by other means, are sterilized
by this method. These have millipores in the membranes of filters which
remove larger particles and bacteria from liquid. This is not so good as
sterilization because certain viruses (smaller one) may pass through
such filters.
There are different types of filters which are:
i. Collodion filter
ii. Asbestos disk filter
iii. Earthenware candles
iv. Sintered glass filter, etc.
Human serum albumin is sterilized in this way.
Chemical Methods
There are some chemical agents, which are used for sterilization. These
chemical substances kill the pathogenic microorganisms and sterilize
the articles.
Special points should be kept in mind while using chemical
disinfectant.
1. It should be used in correct and recommended strength.
2. These are very irritant and can cause chemical burn of skin, mucous
membrane so correct strength should be used.
3. Always wear gloves while using irritant agents.
4. Articles should be fully dipped in it.
5. Articles should be kept for sufficient time.
6. Before dipping instrument, articles must be clean and free from blood
or other lubricants.
7. All these chemical solution should be kept away from children.
It is very important to note that all the instruments which are dipped
in chemical solutions – must be rinsed with sterile normal saline
before use.
Formaldehyde
Formaldehyde is used principally in a water-based solution called
formalin. It is non-corrosive and is not inactivated by organic matter.
Although formaldehyde-alcohol is a chemosterilizer and formalin is a
high-level disinfectant, its uses are limited by its pungent odor and
fumes, which irritate the skin, eyes and respiratory tract at very low
level.
Glutaraldehyde
Glutaraldehyde-based solutions have been widely used because of their
excellent biocidal properties, activity in the presence of organic matter,
non-corrosiveness with most equipment and noncoagulation of protein
material.
Glutaraldehyde-based germicides are noxious and irritating. It may
result in a variety of toxic reactions in health care-workers if proper
ventilation and personal barriers (e.g. gloves, face protection) are not
consistently used. It is two percent glutaraldehyde solution. It kills the
microorganism (bacteria, virsus, fungus) as well as spores.
• Time required is 20 minutes and for sporicidal four hours.
• It is a best disinfectant.
• Once it is activated can be used for two weeks.
Special tray is there for sterilization, one outer tray and on inner
tray which has multiple pores in which instruments are kept. It cannot
be used for all types of equipment.
Formaldehyde + Absolute Alcohol + Sod. Nitrate (Ethicon)

This is used for sterilization of suture-packing.
It contains:
– 2.5 % formaldehyde
– Denatured absolute alcohol
– 87.5% sodium nitrate.
Formalin Solution
It is 30% aldehyde + 10% methane solution.
Uses
1. OT sterilization
2. 4-10% solution in saline is used as preservative for biopsy specimens.
Sterilization 71
Quaternary Ammonium Compounds
Quaternary ammonium compounds (quats) are low-level disinfectants.
They are bactericidal, fungicidal AD viricidal at room temperature
within 10 minutes, but have not demonstrated sporicidal effects. These
compounds are more effective against gram-positive than gram-
negative bacteria and are only marginally effective against P. aeruginosa.
Quats inactivate HIV but some do not inactive the hepatitis virus.
Recently hepacide quat-based disinfectants have become available.
Newer ones are mixed with various substances to produce synergistic
antimicrobial and detergent activities. They are quick acting, relatively
nontoxic and non-caustic, and do not produce noxious fumes. They
are useful for cleaning as well as disinfection.
Phenolic Compounds
Phenolic compounds are derived from carbolic acid. They are good
bactericides and are active against fungi. Phenolics remain active in
contact with organic soil and for this reason, often one of the
disinfectants of choice when dealing with gross organic contamination
in general housekeeping or for environmental disinfection in laboratory
areas. They are used mainly on environmental surfaces and for non-
critical devices.
Phenol (Carbolic Acid)

It is 0.5 to 1% carbolic acid. It is dark pink in color and very irritant. It
can burn the skin. For disinfection of sharp instruments
• 100% solution for 2 to 3 hours or
• 20% solution for 24 hours.
Other uses
1. Injection treatment for first degree piles used with almond oil.
2. Can be used to carbolize the stump of appendix in case of
appendectomy.
3. It is used for chemical sympathectomy (Phenol + Almond oil).
4. To disinfect dog bite wounds.
Lysol
It is a concentrated solution of cresol. It is dark brown in color. It is a
very irritant solution. It can cause burn of skin. Wear gloves while using
this solution. Rinse the instruments by sterilized normal saline before
use.
Time – 30 minutes in 100 % solution
– 1 to 2 hours in 1:1000 dilution
Instruments which can be sterilized are:
• Needles
• Scissors
• Knives, etc.
Hospital Concentrate (Savlon Aseptic HC)

It contains:
• Chlorhexidine gluconate
• Cetrimide
• Isopropyl alcohol
It is yellow in color. It is germicidal and detergent also. It is used in
different concentration for different purposes.
Uses
1:100 concentration solution (means 10 ml made up to 1 liter with water)
1. To store the previously sterilized instruments.
2. To clean and disinfect the instruments.
3. To clean postoperative wound.
4. To clean the vagina and perianal region in delivery, vaginal
operations and anorectal surgery.
5. For scrubbing.
6. Used in case of burn for aseptic purposes.
1:30 conc. solution (35 ml made up to 1 liter of water)
7. To clean dirty wounds.
8. To clean and disinfect the catheters and rubber appliances.
1:30 conc. in 70% alcohol (35 ml savlon + 200 ml sterile water,
made up to 1 liter with 95% alcohol).
9. For skin disinfection.
10. To disinfect the surgical instruments in an emergency situation
(immense for 2 minutes).
11. To keep the clinical thermometer.
12. To keep the cheatle forceps.
Bacilocid Special
It contains:
• 1, 6 dihydroxy, 2-5 dioxahexane (Chemically bound formaldehyde)
• Glutaraldehyde
• Benzyalkonium chloride
• Alkyl urea derivatives.
Sterilization 73
Special features
1. It causes excellent cleansing.
2. Rapid disinfection within 10 to 30 minutes.
3. Prolonged residual action.
4. Compatible with all types of surfaces.
5. No corrosion on frequent use.
6. It has pleasant odor and not irritant to eye.
7. Excellent viricidal activity against HBV, HIV, Polio viruses, etc.
Uses
1. High-risk areas – ICU, ICCV, oncology department, operation
theatre, trauma care ward, neonatal, pharmaceutical sterile section.
2. Noncritical areas – wards, corridors, OPD’s clinic, mobile unit,
laboratories, dental division, in between cases, for emergency
disinfection.
Precautions
1. Avoid contact with concentrated solution.
2. Keep away from children.
3. Do not mix with other solution.
Mode of use
• Spray over all exposed surfaces with a hand compression sprayer.
• Add – 25 to 50 ml to 10 liter of tap water to get 0.25 to 0.5% solution.
• Spray or mop liberally on exposed surfaces, keeping wet for 10 to
20 minutes for optimum results.
• To reduce evaporation before and after application, close doors and
windows and switch off AC/Fans.
• Disinfected surfaces must remain in contact (wet) with this solution
for 10 to 20 minutes for optimum results.
Ethanol + 1 and 2 Propanol Solution (Bacillol 25)

It is used for disinfection of water sensitive surfaces. It is quick acting
surface infectant. It is used for disinfection of “water-sensitive” surfaces.
It can be used for disinfection of:
NICU/ICU
– Syringe pump – ECG monitor
– Infusion pump – Pulse oxymeter
– Ventilator – Phototherapy unit
– Accessories: cables, cords, – Incubators
adaptor, connector, wires – Warmer
– Emergencytrolley – ECG machine
OT
– OT table – Heart Lung machine
– Overhead light – Defibrillator
– OT in between surgery – Instruments trolley
– Camera – C–arm
– Video recorder – Monitor
– Insufflator – Tonometer
– Ophthalmic and ENT, Neurosurgery microscope
– Probes
Others
– Imaging machine – CT scanner
– Digital X–ray – X-ray machine
– HIV endangered areas – Pharmaceutical sterile section
Precautions
1. No disinfection to be done when combustible vapours (ether, etc.)
are present in the room.
2. All hot surfaces must be cooled before use.
3. Switch off all the electric devices.
4. For best results, ventilation should be kept low, or started five
minutes after spraying.
Alcohol (Spirits)
Optimum concentration is 70% alcohol.
Uses
Instruments which are required in emergency at the spot can be dipped
in it and can be used.
Other uses of spirit are:
i. It is used to remove povidone iodine from skin in operation.
ii. To clean the skin for IV, IM, SC, Intradermal injection.
iii. To clean the stitched wound.
iv. To clean the surrounding skin of a wound, ulcer, etc.
v. It is used along with povidone iodine in skin preparation for
operation as it increases the penetration power of iodine solution.
vi. To clean the hands before sterile dressings.
Ethyl alcohol is bactericidal in 60 to 90% concentrations (70% is best)
and isopropyl alcohol in 60% or greater concentration (90% is best).
Both kill most bacteria, including mycobacteria during an exposure of
1 to 5 minutes. They do not kill spores. Their action against viruses is
variable. Ethyl alcohol is superior to isopropyl alcohol. The CDC
recommends exposure to 70% ethanol for 15 minutes to inactive the
Sterilization 75
hepatitis virus, but one minute should be adequate for HIV. Their
effectiveness is limited because of their rapid evaporation that results
in short contact times are immersed and because they lack the ability
to penetrate residual organic material. Items to be disinfectant with
alcohol should be carefully pre-cleaned and then totally submerged
for an appropriate exposure time. They are sometimes combined with
other agents to form a tincture.
They are also used to disinfect external surface of equipment (e.g.
stethoscopes and ventilators). They have been used to clean fiber-optic
cables.
Alcohol can damage the mounting of lens instruments and tend to
swell and burden rubber and certain plastics after prolonged and
repeated use.
Iodophors
They are bactericidal, viricidal and tuberculocidal but may require
prolonged contact time to kill certain fungi and bacterial spores.
Iodophors are used principally as antiseptics. Some metallic instruments
can be corroded if they are routinely disinfected with iodophors for
long period. Non-metallic items are seldom damaged but may become
stained or discolored.
Para-acetic Acid
Para-acetic acid is acetic acid with an extra oxygen atom. It is
bactericidal, sporicidal, fungicidal and viricidal at low temperatures. It
remains effective in prepresence of organic material. One problem is
that it is corrosive and irritating to skin in a concentrated solution.
Advantages
• This system provides a quick method of sterilizing a wide variety
of heat-sensitive instruments, including some fiberscopes.
• It is less damaging to delicate instruments than steam sterilization
and is compatible with a wide variety of materials, including plastics,
rubber and most heat-sensitive items.
• The steris system is especially useful for items requiring a quick
turn around time. It is faster than sterilization with EO or
glutaraldehyde and can be used on wet or dry items.
• No dilution of the sterilant by personnel is necessary and the rinse
is automatic so personnel are not exposed to any toxic chemicals.
Disadvantages
• Only items that can be totally immersed can be sterilized.
• The use of instruments sterilized in this system should be consistent
with just-in-time processing and delivery.
Chlorine and Chlorine Products
Hypochloride solution
• One percent hypochloride solution
(Bleaching powder 10 gm + 1 liter water)
• It is used to disinfect the floor of operation theatre and wards. They
are available in both liquid (e.g. soldium hyopochlorite) and solid
(e.g. calcium hypochlorite) forms. They are inexpensive and fast
acting. They are active against all bacteria.
• 1:100 to 1:1000 dilution is effective against the human immuno-
deficiency virus.
• 1:5 to 1:10 dilution will destroy the hepatitis virus.
• 1:10 dilution of 5.25% sodium hypochlorite has been recommended
by the CDC for cleaning the blood spilled on the floors.
Hydrogen peroxide: Hydrogen peroxide is an effective bactericide,
fungicide, viricide and sporicide. Synergistic sporicidal effects have been
observed with a combination of hydrogen peroxide and para-acetic acid.
It is commercially available in a three percent solution but can be used
in up to a 25% concentration. It is non-corrosive and is not inactivated
by organic matter but is an irritant to the skin and eyes. It is said to be
safe for use with rubber, plastic, and stainless steel.
Advantages: Economic, speed and simplicity.
Disadvantage: The hazard is that the chemicals employed can be
absorbed onto the items.
Gas Sterilization
These are:
i. Formaline sterilization (Fumigation)
ii. Ethylene oxide (ETO gas)
iii. Betapropiolactone
Formalin Sterilization
There is a specially designed air tight chamber in which temperature
and humidity is controlled and all the air is removed. About 8-10 tablets
(according to the size of chamber) of formaldehyde is kept just below
the lower most tray. It is kept closed for 8 hours. It is used to sterilize
delicate surgical instruments like:
• Optical lenses
• Plastic syringes
Sterilization 77
• Tubings
• Plastic parts of heart machine.
Fumigation of operation theater: A special type of instrument-Fumigator
or Aerosol disinfector is used, in which diluted liquid formalin and
liquid ammonia (1:5 ratio ) is used. It is electrically operated machine.
It is simple and quick. Routine disinfection may be done once a week
or oftener. By this equipment all the articles are disinfected like—
Anesthesia machine, OT table, Suction machine, Laparoscopic trolley,
OT lights, Gas cylinders, Instrument trolley, Blankets, Pillows,
Mattresses, as well as OT room itself, etc.
Recommended formaline dosages: For every 1000 cubic feet room volume
for routine disinfection—30 ml formaline of 40% concentration with 90
ml of clean water.
For intensive disinfection—90 ml formaline of 40% conc. with 90 ml
of clean water. To neutralize the irritating effect of formaline, liquid
ammonia is used in a ratio of 1:5.
Disinfection procedure:
• Ascertain the dosage required for room to be disinfected.
• Place disinfector inside the OT.
• Pour in the desired formaline from top of the unit.
• Do not pour liquid directly over the fan.
• Close and seal all windows ventilators/openings, AC and doors of
OT.
• Switch on the unit and allow it to run for 30 minutes, then switch it
off (switch must be on outside the OT, as formaline is hazardous).
• Wait for 6 hours and open the door. It is ready for use.
Disadvantages
• These have very pungent smell.
• These are irritant to eyes, mucous-membrane and skin.
• Minimum of 24 hours of aeration is necessary to ensure the removal
of gas from sterilized articles. Chemical burns may occur when
materials treated with these gases and are applied to the tissues.
Exposure period 3 to 6 hours is needed for sterilization. Its irritant
property and pungent smell can be neutralized by adding liquid
ammonia (ammonium chloride) in the ratio of 1 : 5.
Ethyleneoxide (EO) Gas Sterilization

EO is a colorless, poisonous gas with a sweet odor. It is a liquid below
11oC (51oF). It is available in high-pressure tanks and unit-dose
ampoules and cartridges. Both the liquid and the gas are flammable
in concentrations of three percent or greater. EO may be mixed with
carbon dioxide or hydro-chloro-fluorocarbons to make it less
hazardous.
EO kills bacteria, spores, fungi and viruses. As a gas, it penetrates
into crevices and through permeable bags. Items can be packed before
sterilization and stored sterile for extended periods of time. EO
sterilization is a more complex and expensive process than steam
sterilization. It is usually restricted to objects that might be damaged
by heat or excessive moisture.
Preparation for ethylene oxide sterilization: It is important to verify that
the product is suitable for sterilization by EO.
Before packing, items must be dis-assembled, cleaned, and dried. It
is important for free movement of gas to allow it to penetrate throughout
the whole product. Items for gas sterilization must be free of water
droplets. They should be towel dried. Items should be loaded in such a
fashion that packages will not contact the operator’s hand.
Exposure time: In automatic sterilizers, the time generally ranges from
1.5 to 6 hours. Up to 12 hours may be required.
Indicators: Three types of indicators (monitors) are available.
Physical monitors: Physical monitors include all sterilizer components
that measure exposure time, temperature, humidity and pressure
during each cycle.
Chemical indictors: Chemical indicators change color when certain
conditions necessary for sterilization have been met they are available
as tapes, strips, cards and sheets.
Biological indicators: They should be used at least once a week. They
should be placed in the most inaccessible location in the sterilized load.
If the articles to be sterilized have not been properly cleaned before
packaging, a biological indicator will not be a valid tool for determining
sterility.
Aeration: EO not only comes in contact with all surfaces of articles being
sterilized but also penetrates some items, which then retain verifying
amounts. These items need special treatment called aeration to remove
EO to a level safe for both personal and patient use.
The minimum recommended times for devices that are difficult to
aerate are 8 hours at 60oC (140oF), 12 hours at 50oC (120oF) and 7 days
Sterilization 79
at room temperature (21oC) (70oF).
Complications of ethylene oxide sterilization
Patient complications: Complications from residuals on sterilized items
include skin reactions and laryngotracheal inflammation. These
problems are caused by excessive levels of EO or its byproducts.
Personnel complications: Possible Hazards of Exposure to EO: Danger of
fires and explosions. Eye irritation, headache, blunting of taste or smell,
a metallic taste, and coughing are common. With higher concentrations,
nausea, vomiting, diarrhea, increased fatigability, memory loss,
drowsiness, weakness, dizziness, inco-ordination, chest discomfort,
shortness of breath, difficulty in swallowing, cramps and convulsions
have been reported. Respiratory paralysis and peripheral nerve damage
have been reported after massive exposure.
Chronic exposure can affect the eyes (corneal burns, cataracts,
epithelial keratitis), nervous system (sensory motor polyneuropathy),
and skin (irritant and allergic reactions). In addition there are concerns
that EO may be mutagenic and that it may adversely affect the
reproductive system.
The worker’s exposure should be limited to an 8 hour time weighted
average (TWA) of one ppm with a short-term excursion limit (STEL) of
five ppm averaged over 15 minutes.
Employers should provide respiratory protection and personal
proactive equipment in work operations such as maintenance, repair,
or other activities.
Source of EO exposure
There are eight principal sources of EO exposure:
1. The area in front of the sterilizer when the door is opened upon
completion of the sterilization cycle.
2. The freshly sterilized goods.
3. The aeration cabinet.
4. The sterilizer.
5. The floor drain.
6. The procedure for changing the tank and/or cartridge.
7. The safety valve.
8. The supply tanks and cartridges.
Recommendations to reduce exposure
1. Unnecessary use of EO should be avoided. Each sterilizer and aerator
should have regular preventive measures especially leaks, are
detected and corrected.
2. Cylinders of EO should be stored in a designated area.
3. Caution should be taken, when changing tanks and filters.
4. A local exhaust should be there near the EO cylinder connection to
capture EO release.
5. Sterilizers and aerators should be located in well-ventilated areas.
6. The room in which the sterilizer and aerator are located should be
large enough to ensure adequate EO dilution and to accommodate
the loading, unloading, and maintenance of the equipment.
7. The single greatest source of EO exposure occurs when the sterilizer
door is opened after completion of sterilization after the cycle is
complete.
8. Goods should never be handled directly. All EO sterilized items
should be aerated before handling.
Advantages
• It is effective against all microorganisms.
• It is very reliable, because the gas penetrates into crevices .
• It can be used on a wide variety of items, including those that would
be damaged by heat or high concentrations of moistures.
• Items can be prepacked and the packet sealed.
• The items can be stored for a longer time.
Disadvantages
• Fires and explosions involving sterilizers have been reported.
• A major disadvantage is that it may require at least 24 hours for
turn around time.
• It is more costly than most other types of disinfection.
• Installation is expensive and the equipments require a big space.
• Personnel need to be highly trained and supervised to ensure proper
sterilization and prevent complications.
• Frequent biological monitoring is required.
• Equipment to be sterilized needs to dry, which can be difficult to
achieve with items such as corrugated tubings. Some materials
deteriorate after repeated sterilization.
• It cannot be used to sterile devices that have petroleum-based
lubricants.
Radiation
Radiation sterilization is the dominant process for sterilizing disposable
products from manufactures.
There are two methods of sterilization by radiation.
1. Ionizing radiation and
2. Nonionizing radiation
Sterilization 81
Ionizing Radiation Method
There are:
• X-ray
• Gamma rays and
• Cosmic rays
Out of these gamma rays are widely used for this purpose. The
articles which are sterilized by this gamma rays are:
– Plastic syringes – Swabs
– Hypodermic needles – IV set
– Catheters – BT set
– Suture materials – Scalp vein set
– Eye/ear droppers – Surgical blades
– Paraffin gauge – Ready for use surgical kits
– Ophthalmic ointments – Prosthesis
– Mesh – Cement
– Heart valves – Aluminum foils
– Orthopedic implants – Plastic packs
Gamma-radiation is an electromagnetic wave produced during the
disintegration of certain radioactive elements. If the dosage applied to
a product is large enough, all microorganisms, including bacterial spores
and viruses will be killed.
Advantages
• The product can be pre-packed in a wide variety of impermeable
containers before treatment. The packet will not interfere with the
sterilization process.
• The treated items remain sterile indefinitely until the packet seal is
broken.
• As there is no temperature rise during treatment, thermo-labile
materials can be sterilized and thermo-labile packet can be used.
• Equipment may be used immediately after gamma-radiation
treatment with no risk from retained radioactivity.
Disadvantages
• Gamma-radiation is not practical for every day use in health care
facilities.
• It requires expensive equipment and is used only by large manu-
facturers to sterile disposable equipment.
Nonionizing Radiation Method
There are two types of nonionizing radiation which is used for
sterilization:
1. Infrared
2. Ultraviolet
Infrared: It is used for rapid and mass sterilization of syringes.
Ultraviolet: It is used for enclosed areas like hospital wards, operation
theatre, entryways, etc.
Disadvantages
• It does not penetrate the shadows thus all the surfaces should be
exposed because radiation travel in straight line.
• These methods are quite expensive.
• These methods have harmful effects on skin and tissues.
• Long exposure of ultraviolet rays damages the conjunctiva of eyes.
• UV rays do not penetrate the liquids.
Indicator: Paper sticks which are yellow in color stuck it on an article,
when it changed to red in color means article is sterilized (for gamma
radiation).
Gas Plasma Sterilization

Gas plasma sterilization uses a gaseous chemical germicide (para-acetic
acid, hydrogen peroxide) and gaseous plasma.
Gas plasma is effective sterilant for a variety of medical device
applications, including most packaging materials, plastics, and stainless-
steel instruments. It has the potential to displace EO and steam from
many uses in health care facilities since it offers rapid low-temperature
sterilization and does not have the environmental problems. No
personnel or exhaust monitoring or protective equipment for changing
tanks are needed.
Sterrad system: In the sterrad system, hydrogen peroxide is the precursor
of the active species of the plasma.
The items to be sterilized are placed in the sterilization chamber,
the chamber closed, and a vacuum is drawn. Vaporized hydrogen
peroxide is injected and allowed to diffuse throughout the chamber,
and thereby come into close proximity with the items to be sterilized.
After reduction of the pressure in the chamber, gas plasma is generated
by applying radiofrequency energy to create and electrical field. The
gas plasma is maintained for a sufficient time to ensure sterilization.
At the completion of the process, the radiofrequency energy is turned
off, the vacuum is released and the chamber is returned to atmospheric
Sterilization 83
pressure by the introduction of filtered air. Total processing time is a
little over one four.
This technology can be used for most items, which are sterilized by
EO or steam, with the exception of cellulosic materials (e.g. cotton,
linens, paper) powders, liquids, implants, and devices containing long,
narrow, dead-end withstand a vacuum. It is not recommended for
flexible endoscopes.
It is well suited to heat and moisture-sensitive instruments since
the temperature does not exceed 50oC. It produces less effect on metal
items than steam sterilization. It can be used with a variety of hinged
and non-hinged instruments, plastic devices such as airways, devices
with lumens, electric and fiber-optic cables, batteries and rigid
endoscopes.
The process requires no aeration, and there are no toxic residues or
emissions.
Plasmalyte system: With this technology, the gas plasma is produced in
a separate plasma chamber where the gas mixture of hydrogen, oxygen
and argon is exposed to a microwave electromagnetic field. Preparation
of instruments is similar to other technologies: cleaning, reassembly,
and wrapping. It is effective with all types of current wraps and
sterilization containers.
Para-acetic acid with a small amount of water and hydrogen oxide
is supplied in a sealed bottle that is placed in the sterilizer. After devices
are loaded in to the sterilization chamber, a vacuum is drawn. Para-
acetic acid vapor is then introduced into the chamber and allowed to
diffuse through for 20 minutes. The chamber is then evacuated. New
plasma is continuously created throughout the cycle. After
approximately 10 minutes, the electromagnetic field vacuum pump
removes the remaining gas. The reactive components of the gas
evacuated from the chamber recombine with one another to form
oxygen, hydrogen and water vapor treatment. Upon completion of the
six repetitions filtered airflows through the chamber for 10 minutes.
Sterilization is carried out at or below 55oC. The duration of the
entire cycle varies from 3½ to 4 hours. Items that will absorb para-acetic
acid (such as cellulosic materials) will cause the time to prolong.
This technology can be used for any items that can be sterilized by
EO. It is not recommended for liquids, powders, non-vented containers
or flexible endoscopes.
The sterilization chamber is larger than the Sterrad system, so more
items can be processed at one time.
It kills all microorganisms both form, i.e. vegetative and spores.
Conclusion of Sterilization and Disinfection
1. Sharp Instruments: In pure lysol or two percent gluteraldehyde
solution for 20 to 40 minutes.
2. Linen, Gowns, Glass syringes, Gloves, Cotton thread, Silk, Needles, Metal
wires, Dressing material, Metal instruments. By autoclaving at, 121°C
temperature,15 PSI pressure, 20 to 40 minutes time.
3. Glass syringes, Bowl: By boiling method, 100°C for 20 minutes.
4. Endoscopes, Gum elastic catheters, Laparoscopic Hand instruments:
two percent gluteraldehyde for 20 minutes and for sporicidal – 4
hours.
5. Enamel ware: Boiling 100°C for 20 minutes.
6. Tubing, Electrosurgery wires, Optic fiber, Light cord/cable and Camera:
Rinsed with 70% alcohol and then cover with autoclaved sleeves
made for these.
7. Dental Instruments: Two percent gluteraldehyde.
8. Tonometer and Ophthalmic Instruments: Acetone or two percent
gluteraldehyde solution or autoclaving.
9. Thermometer, Cheatle forceps: 1:30 conc. of savlon in 70% alcohol.
10. Incubators: Application of two percent gluteraldehyde or carbolic
acid, two percent hypochloride solution or surgical spirit.
11. Humidifiers: Fill with sterile water containing silver nitrate 0.1%.
It should be changed daily.
12. Ampoules, vials: By surgical spirit, Povidone iodine.
13. OT Table: With two percent hypochloride solution, surgical spirit.
If soiled then by two percent gluteraldehyde (after washing with
soap and water).
14. Mattresses and Pillows:
• These should be kept in sunlight.
• Two percent hypochloride solution or if soiled then with
two percent gluteraldehyde.
15. Bed pans, Urine pots, Kidney tray: By - Seven percent Lysol or two
percent hypochloride solution.
16. Ventimask, Spirometer: 70 percent alcohol ( surgical spirit).
17. Soiled Linen: First immersed in one percent hypochloride solution,
dry it and then autoclave.
18. OT, Ward and Entry Way: One to two percent hypochloride
solution.
19. Cap, masks, OT dress: Autoclave.
20. McIntosh, Plastic Gowns: One to two percent hypochloride solution.
Now plastic gowns are made in such a way that can be autoclaved
also.
9 Anesthesia
INTRODUCTION
Anesthesia means loss of all sensations. It is of three types:
1. General anesthesia.
2. Local anesthesia
3. Regional anesthesia
Local Anesthesia
Local anesthesia means reversible loss of sensation (specially of pain)
in a restricted area of the body.
General Anesthesia
General anesthesia means reversible loss of all sensation and
consciousness.
Anesthetic
Anesthetic are the drugs which causes anesthesia. These are of local
regional and general.
LOCAL ANESTHESIA
Local Anesthetics
These are:
• Procaine, Lignocaine, Amethocaine, Prilocaine, Bupivacaine,
Dibucaine, Benoxinate, Oxethazaine.
Local anesthesia can be produced by cooling, e.g. application of ice,
CO2 snow, ethyl chloride spray.
Mechanism of Action
They block the nerve conduction. There is loss of sensory as well as
motor loss where they are used.
Local Actions
They cause anesthesia of skin and paralysis of voluntary muscle
supplied by that nerve. Pain, temperature sense, touch and deep
pressure sense is lost. When applied to tongue or mucosa causes loss
of taste ( sweet, sour, salty taste) and pain sense is lost.
Systemic Actions
When LA applied or injected locally is ultimately absorbed and produces
systemic effects also (depending upon the concentration and amount
used).
1. Central Nervous System (CNS): All local anesthetics produces first
stimulation then depression.
2. Cardiovascular System (CVS): Local anesthetics are cardiac (heart)
depressants. Bupivacaine is more cardiotoxic (ventricular
tachycardia or fibrillation).
Lignocaine has little effect on contractility and conductivity (used
in arrhythmia).
3. Causes fall in BP: These are absorbed by mucous membrane and
abraded (injured) areas.
Side Effects
Hypersensitivity reaction can occur in the form of rashes, edema,
asthma, dermatitis. When it is given intravenous or overdose can cause
systemic toxicity.
CNS Effects
Headache, vertigo, visual and twitching, convulsion and respiratory
arrest.
CVS Effects
Decreased BP (hypotension) decreased pulse rate (bradycardia),
arrythmia and even collapse (death).
Availability
These are available in-ampoules, vials, spray, jelly, ointment, eye drops,
ear drops, with antacids gel, suppository, powder and in different
concentrations 0.25%, 05%, 1%, 2%, and 5%.
Adrenaline (1:50,000 to 1:200,000) is used in addition to local
anesthetic. Adrenaline has added advantages:
Anesthesia 87
• It prolongs the duration of action.
• It decreases/reduces the systemic toxicity.
• It provides a more bloodless field for surgery.
Adrenaline and LA Precautions

1. It should not be used in hypertensive patient as it increases BP.
2. It should not be used in finger, toes, penis, ear lobule as it can cause
necrosis of terminal part (because of its vasoconstriction effect).
3. It makes the injection more painful.
Different Types
Surface Anesthesia
It is produced by topical application (with spray ointment, gel, jelly) to
mucous membrane and abraded skin. It produces only superficial
anesthesia.
It takes two to five min and last for 30 to 45 min.
• Eye drops/oint-tetracaine, benoxinate.
• Nose, Ear drops—Lignocaine, tetracaine.
• Abraded skin—Cream, ointment, powder of tetracaine, benzocaine.
• Esophagus, Stomach—Oxethazaine suspension with antacids.
• Urethra—Lignocaine jelly.
• Anal Canal—Lignocaine, dibucaine, benzocaine ointment/cream/
suppository.
• Tatracaine/Lignocaine spray in throat.
Infiltration Anesthesia
Diluted solution of LA is infiltrated under the skin where surgery is to
be done or where local anesthesia is required (desired). It blocks the
sensory nerve endings. Anesthesia begins immediately after the
injection and remains for 30 to 60 min if lignocaine is used. 120 to 180 min
if bupivacaine is used.
It is used for minor operations.
REGIONAL ANESTHESIA
Field/Nerve Block
When LA is injected around nerve trunk, area distal to injection is
anesthetized. It is used for minor operations/procedures, e.g. hernia,
scalp stitching, procedure on forearm, legs. Tooth extraction, operation
on eye, abdominal wall operation, fracture setting, neuralgia (nerve
block), etc.
Fig. 9.1: Local anesthesia by field block
Fig. 9.2: The raising of a cutaneous wheal
Fig. 9.3: Subcutaneous infiltration

Anesthesia 89
Fig. 9.4: Blocking the facial nerve (O Bren’s method)
Fig. 9.5: Blocking the facial nerve (Van Lint’s method)

Fig. 9.6: Retrobulbar block
Fig. 9.7: Subcutaneous ring block and position of dorsal nerve of penis
Anesthesia 91
Fig. 9.8: Illionguinal, iliohypogastric, and genitofemoral nerve blocks: To block the ilioinguinal
and iliohypogastric nerves the needle is inserted one (child’s) finger breadth medial to the
anterior superior iliac spine (X1) and directed posterolaterally until it strikes bone. It is then
withdrawn slightly and the injection made as the needle is withdrawn to a subcutaneous
position. The needle is then reinserted through the external oblique aponeurosis (a slight
‘click’ should be felt) and further solution injected both above and below the aponeurosis as
the needle is with drawn. For orchidopexy, one-fourth of the total volume should be injected
in each maneuver, with the remaining fourth deposited adjacent to the pubic tubercle, above
the inguinal ligament (X2). Because nerve fibers may cross the midline, it is desirable to
infiltrate the subcutaneous tissues for a few centimetres upwards from the symphysis pubis
Fig. 9.9: Iliohypogastric and ilioinguinal nerve blocks (1) Umbilicus,

(2) Anterior iliac crest, (3) Pubic tubercle
Fig. 9.10: Hand position for supraclavicular block. The needle is directed caudad behind the
midpoint of the clavicle in the interscalene groove. Again, control of depth is maintained by
the hand resting on the clavicle. The syringe is kept in the sagittal plane parallel to the patient’s
head to prevent medial angulation, which increases the chance of pneumothorax
Fig. 9.11: Sites of deposition of the local anesthetic solution

during the retrobulbar and the peribulbar blocks
Fig. 9.12: Peribulbar block

Anesthesia 93
Figs 9.13A and B: (A) Intercostal block: The mid-axillary line and lower border of the rib of
the segment to be blocked are marked. A short bevelled needle (with the bevel facing upwards)
and attached to a primed extension tube in inserted at 80° to the chest wall until it strikes the
lower border of the upper rib of the space to be blocked. The needle is then withdrawn slightly
and slid under the rib until loss of resistance is felt. (If loss of resistance is not felt after sliding
the nedle under the rib, the needle should be inserted no more than 2 mm). Up to 2 ml of
solution is inected in each space (B) Needle advancement for performance of an intercostal
nerve block
Fig. 9.14: Supraclavicular brachial plexus blocks Fig. 9.15: (1) Skin projection of
interscalene (1) perisubclavian (2) artery chassaignac tubercle (2) Midpoint of
approaches parascalene approach the clavicle
Figs 9.16A to C: Dorsal penile nerve block: (A) With the base of the penis as a clock face, the
needle is inserted at 10:30 and 1:30 (shown here) and advanced in a plane perpendicular to
the skin, (B) The short 25 gauge needle is gently advanced until the hub is reached or until
the needle tip gently touches the pubic bone, (C) Local anesthetic is injected around the
dorsal penile nerves as the needle is withdrawn
Fig. 9.17: Penile block via the subpubic space: Landmarks
Toxic Effect of Local Anesthesia

Reactions are generally caused by allergy or anaphylaxis due to its
preservative (methylparaben) or due to overdosage. These are liable to
occur when the recommended dosage is exceeded or when it is given
by inadvertent intravenous or intravenous or intraarterial injection.
Signs and Symptoms of Toxicity

Anxiety, excitement, drowsiness, coma, convulsions, cessation of
respiration, areflexia, hypotension, bradycardia and heart block.
Treatement
• Administer oxygen.
• If convulsions—inject inj. Diazepam.
• If hypotension—inj. Ephedrine, inj. Atropine
• IV line should be maintained.
CAUDAL ANESTHESIA
Caudal analgesia is the most popular block performed in pediatric
patients. The sacral hiatus is situated at the lower end of sacrum. It is
very easy to identify in infants and children. It is due to non-fusion of the
fifth sacral vertebral arch immediately cephalad to coccyx. The hiatus is
covered with sacrococcygeal membrane. The large bony process on each
side are cornua. In infants and young children, these landmarks are easily
palpable or even visible through the skin, because of the absence of the
large sacral pad of fat that usually develops at puberty.
Anesthesia 95
Indications
• Herniorrhaphies.
• Operations on the urinary tract (e.g. hypospadias, circumcision)
• Operation of rectum and anus.
• Orthopedic procedure on pelvic girdle and lower extremities.
• Operations below the level of umbilicus.
• Continuous caudal blockage has also been used successfully for
upper abdominal surgeries.
• Gynecological operations.
Technique
• Identify the sacral hiatus by locating the tip of coccyx.
• Apply firm pressure to the coccyx, then palpate in cephalad
direction, moving the finger gently from side to side. The first pair
of bony prominence encountered are the two cornua of the sacrum
that surrounds the sacral hiatus.
• The needle is inserted at a 45 degree angle to the coronal plane
perpendicular to all other planes after the definite 'pop' is felt, the
angle is dropped.
• The commonest mistake in the performance of this block is to insert
the needle too low.
• After negative aspiration for CSF and blood, the local anesthetic
solution is injected slowly and continuously, provided there is no
increased resistance to injection.
Doses
The volume, dose and concentration of drug determine the quality
duration and extent of any block. Bupivacaine is best at 0.25%
concentration, it confers analgesia for four to six hours. Doses are
calculated according to weight and the site of operation.
Complications
Complications are unusual and usually minor.
• Systemic toxicity—result from misplacement of the needle into
intravascular or interosseous injection.
• Failure of block—result from misplacement of the needle into
superficial soft tissue.
• There may be chances of penetration into pelvic viscera and vessels.
• Hypotension may occur but rare.
• Vomiting but rare.
Fig. 9.18: Anatomic differences beween infant and adult

important in performing a caudal block
Fig. 9.19: Caudal block

Anesthesia 97
SPINAL ANESTHESIA
Fig. 9.20 : Complications of epidural block
Fig. 9.21 : Types of needle insertion: In the vertical versus parallel insertion, the bevel of the
spinal needle is inserted through the dura mater internal perpendicular to, instead of parallel
to the long axis of the vertebral column
Fig. 9.22 : The hanging drop technique
It is the temporary interruption of nerve transmission following

injection of a local anesthetic solution into the subarachnoid space. It is
method of regional anesthesia. It is used in surgical and obstetric
anesthesia as well as in the management of certain pain problems. This
regional anesthetic technique offers significant advantages over general
anesthesia for surgical procedures of the:
1. Lower extremities
2. Pelvis
3. Perineum
4. Lower abdomen and abdominal wall by producing specific sensory,
motor and sympathetic blockade.
EPIDURAL ANESTHESIA
Epidural anesthesia (peridural or extradural) is anesthesia obtained by
blocking spinal nerves in the epidural space as the nerves emerge from
the dura and then pass into the intervertebral foramina. The anesthetic
solution is deposited outside the dura and therefore differs from spinal
or subdural anesthesia, where the solution is deposited in the
subarachnoid space. A segmental block is produced chiefly of spinal
sensory and sympathetic nerve fibers. Motor fibers may be partially
blocked.
Different Positions for Performing Spinal Block

The three primary methods of patient positioning include:
a. Lateral decubitus
b. Sitting, and
c. Prone
Lateral Decubitus Position

Two aspects of this position are important.
Anesthesia 99
Fig. 9.23 : Lateral decubitus position for spinal anesthesia
Fig. 9.24 : Anatomical landmarks for epidural or spinal anesthesia
It is the most commonly used position, for most surgical procedures

in spinal anesthesia. The anesthetic procedure is performed with the
patient flexed in the lateral position, with back parallel to the edge of
the operating table nearest to the anesthetist. Thighs are flexed upon
the abdomen, and the neck flexed to allow the forehead to be as close
as possible to the knees. The assistant place one hand on the soles of
the patient’s feet and the other on his or her head, while the abdomen
presses against the patients knees. No attempt should be made to
achieve maximum flexion. The patient should be comfortable and
relaxed. This minimizes longitudinal pull on the dura and consequently
leaves a smaller opening in the dura.
The lateral decubitus position has the advantage that, it is more
comfortable for the patient and the patient is not as likely to experience
a faint. The disadvantage is that, it is often difficult to communicate the
posture that the anesthesiologist would like the patient to assume
It is easy for patient to make their back lordotic at the precise moment
when an arched out back is more desirable.
If the patient is obese, it is more difficult to locate the midline with
the patient in the lateral decubitus position.
Sitting Position
This position is chosen when low lumber and sacral levels of sensory
anesthesia is required. It is adequate for the surgical procedure, such
as perineal and urologic operations, or when obesity makes identifi-
cation of midline anatomy difficult in the lateral position. When placing
a patient in this position, a stool can be provided as a foot-rest, and a
pillow is placed in his lap. The assistant maintains the patient in a vertical
plane while flexing the patients neck and arms over the pillow to open
up the lumbar space. The patient should be put supine immediately
after the injection .
The advantage of the sitting position is that the proper curvature of
the back for lumbar puncture is easier to obtain. The correct posture is
easily communicated to the patient by asking him/her to merely lean
forward. Another advantage is that it is more difficult for the patient to
‘move away from the needle’ when in this position. The major
disadvantage to this position is the increased incidence of fainting.
Fig. 9.25 : Sitting position for spinal anesthesia

Anesthesia 101
Prone Position
This position should be chosen when the patient is to be maintained in
that position (often with jack knife modification) during the surgical
procedure. This is often appropriate for rectal, perineal or lumbar
procedures. This position is quite suitable for hypobaric techniques,
especially when the jack knife position is desired for rectal and lower
back surgery.
Patient should be made comfortable in the prone position with the
OT table flexed under their flanks, i.e. just above the crests of the ileum.
This will flex the lumbar spine. Patient should remain in this position
for 3 to 8 minutes until good onset and fixation of anesthesia occurs.
An advantage of hypobaric techniques is that patients can help
positioning themselves, thus minimizing the opportunity for
positioning injuries. Once the patient is in position, lumbar lordosis
should be minimized and most often the paramedian approach used.
Also, one may have to aspirate for CSF, since CSF pressures are
minimized when lumbar needle insertion is carried out in this position.
DIFFERENT TECHNIQUES OF LUMBAR PUNCTURE

Midline Technique
Traditionally, midline technique with the patient lateral is the most
popular approach. The spinous process of the vertebra above and below
the level to be used defines the superficial limits of the interspace. The
needle is directed so as to pass just under and parallel to this spinous
process in the midline, taking into account the slightly cephalad location
of the interlaminar space. Smooth passage suggests a spinous process,
whereas deeper bone contact is either lamina (on midline) or pedicle (off
midline). This information can be used to redirect the needle.
Fig. 9.26 : Midline approach for lumbar puncture

Paramedian or Lateral Approach
The paramedian technique is selected when lumbar puncture is difficult,
particularly in patients with severe arthritis, kypho-scoliosis, and prior
lumbar spine surgery. The midline is identified, and an interspace is
chosen. A skin wheel is raised two cm lateral to the superior spinous
process. The needle is directed 10 to 15 degrees toward the midline and
then advanced. It may help to imagine the needle reaching the midline
4 to 6 cm below the surface in order to select the angle of approach.
With free flow of cerebrospinal fluid, the procedure is then the same as
midline.
Fig. 9.27: Paramedian approach for lumbar spinal anesthesia
Taylor Approach
The Taylor approach is a special paramedian approach to enter the L5
interspace (the largest interlaminal space). It was originally described
for urological procedure but was subsequently used for other operations
in the pelvis and perineum.
Fig. 9.28: Taylor approach to spinal anesthesia

Anesthesia 103
The Methods for Detection of Epidural Space
To recognize the position of a needle in the epidural space, several
methods have been recommended.
1. Loss of resistance technique
2. Hanging drop technique
3. Capillary tube method.
Different Types of Needles Used for

Spinal and Epidural Blockade
Standard Spinal Needle
It consist of three parts: A hub that is fused to a cannula with a point,
and a fitted, removable stylet that occlude the distal lumen and point
of the cannula. A wide variety of sizes with different applications are
available from 16 gauge to 30 gauge.
Fig. 9.29: Spinal needles
Epidural Needle
The standard epidural needle is typically 16 to 18 gauge, 3 inches long,
and has a blunt bevel with a gentle curve of 15 to 30 degrees at the tip.
This blunt bevel and curve allow the needle to pass through the
ligmentum flavum and against dura, pushing it away rather than
penetrating it. This creates the negative pressure that identifies the
epidural space. The most common version of this needle is referred to
as a Tuohy needle, and the curved tip is referred to be a Humber tip.
Another commonly used epidural needle is the Crawford needle, a
thin-walled needle with a straight blunt bevel without the curved Huber
tip. This needle allows the catheter to pass directly through the end of
the needle. In situations where catheter advancement into the epidural
space is difficult, this needle may be preferred.
The duration depends upon the concentration and drugs used.
Drug Conc. Volume Duration of
(%) (ml) action(mt)
Lignocaine 1.5 to 5 1 to 2 60 to 90
Bupivacaine 0.5 to 075 2 to 4 90 to 150
Fig. 9.30: Epidural needles
These agents are fixed quickly when mixed with CSF. That’s why
position should be adjusted according to the type of operation before
the procedure.
Advantages
• It is less costly than GA.
• It is safer.
• It produces good analgesia and good muscle relaxation.
• It is safe in most of the heart, lung and renal diseases and diabetes.
Complications
1. Respiratory paralysis
2. Hypotension
3. Headache
4. Meningitis
5. Nausea and vomiting.
Anesthesia 105
IV Regional Anesthesia
In this type of anesthesia a tourniquet is applied to occlude the vessels
and LA is injected in the peripheral vascular bed to non-vascular tissues
including nerve endings.
Methods
1. Elevate the limb
2. Apply the elastic bandage tightly
3. Apply tourniquet proximally
4. Inflate the tourniquet above the arterial BP
5. Remove elastic bandage
6. Inject 20 to 40 ml of 0.5% lignocaine IV under pressure distal to the
tourniquet.
Regional anesthesia will be produced within 2 to 5 minutes and last
till 5 to 10 minutes after deflating tourniquet.
Use
It is mainly used for the upper limbs and for orthopedic procedures.
Limitations
It is more difficult to obstruct the blood supply of lower limits and
larger volume of LA is needed.
Bupivacaine should not be used because of its higher cardiotoxicity.
Side Effect
Bradycardia.
GENERAL ANESTHESIA
General anesthesia produces reversible loss of all sensations and
consciousness. There is loss of all sensation especially pain, sleep and
amnesia, immobility, good muscle relaxation and obscure of reflexes.
GA is produced by using combination of drugs.
Mechanism of Action
Different anesthesia may be acting through different molecular
mechanisms and various components of the anesthetics and various
components of the anesthetic state involve action at discrete loci in the
cerebrospinal axis. The principal focus of causation of unconsciousness
appears to be in the thalamus or reticular activating system. Amnesia
may result from action in hypothalamus. Spinal cord is the likely seat
of immobility on surgical stimulation.
Properties of Ideal Anesthesia

1. It should be pleasant, non-irritating and should not cause nausea
and vomiting.
2. Induction and recovery should be fast.
3. It should provide adequate analgesia, muscle relaxation.
4. It should be non-inflammable and non-explosive so that cautery may
be used.
5. Its administration should be easy and controllable.
6. Margin of safety should be wide-no fall in BP.
7. It should be cheap.
8. It should not react with rubber tubing.
9. Heart, liver and other organs should not be affected.
Classification of General Anesthetic

Inhalational Gas Liquids
Nitrous oxide - Halothane
- Ether
- Isoflurane, etc.
Intravenous - Thiopentone Sod
- Propofol
- Diazepam
- Midazolam
- Ketamine, etc.
Nitrous Oxide
• It is a gas supplied under pressure in blue cylinder
• Onset is quick and smooth
• It is generally used 70% N2O + 25 to 30% O2 + 0.2 to 2% another
patent anesthetic.
• It has little effect on respiration, heart and BP
• It is non-toxic to liver, kidney and brain.
• It is cheap.
Ether
• It is highly volatile.
• It is inflammable and explosive.
• It is very unpleasant.
Anesthesia 107
• Induction is prolonged and unpleasant and chances of breath
holding is more.
• Recovery is slow and PONV is more.
Because of better alternatives are available, that’s why it is not used
nowadays.
Although BP and respiration are well maintained. It is cheap, it can
be given by open drop method, no need for any equipment.
Halothane
• It is a volatile with sweet odor.
• It is non-irritant and non-inflammable.
• It is a patent anesthetic.
• 2 to 4% for induction and 0.5 to 1% for maintenance.
• PONV is very less.
It is used with N2O or opioids. It is commonly used.
Disadvantages
• It depress the heart and causing fall of BP and heart rate.
• It requires a special vaporizer.
• It is not good analgesic and muscle relaxant.
• It causes greater depression of respiration (so it should be used with
caution in heart patient and asthmatic patient).
• Urine formation is decreased.
• Postoperation shivering is more.
Isoflurane
• It is more volatile, more potent.
• It produces rapid induction and recovery.
• It is administered through a special vaporizer 1.5 to 3% for induction
and 1 to 2% for maintenance.
• It is safer in neurosurgery (it does not provoke seizures).
• It is safer in MI patient (coronary circulation maintained).
• It causes more respiratory depression.
• Secretions are slightly increased.
• PONV is low.
• Pupils do not dilate and light reflex in not lost even at deeper level.
• It is less toxic.
• It is too costly.
Thiopentone Sodium
• It is available in powder form. It is highly soluble in water and make
a very alkaline solution. It should be prepared freshly.
• Extravasations (outside the vein) of this injection causes very severe
pain and may cause gangrene.
• Dose 3 to 5 mg/kg as a 2.5% solution.
• It produces anesthesia within 15 to 20 sec.
• It should not be mixed with same syringe with succinylcholine.
• It causes respiratory depression.
• Cardiovascular collapse may occur if hypovolemia, shock or sepsis
are present.
• It is commonly used as an inducing agent.
• It can be used as full anesthetic for short operations.
Adverse effects
• Laryngospasm.
• Shivering and delirium may occur during recovery.
• PONV is common.
Propofol
• It is an oily liquid used as 1% for IV.
• Unconsciousness occurs after 15 to 95 sec of IV injection and last for
10 minutes.
Dose
– 2 mg/kg Bolus IV for induction.
– 9 mg/kg/hr for maintenance
• It is used for total IV anesthesia.
• It is very suitable for short procedures.
Adverse effects
Decrease in BP, Bradycardia, respiratory-depression.
Diazepam
• It is given as preanesthetic medication.
• Dose 0.2 to 0.5 mg/kg.
• It produces amnesia and sedation.
• It do not markedly depress the respiration, heart and BP but when
it is given with opioids (pentazocine) then it depress respiration,
heart and BP.
Uses
1. Preanesthetic medication.
2. Endoscopies.
Anesthesia 109
3. Cardiac catheterization.
4. Angiography.
5. Fracture setting.
6. ECT (Electro-convulsive Therapy).
Ketamine
• It produces anesthesia.
• Respiration is not depressed.
• Muscle tone increases.
• Heart rate, and BP are increased.
Dose
– 1 to 3 mg/kg for 1V.
– 10 mg /kg for 1M
• It produces its effect within minutes and last for 10 to 15 minutes.
• Children tolerate better.
• It is very much useful in asthmatic patient (as it relieves broncho-
spasm)
• It is used for short procedures.
• It is good for hypovolemic patients.
• BUT it is dangerous for hypertensive and IHD patients.
PRE-ANESTHETIC MEDICATION (PRE-MEDICATION)

Different drugs have different purposes.
Use of pre-medication is to make the anesthesia pleasant and safe.
The aims are:
1. To Relieve Anxiety and for Amnesia: A patient who is going to have a
surgical operation is naturally anxious. This anxiety can be reduced
by reassurance and by medicine.
• Diazepam, Midazolam, Promethazine, these also decrease the
incidence of postoperative vomiting and produces smooth
induction and sedation.
• Very anxious patients will secrete a lot of adrenaline this may
cause cardiac arrythmias.
2. To get analgesia: Analgesia is indicated if the patient have preopera-
tive pain. Common drugs which are used—Ketorolac, Diclofenac,
Paracetamol, Tramadol.
3. To dry bronchial and salivary secretions: Atropine or glycopyrrolate or
hyoscine are used commonly. These drugs reduces secretions, as
bronchial and salivary secretions can cause laryngospasm. These
drugs also prevent bradycardia and hypotension.
4. To decrease acidity and volume of gastric juice: Patients are at risk of
aspiration especially who are full stomach and are taken for
emergency operation. Pulmonary aspiration of gastric contents can
cause severe pneumonitis. Dugs used are Ranitidine, Omperzaole.
These drugs also prevent postoperative nausea and vomiting
(PONV).
5. Antiemetic Effect: Metochlopromide or Ondansteron are used.
Combined use of Metochlopromide or Ondansteron with Ranitidine
are more effective. These also prevents PONV.
General Anesthesia
The aim is to induce:
• Unconsciousness
• Analgesia
• Muscles relaxation
Induction
1. Intravenous induction
• Pre-oxygenation
• Inj Propofol or Thiopental or Ketamine
Followed by Succinylcholine
Combination of Thiopental and Succinylcholine is considered better.
This allows anesthesia to be induced within 30 seconds and trachea
to be intubated within 60 to 90 sec.
2. Inhalation Induction: Nitrous oxide and muscle relaxation.
Maintenance
Most commonly with—nitrous oxide and oxygen + opioid or halothane
1. A continuous IV infusion of propofol can be used to maintain
anesthesia. Advantages of this total IV anesthesia is better recovery.
2. Monitoring the depth of anesthesia- by BP, HR, Respiration,
Sweating, Pupils size, Movements, Muscle relaxation.
Reversal of GA
• Reversal with Neostigmine if there is effect of muscle relaxation
• Extubate the patient
• Watch for reflex (gag reflex, cough reflex)
• Spontaneous respiration
• Eye opening
• Follow verbal commands
Anesthesia 111
• For relief of postoperative pain - analgesics are given- Inj. Diclofenac
or Inj Ketorolac or Diclofenac Suppository.
For postoperative nausea and vomiting (PONV)—It is common after
laparotomy. Antiemetics are used, e.g. Inj. Metochlopromide or
Ondensteron or Hydroxyzine are used.
Best is inj.Ketorolac + inj. Hydroxyzine
Complications
1. Respiratory depression
2. Hypercarbia
3. Cardiac arrhythmia
4. Fall of BP
5. Laryngospasm and asphyxia
6. Aspiration of gastric contents
7. Convulsion, delirium
Postanesthesia
1. Nausea and vomiting
2. Sedation, drowsiness, delirium
3. Pneumonia
4. Oxygen toxicities
5. Nerve palsies due to faulty positioning of patient
The Anesthetic Plan includes

Pre-medication
1. Type of anesthesia
a. General
• Airway management
• Induction
• Maintenance
• Muscle relaxation
b. Local or regional anesthesia
• Technique
• Agents
c. Monitored anesthesia care
• Supplemental oxygen
• Sedation
2. Intraoperative management
a. Monitoring
b. Positioning
c. Fluid management
d. Special techniques
Fig. 9.31: Arm restraint, if excessively tight, can compress the anterior interosseous nerve
and vessel against the interosseous membrane in the volar forearm to produce an ischemic
neuropathy
3. Postoperative management
a. Pain control
b. Intensive care
c. Postoperative ventilation
d. Hemodynamic monitoring
Routine preoperative anesthetic evaluation includes:
1. History
a. Current problem
b. Other known problems
c. Medication history
– Allergies
– Drug intolerances
– Present therapy
• Prescription
• Non-prescription
– Non-therapeutic
– Alcohol
– Tobacco
d. Previous anesthetics, surgery and obstetric deliveries
e. A family history of anesthetic problems may suggest a family
problem such as malignant hyperthermia.
f. Review of organ systems
• General (including activity level)
• Respiratory
• Cardiovascular
• Renal
• Gastrointestinal
• Hematologic
Anesthesia 113
• Neurologic
• Endocrine
• Psychiatric
• Orthopedic
• Dermatologic
g. Last
• Oral intake
2. Physical Examination
a. Vital signs
b. Airway
c. Heart
d. Lungs
e. Extremities
f. Neurologic examination
3. Laboratory evaluation
4. ASA classification: Preoperative physical status classification of
patients according to the American Society of Anesthesiologists
(ASA).
Class Definition
1. A normal healthy patient.

2. A patient with mild systemic disease and no functional
limitations.
3. A patient with moderate to severe systemic disease that results
in some functional limitations.
4. A patient with severe systemic disease that is a constant threat
to life and functionally incapacitating.
5. A moribund patient who is not expected to survive 24 hours
with or without surgery.
6. A brain dead patient whose organs are being harvested.
7. If the procedure is an emergency, the physical status is followed
by “E” (for Example “2E”).
10 Intravenous Cannulation
The choice of vein depends on the patency of the veins and individual
requirements for each patient.
PERIPHERAL VEINS
Fig. 10.1: The main veins of the right arm

Intravenous Cannulation 115
Fig. 10.2: The vena cavae and the main veins of the limbs.
Deep veins in dark blue and superficial veins in light blue
Fig. 10.3: Superficial veins of the leg

Whenever possible, the most peripheral veins which are away from
the joint should be used first.
It is an advantage to use veins on the dorsum of the hand or on the
forearm veins.
1. The cephalic vein on radial side (thumb side) of forearm can usually
be identified even when the veins generally are collapsed and it is
of convenient size. Another advantage of this vein is, since it lies
between the wrist and elbow joints, the cannula is les likely to be
disturbed by movement. Third advantage is—there is no need for
splintage.
2. Veins of the dorsum of hand: There are arch of several veins on the
dorsum of hand. These are easily identified and can be made
prominent easily by tapping.
3. Veins of cubital fossa: In an emergency situation when other veins
are not prominent, these veins are used and because of their larger
size are easily identified. Disadvantage is that because of movement
of elbow joint, may displace the cannula.
Fig. 10.4: Anterior cubital vein puncture right side

4. Scalp vein: These are also prominent veins and may be suitable for
infusion.
Cephalic vein in the upper arm and long saphenous vein in the leg (anterior
to the medial malleolus) can be used BUT is not recommended because
of the tendency of these veins to become thrombosed.
CENTRAL VENOUS CATHETERIZATION

There are different sites for rapid infusion or for placement of a cannula
within the right heart via: (1) sub-clavian, (2) jugular, (3) basilic, and
(4) femoral veins. A special type of central line of different size and
different lengths are available to cannulate these veins. Expertization
and experience is essential to cannulate these veins.
Techniques for Central Venous Catheterization

Subclavian Vein
In this technique the appropriate vein is punctured, an intravenous
catheter is advanced towards the heart and both the needle and stylet
are withdrawn. Some indication of the position of the catheter tip is
obtained by comparing the length of the stylet with the length of catheter
which is visible outside the vein. However, radiographic confirmation
of the catheter, position should be obtained whenever possible.
Steps
It is entered below the clavicle and requires experience to avoid the
risk of pucture the pleura which causes pneumothorax. Patient's head
is rotated to the opposite side and head is tilted downwards, the needle
is introduced below the midpoint of the clavicle and advanced towards
the back of the sternoclavicular joint keeping close to the clavicle.
Internal Jugular Vein

It is punctured deep to the sternomastoid, aiming in the direction of
the vein at the sternal end of the clavicle.
Basilic Vein
It is punctured at the medial border of the biceps muscle or through
the median cubital vein.
Femoral Vein
It is punctured (it lies medial to the femoral artery) by palpating the
femoral artery which lies a point midway between the anterosuperior
iliac spine and the pubic symphysis (i.e. mid inguinal point). Just one cm
medial to this artery, femoral vein is punctured, needle and stylet is
withdrawn after confirmation and catheter is advanced till it reaches
the right heart and fixed. It also requires experience to avoid puncturing
the peritoneal cavity.
Complications
• Trauma
• Thrombosis
• Phlebitis
• Pneumothorax (with subclavian vein cannulation)
• Air embolism
• Malpositioning
• Sepsis
• Kinking.
Precautions
• All aseptic and antiseptic precaution must be taken.
• Dressing should be changed regularly with aseptic precautions.
• Do not use stiff and cheap cannula.
• Fix the cannula properly.
• Catheter with locking device should be used.
• Extravascular placement of catheter or intra-arterial placement of
catheter may be there. So aspiration of blood form catheter is very
important.
• Periodic blood samples should be taken for culture.
• Infusion set should be changed daily.
• It requires expertization in technique otherwise fatal complications
may occur.
Advantages
• It can be kept for a long time.
• Rapid infusion can be given.
• When irritant solutions are used central veins are preferred.
Material of these Cannula

The material of these cannula is polyurethane, silicone, polyvinyl
chloride (PVC) and teflon (polytetra fluroethylene PTFE). PVC is
thrombogenic while PTFE is less thrombogenic.
Rate of Administration
It should always be followed as advised by treating physician. The
rate of administration in drops per minute can be determined by
multiplying the required number of liters per day by 11. For example,
three liter fluid is given in a day (in 24 hours) 11 × 3 = 33 drops per
minute rate will infuse approximately three liter of fluid in 24 hours.
CUT DOWN OR VENESECTION OR CANNULATION BY

EXPOSURE OF SUPERFICIAL VEIN
Fig. 10.5: The cannula is inserted and the wound sutured
Fig. 10.6: Method of exposing a vein in the forearm

Fig. 10.7: The vein is controlled by ligatures and a

nick is made with scissors
Figs: 10.8A and B: Saphenous venous cutdown

After invention of IV cannulas and central line, cut down procedure
is not more in practice. It is used when:
1. Superficial veins are thrombosed.
2. The skill of placing a central line is not available.
3. It is also used when large cannula is required for rapid infusion of
fluids.
Techniques or Steps of Cutdown

1. With all aseptic and antiseptic precautions a little amount of local
anesthetic solution is infiltrated intradermaly in a line transversly
across the view and a small incision is made.
2. The superficial fascia is cleared by inserting the point of scissor and
opening them on each side of the line of the vein.
3. Once vein is cleared two ligatures are passed around it.
4. Distal one is tied and held in forcep. The proximal one is half tied,
with the sharp pointed scissors a nick is made in the vein on its
anterior wall only.
5. The ready cannula (which has been filled with the infusion solution
in order to remove air) is quickly inserted.
6. The proximal ligature is tied to enclose it.
7. Then pass a stitch through skin to fix it in order to prevent it from
being pulled out of the vein.
8. The skin wound is closed and antiseptic dressing is done.
PROBLEMS ENCOUNTERED WHILE CANNULATION

1. Sometimes due to vasospasm veins are not prominent, which can
be made prominent by gently tapping the vein.
2. The bevel of needle may be pressing against the wall of the veins
this can be corrected by placing a cotton ball under the needle.
3. Speed of infusion can be increased by increasing the height of the
bottle on the stand.
4. Make sure that backflow of blood into the cannula when vein is
punctured, means it is in vessel.
5. When cannula is displaced there is swelling at the site of injection.
6. There should be airway in infusing bottle. In some infusion sets
there is in-built airway in that case no need to put airway in the
infusion bottle.
7. If there is shivering, check the temperature of fluid or there may
be reaction due to fluid which may be contaminated. Thus, warm
the fluid by keeping in hot water to bring it to the body
temperature.
8. Any precipitation of fluid and expiry of fluid should always be
checked before infusing the fluid.
9. The bottle should be changed before it gets emptied to prevent air
into the vessel (air embolism may be fatal).
10. Cover the patient with a blanket to keep him warm.
11. Always choose the vein away from the joint so patient can move
the part without disturbing the cannula.
12. In case of children, old age people or irritable, unconscious
patients—immobilize the limb by splinting it, to prevent displace-
ment.
Nasogastric Tube
11 Insertion and
Catheterization
RYLE’S TUBE (NASOGASTRIC TUBE)

These are available in different sizes and lengths. They are made up of
polyvinyl chloride.
Features
• Manufactured from non-toxic, non-irritant PVC
• Distal end is coned with corrosion resistant stainless steel pallets sealed into
the tube
• Four lateral eyes are provided for efficient aspiration and administration
• The tube is marked at 50, 60 and 70 cm from the tip for accurate placement
• Radiopaque line is provided throughout the length
• Proximal end is provided with universal funnel shape connector
• Sterile, individually packed in peelable soft blister pack.
Fig. 11.1: Ryle’s tube
Features
Its tip is blunt to avoid trauma. At the tip there are three metal heads
which facilitate the passage of the tube by action of the gravity and
facilities swallowing due to their weight. As metal is radiopaque,
radiologically we can confirm the position of the tip. There are number
of side holes present near the lower end of the tube. They allow easy
suction of the contents. There are three black markings on the tube at
Nasogastric Tube Insertion and Catheterization 125
different levels by which we can assess the position of the tube. The
first circular mark is at 40 cm indicates that the lower end of the tube is
lying at gastroesophageal junction in an adult patient. The second mark
is at 50 cm means the tip of the tube is in the body of stomach. The third
mark is at 60 cm means the tip of the tube is at the pylorus.
LEVINE’S TUBE
It is similar to Ryle's tube but it has no lead shot at its lower end. There
is some radiopaque material is incorporated in its substance to help its
visualization by X-ray.
Indications
• Aspiration of gastric juice to study secretory activity and motility of
the stomach in various conditions like chronic gastric ulcer, chronic
duodenal ulcer, gastric cancer, Zollinger-Ellison syndrome.
• To confirm the diagnosis of pernicious anemia associated with
achlorhydria.
• To diagnose pseudopancreatic cyst (Baid's sign)—tip of Ryel's tube
is felt in the abdominal wall in lateral position of abdomen. Due to
compression of stomach by cyst from behind.
• Gastric Lavage—in case of non-corrosive poisoning.
• To decompress and rest in acute abdominal conditions like—
peritonitis, perforation, acute intestinal obstruction, obstructed/
strangulated hernia, etc.
• In certain postoperative conditions like—any intestinal surgery after
repair of incisional hernia, Gallbladder operations, etc.
• For feeding purpose.
Contraindications
• In acute corrosive poisoning.
• Esophageal varices.
• Unco-operative patient
• Patients with respiratory distress
• In cardiac patients
Complications
• Upper respiratory tract infection
• Aspiration pneumonia
• Rhinitis, sinusitis, nasal bleeding, otitis media
• Esophageal ulceration.
Method
The procedure is explained to the patient. In uncooperative
apprehensive patient nasal spray or inj. Diazepam or inj. Midazolam
should be given half an hour before the procedure. Tip of Ryle’s tube is
lubricated with xylocaine jelly, nostril is moistened and cleaned with
diluted savlon. Head is kept steady or can be turned to one side. Tip of
nose is tilted upward to facilitate its insertion. As soon as tip is reached,
there is a gag-reflex (cough). Now repeatedly request the patient to
swallow it down and at this time one table spoonful water can be given
to swallow down to facilitate its downward insertion. Check the tube
whether it is in the stomach or in the air passage. Suck the tube—
withdrawal of gastric contents indicates that the tube is in the stomach.
Keep the tubes outer end in the water, if bubbles appear on expiration,
indicates that it is in the air passage. Inject the air by syringe through
the tube and simultaneously auscultate the epigastrium, if bubbling
sounds are heard means it is in the stomach. Now fix the tube by
adhesive plaster at the level of external nares by sticking the ends to
each side of the nose.
In unconscious patient with the help of Magill's forcep and
laryngoscope, Ryle's tube is advanced in the esophagus under vision.
(because there is no swallowing reflex).
Fig. 11.2: Nasogastric intubation.

Note the correct direction for inserting the tube
Care of the Tube
If there is no gastric contents then withdraw it or advance it by 5 cm
and aspirate. If it is blocked by food debris or jelly inject 10 ml of sterile
water, if functions then it is OK. If this does not function then remove
the blocked tube and clear it and reinsert. Keep the nostril clean by
cotton/gauze piece check it regularly.
Urethral Catheterization
Fig. 11.3: Male catheterization
Fig. 11.4
Fig. 11.5
Fig. 11.6
Fig. 11.7
Fig. 11.8
Fig. 11.9
Fig. 11.10
FOLEY’S CATHETER (FOLEY-AMERICAN UROLOGIST)

It is available in different sizes in French scale available from 12 to 24 F.
Balloon capacity is usually 30 ml.
The French in often called Charriere (CH)—gauze is used for sizing
catheters, endoscopes and many other tubes. Dividing the French gauze by
three gives the outside diameter of the tube in mm. For example, 18 F catheter
has an outer diameter of 6 mm.
Indications
• To monitor/measure the urine output.
• Retention of urine
• Pelvic surgery
• Gyne surgery
• Cesarian surgery
• During delivery
• Surgery on urinary tract, etc.
Equipments/Articles
• Foley catheter of required size
• Urine collection bag
• Sterile pair of gloves
• Xylocaine jelly
• Disposable sterile syringe
• 10 ml distilled water
• Povidone iodine/savlon
• Sterile cotton and gauze piece
• Sterile hole towel
• Artery forcep
• Sponge holding forcep.
Procedure
Clean the penis and retract the fore skin and clean the glans penis with
povidone iodine solution or dilute savlon. Drape the area with sterilized
hole towel. Hold the penis at right angles to the body and gently empty
the jelly in the urethra by its nipple and massage on ventral aspect
proximally and wait for two minutes to anesthetize the whole urethra
and divert the patient's attention and try to relieve his anxiety/
apprehension. Apply xylocaine jelly on the tip of catheter and insert
into the tip of urethra gently by holding the penis in vertical direction.
Advance the catheter by maintaining the shield of the outer plastic
covering. Once the catheter has reached the prostatic urethra (when
resistance is felt), keep the penis down horizontally (as the curvature
of urethra) and advance the catheter further and advance it at its full
length but gently. Once it is the urinary bladder inflate the balloon with
10 cc distilled water. Withdraw the catheter gently until you feel it rest
at the internal urethral orifice. Attach it to urine collecting bag. Fix the
catheter to one thigh with sticking plaster. Make the urine column in
tube, sometime air between the column interfere in the drainage.
Sometimes urine does not come then milk the catheter and gently press
the suprapubic region because jelly may stick to the side tip hole of the
catheter.
In female—position is supine with the ankles placed together, knees
flexed and the thigh abducted. With all antiseptic precautions, paint
the vaginal area with weak povidone iodine or dilute savlon and then
apart labia majora and identify the urethral meatus. After applying
little jelly on the urethra, advance the catheter gently up to 10 cm (as
urethra length is short in females). Once it is in urinary bladder inflate
the balloon and connect it to urine collecting bag and fix to one thigh.
How the Catheter is Removed?

Deflate the balloon completely and gently withdraw it.
If the balloon of Foley's catheter cannot be deflated, following steps
should be taken.
1. Cut the valve of the balloon channel and try to deflate the balloon
by applying a syringe directly to the channel. If still it is not deflated
then a long wire/stylet (made for this purpose) is introduced in the
already cut channel and puncture, under ultrasound guidance.
2. The balloon can be punctured with 19 gauze spinal needle passed
suprapubically, provided that bladder should be partially distended
and it should be under ultrasound guidance.
Over inflation of balloon and rupturing it by injecting more fluid or
ether or turpentine oil is not recommended because it often leaves pieces
of balloon in the bladder which act as nidus for stone formation.
Secondly ether and turpentine oil is much irritant to the bladder mucosa.
Caution
1. The inflated balloon of a Foley catheter provide a large surface area
for the deposition of calcium phosphate and the formation of stones.
It is a good practice to deflate in patients requiring prolonged
catheterization.
2. Do not inflate the balloon with air, as it will float in the bladder and
will not drain the urine.
Normally, two way Foley is used in routine use. Three way Foley
(irrigating catheter) is used after endoscopic and open operations on
the bladder or prostate to prevent clot retention. It can also be used for
the continuous irrigation of a very infected bladder. In this type of
catheter there are third channel is for continuous irrigation.
12 Operative Notes
This is a very important document. It is an important source of

information for medical and nursing staff who manage the patient
postoperatively. It is useful in subsequent audit. It carries a great weight
in any subsequent enquiry into complications or in an adverse outcome.
It is also important for research purposes.
It should be legible, comprehensive and signed. It may include
diagrams if this helps to explain the procedure.
It should include:
1. Names—names of the surgeon, assistants and anesthetist.
2. Date and time and duration of surgery.
3. Indication—briefly, the reason why the operation was undertaken.
4. Procedure—name the operation, e.g. appendicectomy, conv.
cholecystectomy or laparoscopic cholecystectomy.
5. Position—describe the position which may be important for
defending yourself against any claims arising from complications
like skin damage, nerve palsy, etc. Thus, description should
therefore include any padding used to prevent nerve or skin
damage or the table for example supine with well padded legging
to support the legs and calf and padding to heels, etc.
6. Incision—name the incision including any extension. A drawing
may be useful.
7. Operative findings—describe the findings what was found, this also
confirm the diagnosis, e.g. “inflamed but not perforated appendix
in right iliac fossa. Caecum and distal ileum was normal”. Also
describe those structures that were identified and protected during
the procedure for example in thyroid surgery “recurrent laryngeal
nerve identified and protected”.
8. Steps of the procedure—describe briefly what was done, step by step.
If special measures were taken to protect important structures
these should be described, for example, “bowel mobilized and
packed off behind a retractor”. Name the special instrument if
used. Note any prosthesis used and their labels can be stuck on
the operation sheet. Also mention the condition of main procedure
performed, for example, in gut anastomosis ends viable and no
leaks at anastomoses. Peritoneal toileting and name the antiseptic
used should also be described.
9. Closure—Any drain, materials used and the layers were closed
and antiseptic dressing was done.
10. Postoperative notes—Instructions regarding postoperative care
must be very clearly written. This is very important for the
postoperative care team. This should start with immediate
postoperative care including anesthetist’s instructions also. This
may include like—nothing by mouth for how many hours or days,
check vitals at what internals (2 hourly, 4 hourly or 6 hourly),
care of tubes, drains, catheters, oxygenation, etc. when to mobilize
the patient, etc.
11. Complications—Any known complication may be listed along with
the action you want the team to take care if they occur, e.g. any
respiratory difficulty after thyroid surgery—remove the dressing
and remove few stitches.
12. Signature with name of doctor and date—it should be signed with
date, and contact number so you can call doctor immediately.
13 Care of Instruments
All the surgical instruments are very delicate and expensive; care of
instruments must be proper and should be on utmost priority and
utmost importance.
CAUSES OF DAMAGE OF INSTRUMENTS

Instruments may be damaged due to:
Fig. 13.1
Fig. 13.2
Fig. 13.3
1. Contact corrosion caused due to preparation on brass rack.

2. Discoloration caused due to impurities in water vapor/steam.
3. Breaking due to stress corrosion caused by chlorides.
4. Spots resulting from improper pre-rinsing or washing.
5. Deposition due to caustic solution containing chlorides, effect of
prolonged immersion in saline.
6. Encrustation of blood due to improper washing or rinsing.
7. Pitting due to chlorides.
8. Crevice corrosion caused due to destruction of natural passive
coating of steal due to mechanical/chemical destruction.
9. Water spots due to high mineral content in water.
10. Encrustations due to nonremoval of organic residues because of
improper cleaning.
11. Fretting corrosion caused due to insufficient treatment with
lubricating oil.
Care of Instruments 137
There are certain recommendations for prevention of corrosion of
surgical instruments:
1. Specifications for Buying
• Choice of material; does it fit the requirements?
• Certificate of quality from the manufacturer.
• Choice of surface finish.
2. Storing of Instruments:
• Avoid any corrosive fumes/chemicals in storage area.
• Avoid area of high moisture to store instruments.
• Brand new instruments should be cleaned.
• Appropriate racks/containers should be used to store
instruments.
3. Usage
• Clean the instruments after every use.
• Avoid prolonged exposure to saline.
• Sterilize USED and UNUSED instruments after proper
cleaning.
4. Preparation for Disinfection and Cleaning
• Check the correctness of the delivery.
• Returning of instruments from OT.
• Dry instruments should be returned in dry condition.
• Returning instruments in wet condition. Instruments should
be immersed in noncorrosive combined disinfecting cum
cleaning solutions.
• All hinges/retches of instruments should be released. Break
part instruments should be dismantled.
5. Re-using the instruments
• Dismantle and immediately immerse used and soiled
instruments, completely in a predisinfection bath.
• Use containers which are hermetically sealed during the
process of thermal disinfection and cleaning. It is done at 93°C
for approximately 10 minutes. For heat sensitive material
chemothermal disinfection is done at 60°C for approximately
10 min.
6. Predisinfection
• Use cold water only. Water over 45°C leads to coagulation of
proteins and causes cleaning problems.
• Epidemic hygiene aspect—disinfection first followed by
cleaning.
• Follow exposure times/dilution parameters/concentration
level as recommended by the manufacturer for optional
cleaning/disinfection, pH value of 4.5 to 9.5 is recommended
for cleaning and disinfection solutions.
• Ultrasonic cleaners may be used in case of stubborn stains/
encrustations.
7. Washing
• Periodically test the water for its chloride/silicate and mineral
content.
• Use enzyme based detergents is recommended and instructions
for dilutions as recommended by the supplier should be
followed. If powdered products are being used - particles
should be dissolved.
• Final rinsing should be done in demineralized water.
8. Drying
• Instruments should be dried immediately after rinsing/
washing.
• Use of air pistol is recommended where ever possible.
• Use lint free paper cloth to wipe.
9. Care of instruments
• Ensure that all instruments are clean.
• Check functionality of individual instruments.
• Separate the instruments which are not functioning correctly/
show signs of corrosion/wear and tear.
10. Maintenance of instruments
• Periodically lubricate hinged/retched instruments and
instruments with joints, with lubricating oil.
• If required, inspect instruments with carbide tips for wear and
tear, replace tip, if required.
• Always maintain correct organization of instruments in terms
of size/old or new/large bulky instruments/microdelicate
instruments.
11. Conditions for sterilization
• Do not overload instruments trays with more than 10 kg.
• Do not mix old instruments with new ones.
• Micro and delicate instruments should be placed in secure
containers.
12. Sterilization
• If all necessary steps prior to sterilization have been followed—
Proceed.
• Use demineralized water if possible/quality of water/steam
is very important.
• Excessive chlorides can set in corrosion in instruments (levels
of chlorides should be less than 120 mg/lit equiv to 200 mg/ l
of NaCl)
• Optimal loading of trays prevents formation of condensates.
14 Drains
It is a channel which is put in the wound or cavity to drain fluid or pus

to the surface. It forms a channel along which fluid / pus reach to the
surface when any cavity is closed.
TYPES OF DRAIN
1. Corrugated drain
2. Closed tube drain
a. Closed suction drain
b. Penrose drain
c. Perforated tube drain
d. T-tube drain
e. Sump drain.
Fig. 14.1
Fig. 14.2
Fig. 14.3: Double-tube suction drainage (sump drainage)

applied to the peritoneal cavity
Drains 141
Figs 14.4A and B: (A) Two plastic tubes, the narrower placed within the wider, for ‘sump’
drainage by suction to the inner tube (B) Shows method of securing the inner tube. The
safety-pin compresses slighlty but does not transfix the inner tube
Corrugated Drainage Sheet

Features
• Designed for efficient multichannel wound
drainage specially where airtight closure of
wound is not possible
• Manufactured from nontoxic, nonirritant
medical grade PVC
• Extra soft PVC does not contribute to local
inflammation
• Radiopaque line provided through out the
sheet length for X-ray visualization
• Sterile, individually packed in a HM polybag.
Fig. 14.5
Indications
• To drain out residual from an abscess after incision and drainage of
a cavity.
• To remove transudate from a slow oozing from wound surface which
prevents collections and facilitates healing.
• Following common bite duct exploration.
• In operation of gut especially resection anastomosis for early
reorganization/diagnose for any leakage.
• In case of peritonitis.
• After cholecystectomy when there is more adhesions and extensive
dissection.
• In operation of perforated appendix.
• In case of prostatectomy.
• In thyroid surgery.
CORRUGATED DRAIN
It is a corrugated sheet made up of red-rubber or soft plastic. It acts by
capillary action. Its corrugation structure provides more surface area
and channel. It is fixed outside to the skin by anchoring suture.
Disadvantage
It makes a portal of entry to bacteria, thus more chance of infection.
CLOSED DRAIN
Advantages
• It is a closed drain, thus it does not allow the bacteria to enter in the
cavity thus minimum chances of infection.
• There is minimal soakage on the dressing site.
• Vacuum drain suck the residual and even minimum amount of fluid.
• The quantity of drainage fluid can be exactly measured.
• The quality of fluid can also be known.
SUMP DRAIN
For thick exedate, 'sump' drainage is instituted by inserting one tube
within the other. The outer tube projects for 2 to 3 cm outside the wound,
the inner tube is longer and is connected to suction. A number of holes
are cut in the lower part of the outer tube, and the inner tube has a
single hole cut in it close to its end. A continual air, activated by the
suction, passes down through the outer tube and up through the inner
tube. Any fluid collecting in the outer tube is immediately sucked away.
Advantages
• It can drain thick fluid
• No suction occurs at the openings in the outer tube, so that
surrounding tissues are not drawn against it.
• It can even drain the fluid from the pelvis when the patient is in
propped up position.
CAUTIONS WHEN YOU PUT A DRAIN

1. It should be put in the most dependent part.
2. It should always be brought out through the shortest route.
3. Kinking of tube should be avoided.
4. It should be away from the vital structures and anastomosis site to
avoid eroding the structure.
5. It should be brought out through a separate stab incision away from
the main incision line to prevent the possibility of infection.
Preoperative Management
15 of Specific Problem in
Surgical Patients
THROMBOPROPHYLAXIS
Thromboprophylaxis is needed for high-risk patients. DVT and PE
(pulmonary embolism) are known complication of surgery.
Anticoagulation carries a risk to the patient of bleeding in the GIT
and intracranial hemorrhage. It also carries a risk of increasing surgical
blood loss or hematoma formation. Thus, in turn may increase the risk
of wound infection.
Thromboprophylaxis can be given by different methods
1. Physical: Early mobilization and minimizing the length of hospital
stay reduce the risk of DVT. Early ambulation (exercise) known to
increase fibrinolytic activity.
2. Mechanical: Foot and calf pumps and TED (Thromboembolic
deterrent) stockings are available. These also prevents venous stasis
and prevents DVT.
3. Drugs: Low molecular weight heparin, aspirin reduces the incidence
of DVT and PE.
Bleeding Diathesis
In patients, taking oral anticoagulants, determine the reason for their
treatment.
The most commonly encountered condition associated with a
bleeding tendency is obstructive jaundice. Injective vitamin K should
be given at least for five days prior to surgery to bring vitamin K at
normal level.
Clotting is abnormal in uremic patient. Uremia directly affects
platelet function and may present as bleeding.
The critically ill patient may also exhibit an abnormal clotting profile
as a result of DIC (disseminated intravascular coagulation), so called
consumption coagulopathy.
The most important factor in the coagulation cascade is temperature,
so hypothermic patient should be actively warmed prior to surgery.
Heat loss is significant in operation theatre in the absence of warming,
measures. It is therefore always worth checking the patient’s tempe-
rature if one encounters unexpected bleeding.
In the absence of bile salts from GIT, decreases the absorption of fat
soluble vitamins, including vitamin K. The shortage of vitamin K
impairs the synthesis of prothrombin by the liver. This results in a
tendency to bleed.
But in severe hepatocellular damage, injection of Vitamin K will not
bring the prothrombin time back to normal, as prothrombin cannot be
made by badly damaged liver cells. The only other source of
prothrombin in these circumstances is FFP (fresh frozen plasma) stored
blood contains little or no plasma.
Hemophilia patient requires cryoprecipitate, preoperatively.
In von Willebrand's diseased patient, FFP or cryoprecipitate is used.
Preoperative Hemostatic Evaluation

Preoperative hemostatic assessment begins with a comprehensive
personal history for bleeding tendencies. Patient should be asked about
epistaxis, gingival bleeding, bruising, ecchymoses, and menorrhagia.
A history of muco-cutaneous bleeding at these sites suggests von
Willebrand’s disease (VWD), thrombocytopenia, or functional platelet
disorders. Patients with hemophilia A or B may recall spontaneous
muscle or joint hemorrhages.
The history should also rule out any underlying hepatic, renal,
immunologic or hematologic diseases. It is important to obtain an
accurate history or drug intake like aspirin, NSAIDs, clopidogrel and
warfarin impair hemostasis.
Patients with hereditary bleeding disorders frequently give a history
of bleeding tendencies in other family members. The physical
examination should focus on any evidence of ongoing mucocutaneous
bleeding, splenomegaly, etc.
Thus, in doubtful cases preoperative testing includes PT, a PTT, CBC,
examination of blood smear and biochemical tests for hepatic and renal
function.
THROMBOCYTOPENIA
Low platelet count may result from decreased production or increased
peripheral destruction.
Preoperative Management of Specific Problem 145
Causes are—aplastic anemia, drug toxicity, neoplastic infiltration,
myelodysplastic syndrome, ITP, SLE, CLL and HIV. Drugs are—
heparin, quinidine, phenytoin, sulfonamide, thiazide.
Identification and treatment of the primary cause is recommended
prior to elective surgery.
Platelet transfusions are recommended if platelet count is less than
50,000/cm.
For patients undergoing neurosurgery maintain a platelet count
above 75,000/cm.
For patients undergoing neurosurgery, the commonly used
threshold for platelet transfusions is 1 lac/cm.
The management of platelet function disorders will depend upon
the etiology. Patients with hereditary disorders of platelet function are
usually managed with conservative measures, platelet transfusions are
reserved for serious bleeding.
Aspirin should be discontinued seven days before surgery.
NSAIDS should be withheld for 2 to 3 days.
Ticlopidine and clopidogrel should ideally be withheld for 10 days
before invasive procedures. In emergency situation DDAVP is given to
reduce bleeding due to drug-induced platelet disfunction.
Platelet transfusion may be needed in high-risk procedures.
In uremic patients—correct the anemia, RBCs should be transformed
to achieve a hematocrit of 30%. Platelet dysfunction improves after
dialysis. Low-dose conjugated estrogens given daily for 4 to 5 days to
reduce bleeding and the effect lasts for 10 to 15 days. For more urgent
reversal of hemostatic defect, DDAVP is recommended.
Dose of Platelet
The usual dose is one unit of platelets per 10 kg of body weight. One
unit increases the platelet count by 5000 to 10,000/ in a 70 kg adult.
Management
Management of DIC (disseminated intravascular coagulation)—In
general, the approach will differ based on whether the clinical
presentation is one of thrombotic complications or one of uncontrolled
hemorrhage. In patients with active bleeding, abnormal coagulation
tests, and hypofrinogenemia, replacement of the consumed clotting
factors with large volumes of FFP may be required to correct the defect.
Cryoprecipitate is given to maintain fibrinogen level above 100 mg/dl.
Severe thrombocytopenia should be corrected with platelet trans-
fusions.
• If patients are not actively bleeding, blood products should not be
infused prophylactically just to correct the coagulopathy of DIC.
• Heparin may exacerbate the bleeding in acute DIC.
• Patients with thrombotic complications like digital gangrene should
be treated with UFH (ultra fractionted heparin) or LMWH (low
molecular weight heparin).
• EACA have been used in conjuction with heparin in severly bleeding
patients.
• Recombinant human activated protein which may have a therapeutic
role in DIC associated with sepsis.
MALNUTRITION
The preoperatively malnourished patient is at increased risk of both
morbidity and mortality following surgery. Therefore, it is important
to determine the nutritional status of the patient. Nutritional assessment
may be assessed by different methods—determination of weight loss,
subcutaneous fat or biochemical markers. Malabsorption status is
corrected by vitamin or enzyme supplementation.
Obstructive condition should be corrected by per nasal feeding,
intravenous nutrition, surgical bypass or formal enterostomy.
Recent work using fish oil supplementation may offer hope for
improved nutritional state and activity.
JAUNDICE AND THE SURGICAL PATIENT

All jaundiced patients should receive antibiotic prophylaxis, as such
patients are at increased risk of infection.
In jaundiced patient there may be deficient of clothing factors II, V,
VII, IX and X which are dependent on vitamin K. It should be corrected
by using FFP and/or vitamin K preoperatively. A history of fevers and
rigors and leucocytosis suggests cholangitis (sepsis). This requires rapid
external or internal biliary drainage with intravenous fluid resuscitation
and antibiotics.
Because of the impairment of liver function, there is a greater risk of
such patients becoming hypoalbuminemic and any deficits of plasma
or blood volume must be corrected. Patients with liver disease tend to
retain salt and thus excessive use of saline solutions must be avoided.
All jaundiced patients must be well hydrated to avoid renal failure
(hepatorenal syndrome). Jaundiced patients have a higher incidence of
renal failure in the postoperative period—the hepatorenal syndrome.
This may be due to abnormal fluid shifts occurring in such patients in
response to surgery, or to the endotoximea. It may be due to the
deposition of bilirubin in the renal tubules or to impaired handling by
the obstructed liver of the various hormones responsible for normal
renal function. Thus, it is important that all jaundiced patients have an
adequate fluid load preoperatively, throughout the operation and in
the postoperative period.
RESPIRATORY DISEASE
COPD of any cause, asthma, chest infection or bronchiectasis causes
increased postoperative morbidity. ABG (arterial blood gas) analysis
should be performed prior to major surgery to obtain a baseline.
Pulmonary function tests PEFR, VC, FEV, provide an objective measures
of obstructive or restrictive ventilatory defects along with the
reversibility of the former when treated with bronchodilators.
Routine inhalers should be continued. Smoking should be stopped
at least four weeks before surgery. This will improve respiratory
function and postoperative recovery. Patient with RTI should receive a
combination of antibiotics, physiotherapy and oxygen supplementation,
and surgery should be delayed if possible.
Upper abdominal or thoracic incision make worse or impair
respiratory function, the use of epidural analgesia postoperatively has
been shown to be of benefit in these patients. Narcotic analgesia should
be minimised to limit respiratory depression. All patients, especially
those with respiratory disease, should receive postoperative oxygen
supplementation and monitored with blood gas analysis. Early
mobilization is helpful.
HEART DISEASE AND THE SURGICAL PATIENT

Cardiac disease may be excerbated by many of the physiologic changes
accompanying surgery, including fluctuations in heart rate, blood
pressure, blood volume, oxygenation, pH and coagulability. These may
lead to myocardial ischemia due to increased myocardial oxygen
demand or reduced coronary blood flow, impaired myocardial
contractility and altered cardiac performance due to changes in preload
or after load. Increased circulating catecholamines or sympathetic
nervous system activity may precipitate arrythmias as well as increase
heart rate and blood pressure. Anesthesia and medications such as
narcolytics and muscle relaxants have direct effect on myocardial
contractility, automaticity and conduction.
The greater risk occurs in the first 72 hours following operation,
when fluid volume shifts, fluctuations in heart rate and BP and
medication changes are greatest. Patients with a family history of
premature coronary disease or with associated peripheral vascular
disease should be assumed to be at high-risk of IHD, and patients with
a long history of diabetes. Patients with hyperlipidemia or
hypertension are also at increased risk. History of recent MI, unstable
or progressive angina, decompensated heart failure, severe aortic or
mitral stenosis and severe hypertension are contraindication to
surgery.
Patients with valvular heart disease and prosthetic heart valves
require antibiotic prophylaxis. The usual regimen is Ampicillin two
gram IV, plus Gentamicin 1.5 mg/kg IV 30 minutes before operation
and may be repeated after eight hours, or Vancomycin one gram IV
over 60 minutes in case of patients allergic to penicillin.
Patients who have had a recent MI within 3 to 6 months, should not
have a surgery under GA. If it is an emergency then some form of local
or regional anesthesia is to be preferred.
In the absence of renal or cardiac dysfunction, surgical risk is
minimally affected by mild hypertension. Those patients with a systolic
BP greater than 160 or 95 mm Hg diastolic BP have elective procedures
deferred until the pressure is under control. Plasma potassium should
be checked before surgery in patients being treated with diuretics.
ENDOCRINE ABNORMALITIES
Thyroid Disease
Both hypo- and hyperthyroidism patients tolerate surgery badly.
Hypothyroid patients are subject to acute hypotension, shock and
hypothermia during surgery. Myxedema coma should be suspected in
patients who fail to awaken promptly from anesthesia. There is
increased tissue friabilily, poor wound healing and even wound
dehiscence may occur. Thus, it is highly advisable to treat any
edematous patients with Levo-thyroxine before elective surgery. In
emergency surgery Levo-thyroxine 0.5 mg IV, by nasogastric tube or
orally. It is always advisable to obtain a baseline cortisol level before
treatment of myxedema to rule out co-existent Addison's disease, since
Levothyroxine therapy can precipitate addisonian crisis in this setting.
The hyperthyroid patient undergoing surgery is likely to develop
hypertension, severe cardiac dyshrythmias, CHF and hyperthermia
(Thyroid storm). This may be precipitated by any operation but
especially by thyroidectomy, which accentuates thyoxine release. Thus,
patient must be euthyroid from hyperthyroid before surgery. This takes
1 to 6 weeks and is best accomplished by treatment with propyl-
thiouracil 800 to 1000 mg/day for about one week followed by
maintenance dose of 200 to 400 mg/day. In case of emergency adequate
sedation and potassium iodide plus a beta-adrenergic blocking agent
(propranolol) should be given in addition to propylthiouracil.
Adrenal Insufficiency
The most important endocrine abnormality of all concern the ‘adrenal
cortical hormones’. Any patients receiving chronic steroid therapy
(more than six months) prior to surgery may present with severe
hypokalemia and at times severe hypertension, both of which should
be corrected before surgery. To avoid stress, of surgery, stress doses of
steroid Inj. Hydrocortisone 100 mg at the time of induction of anesthesia,
then it is given 100 mg q.i.d. for the first 24 to 48h and gradually diminish
the dosage in the postoperative period.
Patients with adrenal insufficiency surgery may at risk of addisonian
crisis—manifested by salt wastage, decreased blood volume,
hypotension shock and death. These patients having adrenal
insufficiency if undergoing surgery. Preoperatively these patients
should receive normal saline 1 to 3 L and cortisol therapy 20 mg in
morning and 10 mg afternoon for 2 to 3 days. On the day of operation
100 mg hydrocortisone IV/1M just before the operation followed by 50
to 100 mg every 6 hours during surgery. Saline is continued
postoperatively at a rate of at least 2 to 3 L/day with careful monitoring
of BP, electrolytes and urine output. In the absence of complications,
the dose of steroid can be decreased by half each day until the usual
maintenance dose of about 30 mg/day is reached.
RENAL DISEASE AND SURGICAL PATIENT

Renal Failure
Surgical patient is primarily concerned with:
a. Management of surgical patient with pre-existing renal disease.
b. Management of surgical patient who develops renal complications
perioperatively.
Acute renal failure (ARF) in surgical patient is due to ischemic ATN
resulting from hypovolemia, hypotension, sepsis. Timely correction of
a pre-renal etiology can prevent or lessen the severity of ATN.
Renal failure may be oliguric when urine output is less than 500 CC
(in 24 hours) or non-oliguric when more than 500 CC of urine (in 24
hours).
Dopamine was formerly used in an attempt to improve renal
circulation and improve renal function in the setting of ARF. It has
been shown no benefit and may in fact be harmful by potentiating
arrythmias, thus this practice should be avoided.
If diuretics are used, Furosemide injection IV 50 to 100 mg should
be given. Intravenous chlorthiazide 250 to 500 mg can be used in
conjunction with furosemide. Metabolic alkalosis may result from
repeated use of diuretics.
Nephrotoxic agents such as amphotericin, aminoglycoside, NSAID
should be withdrawn. Recovery from ATN can require several days to
several weeks. Prolonged obstructive uropathy can lead to renal failure.
Obstruction should be relieved as early as possible to prevent further
damage and preserve renal function. Internal or percutaneous
nephrostomy tube placement may be needed for urgent relief of
obstruction.
Remember that significant uremia from whatever cause, can alter
platelet function, which may present as a bleeding tendency and is
immunosuppresive requiring administration of prophylactic antibiotics.
Patients who have chronic renal failure are at high-risk of the
precipitation of end-stage renal failure by intraoperative hypotension
or inadequate fluid and electrolyte management postoperatively.
Electrolytes and Fluids

The development of hypernatremia or hyponatremia in the surgical
setting is usually iatrogenic and results from fluid administration or
water restriction. Hyponatremia can also result from fluid shifts in
hyperosmolar states such as hyperglycemia.
Hypernatremia can result from administration of hypertonic fluids
including sodabicarb injection as well as from inadequate free water.
Osmotic diuresis in the setting of hyperglycemia, mannitol or tube feeds
can also lead to free water loss and hypernatremia. Ongoing losses
including insensible losses, need to be taken into account when
correcting hypernatremia.
Hyperkalemia is most commonly encountered in the setting of renal
insufficiency. Hyperglycemia causes cellular shifts of potassium and is
easily treated. Urgent treatment is seldom indicated in any patient of
hyperkalemia. ECG findings are—peaked and narrowed T waves,
shortened QT interval, prolonged PR interval and finally widened QRS
complex that can eventuate in ventricular fibrillation or asystole.
Calcium gluconate administration immediately stabilizes the cell
membrane and should be administered first if marked ECG changes or
clinical signs are present. Subsequent treatments are designed to shift
potassium into the cells but urinary or GIT elimination (or hemodialysis)
is required to reduce the potassium burden. Inj of regular insulin 10 units
IV with 50 gm dextrose and 50 meq sodium bicarbonate injection should
be given (dextrose with insulin is given to avoid hypoglycemia).
Where renal failure results in hyperkalemia, potassium exchange
resin such as Resonium administered rectally may be effective as an
emergency treatment. Alternatively, the combination of infusion of 50%
dextrose with insulin, will be sufficient to force potassium into the cells
and thus reduce the risk of cardiac arrythmia. This must be seen a
'first-aid measure' and steps taken thereafter to correct the underlying
cause.
Sodium biocarbonate likely produces the majority of its effect via
dilution and diverse rather than by correction of acidosis and should
be avoided in patients with volume overload or diminished urine
output.
Other agents like sorbitol, sodium polystyrene may presents a risk
of bowel ischemia and a significant sodium overload and profound
diarrhea. Thus, when possible restoration of renal perfusion with fluids
and diuretics is the ultimate goal.
Hypokalemia usually results from diuresis or GIT losses. Potassium
replacement should be given orally whenever possible. In patient with
renal failure and hypokalemia, replacement should be cautious unless
the deficit is thought to be severe.
DIABETES AND SURGICAL PATIENT

Diabetics patients are at increased risk in surgery because of:
i. Sustained hyperglycemia makes for great susceptibility to septic
complications.
ii. Impaired wound healing due to impaired immune function.
iii. Alternations in the catabolic response to surgery.
iv. An increased risk of cardiac and renal disease.
v. Sensory neuropathy.
vi. Acclerated atherosclerosis.
The main aim is to avoid both hypoglycemia and ketoacidosis.
Preoperative fasting lipids should also be measured as this may
indicate that lipid–lowering medication is needed postoperatively. This
has recently been shown to lower the incidence of both cardiac and
cerebrovascular events.
Intraoperative blood glucose monitoring and postoperative
measurement of urea and electrolytes should also be performed.
It is important to realize that the diabetic patient offers one of the
common cases when optimization rather than normalization should
be the goal. Careful postoperative monitoring of blood glucose is
required to avoid a rebound hypoglycemia.
Summarized Protocol of Diabetic Care

for Surgical Procedure
1. Ensure reasonable preoperative control. Operate in the morning, if
possible.
2. Omit patient's breakfast, and insulin or oral hypoglycemic drug, on
morning of surgery.
3. Non-insulin treated diabetic patients having non-major surgery need
observation only. Chart 2 - hourly test strip glucose results on day
of surgery. If patient on oral blood glucose lowering drugs, restart
with next meal.
4. Glucose-potassium-insulin (GKI) is used in all other cases, i.e. all
insulin-treated diabetic patients and for major surgery in non-insulin
treated diabetic patients.
i. At 8 to 9 am on morning of surgery commence GKI infusion
500 ml 10% dextrose
+ 15 units soluble (regular) insulin
+ 10 mmol KCl
Infuse 5-hourly (100 ml/h)
ii. Check blood glucose levels 2-hourly initially with test strips:
aim for 6.5 to 11 mmol/1 (117 to 200 mg/dl). If glucose level
above 11 mmol/1 (200 mg/dl) change to GKI with 20 U
soluble insulin: if glucose level below 6.5 mmol/1, change to
GKI with 10 U soluble insulin. Continue to adjust in five unit
steps as necessary. Check plasma potassium levels 4 to 6 h,
postoperatively.
iii. Continue GKI till patient eats, then revert to usual treatment,
if GKI is prolonged (more than 24 h), check urea and
electrolytes daily (and consider further nutritional support).
Supplemental Insulin
Use of sliding scale alone is inappropriate: A common misconception is
that a sliding scale insulin regimen alone is sufficient for diabetic
management. A sliding scale, when used alone, cannot achieve adequate
management of hyperglycemia. These regimens react to the presence
of hyperglycemia instead of acting to prevent the occurrences of
hyperglycemia. Therefore, by definition, patients using this regimen
must reach an unacceptable level of hyperglycemia before receiving
insulin. Sliding scale insulin given at meal times alone also provides no
coverage at night and therefore, may result in the development of fasting
hyperglycemia. Therefore, a sliding scale regimen should be used only
as a supplemental regimen in conjunction with a scheduled insulin
dosage.
Calculating Supplement Insulin Dose

Supplement insulin should be administered at meals only. The addition
of supplement insulin at bedtime or three am is discouraged because it
may cause hypoglycemia. The type of insulin used for the supplement
should correspond to the type of short acting insulin given in the
standing dose regimen. A patient receiving standing dose lispro should
also receive lispro in the supplement rather than regular insulin.
Calculating supplemental insulin dose (the interval of the
supplement should be five percent of the total daily scheduled standing
dose insulin. The number of dosage units shown in the table are
provided on a patient receiving hundred units of insulin daily.
Plasma glucose (mg/dL) Supplemental regular insulin
70 to 200 Give scheduled insulin
201 to 250 Add five units to scheduled insulin dose
251 to 300 Add 10 units to scheduled insulin dose
Management of Type 2 (NIDDM) DM

If the serum glucose level is below 250 mg on the morning of surgery,
sulfonylureas should be withheld. Long acting sulfonylurea (glipizide,
glyburide and chlorpropamide) should be discontinued on the day
before surgery and five percent glucose solution should be started at a
rate of about 100 ml/hour.
If the fasting glucose level is above 250 to 300 mg% add five units to
each liter of five percent glucose being given at 100 ml/hour. The goal
is to maintain glucose level between 100 and 200 mg.
Management of Type 1 (IDDM) DM

• Plan for surgery as early in the morning list as possible.
• Adjust potassium to keep at upper end of normal range.
• Replace requirement for sodium, plasma or blood in addition to
five percent dextrose regimen.
• Blood sugar profiles are needed while regimens in progress.
• Insulin can be administered by different methods.
Conventional Procedure
It is most widely used method of controlling blood glucose levels during
surgery. It is given on the morning of the operation, this is followed by
IV infusion of five percent glucose at a rate of 100 ml/hour
preoperatively and intraoperatively. If operation is prolonged,
potassium chloride should be added at a rate of 20 meq /hour.
Disadvantages of this method are:
• It requires full day's insulin preoperatively.
• Absorption after subcutaneous injection varies greatly in indivisual
patients.
• Surgeons may prefer that operations on diabetics be scheduled early
in the day, often the procedure must be delayed until the afternoon.
• The relatively small amount of glucose being administered are then
inadequate to compensate for the 18 to 20 hours for fasting, with
result that the insulin causes severe afternoon hypoglycemia.
• An average 6 hour lag for maximal response.
Intravenous infusion of insulin in glucose solution—another option
is to give infusion of five percent or 10% glucose solution containing 5,
10 or even 15 minutes of regular insulin per liter depending on the
patients' initial blood glucose concentration. At an infusion rate of 100
ml/hour, the insulin is administered at a rate of 0.5, 1 or 1.5 units/hour
respectively. In patients who are receiving steroids, 20 units of insulin
may be required.
Advantages of this regimen are:
• Problem of absorption is avoided, since it is given IV.
• In stead of an average six hour lag for maximal response to regular
insulin, the effect starts within 10 to 15 minutes and is relatively
constant.
• Unlike the fixed dose with SC administration the insulin infusion
can be changed at any time.
• The damage of hypo- and hyperglycemia are minimized .
• Since only about 10% of insulin absorbs to glass or plastic the
resulting reduction in dosage is of little therapeutic importance.
Normally, one unit regular insulin neutralizes two gram of glucose.
A 500 ml vac of five percent glucose contains 25 gm of glucose. Thus,
12 units is required to neutralize 500 ml vac of five percent glucose.
Use of insulin “piggy-backed” into the glucose infusion. Instead of
mixing insulin in the same bottle as the glucose, an insulin solution is
infused (piggy-backed) into the tubing delivering the five percent or
10% glucose. Generally, 50 units of regular insulin are mixed with 500 ml
of normal saline—a solution containing one unit of insulin per 10 ml of
solution. The glucose solution is given at a rate of 100 ml/hour, and
the insulin infusion is adjusted (usually by IVAC pump) to deliver a
total of five ml (0.5 units), 10 ml (1 unit), 30 ml (three units) per hour,
etc. depending on the results of blood glucose determinations obtained
approximately hourly during the surgical procedure.
Out of the three techniques, this is the most flexible and allows the
closest control of blood glucose levels. It requires careful monitoring of
the pump delivery rate, because too rapid infusion of insulin will cause
hypoglycemia. This approach is especially useful during prolonged
operations.
The simplest and most practical procedure is to give no insulin if
plasma glucose is less than 90 mg%. Above values of 90 mg% the dosage
of regular insulin in units per hour should equal 1 percent of the
previous hour's plasma glucose (mg%), e.g. at a glucose level of 200
mg% at 300 mg% give three units/hour.
A marked increase in glucose and insulin requirements
postoperatively suggest the presence of occult infection (e.g. wound
infection, cellulitis at IV site, UTI, or unrecognized aspiration
pneumonia).
Adjustments in the rate of glucose or insulin administration must
be based on blood glucose levels.
Hyperosmolar Coma
It is the result of severe dehydration in undiagnosed diabetics who have
been given large amounts of glucose during surgery. The resulting
osmotic diuresis leads to disproportionate water loss, dehydration and
hyperosmolarity. Hyperosmolar coma occurs when glucose level
exceeds 800 mg%. It is best avoided by monitoring fluid input and
output, measuring blood glucose levels and promptly starting the
treatment if blood glucose exceeds 400 mg%.
Obesity
The clinically obese is when more than 30% above ideal weight. The
patient who is obese is at risk because:
1. Any procedure is technically more difficult as exposure is impaired,
thus errors are more likely to occur.
2. Obesity carries an increased risk of venous thromboembolic disease
(DVT) and subsequent pulmonary embolism (PE) are more common.
3. In the postoperative period there is increased risk of pulmonary
infection results from impaired ventilatory mechanics.
4. There is increased risk of postoperative CVA and IHD.
5. Obese patients are more difficult to nurse and thus higher incidence
of pressure sores.
6. There is increased risk of wound infection, higher incidence of
wound dehiscence (poor wound healing) and incisional herniation.
It is best to delay procedure while the patient attempts to lose weight.
Preoperative physiotherapy may be instituted. Preoperative
thromboprophylaxis is needed. Postoperative intensive nursing care is
must.
MANAGEMENT OF OLDER SURGICAL PATIENT

As the population continues to age and preoperative care has become
more sophisticated, surgeons are presented with ever-increasing
numbers of older patients seeking surgical treatment.
More than the mere accumulation of years, aging represents, the
aggregated effect of often multiple chronic conditions/impairments that
lead to a narrowing of physiological reserve known as homeostasis.
Actual chronological age is less important than the nature, extent and
chronicity of the impairment. An acute illness normally has a rapid
onset and is often accompanied by severe symptoms that are usually
of short duration. On the other hand, chronic illness persists over a
long period of time (more than three months) and affects the overall
function at many levels including intellectual, emotional, social and
spiritual, not just the physical level of function. Acute illness are typically
encountered and managed as disease, whereas chronic illness is more
often manifested as impaired function. There is limitation of activities
of daily living. Hospitalization and especially surgery threatens
maintenance of the older patient's independent performance of the
activities of daily living because of the frequent deconditioning and
debility that occur in the postoperative period.
AGE-RELATED CHANGES
CNS Function
The aged brain has a diminished ability to maintain cerebral blood flow
during hypotension and a decreased acetylcholine content in the
cerebrum. Autoregulatory control of carebral blood flow is impaired
in older person so signs of cerebral ischemia may appear when mean
arterial pressure falls below 80 mm Hg. Geriatric surgical patients whose
systolic BP is 105 mm Hg or les should be closely monitored for cognitive
impairment or confusion and appropriate action should be taken as
decrease vasodilator therapy and improve blood volume status.
Postoperatively, who receive anticholinergic drugs should be examined
for acute confusion, retention of urine. Thus, these drugs should be
used only when absolutely required.
CVS
There is diminution of SA node activity and loss of cardiac conducting
tissue in old age, increases the incidence of arrythmias. Decreased
responsiveness to catecholamines may limit the ability of the aging
CVS to cope with stress due to increased vascular resistance and
reduced left ventricular compliance. Baroreceptor reflexes are bunted
in older age which increases the risk of postural hypotension especially
during ambulation shortly after surgery.
Patients should be monitored few hours after surgery with great
care for pain, hypoxia, hypotension that may increase the cardiac work
and dangerous for patient.
Patients are at increased risk for postural hypotension. If postural
hypotension is detected (by drop of 20 mm Hg in systolic BP after 2 to
3 minutes in the upright position following a five minutes period in the
supine position), ambulation should be allowed with caution.
Volume status and hypotensive drugs must be attended to in the
immediate postoperative period. Unless contraindicated cardiac
medications should be continued until the morning of surgery. Good
management of pain decrease catecholamine release and arrythmias.
Early ambulation of older patients protects than against deconditioning
and low dose of heparin reduces the incidence of thromboembolism.
Respiratory System
The diminished pulmonary reserve may exaggerate conditions with a
risk of postoperative hypoxia, atelectasis and pneumonia, pain over
sedation, infection and thoracic or upper abdominal surgical procedure
may increase this risk.
However, decreased pulmonary function due to aging should pose
no risk to surgical candidates who are otherwise free of pulmonary
disease.
Renal Function
A reduction in GFR and renal blood flow may predispose geriatric
patients to postoperative renal failure and toxicity from drugs cleared
by the kidney.
Decreased dilutional capacity may lead to over hydration and
hyponatremia after vigorous fluid administration, with serious
cardiovascular (pulmonary edema) or CNS (cerebral edema)
complications. Reduced NH4 secretion impairs the aged patients ability
to correct acidosis.
A 50% or more reduction in GFR reflects on increased risk of
postoperative renal failure. Avoiding drugs or drugs cleared by the
kidney, monitoring acid-base status and urine output, and monitoring
urine volume at one ml/min all helps to minimize renal complications
postoperatively.
Pain
Older individuals under report their pain. Nonverbal cues are much
more important signs of pain in the older patients than the young. Social
withdrawal, decreased activity and movement, even confusion are
subtle but important potential signs of poorly controlled pain.
Unfortunately, even the mildly cognitively impaired surgical patient
may not be able to verbalize his or her pain, but will manifest it by
being unable to get out of bed, deep breathe and cough should also be
titrated cautiously to achieve pain relilef with lower initial doses (start
low and go slow). Fentanyl and methadone are the two opiates that do
not require adjustment in renal insufficiency because of their primary
clearance through the liver.
Delirium
In the older surgical population (65+ year) the incidence of delirium
may be as high as 60%. The best approach to the management of
delirium is its prevention. Minor stressors (e.g. change of environment,
mild infection, mild hypoxia) may be sufficient to trigger delirium in
the compromised elderly. Thus, the most important strategy for treating
delirium is to reduce or eliminate the potential and real stressor that
may have triggered the delirium. For the older, agitated patient with
delirium, low doses of antipsychotic medications - Haloperiodol 0.25
to 05 mg orally or 0.125 to 0.25 mg parenterally or 0.25 to 1.0 mg
Risperiodone orally should be given.
Falls
A number of problems may contribute to the etiology of falls: poor
vision, incontinence, various medications, e.g. opiates, antihyper-
tensives, psychotropic agents, etc. altered vestibular function and
delirium. “Get-up and Go” test. Each patient who has had a history of
atleast one fall will benefit from this screening test. The patient should
be observed for posture while sitting in a straight back chair without
arm rests. The patient is then asked to rise from the chair preferably
without using his or her arms and then walk 10 feet, turn 100 degrees
and return to the chair to sit down. Abnormalities in transfer, balance
or gait are good predictors of fall risk and should be followed up with
a full geriatric evaluating.
Pressure Sores
The incidence of pressure sores varies depending on the venue and
quality of care and the population being treated. Immobilization,
urinary and fecal incontinence and malnutrition expose aged patients
to the development of pressure sores. Stages of pressure sores which
can be judged by daily inspection of pressure points.
First sign of pressure sore is reddening of the skin, i.e. blanching
erythema which indicate skin ischemia.
Stage I—nonblanching erythema
Stage II—shallow ulcers
Stage III—progressively deeper ulceration.
Heels and buttocks are particular danger areas. Any bony
prominence may be involved.
Prevention is better than cure: This depends on an awareness of
pressure sore risk in all patients and the implementation of appropriate
measures includes:
1. Regular turning (ideally every two hours) or lifting of the patient
(to reliance pressure).
2. The use of air or foam mattress (pressure relieving matteress) and
special seating and cushions and educating patients and their carers
about pressures relief.
3. Keep the bed-sheet dry and clean.
4. There should not be any fold or crease on bed-sheet.
5. Some talcum powder may be used on pressure points and area of
sweating to avoid wetting of bed.
Treatment of Pressure Sores

1. Identification and correct the cause, e.g. incontinence should be
managed appropriately.
2. Nutritional support provided if needed.
3. Wet to dry dressing to remove dead tissue and surgical debridment
to remove more extensive areas of necrotic material.
4. Hydrocoloid dressings may be useful in clean wounds with viable
tissue present to help maintain a moist, less traumatic environment.
5. Ultimately, skin grafting or flap coverage may be indicated for more
extensive decisions.
16 Intestinal Stomas
An intestinal stoma is an opening of the bowel on to the surface of the

abdomen. It may be temporary or permanent.
Gastrostomy, jejunostomy and cecostomy are usually temporary.
Ileostomy and colostomy are often permanent.
Figs 16.1A and B: (A) Closure of colostomy—bowel freed and mucocutaneous junction
trimmed, (B) Closure of colostomy—suture in transverse axis and drain inserted
Intestinal Stomas 161
Figs 16.2A and B: Split colostomy (A) Loop of colon; exteriorized. Dashes show line of
transection of colon, (B) Two stoma separated 1.0 cm; proximal stoma everted 3 mm above
skin and distal stoma flush with skin
Fig. 16.3: Single-barreled end colostomy. The margins of the stoma are
fixed to the skin with sutures
Figs 16.4A to D: Ileostomy after colectomy. (A) A midline incision for colectomy is indicated
by the dotted line and the site of the ileostomy by the black dot. (A midline incision is favored
by many surgeons), (B) The ileum has been brought through the abdominal wall, (C and D)
The ileostomy stoma has been everted and its margins sutured to the edges of the wound
Fig. 16.5: Closure of colostomy—skin incision
PREOPERATIVE PREOPERATION OF THE COLON

Complications of colonic surgery such as wound infection and
anastomosis leakage are partially related to high bacterial content of
the large bowel. Elimination of fecal mass and reduction of the numbers
of bacteria prior to operation is achieved by bowel preparation.
Mechanical cleansing is employed except in patients with obstructing
lesions, severe inflammatory bowel disease. A solution containing
polyethylene glycol (PEG) is given.
Gut sterilization may be done by oral antibiotic, i.e. neomycin and
erythromycin.
Stoma care therapist should provide the following:
1. Preoperative education and counseling of patient and family.
2. Immediate postoperative care of the stoma.
3. Equipment (appliance) training and self care.
4. Advice/instruction on day-to-day living with stoma.
5. Management of skin problems and odor control.
6. Reorganization of surgical stoma problems.
7. Long-term emotional, moral and physical support.
Complications of Stomas
1. Skin irritation (excoriation)
2. Prolapse
3. Retraction
4. Necrosis
5. Stenosis
6. Parastomal hernia
7. Bleeding
8. Colotomy diarrhea—this is usually an infection enteritis and well-
respond to oral metronidazole 200 mg three times a day.
In addition to this ileostomy carries more complications like—
urinary tract calculi, this is the result of chronic dehydration due to
inadequate fluid intake. It is associated with lower urine pH and volume
and higher concentration of calcium, oxalate and uric acid.
Gallstones—These are three times more common in ileostomy patient
than in general population. Altered bile acid absorption may be
responsible.
ILEOSTOMY
Indications—for permanent ileostomy
1. After colectomy for ulcerative colitis.
2. Crohn’s disease
3. Familial polyposis
For temporary ileostomy that is loop ileostomy:
1. It is used to divert the fecal mater for three months when ileo-anal
or colo-anal anastomosis is performed.
2. As a part of a ‘pouch operation’ until healing is satisfactory.
Ileostomy in Children
A temporary ileostomy may be necessary in a baby to:
i. relieve obstruction or
ii. to defunction ischemic bowel in necrotizing enterocolitis.
A reservoir is constructed out of the distal ileum and outlet from
the reservoir is arranged as a value so that fluid cannot onto the
abdominal wall. Problems with pouch are pouchitis, fistula. It is
contraindicated in Crohn's disease because of the risk of occurrence
necessitating excision of the reservoir.
Position of Ileostomy—Optimal Position is

Right Lower Quadrant
The ileum is brought through the rectus abdominis muscle and everted
upon itself and the mucosa is sutured to the skin. An appliance is placed
immediately. It should lie flat against the abdomen, adhere firmly to
the skin. Physiologic changes after ileostomy are due to loss of water
and salt absorption. The ileostomy patient is susceptible to acute or
subacute salt and water depletion which is manifested by fatigue,
anorexia, irritability, headache, drowsiness, muscle cramps and thirst.
Management of an Ileostomy
1. Patient should be advised to take salty food.
2. Patient with high outputs may need supplement with high
potassium in the form of bananas or orange juice.
3. Water intake in response to thirst may not be adequate to maintain
hydration and patient should consume enough water to keep the
urine pale or to maintain a urine output of at least l lit/day.
4. A low-residue diet should be advised at least initially.
5. Certain foods, e.g. fish, eggs, garlic may cause excessive odor and
gas, thus should be avoided.
6. Ordinary physical activity, employment and social activities are
encouraged.
7. Bathing, swimming, sexual intercourse and pregnancy, and delivery
are unrestricted.
The ileotomy does not usually act for 12 to 24 hours after operation.
It may then act profusely and the sudden and unaccustomed loss of
small bowel contents may lead to dehydration and salt depletion. For
this reason, intravenous infusion should be maintained for at least the
first two postoperative days.
Ileostomy efflux may cause excoriation of the skin. To prevent this
collecting appliance (ileostomy bag) should be fitted immediately after
the operation. After a week or two the discharge becomes more solid,
but it never becomes like normal stool, and relatively it is odorless when
stability has been reached, the bowel acts shortly after meals and usually
remains quiescent at other times.
Stoma Care in Children

In a baby it is preferable to cover a stoma with an appliance rather than
addressing or nappy so as to prevent excoriation of surrounding skin.
The baby can be bathed in the normal manner and the stoma is cleaned
with cotton wool soaked in warm water. The parents must be fully
conversant with stoma care before the baby leaves hospital.
In an older child: In addition to physical problems of the stoma, there
may be profound psychological disturbance which may increase with
puberty. The disturbance may be such as to cause behavioral problem
and this should be recognized. Under favorable circumstances a child
will learn to manage the stoma independently. He should be able to
attend a normal school and take part in a full range of outdoor activities
including swimming.
Loop ileostomy: It is used by some surgeons as an alternative to colostomy
particularly defunctioning for a low rectal anastomosis. The advantages
of a loop ileostomy over a loop colostomy are—easy to bring the bowel
to the surface and the absence of odor.
COLOSTOMY
A colostomy is an artificial opening made in the large bowel to divert faces and
flatus to the exterior, where it can be collected in an external appliance.
Depending on the purpose for which the diversion has been
necessary, a colostomy may be temporary or permanent, end or loop.
Colostomy can be constructed by making an opening in loop of colon
(loop colostomy) or by dividing the colon and bringing out one end on
the surface (end/terminal colostomy). A colostomy is double-barreled
if a loop or both ends of a colon are exteriorized and single-barreled if
only one end is brought out.
Indications
• To decompress an obstructed colon.
• To divert the fecal stream in preparation for resection of an
inflammatory, obstructive lesion.
• To defunction an anastomosis after anterior resection.
• To prevent fecal periotonitis developing after traumatic injury to
the colon or rectum.
• In the treatment of high fistula-in-ano.
Temporary Colostomy
This is most commonly performed to defunction an anastomosis after
an anterior resection, to prevent fecal peritonitis following traumatic
injury to colon or rectum and to facilitate the operative treatment of a
high fistula in ano. It is also called diverting colostomy.
Defunctioning Colostomy
A temporary colostomy is made, by bringing a loop of colon to the
surface, where it is held in place by a plastic or glass rod passed through
the mesentry. The bowel is best attached to the parietal peritoneum
internally by returns and to the anterior rectus sheath or external oblique
aponeurosis similarly and adjacent skin margin.
Opening and Closing of Colostomy

In the presence of obstruction it is usual to open at the time of operation.
This is carried out with diathermy or by simple incision. In
nonobstructed cases opening is delayed for two or three days after to
operation.
When firm adhesion of the colostomy to the abdominal wall has
taken place, after seven days the bridge can be removed. This colostomy
is made in the transverse colon but sigmoid colon can also be suitable.
Following the surgical cure or healing of the distal lesion for which the
temporary stoma was constructed, the colostomy can be closed. It is
usual to perform a contrast X-ray (distal loopogram). Closure is usually
performed (after two months) by an intraperitoneal technique, which
is associated with fewer closure breakdown with fecal fistula.
Permanent Colostomy
This is made after the excision of the rectum for a carcinoma. It is formed
by bringing the distal end (end colostomy) of the divided colon to the
surface in the left iliac fossa or the site choosen where it is sutured in
place joining the colonic margin to the surrounding skin. The best site
for permanent colostomy is through the lateral edge of the rectus sheath
six cm above and medial to the bony prominence.
The most common permanent colostomy is a sigmoid colostomy
made at the time of APR for ca rectum. Such a colostomy is compatible
with a normal life except for the route of fecal evacuation. Diet is
indivisualized, generally patients are able to eat the same foods. Fresh
fruits, fruit juices and other foods may cause diarrhea.
Transverse colostomy should not be constructed as a permanent
stoma. These stoma are bulky, foul smelling and extremely difficult to
manage. They are prone to leak under the appliance and prolapse is
common.
Care of Colostomy
Watertight junction between skin and collecting appliances is not
necessary as efflux is solid or semisolid. It is possible to mange
colostomy with a pad of wool held in position by a belt or elastic bandage
if collecting appliance is not available.
Colostomy in Children
Indication
• Anorectal agenesis.
• Hirschsprung’s disease.
Closure of Colostomy
This procedure is applicable where a temporary colostomy has been
performed. An elliptical incision is made around the colostomy opening
0.5 cm from the mucocutaneous junction. Bowel is separated by sharp
dissection from the layers of abdominal wall. The edges of colostomy
are excised/trimmed. The default in the anterior wall of the colon is
repaired by sutures placed in the transverse axis of the bowel, inverting
the mucosa. The bowel is allowed to fall back or gently pushed in. A
drain should be put in because sometimes leakage occurs, but it usually
ceases spontaneously within a few days.
CECOSTOMY
This is rarely used now.
Indication
• In desperately ill patients with advanced obstruction.
• Cecal gangrene
• Devitalization of the cecum resulting from pseudo-obstruction.
In late cases of obstruction, the cecum may become so distended
and ischemic that rupture of the cecal wall may be anticipated. In such
cases, it should be decompressed. Following on table lavage via the
appendix stump, the irrigating catheter can be left in place as a tube
cecostomy. Cecostomy is only a short-term measure to allow for a few
days till the condition of the patient improves. Re-operation should
normally follow fairly soon thereafter and a proper surgical procedure
carried out.
Colostomy Irrigation
Irrigation is a part of management of permanent colostomy. The goal
of managing colostomies with irrigation is to empty the colon and
prevent fecal elimination between irrigations. Only colostomies in the
descending or sigmoid colon can be regulated with irrigation. The
ascending and transverse colon, lack of reservoir function.
Irrigation is a management option and is not required to maintain
normal bowel function.
Advantages of Irrigation
• Regaining control of bowel elimination.
• Successful irrigation facilitates emotional adjustment to the
colostomy.
• Bowel movement occurs at the time of irrigation as determined by
the patient, who may choose not to wear a pouch between irrigation.
Disadvantages of Irrigation
• Irrigation is a time consuming procedure usually takes 45 to 60
minutes procedure.
• It causes intrusion into the patients' life style.
• Irrigation does not work for everyone. It may take up to six weeks
to determine whether irrigation will be successful.
• There is a risk of bowel dependency overtime.
• To be successful, irrigation should be performed daily on other day
to develop a routine elimination pattern.
Irrigation Procedure
Use 600 to 1000 ml of luke warm tap water. The fluid is delivered
through a traditional enema bag with a soft rubber cone tapered at the
end of the catheter. The cone tip prevents bowel perforation and
prevents backflow of the irrigation solution. An irrigation sleeve is
attached to a wafer adhered to the skin or fitted into place around the
stoma. The irritants should be delivered over a 5 to 10 minute period to
prevent cramping of stool. When returns are complete, remove the
sleeve, clean and dry the skin, and apply the pouch or desired stoma
covering.
Criteria for Choosing Colostomy Irrigation
1. Descending/sigmoid colostomy.
2. History of regular, normal bowel movements.
3. Ability to learn and perform the procedure.
Contraindications for Colostomy Irrigation

• Multiple colon resections.
• Peristomal hernia or stomal prolapse.
• Any disease in the proximal colon.
• Chemotherapy or pelvic/abdominal radiation therapy.
Ileostomy Lavage
The goal of ileostomy lavage is to gradually dislodge the blockage with
repetitive saline irrigation.
Dietary and fluid management of stoma patient.
Patient with stoma needs certain diet modifications. It is important
to encourage patients to chew food slowly and completely, drink plenty
of fluids and add foods gradually to their diet. Dietary factors may be a
deep concern for many colostomy patients.
Postoperatively a patient may complain of fullness and distention
which can be avoided by eating small and frequent meals. If nutritional
intake is poor, encourage high caloric snacks between meals and liquid
nutritional supplements.
CHARACTERISTICS OF VARIOUS FOODS

Food that thicken the stool
1. Cheese
2. Peanut
3. Rice
4. Pista
5. Marshmaloos
Food that Causes Diarrhea

1. Coffee, tea
2. Beer
3. Spinach
4. Raw fruits and vegetarians
5. Broccoli
6. Prunes
7. Highly spiced foods
8. Prunes
Gas Forming Foods
1. Beer
2. Milk
3. Soda
4. Cold drinks
5. Onions
6. Peas
7. Spicy
8. Nuts
9. Cabbage
10. Broccoli
11. Sported seed
12. Cauliflower
13. Corn
14. Dried beans
15. Mushrooms
Food that Causes Odor

1. Cabbage
2. Cheese
3. Egg
4. Fish
5. Garlic
6. Onion
7. Radish
8. Spices
Food that Causes Blockage

1. Coconut
2. Corn
3. Dried fruits
4. Nuts
5. Peelings
6. Raisins
7. Stringy vegetables
These foods should be choosen/given according to the situation.
17 Preoperative Care
INTRODUCTION
Gathering and recording information—this process starts from the
moment the patient is first entered to the OPD or emergency
department. Record only verifiable facts not subjective (based on your
own idea). Avoid ambiguous (having different meanings) or unusual
abbreviations. Write all your notes or if they may be used one day as
evidence of your professional competence in a court of law. By the
time a case comes to court, it may be years after the event and yet you
will be expected to recount and justify your every action. This will be
difficult to do without notes to remind you. Remember that, as far as a
court of law is concerned, if it is not written down, it never happened.
A little knowledge is a dangerous thing (Huxley), but information
overload can also cause problems. Operation must not begin until their
preoperative condition is as good as can be achieved. Anesthetist
postpone surgery not because the patient is ill, but because their
condition could be improved.
Preoperative Care
It includes:
1. Diagnostic Workup
2. Preoperative Evaluation
3. Preoperative Preparation
Diagnostic Workup
Diagnostic workup is concerned primarily with determining the cause
and extent of the present illness.
Preoperative Evaluation
It consists of an overall assessment of the patient’s general health in
order to identify significant abnormalities that might increase operative
risk or delay recovery.
Preoperative Preparation
It includes interventions dictated by the findings on diagnostic
workup and preoperative evaluation and the nature of the expected
operation.
Preoperative History
It includes complete history and physical examination:
Cardiovascular • Anemia
• Hypertension
• PVD
• Angina/MI
• Arrhythmia
• DVT
• Bleeding tendencies
Respiratory • History of smoking
• Active RTI
• Asthma
• COPD
Gastrointestinal • History of alcohol
• Diabetes
• Bowel habits
• Bleeding per rectum
• Dyspepsia
Urological • UTI
• Renal disease
• Prostate problem
Neurological • History of CVA
• Epilepsy
• TIA
Surgical/Anesthetic History • Previous surgery
• Any problem with previous
anesthesia regarding
intubation or
with any anesthetic drug.
History of drug • Reaction
• Present medication
Preoperative Care 173
Preoperative General Examination
Related to the system
1. Sepsis—check teeth, feet and leg for ulcer.
2. General—check nutritional status.
3. Neurological—check state of consciousness, neurovascular status
of preoperative limb.
4. Cardiovascular—check pulse, BP, state of hydration, and degree of
shock.
5. Respiratory—check cyanosis, clubbing of finger, respiration rate and
any added sounds.
6. Gastrointestinal—check for any abdominal mass, any tenderness,
hernial orifice, bowel sounds, DRE (digital rectal examination).
7. Genitourinary—check external genitalia, DRE for prostate, and
abdominal examination for distended bladder, palpable kidney.
• Weight—weight loss of more than 20% caused by illness results
in higher death rate and more than three fold increase in
postoperative infection rate.
• History of bleeding tendencies, medications currently being taken
and allergies and reaction should be recorded and displayed on
the BHT (Bed Head Ticket).
• Smoking—even a few days of abstinence from smoking will
decrease sputum production. Oral or inhaled bronchodilators
along with twice daily, chest physical therapy and postural
drainage will help to clear inspissated secretions from the airway.
Use of incentive spirometry device increases the inspiratory
effort.
• When radiation is given prior to operation, there is an optimal
delay period (2 to 12 weeks) after completion of the radiation
therapy before operation.
• Use of drugs—prolonged use of corticosteroids (even though
discontinued/month or more preoperatively) may be associated
with hypofunction of the adrenal cortex, which impairs the
physiologic responses to the stress of anesthesia and operation.
The standard stress dose of hydrocortisone 100 mg three times a
day. Such a patient should receive corticosteroids immediately
before, during and after operation.
Long-term use of CNS depressants, e.g. barbiturates, opioids,
alcohol may be associated with increased tolerance for anesthetic
drugs. Chlorpromazine and antihypertensive agents may be
associated with hypotension in response to anesthesia.
Use of aspirin should be stopped at least one week prior to
surgery.
• Aged—aged patients generally require smaller doses of strong
narcotics and are frequently depressed by routine doses. But
codeine is usually well tolerated. Sedation and hypnotic drugs
often causes more restlessness, mental confusion in elderly
patients. Preanesthetic and anesthetic agents should be
administered in smaller amounts.
• Individual examination—check for any other medical conditions
that they may have. A patient with IDDM undergoing surgery
for carcinoma of colon will also need to be carefully examined
for any sepsis, neuropathy or microvascular disease.
INVESTIGATION
Routine Investigation
Perform only routine investigation required by protocol. The use of
routine tests normally performed on most of patients are:
• CBC (Complete Blood Count)
• Basic biochemistry test
• C X R (Chest X-ray)
Special Investigations
These should be organized in consultation with the specialists who will
be advising on the results and with the anesthetist, to decide whether
the patient is fit /unfit for surgery.
Common Investigation for Surgical Patients

Hemotology
• Hemoglobin
• CBC
These tests give a guide to anemia, any possibility of infection. Total
lymphocyte count tells about the assessment of immune competence.
All tests must be interpreted, e.g. Hb of 8 g/dl is generally
physiologically safe for tissue oxygen delivery but may be inadequate
in the patient with reduced cardiac output.
Biochemistry
Blood Glucose, Urea, Serum Electrolytes, Creatinine
These tests give a guide to state of dehydration diabetes, renal
insufficiency. Kidney play a major role in response to and clearance of
various anesthetic agents.
Liver Function Tests (LFT)
These guide us about potential hepatic reserve. Albumin and total
protein levels may give a guide to nutritional status. Serum albumin
less than 3g/dl or a serum transferrine of less than 150 mg/dl warn of
possible problems with wound healing and immune function. Abnormal
LFT may also warn of clotting problems.
If patient is on anticoagulant and has compromised LFT or having
any bleeding tendency or diathesis then clotting screen is also required.
Urine Examination
Complete and microscopic examination of urine is required to detect –
UTI, glucosuria, beliuria, ketone bodies, etc.
CXR
Any patient over the age of 40 should go for CXR in preoperative
evaluation.
Indications of CXR are:
• Cardiac failure
• Hypertension
• Cardiomegaly
• Chest infection
• COPD
• Asthma
Cardiac Evaluation
ECG should be done in all patients of over 50 years of age. If any cardiac
problem is detected, go for echocardiography and TMT. Ventricular
ejection fraction of less than 35% implies the greater risk of cardiac
complications. Resting ECG fails to demonstrate a predictive value for
ischemic preoperative events. Thus, exercise ECG, thallium scanning
or stress echocardiography is recommended.
Hepatitis Screen
In doubtful cases or in endemic area one should go for hepatitis
screening.
HIV Testing
HIV testing must be considered in any patient who is felt to be at high-
risk.
BLOOD GROUPING AND CROSS-MATCHING
It is mandatory in all patients undergoing major surgery.
PREGNANCY TEST
It is mandatory in all female patients of child bearing age to exclude an
ectopic pregnancy underlying abdominal pain.
PREOPERATIVE PREPARATION
In emergency conditions, time for preparation is limited but is usually
sufficient to permit the principles of good surgical preparation to be
followed. In elective operation, meticulous preoperative preparation is
mandatory.
It includes the following steps:
1. Information and consent—Inform the patient about the type of
surgery – surgery is a frightening prospect for both patient and
family. Their psychological preparation and reassurance, moral
boosting should be done. Explain all about the nature, purpose of
preoperative evaluation, risks, possible consequences, potential need
for blood transfusion and reaction and side effects of drugs.
Anesthesia complication must be explained. There must be a written
consent from the patient or the patient’s legal guardian for a major
or minor operation.
Emergency life saving operations or procedures may have to be
done without a permit. In such cases, every effort should be made
to obtain adequate consultation. The situation should be carefully
documented in the chart. Legal and institutional requirements
regarding permits vary. It is essential that the surgeon understand
and follow local regulations.
2. Asepsis and antisepsis in the prevention of wound infection. It
includes—sterilization, skin antiseptics, control of hospital
environment, antibiotics, etc.
There are two types of operation for which we have to prepare the
patient for operation.
1. Emergency Operations
2. Elective Operations
Emergency Operations
This type of operation is done as early as possible to save the patient’s
life, for example, Ac Appendicitis, Peritonitis (perforation), Ruptured
ectopic gestation, Accidental cases, Intestinal obstruction, Obstructed
or strangulated hernia, etc.
Immediately follow the preoperative instructions or orders written
or told by surgeons:
1. NBM/NPO (Nothing By Mouth or Nothing Per Oral): Patient
should be strictly told about this, not to take any liquid or oral
medicines.
2. Fluid therapy—IV fluid therapy should be started immediately
to correct dehydration and electrolyte imbalance. Always use large
cannula and always choose the peripheral vein. The vein should
be large and away from the joint and properly fixed.
3. Medicines—should be given as told by surgeon
i. Antibiotics
ii. Analgesics
iii. Antiemetic
iv. Any specific medicines like Inj. Tetvac, etc.
4. Nasogastric tube insertion—(Ryle’s tube suction).
5. Catheterization—if necessary.
6. Investigations—All the investigation like blood for grouping and
cross matching, other blood and radiological investigations like
X-ray, ECG, ultrasound (US) should be sent immediately and
report when it will come.
7. Prepare the part to be operated.
8. Consent—routine consent and high-risk consent must be taken
and explain the possible risk and complications to the patient’s
relative. Consent should always be taken in writing and also get a
sign of witness.
9. Any special instructions about medication like—insulin, specific
fluid, blood transfusion, vitamin K should be checked carefully
and follow.
10. Psychological preparation—almost all the patients are worried
about operation. Every patient should be explained the nature
and extent of operation. Reassure the patient and by talking with
him/her, gain a confidence to the patient and try to remove the
fear.
11. Allergy to any medicine should be noted on Bed Head Ticket (BHT)
with red ink.
12. Check the blood-arranged or not.
13. Do not make yourself hotchpotch, be cool and polite and satisfy
the patient what he/she says.
Elective Operations
It is the operation that is not an emergency. It is usually done at a fixed
time—suitable and convenient and beneficial for the patient. In this
there is enough time to study the conditions of patient and prepare
him/her for the operation.
History
The patient is enquired for:
1. Illness.
2. Any specific other diseases like—Diabetes, Asthma, Tuberculosis,
Hypertension, Heart disease.
3. Allergic to specific medicine—that should be written on the top of
bed head ticket in red pen and should be informed to surgeon.
4. Medication—intake of any drug like—steroid, insulin, antiepileptic
drug.
5. History of previous operation.
6. History of previous blood transfusion.
7. If female patient—enquire about her menstrual cycle, parity and
number of children, any complications at the time of delivery.
Examination
General examination of patient should be carried out that include:
1. Vitals—Pulse, BP, Respiration, Temperature (PTR and BP).
2. Hydration (by watching his/her tongue dry or wet).
3. Presence of loose tooth, denture (artificial teeth).
Investigations
• Check all the routine investigations like Hb, CBC (complete blood
count), ESR, BT, CT, Urine, Blood for sugar, Urea, Creatinine, CXR,
ECG, etc.
• Specific Test—Liver function test, Thyroid function test, IVP,
Ultrasonography, Echocardiography, CT Scan, MRI, HIV, HbS Ag,
HCV Blood grouping and Rh typing, Serum electrolytes (Sodium,
Potassium, Chloride), etc.
General Measures
1. Activity—keep the patient ambulatory within the limit of patient’s
condition and encourage the patient. Because inactivity leads to
complications like deep vein thrombosis, lung infection.
2. Diet—appropriate diet should be given according to the patient’s
need
• Soft diet or liquid diet
• Salt free
• Fat free
• Extra glucose—but check the diabetic status of the patient.
3. IV fluid—if required to correct electrolyte imbalance.
4. Bowel preparation—by giving oral laxative, gut sterilizer medicines
like—erythromycin, metronidazole, tinidazole, neomycin, peglac,
etc.
5. Specific medications—like vitamin K, antidiabetic drug (Insulin or
oral medicine) and for hypertension.
6. Psychotherapy to patient—mentally prepare the patient, gain the
patient in confidence remove his/her fear and anxiety, explain the
procedure to be done. Fulfill the patient’s spiritual need.
7. Improve the lung function—by postural drainage, medication and
chest physiotherapy, incentive spirometry device.
Preoperation Instructions for Elective Operation

Carry out all the preoperative instruction. There is sufficient time for
elective operation. It includes:
1. Written consent for surgery and anesthesia.
2. Complete all the entries in BHT (Bed Head Ticket) of the patient.
3. Shaving and preparation of local parts.
4. Nothing by mouth—at least 6 hours prior to operation.
5. Oral medication—like antihypertensive, antidiabetic should be
given in morning time, if surgery is posted in evening.
6. Mouth care—if there is poor hygiene then clean him/her mouth
with diluted hydrogen peroxide or with antiseptic gargles.
7. Take weight of the patient.
8. Enema.
9. Empty the bladder before entering to OT.
10. Handover all the ornaments and hand over to patient’s close
relatives.
11. Premedication—it is written on the BHT—like Inj. Tetvac,
Antibiotics, Diazepam, Phenergan, Atropine, Glycopyrolate,
Hydrocortisone, Deriphylline, etc.
12. Recheck all the investigations, consent for operation and
anesthesia, ornaments, etc.
13. Remove nail polish—it interfere in the sensor of pulse oxymetry.
14. Send the patient to OT in sterilized gown.
18 Incisions
INCISION
Incision it is a (Latin word, which means a cut) a surgical wound made
with knife.
Fig. 18.1
Fig. 18.2: Abdominal incisions

Incisions 181
Fig. 18.3
MIDLINE INCISION
It may be upper, central or lower midline used for access to different
structures.
Upper is used for operations of—esophagus, stomach, duodenum,
spleen, liver, pancreas and gallbladder.
Central for—small intestine
Lower for—large intestine, uterus and its appendages, urinary
bladder, prostate, etc.
Steps
After the skin has been incised the linea alba is divided to expose the
peritoneum, which is usually covered by transversalis fascia.These are
divided in one layer. In the upper abdomen this division should be
made a little to one side of the midline, or the knife may pass between
the layers of the falciform ligament. Below the umbilicus, care is taken
at the lowest part of the incision to avoid injury to the bladder.
Closure by a single layer of sutures as a mass closure technique
followed by skin suture. Continuous or interrupted sutures of
monofilament are used, inserting the needle at least one cm from the
edge of the incision and one cm from the adjacent suture.
Advantages
1. It is an avascular so that abdomen can be both quickly opened and
quickly closed.
2. It is particularly useful in the peritoneal contamination (since tissue
exposed to the infection is minimized).
Disadvantage
Wound dehiscence is more than paramedian incision but since the use
of monofilament sutures retain their strength until healing is complete.
PARAMEDIAN INCISION
• It may be upper and lower and right or left.
• Right upper for—biliary tract, liver, duodenum, small bowel and
upper part of large intestine.
• Right lower for—Rt ureter, appendix, caecum, part of small bowel,
Fallopian tubes
• Left lower for—Left ureter, lower colon.
Steps
The incision is made to the midline, at a distance of 2 to 3 cm from it.
The anterior rectus sheath is divided in the line of the skin incision. The
rectus is then displaced laterally to expose the posterior sheath. This is
incised in the line of the skin incision, together with transversalis fascia
and peritoneum.
Closure
The incision is sutured in three layres—firstly peritoneum and posterior
sheath as one layer, secondly anterior sheath, and thirdly skin.
SUBCOSTAL INCISION (RIGHT OR LEFT)

• Used for operations on—gallbladder
• Right side—gallbladder (biliary tract), liver
• Left side—spleen
• Rt subcostal is also known as Kocker’s incision.
Advantages
• It gives better view of biliary tract.
• It gives less scar.
• Chances of wound dehiscence is minimal.
Incisions 183
Steps
Incise the skin 2.5 below and parallel to the costal margin from xiphoid
to downwards, sheath is cut. Then all three muscles are either splitted
or cut in the same line to expose the peritoneum. Enter the abdomen by
incising the peritoneum. Closure—close the peritoneum and posterior
sheath, muscles are sutured back in layers (if they are divided). Then
suture the anterior sheath and finally skin.
TRANSVERSE INCISION
• Upper and lower transverse incision.
• It is used in pediatric patient, upper is for operations on—Biliary
tract, pylorus (stomach), kidney, small and part of large bowel.
Lower is for operation on—Small part of lower bowel, uterus,
fallopian tube, kidney.
Steps
Incise the skin, then both anterior and posterior sheaths are divided
transversely (in the line of the fibers). The recti are also divided
transversally then peritoneum is opened vertically or transversally
(surgeon's choice).
Closure—peritoneum, muscles, ant sheath and skin.
PFANNENSTIEL INCISION
Incise the skin two cm above the pubic symphysis. In this type of
incision, abdomen is opened as in lower transverse incision but here
recti muscles are not divided but vertically separated. Transversalis
fascia and peritoneum is incised vertically.
It is commonly used incision for operation of: Prostate, urinary
bladder, Fallopian tubes, uterus and ovaries, upper rectum.
GRID IRON INCISION

This is the incision most commonly used for removal of appendix.
Incision lies at right angle of lower 1/3 point of spino-umbilical line. A
line that joins the right anterior superior iliac spine to umbilicus. It is
arbitrarily divided into three parts. Lateral 1/3 point is known as
Mc Burney’s point. At this point, the supposed base of appendix is lies.
Skin is incised then external oblique aponeurosis in the line of skin
incision, then muscles are splitted with the help of scissor or handle of
knife to expose the peritoneum. Now peritoneum is opened in the line
of skin incision.
Closure—peritoneum, then approximate the muscle by loose stitches,
external oblique aponeurosis and finally, the skin.
RUTHERFORD MORRISON INCISION

This incision is same as above grid iron but here, when more access is
required in medial direction oblique muscle is cut in upward or
downward direction.
LANZ INCISION
This incision is a modified grid iron. This incision is transverse and lies
in the interspinous crease. Other steps are same as for grid iron incision.
Advantage
Invisible scar due to skin crease.
INGUINAL INCISION
This incision is for inguinal hernia. It is an oblique incision, made 2.5 cm
above and parallel to the medial 3/5th of the inguinal ligament.
In children for herniotomy.
CURVED SUBUMBILICAL OR SUPRAUMBILICAL INCISION

It is given through a curved skin incision below and parallel to the
inferior margin of umbilicus.
MIDLINE SUPRAUMBILICAL INCISION

For epigastric hernia.
LUMBAR SUBCOSTAL INCISION

It is used for operations of kidney, upper and mid ureter. It begins
below the angle between 12th rib and lateral border of sacrospinalis
and carried downwards and forwards as curved line between the 12th
rib and iliac crest and usually stops 4 to 5 cm above the anterior superior
iliac spine.
Incisions 185
Fig. 18.4: The skin incisions for the various posterolateral exposures of the kidney. From
below upwards, the subcostal approaoch, the twelfth rib approach, the eleventh rib approach
and the thoraco-abdominal incision through the tenth intercostal space
Fig. 18.5
INSTRUMENTS FOR INCISION
There are two instruments for incision one is scalpel handle another is
knife.
Scalpel
Two types of scalpels are available:
1. Scalpel handle combined with blade.
2. Scalpel handle with detachable blade.
Fig. 18.6: Scalpel handles

Incisions 187
It is available 3 and 4 in number in which particular number of blades
fits in it. For example, 10, 11, 15 number blades fits with 3 number
scalpel and 21, 22, 23, 24 number blades fits with 4 number scalpel.
Some scalpels are available in which on one end—fitting of size 3 and
on other end 4 number.
In some scalpel there is a scale on the handle, which is helpful to
measure the length of incision and other landmarks for the beginners.
DIFFERENT METHODS OF HOLDING A SCALPEL

1. Writing or dissecting or pen holding position—this position is used for
fine dissection and dissection on delicate structures, e.g. artery, vein
or nerve.
2. Dinner knife position—This position is used while making a long
incision and when separating muscle from bone.
3. Grasping position—This position is used to make incision with
minimum pressure over delicate structures but drawback of this
position is that grip is not good so it can slip from hand.
19 Assisting at Operations
PRECAUTIONS IN OPERATION THEATER

1. It is necessary to change his/her dress in changing room and wear
OT cloths before entering into the main theatre.
2. Always wear a cap and mask.
3. Put off shoes outside the OT and wear theatre shoes or chappal.
4. Keep all the doors of OT closed.
5. There should be a separate patient's trolley for OT.
6. The movement in and around the operating room and table should
be kept minimum.
7. There should be proper members of nursing staff in the OT but
over crowding must be avoided.
8. Ensure that patient’s position in OT table is correct.
9. Check all the equipments before starting the operation like—OT
light, suction machine, electrosurgery (diathermy), multi-
parameter, defibrillator, gas cylinder, laryngoscope and its battery,
anesthesia medicine, emergency medicines, monitor, insufflator,
camera, etc.
10. No part of the skin surface should be in contact with anything of
metal (like IV stand and OT table) if electrosurgery is to be used.
11. OT table should be very well covered by mattress.
12. It is sensible before the procedure to know and check the blood
for transfusion and match with the patient's name, blood group,
registration no.
Assisting at Operations 189
Check List
Patient's Name Registration No.
1 Consent for Operation
2 Preparation for Operation site
3 Patient is NBM/NPO
4 Investigation Reports attached
X-ray
Ultrasound
CT
MRI
5 Removal of
Denture (artificial teeth)
Jewellery
Nail polish
Hair pins
6 Enema administered
7 Bladder emptied
8 Vitals taken
BP, Pulse, RR, Temperature
9 Premedication given
10 Name tag on
11 Patient transferred to OT with hospital gown
Signature of OT In-charge
PREPARATIONS FOR THE OPERATION

1. Theatre Dress: All persons entering into the theatre should change
and wear OT dresses. Different colors may be used for dresses of
staff of different grades.
Fig. 19.1
2. Cap and Mask: Every person in the OT must wear cap and mask.
3. OT Shoes: Every person should putt off his/her shoes outside and
wear OT chappal/shoes.
4. Scrubbing: Surgeons, sister and all the assistants are required to scrub
the hand and forearm up to the elbow thoroughly before gowning.
In first operation minimum time for scrubbing is five minutes and
on subsequent operations is 2 to 3 minutes is sufficient. Then wipe
off with sterilized towel and pour some Povidone iodine or surgical
spirit and rinse both the hands before gowning.
5. Gowning: After proper scrubbing wear the gown—holding gown
by inner, top edge while gown unrolls, ask assistant to tie gown
back, hands are kept pointing upwards. Hold the gown by neck
and gently unfold it, care is taken not to touch other parts. Hands
are inserted into the sleeves. Then ask the assistant to tie the
gown across the back. Lastly string at the cuff is tied around the
wrist or in some gown there is elastic crape in which no string is
required.
6. Gloves
a. Appropriate size is taken.
b. Pick left glove by right hand from its folded part. Pull it ones the
finger of the left hand is in.
Figs 19.2A to C
c. Now pick-up right glove by left gloved hand, insert the fingers
in the folded portion so that it may not touch the other hand,
then it is pulled over the right hand, cover the other sleeve gown
by other hand.
d. Gloved hands are held in front of the chest.
e. Do not put the gloved hand in the axilla, as that area is sweaty
and may contaminate the gloves.
PREPARATION OF INSTRUMENT TROLLEY

• The instruments should be very well arranged in the manner so
that there should be no hodge podge when required.
• Trolley is covered by double sterile trolley sheet with rubber sheet.
• The instrument are kept in their respective places at all time and
when they are replaced when necessary, to avoid wasting time
looking for a particular instrument when needed.
• For example, they can be arranged in this order.
First Trolley
Scapel ( knife) Artery forceps Needle holder

Kidney tray Allis forceps Scissors
Diathermy point Babcock forceps Dissecting forceps
Bowl for saline and
Povidone Iodine
Suction Tip Retractors
Second Trolley
Gauze Sutures Gowns
Laparotomy pads Bowl Towels
Drapping sheets
Fig. 19.3
TROLLEY FOR LAPAROSCOPIC SURGERY
All laparoscopic instruments are very expensive and delicate, should
be handled gently and carefully.
They are arranged like:
First Trolley
Trocars All hand Camera

Knife with instruments Diathermy wire Light cord
Handle CO2 tubing Laparoscope
Veres needle Irrigation tube
Swabs, gauze
Second Trolley
Gowns Cattle for hot water

Towels Needle holder Bowl for povidone
Drapping sheets Allis forcep
Towel clips Artery forcep
Sponge holder Dissecting forcep
Similarly for other operations of orthopedics, ENT should be

arranged in the same manner with different instruments needed in
different specialty operations.
INSTRUCTIONS FOR ASSISTANT OR SCRUB NURSE

1. All swabs packing, laparotomy pads, number must be counted
and noted before starting the operation and check before the
closure of wound (especially abdomen and thorax).
2. All instruments are taken after counting.
3. It is her/his responsibility to provide the surgeon with any
instrument he requires.
4. Scrub nurse must know the steps of operation so that she must
anticipate that which instrument is required.
5. Contaminated instruments are kept away from the operative field.
6. Sharp instrument (knife) is kept in kidney tray or away.
7. The instruments, are placed firmly on surgeon’s hand, their points
or cutting edges should be directed away from him.
8. The instruments are handed over in such a way that the surgeon
can use them without readjusting their position to avoid
unnecessary time.
9. If a needle is mounted on a needle holder, it should be handed
over with the needle facing left hand of a right handed surgeon.
10. Positions of scrub nurse, surgeon and assistant
i. The surgeon makes position himself where he will be most
comfortable while performing the procedure.
ii. First assistant should stand on opposite side.
iii. On the same side as the theatre sister or scrub nurse on the
left or right of the surgeon if additional assistants are required.
11. Prepared instrument trolley should be covered with sterile sheet
till the operation starts.
12. Position and height of the table should be according to the
surgeon's comfort- usually height should be at the level just below
the elbow height of surgeon so that hand and forearm movements
are free.
13. If the position is not suitable for the assistant or nurse, a small
foot stool may be used.
PAINTING AND DRAPING THE OPERATIVE FIELD

1. Patient's skin is scrubbed with antiseptic solution where operation
is to be performed.
2. It is usual to perform two wash/painting on each occasion-start the
area of the incision planned and then spreading radially around
this, so that there is minimum contamination of the area of the
incision.
3. Particular attention must be paid to the umbilicus because of a site
of contamination. It should be thoroughly cleaned.
4. A large area should be painted, to decrease the chances of
contamination and if required for extension of the incision.
5. Sterile drapes are then placed to cover all the body except that part
to be used for incision. The minimum area of skin should be left
exposed.
6. Towels should be clipped in place, using towel clips, care should be
taken that clips should be passed through the drapes only, not into
the skin of patient.
FUNCTIONS OF ASSISTANTS DURING OPERATION

Mopping
• Keep the operating field dry and free of blood and body fluid by
careful use of pads, swabs, packs.
Fig. 19.4
Fig. 19.5
Fig. 19.6
• Gently press the area by swab or pack, do not rub it (as rubbing will
remove any blood clot which has formed at the end of bleeding
vessels).
• Sudden bleeding should not be dealt by blind and sudden application
of artery forceps, into the depth of wound. Gently press it with the
pad and then catch the bleeder only, otherwise you may damage
other associated vital structures.
• Swabs, packs should be rinsed with normal saline as it will mop up
cleanly and better than dry pads.
Suction Device
The field may also be kept clean by careful use of surgical suction device.
It is important to avoid sucking viscera, omentum (it may go into the
sucker).
Direct sucker on bleeder should be avoided.
Diathermy/Electrosurgery
• Vessels coagulation is achieved by the use of electrosurgery (passing
intermittent current) from a point electrode to the metal forceps
holding the specific vessel which is bleeding.
• Precautions
i. A diathermy plate must be applied to the patient to provide
earthing otherwise it may burn the patient as well as surgeon.
ii. No other part of the patient should be in touch with metal
part of OT table, IV stands, etc.
iii. Diathermy should not be applied to skin or skin flaps as this
may cause skin burn.
iv. The area surrounding the point to be diathermied must be
dry, there should be minimal amount of fat.
Retraction
• It is done to provide an adequate exposure of the operating field.
Although self retaining retractor and fixed retractor are there for
exposure.
• While retraction, assistant must be aware that tissue are to be
handled carefully and not to damage or tear the tissues and organs
and bowel by aggressive retraction.
• Hold the retractor gently in the position indicated by the surgeon.
• Assistant must not lean on the patient’s chest or arm.
• Retractors blade may be wrapped to avoid injury.
Ligation of Vessels
• When there is large vessel in the field which should not be
diathermised as it may bleed later on, so it must be ligated. Tie off
the vessel by using a square (reef) knot.
• Avoid undue tension and traction on the vessel as this will increase
the risk of slipping or pulled off the ligature and secondly it may
cause avulsion of vessel.
Fig. 19.7: Method of making skin incision

and of arresting hemorrhage
Fig. 19.8: Method of tying off a bleeding point
Use of Hemostatic Agents

• Gelatin foam (Surgicel or gel foam) is used where no bleeding point
can be identified but oozing is more and not controlled by pressure.
For example in the liver.
• Bleeding from bone edges is controlled by applying bone wax.
Choice of Suture Materials

• Absorbable sutures are used where great tensile strength is not
required.
• Cutting needle is used for passing through in, fascia or scar tissue
or tough tissue.
• Round body needle is used for softer tissue where it is necessary to
ensure the smallest residual hole possible, e. g. in bowel anastomosis.
• Within the body cavities silk may be cut shorter but in catgut longer
margin must be left to prevent undone of knot as catgut tends to
swell when it comes in contact with blood or body fluids.
• For repair of defect in case of hernia or where longer tensile strength
is required, nonabsorbable sutures is used. There should be multiple
knots as the memory of this suture is short.
• Skin is closed by silk thread or by metal clips.
• Before applying skin suture there should not be any dead space
(future site of collection).
Peritoneal Toileting
• If there is a contamination of peritoneal cavity (e.g. perforated
viscera) it must be washed thoroughly to remove the contamination.
It can be done by using diluted povidone iodine, tetracycline solution
(one gm in one liter normal saline). The fluid is allowed to go into
the recesses of the abdomen by exploring by hand and trapped debris
is aspirated.
• The priority in all cases of peritonitis is rapid evacuation of toxic
exudates by suction.
• Discard all the swabs, pads, packs from the surgical field.
Completion of Operation
It is an honest duty of assistant to count the swabs, packs, instruments
before the final closure of the cavity.
• Re-check to ensure that hemostasis is adequate.
• Position of the drain is also checked, it should remain in correct
place.
• It is important that the drain is stitched in position at an early stage
to avoid dislodgement. It has not become compressed when passing
through the surface stab incision.
Method of Closure
• There is no hard and fast rules about closure, it is the surgeon's
choice.
• There may be single layer closure or closure in layer by layer
(anatomical closure).
Fig. 19.9: Layer closure of all deeper abdominal wall layers with continuous Prolene
stitches, strengthened by interrupted tension stitches (now rarely used)
Figs 19.10A and B: (A) Continuous overhand suture

(B) Continuous blanket suture
Figs 19.11A and B: Correct method of suturing. The needle is introduced vertically
through the skin, and traverses the entire thickness of subcutaneous tissue
• Tension sutures—when there is doubt of wound dehiscence (in case

of peritonitis) tension sutures may be applied to give extra-strength
to the wound closure. These are made of non-absorbable strong
material sutures and are taken deeply and tied with the aid of a
polythene cover to avoid the risk of being tied to tightly.
Dressing
• Antiseptic dressing (ASD) is done which may be occlusive dressing
or (sealed) nonocclusive, according to the operation performed.
• Any drain if used is fixed properly, it should not be kinked or bent.
Care of Instruments
It is very important to care the instruments. Basic thing is:
• Respect your instrument otherwise they will not respect you.
• All the instruments must be properly cleaned and wipe off (make
them dry) and keep in respective tray.
• Delicate things like camera, light cord, diathermy wire, electrodes,
loops, resectoscope, urethrotome, uretroscope, etc. must be handled
first and delicately and keep them safely before the other
instruments.
Record Keeping
• Ensure the entry in OT register, with all the relevant information,
should be checked by senior person.
• Postoperative orders should be passed to postoperative ward staff.
• Label any pathological or bacteriological specimens and send it to
respective lab.
Surgery is a team work, it is the responsibility of all attending persons not
only the surgeon’s responsibility. Do it in a cool, active, honest and responsible
manner, best possible results will be in your hand.
20 Postoperative Care
The postoperative (PO) care of operated patient is very essential in

post operative ward or in recovery room. Few hours immediately after
the operation, during which acute reaction to operation and the residual
effects of anesthesia subside. A recovery room with special staff,
equipment and necessary medicines are usually provided for this
purpose. The major cause of early complications and death following
major surgery are:
i. Acute pulmonary,
ii. Cardiovascular, and
iii. Fluid derangements.
The patient can be discharged from the recovery room when
cardiovascular, pulmonary and neurological function have returned
to baseline, which usually occur 1-3 hours after operation.
Principles of postoperative care are:
1. Provide physiological support
2. Give adequate pain relief
3. Anticipate and take early action on complications
4. Maintain a good team communication regarding treatment plan
5. Regularly review the treatment plan.
General Postoperative Daily Check-up

General look of patient and conversation with patient, tells us a lot of
things, so always spend sometime.
Check what Looking for what
1. Hello to patient Assess, consciousness and morale
2. General look Difficulty in breathing, pain, shock,
cyanosis, jaundice, hydration status
3. Pulse and BP chart Shock
4. Temperature chart Fever
Postoperative Care 203
5. Urine output and skin Hydration state
and tongue
6. Back Pressure sores
7. Wound Infection and discharge
8. Ask the patient to cough Chest infection, pain
Taking the patient’s hand will be an opportunity to check peripheral
perfusion. Temperature chart may give warning of infection but short
period of pyrexia may occur after major surgery. A persistent pyrexia
requires some investigations, that includes—urine, sputum, blood and
radiological and clinical examination. Wound must be checked with
full sterile precautions. A decrease in oxygen saturation or tachypnoea
is most commonly due to basal atelectasis as a result of general
anesthesia and subsequent sedation. Every acutely ill patient requires
oxygen. A patient who has just undergone abdominal surgery should
be told to expect some discomfort on movement or coughing despite
analgesia. Sudden onset of severe abdominal pain is an important
symptom—it may indicate an acute intra-abdominal event and should
never be ignored. It may be due to:
i. Anastomotic breakdown
ii. Perforation
iii. Bleeding
When there is low urine output – the most common cause is
hypovolemia,
• Check that the catheter is not blocked.
• Furosemide should not be given for low urine output until the patient
is adequately hydrated.
Postoperative Orders/Care
All orders must be written and revised daily according to the patient’s
progress and patient’s condition. PO care should cover the following:
1. Position of the patient—If specific for a specific operation like
• Head turn to one side
• Lateral position
• Fowler’s position
• Any special position for orthopedic surgery
2. Warming of patient
• Application of hot water bottle
• Patient should be covered by blanket
3. Mobilization—Early ambulation is encouraged to reduce venous
stasis.
Venous stasis should also be minimized by elastic stocking or by
a pneumatic device.
4. Care of tubes—like
i. Nasogastric tube suction (Ryle’s tube) intermittent or
continuous.
ii. Drains—like intra-abdominal drains, intercostals tube
drainage, vacuum suction drain- should be checked for
amount and nature of fluid and properly fixed.
iii. Foley’s catheter—amount and color of urine should be
checked time to time.
iv. Colostomy bag, etc.
5. Vitals—pulse, temperature, respiration, BP, CVP should be
checked regularly as advised by surgeon.
6. Day of operation—should be written on the top of PO treatment.
7. Diet—NBM, when to start fluid soft diet or normal diet should be
strictly followed.
8. IV fluids and electrolytes—fluid should be given as charted which
is based on maintenance and replacement of losses from (i) fistula,
(ii) drain, (iii) urine output, (iv) Ryel’s tube suction, etc. Any special
electrolytes should be added or not.
9. Medication—analgesics, antibiotics, anti-emetics, sedatives
• Other medications like corticosteroid, hemostatic, vitamin K,
bronchodilators.
10. Respiratory care—In early PO period patient may be needed—
oxygen by mask or nasal prong.
11. Blood transfusion—If blood is required postoperatively, it should
be followed as instructed by surgeon.
12. Physiotherapy
• By incentive spirometry
• Deep breathing exercise
• Change of position and turning of patient
• Free movements of limbs
This helps to reduce the pulmonary complications (like
pneumonia, atelectasis) and venous stasis. All these help in early
recovery of patient.
13. Care of wound
• Note any soakage in dressing.
• Dressing over clean wound is sealed and removed on 3rd or
4th postoperative day.
• Dressing should be changed if soaked /wet, because soaked
dressing increase bacterial contamination of the wound.
14. Any investigation—Any postoperative investigation like blood
sugar, urea, creatinine, CBC, urine examination, electrolytes, CXR
should be carried out as per advised by surgeon.
Postoperative Care 205
15. Removal of any packing—wound packing, rectal or vaginal
packing.
16. Always check for
• Abdominal distention
• Bowel sounds
• Air entry into both the lungs—that should be equal and normal
on both the sides.
17. Cleanliness—postoperatively patient’s cloths, bed sheet and all
must be neat and clean.
18. Oral hygiene—keep the mouth clean with lukewarm water,
brushing, by gargles. In GA with endotracheal tube insertion and
by Atropine - there is lack of secretions and throat irritation.
19. Removal of sutures—removal of sutures depends upon which
type of sutures has been applied and in which part of surgery
was performed.
20. Return of work—a certain time is needed after removal of stitches.
Then he/she is advised for light work or routine work according
to the type of surgery performed.
Most important is always listen the patient’s problem very carefully . Behavior
with the patient must be well mannered, polite way and try to solve his/her
problem.
POSTOPERATIVE CARE OF GIT

After laparotomy, peristalsis of GIT decreases. Peristalsis returns in
the small intestine within 24 hours. Gastric peristalsis returns more
slowly. In right colon it return by 48 hours and in the left colon by
72 hours.
In the immediate postoperative period if there is distention and
vomiting, it should be decompressed by nasogastric intubation (NGA
or RTS/ nasogastric aspiration or Ryel’s tube suction).
The NGA should be connected to low intermittent suction and
irrigated frequently to ensure its patency. The nasogastric tube enhances
gastroesophageal reflux. It is clamped for overnight to assess the
residual volume but there is greater risk of aspiration.
Once the Ryel’s tube is withdrawn, fasting is usually continued for
another 24 hours. After that patient is started on a liquid diet. Opioids
generally interfere with gastric motility and should be stopped in
patients who have an evidence of gastroparesis beyond the 1st
postoperative week.
Gastrostomy and Jejunostomy Tube Care
These should be connected to low intermittent suction or dependent
drainage for the first 24 hours after surgery. Absorption of nutrients
and fluids by small intestine is not affected by laparotomy. So enteral
nutrition through a jejunostomy feeding tube may be started or the
second postoperative day even if the intestinal motility is not entirely
normal. These tubes should not be removed before the third
postoperative week, because firm adhesions should be allowed to
develop between the viscera and the parietal peritoneum.
Stoma Care
Ileostomy
The ileostomy does not usually act for 12 to 24 hour after operation. It
may act then profusely. Sudden and unaccustomed loss of small bowel
contents may lead to dehydration and salt depletion. For this reason
IV fluids should be maintained for at least first two postoperative days.
It is most important to prevent excoriation of the skin by ileostomy
efflux and for this purpose a collecting appliances (ileostomy bag)
should be fitted immediately after the operation. After a week or two,
the discharge becomes more solid and relatively odorless. Physiologic
changes after ileostomy are due to loss of water and salt absorbing
capacity of the colon. Thus, these patients are susceptible to salt and
water depletion. Patients with unusually high ileostomy outputs may
need supplemental potassium in the form of bananas or orange juice.
Patient must be informal about these physiological alterations and
measures to compensate for that. A low residue diet should be advised
at least initially. Certain foods (e.g. eggs, fish, cold drinks) may cause
excessive gas and odor.
Colostomy
It is just like the management of an ileostomy. This has been made
much easier by the well fitting disposable bags. Efflux from colostomy
unlike a water tight junction between skin and collecting appliances is
by no means so necessary.
Postoperative Fluid
21 Therapy
It is not possible to measure the exact fluid deficit, so replacement is

carried out on a trial bases. Overloading of fluid should be avoided.
The clinical response to this fluid is monitored and dose can be repeated
if desired clinical effects of the deficit are reversed. This fluid can be
monitored by clinical examination.
1. Rise in BP
2. Fall in pulse
3. Normal urine output
4. CVP to normal levels
For patients requiring IV fluid replacement for a short period, it is
not necessary to measure serum electrolytes during the postoperative
period. But it is indicated in more complicated patients – those with
extra fluid losses, sepsis, pre-existing electrolyte abnormalities or other
with serious problems.
As a rule 2 to 2.5 liter of five percent dextrose in normal saline or
lactated Ringer solution is given daily. Potassium should usually not
be added during the first 24 hours after surgery, because increased
amounts of potassium enter the circulation during this time, as a result
of operative trauma and increased aldosterone activity.
Postoperative patients tend to have an impaired free water clearance
due to the effects of trauma, stress and infection. If dextrose is used
exclusively, postoperative hyponatremia with serious CNS
complications may result. Two bags of five percent dextrose to one
normal saline is the preferred regimen. After 24 hours alternate bags
of five percent dextrose to one normal saline is the preferred regimen.
After 24 hours alternate bags of saline and dextrose saline with
supplementary potassium (at least 20 mg) give the best balance.
Water accounts for 60% of normal body weight the remainder being
fat and ash. In a 70 kg man total body water (TBW) is therefore 42 liters.
This is distributed according to the rule of thirds—two-thirds of TBW
28 liters is intracellular (with high potassium and low sodium
concentrations) one-third of TBW 14 liters is extracellular (with high
sodium and low potassium concentration) ECF compartment is further
divided into two-thirds extra vascular, one-third intravascular.
Extravascular deficit is treated with saline. Intravascular fluid deficit
is ideally treated with colloid (best of which is blood).
Principles of postoperative fluid therapy is for:
1. Maintenance
2. Ongoing losses
3. Deficit
Maintenance
In an average adult, average fluid intake is about 1.5 ml/kg/hour that
is 2.5 lit/day.
For children one can use the simplest rule of thumb method to
calculate their requirement is 4, 2, 1 rule
• for the first 10 kg – 4 ml/kg/hour
• for the next 10 kg – 2 ml/kg/hour
• for the next 10 kg – 1 ml/kg/hour
• for each additional kilogram – 1 ml/kg/hour
For example, the maintenance fluid requirement for a 30 kg child
would be 70 ml per hour.
• 4 ml/kg/hour for first 10 kg = 40 ml/hour
• 2 ml/kg/hour for next 10 kg = 50 ml/hour
• 1 ml/kg/hour for remaining 10 kg = 10 ml/hour
• Total 70 ml per hour.
Ongoing Losses
Continuing fluid losses may be predicted by the type of surgery and
measure the losses in vomitus, diarrhea, blood loss, drain, urine output.
The insensible losses can be doubled for every degree rise in temperature
in a pyrexial patient.
Deficits
Fluids deficit may be difficult to estimate. Clinical examination may
reveal:
1. Reduced skin turgor, dry mucous membrane, dry tongue and lips.
2. Sudden weight loss.
3. Tachycardia and orthostatic hypotension, indicating intravascular
fluid depletion.
4. Persistent oliguria.
Postoperative Fluid Therapy 209
The success of fluid therapy may be judged by—Pulse, BP, urine
output and CVP.
• Extravascular deficit is treated with saline.
• Intravascular fluid deficit is ideally treated with colloid, the best of
which is blood.
Third Space Losses

As a result of:
i. Tissue trauma,
ii. Inflammation
iii. Infection
iv. Edema
The volume of the extravascular extracellular fluid increases, taking
water and sodium from the intravascular compartment. Third space
losses may be considerable and are often underestimated. If an organ
with a large surface area such as the bowel, is handled and traumatized,
even very small degree of edema can increase the extravascular volume
considerably. Just one mm of edema occurring over 5 m2 of bowel would
result in third space losses equivalent to five liters of extracellular fluid.
• Septic shock expands the vascular compartment.
• Third space loss expands the extracellular compartment.
There may be no need to supplement with potassium in the
immediate postoperative period because the high levels of ADH will
lead to potassium conservation at this time.
Dextrose will produce hyponatremia in a postoperative patient.
Alternate bags of saline and dextrose saline with supplementary
potassium give the best balance.
Which Fluids Go Where

Intravascular compartment—is the port of entry for IV fluids
administration. Colloid solutions like blood, gelatin solution, albumin
remain in this compartment because the capillaries are impermeable to
the colloid. Water will then be retained by osmosis. For example, if one
liter of colloid is infused to a shocked patient with an intravascular
volume will be four liters, an increase of 33%.
EXTRAVASCULAR (INTERSTITIAL) COMPARTMENT

The capillary wall is freely permeable to sodium and water, while the
cell membrane is freely permeable to water but not to sodium. If 0.9%
NS is infused, the sodium will pass freely out of the vascular
compartment but remains in the extravascular compartment. Since
normal saline is isosmolal, the water will remain with the sodium, 0.9%
NS thus expands only the extracellular compartment.
If one liter of 0.9% NS is administered to an acutely shocked patient
with an intravascular fluid volume down from 4 to 3 liter, it will initially
expand the intravascular volume by an amount dependent on its rate
of infusion. However, since the capillary endothelium is permeable to
both sodium and water, the liter of normal saline will soon equilibrate
with the extravascular compartment. Thus, it increases intravascular
volume by eight percent.
INTRACELLULAR COMPARTMENT
This is the largest single compartment. The cell membrane is freely
permeable to water and dextrose but impermeable to sodium. If one
liter of five percent dextrose is administered to an acutely shocked
patient with an intravascular volume of three liters, it will initially
expand the volume of this compartment by an amount dependent on
its rate of infusion. Since the capillary endothelium is freely permeable
to water and dextrose, the infused fluid will distribute homogenously
throughout the extracellular compartment (as normal saline). In a short
period of time all of the infused dextrose will be metabolized, leaving
only water. This reduces the osmotic pressure of the extravascular fluid,
thus allowing water to pass through the cell membrane into the
intracellular volume by 2.5%.
When resuscitating an acutely shocked patient in whom perfusion
is compromised, it is critical to expand the intravascular compartment.
From the above description it is clear that only colloid or blood produces
a sustained and significant expansion of this compartment.
• Colloid stays in the vascular compartment.
• Saline stays in the extracellular compartment.
• Dextrose eventually goes into all compartment.
Postoperative
22 Complications
The common postoperative problems which is encountered are:
SHOCK
It is one of the most possible complication after surgery.
Signs and Symptoms

i. Perspiration (sweating)
ii. Pulse becomes feeble, slow and then become fast
iii. Blood pressure-comes down (systolic BP less than 100 mm Hg)
iv. Patient becomes restless temperature—low
v. Skin—cold and moist.
Treatment
i. Rest—Trendlenburg position (foot end elevation with blocks—
i.e. head down position)
ii. IV fluid/blood transfusion
iii. Oxygen inhalation
iv. Relief of pain
v. Vasopresor—if indicated.
HEMORRHAGE
It may be internal—when it takes place in the peritoneal or other cavities
and external when it is seen on the surface. It can be arterial, venous or
capillary.
It also depends upon the time at which it occurs.
i. Primary—when it occurs at the time of surgery.
ii. Reactionary—it is due to raised blood pressure or slipping of
tied node on vessels, by increased intra-abdominal pressure
due to vomiting, coughing. It occurs within 24 hours of
surgery.
iii. Secondary—It occurs few days after surgery (usually between
6-10th postoperative day). It is almost always due to sepsis.
Signs and Symptoms

• Low temperature
• Low BP
• Tachycardia (fast pulse)
• Sweating
• Pallor
• Yawning
• Sighing respiration
Treatment
• Nurse should make regular check-up to note any change in vitals
and conditions of the patient.
• Inform to surgeon.
• Blood transfusion.
• Patient is taken to theatre and vessel is ligated.
VOMITING
Vomiting may occur after the operation due to medication. It should
be treated by medications. It should be treated by giving—Inj. Ranitidine
or Inj. Ondansteron or both.
Postoperative Pain
Severe pain occurs especially after intrathoracic, intra-abdominal and
major bone operations. There should be no pain after operation, as it
increases the chances of pneumonia and atelectasis because of patient
may be reluctant to take deep breath. Postoperative pain also causes
vasospasm and hypertension which may lead to heart complications
like stroke and MI. Thus, prevention of postoperative pain is very
important.
Management of Postoperative Pain

Postoperative pain not only unpleasant to patient but it may affect the
other systems as well as endocrine changes which are:
1. Tissue trauma and infection produce a characteristic elevation in
the level of growth hormone, cortisoil, catecholamines and ADH.
This is referred as “stress response” to surgery. The result of this
includes increased protein catabolism results into depressed immune
Postoperative Complications 213
function, reduced resistance to infection subsequently inhibition of
tissue healing.
2. In case of upper abdominal or thoracic surgery due to pain there is
impairment of pulmonary function which leads to basal atelectasis,
mucous plugging and subsequent bacterial infection.
3. The simplest and most effective prophylaxis against thromboembolic
disease in the postoperative period is early mobilization. Adequate
analgesia is needed to achieve this. The sympathetic adrenergic
response to pain results in increased cardiovascular stress and
increases platelet adhesion. This explains the relatively high inci-
dence of preoperative myocardial infarction and thromboembolism.
4. Delayed gastric emptying is common and affects non bowel surgery
almost as much as that involving the GIT. Postoperative opioids as
well as pain itself have an effect.
Some other factors which may cause postoperative pain
1. Superficial and peripheral sites tends to produces less pain than
deep and central sites.
2. Upper abdominal and thoracic incisions are typically associated with
severe pain.
3. Muscle cutting produces more pain than muscle splitting.
4. Movement at a wound site exacerbates pain. Immobilization when
splinting a long bone fracture dramatically reduces pain.
5. Clearly, pain itself may result in further anxiety and low mood, so
potentiating its own perception. This can lead to vicious cycle of
pain. This should be prevented by good pain management from the
outset since it is difficult to stop once it has begun.
Treatment
• Opioids—like Morphine, Pentazocine, Tramadol-IM are the mainstay
for PO pain.
• Nonopioids—Ketorolac 30 mg IM—its efficacy is equally good to
Morphine and main advantage over is it causes no respiratory depre-
ssion.
• Other agents
– Inj. Hydroxyzine
– Best is Inj. Ketorolac and Inj. Hydroxyzine
• Ibuprofen is one of the cheapest, most effective and safest NSAID.
• Retention of urine: It is common after spinal anesthesia especially in
old age. Following trial should be given before catheterization.
– Change of posture
– Hot water bag over lower abdomen
– Provide privacy
– Inj. Carbachol 1 ml IM.
If all these measures fail then catheterize the patient.
• Abdominal distention: It is due to gas collection in the intestine
following laparotomy, GIT peristalsis temporarily decreases, it takes
time to return.
– In immediate postoperative period, the stomach may be
decompressed with a nasogastric tube.
– Flatus tube may be passed to releive the distension.
• Phlebitis: Inflammation of superficial veins where IV cannula is
inserted. Symptoms are induration, redness, edema and tenderness.
– Remove the cannula
– Local application of heparin ointment.
• Postoperative fever: Most common causes of postoperative fever are:
i. Atelectasis
ii. Phlebitis
iii. Urinary tract infection (usually by catheter).
IN NUTSHELL
i. If fever occurs within 48 hours after the surgery, it is usually caused
by atelectasis.
ii. If fever occurs after 48 hours of surgery, it is due to-Phlebitis,
Pneumonia, Urinary tract infection (UTI).
iii. If fever occurs after fifth day of surgery, it is usually due to—
Wound infection, Anastomotic leakage, Intraabdominal abscess.
23 Cryosurgery
INTRODUCTION
Cryosurgery (Cryo-cold) by cryogenic technique it has become possible
to freeze limited areas of living human tissue in many parts of the body.
Such tissue, after being frozen becomes solid, undergoes a gradual
necrosis, due partly to thrombosis of the microcirculation.
Use
• Hemorrhoids
• Polyp
• Erosion cervix, etc.
One of the great advantage is, it is suitable for application to
outpatients without anesthesia.
Equipment
The essential item is the cryo probe, which has an active end 3 to 4 cm
long, capable of being cooled by circulation through it of liquid nitrogen
or nitrous oxide gas. Liquid nitrogen can produce a reduction of
temperature to 180°C as compared with 70°C with nitrous oxide gas.
Advantages
• Easy to perform
• No hospitalization
• No anesthesia
INFRARED COAGULATION (IRC)

One of the latest innovation in the treatment of internal hemorrhoid is
coagulation by infraradiation. IRC has a 14 to 15 volt tungston – halogen
lamp. The light is reflected by a 24 carat gold plated surface and carried
through a quartz glass guide to a sapphire contact tip. The temperature

at the tip reaches 100°C, which causes coagulation. Depth of coagulation
is determined by the time of exposure. The automatic time range is 0.5
to 3 sec giving a coagulation depth range of 0.5 to 2.5 mm. The working
setting is between 1 and 1.5 sec to give a depth of one mm.
Use
In hemorrhoids.
The tip of IRC is placed in firm contact with base of hemorrhoid.
The tip should not be embedded in the tissue. A circular whitish eschar
will appear on the mucosa after each exposure. 3 to 5 exposure are
made in a semicircular around the base of hemorrhoid, allowing a gap
of few mm between each. The tip is wiped with moist gauze after each
exposure. A white area of burn is identified after completion of the
treatment.
Advantages
• Fast and easy to perform
• Easy on the patient
• No hospitalization
• No anesthesia
• No discharge after the treatment.
Uses
• Hemorrhoids
• For arresting hemorrhage
• Warts
• Tattoos
• Chronic rhinitis – turbinate hypertrophy
• Benign disease of cervix
• Angioma
• Port wine stain.
Application of
24 Plaster and Splints
Plaster is used to immobilize the joints or part.
PLASTER TECHNIQUE
Preparation of Plaster Bandages
Plaster of Paris (POP)—It is anhydrous calcium sulphate soaked in
water. It absorbs water and thereafter as it dries and becomes tough
and hard mass.
POP bandages are available readymade but it is costly. It can be
prepared at the center.
Equipment
• Gauge bandage 500 cm long and 15 cm wide.
• POP powder.
• Gloves.
Technique
• Place the rolled bandage on a dry table.
• Unroll the bandage according to the size required. Apply the POP
evenly to the surface of bandage. Gently but firmly rub the powder
into the mesh of the cotton bandage. Once this is done, carefully roll
up the powdered length of bandage and begin the same process
again with a new section of bandage. Continue till the whole bandage
is impregnated with POP. The weight of an average plaster bandage
should be 85 to 90% plaster. This plaster bandage can be used
immediately or stored in a dry place for future use.
• To prepare a plaster slab, unroll the required length of plaster
bandage and superimpose layer upon layer to the required thickness
usually 6 to 12 layers are necessary.
• For a small size, first make a thin slab and then fold it accordingly
along its length.
Figs 24.1A to K: Application of plaster bandages. Identifying the bony landmarks (A); taking
measurement (B); applying a padding of cotton wool (C,D); measuring plaster bandage and
superimposing and trimming several layers for a plaster slab (E-G); soaking the plaster bandage
(H, I); application of plaster bandages (continued). Squeezing the bandage (J); applying the
plaster bandage the forearm over the cotton wool (K).
Application of Plaster and Splints 219
Figs 24.1 L to Q: Applying and moulding a plaster slab (L, M); folding the margins of the
plaster after applying a further layer of plaster bandage (N, O); application of plaster cast
completed (P, Q)
Figs 24.2A and B: Making a plaster bandage. A cotton gauze bandagae is unrolled as
plaster powder is applied to the surface (A); Rolling the powdered gauze (B)
HOW TO APPLY A POP
Procedure for POP Slab
• If there is soft tissue swelling then POP slab should be applied
posteriorly.
• If there is doubt in circulation of a limb apply only a POP slab.
• Identify the bony landmarks.
• Take the measurement for the size of slab.
• Clean the skin and dry it and also clean with surgical spirit.
• Apply cotton wool with a uniform thickness 0.5 to 1 cm all around
the area where slab is to be applied.
• Apply extra layer of cotton pad on bony prominence.
• Prepare the plaster slab according to the size.
• Soak a plaster slab in water at room temperature. Keep in water
until air bubbles cease to rise means it is saturated with water.
• Gently pick it up with both the hands and lightly squeeze it (not
twist it).
• Ask your assistant to hold the part of body where it is to be applied
in the correct position.
• Apply it gently but rapidly without any break, posteriorly.
• Rub each layer firmly with the palm to make it homogeneous.
• Apply wet bandage around it.
• Now mould the plaster evenly around the bony prominances and
contours.
• At least three centimeter of cotton should be left above and below
the margin of the plaster (to protect the skin against friction).
For Plaster Cast

Apply plaster bandage soaked in water by winding it round the
padding. Continue till your desired thickness is achieved by gently
folding over the sharp margins of the cast leaving the cotton padding
exposed.
• Continue moulding the plaster until it sets.
• When plaster begins to stick your hand it mans we should stop.
Conversion of POP Slab to Plaster Cast

• To form a complete plaster cast.
• Apply a light and uniform layer of plaster bandage by winding it
round the already applied slab.
Instruction to be given to the Patient after
Applying the POP Slab/cast
1. Do not cover it with any other thing.
2. Let it dry in sun or hot air (wet plaster tends to break).
3. Exercise all the free joints especially those of fingers, toes, shoulders,
elbow and knee, otherwise joint may stiff.
4. If there is any impairment in the circulation or feel more pain, report
the doctor immediately.
5. If hospital is far away and patient feels pain or impairment in
circulation - advise him/her to soak in water to soften the POP and
then cut it through the plaster including the cotton. Keep it in
alignment temporally by loosely applying bandage and report the
doctor as soon as possible.
TECHNIQUE OF PLASTER REMOVAL

Equipment
• Plaster saw manual or electric
• Shear
• Plaster scissor
• Plaster spreader
• Scalpel handle with blade
Technique
• Feel the weakest or thinnest border of POP slab/cast
• Use shears to cut through the plaster
• Start it from one edge and then loose it with a plaster spreader,
continue till all plaster is cut.
• If you find any difficulty in case of very hard plaster, allow to soak
in water and wait for 15 to 20 minutes till it softens then remove it
like a bandage or cut with scalpel knife.
SPLINTS
Splint is an appliance for preventing movement of a joint or for fixation
of displaced or movable parts.
Types of Splints
Most commonly used splint is Thomas splint. It is made up of rigid bar
extending from a ring at the hip to beyond the foot, allowing traction
to a fractured leg for emergencies and transportation.
Figs 24.3A to F: Splitting a plaster cast. Splitting a newly applied plaster cast with a scalpel
(A); a plaster spreader (B) Or stout scissors (D) are used to open up the gap in the plaster
cast; dividing the underlying cotton wool with a pair of blunt, angled scissors (C, E) and then
holding the split plaster with an elastic bandage (F)
Technique/Method
• Measure the limb for selecting a splint of suitable size.
• Apply skin traction assembly. Then put the Thomas splint in the
limb (ring must be well padded). Long ends of strands of skin traction
are tied at the lower end of Thomas splint with a good traction.
Figs 24.4A to E: Removing a plaster. Cutting and spreading the plaster using plaster
shears and a spreader (A to C); soaking a plaster before removing it (D, E)
Figs 24.5A to K: Stabilization (immobilization) of fractures. A padded plaster slab (A); Thomas
splints with and without slings (B, C); measuring the limb for selecting a splint of suitable size
(D-F); fixed skin traction in a Thomas splint (G); fixed skeletal traction in a Thomas splint (H);
fixed skin traction in a Thomas splint reinforced with a plaster cast (Tobruk plaster) (I);
stabilization with Steinmann’s pins and a plaster cast (J, K)
Figs 24.6A to G: (A) Airplane splint; (B) Cervical splint; (C) Plaster splint; (D) Banjo splint;
(E) ‘T’ splint; (F) Short convalescent splint; (G) Hodgen’s splint
25 Oxygen Therapy
Oxygen is one of the basic essentials for maintenance of life. It is taken

up from environment through lungs. It is carried to cells by blood with
attachment of hemoglobin as oxyhemoglobin. One gram Hb
(Hemoglobin) carries 1.34 ml oxygen. Thus, 100 ml of blood (with
normal Hb 14.6 gm %) carries about 19.8 ml of O2 when atmospheric
pressure is fully saturated. Atmosphere air contains 20% O2.
• Normal arterial O2 content is 18 to 21 ml O2/dl.
• PaO2 (Arterial oxygen tension) 75 to 100 mm
• PaCO2 (Arterial carbondioxide tension) 35 to 45 mm kg.
• SaO2 (Arterial Oxygen saturation) 95 to 100%.
• Minute ventilation (VE) 4 to 6 liters/min.
INDICATION OF OXYGEN THERAPY

All types of hypoxia.
Conditions are:
1. Ac respiratory distress syndrome (ARDS)
2. High altitude
3. Anemia
4. Carbon monoxide poisoning
5. Hyperthyroidism
6. Hyperpyrexia
7. Hypotension
8. Septicemia
9. Head Injury
10. Shock
11. Severe hemorrhage
12. Coronary thrombosis
13. Pulmonary embolism
14. Heart diseases
15. Chest injury
16. Rib fracture
Oxygen Therapy 227
17. During surgery
18. During general anesthesia
Hypoxemia
It is a condition in which arterial oxygen is low or decreased (PaO2 is
less than 80 mm Hg).
Hypoxia
It is a condition in which oxygen level at cellular level is low.
Hypercapnia
Abnormally large amount of CO2 in the circulating blood.
METHODS OF OXYGENATION OR OXYGEN THERAPY
Fig. 25.1: Manley ventilator

(Courtesy: BOC Medishield, England)
Oxygenation—addition of O2 to physical system.

The goal of oxygen administration is to facilitate adequate uptake
of O2 into the blood to meet the needs of peripheral tissues.
Oxygen therapy is given by different methods.
Nasal Prongs
There are two small prongs which are just inserted in the nose. It can
cause very less irritation and patient can tolerate it well. Patient is able
to eat, drink, and speak well when prongs are in place. It's disadvantage
is that the exact concentration of inspired oxygen (Fi O2) delivered is
not known. Flow rates should be limited to less than 5 liters/minute.
1 liter/minute of nasal prong oxygen flow is approximately equivalent
to a Fi O2 of 24%, with each additional liter of flow increasing the Fi O2
by approximately four percent.
Face Masks
These are available in black rubber or transparent mask, available in
different sizes 0 to 4 No. (Pediatric to adult size). It is well tolerated by
patient. If patient vomits, chances of aspiration are high. In case of
unconscious patient, patency of airway should be maintained. Use
transparent mask through which vomitus/secretion can be observed.
Mask may be simple with venture, with nonbreathing valve, with re-
breathing reservoir bag.
Venturi Masks
It allows the precise administration of oxygen. Usual FiO2 values are
delivered with these masks are 24%, 28%, 31%, 35%, 40% and 50%.
It is common in use because
• It prevents re-breathing and minimize CO2 retention.
• It is well tolerated by patient.
Fig. 25.2: Flexi mask

Oxygen Therapy 229
Fig. 25.3
• O2 toxicity is less as airtight fitting is not necessary so air gets mixed

with CO2.
• It is useful in COPD patients, and with hypercapnia.
Nonbreathing Masks
By this we can achieve higher O2 concentration (approximately 90%).
A one-way valve prevents exhaled gases from entering the reservoir
bag in a nonbreathing system to maximize the FiO2.
CPAP Mask (Continuous Positive Airway Pressure)

It is used if PaO2 is less than 65 mm Hg. During it's use patient is
conscious and cooperative, able to protect the lower airway, and
hemodynamically stable. CPAP is delivered by a tight-fitting mask
equipped with pressure limiting valves. Many patients will not tolerate
this mask due to feeling of:
i. Claustrophobia (fear of being in a closed place)
ii. Aerophagia (excessive swallowing of air)
iii. Persistent hypoxemia or
iv. Hemodynamically instability.
Initially, 3 to 5 cm H2O of CPAP should be applied while monitoring
the PaO2. If the PaO2 is still less than 60 mm Hg (SaO2 < 90%), then the
level of CPAP should be increased in steps of 3 to 5 cm H2O up to a
level of 10 to 15 cm H2O.
Bilevel Positive Airway Pressure (BiPAP)
It is a method in which inspiratory and expiratory pressure can be
applied by a mask during the patient respiratory cycle. The inspiratory
support decreases the patient's work of breathing. A pressure-support
ventilation (PSV) level of 5 to 10 cm H2O is reasonable starting point.
These noninvasive methods are useful in patients with:
i. Neuromuscular disease.
ii. COPD.
iii. Postoperative respiratory insufficiency.
Nonbreathing Masks
By this we can achieve higher O2 concentration (Approximately 90%).
A one-way valve prevents exhaled gases from entering the reservoir
bag in a non-breathing system to maximize the FiO2.
OTHER OXYGEN THERAPY DEVICE WHICH ARE USEFUL IN

PEDIATRIC PATIENT
Oxygen Tent
It is useful in un cooperative patients. Oxygen therapy can be
discontinued when feeding is to be given. It delivers 8 to 10 liter/minute
(50% FiO2).
Oxygen Hood
These are made of transparent Plexiglas hood of different sizes. Oxygen
therapy can be continued when feed is to be given. Three times a minute
volume gas flow is required.
Oxygen in Incubator
Oxygen in incubator is given to a child by this method, venture masks
principle works. It can provide FiO2 up to 40%.
Caution
Humidification and temperature of inspired air should be well
maintained.
Disadvantages
Oxygen concentration decreases whenever the incubator is opened.
Oxygen therapy by invasive procedure, e.g. endotracheal incubator,
Oxygen Therapy 231
• Oral and nasopharyngeal airways.
• Cricothyrotomy
• Cricothyroid needle cannulation (described in the emergency
chapter).
Oxygen Supply
Oxygen is given by above masks/methods is attached to central gas
supply system or directing from oxygen cylinder. In either of two,
oxygen cylinder is required. For central oxygen supply large cylinders
are used. In ward usually medium size cylinder is used.
Oxygen Cylinder
Color code is universally accepted for easy identification and safety.
These are available in different sizes. These are filled with oxygen under
high pressure about 1900 to 2000 lbs/square inch or 148 kg/cm2. It is
made up of strong and heavy metals, i.e. molybdenum alloy. Medical
O2 should have a minimum of 99.5% oxygen. It is commercially
prepared by fractional distillation of liquid air. In the cylinder it remains
in gaseous form.
Parts of Cylinder
It has body, shoulder and valve. Near to this valve there is pressure
gauge by which we can assess the amount of oxygen in the cylinder.
For easy transportation in the OT, ward, ICU a special stand with wheel
is there.
Figs 25.4A and B: (A) Spanner (B) Cylinder valve—flush type

Figs 25.5A to C: (A) Cylinder valve-bull nosed,

(B) Cylinder valve—straight type, (C) Cylinder valve—angled type
Humidification of Oxygen
It is very important to humidity the oxygen because it prevents the
drying of mucus membrane of respiratory system. Dry secretions forms
crust, which may cause obstruction of the airway. Further this humidity
air allows optimum functioning of mucosal lining of respiratory system.
Normally, breathed air should be 45% humidified. There are different
methods or devices for humidification of oxygen, e.g. bubble through
water.
1. Humidifier
2. Moisture exchanger.
Fig. 25.6
Oxygen Therapy 233
Fig. 25.7
Normally, humidifier is used. It is nothing but a glass bottle with a

cork is fitted with two openings one is inlet and other is outlet. Tubing
is attached to the outlet. Inlet pipe is dipped in water, so when valve is
opened, first it goes through the water and then through outlet. This
way it is humidified. There will be bubbles when cylinder is on. Thus,
in this way it is checked that if bubbles stops coming up means either
the cylinder is empty or valve is closed. Normally, 3 to 5 lit/minute
flow is maintained.
Precautions
1. No inflammable things should be near to oxygen cylinder, and it
should be kept in cool place, away from heater, sunlight.
2. Valve should be checked regularly for leakage.
3. Pressure should be checked regularly.
4. Valve should be opened very slowly as oxygen in the cylinder is
under a very high pressure.
5. When it is not in use close the valve tightly.
6. Bolt, valve, bottom and junction of cylinder and the color of cylinder
should be checked carefully before you take the delivery.
7. Tag should be put on cylinder about date of use.
8. Any lubricant or oil should not be used on the valve or other fittings
of the cylinder. O2 under pressure may cause ignition with oil or
grease.
9. Leakage can be checked by soap water or savlon on a sponge. If any
leakage is found, check or tight the main hexagonal nut.
Untoward Effects of Oxygen Therapy

Although it is essential but if it is given in large amount and pure it
may cause some adverse effects.
1. Convulsion—when it is given rapidly in higher concentration. Acute
oxygen poisoning can occur and manifested as convulsions, sore
throat, congestion of eyes and nose, chest pain, cough, pulmonary
congestion, pulmonary edema may occur.
2. Bronchopulmonary dysplasia—abnormal tissue development can occur
in bronchopulmonary linings.
3. Chronic oxygen poisoning—when oxygen therapy is given in higher
concentration more than 60% for prolonged period at atmospheric
pressure. It may manifest as—parasthesia, anorexia, nausea, vomit-
ing, mental changes, disturbed vision (visual field), parasthesia, joint
pain. It is due to the damage of pulmonary epithelium and
inactivation of surfactant (a wetting agent of pulmonary alveolar
surface which stabilizes this surface by reducing surface tension)
which cause reduction of vital capacity and lead to all these effect.
This effect is also called Lorrain smith effect.
4. Retrolental fibroplasias—in this when premature baby is exposed to
high pressure of oxygen just after birth for resuscitation. There is
tiny hemorrhage from retinal vessels and formation of a fibro-
vascular sheath posterior to lens. This may lead to retinal detachment
and even blindness. Therefore, in cases of cyanosis in neonates 100%
oxygen should be administered so long as till cyanosis persists but
thereafter, 40% oxygen should be given intermittently for a short
period.
HYPERBARIC OXYGENATION
In some conditions oxygen therapy with greater tension more than
one atmosphere of gas may be indicated. Here it provides an efficient
and rapid restoration of cellular oxygenation whenever a subject breaths
100% oxygen, 100 ml of oxygen. But breathing 100% oxygen at
two atmosphere it may increase to 4.2 ml and at three atmosphere
pressure it may increase preferred as it provides high inspired oxygen
concentration and gives better surface contact with high oxygen
pressure. Disadvantage of this is (i) difficulty in monitoring and (ii)
costly.
Oxygen Therapy 235
Hazards of Hyperbaric Oxygen
1. Risk of fire and explosion
2. Barotrauma
3. Ear discomfort
4. Rupture of ear drum
5. Decompression bone necrosis
6. Avascular bone necrosis
7. Nitrogen narcosis
8. Gaseous emboli
9. Oxygen toxicity—convulsion, pulmonary hyperemia, edema,
atelectasis
10. On long-term exposure leads to depression of hemopoiesis and
anemia to 6.5 ml of oxygen.
Indications of Hyperbaric Oxygen

This high pressure is indicated in various medical conditions:
1. Carbon monoxide poisoning
2. Cerebral edema following cardiac arrest
3. Gas gangrene
4. Myocardial infarction
5. Neonatal asphyxia
6. Chronic osteomyelitis
7. Cardiac surgery (to prolong the period of circulatory arrest).
How it is Given?
Hyperbaric oxygenation is given in pressure chambers. It is large
compressed air pressure vessel. The patient breathes oxygen through
an endotracheal tube or face mask. Ordinarily a pressure of two
atmospheres is employed. This can also be given by one main pressure
chamber, consist of steel chamber in which oxygen or air is employed
as compressing gas. Oxygen is referred to as it provides high inspired
oxygen concentration and gives better surface contact with high oxygen
pressure.
• It is difficult to monitor.
• Large chambers are two costly.
26 Emergency Drugs
Following are the drugs commonly used in the OT.
ADRENALINE
Injection of adrenaline is available in 0.5 and 1 ml ampoule (1:1000
adrenalines in water).
It is an adrenergic drug. It is orally inactive. It should not be mixed
with sodabicarb injection (NaHCO3) in same bottle (because rapid
oxidation occurs).
Uses
1. Acute attack of bronchial asthma: It is used in the emergency situation.
Injection should be given subcutaneously. Other alternative drugs
which are used- nebulize with salbutamol + Ipratropium bromide.
2. Allergic disorders: It gives a very quick relief in anaphylactic sock,
urticaria, angioneurotic edema of larynx. Thus, it is a life saving in
laryngeal edema and anaphylaxis. Injection should be given
intramuscularly (IM).
3. Cardiac arrest: It is given intracardiac injection (0.2 to 0.3 ml) make it
sure before injecting the drug that it must be in the chamber.
Otherwise if it is given in cardiac muscle it precipitate ventricular
arrhythmia. IV administration is justified in cardiac arrest with
external cardiac massage.
4. Control of local bleeding: It controls the arterioles and capillaries
bleeding if applied locally. Adrenaline in a concentration of 1:10000
to 1:20000 is used. Adrenaline soaked gauze is packed in oozing
wound can stop bleeding. For example, epistaxis, after tooth
extraction, oozing from a large surface area after operation, e.g. after
hemorrhoidectomy.
5. For blood less field: Adrenaline in 1:10000 or 20000 conc. is used with
normal saline or local anesthetic before surgery for bloodless field.
Emergency Drugs 237
It is injected subcutaneously.
6. To prolong the action of local anesthetics: Along with local anesthetic
because of its vasoconstrictor effect it prolongs the action of local
anesthetic. It should not be used in block of finger, ear lobule, penis
because these are supplied by end arteries, so chances of gangrene
of these are high due to its vasoconstriction effect.
Adverse Effects
• Transient restlessness, palpitation, anxiety, tremor, pallor.
• Marked rise in BP, leading to cerebral hemorrhage, ventricular
tachycardia ventricular fibrillation if injected rapidly and intra-
venously.
Contraindications
• Anginal pain.
• Hypertensive patient.
• Hyperthyroid patient.
• It should not be given during anesthesia with Halothane (risk of
arrhythmia).
• It should not be given to patients receiving β-blockers (marked rise
in BP can occur).
• Pheochromocytoma.
Accidental Overdose
With adrenaline occurs occasionally. It is treated with:
1. Propranlol.
2. Phentolamine or chorpromazine.
ATROPINE
It is an anticholinergic drug. It is a natural alkaloids (Belladonna). It is
available in 0.65 mg/ml. 1 ml ampoule and 6 mg/ml ampoule or bottle,
eye ointment and tablet form.
Uses
1. As a pre-anesthetic medication: To dry up the secretions if general
anesthesia is to be given. Atropine markedly decreases sweat,
salivary, tracheobronchial and lachrymal secretion.
2. Before minor procedure: To prevent vasovagal shock in minor
procedures like intercostal tube insertion, ascitic fluid taping, pleural
tapping and minor surgical procedures.
3. As a mydriatic: It is a potent mydriatic and blurring of division
remains about a week that’s why its substitute homatropine is used
which is short lasting (1 to 2% eye drops).
4. In Bradyarrythmias: The most prominent effect of atropine on heart
is to cause tachycardia. It is used as cardiac vagolytic.
5. In the treatment of organophosphorus poisoning: Atropine is the
specific antidote for anti ChE and early mushroom poisoning. Inj.
atropine must be given promptly 2 mg IV repeated till pupil dilates
(till atropinization) and continued with maintenance doses may be
required for 1 to 2 weeks. The patient’s respiration, BP, pulse and
salivation should be observed to prevent over atropinization. The
pulse rate should not be allowed to exceed 120/minute.
Side Effects
• Retention of urine: It can occur in older and males with prostatic
hypertrophy.
• Rise of body temperature: Flushing of face and rise of body
temperature occurs.
• Skin, eyes become dry, talking and swallowing may be difficult.
• Blurring of vision: If used for mydriatic purposes.
Contraindications
• In elderly patient—glaucoma and retention of urine.
• In chronic lung disease—it dries up the secretion and make it worst.
DOPAMINE
1. It is available in five ml ampoules and contains 40 mg/ml. It is given
in five percent dextrose or normal saline infusion. Dopamine is stable
for 24 hours in NS and dextrose.
2. Subcutaneous leakage should be avoided as it can cause necrosis
(due to vasoconstriction). If it occurs, it should be treated by local
injection of phentolamine (5 mg diluted). It may be mixed with
dobutamine.
3. Dose should be properly titrated. A 200 mg ampoule in 500 ml of
dextrose or NS roughly contains 400 microgram in 15 drops (i.e.
one ml) dose is 2 to 50 mcg/kg/min.
2 to 5 mcg/kg/min (dopaminergic range).
5 to 10 mcg/kg/min (dopaminergic range)
10 to 20 mcg/kg/min (beta range)
20 to 50 mcg/kg/min (alpha range)
Emergency Drugs 239
Pharmacologic effects are dose dependent—Renal and mesenteric
vasodilatation predominate at lower doses, cardiac stimulation and
vasoconstriction develop as the dose is increased.
a. Renal and mesenteric blood vessels are the most sensitive to IV
infusion of Dopamine. It raises cardiac output and systolic BP with
little effect on diastolic BP.
b. Dose is regulated by monitoring BP and rate of urine formation.
Uses
1. Renal failure.
2. Hypotension with inadequate cardiac output, it increase peripheral
circulation.
3. Cardiogenic shock.
4. Septic shock.
5. Severe CHF.
Caution
1. Dopamine should not be added to sodium bicarbonate .
2. Dopamine drip should not be continued for more than 72 hours
otherwise it will lead to tachyphylaxis.
3. Stop or decrease the dose if there is decreased urine output,
increasing tachycardia and development of new arrythmias.
Overdose Treatment
If overdose is not responding to withdrawal of drip then it should be
treated by Inj. Phentolamine.
Contraindications
• Ventricular fibrillation.
• Uncorrected cardiac tachyarrythmias.
• Pheochromocytoma.
SODIUM BICARBONATE
It is available in 10 ml ampoule containing 7.5 % solution (1 ml = 1 mmol
NaHCO3).
Uses
1. Diabetic ketoacidosis.
2. In methyl alcohol (Methanol) poisoning (to combat acidosis).
3. In acute barbiturate poisoning.
4. Hyperkalemia.
5. Severe respiratory acidosis (status asthmatics).
6. Lactic acidosis following D C shock during cardioversion.
Adverse Effects
• Metabolic alkalosis.
• Edema (due to sodium retention).
CALCIUM GLUCONATE
1. It is available in 10 ml of ampoule (10% W/V containing 1 gm in an
ampoule).
2. Calcium controls excitability of nerves and muscles. It also maintains
integrity of cell membrane.
3. It is an intracellular messenger for hormones, autocoids and
transmitters.
4. It has a very important role in coagulation of blood.
5. When it is given IV a sense of warmth is produced.
Uses
1. Tetany for immediate treatment of severe cases.
2. Hyperkalemia.
3. Hypoparathyroidism.
4. As an ionotropic drug in cardiac arrest.
5. After two units of blood transfusion (as anticoagulant chelates the
calcium).
6. Osteoporosis.
7. As dietary supplement.
POTASSIUM CHLORIDE
It is available in injection and syrup. 10 ml ampoules containing 150 mg/
ml of KCl. It should be given in slow infusion. Each gram of KCl is
equivalent to 13.4 mmol of K+.
Uses
1. In diabetic ketoacidosis: Infusion of KCl should be guided by serum
K+ estimation and ECG.
2. For tachyarrythmia caused by chronic use of digitalis and diuretics
(these both induce K+ depletion).
3. When thiazide diuretics are used: KCl should be given as it causes
hypokalemia.
Emergency Drugs 241
4. Hypokalemia
5. Paralytic ileus due to hypokalemia.
Adverse Effects
Cardiac arrest, if excessive dose is given rapidly.
AMINOPHYLLINE
1. It is available in 100 mg tab, and 10 ml ampoules (containing 250
mg in 10 ml).
2. It is given in diluted form either in 20 ml of 10% glucose IV very
slowly or given in five percent dextrose drip.
Uses
1. Bronchial asthma.
2. Cardiac asthma.
Adverse Effect
• Nausea, vomiting.
• Epileptic fit.
• Twitching of mouth.
Caution
Aminophylline injection should not be mixed in same infusion/syringe
with—Ascorbic acid, promethazine (phenergen), chlorpromazine
(Largectil).
Morphine (pethidine), Phenobarbitone, Insulin, Penicillin G,
Tetracycline, etc.
Recent evidence shows that it does not afford additional benefit
because of its side effects and drug interactions and better preparations
are more effective.
THEOPHYLLINE (DERIPHYLLINE)
It is available in two ml ampoules (220 mg/2 ml), tablet 100 mg and
300 mg SR, syrup.
Uses
1. Bronchial asthma.
2. Apnoea in premature infant.
3. COPD.
Adverse Effects
Theophylline has a narrow margin of safety.
• Gastric pain (with oral).
• Pain at the site of 1 M injection.
• Rapid IV injection causes precordial pain, syncope and even death
due to marked fall in BP, ventricular arrhythmias or asystole.
Cautions
It should be given very slowly.
PROPRANOLOL (PPNL)
Commonly known as beta-blocker. It is available as 1 mg/ml ampoules
and tablet form.
Uses
1. Thyrotoxicosis (thyroid storm)—It is an important form of therapy
and rapidly alleviates the manifestations that are due to sympathetic
over activity (palpitation, tremor, nervousness, severe myopathy,
sweating). It has little effect on thyroid function and hypermetabolic
state. This is used along with propylthiouracil, glucocorticoids.
2. For preoperative preparation before subtotal thyroidectomy along
with iodide.
3. In anxiety—many symptoms of anxiety like palpitation, rise in BP,
shaking, tremor, gastrointestinal hurrying, etc. are due to sympa-
thetic over activity and these symptoms reinforce anxiety. PPNL
may be used to relieve these symptoms.
4. For supraventricular arrhythmias.
5. For sinus tachycardia, atrial and nodal extrasystole provoked by
emotion or exercise.
6. As Antihypertensive.
7. Pheochromocytoma.
8. In migraine.
Adverse Effects
• CHF, bradycardia
• Bronchospasm
• Hypoglycemia
• Nausea and vomiting
• Thrombocytopenia and leucopenia
• Uterine hypomotility and prolonged labor.
Emergency Drugs 243
Caution
• It should not be used alone in unstable angina because of risk of
worsening coronary vasospasm if present.
• In myocardial infarction—it should be taken on a regular schedule
and not on as and when required basis. Abrupt withdrawal after
chronic use may precipitate severe attacks.
• It should be avoided in asthmatic patient as it causes bronchospasm.
LIGNOCAINE
1. It is the most commonly used local anesthetic.
2. It is a popular antiarrythamic drug. The most prominent action of
lignocaine is suppression of automaticity in ectopic foci.
3. Action of IV bolus dose lasts only 10 to 20 min because of rapid
redistribution.
4. It is available in ampoule five ml and 50 ml vial as two percent.
These preparations are of cardiac use and do not contain any
preservative.
Use
1. Lignocaine is used only in VT (ventricular tachyarrythmias). It is
ineffective in atrial arrythmias. It is used in emergency setting in
arrythmias following acute MI, during cardiac surgery.
2. Can be used as local anesthetic when individual is sensitive to
methylparaben (preservative used in local anesthetic).
3. It is also useful in digitalis toxicity (because it does not worsen AV
block).
4. During diagnostic procedures, e.g. cardiac catheterization and
angiography if VT occurs, it is used.
Contraindication
• AV block of all degrees.
• Bradycardia.
Caution
• Treatment with lignocaine should not be performed without ECG
control.
• Too rapid infusion should be avoided, it may be lethal.
• If overdose occurs (by ECG – prolong PQ or widening of QRS and
QT complex) drip should be reduced.
MEPHENTERMINE (MEPHENTINE)
It is a pressor agent of adrenergic drug. It is available in one ml ampoule
containing 15 mg and 10 ml vial containing 3 mg/ml and 10 mg tab
Dose is given in infusion or IV injection.
Uses
1. It is used to prevent and treat hypotension due to spinal anesthesia.
2. Hypotension in surgical procedures.
3. Shock in myocardial infarction.
Precautions
• It should be used cautiously in hypertensive patient.
• In hypovolemic shock, first hypovolemia is corrected then it is used.
FRUSEMIDE
It is available in tablet (40 mg) and two ml ampoule containing 20 mg/
2 ml. Its solution degrades spontaneously on exposure to light. It is
given orally or 1 M or IV.
Uses
1. In pulmonary edema.
2. In poisoning—for forced diuresis.
3. Renal failure.
4. In prostatectomy—to induce forced diuresis to prevent clot retention.
5. In CHF, it decreases the preload.
6. Acute LVF.
Side Effects
• It can cause severe electrolyte and water imbalance.
• Orthostatic hypotension.
• Hearing loss if large doses of frusemide are used in a patient with
severe renal failure.
MANNITOL
Mannitol is a sugar (polyhydroxyl aliphatic alcohol). It is pharmacologi-
cally inert. It is not metabolized in the body, freely filtered at the
glomerulus. It is used as an osmotic diuretic. It expands the extracellular
fluid volume, increases GFR and inhibits the rennin release. It is
available in 10%, 20% in 100, 350 and 500 ml vac.
Emergency Drugs 245
Uses
1. It decreases intracranial tension in head injury and stroke, to decrease
the intracranial tension and cerebral edema.
2. Hepatic encephalopathy.
3. Forced diuersis in hypnotic or other poisonings.
Side Effects
• It can precipitate CHF in a decompensated heart.
• Headache (due to hyponatremia).
• Nausea and vomiting.
Contraindications
• Acute tubular necrosis.
• Anuria.
• Pulmonary edema.
• Acute LVF.
• CHF.
• Cerebral hemorrhage.
Precautions
• IV set should be flushed with NS or changed when mannitol is
followed by blood.
• There should not be any extravasation or leakage.
• It should not be used in a patient with head injury before confirming
or ruling out the subdural or intracerebral hematoma. But can be
used in rapidly deteriorating patient of head injury.
HYDROCORTISONE
It is available in injection form as hemisuccinate and acetate form
available in powder. It is reconstituted with two ml of distilled water.
Uses
1. Anaphylactic shock.
2. Acute severe asthma.
3. Thyrotoxicosis crisis.
4. Addison’s crisis.
5. Hypoglycemia.
6. Hypercalcemia.
7. Topically injected in the treatment of keloid.
8. Intraarticularly in osteoarthritis.
9. In ulcerative colitis 100 mg is dissolved in 120 ml of normal saline as
retention enema.
Caution
It should not be withdrawn suddenly when long-term use. It may
suppress the hypothalamo, pituitary adrenal axis, Precipitate
withdrawal syndrome—malaise, fever, weakness, pain in muscle, joints
and reactivation of diseases, subjected to stress. These patients may go
into acute adrenal insufficiency. Thus, withdrawal should be in tapering
(reducing) dose.
Contraindications
• Peptic ulcer.
• Diabetes mellitus.
• Hypertension.
• Osteoporosis.
• Viral and fungal infection.
• Epilepsy.
• Herpes simplex keratitis.
• Renal failure.
• Psychosis.
DEXAMETHANSONE
It is a very potent and highly selective glucocorticoid. It is available in
tablet (0.5 mg tab), 4 mg/ml as sod. phosphate in vial for IV, 1M inj.,
0.5 mg/ml oral drops.
Uses
1. Used for inflammatory conditions.
2. Used for allergic conditions.
3. In shock.
4. In cerebral edema.
Side effects and contraindications are same as of hydrocortisone.
DIAZEPAM
Uses
1. As muscle relaxant in case of tetanus and spinal injury.
2. As preanesthetic medication to remove anxiety and apprehension.
Emergency Drugs 247
3. In alcohol withdrawal syndrome. (withdrawal syndrome consist of
anxiety hallucination, delirium tremens, convulsion, confusion,
tremor, impairment of sleep).
4. In epilepsy.
5. Febrile convulsions.
6. In anxiety.
7. For sedation.
Adverse Effects
Although it is safe drug, sedation, mild headache, vertigo confusional
state (especially in elderly), alterations in sexual function, disorientation,
impairment of psychomotor skills (should not drive) weakness, blurring
of vision, dry mouth.
FLUMAZENIL
Is an antagonist of diazepam (benzodiazepines) available in injection
form. It is used in diazepam overdose.
MORPHINE
It is available in ampoule of 15 mg. It is given SC or IM.
Uses
1. For pain—especially cardiac pain of MI, postoperative pain.
2. In LVF.
Adverse Effects
• Hypotension.
• Respiratory depression.
• Drug dependence (if used for longer time).
• Retention of urine.
• Miosis.
PETHIDINE (MEPERIDINE)
1. It is available in two ml ampoule contains 100 mg.
2. It is given IV/IM but slowly.
Uses
1. LVF
2. Empirically it is used for postoperative rigor.
Side Effects
Side effects are same as of Morphine.
BUPRENORPHINE
It is an analgesic and more potent than morphine. It is available in
one and two ml ampoules. 3 mg/ml and 0.2 mg sublingual tablet.
Uses
1. Painful condition, e.g. cancer pain.
2. Postoperative pain.
3. Myocardial infarction.
Side Effects
• Sedation.
• Vomiting.
• Postural hypotension.
• Dependence on longer use.
• Miosis.
NALOXONE
It is available in 1 ml (0.4 mg) ampoule for adult and 2 ml (0.04 mg in
two ml) ampoule .
It is a competitive antagonist of (morphine) opioids.
Uses
1. Morphine Poisoning—It is a drug of choice in morphine poisoning
0.4 to 0.8 mg IV and repeated accordingly.
2. To reverse respiratory depression due to intraoperative use of
opioids.
3. In alcohol intoxication.
PENTAZOCINE
It is available in Tab (25 mg) and 1 ml ampoules (30 mg).
Uses
1. Pain-postoperative pain, renal pain, ureteric colic, burn, trauma,
fracture.
2. Anesthetic medication.
3. For sedation.
Emergency Drugs 249
Cautions
It should be avoided in MI.
Side Effects
• Vomiting.
• Tachycardia.
• Rise in BP.
• Constipation.
• Dependence if used for longer time.
BUTORPHANOL
It is available in 1 and 2 ml ampoule containing – Butorphanol Tartrate
1 and 2 mg.
It is more potent than pentazocine.
Uses
1. Pain.
2. Sedation.
3. Preanesthetic medication.
Side Effects
• Vomiting.
• Sedation.
Contraindication
It should be avoided in cardiac ischemia.
TRAMODOL
It is a synthetic opioid. It is a centrally acting analgesic.
It is available in tablet, cap. (50 mg) and ampoules 1 ml, 2 ml
containing 50 and 100 mg.
Indications
• In pain—due to diagnostic procedures, surgery, injury.
• Chronic pain—cancer pain.
It is not effective in severe pain.
Side Effects
Respiratory depression, sedation, constipation, urinary retention, rise
in biliary pressure, dizziness, nausea, sleepiness, dry mouth, sweating.
PROMETHAZINE HYDROCHLORIDE
It is available in tablet (10, 25 mg), syrup, (5 mg/5 ml), Injection 2 ml
(25 mg/ml) form.
It causes very little respiratory depression and has been used
particularly in children.
Uses
1. Preanesthetic medication—for its anticholinegic and sedation
properties.
2. For cough—as an antihistamine.
3. Vomiting.
4. Motion sickness—promethazine theocolate (Avomine 25 mg tab).
It has been specially promoted as an antiemetic to control vomiting
during journey.
5. Used in extrapyramidal side effects of metochlopromide.
6. To produce hypothermia a lytic cocktail- mixture of following drugs
are injected Intravenously.
Promethazine—50 mg (Phenergan)
Chlorpromazine—50 mg (Largectil)
Pethidine—100 mg
ONDANSETRON
It is available in two ml ampoule (4 mg), four ml ampoule (8 mg), tablet
and drops form. It is an antiemetic drug.
Indication
• Postoperative nausea and vomiting.
• Cancer chemotherapy induced vomiting.
• Radiotherapy induced vomiting.
• Vomiting due to drug over dosage.
• Uremia.
It is commonly used drug just before operation. It prevents PONV
(postoperative nausea and vomiting). Adjuvant drugs dexamethasome,
promethazine or diazepam are also used along with this to prevent
delayed vomiting in postoperative period.
Emergency Drugs 251
Side Effects
It is generally well tolerated, mild side effects are: Headache,
constipation, diarrhea, abdominal discomfort, rashes, allergic reactions.
GRANISETRON
It is a more potent (10 to 15 times than ondansetron) antiemetic drug
than ondensetron.
It is available in 1 to 2 mg tablet, 1mg/ml (1and 3 ml) injection form.
Indications
• Postoperative nausea and vomiting.
• Before cancer chemotherapy and radiotherapy.
• With pre anesthesia medication to prevent PONV.
Side effects are same as of ondansetron.
PHENIRAMINE
It is available in 25 and 50 mg tablet, 15 mg/5 ml syrup and 22.5 mg/
ml injection of two ml ampoules form.
Indication
Allergic disorders, pruritus, common cold, cough.
Side Effects
Sedation, diminished alertness and concentration, light headedness,
fatigue, motor in coordination and tendency to fall asleep.
PHENYTOIN (DIPHENYLHYDANTOIN)
It is available in 25, 100 mg cap, 100 mg/4 ml oral suspension, 100 mg/
2 ml injection. It is an epileptic drug.
Uses
1. Status epilepticus.
2. Generalized tonic-clonic seizure.
3. Trigeminal neuralgia.
4. Digitalis induced cardiac arrythamias.
Side Effects
• Gum hypertrophy (on long-term use).
• Hirsutism (troublesome in young girls).
• Megaloblastic anemia.
• Osteomalacia.
• Hyperglycemia.
• Vertigo.
• Ataxia.
• Fall In BP.
• Epigastric pain.
• Nausea, vomiting.
• Drowsiness.
• Mental confusion.
• Hallucinations.
Precaution
• It is highly alkaline solution so there should not be extravasations
during IV injection.
• It precipitates on dilution so it should be given without diluting it.
• Intravenous injection can cause local vascular injury.
• Edema and discoloration may occur.
• It should be given slowly.
FOSPHENYTOIN (FOSOLIN)
Same as phenytoin. The advantage of fosphenytoin is that it can be
used more quickly than phenytoin without the risk of inducing
hypotension.
VITAMIN K (VITAMIN K, KAPLIN)

It is required for the synthesis of clotting factors. It is available in
injection 10 mg/ml and tab form. It is also available with other medicines
like calcium and iron. Inj. phytonadione is used for 1 M only and
Menadiol Sod. Diphosphate can be used 1 M or IV.
Uses
1. The most common use of this vitamin is in prophylaxis and treatment
of bleeding due to deficiency of clotting factors like—dietary
deficiency, prolonged, malabsorption syndrome, liver disease and
newborns.
2. To reverse the effect of overdose of oral anticoagulants.
Phytonadione (K) is the preparation of choice.
3. Prolonged high dose of salicylate therapy.
Emergency Drugs 253
Precaution
Rapid IV injection should not be given, it may cause flushing,
breathlessness, a sense of constriction in chest and fall in BP.
Contraindication
G-6 phosphatase deficiency patients.
GELATIN FOAM (GELFOAM, SURGICEL)

It is a local hemostatic. It is a spongy gelatin. It is moistened with saline
or thrombin solution and used for packing the oozing wounds. If gets
absorbed into time. It seals off the oozing wound.
ADRENOCHROME
It is a coagulant. It is available in tab 1 mg, 0.5 and 2 mg/2 ml injection
form. It controls bleeding or oozing from raw surfaces. It prevents
microvascular bleeding.
Uses
1. Epistaxis
2. Hematurea
3. Retinal hemorrhage
4. Secondary hemorrhage
HEPARIN
1. Mclean, a medical student, discovered this in 1906.
2. It is available in 1000, 5000 units/ml in 5 ml vial.
3. It is given subcutaneously (SC) or IV.
Uses
1. As an anticoagulant.
2. To maintain patency of IV cannula and shunts in dialysis patient.
3. Before major surgery to prevent DVT.
Side Effects
• Bleeding due to overdose.
• Thrombocytopenia.
• Hypersensitivity reaction.
• Osteoporosis.
• Transient and reversible alopecia.
Contraindications
• Bleeding disorder
• Hypertension
• SABE (Subacute Bacterial Endocarditis)
• Ocular and neurosurgery
• Lumber puncture
• Chronic alcoholics
• Cirrhosis
• Renal failure
• Patient is on aspirin, antiplatelet drugs.
NADROPARIN (FRAXIPARINE)
It is a low molecular weight heparin. It has many advantages over
heparin.Better subcutaneous bio availability. Longer action. PTT and
clothing time is not prolonged.
It is available in 0.3, 0.4 ml containing 3075 and 4100 IV. It is costly.
Indication
• Prophylaxis and in the treatment of DVT (deep vein thrombosis).
• Prophylaxis of PE (pulmonary embolism) in high-risk patients
undergoing surgery.
• Unstable angina.
PLASMA EXPANDERS
When infused it retains fluid in the vascular compartment.
Indications
• Burns
• Hypovolemic shock
• Hypotension
• Acute liver failure
• Dialysis
Adverse Reaction
Hypersensitivity reactions.
Human Albumin
1. It is available in 50, 100 ml inj (5% or 20%).
2. 100 ml of 20% human albumin is osmotic equivalent of 400 ml of
FFP.
Emergency Drugs 255
3. It is obtained from pooled human plasma.
4. It does not interfere with coagulation an can be used without
interfering to patient’s blood group.
5. It is expensive.
DEXTRAN (DEXTRAN 70, LOMODEX 70, LOMODEX 10%)

It is obtained from sugar beat. It is available in two forms.
• Dextran 70 and 40.
• Dextran 70 is most commonly used.
• It expands plasma volume for nearly 24 hours.
• It may interfere with blood grouping and cross-matching.
Precautions
It should not be used in thrombocytopenia or in presence of bleeding.
DEXTRAN 40
It acts rapidly than Dextran 70. It reduces blood viscosity and prevent
and RBC sludging.
Indications
• DVT (deep vein thrombosis)
• Pulmonary infarction.
Side Effects
• Anaphylactic reaction.
• Urticarea
• Itching
• Bronchospasm
• Fall in BP.
DEGRADED GELATIN POLYMER (POLYGELINE, HEMACCEL,

SERACEL 500 ML VAC 3.5% SOLN)
It is similar to albumin but not antigenic. Hypersensitivity reactions
are there. It does not interfere with blood grouping and cross-matching.
Expansion of plasma volume lasts for 12 hours.
Side Effects
Bronchospasm, urticarea, fall in BP, itching, chills and rigor.
HYDROXYETHYL STARCH
(HES, EXPAN 6% HAES-STERIL, 100, 500 ML VAC)
Plasma volume expands slightly in excess of the volume infused.
Hemodynamic status is improved for 24 hours or more. The colloidal
properties of six percent HES is equal to those of human albumin. It is
used to improve harvesting of granulocytes because it accelerates
erythrocyte sedimentation.
Side Effects
Vomiting, mild fever, itching, chills, flu like symptoms, swelling of
salivary glands, anaphylactic reaction.
METOCLOPRAMIDE
It is available in 10 mg tab, 5 mg/ 5 ml syrup, 10 mg/2 ml injection and
50 mg/10 ml vial.
It is a widely used as an anti-emetic drug. It increases gastric
peristalsis, relax the pylorus and first part of duodenum and speeds
gastric emptying. It increases the lower esophageal sphincter (LES) tone.
Thus, prevents the reflux. It acts on CTZ and blocks the vomiting.
The gastronomic action may contribute to the anti-emetic effects.
Uses
1. Anti-emetic
2. Dyspepsia
3. GERD (gastroesophageal reflux disease).
Side Effects
• Sedation
• Diarrhea
• Extra-pyramidal symptoms (EPS)
• Dizziness
• Galactorrhea (on long-term use).
PROCHLORPERAZINE (STEMETIL)
It is available in 5.25 mg tablet, 12.5 mg/ml ampoule and 10 ml vial. It
is used for vertigo associated with vomiting.
Side Effects
• Muscle myotonia.
• EPS (Extrapyramidal symptoms)
Emergency Drugs 257
INSULIN
It is used in insulin diabetes mellitus to control the higher level of
blood sugar. It is used to neutralize the IV glucose when given to a
diabetic patient. It is used prior to operation to control the diabetes.
It is available in different forms as longer acting or retard preparations
and short acting regular insulin. All are given by a special type of
syringe on which units are marked (Insulin syringe).
Regular insulin is also available in 100 units/ml and 500 units/ml
strength.
All preparation of insulin are given SC (subcutaneously). Only
regular insulin can be injected IV or IM.
Preparations are categorized into:
Highly Purified Insulin Preparations

Single Peak Insulin
• Actrapid, Rapidica—highly purified pork regular insulin 40 U/ml.
• Lentard, Zinulin—Lente insulin 40 U/ml.
• Actraphane, Rapinix, Mixtard—highly purified pork regular insulin
(30%) and isophane insulin (70%) 40 U/ml.
Monocomponent (MC) Insulin

• Actrapid MC—Pork regular insulin 40 U/ml, 100 V/ml.
• Monotard MC—Pork lente insulin 40 U/ml.
These are more expensive but greater the advantage of stability,
less allergic reactions, less insulin resistance and less lipodystrophy.
HUMAN INSULIN
It is more water soluble. It has more rapid SC absorption, earlier and
more defined peak and slightly shorter duration of action.
- Human Actrapid—human regular insulin 40 U/ml, 100 U/ml.
- Actrapid HM PENFIL—100 U/ml mg.
- Human Monotard—Human lente insulin 40 U/ ml 100 U/ml.
- Human Actraphane, Huminsulin 30/70.
- Human Mixtard—H. soluble insulin (30%) + Isophane insulin (70%)
100 U/ml pen injector.
Reactions to Insulin
Hypoglycemia this is the most common and most serious reaction.
Symptoms of hypoglycemia (when blood glucose falls below the
normal level)
– Sweating – Anxiety – Palpitation
– Tremor – Dizziness – Headache
– Behavioral changes – Visual disturbance – Weakness
– Hunger – Fatigue
– Muscle in coordination – Fall in BP
– Finally – mental confusion, seizures (fits) and coma occur.
Treatment
Glucose must be given orally or IV according to the condition (severity).
It reverse the symptoms rapidly.
Others—
i. Local Reaction—like swelling, erythema, stinging.
ii. Allergy—urticaria, angioedema and anaphylaxis.
iii. Edema
Uses
1. Diabetes mellitus.
2. Diabetic ketoacidosis (diabetic coma).
3. Hyper osmolar (non-ketotic hyperglycemia).
Caution
Every patient (who is on insulin therapy) and his attendant must be
known about the symptoms of hypoglycemia.
27 Blood Transfusion
For safe transfusion it requires a specialist facilities for the collection,

testing and processing of blood and for the necessary tests on the
patient.
INDICATIONS FOR TRANSFUSION

1. Acute blood loss due to trauma/accidents.
2. Hemorrhage from pathological lesions, for example, bleeding from
gastrointestinal tract (GIT).
3. During major operative procedures.
4. Severe burns.
5. Postoperatively in patient who is anemic.
6. Preoperatively in cases of chronic anemia in which surgery is
indicated urgently.
7. As a prophylactic measure prior to surgery in patient with a bleeding
disorder such as thrombocytopenia, hemophilia, liver disease.
8. Exchange transfusion, for example, incompatibility in fetus, hepatic
coma, etc.
BLOOD STORAGE AND PRESERVATION OF BLOOD

1. All blood for transfusion must be stored in refrigerator at 2 to 6°C.
2. Blood allowed to stand at higher temperature for more than two
hours is in danger of transmitting infection.
3. White blood cells (WBC) are rapidly destroyed in stored blood.
4. Platelets survival is reduced after few hours.
5. Clotting factors – factor V and VIII levels falls quickly.
6. RBC–CPD (Citrate Phosphate Dextrose) blood has a shelf life of three
weeks.
7. The RBC suffer a temporary reduction (24 to 72 hours) in their ability
to release oxygen to the tissues of the recipient, thus it is preferably
to give blood that are less than 7 days old.
Acid Citrate Dextran (ACD) - Why it is used?
Citrate – acts as an anticoagulant.
Dextrose – Viability of red cells decreases rapidly in citrate. Addition
of glucose (dextrose) to the anticoagulant solution increases the post-
transfusion survival of RBCs. Glucose is necessary for cell metabolism
of stored RBCs. It decreases the rate of hydrolysis (of ester phosphorus)
during storage and provides energy for synthesis of ATP. There is close
association between ATP contents of RBCs and their viability.
Citric Acid – Citric acid prevents carmalization of glucose in citrate
dextrose solution during its process. Citric acid along with citrate gives
an optimal pH which has a least deleterious effect on red blood cells.
Acid citrate has minimal effect on acid base balance of the recipient.
15 ml of ACD solution is used for 100 ml of blood.
Temperature
A constant low temperature above freezing point is important for red
cell preservation. The blood should be stored in the anticoagulant
solution at a controlled constant temperature of 2 to 6°C. The lower
temperature keeps the rate of glycolysis at a lower limit.
Freezing of blood must be avoided because it causes the cells to
hemolyze (unless they have been treated with glycerol). Low tempe-
rature minimizes the proliferation of bacteria (that might have entered
the blood unit during venupuncture or from the atmosphere).
Electrolyte balance is not disturbed at low temperature because the
rate of diffusion of electrolytes across the cell membrane is less at low
temperature.
Citrate Phosphate Dextrone Solution (CPD)

CPD solution is better than ACD.
1. Due to slightly higher pH and because of phosphate compound.
2. The survival of red cells 24 hours after transfusion is better (80%) in
CPD solution compared with ACD (70%) solution and can be stored
for 21 days.
3. CPD contains enough dextrose to support continuing ATP
generation by glycolytic pathways.
4. Red cells 2, 3 – DPG (Diphosphoglycerate) is better maintained in
CPD than in ACD. 410 ml of blood is taken in a bag which contains
75 ml of CPD, i.e. 14 ml of solution is used for 100 ml of blood.
Blood Transfusion 261
Adenine with CPD
Adenine blood is superior with respect to ATP concentration and
viability.
Heparin
Nowadays heparin is not used in blood for transfusion.
Ethylene Diamino–Tetraacetic Acid (EDTA)

• It is ten times more potent than citrate.
• It is not in use because it has no advantage over citrate.
• It is toxic and damages platelets.
• It is used only for preserving the blood samples.
• One mg is used for one ml of blood for preservation.
Preparation of Blood for Transfusion

• Blood donor should be fit and should not have communicable
diseases like Hepatitis, AIDS and Malaria.
• Blood is collected in a specially prepared sterile plastic bag.
• Blood of donor and recipient is checked for blood group, cross
matching and for australian antigen (hepatitis HBsAg) AIDS and
malaria.
Donor Selection for Blood

Donor selection is based on medical history, physical examination and
simple laboratory tests.
1. The donor should be in good health (in order to the donor or
recipient).
2. Donor should not be under the influence of alcohol or any drugs.
3. Donor should not have any illness like:
– Malignant disease
– Epilepsy
– CVA
– Renal disease
– Malaria
– AIDS
– Hepatitis
– Syphilis
4. Donors are not accepted during the period of pregnancy and till six
months preferably on year during lactation.
5. Age- donor’s age should be between 18 to 60 years and should be in
a good health.
6. A donor of 45 kg can give 350 ml blood (8 ml/kg body weight)
depending upon the weight, amount of blood that may be drawn
can be calculated by applying this formula.
Weight
Amount of blood to be drawn =  450 ml
55 kg
BLOOD TRANSFUSION SERVICES

DONOR SCREENING AND REGISTRATION
Donor’s Name………………………………… Date…………………
Father’s/Husband’s Name…………………………….. Donation No………..
Age……………………Sex: M/F……………………. 1. Blood Pressure…...
Address………………………………………………. 2. Pulse Rate………..
………………………………………………………... 3. Weight/Height……
……………………………………………………….. 4. Temp…………….
Phone…………………Occupation…………………. 5. Hemoglobin…….
Blood Group………………… Examination results:
Donation for ………………………… …………… accepted
Name of the patient ……………………………… rejected:
Ward/Bed No……………….
1. Have you eaten today. Yes/No
2. Have you donated blood before? Yes/No, Date of last donation
3. Have you taken aspirin in the last three days? Yes/No
4. Are you being treated or have you been treated by
a doctor in the last six months. Yes/No
5. Have you had any surgery in last one year. Yes/No
6. Have you had malaria or taken anti-malaria drugs over the
last three months? Yes/No
7. Have you had jaundice in the previous three years? Yes/No
8. Have you had any tattoo, piercing or acupuncture over the last
six months? Yes/No
9. Have you received blood or blood products over the
last six months? Yes/No
10. Have you had any allergic reaction or medication
during the last six months? Yes/No
11. Do you have any respiratory disease? Yes/No
12. Do you suffer fainting spells or convulsions? Yes/No
13. Do you suffer from any mental disease? Yes/No
14. Do you have prolonged bleeding from a cut/wound? Yes/No
15. Have you received antirabies vaccination for dog
bite in the last one year? Yes/No
16. Any other vaccination/inoculations? Yes/No
17. Have you ever has venereal disease? Yes/No
18. Have you heard of disease AIDS? Yes/No
19. Persons who inject themselves with drugs,
have multiple sex partners or same sex partner are
more likely to be infected with the virus causing AIDS. Yes/No
20. In the last six months have you had any of the following:
a. Persistant cough Yes/No
b. Loss of weight Yes/No
c. Unexplained fever Yes/No
d. Diarrhea Yes/No
e. Swollen glands Yes/No
21. Are you taking medicines. If so, which ones. Yes/No
WOMEN DONOR
22. Are you pregnant? Yes/No
23. Any h/o abortion/miscarriage in past six months. Yes/No
24. Are you breast feeding? Yes/No
I have answered the questions truthfully. I permit the Blood Bank to collect
and process my blood when necessary to destine it for examination and to distribute
this blood and/or its components to patients in need of blood transfusion.
Signature of Donor
Methods of Taking Blood from Donor
• Ask the donor to lying down on a couch.
• A sphygmomanometer cuff is applied to the upper arm and inflated
to a pressure of 70 mm Hg to make the vein prominent.
• Infiltrate local anesthetic at the site of median cubital vein with all
aseptic and antiseptic precautions.
• Preferably 15 G needle is introduced into the median cubital vein
and is taken in the bag which already contains anticoagulant, i.e.
CPD (Citrate phosphate dextrose). Another anticoagulant which is
used is – ACD (Acid Citrate Dextrose).
• Have the donor open and close hand by squeezing a rubber ball.
• Donor should be under constant observation throughout the
phlebotomy and should never be left unattended.
• Mix the blood and anticoagulant gently during collection of blood.
• The flow of blood should be uninterrupted and constant.
• As soon as the required amount of blood is collected, clamp the
tubing of the bag with artery forceps or plastic clip. Deflate the cuff.
Place the sterile swab at the venupuncture site, apply light pressure
and withdraw the needle.
• Apply pressure over swab and apply bandage.
• The donor should remain on the bleeding couch for a few minutes
under the observation of staff. Check the venupuncture site then
the donor is allowed to sit up and go for refreshment.
• The donor should be thanked for the contribution and encouraged
to donate again for needy patient.
DONATION INTERVAL
The interval between the donation of a unit of blood should be atleast
12 weeks.
Instructions to Donor
1. Drink more fluids than usual in the next four hours.
2. Do not remain hungry.
3. If there is bleeding at the puncture site—ask him to apply pressure
and raise the arm.
4. If feeling of faintness—instruct him to either lie down or sit with
head between knees.
5. If any other symptoms persist ask for help and consult to blood
bank doctor.
6. Remove the bandage after 5 to 6 hours.
ADVERSE REACTIONS IN DONOR AND TREATMENT

Donor reactions are rare but sometimes they may occur during or after
the donation, but are manageable and harmless. Common adverse
reaction that may occurs are:
Fainting/Syncope/Vasovagal Syndrome
• This include—sweating, weakness, dizziness, transient unconscious-
ness. The skin becomes cold, BP falls, pulse becomes fast.
Management
1. Place the donor on his back and raise the legs above the level of
head.
2. Loose tight clothing.
3. Ensure adequate airway.
4. Apply cold compresses to head.
5. Keep a swab of irritant solution like ammonia or spirit near the
nose.
Twitching or Muscular Spam
This occurs due to hyperventilation or deep breathing which works
out CO2 which results into hyperventilation tetany.
Nausea and Vomiting

1. Make the donor comfortable and reassure him/her.
2. Ask to breath slowly and deeply.
3. Turn his/her head to one side.
4. If vomits give some anti-emetic.
Convulsions
1. Prevent from injury himself.
2. Ensure adequate airway.
3. Place tongue bite in between teeth.
Hematoma
1. Remove tourniquet and withdraw the needle.
2. Keep gauge piece over there with pressure for atleast 5 to 10 minutes.
3. Hold the arm above the head level.
4. Apply ice over there for 5 to 7 minutes.
BLOOD GROUPING AND CROSS-MATCHING

(COMPATIBILITY TESTING)
On the red blood cell surface there are many antigens. For practical
purposes, there are two groups of antigens that are of major importance
in surgical practice.
ABO Grouping
Red cells of the patient is tested with anti-A, anti-B, anti-AB and the
serum is tested with A, B and O red cells.
Antigens of the ABO blood groups are strongly antigenic.
Blood Group Antigen on RBC Antibody in Serum/Plasma

A A anti-B
B B anti-A
AB AB No ABO antibody
O None Anti-A and anti-B
Rh Grouping
The antigen of this group is Rh (D), which is strongly antigenic. It is
present in approximately 85% of the person and labeled Rh positive. In
remaning 15% population, it is absent and labelled Rh negative blood
group.
The patient’s red cells are tested for Rh (D) antigen with anti-D.
This antigen is capable to make anti Rh antibodies, that’s why Rh
positive individual should be given to Rh positive individual.
Crossmatch (Compatibility testing)

Compatibility test is done for safe transfusion. For compatibility testing
donor’s red cells are tested against the recipient’s serum. If antibodies
present in the recipient’s serum are incompatible with the donor’s cells,
a transfusion reaction will result. This is the result of agglomeration
and hemolysis of the donated cells, leading in severe condition to acute
renal tubular necrosis and renal failure. Blood group A+ individual
make neither anti –A nor Anti –B, that’s why it is known as Universal
recipients. Transfusion of blood group A, B into these is safe. Blood
group ‘O’ individual can make both anti-A and Anti-B antibodies. These
individuals have no A and B antigens, so their blood may be safely
transfused into the individual of all blood groups, i.e. A, B, AB and O,
therefore, it is known as Universal Donor.
Blood Group Donor Compatible with Recipient Compatible with

A A and AB A and O
B B and AB B and O
AB AB only All blood groups
O All blood groups Only with ‘O’ Blood Group
OTHER BLOOD GROUPS

1. Lewis Blood groups
2. System MNSs
3. Ss
4. P
5. Kell System
6. The Duffy (Fy) System
7. Kidd blood group system
8. The Lutheran (Lu) blood group system
9. Ii blood group system.
Adverse Effects of Blood Transfusion
Adverse effects which occur during or after transfusion are commonly
called blood transfusion reactions. They may be very mild and
occasionally may be very severe and life threatening which need
immediate stoppage of the transfusion and start emergency measure
to control these reactions.
IMMEDIATE REACTIONS
Anaphylaxis/Anaphylactic Reactions
These may occur after transfusion of few ml of blood. It is due to anti
Ig A.
Signs and Symptoms

• Flushing
• Nausea
• Vomiting
• Respiratory distress
• Choking feeling in throat—Constricting chest pain
• Shock and death within a few minutes.
Treatment
• Stop transfusion immediately
• Inj. Adrenaline 1 mg SC or slow IV
• Inj. hydrocortisone 200 mg IV
• Inj. Pheneramine maleate (Avil) IV
• Airway should be secured
• Oxygen at a high flow rate
• Circulatory support with volume infusions
• Inj. Ionotropes if necessary (Dopamine)
• Blood bank should be immediately informed about the untoward
reaction.
Febrile Nonhemolytic Reactions

It is due to antibodies to donor leucocytes or to plasma proteins.
Signs and Symptoms

• High fever with chills
• Tachycardia
• Tachypnoea
• In severe cases-cyanosis.
Leucoaglutinin reaction may occasionally produce pulmonary
infiltrates which may be mistaken for pulmonary edema on CXR.
Treatment
• The transfusion should be promptly stopped
• Antipyretics Inj. paracetamol IM
• Inj. Pheneramine (Avil) IV/IM.
Acute Hemolytic Reactions

These reactions are almost always due to human error due to transfusion
of incompatible blood. Hemolytic transfusion reactions may vary from
mild to fulminant and fatal.
There are four phases of reactions. All phases may not occur in a
patient.
1. Shock phase
• Fever, chill
• Pain in chest
• Pain in lumber region and back
• Burning sensation at the site of transfusion
• Hemorrhage
• Shock
2. Postshock Phase—if the reaction is not checked there may be
• Hemoglobinurea
• Hyperbilirubinemia
• Hemoglobinemia
• Disseminated intravascular coagulation (DIC)
3. Anuric phase
• Acute renal failure
• Oliguria
• Uremia.
4. Recovery Phase (Between 8 and 12 days)
In this phase patient passes large amount of urine. In the beginning,
urine is glomerular filtrate with a low concentration of urea. After
some days the tubular functions return and diuresis may have effect
on blood urea and creatinine. There may be excessive loss of pota-
ssium, thus hemolytic transfusion reactions may vary from mild to
fulminant and fatal. Back pain, fever and chest tightness are the
warning complaints in conscious patients.
If the patient is undergoing surgery under general anesthesia—in
incompatibility there is:
1. Unexplained hypotension
2. Tachycardia
3. Fever
4. Red Scanty Urine
5. Generalized oozinig
6. Recovery from anesthesia may be slow
Acute hemolytic transfusion reaction often produces acute oliguric
renal failure. Hemoglobinurea is present. Cardiovascular collapse and
DIC are important and serious complications which are due to immune
complex deposition and stimulation of the coagulation cascade,
resulting in a consumption coagulopathy. In severe cases, the perfusion
to vital organ system is grossly impaired leading to tissue hypoxia and
damage.
The degree of damage is dose related. For this reason, even mild
febrile reactions occurring in a patient receiving a transfusion, should
promptly stop transfusion.
Treatment
1. Stop transfusion immediately.
2. Vital signs are monitored.
3. Intravenous fluid should be infused to maintain adequate blood
pressure and renal perfusion.
4. Inj. Furosemide 60 to 250 mg (Lesix) intravenously together with
Inj. Mannitol should be used to maintain a urine output of 100 ml/
hour or more. A larger dose of furosemide may be repeated if the
urine output falls.
5. DIC may need to be treated by replacement of clotting factors and
or by infusion of cryoprecipitate.
Following measure should also be done:
1. Re-check all labels, forms and identity of the patient to confirm that
patient had received correct blood and there was no clerical error.
2. Preserve the urine passed after the transfusion to check the presence
of hemoglobin produced by the lysis of red cells.
3. Compare the patient’s pre and post-transfusion specimen for the
color of serum or plasma.
• Pink or red discoloration in post-transfusion sample indicates
the presence of free hemoglobin due to destruction of red cells.
• Yellow or brown discoloration in samples drawn 4 to 10 hours
after the transfusion indicates increased bilirubin.
4. Repeat ABO, Rh (D) testing.
5. Do antiglobulin test for incompatibility.
Urticaria
This is due to antibody to plasma proteins.
Treatment
1. Stop transfusion immediately.
2. Inj. Pheneramine maleate (Avil)
3. If urticarea are severe Inj. Adrenaline subcutaneously or intra-
venously.
4. Inj. Hydrocotissue 100 to 200 mg IV.
5. Check for further signs and symptoms of reactions.
Other Nonimmunoliogic Effects

i. Fever with shock – due to bacterial contamination.
ii. Congestive Heart Failure (CHF) due to volume overload.
iii. Hemolysis with symptoms – due to freezing or overheating,
mixing non-isotonic solutions with red cells.
DELAYED REACTIONS
Delyaed Hemolytic Reactions
These are mild and generally occur one week after the transfusion. Initial
cross-matching fails to detect antibodies to donor red cell antigens.
A several transfusion with a repeated exposure to the red cell antigen
provokes an anamnestic reaction of the antibody and which is sufficient
to cause hemolysis. In this: (i) there is fall in hemoglobin (Hb), (ii) rise
in bilirubin and mild jaundice 5 to 7 days after the transfusion.
Allergic Reactions
These may be caused by the patient’s pre-formed reagins reacting with
transfused allergies or by the passive transfer of reagins present in the
donor blood.
Signs and Symptoms

• Wheels (urticaria)
• Itching
• In rare cases—laryngeal edema or bronchial spasm.
Treatment
Inj. Antihistamines (Avil).
Graft vs Host Disease (GVH)

It is common in patients receiving bone marrow transplants.
Symptoms
• Fever
• Bone marrow depression
• Skin rashes
• Diarrhea
• Hepatitis
Nonimmunologic Effects
i. Iron overload
ii. Transmission of infection
• Hepatitis
• AIDS
• Protozoal infection, e.g. malaria
• Syphilis
• Mononucleosis like effects
• Cytomegalovirus (CMV).
MASSIVE TRANSFUSION
Massive transfusion is defined as transfusion of blood equal to the
patient’s blood volume within a period of 24 hours.
For massive transfusion, it is best to use blood that is not more than
7 days old.
Complications Associated with Massive Transfusion

1. Increased O2 affinity of red blood cells
2. Increased plasma potassium
3. Microaggregates
4. Coagulation factor depletion
5. DIC
Management
Traditional regimens for managing massive transfusion include routine
use of supplements like:
1. Fresh frozen plasma
2. Platelets, or both
3. Alkalizing agents
4. Calcium supplements.
All in fixed quantities according to the amount of blood transfused.
The need for supplements should be judged by careful clinical
assessment and laboratory measurements.
AUTOLOGOUS TRANSFUSION
Autologous transfusion is the re infusion of patient’s own blood.
The broad categories of autologous transfusion.
1. Predeposit, in which blood is withdrawn and stored before the
intended transfusion.
2. Hemodilution and short-term storage, in which blood is withdrawn
just before the operation and is stored for a short period.
3. Intraoperative blood salvage.
Advantages
• There is no risk of transmission of diseases like AIDS, Hepatitis,
Syphilis, Malaria, etc.
• Elimination of allo-immunization to red cells, leucocytes, platelets
and plasma proteins.
• No risk of hemolytic, febrile and allergic reactions.
• To provide fully compatible blood.
• Provision of blood in remote area where blood supply is
unpredictable.
• Valuable source to supplement the blood supply.
Indications
• Requirement of rare blood groups.
• Presence of unexpected antibodies in recipients.
• Prevention of allo-immunization.
• Religious belief.
• Elective major surgery.
Criteria for Donation

Age
There is no upper age limit for autologous donation. The lower age
limit is determined by the capacity of the child to understand and
cooperate. The volume withdrawn is dependent on the patient’s blood
volume.
Volume of Blood Collection/Weight

There are no specific requirements of weight. A donor weighing 45 kg
can give 300 ml blood. A donor weighing 55 kg or more can give 450 ml
of blood (8 ml per kg body weight).
Hemoglobin
The hemoglobin of the patient-donor should not be less than 11 gm/dl.
Hemotocrit should be 34% or greater.
Frequency of Donation
Blood should not be drawn more often than once a week. Donation for
pre-deposit transfusion should not be undertaken when patient-donor
has or is being treated for bacteremia.
Iron Supplementation
Iron supplementation may be necessary when frequent phlebotomy is
being done.
Hazards
1. Anemia and hypovolemia.
2. Clerical error in recipient identification labeling and storage.
3. Increased cost, professional time and paper work.
4. Patient-donor reactions due to anemia and hypovolemia.
5. Units lost when surgery is postponed or cancelled.
6. Loss of working time and difficulties experienced by patient-donor
to travel several times to blood bank for blood donation.
INTRAOPERATIVE BLOOD SALVAGE

In certain operations like:
1. Total hip replacement
2. Ruptured spleen or liver
3. Aneurysm.
The blood is salvaged from the operative area which is processed
and reinfused into the patient. Large variety of devices (cell savers) are
available for the processing of salvaged blood through filtering,
mechanical washing and concentrating devices.
Blood salvaged should not be transfused to another patient.
Contraindications
It is contraindicated in:
• Patient with malignancy
• Perforated viscera
• In gross contamination or infection.
Hazards
1. Consumption of coagulation factor and platelets.
2. Sepsis from contaminated blood.
3. Cancer dissemination.
EXCHANGE TRANSFUSION
Exchange transfusion is an effective method for correcting anemia
without increasing probability of circulatory overload and CHF
(Congestive Heart Failure) and removing harmful toxic substances from
circulation. It is the limited or partial replacement of patient’s blood by
homologous blood or red cells having adequate oxygen carrying
capacity.
Indications
• Hemolytic disease of new born.
• Sickle cell anemia.
• Small volume of exchange transfusion in pregnant women.
• Disseminated intravascular coagulation (DIC).
• Sepsis, etc.
FRESH FROZEN PLASMA (FFP)

FFP is plasma obtained from a single donor and rapidly frozen within
six hours. It contains all coagulation factors. Great care must be taken
during collection of blood, freezing and thawing to preserve their
activity.
Collection of Blood
Blood should be collected by a clean, single venupuncture at the first
attempt and the flow of blood should be rapid and constant. It is
recommended that the total time taken to collect 450 ml blood be not
more than 10 min (at an approximate rate of 45 to 50 ml/min). The
blood and the anticoagulant should be thoroughly mixed during
collection.
Freezing
This should be done as soon as possible after collection, in any case
within four hours. The complete freezing process should be as short as
possible and preferably should not take more than one hour, at 70o C
in ethanol dry ice bath. Alternatively least freezing can be achieved
using chilled metal plates and then freezing.
Storage
It has been shown that the most labile coagulation factors are preserved
for one year if FFP is kept at 30°C or below.
If FFP is not used within one year it is redesignated as a signle donor
plasma which can be kept further for four years at 30°C or below.
Procedures
1. Collect appropriate volume of donor blood in 350/450 ml CPD.
2. Store at 4°C till processed, but nor more than four hour.
3. Place bags in the bucket of the refrigerated centrifuge and balance
them accurately.
4. Centrifuge at 5000-X-gm for 5 minute OR 4000-X-gm for 10 minute
at 4°C.
5. Express approximately three-fourth of the plasma into a sterile
satellite bag.
6. Double seal the tube between primary bags and the satellite bag
having plasma with metal clips or dielectrical sealer and separate
the satellite bag.
7. Label the plasma bag and is rapidly frozen by any method.
FFP Contains
1. Factor VIII 2. Factor IX
3. Factor XI 4. Other clotting factors
Storage and Shelf Life

At 30oC or below – one year.
Uses
1. After multiple transfusion.
2. Disseminated intravascular coagulation (DIC)
3. Volume replacement
4. Bleeding disorders – treatment of acquired deficiency of factors II,
VIII, IX and X.
5. Familial factor V deficiency.
6. Coagulopathy in liver diseases.
7. Deficiency of Vit. K dependent coagulation factors (II, VII, IX and X)
8. During cardio-pulmonary by-pass.
9. Hemophilia A B.
Adverse Effects
• Urticaria and anaphylactoid reactions.
• Circulatory overload.
• Reaction caused by vasoactive substances.
• Transmission of diseases.
Plasma Volume
28 Expanders
PLASMA PROTEIN SOLUTION AND PLASMA SUBSTITUTES

Plasma Protein Solution (PPS)
Plasma protein solution is prepared from pooled plasma after removal
of factor VIII concentrate, fibrinogen and immunoglobulins.
The protein contents of plasma protein solution is mostly albumin.
Albumin Preparations
Albumin is available for clinical use as:
1. Albumin 5%
2. Albumin 25%
3. Plasma protein fraction (PPF)
All these preparations are heated to 60o C for 10 hours to inactivate
viruses like hepatitis viruses and HIV.
Shelf Life Depends on the Storage

Shelf-life depends on the storage temperature:
Temperature Shelf-life
• Room temperature (20 to 25°C)—3 years
• 2o to 8o —5 years
• After opening bottle/vial—4 hours.
One of the most urgent requirements is plasma volume expanders
in a patient suffering from acute blood loss for the re-establishment of
a normal blood volume.
Plasma protein fraction (PPF) is available as five percent solution in
electrolyte and contains 83% albumin and 17% alpha and beta-globulins.
Albumin is responsible for 80% of the colloid oncotic pressure of plasma.
These are also named plasma volume expanders or blood substitutes.
These solutions remain in the circulation long enough to maintain
normal blood volume (4 to 6 hours).
Plasma Volume Expanders 277
Classification of Plasma Volume Expanders
1. Natural
– Albumin (Human)
2. Synthetic
– Degraded Gelatin
Hydroxy Ethyl Starch

Dextrans.
Human Albumin
It is an ideal naturally occurring colloid solution. It is in 5% and 25%
strength.
Albumin 25% contains 96% albumin and four percent globulins.
It is diluted to five percent solution in electrolyte before infusion.
Mostly it is available in 100 ml vials.
Indications of Five Percent Albumin and PPF

• Five percent human albumin is used for the treatment of burn.
• Hypovolemia due to any cause.
• Hypoproteinemia following burns and extreme surgery.
• Hemorrhagic shock.
Indications of 25% Albumin

• Severe hypoproteinemia in acute nephritic syndrome and acute liver
disease.
– In adults – 100 to 400 ml daily.
– In children 1.5 to 6 ml/kg body weight in 24 hours.
– Diuretics should also be given along with albumin if edema is
present.
• Hyperbilirubinemia in the new born. 5 to 10 ml of salt poor albumin
is given along with blood for exchange transfusion. It binds excessive
bilirubin and reduce incidence of kernicterus.
• Toxemia of pregnancy – 50 ml of salt poor albumin is given daily.
Contraindications
• Hypoproteinemia in malnutrition
• Chronic nephritic syndrome
• Cirrhosis of liver.
Adverse Effects
• Urticaria and anaphylactoid reactions
• Circulatory overload
• Febrile reactions
• Hypotension due to vasoactive substances from plasma. Sometimes,
it is seen with PPF when the role of administration is more than 10
ml/minute.
Disadvantages
• It is quite expensive.
• It can transmit infectious agent causing Creutzfeld-Jakob disease.
• It is not freely available.
Plasma Substitutes
1. These are designed to provide colloid osmotic pressure or expand
the plasma volume, i.e. colloid and crystalloid.
2. Those able to transport oxygen, i.e. perfluoro–compounds and
encapsulated hemoglobin.
Colloid solutions are:
1. Degraded gelatin
2. Hydroxy ethyl starch 450
3. Dextrans – this a mixtures of polysaccharide molecules of different
molecular weight, i.e. Dextran 40 and Dextran 70.
Generic name Contents Intravascular half life
1. Gelatine 3.5% gelatine polypeptide 3 to 5 hours

(MW 35000) with
Ringer’s solution
2. Hydroxyethyl 3 or 6% solution 24 hours
starch (MW 45000) with
0.9% Saline
3. Dextran 40 10% Polysaccharide 4 to 6 hours
(MW 40000)
with normal saline
4. Dextran 70 6% Polysaccharide 6 to 8 hours
(MW 70000) with
normal saline
Disadvantages
• It is not available freely.
• It can transmit infectious agent, e.g. causing Creutzfeld-Jakob
disease.
Degraded Gelatin (MW 35000)
It is available in 500 ml pack, 3.5% solution. It is polymer of degraded
gelatin with electrolytes. It remains in blood for 4 to 5 hours.
It contains – Succinyl gelatin and partially degraded gelatin in 3.5 to
4% solutions in 500 ml bottles.
Gelatin has no antigenic property and does not interfere with
hemostasis. This solution is least potent of the colloidal plasma solutions.
Blood volume expansion effects are satisfactory while awaiting blood.
The dose is 500l to 1000 ml.
These solutions have intermediate duration of action and
anaphylactoid reaction is less. It does not interfere with blood grouping
and cross matching.
Precautions
1. Solution should be clear.
2. No drug should be added in the solution.
3. Blood should not be given with same tubings/set used for this
solution. It contains calcium, so when mixed with citrated blood it
may cause clotting. But citrated blood can be transfused before or
after this infusion provided the tubings has been changed or flushed
with ringer lactate or normal saline solution.
4. When any sign of anaphylactic reaction occurs, infusion should be
stopped immediately. Give inj. Avil, Hydrocotisone, Adrenaline and
vasopressors.
Uses
1. All types of hypovolemic shock.
2. To keep the circulatory system stabilize during anesthesia in major
surgery.
3. Can be used prophylactically before any major surgery.
Adverse Effects
• Hypersensitivity reactions like urticaria, rigor, flushing.
• Bronchospasm.
• Hypotension (Fall of BP).
• Acute circulatory overload.
HYDROXYETHYL STARCH
It is available as 3%, 6% solution in 0.9% saline (MW 45000).
Hydroxyethyl starch, produced from sorghum or maize. The
duration of intravascular retention is more than six hours. Starch
preparations are stable at room temperature and have long shelf-lines.
Its expander effects more modest than those of Dextran 70. Its initial
half life in the circulation is 24 hours, but almost 20% of the infused
HES remains in the body after one week after a single infusion of HES
and repeated administration has a cumulative effect. It has low incidence
of adverse reaction.
Adverse Reaction
• If large amount of HES are infused over several days, tissue
deposition may result in intractable itching.
• Anaphylactoid reaction but incidence are less.
• It can cause – vomiting, chills, mild temperature.
• It can cause enlargement of parotid and submandibuler glands.
• Headache.
• Muscle pain.
• Edema of lower extremities.
If sign of adverse reaction noted infusion should be discontinued.
Dextrans
1. It is a polysaccharide polymers of varying molecular weight
producing an osmotic pressure similar to that of plasma.
2. These have the disadvantage of inducing rouleaux formation of
RBCs.
3. These interfere with blood grouping and cross matching.
4. There interfere with platelet function and may be associated with
abnormal bleeding. For this reason it is recommended that the total
volume of dextran should not exceed one liter.
5. Both dextrans can precipitate anaphylactic reaction.
6. It remains in circulation for 76 hours.
Dextran 40
It is polysaccharide (40000) solution in normal saline. It is generally
accepted that the dose of dextran 40 should not exceed 500 ml in 24 hour
in an adult.
Uses
1. In the management of crush syndrome, severe burn, fat embolism,
mesenteric infarction, pancreatitis, peritonitis.
2. It prevents intravascular sludging thereby improves capillary blood
flow and maintain renal function.
3. In vascular surgery.
Dextran 70
Its molecular weight is 70000. It is six percent polysaccharide solution
in 0.9% sodium chloride.
Its use of more than 1000 to 1500 ml may cause abnormal bleeding
in patients and due to this use of dextran 70 has reduced.
Uses
1. Shock
2. Trauma
3. Surgery
4. Severe burns
5. Deep vein thrombosis
6. Prophylaxis – post-traumatic thromboembolism.
Advantages of Colloids
• Readily available
• Storage and administration easy
• Do not transmit disease
• Provide oncotic pressure
• Blood volume expansion effects are satisfactory while awaiting
blood.
Disadvantages of Colloids
• Short half life in circulation
• Mildly immunogenic
• Lack of oncotic pressure in plasma
• May interfere with hemostasis
• May delay replacement of albumin.
Crystalloid Solutions
These are formulated to correct fluid deficits. They have the capacity
to expand the plasma volume temporarily.
Replacement Crystalloids are Isotonic

It includes: (1) Lacated Ringers, and (2) 0.9% sodium chloride (Normal
saline solution).
These fluids enter both the plasma and interstitial fluid compartment
without shifting the osmotic balance. As a result large volumes of these
replacement fluids are required to expand the intravascular plasma
volume. They should be carefully administered to avoid overload of
fluid to prevent pulmonary edema.
Advantages of Crystalloids
• Readily available
• Storage and administration is easy
• Do not transmit disease
• Cheap
• Do not inhibit synthesis of albumin
• Non-immunogenic.
PERFLUOR COMPOUND
Oxygen is highly soluble in perfluro-chemicals components. Perfluoro
compound known as fluosol BA has been available for a number of
years for investigation use. It has limited oxygen carrying capacity. It
can carry substantial amount of oxygen, only when exposed to high
oxygen tensions which may be toxic. The emulsion is not been found
to be safe. However, other compounds have been developed but none
of these are presently available for clinical use.
29 Intravenous Fluids
INTRODUCTION
These are the fluids which are infused in the body via intravenous route
to restore the volume and to maintain homeostasis. Homeostasis—is a
process through which body equilibrium is maintained.
Purpose of Infusion
1. To maintain electrolyte balance of the body.
2. To correct dehydration or to restore the volume lost from the body
due to vomiting, bleeding, high grade fever, heat stroke, diarrhea,
fistula, drainage, etc.
3. To administer various medicines like-antibiotics, antispasmodic,
dopamines, diuretics, sedatives, etc.
4. To keep the patient fasting - before, during and after operation when
patient is kept NPO/NBM.
5. To give nutrients and electrolytes like - amino acids, multivitamins,
potassium, fat emulsions, calcium gluconate, plasma expanders, e.g.
dextran, hydroxyethyl starch.
6. To give total parenteral nutrition (TPN)
7. To give fluids when patient is unable to take by orally or patient is
kept nothing by mouth (NBM) or nothing per oral (NPO).
Different Types of IV Fluids

Commonly used intravenous fluids are:
1. Dextrose 5%, 10%, 20%, 25%, 50%.
2. Normal saline (0.9%)
3. Half normal saline (0.45%)
4. Normal saline with 5% dextrose/glucose (DNS/GNS)
5. Ringer lactate (RL) solution.
6. Isolyte-G, Isolyte-M, Isolyte-E, Isolyte-P
7. Mannitol
8. Plasma volume expanders
9. Amino acids
10. Fat emulsions
INTRAVENOUS SOLUTION
Normal Saline
• It is an isotonic solution. It contains 0.9% solution of sodium chloride.
• The concentration of Na+ 154 meq/L, Cl– 154 meq/L.
Uses
1. It is used in dehydration, shock condition, e.g. vomiting, excessive
sweating, intestinal obstruction, heat exhaustion.
2. It is used to clean the wound, irrigate the body cavities, abscess
cavity, etc.
3. To dress clean wound.
4. To flush out the infusion set before and after the blood transfusion,
as it does not cause aggregation of red blood cells.
Precautions
1. It should not be used in early postoperative period as there is already
sodium retention (due to increased aldosterone activity).
2. It should be used with a great precaution in cardiac failure, cirrhosis
of liver, renal failure patients.
Dextrose Solution
• It is available in different strengths, e.g. 5%, 10%, 20%, 50%.
• One gram glucose provides 4 kalories.
Uses
1. During preoperative fasting stage .
2. It protects the liver against toxic substances.
3. It is used in the treatment of - hypoglycemia, starvation, jaundice,
diarrhea, vomiting, high grade fever.
4. It is used in early postoperative period as there is already retention
of sodium and potassium due to increased aldosterone activity and
increased amount of potassium which enters the circulation as a
result of operative trauma.
5. 50% glucose/dextrose solution may be used to decrease the cerebral
edema.
Intravenous Fluids 285
Precautions
1. It should never be used in water intoxication.
2. It should not be used in diabetic patient without neutralizing with
insulin, unless there is hypoglycemia or ketosis.
3. It should not be used along with blood transfusion as it may cause
pseudo-agglutination of RBC when acid citrate-dextrose
anticoagulant is used.
4. Higher concentration of glucose may cause irritant effect in veins
and may cause thrombophlebitis.
Dextrose 5% in Normal Saline (GNS or DNS)

This solution is most common in use. It contains 5% dextrose and 0.9%
sodium chloride. It provides about 200 calories/liter.
1. It is used during preoperative and post operative period.
2. It is used for prevention and treatment of various conditions like
vomiting, excessive sweating and diarrhea.
Cautions
It should be used with great caution in case of renal insufficiency,
cardiac, renal or liver disease.
RINGER LACTATE SOLUTIONS (RINGER- SIDNEY ENGLISH

PHYSIOLOGIST)
It contains sodium, chloride, lactate and potassium.
It is used:
1. In the treatment of dehydration associated with metabolic acidosis,
e.g. diarrhea, burn, infection, diabetic keto acidosis.
2. To correct metabolic acidosis.
POTASSIUM CHLORIDE SOLUTION

It is available in ampoules and infusion bottles.
Uses
1. Postoperative paralytic ileus.
2. Metabolic alkalosis.
3. Prolonged diuresis.
4. Diabetic ketoacidosis.
Contraindications
• Hyperkalemia state.
• Along with potassium sparing diuretics.
• Renal insufficiency.
CALCIUM GLUCONATE, CALCIUM CHLORIDE SOLUTION
Available in Ampouls
• Calcium gluconate 10% solution contains 0.45 meq calcium/ml.
• Calcium chloride 5-10% solution equivalent to 0.68 to 1.36 meq
calcium/ml.
Precaution
It should be given in infusion or very slowly otherwise sudden
cardiovascular collapse may occur.
It is used in:
1. Tetany.
2. Postoperative paralytic ileus due to potassium deficiency.
3. In the treatment of prolonged vomiting and diarrhea.
4. Hyperkalemia.
5. Hypoparathyroidism.
6. After massive transfusion of citrated blood.
7. Renal insufficiency.
8. In hyperphosphatemia.
PROTEIN SOLUTION
• Daily requirement of protein is 1 gm/kg body weight/day.
• Protein provides 4 kcalories/gm.
Intravenous fluids which supply the proteins are:
1. Blood
2. Albumin
3. Amino acids
4. Protein hydrolysate
Protein Hydrolysates
One gram of protein hydrolysate is equal to 0.75 gm of protein. It is
available as 5% solution with dextrose or fructose. These are sterile
solutions of amino acids and short chain peptides.
Casein hydrolysates contains free amino acids, peptides, phosphates
and sodium.
AMINO ACIDS SOLUTION

It is available in 3.5 to 20%. It contains essential and non-essential amino
acids.
Complications while Using Protein Solution
1. Hypersensitivity reactions
2. Thrombophlebitis
Cautions
1. Its infusion should be discontinued if any signs of hypersensitivity
reaction are observed.
2. During TPN (total parental nutrition), carbohydrates should be given
simultaneously to avoid catabolism.
3. Higher concentration of dextrose or amino acids will lead to various
thrombosis and must be given through a central vein.
Contraindications
• Hypokalemia
• Acidosis
• Hepatic, renal and cardiac complications
Uses
1. Malabsorption syndrome
2. Malnutrition
3. Total parental nutrition
4. Postoperative period
5. In septicemic conditions
6. Burn
7. Cachexia
8. In advanced malignancy
9. Hepatic encephalopathy.
FAT EMULSION SOLUTION (INTRALIPID)

Fat gives 9 kcal per gm. It is available in 10%, 20%. This emulsified fat
is stable, isotonic and is rapidly absorbed in the body. It is without
osmotic effects and well-tolerated by the body. It is made isotonic by
addition of glycerol.
Dose - 3 mg/kg body weight/day.
It is given slowly. The chief source of fatty acids in IV fate emulsion
is soya bean with or without safflower.
Precautions
1. It should be given slowly.
2. No drug should be added in this.
3. Inj. heparin 2.5 units/ml should be added to increase the rate of fat
clearance and to prevent hypercoagulation.
4. When side-effects are noted it should be discontinued immediately.
Uses
1. Malabsorption syndrome.
2. Burns
3. Patient with high calorie deficiency
4. Cachexic patient
5. Total parenteral nutrition
Adverse Effects
• Nausea and vomiting.
• Fever
• Urticaria
• Pain in loin and chest
• Cardiorespiratory embarrassment.
Contraindications
In following conditions it should be avoided in:
• Pregnancy
• Diabetic patient
• Renal failure
• Hyperlilpedemia
• Coagulation defects/blood disorders.
ISOLYTE-P SOLUTION
It is an electrolyte solution contains dextrose, sodium, potassium,
magnesium, chloride, phosphate. It is used for maintenance of
electrolytes in infants and children.
Isolyte-G solution
It is an electrolyte solution contains - dextrose, sodium, potassium,
ammonium ion and chloride.
Uses
1. It is used as replacement gastric fluid that is lost due to vomiting,
nasogastric aspiration.
2. Metabolic alkalosis, resulting from excessive ingestion of sodium
bicarbonate.
3. Over use of organomercurial diuretics.
Precautions
It should not be used in severe liver disease as it contains ammonia
which is not converted into urea in liver disease.
ISOLYTE-M SOLUTION
It is an electrolyte solution contains - dextrose, sodium, potassium,
chloride, acetate and phosphate.
Uses
1. It is mainly used for maintenance drip.
2. In case of excessive sweating.
3. Acute abdomen, e.g. peritonitis, intestinal obstruction, pyloric
stenosis.
4. Vomiting
5. Diarrhea.
Precautions of Infusing Electrolytes Solutions

These should be avoided in
1. Renal failure
2. Adrenal insufficiency
3. Hypoparathyroidism
4. Severe liver disease—particularly Isolyte G solution which contains
ammonia which is not converted into urea in liver disease.
5. Hyperkalemia.
PLASMA VOLUME EXPENDERS OR BLOOD SUBSTITUTES

One of the most urgent requirement in a patient suffering from acute
blood loss is the re-establishment of a normal blood volume. This may
be achieved satisfactorily with plasma substitutes. These solutions
remain in the circulation long enough to maintain normal blood volume
(4-6 hours).
Classification
I. Natural - Albumin (Human)
II. Synthetic - Degraded
• Hydroxyethylstarch
• Dextrans
Human Albumin
It is an ideal naturally occurring colloid solution. It is prepared from
human plasma and heat treated to ensure that neither hepatitis nor
HIV can be transmitted. It has a relatively short shelf life (about year)
at room temperature but a 5 year shelf - life at 2 to 8°C.
Uses
1. Five percent Human albumin is used for the treatment of burn.
2. Concentrated salt poor 20% human albumin is used for the treatment
of severe hypoalbuminemia in the pressure of salt and water
overload, e.g hepatic failure with ascites.
3. Hypovolemia due to any cause.
Adverse Effects
It can cause anaphylactoid reaction.
Disadvantages
• It is not available freely.
• It can transmit infectious agent, e.g. causing creutzfeldt-jakob
disease.
DEGRADED GELATIN (HAEMACCEL)

It is available in 500 ml pack, 3.5 % solution. It is a polymer of degraded
gelatin with electrolytes. It remains in blood for 4-5 hours. Each 100 ml
contains:
Polymer from degraded gelatin 3.5 gm and electrolytes in mmol/
litre
Na+ – 145, Ca++ – 6.25, K+ – 5.1, Cl– 145
The composition is made isoionic with polypeptides.
These solutions have intermediate duration of action and
anaphylactoid reaction is less. It does not interfere with blood grouping
and cross-matching.
Precautions
1. Solution should be clear.
2. No drug should be added in the solution.
3. Blood should not be given with same tubing/set used for this
solution. It contains calcium, so when mixed with citrated blood it
may cause clotting. But citrated blood can be transfused before or
after this infusion provided the tubing has been changed or flushed
with ringer lactate or normal saline solution.
4. When any sign of anaphylactic reaction is noted, infusion should be
stopped immediately. Give inj. avil, hydrocortisone, adrenaline and
vasopressors.
Uses
• All types of hypovolemic shock.
• To keep the circulatory system stabilizes during anesthesia in major
surgery.
• Can be used prophylactically before any major surgery.
Adverse Effects
• Hypersensitivity reactions like urticaria, rigor, flushing.
• Bronchospasm.
• Hypotension (fall of BP)
– Hydroxy Ethyl Starch (Hestar 3% and 6%, Expan, HAES - Steril
6%)
– Hydroxyethyl starch, produced from sorghum or maize. The
duration of intravascular retention is > 6 hours. Starch
preparations are stable at room temperature and have long shelf
lives. Each 100 ml contains:
– HES - 6 gm
– Sodium chloride - 0.9 gm
– Electrolytes in meq/lit Na+ 154, Cl– 154
– It has low incidence of adverse reaction.
Adverse Reactions
• If large amount of HES are infused over several days, tissue
deposition may result in intractable itching.
• Anaphylactic reaction but incidence is less.
• It can cause—vomiting, chills, mild temperature elevation.
• It can cause enlargement of parotid and submamdibular glands.
• Headache
• Muscle pain.
• Edema of lower extremities.
Caution
If signs of adverse reactions is noted infusion should be discontinued.
Dextrans
• It is a polysaccharide polymer of varying molecular weight
producing an osmotic pressure similar to that of plasma.
• These have the disadvantage of inducing rouleaux formation of
RBCs. These interfere with blood grouping and cross-matching.
• These interfere with platelet function and may be associated with
abnormal bleeding. For this reason it is recommended that the total
volume of dextran should not exceed one liter.
• Both dextrans can precipitate anaphylactic reaction. It remain in
circulation for >6 hours.
Dextron 40
Uses
1. In the management of crush syndrome, severe burn, fat embolism,
mesenteric infarction, pancreatitis, peritonitis.
2. It prevents intravascular sludging thereby improves capillary blood
flow and maintain renal function.
3. In vascular surgery.
Dextran 70
Its molecular weight is 70000 contains 09%. sodium chloride and 5%
dextrose.
Uses
1. Shock
2. Trauma
3. Surgery
4. Severe burns
5. Deep vein thrombosis
6. Prophylaxis—Post-traumatic thromboembolism.
Human
30 Immunodeficiency
Virus (HIV)
NATURAL HISTORY OF HIV DISEASE

First reported in December 1981, with the description of opportunists
and Kaposi’s sarcoma occurring in homosexual men. Following
infection by the HIV-I virus into the blood, there is a brief seroconversion
illness that is characterized by flu-like symptoms of lymphadenopathy.
Then there is a latent period in which infected person remains well but
has a progressive fall in CD4+ lymphocyte count. It is expected that
25 to 35% of those infected will develop AIDS within 2 years of infection
if left untreated. The mortality from AIDS is thought to be 100%. HIV-
I viral titres are at their highest during the initial seroconversion and the
late AIDS phase of the illness.
There are three important factors—CD4 (T-helper Cells) count, HIV
plasma load and the ability of the patient to receive highly active
antiretroviral therapy (HAART).
HIV-seropositive patients die as a result of a wide variety of
opportunistic infections caused by the CD4 count falling below a critical
level. A low CD4 count is often below a critical level. A low CD4 count
if often the best guide to likely clinical events or death within the near
future. The plasma viral load is the best long term guide to prognosis
in part because it predicts the rate at which the CD4 count is likely to
fall. HAART therapy is capable of inhibiting all detectable
viral replication and clearing the virus from both plasma and lymph
nodes.
HIV has been isolated from blood, semen, saliva, tears, vaginal
secretions, alveolar fluid. Only blood and blood products,
semen, vaginal secretions, and breast milk have been linked to
transmission.
The Centers for Disease Control (CDC)
Classification of HIV Disease
Group Description
I Acute Infection
II Asymptomatic infection
III Persistent generalized
lymphadenopathy
IV
Subgroup A Neurological disease
Subgroup B Secondary infection disease
Subgroup C Specified secondary infection disease listed in the CDC
Surveillance definition for AIDS
Category
C-I Other specified secondary infection disease
C - II Secondary cancers, including those within the CDC
Surveillance definition for AIDS
Subgroup D Other disease
Subgroup E Other conditions
TRANSMISSION
The most certain mode of transmission is by transfer of infected blood.
The HIV-I virus is considerably less infective than hepatitis B, and 1 ml
of infected blood contains approximately 50 HIV-particles compared
with 109 hepatitis B particles.
Groups as high risk for acquisition of HIV-I infection include the
following:
1. Homosexuals and hetrosexuals who indulge in anoreceptive
intercourse.
2. The risk of infection increases with the number of partners,
associated infected such as gonorrhea and history of hepatitis B.
3. Drug addicts who become infected by using a contaminated needle
from a HIV-I positive source.
4. Hemophiliacs who receive factor VIII prepared from HIV infected
blood.
5. Sub- Saharan Africans. In Africa, heterosexual transmission and HIV
enteropathy (diarrhea - wasting syndrome, 'skin' disease) occur
much more frequently than in the west.
6. Children born to HIV positive mother.
Recipients of transfusion of blood and blood product from HIV
positive donors have approximately a 95 percent chance of developing
HIV infection, and over 4500 cases of transfusion-acquired AIDS have
Human Immunodeficiency Virus (HIV) 295
been reported to the CDC. This number could eventually reach 12000
because HIV positive transfusion recipients who are thought to exist
but have not yet developed AIDS. Since testing blood donors for
evidence of HIV became mandatory in1985, transfusion-acquired HIV
infection has been virtually eliminated.
HIV seroprevalence varies greatly depending on the specific
population studied, the location of the population, sex, race and ethnic
origin and year of study. The lowest HIV seropositive rate are found
among blood donors and are highest among hemophiliacs, intravenous
drug users, homosexual men.
SEROLOGIC EVENTS
Patients infected with HIV develop viremia accompanied by a
generalized lymphadenophy, fever and malaise. Approximately 6 to
12 weeks after infection antibody to HIV develops. During this time
the viral titer in blood decreases markedly from 104/ml. A low level of
virus persists until the patient develops AIDS approximately seven to
nine years after infection. When AIDS develops, the virus titer rapidly
in creases to a level of 104/ml. Since serologic testing examines antibody
to HIV, it is seldom positive before 12 weeks after infection. During
this early period (“the window”), it is possible for patients to have
circulating virus and be potentially infectious to those around them
and yet test negative for HIV.
Risks of Transmission of HIV Disease/

Presentation to the Surgeon
The surgeon is regularly exposed to blood, which is the most infective
medium for HIV transmission.
The principle route of occupationally acquired HIV infection is health
care workers is by skin perforation with a hollow needle containing
HIV-infected blood.
Precautions
The risk of contamination to the surgical team can be reduced by the
use of universal precautions which involves—
1. Wearing either safety spectacles or a face mask.
2. Wearing gown that provides water-proof protection to the
surgeon's anterior trunk and arms.
3. Wearing boots rather open toed shoes should be worn to protect
the feet when something sharp is dropped.
4. Needle-stick injuries to the hands most frequently occur on the
index finger and palm adjacent to the thumb of the non-dominant
hand. This is presumably a result of passing the needle through
tissue with a needle holder held by the dominant hand and
attempting to locate the tip of the needle with the non-dominant
hand.
5. Skin contamination from glove perforation can be reduced by
approximately five fold by wearing two pairs of gloves. It is usually
more comfortable if the larger sized glove is worn on the inside
next to the skin and a half size, smaller glove is worn as the outer
second layer.
6. Sharp instruments or scalpels should not to passed across the
operative field from hand to hand. All sharp instruments should
be passed in a dish, thereby reducing the risk of injury while
passing instruments.
7. All health care workers should take precautions to prevent injuries
caused by needles, scalpel and other sharp instruments or devices
during procedures. When cleaning used instruments; during
disposal of used needles; and when handling sharp instruments
after procedures. To prevent needlestick injuries, needles should
not be recapped, purposely bent or broken by hand, removed from
disposable syringes or otherwise manipulated by hand. After they
are used, disposable syringes and needles, scalpel blades, and other
sharp items should be placed in puncture-resistent containers for
disposal. The puncture resistant containers should be located as
close to practical to the area of use. Large-bore reusable needles
should be placed in a puncture-resistent container for transport
to the reprocessing area.
8. All health care workers should use appropriate barrier precautions
routinely to prevent skin and mucous membrane exposure when
contact with blood or other body fluids of any patient is
anticipated. Gloves should be worn for touching blood and body
fluids, mucous membranes, or nonintact skin of all patients; and
for performing venipunctures that are likely to generate
aerosolized droplets of blood or other body fluids, masks and
protective eyewear or face shields should be worn to prevent
exposure of mucous membranes of the mouth, nose and eyes.
Gowns or aprons should be worn during procedures that are likely
to generate splashes of blood or other body fluids.
9. Hands and other skin surfaces should be washed immediately
and thoroughly if contaminated with blood or other body fluids.
Hands should be washed immediately after gloves are removed.
10. Although saliva has not been implicated in HIV transmission to
minimize the need for emergency mouth -to-mouth resuscitation
is predictable.
11. Health care workers who have exudative lesions or weeping
dermatitis should refrain from all direct patient contact and avoid
handling patient, and equipment until condition resolves.
12. Pregnant health care workers are not known to be at greater risk
for contracting HIV infection than health care workers who are
not pregnant; however if a infant is at risk for infection resulting
from perinatal transmission. Because of this risk, pregnant health
care workers should be especially familiar with an strictly adhere
to precautions to minimize the risk of HIV transmission.
ADDITIONAL PRECAUTIONS FOR INVASIVE PROCEDURES

1. All health care workers who participate in invasive procedures
must use appropriate barrier precautions routinely to prevent skin
and mucous membrane contact with blood and other body fluids
of all patients. Gloves and surgical masks must be worn for all
invasive procedures. Protective eyewear of face shields should be
worn for procedures that commonly result in the generation of
aerosolized droplets, splashing of blood or other body fluids. All
health care workers who perform or assist in vaginal or cesarean
placenta or the infant until blood and amniotic fluid have been
removed from the infant's skin and should wear gloves during
post delivery care of the infant's skin and should wear gloves
during post delivery care of the umbilical cord.
2. If a glove is torn or a needle stick or other injury occurs, the glove
should be removed and a new glove used as promptly as patient
safety permits; the needle or instruments involved in the incident
should also be removed from the sterile field.
Procedure in the Event of Contamination with Infected Blood

1. A surgeon who has been contaminated with HIV - infected blood
should immediately clean the contaminated area by washing under
running water.
2. Post-exposure prophylaxis to HIV should be offered when the
patient comes from a high risk group and the HIV status is unknown.
Prophylaxis consists of Zidovudine 250 mg bid, Lamivudine 150
mg b.i.d and Indinavis 800 mg t.i.d for one month.
The surgeon should also be given hepatitis prophylaxis as the risk
of developing hepatitis after contamination with blood from a high risk
patient is greater than the risk of HIV infection. A baseline HIV test
should be carried out immediately, as seroconversion will not have
occurred immediately after injury. The HIV test should then be repeated
approximately 12 weeks after contamination to determine whether
seroconversion has occurred.
Infection of the Patient by Surgeon

1. Patient infection from an HIV-positive dentist may be carried while
undergoing a dental procedure.
2. Patient cross infection may also have occurred from a HIV-positive
to an HIV-negative patient undergoing a minor surgical proce-
dure on the same operating list. Yet now there is no reported case of a
patient undergoing a general procedure acquiring HIV infection from the
surgeon.
Surgery and HIV Infection

Patients with HIV infection and AIDS generally do not require any
extrapreoperative preparation because of their infection. Malnutrition
associated with HIV infection may require correction of the
undernourished state if time permits. Perioperative antimicrobial
therapy is given for the same indications as patients without HIV
infections. These patients generally do not have difficulty with wound
healing and do not have higher rate of wound infection or other
postoperative hospital acquired infections. The use of drains and open
wounds requires extra cautions to avoid contamination with HIV-
infected blood and other body fluids.
Patients with HIV infection and AIDS may require surgery for
problems related to their vital illness or to other infectious or neoplastic
causes. These problems include:
1. Peritonitis due to bowel perforation which occurs as a result of CMV
infection.
2. Gastrointestinal obstruction due to Kaposi's sarcoma or lymphoma
of the gastrointestinal tract.
3. Gastrointestinal hemorrhage due to CMV, lymphoma or Kaposi's
sarcoma and
4. Intraabdominal or retroperitoneal infection by mycobacteria and
other opportunities organisms.
5. Management of colorectal and anal disorders including infections
and cancers.
6. Splenectomy for thrombocytopenia.
7. Lymph node excision biopsy, where there is diagnostic uncertainity.
8. Provision of chronic venous access to facilitate chemotherapy for
infection or neoplasm.
Surgeons are frequently exposed to patient's blood and other body
fluids. Most exposures are to the skin and can be decreased by wearing
two pairs of gloves and face shields.
CDC issued new guidelines, which have come to be called "universal
precautions". They are applicable to clinical and laboratory staffs,
emergency service personnel, and to health care workers performing
invasive procedures as well as to those who are not included in direct
patient care. (e.g. housekeeping personnel, kitchen staff, and laundry
workers).
Management of Health Care Workers

Exposed to Patients’ Blood and Other Body Fluids
The CDC and others have issued recommendations for the management
of health care workers exposed to patient blood and other body fluids.
Hospitals, physicians officers and other employers of health care
workers should establish a systematic approach for managing adverse
exposures that is consistent with CDC and Department of Labor
guidelines and state laws. The Department of Labor and CDC have
published detailed employer responsibilities in protecting workers from
acquisition of blood-borne diseases in the workplace. Employers should
develop standard operating procedures for all activities having the
potential for exposure and should provide an initial and periodic
workers education program.
The CDC recommends that if an exposure occurs, a blood sample
should be drawn after consent is obtained from the individual from
whom the exposure occurred and tested for hepatitis B surface antigen
and antibody to HIV. Local laws regarding consent for testing source
individuals should be followed. Policies should be obtained (e.g. an
unconscious patient). Pretest counseling, posttest counseling, and
referral for treatment. If appropriate, of the source individual should
be provided.
Transmission of blood-bone pathogens from health care workers to
patients.
Blood-borne pathogens can also be transmitted from health care
workers to patients. HIV, HBV and non A, non B, hepatitis (HCV) can
potentially be transmitted form surgeons to patient during invasive
procedures when they sustain a percutaneous injury with a needle or
sharp instrument which then recontacts the patient. Only HBV has been
demonstrate to be transmitted from physicians to patients. One dentist
has transmitted HIV to five patients. There are no other reports of
transmission of HIV from a health care worker to a patient.
31 Anaphylactic Shock
INTRODUCTION
(Ana—away from, phylactic—protection)
Anaphylactic shock is an anamnestic (relating to previous history
of patient) response in which a sensitized individual comes in contact
with an antigen. The antigen combines with specific IgE antibodies on
mast cells and basophils, and includes the release of mediators such as
histamine, PAF (platelet activating factor) and other mediators that
mediate the anaphylactic response. This is characterized by
• Severe vasodilatation
• Broncho-constriction
• Pruritus
• Increased vascular permeability
Anaphylactoid reactions are different from anaphylactic shock. It is
related to the direct release of mediators by the offering agent from
mast cells and basophils without IgE antibodies coming into play. This
direct release of mediators brought about by complement-mediated
reactions.
The most common precipitating agent for anaphylaxis is penicillin.
Other common agents are contrast material, blood products, etc.
List of commonly used agents causing anaphylactic and
anaphylactoid reactions are:
1. Antibiotics
a. Penicillin
b. Sulfonamides
c. Tetracycline
d. Streptomycin
2. Local anesthetics
3. General anesthetic
a. Thiopental
4. Non-steroidal anti-inflmmatory drugs like diclofenac
Anaphylactic Shock 301
5. Blood and blood products
6. Vaccines for
a. Rabies
b. Tetanus
c. Diphtheria
d. Snake and spider antivenoms
7. Diagnostic (Contrast) agents
a. Iodinated radiocontrast agents
8. Venoms
a. Beas
b. Wasps
c. Spiders
d. Jellyfish
9. Hormones
a. Insulin
b. Hydrocortisone
c. Vasopressin
10. Extract of allergens used for desensitization
11. Foods
a. Eggs
b. Milk and milk products
c. Legumes
d. Nuts
e. Shellfish
f. Citrus fruits
12. Other drugs
a. Protamine
b. Dextrans
c. Parenteral iron
In fact, almost every drug, including steroids has been shown to
cause an acute anaphylactic reaction.
Clinical Features
Symptoms may occur immediately or within a few minutes after an
injection and 1-2 hours after oral intake of the offending agent.
The major features are:
• Hypotension
• Severe dyspnoea
• Angioedema
• Perspiration
• Pruritus
• Urticaria
• Tachycardia
• Syncope and seizure
• Abdominal pain with cramps
• Diarrhea.
Management of Anaphylactic Shock

1. Intubate and administer oxygen at high flow rates. If intubation is not
possible emergency tracheostomy or criocothyroid membrane.
2. Epinephrine 0.5 to 1 ml of 1:1000 solution subcutaneously and is
followed by a maintenance infusion of epinephrine (adrenaline).
3. If no response to subcutaneous injection of epinephrine, then
intravenous epinephrine 5 to 10 ml of 1:10000 solution may be given,
if laryngospasm or cardiovascular collapse present.
4. If it is not possible to give IV when intravenous access is unavailable
then epinephrine 0.5 to 1 ml of 1:1000 solution IM or 10 ml of 1:10000
solution is instilled through endotracheal tube.
5. Start IV drip and increase volume load prefer crystalloids (NS, RL)
6. Inj. antihstamins—Hydroxyzine, diphenhydramine.
7. Inj. hydrocortisone 300 mg IV Stat and followed by 100 mg IV
6 hourly. Steroids have little or no role in immediate alleviation
of anaphylactic shock but it prevents late manifestations of
anaphylaxis.
8. If hypotension persist even after epinephrine, volume load and
antihistamines then start dopmine, infusion. If still BP remains low,
start epinephrine infusion.
9. Critically ill-patients may need both cardiovascular support and
ventilatory support with a high FIO2.
Reaction due to Local Anesthetic

The most popular drug for local anesthetic is lignocaine. Reactions due
to local anesthetic is virtually never due to allergy or anaphylaxis but
are caused by over dosage or reaction due to its preservative, i.e.
methylparaben.
TOXIC EFFECTS OF LIGNOCAINE

These are due to excess dosage or when it is given by an inadvertent
intravenous or intra-arterial injection. It causes two types of toxicities—
1. Cerebral toxicity—Anxiety, excitement, drowsiness, coma,
convulsions, cessation of respiration, areflexia.
2. Cardiac toxicity—Causes hypotension, bradycardia, heart block.
Anaphylactic Shock 303
Treatment of Lignocaine Toxicity
1. Excitability or drowsiness alone require no specific treatment but it
may give early warning of serious toxic effects. But oxygen should
be given.
2. Start IV drip if convulsion develops. Give inj. diazepam slow IV.
3. If hypotension give inj. atropine 0.6 mg.
4. Inj. ephedrine 15 to 20 mg slow IV.
5. The patient should be placed flat, with the legs elevated and saline
infusion should be given.
(Adverse reaction to blood and its products—refer blood transfusion
chapter).
32 Endoscopy
INTRODUCTION
By endoscopy the diagnosis of lesions in the GIT has become easy and
quick. These lesions can be viewed and biopsy is taken, thus confirming
the diagnosis.
Two types of flexible endoscopies are currently in use: flexible
endoscope and video endoscope.
Fiberoptic Endoscopes
Fiberoptics is a term applied to a system for transmitting lights and
images through separate bundle of fine optical fibers by internal
reflection.These light is conveyed through a bundle of fine glass fibers,
which are smaller than a human hair (8 to 10 mm in diameter). These are
tightly packed together. One bundle of fibers carries light into the
examined organ, and a second bundle transmits the image from the
organ interior to the viewing optic. Major disadvantage with flexible
Fig. 32.1: A flexible fiberoptic bronchoscope

Endoscopy 305
fiberoptic endoscopes is fragility. When individual fibers break, light
transmission is decreased and the visual image develops dark spots
(corresponding to the broken fibers). These endoscopes are generally
direct-viewing endoscopes. The endoscopist looks directly into an
eyepiece. A small video camera may be placed on the end of the
endoscope and the image viewed on a video screen.
Fiberoptic endoscope system consist of three parts:
1. Light source
2. Insertion tube with optical image bundle
3. Instrument or endoscope control suction near the eyepiece.
Video Endoscopy
Light is transmitted to the tip endoscope through a fiberoptic bundle,
as in the endoscopes described above. The viewing fiberoptic bundle is
replaced with a charge-coupled device (CCD) chip camera placed at
the tip of the endoscope. This chip carries a digital image back to a
video processor, which displays an image on a color monitor.
Newer video endoscopes use three-color CCD chips and provide the
most accurate color resolution.
Flexible endoscopes provide one or more channels for passage for
instruments as well as for suctioning. Air and water channels permit
distention of the bowel and cleaning to the lens tip. Deflection is
controlled by rotating wheels on the headpiece. The wheels should be
allowed to move freely. Modern endoscopes also include electronic
systems to capture still images and record video footage.
Fig. 32.2: Rotating wheels on the headpiece of the endoscope control tip deflection. Instruments
may be passed through an access port, which is kept capped when not in use (to prevent loss
of insufflation and splashing with fluids)
EQUIPMENT SETUP
The cart generally includes a monitor, video processor, light source,
water bottle and an image printer.
1. A fiberoptic cable connects the endoscope to the light source. This
umbilical cable also contains connectors for suction, water, and
insufflation.
Fig. 32.3: Cart with video monitor, light source, video processor, water bottle, and image
printer. A keyboard allows entry of patient and physician name patient, number, date and any
additional documentation desired
Endoscopy 307
Figs 32.4A and B: A video-gastroscope (A) The camera stack,

(B) The gastroscope and biopsy forceps, in the working channel
2. Air (for insufflation) and water are introduced through a common

channel by depression of a trumpet like valve on the control head
of the scope.
3. Partial depression of the valve insufflates air.
4. Complete depression of the valve forces the air backward, causing
increased pressure in the attached water bottle and forcing a
stream of water to the tip of the instrument where it serves to
wash the lens.
5. Depression of an adjacent trumpet valve is for the suction function
6. Insufflation, irrigation and suction should be tested before the
procedure.
7. Connect the umbilical cable of the endoscope to the light source.
8. Turn on all electronic equipment on the cart.
9. Ensure that the water bottle is filled with clean water.
10. Connect suction to the site on the umbilical cord.
11. Obtain a cup or basin of water to test the insufflation by insufflating
air under water and observing bubbles water irrigation (with the
tip of the endoscope out of the water), and suction (by aspirating
the water from the cup).
12. A sharp image of the fingers should be seen on the monitor.
TROUBLE SHOOTING
Common problems and solutions are:
Problem Solution/causes
No light at distal end 1. Light source plugged and turned off.

2. Light source ignited.
3. Not in "stand by" mode
4. Lens at distal tip is dirty
5. Bulb burned out
Out of focus 1. Adjust focus ring
2. Fiberoptic scope—clean lens
No irrigation 1. Water bottle contains water
2. Water bottle connected to umbilical cord
3. Connection tight
4. Lid of water bottle screwed on tightly
5. Power turned on
6. Valve stuck or occluded
No insufflation 1. Umbilical cord firmly seated into light
source and screwed in if necessary
2. Power turned off
3. Valve stuck or occluded
Clogged valve or nozzle 1. Take valve apart and clean
2. Flush channel of endoscope with
cleaning solution, followed by clean
water
Difficulty passing instrument 1. Check tip angulation; decrease
angulation and try again
2. Ensure that the instrument is fully closed
3. Check size of instrument relative to
instrument channel; try smaller diameter
instrument
Endoscopy 309
EQUIPMENT CARE
Flexible endoscopes are expensive and relatively fragile, attention to
care is important:
1. The light fibers are fragile and easily broken. Coil the endoscope
into gentle curves. Do not fold it in acute angles. Do not drop the
endoscope. Allow a wheeled cart to roll over it. Do not allow the
patient to bite down on the endoscope.
2. Avoid extreme angulation of the tip wherever possible. Do no force
biopsy forceps or other instruments down the channel when tip is
sharply angulated. It may damage to the biopsy channel.
3. Lubricate instruments with a suitable lubricant to facilitate passage.
4. The outer coating of the endoscope is delicate, particularly in the
region near the tip. Cover this with a cap.
5. After each use, wash off any gross contamination and suction water
through the endoscope. Do not allow blood, mucus, stool or other
foreign matter to dry on the endoscope or in the channels or valves.
6. Endoscope must be mechanically cleaned before disinfection.
7. Be careful to follow the manufacturer’s instruction for sterilization
to avoid potentially severe damage to the endoscope.
ROOM SETUP
The room should have oxygen, suction and monitoring devices.
1. For upper gastrointestinal (UG I) endoscopy, the patient is positioned
with the left side slightly down. The endoscopist faces towards the
patient, standing at the patient’s left side near the head of the bed.
This provides easy access.
2. For colonoscopy or flexible sigmoidoscopy, the patient is usually
positioned in the left lateral decubitus position and the endocopist
stand facing the back of the patient, just below the patient’s buttocks.
MANIPULATION OF ENDOSCOPE
Specific techniques useful for performing various endoscopic
examination which are:
1. Stand in a comfortable position, facing the patient and the video
monitor.
2. If the endoscope is a direct-viewing fiberoptic endoscope, hold it
comfortably upto your eye. Avoid a hunched-over posture.
3. Cradle the endoscope in the upper palm of the left hand. Rest
the controls between the thumb and forefinger. The key is to keep the
hand rotated so that the thumb can manipulate the control wheel.
Fig. 32.5: Correct technique for manipulating fiberoptic bronchoscope through endotracheal
tube is shown in the top panel avoid curvature in bronchoscope, which makes manipulaltion
difficult
4. The index and long finger work the two trumpet valves and thus
control suction and insufflation. The ring and little finger hold the
control handle firmly against the palm.
5. The thumb of the left hand manipulates the large control wheel on
the right side of the scope. This wheel angulates the scope tip in an
up or down direction.
6. The endoscopist's right hand works on the small outer wheel, which
controls right and left motion of the instrument tip. There are locking
brakes associated with each control knob so that a position may be
held while the hand is removed to perform another function.
7. Never use force to advance the endoscope.
DOCUMENTATION OF FINDINGS
Modern endoscopes enjoy the ability to record and document findings,
a variety of formats. Newer video endoscopes produce digital signal
that can be recorded on film, video tape or computer disk.
Endoscopy 311
MONITORING
Level of consciousness, responsiveness and pain should all be watched
closely. Continuous monitoring of the following parameters is
recommended.
1. Pulse—rate and rhythm
2. Blood pressure
3. Pulse oximetry
It is important to remember that oxygen saturation with
hypercapnea may occur despite adequate oxygen levels. Observation
of patient's ventilation, discomfort and state of consciousness should
be constantly observed.
CONSCIOUS SEDATION
Safe and effective administration of conscious sedation is very important
characteristics of conscious sedation
Conscious sedation is a state of minimally depressed consciousness
in which the patient.
• Retains protective airway reflexes
• Responds appropriately to physical stimuli and verbal commands
• Maintains continuous communication with caregivers
An intravenous line must be maintained during endoscopy.
Following agents are commonly used.
Name of the drug Advantages Disadvantages
Diazepam 1. Reduces anxiety 1. Pain on injection

2. Causes amnesia 2. High incidence of chemical
phlebitis
3. Minimal cardiovascular
effects
4. Relatively flat dose-
response curve
Midazolam 1. More rapid onset 1. Significantly more potent,
2. Less pain on injection requiring dose adjustment
3. More amnesia 2. Avoid combination with
narcotic agents
Demerol 1. Analgesic effect 1. Minimal amnesia
2. Cardiopulmonary depression
RECOVERY
Continue monitoring is necessary until the patient has fully recovered
from the procedure and any sedation. By the way if patient is over
sedated with benzodiazepine then use flumazenil. Flumazenil rapidly
reverses the central effects of diazepam or midazolam but may not
completely reverse the respiratory depression. Patients should be
cautioned against driving.
INDICATIONS
Indication Specific examples
Symptoms • Dyspesia*
• Dysphagia
• Odynophagia
• Pyrosis*
• Nausea and vomiting
* If persistent, recurrent despite medical
management, or associated with other
gastrointestinal symptoms or signs such
as weight loss
Malignancy surveillance • Barrett's epithelium
• Gastric polyps
• Familial polyposis syndromes
• Gastric ulcer
• Esophageal ulcer
• Marginal ulcer
Other circumstances • Occult gastrointestinal bleeding
• Cirrhosis (to evaluate varices)
• Malabsorption (for small intestine biopsy)
Therapeutic EGD is appropriate for acute upper gastrointestinal

bleeding, foreign body ingestion, polyp removal, dilatation of stenoses,
placement of feeding or drainage catheters, eradication of esophageal
varices, and palliative therapy of obstructing neoplasms.
PATIENT PREPARATION
1. Keep the patient NPO (nothing per oral) for 6 to 8 hours before
routine elective EGD. This minimizes aspiration risks with a sedated
procedure.
2. Obtain informed consent for the procedure. This includes a
discussion of specific complications .
3. Apply monitoring devices and ensure that a secure intravenous line
is in place.
4. Patient dentures should be removed.
5. Topical anesthesia is usually employed prior to EGD. Effective
topical anesthesia facilities intubations .
a. Deliver the topical agents to the posterior pharynx by spray or
gargle, rather than to the oral cavity and tongue only.
Endoscopy 313
b. Topical anesthetics take a few minutes to work. Use this time to
check the endoscope and verify all items .
c. Test the patient gag response before attempting endoscopy. This
is good indicator of patient tolerance.
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY (ERCP)
Indications
1. Visualization of ampulla of vater for—
• Adenomas
• Carcinoma
• Surveillance in patients with polyposis syndromes
2. Cholangiography (radiographic study of the common bile duct)
• Cholestatic jaundice of unknown cause
• Choledocholithiasis
• Cholangitis
• Carcinoma of the bile duct
• Bile duct stricture
• Bile duct injury
3. Pancreatography (radiographic study of the pancreatic duct)
• Chronic pancreatitis
• Pancreatic carcinoma
• Pancreatic ascites
• Pancreatic pseudocyst
• Pancreatic trauma
• Gallstone pancreatitis
ERCP Requires following Equipments

1. An X-ray room capable of both fluoroscopy to visualize which duct
has been cannulated and for digital radiography.
2. The ERCP endoscope is a side-viewing instrument that allows
accurate visualization of the ampulla of Vater. Video endoscopy is
now considered standard for ERCP.
3. A variety of different catheters are used to cannulate the ampulla.
PATIENT PREPARATION
1. Explain the technique and possible complications to the patient
and obtain informed consent. A knowledgeable, informed patient
will cooperate with the endoscopist so that the procedure can be
done quickly and safely.
2. The patient is kept NPO for six hours prior to the procedure.
Diabetic patients should have on Insulin intravenous drip.
3. If therapeutic ERCP (papillotomy, biopsy, stone extraction) may
be required, evaluate the coagulation status of the patient. This is
particularly important in jaundiced patients.
4. Patients with possible billiary obstruction, cholangitis, or
choledocholithiasis should receive antibiotics prior to the
procedure.
5. Anesthetize the oropharynx with topical anesthetic. The author
prefers xylocaine four percent.
6. Place a secure intravenous catheter in the right hand or arm.
7. Position the patient prone with the head turned to the right.
8. Analgesia and conscious sedation facilitate the procedure.
9. Appropriate monitoring includes pulse oximetry, heart rate, and
blood pressure.
10. As soon as the endoscope is within the duodenum, give buscopan
(hyoscine butylbromide) 20 to 40 mg IV or glucagon HCl one mg
IV to decrease duodenal peristalsis.
FLEXIBLE SIGMOIDOSCOPY
The flexible sigmoidoscope is now the standard device for evaluation
of the distal large bowel. When neoplastic polps are found in the distal
colon during asymptomatic screening, the entire colon must
subsequently be examined.
Instrumentation
Two main 65 cm flexible sigmoidoscope are available.
1. The older style instrument is the flexible fiberoptic sigmoidoscope.
A fiber bundle carries the illumination light down the shaft and a
second fiber bundle carries the image back to the eyepiece.
2. The second instrument is an electronic videoscope. The light is
carried down by a fiber bundle but the image is registered on a CCD
chip at the tip of the scope. As with other endoscopes, the video
system provides better image quality, image capture and printing.
Patient Preparation
Adequate bowel preparation is essential. Any residual material prolongs
the examination, contributes to discomfort by requiring greater air
insufflations, and also to the risk of injury. Formed stool, once adherent
to the viewing lens can be very tenacious, requires blind removal of the
instrument. Stool coating the mucosa obscures surface morphology and
Endoscopy 315
vasculature. A pool of opaque liquid between fold may be much deeper
than apparent and consequently hide a significant lesion beneath the
surface. Fecal residue has a tendency to adhere to an abraded or
demucosod surface more readily than to the surrounding normal
epithelium.
Either cathartic, lavage, or enema preparation can be used for flexible
sigmoidoscopy preparation. Preparation with a hypertonic sodium
phosphate enema is simple and safe in most patients. Severe loss by
bowel preparation may cause hyperphosphatemia and hypocalcemia .
COLONOSCOPY
Indications for diagnostic colonoscopy
1. To evaluate gastrointestinal bleeding
a. Occult blood positive stools
b. Hematochezia when anorectal source is not certain
c. Melena after excluding an upper GI source
2. Surveillence for colon neoplasia
a. Postoperative carcinoma or malignant polyp.
b. In high cancer risk patients
• History of first degree relative or multiple family members
with colon cancer
• Cancer family syndrome
• Chronic ulcerative colitis with pancolitis
c. Inflammatory bowel disease
• To determine the extent of disease
• To confirm the diagnosis
• Cancer surveillance in chronic ulcerative colitis
Contraindications
• Peritonitis or suspected colorectal perforation
• Severe acute diverticulitis
• Fulminant colitis
• Hemodynamic instability.
• Large bowel obstruction
• Recent myocardial infarction or pulmonary embolus.
Preparation and Positioning of the Patient and Room Setup

1. Bowel preparation is essential; the entire colon should be cleansed
of all fecal matter for an adequate examination.
a. Discontinue iron—containing medications or constipating agents.
b. Clear liquids or other residue free, diets for 24 hours.
c. Four liters of specially balanced electrolyte lavage solution, e.g.
polyethylene glycol- electrolyte (PEG) given orally, beginning
of one to two per hour (8 ounces every 10 minutes). Sugars should
not be added to the gut lavage as it may cause sodium retention
or lead to production of potentially explosive gases.
Metochlopromide is occasionally given prior to the preparation
to prevent the associated nausea and vomiting.
d. Do not use mannitol or other fermentable carbohydrates, which
could be converted to explosive gases.
2. The instruments: Always check the instrument before the
examination.
3. Patient preparation and positioning: Before beginning any endoscopic
procedure, review the procedure with the patient.
4. Appropriate monitoring includes continuous ECG, pulse rate and
pulse oximetry monitoring and intermittent blood pressure record-
ing.
5. Conscious sedation is used.
General Principles of Colonoscopy

After ensuring adequate sedation, the exam should always start with a
visual inspection of the anus and a digital rectal exam.
1. Place your index finger about an inch from the tip of the scope and
insert the scope by sliding the tip across the perineal body and into
the anus. This reduces trauma to the anal canal. Insert the scope
straight without twists.
2. Use air insufflation to open the rectum and to visualize the lumen,
and from there on advance the scope while keeping the lumen of
the colon in view.
3. Avoid over-insufflation
4. Minimize “loop” formation while withdrawing the colonoscope.
5. Always try to keep the lumen in view and avoid pushing the scope
blindly or “sliding by” this may increase the risk of perforation.
Bibliography
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William and Wilkins, Philadelphia.
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Disease Foundation, Coimbatore 2002.
13. Palmer PES, Cockshott WP, Hegediss V, Samuel E. WHO Basic Radiological
system: Manual of radiographic interpretation for general practitioners. World
Health Organization, Geneva, 1985.
14. Rintoul RF. Farquharson’s text book of operative surgery, Church Hill
Livingstone, Edinburgh, 1995.
15. Russel RCG, Williams Normans, Bulstrode JK. Christopher, Bailey and Love’s
Short Practice of Surgery, Arnold, A member of Hodder Headline Group,
London 2004.
16. Schwarty, Seymour I, Shires, Tom G. Spencer, Frank C, Husser, Wendy
Cowles. Principles of Surgery, McGraw Hill Health Professions Divisions,
New York, 1999.
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of laparoscopy and GI endoscopy, Springer, New York, 1999.
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Walfe, London, 1997.
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Anatomy and Technique, Springer, New York 2000.
20. Sosa Ernest R, Jenkins Alan D; Alabala David M. Perlmutter Aarron P. Text
Book of Endourology, WB Sounders Company, Phildelphia 1997.
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23. Udwadia Farokh Erach. Principles of Critical Care. Oxford University Press,
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Compbell’s Urology 2002, Saunders, Philadelphia.
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Heinemenn Ltd, Oxford 1993.
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Operations, Prentice Hall International Inc, London, 1997.
Index
A side effects 86
types 87
Abdominal binder 32 regional 87, 105
ABO grouping 265 field/nerve block 87
Acid citrate dextran 260 signs and symptoms 94
Acriflavine 24 toxic effect 94
Adrenal insufficiency 149 spinal 97
Adrenaline 236 Anterior cubital vein puncture 117
Adrenochrome 253 Antiseptic agents 21, 61
Aerosol disinfector 77 Argon beam coagulation 57
Age-related changes 156 Asepsis 21, 61
CNS 156 Atropine 236
CVS 156 Autoclaving 65
delirium 158
falls 158
B
pain 158
pressure sores 158 Bacteremia 61
renal 157 Bacteria 62
respiratory 157 Bacteriostat 62
Amino acids solution 286 Bandaging techniques 29
Aminophylline 241 Barrel bandage 36
Anaphylactic shock 300 Bilevel positive airway pressure 230
clinical features 301 Bioburden 62
management 302 Bleeding diathesis 143
reaction due to local anesthetic 302 hemostatic evaluation 144
toxic effects of lignocaine 302 Blood grouping 176, 265
treatment 303 Blood substitutes 289
Anesthesia 85, 105 Blood transfusion 259
caudal 94 adverse reactions in donor 264
complications 95 autologous transfusion 272
doses 95 blood grouping 265
indications 95 blood storage 259
technique 95 blood transfusion services 262
epidural cross-matching 265
lateral decubitus position 98 donation interval 264
prone position 101 donor selection for blood 261
sitting position 100 immediate reactions 267
general 85 acute hemolytic reactions 268
classification 106 allergic reactions 270
mechanism of action 105 anaphylactic reactions 267
properties 106 delayed hemolytic reactions 270
local febrile nonhemolytic reactions
mechanism of action 85 267
precautions 87 graft vs host disease 270
indications 259 validity
massive transfusion 271 capacity to consent 11
taking blood from donor 263 consent in emergency 12
Boiling (moist heat) 68 knowledge 12
Bruise/contusion 42 refusal of treatment 13
Buprenorphine 248 voluntariness 11
Butorphanol 249 Contamination 62
Cotton 28
C CPAP mask 229
Cross-matching 176, 266
Calcium chloride solution 286 Cryosurgery 215
Calcium gluconate 286 Crystalloids 281
Cap and mask 190
Care of instruments 135
D
prevention of corrosion 137
Cavitational ultrasonic surgical Decontamination 62
aspiration 59 Degraded gelatin 290
Cecostomy 167 Delirium 158
advantages 168 Dexamethansone 246
colostomy irrigation 168 Dextran 255, 280
contraindications 169 Dextrose 284
disadvantages 168 Diabetes and surgical patient 151
indication 167 management of type 1 153
irrigation procedure 168 management of type 2 153
Central venous catheterization 118 protocol of diabetic care 151
Cetrimide 26 supplement insulin dose 152
Chemosterilizer 62 supplemental insulin 152
Citrate phosphate dextrone solution Diathermy 7, 50
260 Diazepam 108, 246
Calcium gluconate 240 Disinfectant 63
Cleaning 62 Disposable device 63
Colloids 281 Dopamine 238
Colonoscopy 315 Drain 139
Colostomy 165 corrugated 141, 142
care of colostomy 167 closed 142
closure of colostomy 167 sump 142
colostomy in children 167
indications 165 E
types 166
defunctioning 166 Ear bandage 36
opening and closing 166 Edinburgh University solution 27
permanent 166 Elastocrepe bandage 31
temporary 166 Elective operations 177
Compatibility testing 265 preoperative instructions 179
Consent 10 Electrocautery 50
medicolegal considerations 14 Electrolytes and fluids disturbance 150
reasons 13 Electrosurgery 7, 50
types 10 causes of diathermy injury 54
expressed 11 different modes of current 55
implied 11 foot switch 55
informal 10 metallic prosthesis 56
Index 321
patient plate electrode 54 Flumazenil 247
patient with pacemaker 56 Foley’s catheter 130
placement of plate 55 Foods
safe sue of diathermy 56 causing diarrhea 169
safety measures 54 causing odor 170
principles of electricity 50 creating blockage 170
tissue effects forming gas 170
coagulation 51 thickening stool 169
cutting 51 Fosphenytoin (Fosolin) 252
desiccation 52 Fresh frozen plasma 274
fulguration 52 Frusemide 244
variables affecting tissue effect Fumigation 1, 77
52 Fungicide 63
types of circuit 52
bipolar 53 G
monopolar 52
Emergency operations 176 Gangrene 40
Endocrine abnormalities 148 Gas forming foods 170
Gas plasma sterilization 82
Endoscopic retrograde
plasmalyte system 83
cholangiopancreatography 313
Sterrad system 82
Endoscopy 304
Gauze 29
conscious sedation 311
Gelatin 279
documentation of findings 310
polymer 255
equipment care 309
Gelation foam 253
equipment setup 306
Gentian violet 25
fiberoptic endoscopes 304 Germicide 63
indications 312 Gloves (gloving) 4
manipulation of endoscope 309 Glycerine magsulf solution 27
monitoring 311 Gowning 3, 190
patient preparation 312 Granisetron 251
recovery 311 Granulation tissue 41
room setup 309
trouble shooting 308 H
video endoscopy 305
Endosurgery 7 Haemaccel 290
Epidural needle 103 Halothane 107
Epidural space 103 Harmonic scalpel generator 58
Esmarch’s bandage 34 Head or scalp bandage 34
Ethylene diaminotetraacetic acid 261 Heart disease 147
Exchange transfusion 274 Hematoma 42
Extravascular (interstitial) Hemorrhage 211
compartment 209 Heparin 253
Eye bandage 35 HIV diseases 293
additional precautions 297
management of health care workers
F
299
Face masks 228 serologic events 295
Fat emulsion solution 287 surgery and HIV infection 298
Filtration 69 transmission 294
Hot air oven 67 J
Human albumin 254, 257, 279
Hydrocortisone 245 Jaundice 146
Hydrogen peroxide 23
Hydroxyethyl starch 256, 279 K
Hyperbaric oxygenation 234
Hypercapnia 227 Ketamine 109
Hypergranulation tissue 41
Hyperosmolar coma 155 L
Hypoxemia 227
Hypoxia 227 Laparotomy pads 29
Levine’s tube 125
Lignocaine 243
I
Liver function tests
Ileostomy 163 cardiac evaluation 175
ileostomy in children 164 CXR 175
management 164 hepatitis screen 175
position 164 HIV testing 175
stoma care in children 165 liver function tests 175
lavage 169 urine examination 175
Incision 180 Lumbar puncture 101
curved subumbilical 184 lateral approach 102
grid iron 183 midline technique 101
inguinal 184 Taylor approach 102
Lanz 184
lumbar subcostal 184
midline 181 M
midline supraumbilical 184 Malnutrition 146
paramedian 182 Mannitol 244
pfannenstiel 183 Masks and caps 3
Rutherford Morrison 184 Massive transfusion 271
subcostal 182
Medicated dressings 48
transverse 183
bactigras 49
Infrared coagulation 215
calcium, sodium alginate dressing
Instruments for incision 186
49
Insulin 257
central gel formula (CGF) dressing
Intestinal stoma 160
complication 163 49
Intracellular compartment 210 integra 49
Intraoperative blood salvage 273 Tulle dressing 48
Intravenous fluids ulcer or wound covering 49
different types 283 Mephentermine (mephentine) 244
purpose 283 Mercurochrome 25
Intravenous solution 284 Methods of sterilization 65
Investigation for surgical patients chemical methods 69
biochemistry 174 alcohol (spirits) 74
hematology 174 bacillol 25 73
Isoflurane 107 bacilocid special 72
Isolyte-M solution 289 chlorine and chlorine products 76
Isolyte-P solution 288 ethicon 70
Index 323
ethylene oxide gas sterilization protection of nerves 5
77, 78 scrubbing the operative site 5
formaldehyde 70 preparation of patient 4
formalin solution 70 set up 2
formalin sterilization 76 transfer of the patient
gas sterilization 76 recovery room 9
glutaraldehyde 70 ward 9
hospital concentrate 72 Operation theater 188
hydrogen peroxide 76 functions of assistants during
hypochloride solution 76 operation 194
iodophors 75 care of instruments 200
lysol 71 choice of suture materials 198
para-acetic acid 75 completion of operation 199
phenol (carbolic acid) 71 diathermy/electrosurgery 196
phenolic compounds 71 dressing 200
quaternary ammonium ligation of vessels 197
compounds 71 method of closure 199
radiation 80 mopping 194
physical methods peritoneal toileting 198
autoclaving 65 record keeping 201
temperature 65 retraction 197
Metoclopramide 256 suction device 196
Microbiocidal process 63 use of hemostatic agents 196
Microbiocide 63 instructions for assistant or scrub
Multitailed abdominal bandage 32 nurse 193
painting and draping the operative
N field 194
precautions 188
Nadroparin (fraxiparine) 254 preparation of instrument trolley 192
Nasal prongs 227 preparations for the operation 189
Nasogastric tube 124 trolley for laparoscopic surgery 193
Necrosis 40 Operative notes 133
Negligence 14
Nitrous oxide 106
P
Nonbreathing masks 229, 230
Nosocomial 64 Packing roll 29
Pasteurization 64
Peanut 29
O
Penetrating wound 41
Obesity 155 Pentazocine 248
Older surgical patient 156 Perfluor compound 282
Ondansetron 250 Peripheral veins 114
Operation theater 1 leg 116
care of instruments after operation 8 limbs 115
linen 8 material 119
table mattress and pillows 8 problems 122
fumigation 1 rate of administration 120
patient in the OT 5 right arm 114
drapping of the patient 6 techniques 118, 122
position of the patient 5 basilic vein 118
femoral vein 118 general examination 173
internal jugular vein 118 history 172
subclavian vein 118 Pressure sores 158
Pethidine (meperidine) 247 Prochlorperazine 256
Phenytoin (diphenylhydantoin) 251 Promethazine hydrochloride 250
Plasma Propofol 108
expanders 254 Propranolol 242
protein solution 276 Protein solution 286
substitutes 278
volume expanders 289 Q
Plaster technique 217
conversion of POP slab to plaster Qxygen therapy 226
cast 220 device 230
plaster cast 220 humidification of oxygen 232
POP slab 220 oxygen cylinder 231
preparation of plaster bandages 217 oxygen hood 230
Position of patient 16 oxygen in incubator 230
anatomical 20 oxygen supply 231
Fowler’s 18 oxygen tent 230
fracture table 19 parts of cylinder 231
kidney 20 indication 226
knee-chest 17 methods of oxygenation 227
lithotomy 17, 20 untoward effects 234
Lloyd-Davis 16
Mayo-Robson 17 R
neck 20
Radiation sterilization 80
prone 17
ionizing 81
Sims’ 17
nonionizing 82
supine 20
Renal failure 149
supine hip 20
Respiratory disease 147
Trendelenburg’s 20
Rh grouping 266
Postoperative (PO) care
Ringer lactate solutions 285
daily check-up 202
Ryle’s tube 124
gastrostomy and jejunostomy tube
care 206
postoperative care of GIT 205 S
postoperative orders/care 203 Saline 284
stoma care 206 Sanitization 64
colostomy 206 Sanitizer 64
ileostomy 206 Savlon (hospital concentrate) 23
Postoperative fluid therapy 207 Scab/crust 41
Postoperative pain 212 Scalpel 186
Potassium methods of holding 187
chloride 240 Scrotal bandage 37
solution 285 Scrub room 2
permanganate 26 Scrubbing 3, 190
Povidone-iodine 22 Septicemia 61
Pre-anesthetic medication 109 Shock 211
Pregnancy test 176 Sigmoidoscopy 314
Preoperative care 171 Silver nitrate 25
Index 325
Slough 40, 61 gentamicin 47
Sodium bicarbonate 239 hydrogen peroxide 48
Splints 221 ichthammol 48
Split colostomy 161 magsulf glycerine solution 48
Spore 64 nitrofurazone 48
Standard spinal needle 103 povidone-iodine 47
Sterilant/disinfection 64 silver sulfadiazine 47
Sterile/sterility 64 forms
Sterilization 64 cream 46
Sterilizer 69 lotion 46
Steri-strip 39 ointment 46
Stump dressing 38 Toxemia 61
Surgicel 253 Tramodol 249
Surgical pads 29 Transparent dressing 39
Turpentine 26
Surgical spirit 24
Suturing 43
removal 45, 46 U
types 43
Ulcer 40
continuous 44 Ultrasonic devices 58
interrupted 44 Urethral catheterization 127
Swabs 29 Urticaria 269
Syncope 264
V
T
Vasovagal syndrome 264
T-bandage 38 Venesection or cannulation 120
Theophylline (deriphylline) 241 Venturi masks 228
Thiopentone sodium 108 Viricide 64
Thrombocytopenia 144 Vitamin K 252
dose of platelet 145 Vomiting 212
management 145
Thromboprophylaxis 143
W
Thyroid disease 148
Tincture benzoin 26 Weak iodine solution 22
Lysol 26 Wound 40
Topical agents 46 care of infected wound 43
common agents 47 treatment 42
combination of neomycin, types 41
polymyxin and bacitracin 47 closed 42
framycetin sulphate 47 open 41

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Fundamentals of

Rajendra Singh Sewta

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Fundamentals of Operative Surgery

First Edition: 2009

1. Sterile Precautions and Operation Theater Safety .................... 1

ENVIRONMENT OF OPERATION THEATER

FUMIGATION OF OPERATION THEATER

Fig. 1.1: Fumigation of operation theater

OPERATION THEATER SET UP

Masks and Caps

Gowning (To Wear Gown)

PREOPERATIVE PREPARATION OF PATIENT

Painting and Scrubbing the Operative Site

Drapping of the Patient

Care of Instruments after Operation

Care of OT Table Mattress and Pillows

Management of Patients in Recovery Room

TRANSFER OF THE PATIENT TO THE WARD

Reasons for Consent

Position of patient should be comfort to the patient, surgeons and

Fig. 3.1: Lloyd-Davis position. Avoid localized pressure on the arms

Sims Position (Lateral recumbent)

Fig. 3.4: Patients in the different position

Fig. 3.5: Trendelenburg position. The patient’s shoulders must be

Fig. 3.6: Bent knee position for meniscectomy.

Fig. 3.7: Fracture table position for hip fracture surgery.

Trendelenburg's Position (Head down)

Supine Hip Position

WEAK IODINE SOLUTION

HYDROGEN PEROXIDE (H2O2)

SAVLON (HOSPITAL CONCENTRATE)

Properties and Uses

Properties and Uses

Properties and Uses

SILVER NITRATE (AgNO3)

Properties and Uses

EDINBURGH UNIVERSITY SOLUTION (EUSOL)

Properties and Uses

GLYCERINE MAGSULF SOLUTION

Properties and Uses

BANDAGING TECHNIQUES (FIGS 5.1 TO 5.4)

Fig. 5.1: Bandage to thumb of hand—spica

Fig. 5.2: Bandage to elbow—spica

Fig. 5.3: A reverse spiral turn

Fig. 5.4: Adhesive strapping to ankle

ELASTOCREPE BANDAGE (FIG. 5.5)

MULTITAILED ABDOMINAL BANDAGE

Fig. 5.6: Tongue and slot adhesive strapping for abdomen

Fig. 5.7: Abdominal corset using adhesive strapping

Fig. 5.8: Interlocking cut-outs in adhesive strapping on abdomen

Fig. 5.9: Many-tailed abdominal binder

Fig. 5.10: Multitailed abdominal bandage

HEAD OR SCALP BANDAGE (FIG. 5.11)

Fig. 5.11: Head bandage

EYE BANDAGE (FIG. 5.12)