Bedside Procedures

1. Supervised by
DR HISHAM
Prepared by
ANWARIAH ARIS
NOOR MOHAMMAD SAFWAN

2. OUTLINES
Objectives
Pre-procedures
Procedures
Post-procedures
Take home messages

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

17. Complications:
Hematoma
Wound breakdown
Infection
Scar

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

25. Complications:
Pain
Incomplete drainage
Scar
Bleeding

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:

29. ACUTE
WOUND
Proliferative
Phase
Proliferation,
Granulation
and
Contraction
Haemostasis &
Inflammatory
Phase
Remodelling
Phase
Healed Wound

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

39. Complications:
Excessive bleeding
Infection
Delay wound closure

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.