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CHAPTER 4 Practical procedures
212
Suprapubic catheterization
Indications
Urinary retention with failed or contraindicated urethral catheterization.
Cautions
• Do not perform suprapubic catheterization on a patient with known
bladder tumour or previous bladder surgery; seek expert advice.
• Ensure by clinical examination (and if available, ultrasound bladder
scanning) that the bladder is full and distended.
Equipment
• Dressing pack.
• Gloves.
• Cleansing solution.
• Two 10mL syringes.
• 25G and 21G needle.
• 10mL 1% lidocaine.
• Prepacked suprapubic catheter set (usually containing catheter, trocar,
and scalpel).
• 1/0 silk suture.
• Catheter bag.
Preparation
• Explain the procedure and consent the patient.
• Lie patient supine and expose abdomen.
• Confi rm clinically an enlarged, tense bladder.
• Identify catheterization site, 3–4cm (two fi nger breadths) above the
symphysis pubis (see Fig. 4.7).
Method
• Clean the skin thoroughly around the site and apply drapes.
• Inject lignocaine into skin and subcutaneous tissues, injecting and
aspirating in turn until urine is withdrawn.
• Two systems for introducing a suprapubic catheter are available.
‘Nottingham’ introducer (uses trocar)
• Make a 5mm incision at the identifi ed site.
• Advance the catheter, with trocar in place, through the incision and
subcutaneous tissues. A ‘give’ will be felt as the bladder is entered.
• Withdraw the trocar and ensure that there is free fl ow of urine from
the catheter.
• Infl ate the catheter balloon and suture the fl ange of the catheter to
the skin.
• Attach a catheter bag.
Bonnano (modifi ed Seldinger technique)
• Make a 5mm nick in the skin.
• Take the introducer needle and advance it, aspirating until urine is
withdrawn.
SUPRAPUBIC CATHETERIZATION
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• Remove the syringe and pass the guidewire down the needle into the
bladder, then remove the needle, holding the guidewire in place.
• Pass the dilator fi rmly over the wire into the bladder.
• Remove the dilator and pass the catheter into the bladder, securing it
as above.
Tips and pitfalls
• Bypassing urine. With some types of catheter and trocar, urine may
initially bypass the catheter. This will cease with full advancement of
the catheter and decompression of the bladder.
• No urine or faeculent matter in catheter. Obtain help; you may have
entered the peritoneum or bowel.
Fig. 4.7 Site of typical suprapubic catheter insertion.
213
CHAPTER 4 Practical procedures
214
Paracentesis abdominis
Key facts
This is a useful technique in some patients for the diagnosis and management of ascites, often in a patient with malignancy.
Indications
• Diagnostic evaluation of ascites.
• Therapeutic drainage of ascites.
Equipment
• Dressing pack.
• Gloves.
• Cleansing solution.
• 10mL syringe and 21G and 25G needles.
• 10mL 1% lidocaine.
• 60mL syringe with 16G aspiration needle for diagnostic ‘tap’.
• Bonano catheter or paracentesis catheter, three-way tap, and
collecting bag for therapeutic drainage.
• Specimen container if appropriate.
• Dressing.
Preparation
• Explain the procedure and consent the patient.
• Position the patient supine and expose the abdomen.
• Percuss out and identify the position of ascites.
• Identify a suitable tap site; the right lower quadrant is the commonest
with the patient turned semilateral to ensure the ascites fi lls this area
(see Fig. 4.8).
Method
• Prepare the skin at the appropriate site and place sterile drapes.
• Infi ltrate local anaesthetic into skin and subcutaneous tissues down to
the peritoneum. Aspirate as the needle is advanced to avoid accidental
vessel puncture.
Diagnostic tap
• Introduce the aspiration needle through the skin and subcutaneous
tissues while aspirating. A ‘give’ should be felt and fl uid freely aspirated
as the peritoneal cavity is entered.
• Withdraw 15–20mL of fl uid for a diagnostic evaluation.
• Remove the aspiration needle carefully and apply an occlusive dressing.
Therapeutic drainage
• Introduce catheter into abdominal wall until a ‘give’ is felt. Trial
aspirate with a syringe to ensure ascites returned.
• Slide catheter over the needle into the peritoneal cavity. Stop if
resistance is encountered.
• Allow up to 1000mL of ascites slowly over 1–2h.
PARACENTESIS ABDOMINIS
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Tips and pitfalls
• Unable to aspirate adequate quantity of fl uid. The ascites may be
loculated. Drainage under ultrasound guidance may be helpful.
• Blood or faeculent material. Continual staining of the ascitic fl uid
with fresh blood or any staining with faeculent material may indicate
puncture of a vessel or viscus. This is potentially serious; inform a
senior colleague.
• Peritoneal catheter. Some patients who require repeated ascitic taps
might benefi t from placement of a temporary intraperitoneal catheter
to allow daily drainage of ascites for symptomatic relief. There is a
risk of peritonitis with these devices and only a short period of use is
usually recommended, e.g. 2–3 days.
The volume of ascites drained should be closely monitored along with the
patient’s serum albumin and overall fl uid balance. A maximum drainage of
2L/day is usually advised.
215
Target areas
Fig. 4.8 Target areas for ascitic tap at the level of the umbilicus, 3–4cm lateral to
the mid-inguinal line.
CHAPTER 4 Practical procedures
216
Rigid sigmoidoscopy
Key facts
This is a useful skill to learn. It is usually performed in the outpatient department as part of the investigation of lower GI complaints, but may have to be
performed on the ward, e.g. acute admissions with rectal bleeding.
Indications
• Investigation of anorectal symptoms.
• Visualization of the rectum.
Equipment
• Rigid sigmoidoscope with obturator and light source.
• Lubricating jelly.
• Gloves.
• Gauze swabs.
Preparation
• Explain the procedure and consent the patient.
• Position the patient in the left lateral position with the hips fl exed as
fully as possible and knees partially extended.
• Carry out a digital examination of the rectum to identify low-placed
lesions or faecal loading, which may prevent safe insertion or obscure
a useful view.
Method
• Lubricate the sigmoidoscope with jelly.
• With the obturator in place, introduce the scope gently through the
anal sphincter in the direction of the umbilicus for approximately 5cm.
• Remove the obturator; attach light source, insuffl ator, and eyepiece.
• Introduce small amounts of air to open up the lumen.
• Advance the instrument slowly under direct vision, ensuring that a
patent lumen is identifi ed prior to advancing the scope further.
• Note the appearance of the mucosa and the presence of any mucosal
lesions. The level of any lesion should also be noted using the marked
scale on the outer casing of the sigmoidoscope.
• If the patient experiences signifi cant discomfort, do not persist.
• Withdraw the scope slowly, again under direct vision.
• Clean the area around the patient’s anus.
Tips and pitfalls
• Biopsy. Unless experienced in the skill, do not attempt biopsy of
lesions. Note and document their position and inform a senior
colleague.
• Unable to see the upper rectum. Remember that the rectum has a
sacral curvature, often pronounced in women; GENTLY use the tip of
the scope as a ‘lever’ to push the anterior wall of the rectum forward
to open to lumen. If this isn’t easy and painless, don’t persist; it may
represent pathology.
RIGID SIGMOIDOSCOPY
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• Rectosigmoid junction. Negotiation of the rectosigmoid junction can be
diffi cult. The best view that can be hoped for is to see the last sigmoid
fold above the junction. Do not attempt to pass the scope into the
distal sigmoid; this is the role of fl exible sigmoidoscopy.
Key revision points—anatomy of the rectum
• The rectum is said to start at the level of S2, but a distance of 15cm
from the anorectal junction is used to defi ne pathology which is
termed ‘rectal’.
• The rectum has two main angles.
The fi rst is the • acute anorectal angle which slopes posteriorly
and is formed in part by the pull of the sling of levator ani.
The second is the • sacral curvature which runs throughout the
rectum, sloping progressively anteriorly up to the level of the
rectosigmoid junction.
• Three ‘lateral valves’ are commonly described, but are only the
mucosal folds of the rectum equivalent to the colonic folds.
• The peritoneal-lined ‘pouch of Douglas’ (or rectovesical pouch in
males) extends a variable distance down the anterior wall of the
rectum. Its contents (e.g. sigmoid colon) may be easily palpable,
particularly in elderly females.
• The upper third is covered by peritoneum anterolaterally, the middle
third just anteriorly, and the lower third is entirely extraperitoneal.
• The rectum has a complete outer longitudinal muscle coat (thus
diverticular disease does not occur in the rectum).
• The rectum and associated mesorectal fat, blood vessels, and lymph
nodes are enclosed and separated from the ‘true’ pelvic organs by a
fascial sheet—the mesorectum.
217
CHAPTER 4 Practical procedures
218
Local anaesthesia
Local anaesthesia is used in a variety of settings and is easy to deliver. It is
essential to become familiar with the different agents, their relative merits,
and potential dangers.
Indications
• Minor procedures requiring anaesthesia, e.g. insertion of a chest drain,
CV access, suprapubic catheterization, etc.
• Excision of skin or subcutaneous lesions.
• Infi ltration of surgical wounds post-operatively.
Cautions
• Allergy. Do not use local anaesthesia if there is a history of allergy to
local anaesthetic.
• Infection at site of infi ltration. Injection may spread infection. The
effect of the local anaesthetic will be diminished (due to an acidic
environment) and injection may be more painful.
• Increased risk of toxicity. Heart block, low cardiac output, epilepsy,
myasthenia gravis, hepatic impairment, porphyria, B-blocker, or
cimetidine therapy.
• Epinephrine. Causes vasoconstriction, reducing bleeding locally and
prolonging anaesthetic effect. It should not be used for injections into
fi ngers, toes, ears, or penis (all supplied by end arteries) or where skin
fl aps are involved to reduce the chance of fl ap necrosis.
Agents The two most commonly used agents are lidocaine and bupi-
vacaine. Other agents, e.g. prilocaine, are less commonly used.
Lidocaine (previously known as lignocaine)
Used for local infi ltration for minor procedures.
• Concentrations. 0.5%, 1%, and 2%. Plain solutions (with no added
adrenaline) or solutions containing adrenaline.
• Duration of action. Rapid onset (2–3min), lasts 30–90min.
• Maximum dose.
Plain solutions• . 3mg/kg, 20mL 1% or 10mL 2% for 70kg adult.
Solutions with adrenaline• . 7mg/kg as systemic absorption is much
slower, 50mL 1% or 25mL 2% for 70kg adult.
Bupivacaine
Useful in some prolonged procedures, wound infi ltration, and regional
blocks as it has a longer duration of action than lidocaine.
• Concentrations. 0.25–0.75% plain solutions or with adrenaline.
• Duration of action. Slower onset than lidocaine; effects last 3–8h.
• Maximum dose. 3mg/kg for an adult, 2mg/kg for a child.
Equipment
• Syringe.
• Needles 21G–25G.
• Alcohol swabs.
LOCAL ANAESTHESIA
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Preparation
• Identify site of infi ltration and check for any sign of infection or
obvious subcutaneous blood vessels.
• Calculate maximum dose of anaesthetic for each individual patient.
• Draw up anaesthetic and check details of drug and dose.
Method
• Clean area with alcohol swabs.
• Inject anaesthetic slowly with a fi ne needle to area required, aspirating
before each delivery to prevent accidental IV injection.
• Injecting local anaesthetic in a fan-shaped area subcutaneously from a
single injection is often more comfortable for the patient.
• Field block. Injecting anaesthetic into the tissues surrounding the
area which is to be anaesthetized (e.g. a cutaneous lesion) will often
produce a fi eld block, including the area itself.
Toxicity
This is caused by an overdose of local anaesthetic with systemic absorption or by accidental IV injection.
Symptoms and signs
• Neurological. Drowsiness, confusion, slurred speech, light-headedness,
tinnitus, numbness of tongue or mouth, convulsions, and coma.
• Cardiovascular. Early tachycardia and hypertension, late bradycardia,
hypotension, cardiac arrhythmias, and cardiac arrest may ensue.
• These features usually will occur at a peak of 10–25min after
subcutaneous injection, but occur immediately with IV injection.
Treatment
• Stop procedure.
• Maintain the patient’s airway and provide oxygen.
• Ensure IV access.
• Perform an ECG.
• Convulsions. Diazepam 5–10mg IV, slowly.
• Hypotension. Raise end of bed and initiate IV fl uids.
• Bradycardia. Usually resolves, atropine is rarely needed.
Tips and pitfalls
• 2 You are more likely to achieve good anaesthetic block with a
large volume of less concentrated local than a small volume of more
concentrated local anaesthetic; generally use 1%, rather than 2%.
• Allow 2–3min for the local to take effect; spend this time setting up
your instruments and draping the patient.
• Accidental IV injection. See toxicity section above.
• Inadequate analgesia. Infi ltrate more anaesthetic up to the patient’s
maximum calculated dose. If the patient is still not tolerating
the procedure, alternative anaesthetic methods may have to be
considered, e.g. regional anaesthesia (note maximum local anaesthetic
dose), sedation, or general anaesthetic.
• The smaller the needle and the more slowly you inject initially, the less
painful it is for the patient.
219
CHAPTER 4 Practical procedures
220
Intercostal nerve block
This may be a useful skill to learn, although it is usually performed by
anaesthetists.
Indications
• Pain due to fractured ribs.
• Post-thoracotomy pain relief.
Equipment
• Dressing pack.
• Skin antiseptic.
• Gloves.
• 20mL syringe and needle.
• 20mL of local anaesthetic, e.g. bupivacaine.
Preparation
The patient is positioned as for pleural aspiration (see ‘Pleural aspiration’,
b p. 635) and the site of infi ltration is identifi ed.
• Broken ribs. Medial to the site of fracture on the posterior aspect of
the chest wall.
• Post-thoracotomy. Medial to the posterior edge of the scar on the
posterior chest wall.
Method
• Ensure that the skin is prepared thoroughly with antiseptic. Drapes are
placed appropriately.
• Insert the needle and syringe containing anaesthetic through the skin,
inferior to the rib (unlike pleural aspiration) associated with the nerve
to be blocked.
• Aspirate the syringe to ensure that the needle has not entered a blood
vessel or the pleural space. If no blood or air is withdrawn, the site is
infi ltrated with 4–5mL of anaesthetic.
• This is repeated at various sites.
• Obtain a CXR to ensure a pneumothorax has not complicated the
procedure.
Note
• Multiple blocks. Ensure that the patient does not receive a toxic dose
of local anaesthetic.
• Air or blood is aspirated. Withdraw the needle slowly, get a CXR.
Mechanism of action of local anaesthetics
Local anaesthetic works by blocking Na channels in the nerve membrane, preventing propagation of the action potential. Small, non-myelinated pain fi bres are blocked fi rst. Large, myelinated fi bres that conduct
impulses from pressure senses are the last to be blocked.
Chapter 5
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Head and neck surgery
Thyroglossal cyst, sinus, and fi stula 222
Branchial cyst, sinus, and fi stula 224
Salivary calculi 226
Acute parotitis 228
Salivary gland tumours 230
Head and neck cancer 232
Facial trauma 234
Neck space infections 236
221
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