This document provides information about peripherally inserted central catheters (PICCs): 1. It discusses the benefits, risks, and characteristics of PICCs including catheter types, styles, sizes, and lengths. 2. It describes the PICC placement procedure and methods for verifying catheter tip location using chest x-ray or EKG tip positioning systems. 3. It outlines considerations for PICC assessment including patient complaints, new cardiac issues, extremity edema, catheter migration, and issues requiring consultation with the IV team. 4. It briefly mentions PICC line care including flushing procedures and discontinuing a PICC which requires a physician/provider order.

1. Presenter:
Choiriyatul’Azmiyati
Chong Kwong Xian (Justin)
Devabharathi A/P Karunagaran
Farah Adiba Binti Mohamad Jahari
Nurul Laili Sofea
Amira Farra Binti Zulfihar
3rd August
2021

2. 2
1. Catheter Bladder Drainage (CBD)
2. Central Venous Line (CVL)
3. Management of Peripheral Inserted Central
Catheter (PICC)
4. Pre-operative Assessment
5. Pre-operative medication and management
(Stopping Antiplatelet and Anticoagulant)
6. Post-operative Complication

3. 3

4. 4
Types of catheter
1)Indwelling catheter
• Rubber catheter
• Plastic (PVC)
• Silicone
• Latex-foleys
• Polyurethane
2) External Catheters
• Condom catheter
3) Short term (Intermittent) catheter
• Robinson catheter
• Infant feeding tube( in case of paediatrics)
Catheterization allows the patient's urine to drain freely from the bladder for collection. It
may be used to inject liquids used for treatment or diagnosis of bladder conditions.

5. Indication
- Short term for acute urinary retention:
- Need for immediate and rapid bladder decompression
- Monitoring of intake and output
- Temporary relief of bladder outlet obstruction secondary to:
• Enlarged prostate gland in men
• Urethral stricture
- Chronic urethral obstruction or urinary retention and surgical interventions,
- Short-term following a urological or gynaecological surgical procedure
- Irreversible medical conditions are present (e.g., metastatic terminal disease, coma)
- Presence of stage III or IV pressure ulcers that are not healing because of continual urine leakage
Contra-indication
 Pelvic/urethral injury
 Acute prostitis
 Patient refusal
5

6. The average catheter size used by adult
men range from 14fr to 16fr, and most
men use 14fr catheters.
The average catheter size used by adult
women range from 10fr to 12fr, and
most women use 12fr catheters.
Catheters are color-coded based on
their french sizes:
Size 10 french: black
Size 12 french: white
Size 14 french: green
Size 16 french: orange
Size 18 french: red
6

7. Preparations
• Dressing trolley
• Dressing set and drapes
• Sterile gloves
• Appropriate size catheter
• Sterile lubricant (lignocaine gel)
• Sterile water to inflate balloon (Normal saline can crystalise and render the balloon porous causing
its deflation and the risk of catheter loss
• 10ml syringe
• Sterile saline
• Drainage bag with hanger 7

8. Step 01
A chaperone is required for this procedure.
Begin by introducing yourself to the patient and clarify his identity. Explaining what you are going to do and
obtain his consent.
Step 02
Position the patient
Lithotomy
(FEMALE)
Procedure Steps
Supine
(MALE)
Position the patient on
her back, lying as flat as
possible. Ask her to put
her ankles together and
let her knees fall apart.
Position the patient
on his back with
legs slightly apart,
and lying as flat as
possible.
8

9. Step 03
• Using an aseptic technique open the catheter pack and pour antiseptic solution into the receiver. Open the rest of
your equipment onto the sterile field.
• Wash and dry your hands, then put on the sterile gloves.
• Open the sterile drapes and place in position
• Cover the area with sterile dressing and minimize the exposure
• Place sterile drape
Step 04
(MALE)
• Hold the penis with your non dominant hand and with the other a sterile swab and clean the penis thoroughly.
• Retract the foreskin and clean around the urethral meatus.
• Hold the penis vertically with one hand and with the other hold the catheter by its sleeve.
• Advance the catheter tip from its sleeve and insert into the urethra.
• Progressively insert the catheter, ensuring that neither your hand nor the sleeve touch the penis until the end arm
reaches the meatus. At this point urine should start to flow into the collecting vessel.
• Inflate the balloon using 10ml of sterile water, ensuring that it does not cause any
9

10. (female)
• With your non dominant hand, part the labia. Using saline soaked gauze balls, clean the
urinary meatus with your right hand. Use single downward movements with each gauze.
• With the labia still parted, and ensuring you identify the meatus, insert the syringe of
lignocaine gel and inject the whole syringe.
• Using your dominant hand only, pick up the catheter by its sleeve and start to insert it into the
meatus. Continuing to use the sleeve, insert the catheter until the end arm reaches the
meatus. At this point, urine should start to flow into the collecting vessel.
• Inflate the balloon using 10ml of sterile water, ensuring that it does not cause any pain.
• Attach the catheter bag.
• Gently pull on the catheter until resistance is felt. This is when the balloon will be resting on
the urethral opening of the bladder.
10

11. During Procedure
- Urethral strictures/ meatul stenosis in en
- Urethral obstruction in men
Post Procedure
- Catheter related infections
- Paraphimosis
- Urethral injury- due to malposition, traumatic insertion, fase lumen
Post Removal
- UTI
- Urine leakage, incontinence
- Acute urinary retention
- Urethral injury- failed to deflate the balloon completely
- Urethral strictures
Complications
11

12. • Ureteric Catheters small-caliber, flexible, open-tipped catheters that are designed to pass into
ureters- Strictures
• Coude catheters- have a slight bend at the tip, helping to maneuver the catheter beyond
obstructions in the bulbar and prostatic urethra
(by trained UROLOGIST)
• Urethral dilators- graduated plastic or metal rods that can be passed over a wire to dilate the
urethra sequentially.
• Filiforms and followers- Filiforms are small; flexible tubes used to maneuver past strictures and
stenosis.
• Guidewires- are useful in assuring access to the bladder. Such wires are most safely used with the
aid of cystoscopic visualization to confirm passage into the bladder, though the blind passage of soft
wires into the bladder has been described
• Percutaneous Urinary Kit - When access to the bladder via the urethra is not able to be safely
completed, or when a urethral stricture repair is being considered, a suprapubic tube (SPT) may be
placed
Troubleshooting difficult insertions
12

13. 13

14. Indications
Types of CVL’s
Procedure IJ cannulation procedure Subclavian cannulstion procedure
Complications
How to read a CV pressure
14

15. • IV access (eg. difficult peripheral access, frequent blood samplings)
• Infusions of irritant substances (e.g. vasoactive agents, chemotherapy or TPN
administration)
• Access for extracorporeal blood circuits eg. RRT, plamapheresis
• CVP monitoring, pulmonary artery pressure
• Transvenous pacing
15

16. • Distorted local anatomy (eg, from vascular injury, prior surgery, or previous irradiation)
• Infection at insertion site
• Presence of anticoagulation or bleeding disorder
• Uncooperative patient
• Vessel thrombosis, stenosis, or disruption
16

17. 17

18. • IJC 1- central approach: find 1cm above the apex
of head of SCM and clavicle -> 60 degrees to
skin aiming towards ipsilateral nipple (blood
should be obtained within 3cm)
2- lateral/posterior approach: find 2-3 finger
breaths above clavicle along posterior border
of SCM, direct needle towards jugular notch
(blood should be aspirated within 5cm)
3- anterior approach: identify the carotid and
mid point of medial SCM border, aim toward
ipsilateral nipple
18

19. • Subclavian
the junction of the lateral two thirds and the
medial third of the clavicle.
The needle tip should be directed at the
index finger (or just superior to its tip)
19

20. • Femoral
the inguinal ligament and the midpoint of
the femoral arterial pulse.
The femoral vein is medial to the femoral
pulse
The puncture should be approximately 1-
1.5cm medially to the maximal femoral
pulse, and approximately 1cm inferior to
the inguinal ligament
20

21. 21

22. • Ultrasound and sterile ultrasound sheath
• Sterile trolley
• Sterile field, gloves, gown and mask
• Seldinger central line kit
• Saline flush
• Chlorhexidine
• Lignocaine
• Suture
• Scalpel
• Sterile dressing
• ECG monitor
Patient Position
• Supine
• Trendelenburg position (head down)
22

23. 23

24. • An over-wire technique of catheter
insertion to obtain safe percutaneous
access to vessels and hollow organs
• Cardiac ectopy may be induced by a
guidewire or catheter in the right atrium
or ventricle.
• Never lose grasp of the guidewire !
Insert dilator
and remove it
Insert cvl and
remove guidewire 24

25. 25

26. 26

27. • Guidewire will exit through brown (distal) port
27

28. • For optimal dilution- tip should
be closest to the right ventricle
• Perforation-cardiac tamponade
(deep) haemomediastinum,
thrombosis (high)
• Above the cephalic limit of the
pericardial reflection
• at a level corresponding to the
carina on a chest radiograph
• Short term- At carina
• Long term/ hemodialysis-cavo-
atrial junction (2 vertebral bodies
below carina )
28

29. 29

30. Immediate
• Pneumothorax (esp subclavian
approach)
• Hemothorax
• Arterial puncture
• Guidewire lost
• Hematoma, Nerve injury
• Arrhythmia
• Air embolus
Delayed
 Infection
Thrombosis
Catheter malplacement
Vascular erosion
Osteomyelitis of clavicle
30

31. • A normal CVP is between 5-
10 mmHg (2 - 5 cmH20)
1. Manometer system:
Intermittent readings and less
accurate
2. Transducer system:
continuous readings which
are displayed on a monitor
31

32. • Patient should be supine
• Manometer has spirit level at zero-
plebhostatic axis 4th intercostal
space mid axillary line
32

33. 33

34. 34

35. 35

36. 36

37. 37

38. 38

39. • https://www.msdmanuals.com/professional/SearchResults?query=cannulation+of+internal+jugular+vein
• https://www.msdmanuals.com/professional/multimedia/video/v8517422
• https://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_central_line_anatomy#top_1st_i
mg (interactive radiology)
39

40. • https://litfl.com/central-venous-catheters/
• https://www.bmj.com/bmj/section-pdf/749788?path=/bmj/347/7933/Clinical_Review.full.pdf
• https://slideplayer.com/amp/3909168/
• https://veteriankey.com/central-venous-catheterization-and-central-venous-pressure-monitoring/
• https://derangedphysiology.com/main/required-reading/equipment-and-
procedures/Chapter%20211/central-venous-access-device-insertion
40

41. NURSINGMANAGEMENTOF VENOUS
ACCESS DEVICES:
PERIPHERALL
YINSERTEDCENTRAL
CA
THETER (PICC)

42. Peripherally Inserted
Central Catheter (PICC)
BENEFITS
•Long-term access -dwell time varies (can be > one year)
•Decreased length of stay in hospital –allows for IV therapy in non-acute
settings, i.e., home care /hospice/ skilled nursing facility (SNF)
•Cost effective compared to all other central VADs
•Decreased infection rate, as compared with other non-tunneled CVADs
•Patient satisfaction andcomfort
•Fewer interruptions inIV therapy

43. Periphe
rally
Inserte
d
Central
Cathet
er
(PICC)
RISKS
•Air embolism
•Infection
•Deep vein thrombosis (DVT)
•Nerve damage
•Increased heparin usage in some PICCs
Other considerations:
•Blood withdrawal can be difficult; may be
dependent on catheterlength.
•Over time, multiple insertions can cause
venous scarring and decrease the ability to
reuse the site

44. PICC CHARACTERISTICS
CATHETER TYPES:
•single lumen (SL)
•double lumen (DL)
•triple lumen(TL)
CATHETER STYLES:
•non-power PICC
•Power PICC®
•saline-only or valvedPICC
(Solo®)
CATHETER SIZESAND
LENGTHS:
•2F to 6F
cut tospecific patient-
dependent length

45. PICC
PLACEMEN
T
•Successful placement is highly technique-dependent; requires formal training.
•A sterile procedure performed at bedside by specially trained IV nurse or by Interventional Radiology.
•Catheter tip location verified by chest xray(cxr) or using EKG tip positioning system (TPS) technology
(see next slide). Contraindicated in extremities affected by
•Axillary lymph nodedissection
•Tissue damage such as burns, cellulitis, fracture, rotator cuff tear
•Vessel occlusion / DVT(deep venous thrombosis)/SVT(superficial venous thrombosis)
•Dialysis catheter (AVF) in same arm
•Vein preservation for future dialysis access needs
•Newly implanted pacemaker ordefibrillator
•Affected arm s/p stroke
•Arm edema/lymphedema

46. PICC Tip Verification
o Via ChestXray(cxr):
•
•
•
•
CXRisdonewhenP wavesonEKGarenot
present,identifiable,orconsistent. Patientis<18
yearsofage
Verbiagein“LineProperties”sectionofprocedure
note:“PlacementVerification: post intervention
verificationpending”
Verbiageatendofprocedurenote:“PICCtip
locationneedstobeconfirmedby chestxraydueto
(reason).Oncecxrisread,linewillrequirean‘okto
use’order”

47. o ViaEKGTipPositioningSystem(TPS)(aka3CG):
•EKGTPSusedwhenP wavesarepresent,identifiable,andconsistent
•CXRnotneededfortipverification
•Approvedforpatients18yearsofageandolder
•Verbiagein‘LineProperties’sectionofprocedurenote:“Placement
verification:ECGdonebyIVnurse”
•Verbiageatendofprocedurenote:“PICCtiplocationintheSVCconfirmed
byECGtechnology.PICCisnowreadyforimmediateuse”.
PICC Tip Verification

48. Multi-lumen PICCs
DoubleLumen
PICC
TripleLumen
PICC

49. Other PICCs
Bard
Power
PICC
Bard SoloPICC
(valved,salineflush
onlyPICC)
Solo PICChas
characteristic
“bubble”

50. PICC Assessment
o
o
o
o
o
Patient comments/complaints(e.g.,pain,palpitations, hearssomethingin earwhencatheterflushed)
Newcardiacirritability:CXRtoverifycathetertiplocation
Extremityedema
•Isextremitycoldormottledinappearance?
•Doarmsappeartobesamesize?If
not… oAssess fordependentedema
oAssess whetherpatientis‘favoring’thatarm
oCheck bicepcircumferences
oRule outDVT
oRule outcatheterfracture
Cathetermigration(changeinexternalcatheterlengthsinceinsertion):
•CXRtoverifynewcathetertiplocation
•Holdcentral-concentrationinfusatesuntilconfirmationofcentralplacement
ConsultwithIVT
eamforanyissuesorsymptoms

51. PICC Line Care: Flushing
Refer to MGH Nursing Policies and Procedures in Ellucid

52. PICC Line Care: Flushing
Refer to MGH Nursing Policies and Procedures in Ellucid

53. Discontinuing a PICC
Physician/provider order requiredtodiscontinuePICC
Procedurehighlights:
•Patientshould berecumbentinbed
•Applyslow,steadytractionwhensliding catheterout
•Havepatient performValsalvamaneuver
•Placepetroleum-basedointment,asterile gauze,andocclusive dressingoverinsertionsite.Dressingshould
remainonforatleast24hours,orlongeruntilepithelialization occurs
•Inspectcatheter;checktipintegrityandlength
•Considertipcultureif infection is suspected
If difficultyremovingcatheter
,applywarmcompresses toarm,shoulder
,andchesttodecreasevenospasm.If
catheterremainssteadfast,DONOTFORCE.Securecatheterandnotifyphysician.
RefertoMGHNursingPolicies andProcedures inMGHEllucidfor full procedure

54. PICCs: Miscellaneous
o Maximuminfusionrate:aspatientconditionwarrants.Pumpmaximum
infusion rate is999 ml/hour
.
o Pumpsaremandatoryforanyinfusion!
o NObloodpressurecuffortourniquetonorabovePICCdressing.
o AnewStat-locksecurementdeviceshouldbeappliedwithdressingand
needleless connectorchange.
o Designateandlabeladedicatedlumenif patienttobeonTPN.Pleasebe
suretoflushandmaintainpriortoTPNinitiation.
o Formulti-lumenpowerPICCs,alwayshaveapower-injectablelumen
available forordered contrast studies.

55. 55

56. 56
• An assessment to gather all information to optimize comorbidities and then organize
anesthetic, surgical and postoperative care before surgery takes place
• The goal of the evaluation of the healthy patient is to detect unrecognized disease and
risk factors that may increase the risk of surgery above baseline and to propose strategies
to reduce this risk.
• Patients scheduled for elective procedures will generally attend a pre-operative
assessment 2-4 weeks before the date of their surgery.
• Preoperative assessment include
• Pre-Operative History
• Pre-Operative Examination
• Pre-Operative Investigations

57. 57
The pre-operative history follows the
same structure as typical history taking,
with the addition of some anesthetic and
surgery specific topics.
History of Presenting Complaint/ Surgery specific symptoms (including
features not present), onset, duration and exacerbating and relieving factors.
Past Medical History (Cardiovascular, Respiratory, Gastrointestinal,
Neurological, Endocrine, Renal, Pregnancy and Hematological)
Past Surgical history
Past Anesthetic History
Drug History including allergies, both drug and non-drug
Family History
Social History (smoking, alcohol, recreational drugs use)

58. 58

59. 59
Two distinct examinations are
performed; the general examination (to
identify any underlying undiagnosed
pathology present) and the airway
examination (to predict the difficulty of
airway management e.g. intubation). If
appropriate, the area relevant to the
operation can also be examined.
General Anaemia, jaundice, cyanosis, nutritional status,
sources of infection (teeth, feet, leg ulcers)
Cardiovascular Pulse, blood pressure, heart sounds, bruits,
peripheral oedema
Respiratory Respiratory rate and effort, chest expansion and
percussion note, breath sounds, oxygen saturation
Gastrointestinal Abdominal masses, ascites, bowel sounds, hernia,
genitalia
Neurological Consciousness level, cognitive function,
sensation, muscle power, tone and reflexes
Airway assessment Samsoon and Young modified Mallampati test
Other indicator of difficult airway (loose teeth,
obvious tumors, scars, infections, obesity,
thickness of the neck)

60. 60
A classification system to assess and communicate a patient’s pre-anesthesia medical co-morbidities.
The classification system alone does not predict the perioperative risks, but used with other factors (eg, type of
surgery, frailty, level of deconditioning), it can be helpful in predicting perioperative risks.
ASA PS
Classification
Definition
Adult Examples, Including, but not Limited to: Absolute Mortality (%)
ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use 0.1
ASA II A patient with mild systemic
disease
Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker,
pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease
0.2
ASA III A patient with severe systemic
disease
Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN,
COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker,
moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of
MI, CVA, TIA, or CAD/stents.
1.8
ASA IV A patient with severe systemic
disease that is a constant threat
to life
Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction,
severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled
dialysis
7.8
ASA V A moribund patient who is not
expected to survive without the
operation
Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel
in the face of significant cardiac pathology or multiple organ/system dysfunction
9.4
ASA VI A declared brain-dead patient
whose organs are being
removed for donor purposes
-

61. Blood Investigation
61
The nature of the exact investigations required depends on a number of factors, including co-morbidities, age, and
the nature of the procedure.
The urgency of the surgery will also dictate which conditions need further investigation and management prior to
surgery. For example, elective surgery is often delayed for poorly controlled blood glucose levels in diabetic patients,
to allow time for optimisation
Cardiac Investigation
• Full Blood Count (FBC)
• Urea & Electrolyte
• Liver Function Test
• Coagulation Profile
• Condition-specific blood test
• Hba1c
• Thyroid function test
• Group and Save (GSH) +/- cross matching
• Electrocardiogram (ECG)
• Echocardiogram (ECHO)
• Myocardial Perfusion Scan
Respiratory Investigation
• Plain film chest radiograph (CXR)
• Spirometry
Other
• Urinalysis
• Urine Pregnancy Test

62. 62
Many patients undergoing major noncardiac surgery
are at risk for a cardiovascular event. The risk is
related to patient- and surgery-specific
characteristics. Identification of increased risk
provides the patient (and surgeon) with information
that helps them better understand the benefit-to-risk
ratio of a procedure and may lead to interventions
that decrease risk.

63. History/Symptoms
63
Physical Examination
• Angina
• Dyspnoea
• Syncope
• Palpitation
• History of heart disease
• History of Hypertension, CKD, Diabetes,
cerebrovascular or peripheral artery disease
• Cardiovascular examination
• Blood pressure measurement
• Auscultation of heart and lung
• Examination of extremities for oedema
Electrocardiogram (ECG)
• The rationale for obtaining a preoperative ECG comes from the
utility of having a baseline ECG should a postoperative ECG be
abnormal.
• Preoperative ECG should be evaluated for the presence of Q
waves or significant ST-segment elevation or depression, which
raises the possibility of myocardial ischemia or infarction, left
ventricular hypertrophy, QTc prolongation, bundle-branch block, or
arrhythmia
Functional status/capacity
• Cardiac functional status or capacity, as determined by doctors
assessing patients with a brief set of questions, has been thought
to be positively associated with postoperative outcomes.
• Functional status can be expressed in metabolic equivalents (1
MET is defined as 3.5 mL O2 uptake/kg per min, which is the
resting oxygen uptake in a sitting position).
• The ability to achieve four METs of activity without symptoms is
thought to be a good prognostic indicator
Can take care of self, such as eat, dress, or
use the toilet (1 MET)
Can walk up a flight of steps or a hill or walk
on level ground at 3 to 4 mph (4 METs)
Can do heavy work around the house, such as
scrubbing floors or lifting or moving heavy
furniture, or climb two flights of stairs (between
4 and 10 METs)
Can participate in strenuous sports such as
swimming, singles tennis, football, basketball,
and skiing (>10 METs)

64. 64
• All patients scheduled to undergo noncardiac surgery should have an initial assessment of the risk (in percent)
of a cardiovascular perioperative cardiac event using validated models that typically include information from the
history, physical examination, electrocardiogram, and type of surgery.
• The purpose of this assessment is to help the patient and health care providers weigh the benefits and risks of
the surgery and optimize the timing of the surgery.
• There few model for cardiac risk assessment
• Revised Cardiac Risk Index (RCRI), also referred to as the Lee index
• American College of Surgeons surgical risk calculator (ACS-SRC)
• Myocardial Infarction or Cardiac Arrest (MICA) calculator (derived from National Surgical Quality Improvement
Program (NSQIP) database)
• AUB-POCES index (renamed AUB-HAS2)
• VSGNE risk index

65. 65

66. 66

67. 67

68. • Medicine that help prevent blood clots, reducing fibrin formation and preventing clots from forming
and growing
• Given to people at high risk of getting clots to reduce risk of strokes and heart attack
Types of anticoagulant
• Warfarin (commonest) – maximum effect at 48 hours after administration and last for next five days
• Heparin – half life about 1 hour
• Rivaroxaban (Xarelto)
• Dabigatran (Pradaxa)
• Apixaban (Eliquis)
• Edoxaban (Lixiana)
68

69. • Decrease platelet aggregation and inhibit thrombus formation
• Interfere with platelet activation in primary hemostasis
• Effective in the arterial circulation in which anticoagulants have little effect
Types of antiplatelet
• Aspirin (half life is 20 minutes, however duration of life is 10 days)
• Clopidogrel (Plavix)
• Prasugrel (Effient)
• Ticagrelor (Brillinta)
69

70. 70

71. Heparin can be ceased for a short time in perioperative period
- Withhold an infusion for 4 hours before surgery
- Recommence once the risk of postoperative bleeding is low
Subcutaneously administered heparin or enoxaparin (Clexane) is withheld the day or evening before the surgery
- Recommence once patient can take oral medication
Rapid reversal of warfarin prior to an emergency operation may be achieved with Vitamin K, pooled fresh frozen
plasma or clotting factors
71

72. • Difficult to reverse acutely
• Need to be ceased 2-5 days preoperatively
• A specific dabigatran reversal agent has recently been released (idarucizumab (praxbind))
72

73. The American College of Chest Physicians recommend that if annual risk for thromboembolism is low, warfarin can
be withheld for 4-5 days before procedure without bridging
73

74. Patients with mechanical heart valve or AF or VTE
- At high risk for thromboembolism
Bridging anticoagulant is recommended with therapeutic-dose subcutaneous LMWH
- At moderate risk for thromboembolism
Base the plan for bridging vs no bridging on the individual patient rather than a generalized
consensus. The bridging anticoagulation can be done with therapeutic-dose SC LMWH,
therapeutic-dose IV UFH or low-dose SC LMWH based on the patient
- At low risk for thromboembolism
Low-dose SC LMWH is recommended
74

75. 75

76. • The antiplatelet agents (aspirin,clopidogrel, or ticagrelor) taken alone
or in combination should be ceased at least 5 days prior to an
operation
• Bleeding will be highly problematic at the time of surgery especially if
multiple antiplatelets agents are continued
• Combined usage often follows coronary artery stenting and so their
withdrawal in context of surgery should be discussed with
interventional cardiologist
76

77. 77

78. • Bridging therapy low molecular weight heparin, similar to what is recommended for
patients on warfarin, has been considered.
• However, heparin has relatively minor effects on platelets, and thus does not prevent a
thrombotic event.
• Therefore, despite being recommended as an alternative therapy by several societies, it
does not seem to be an appropriate choice.
• Alternatively, bridging with short-acting GP IIb/IIIa inhibitors (tirofiban and eptifibatide) can
be considered
• Society of Thoracic Surgeons, ESC and Australia/ New Zealand guidelines recommend
such an approach in patients at high risk of cardiovascular events
78

79. 79

80. • Post-operative complications may either be general or specific to the
type of surgery undertaken
• the management provided should consider the type of surgery, patient’s
needs and medical history
80

81. Common:
• Post-operative fever
• Respiratory complication- Atelectasis
• Wound infection
• Embolism
• Deep vein thrombosis
Immediate
• Primary haemorrhage: either starting during surgery or following post-operative increase
in blood pressure
• Basal atelectasis: minor lung collapse
• Shock: blood loss,acute myocardial infarction, pulmonary embolism or septicaemia.
• Low urine output: inadequate fluid replacement intra- and post-operatively.
81

82. • Acute confusion: exclude dehydration and sepsis
• Nausea and vomiting: analgesia or anesthetic-related, paralytic ileus
• Pyrexia
• Secondary haemorrhage: often as a result of infection
• Pneumonia
• Wound or anastomosis dehiscence
• Deep vein thrombosis (DVT)
• Acute urinary retention
• Urinary tract infection (UTI)
• Post-operative wound infection
• Bowel obstruction due to fibrinous adhesions
• Paralytic Ileus
82

83. • Bowel obstruction due to fibrous adhesions
• Incisional hernia
• Persistent sinus
83

84. Causes
• The Five “W”
• Wind (POD#1) Atelectasis, pneumonia
• Water (POD#3) UTI, anastomotic leak
• Wound (POD#5) Wound infection, abscess
• Walking (POD#7) DVT / PE
• What we give/do?
• Blood transfusions, central lines we put in (line sepsis)?? Operation related??
• Another W  What can kill?
• necrotising fasciitis, malignant hypoerhermia, allergic reaction/transfusion
84

85. Early (Day 1-3)
Mild fever - Temperature <38°C (common)
• Tissue damaged and/or necrosis at the op-site
• Haematoma
Persistent fever – Temperature >38°C
• Atelectasis: collapsed lung may become secondarily infected
• Specific infections post surgery
• Blood transfusion or drug reaction
85

86. • Attend to the patient, assess clinically
• History
• Examination
• Temperature
• Look for sign to rule out each causes
• Investigations
• Septic workout
• U/S Doppler if indicated
• Management
• Manage the cause involved – antipyretic, sponging, IV fluid resuscitation
86

87. Predisposing Factors
• Patient’s age, past medical illness, comorbidities
• Airways obstruction, spasm of vocal cords, glottic edema,
laryngospasm, aspiration
• Lung – Pneumothorax, pleural effusions, COPD, Fibrosis
Management
• Supplemental oxygen supply – nasal prong, masks,
endotracheal intubation, mechanical ventilation
87

88. • Symptoms - Unexplained dyspnoea, arrhythmias, pleuritic chest pain,
hemoptysis
• Signs – Tachycardia, heart murmur, ventricular gallop, pleuritic rub,
hypoxia
• Investigation – ECG, CXR, ABG, pulmonary angiogram
• Treatment – Heparin, Streptokinase, Urokinase, Surgery
88

89. Virchow’s Triad – venous stasis, endothelial injury, hypercoagulable blood
Investigation:
• Doppler
• Venogram
Management:
• DVT prophylaxis – Low molecular weight heparin, unfractionated heparin,
Fondaparinux
• Surgery
89

90. • Type – concealed/open
• Factor
a. Local – infection, ischemia
b. Suture – poor handling, material, tight closure
c. Systemic – age, nutrition, DM
• Management
a. Superficial – release suture, drain pus/haematoma
b. Burst abdomen – cover gut, early abdominal wall closure, tension suture
c. Concealed Dehiscence – incisional hernia repair, mesh repair, abdominal corset
90

91. May be resulted from:
• Ineffective local hemostasis
• Complications of blood transfusion
• Undetected hemostatic defect
• Consumptive coagulopathy and/or fibrinolysis
Perioperative Hemorrhage:
• Primary – bleeding that occurs within intra-operative period
• Reactive – occurs within 24 hours of operation
• Secondary – occurs 7-10 days post opratively
91

92. 1. Review Medications History
2. Personal History
3. Family History
4. Comorbidities – Bleeding Assessment Tool (BAT)
5. Physical Examination
92

93. 93

94. 94

95. Management/Methods of Homeostasis
• Mechanical methods – direct pressure, digital pressure, fabric
pads/gauze, sutures/staples/ligateing clips
• Thermal based methods – electrosurgery, ultrasonic device, laser,
cryogenic cautery
• Pharmacological methods – epinephrine (local), vitamin K, protamine,
fibrinogen concentrate, tranexamic acid
95

96. Management
• Determine Pain Score – numeric rating scale
• Methods – Systemic (IV, IM, SC, Oral, Nasal, sublingual) anelgesic,
Regional anelgesic
• Pain Ladder (WHO) –
a. Minor pain – PCM, Aspirin, NSAIDS
b. Moderate pain – minor opiods (codeine, tramadol)
c. Severe pain - morphine
96