Bedside Procedures
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This document outlines procedures for various minor surgical procedures, including wound toilet and suturing, incision and drainage, wound desloughing and dressing, and chest tube insertion. It discusses indications, contraindications, anatomy, equipment, steps for each procedure, as well as post-procedure care and potential complications. The objectives are to identify when each procedure is appropriate, know how to perform them properly, and be aware of how to avoid or minimize complications.
Bedside Procedures
- 1. Supervised by DR HISHAM Prepared by ANWARIAH ARIS NOOR MOHAMMAD SAFWAN
- 3. OBJECTIVES To identify indications & contraindications To be able to perform To be aware of complications and how to avoid or minimalize
- 4. PRE- PROCEDURE Informed consent: • Indications • Anatomy • Procedure ( Risks & Benefits)
- 5. PRE PROCEDURE Aseptic technique: Prepare equipment- Mask Apron Gown Hand wash Sterile glove Povidone
- 6. PRE PROCEDURE Local anaesthesia: Lidocaine/lignocaine 1% (10mg in 1ml)/2%(20mg in 1ml) With/without epinephrine 100000u
- 7. PRE PROCEDURE Max dose 4mg/kg Max dose with epinephrine:7mg/kg 1% lignocaine: Alone: 28ml in 70kg pt With epinephrine: 49ml in 70kg pt
- 8. 1.TOILET AND SUTURING Indications: Presence of laceration wound Laceration wound closed by: Primary closure in clean wound or Secondary closure in dirty wound
- 9. Anatomy
- 10. Equipments: T&S set Scalpel Water for irrigation Syringe Lignocaine injection Suture Needle holder Forceps
- 11. Sutures: Type: Non-absorbable for skin, absorbable for deep tissue Size Face & Scalp - 3/0 Limb & Trunk - 3/0 Lips & Ear -4/0 Needle: Cutting edge body for skin Rounded body for tissue
- 12. Procedure: Clean surrounding skin with povidone Give adequate local anaesthesia Wound assessment Depth Foreign body Sign of infection Active bleeding Necrotic tissue Any structural injury
- 13. Irrigation with copious amount of saline Remove foreign body Debride ragged, nonviable skin edges and necrotic tissue
- 14. Secure hemostasis: • Compressed with gauze • Suture with figure of 8
- 15. Continuous interlocking • Ensure good bite of tissue taken • Make sure wound are free of contaminant before closing
- 16. Timing of closure: Primary closure: Immediate closure for clean wounds <12 hours old (24 hours on face)e.g. assault wound, clean cut Secondary closure: Dirty wound e.g. animal bite, wound contaminated with soil
- 18. Post T&S Dressing with CMC For patient to keep wound clean and dry Suture removal: Face: 3-5 days Scalp: 7-10 days Arms: 10-14 days Legs: 10-14 days Trunk : 10-14 days
- 19. 2.INCISION AND DRAINAGE Indications: Cutaneous abscess: painful swelling at cutaneous, indurated, tender, warm, redness, fluctuant If in doubt, confirm with needle aspiration
- 20. ANATOMY
- 21. Equipment: Scalpel Povidone Lignocaine injection Artery forceps Gauze/gamgee Syringe Swab for c+s
- 22. PROCEDURE Clean and drape Give adequate local anaesthesia Make a cruciate incision at most fluctuant area
- 23. PROCEDURE Express pus (swab for C+S) Break loci using artery forceps Secure hemostasis with gauze compression
- 24. PROCEDURE Copiously irrigate with sterile water Wash with povidone + hydrogen peroxide Packed the wound loosely with ribbon gauze(soaked with povidone) Dressing with gauze/gamgee
- 26. POST INCISION AND DRAINAGE Wound inspection: pus or slough Daily dressing–normal saline or povidone Pain management Continue packing of wound until no significant discharge Antibiotics in presence of Localized cellulitis Fever or chills In immunocompromised patient
- 27. 3.WOUND DESLOUGHING & DRESSING Indications: Acute Wounds Chronic Wounds
- 28. Anatomy:
- 30. Time Hemostasis Platelet Aggregation Neutrophil Immigration Monocyte Immigration Granulation Re-epithelialization Wound Closure Scar Formation Remodeling Minutes Hours Days Weeks Months Years CHRONIC WOUND
- 31. Wound Healing Continuum (Gray et al. 2005) have been developed. This tool incorporates intermediate colour combinations between the four key colours
- 36. Procedure Equipments: Curettage Dressing set Blade Gauze Cotton wool Cleansing agents Normal Saline Hydrogen Peroxide Povidone iodine
- 38. Post Wound Dressing & Desloughing: Wound Inspection Daily desloughing or dressing Antibiotic Analgesia
- 40. 4. CHEST TUBE INSERTION Indications: •Pneumothorax / hemothorax •Massive pleural effusion •Empyema •Post operative procedures Eg : Thoracotomy, Cardiac surgery •Pleurodesis : Chronic, recurrent pneumothorax or effusion
- 41. Procedure Equipment: Chest tube Child : 16-20F Average size adult :24-32F Large size adult : 36-40F Underwater seal system Accessory : Chest tube set, blade, LA, gauze, suture Insertion site: Safety triangle Procedure
- 42. Lateral border of pectoralis major Mid Axillary Line 4th or 5th intercostal space
- 45. Complications: • Bleeding • Lung injury • Infection • Abdominal organ injury if chest tube inserted too low
- 46. Post Chest Tube Insertion: Vital signs monitoring (BP, HR, T) and Spo2 monitoring Start analgesia & start antibiotic if indicated Encourage incentive spirometry CXR Watchout for complications of chest tube insertion
- 47. TAKE HOME MESSAGES 1. Adequate analgesia maximum of 4mg/kg without adrenaline or 7mg/kg with adrenaline should be administer before invasive procedure. 2. Clearly written details of each procedure and post procedure instructions is a must. 3. Disposal of all sharp equipment are done by the person performing the procedure. 4. Informed consent should be taken and explained by the person performing the procedure.
- 48. CONT.. 5. Puncture all loci to ensure complete drainage of pus and packed adequately to ensure good healing of the wound. 6. In toilet and suturing, make sure the wound is clean and free of contaminant before closing. 7. Desloughing are done until we reach to the normal tissue and evidence of bleeding seen. 8. Open method of chest tube insertion at the safety triangle is the preferred method.
- 49. Referrences Herbert Chan, Juan E. Sola, Keith D. Lillemoe, “Manual of Common Bedside Surgical Procedure”, 2nd ed,2000. Henry Gray, Susan Standring, Harold Ellis, BKB Berkovitz, “Gray’s Anatomy and Basis Clinical Practice”, 39th ed, 2005.
Editor's Notes
- #5: Consent indication C/I, complication Aseptic – handwashing, ppe, glove, mask Monitoring – pulse oxy – spo2 PR Verify the abnormal site
- #31: Chronic wounds The wound healing cascade impairs and arrests at different stages
- #41: Pneumothorax Massive pleural effusion Empyema Post operative procedures : thoracotomy, cardiac surgery, esophageal surgery Pleurodesis : chronic, reccurent pneumothorax or effusion