Instruments required in various surgical procedures

1. Instruments and Procedures
for Ugs
Dr. Shraddha More

2. Bone Marrow Aspiration and Biopsy

3. Indications- Blood, Infections &Storage
disorders
• Diagnosis, staging, and therapeutic monitoring for lymphoproliferative disorders
such as CLL, Hodgkin and non-Hodgkin lymphoma, hairy cell leukemia,
myeloproliferative disorders, myelodysplastic syndrome and multiple myeloma
• Cytopenia ( Aplastic ITP), thrombocytosis , leukocytosis, anemia, and iron
status
• Inflitrative infectious diseases such as fungal infections- histoplasmosis,
tuberculosis, Mycobacterium avium complex [MAC], and other granulomatoses.
infections, leishmaniasis
• PUO workup
• HLH- Hemophagocytic lymphohistiocytosis
• Diagnosis of storage diseases (eg, Niemann-Pick disease and Gaucher disease)

4. Aspiration and biopsy
• The posterior superior iliac crest is the most commonly employed site
for reasons of safety, decreased risk of pain, and accessibility.
• The anterior superior iliac crest is an alternative site when the
posterior iliac crest is unapproachable or unavailable as a result of
infection, injury, or morbid obesity

5. Aspiration only
• The sternum is sampled only as a last resort in those older than 12
years and in those who are morbidly obese, but sternal sampling
should be avoided in highly agitated patients. To decrease the risk of
penetrating the underlying soft-tissue organs, the sternal site is
limited to a region that spans between the second and third
intercostal spaces.
• Complications -Mediastinitis, pulmonary embolism, pneumothorax,
cardiac tamponade, and cardiac tissue injury

6. • The tibia is sampled only for infants younger than 2 years, and the
procedure is conducted with the patient under general anesthesia.
This site is localized to the proximal anteromedial surface, below the
tibial tubercle.
• The tibial location is not utilized in older patients, because the
marrow cellularity is not consistent.

7. • Sterile Procedure
• Consent
• Local anesthesia is employed.
• The patient is placed in the lateral decubitus position, with the top leg
flexed and the lower leg straight. Alternatively, the patient may be
placed in the prone position
• Aspiration sampling is generally performed before marrow biopsy of
the posterior or anterior iliac crest. The reason is that the biopsy
technique induces elevated thromboplastic substances, and this leads
to a reduction in the effectiveness of an aspiration sampling.

8. Positioning

9. BM tray

11. Salah Aspiration
Needle Needle

12. Sterile Preparation

14. LA

16. Aspiration 0.2-0.3ml

17. Biospy

18. Biopsy

19. Reverse end technique

20. Biopsy sample

21. Slide Preparation

22. • Dry tap (ie, failure to obtain a specimen during the aspiration
sampling process) is most commonly due to technical problems such
as misalignment of the needle; other conditions that should be
considered and may contribute to the decision of obtaining a biopsy
are recent radiation therapy exposure, aplastic anemia, myelofibrosis,
and bone-infiltrating neoplasm

23. Lumbar Puncture
• Indications
• Diagnostic
• Infections -Menigo encephalitis
• Demylinating- MS NMO( OCB[oligoclonal bands] MOG Myelin
oligodendrocyte glycoprotein ) , GBS (ACD)
• Hydrocephalus, benign intracranial hypertension (BIH) or normal
pressure hydrocephalus (NPH)
• Therapeutic – Intrathecal injections, Therapeutic drainage in
cryptococcal meningitis

25. • The Quincke needle allows for direct communication between the
subdural space and the manometer, and therefore gives a more
accurate measurement of CSF pressure.
• However, these needles cause more traumatic punctures of the dura
unlike pencilpoint needles such as the Sprotte needle. These
“atraumatic” needles reduce dural injury and CSF loss and hence
reduce the incidence of postdural puncture headache (PDPH).
• PDPH occurs as a result of intra-cranial hypotension following excess
CSF leak and it is also dependent on the size of the spinal needle.

27. Position

28. • left lateral position with their knees pulled up to their chest or with
the patient sat up and leaning over a table.
• Both allow flexion of the lumbar vertebrae, thus reducing lordosis and
increasing the spaces between the lumbar vertebral spinous
processes.
• The left lateral position should be used in all cases that require
measurement of CSF pressure.

29. Method
• Sterile
• Consent
• LA
• locate the L3-L4 interspace by palpating the right and left posterior
superior iliac crests and moving the fingers medially toward the spine
• Palpate that interspace (L3-L4), the interspace above (L2-L3), and the
interspace below (L4-L5) to find the widest space. Mark the entry site
with a thumbnail or a marker.

30. • The spinal cord ends at the level of the intervertebral disc between L1 and
L2 around 50% of adults, but the range varies from T12 to L3/L4
intervertebral disc .
• In order to avoid damage to the spinal cord, LPs should be performed
below the L3 vertebrae, typically in the L3/L4 or the L4/L5 intervertebral
spaces.
• The most accurate surface anatomy is the intercristal line (Tuffier’s line),
which is an imaginary horizontal line between the superior aspect of the
posterior iliac crests .
• Tuffier’s line crosses the body of L4 in most patients in the left lateral
position and the L3/L4 intervertebral space in most patients in the seating
position

32. • 20- or 22-gauge needle
• Orient the bevel parallel to the longitudinal dural fibers to increase the
chances that the needle will separate the fibers rather than cut them; in
the lateral recumbent position, the bevel should face up, and in the sitting
position, it should face to one side or the other.
• Insert the needle at a slightly cephalad angle, directing it toward the
umbilicus. Advance the needle slowly but smoothly. Occasionally, a
characteristic “pop” is felt when the needle penetrates the dura.
Otherwise, the stylet should be withdrawn after approximately 4-5 cm and
observed for fluid return. If no fluid is returned, replace the stylet, advance
or withdraw the needle a few millimeters, and recheck for fluid return.
Continue this process until fluid is successfully returned.

33. • For measurement of the opening pressure, the patient must be in the
lateral recumbent position. After fluid is returned from the needle,
attach the manometer through the stopcock, and note the height of
the fluid column. The patient’s legs should be straightened during the
measurement of the open pressure, or a falsely elevated pressure will
be obtained
• Normal CSF pressure in the lumbar region when the patient is
horizontal (lateral decubitus) position is 5-15 cm H2O.
• If the CSF flow is too slow, ask the patient to cough or bear down (as
in the Valsalva maneuver)
• Replace the stylet, and remove the needle

35. • Tube 1 - Cell count and differential
• Tube 2 - Glucose and protein levels
• Tube 3 - Gram stain, culture and sensitivity (C&S)
• Tube 4 is reserved for special studies when indicated.

36. • The lymphocyte count in normal CSF may be as high as 5/µL.
• CSF with increased WBCs-infection or, more rarely, leukemic
infiltration
• bacterial infections are traditionally associated with a
preponderance of polymorphonuclear leukocytes (PMNs), many
cases of viral meningitis and encephalitis also show a high
percentage of PMNs in the acute phase of the illness
• inflammation from any source (eg, CNS vasculitis) can raise the WBC
count.

37. • Multiple lumbar puncture examinations may be required in testing for
leptomeningeal malignancies.
• At least 3 negative cytologic evaluations (ie, 3 separate samplings)
are required to rule out leptomeningeal malignancy (eg,
leptomeningeal carcinomatosis).

38. Traumatic Tap
• An approximation of 1 WBC for every 1000 RBCs can be made
• An approximation of 1 mg of protein for every 750 RBCs may
be used

39. Protein assessment
• The high protein levels in demyelinating polyneuropathies, or
postinfectious states

40. Glucose assessment
• CSF glucose level normally approximates 60% of the peripheral
blood glucose level at the time of the tap
• A simultaneous measurement of blood glucose (especially if the
CSF glucose level is likely to be low) is recommended
• Low CSF glucose in bacterial infection and tumour infiltration
meningeal carcinomatosis
• A high CSF glucose level has no specific diagnostic significance
and is most often spillover from an elevated blood glucose level.

41. Xanthochromia
• The best way of distinguishing RBCs related to intracranial
bleeding is to examine the centrifuged supernatant CSF for
xanthochromia (yellow color). Although xanthochromia can be
confirmed visually, it is more accurately identified and quantified
in the laboratory.
• xanthochromia in a fresh specimen is evidence of preexistent
blood in the subarachnoid space. However, it should be
remembered that an extremely high CSF protein level, as seen
in lumbar punctures below a complete spinal block, also
renders the fluid xanthochromic, though without RBCs. Froin
Syndrome

42. Other tests
• VDRL
• CRAG India Ink
• CBNATT MGIT LPA
• HSV PCR
• ACE levels

43. Contraindications
• Absolute contraindication-Infected skin over the needle entry site and
the presence
• Increased ICP from any space-occupying lesion (mass or abscess) and
trauma or mass to lumbar spine.
• Relative Contraindication -Bleeding Diathesis-Coagulopathy (high INR,
marked thrombocytopenia – ≤ 50 × 109 cells/L)

44. Complications
• Iatrogenic Infections
• Brainstem Herniation
• Headache (analgesics , caffein)
• Local pain
• Dry tap

45. PDPH-post-dural puncture headache
• The patient should be advised to remain in the horizontal position for
up to an hour after the procedure to prevent low pressure headaches,
especially when lots of CSF is withdrawn.
• More than 80% of PDPH resolve with supportive treatment –
rehydration, analgesia and antiemetics. If the headache fails to
resolve in 72 hours, then specific treatment is indicated
• Blood patch – 20-30 ml of blood is taken from a vein and injected into
the epidural space. It will form a clot and seal the perforation,
preventing further leak of CSF.
• Other measures: epidural saline – also has a sealing effect; caffeine;
surgical closure of the dural gap

46. Central Line

47. Types of insertion
• IJV
• Subclavian
• PICC

48. Central line
• Indications
• Shock
• Fluid rescucitation
• CVP assessment
• Long term IV antibiotics treatment – IE , Antifungals for mucour

49. Procedure
• Sterile
• Consent
• Positioning
• LA

50. Complications
• Iatrogenic Pneumothorax ( CXR)
• Catheter related Blood stream infections
• Bleeding
• Guidewire dislodgement (VIR Intervention )

51. Blood set and IV set

53. Foleys Catheter

54. ICD

55. ICD
• Indications
• Tension Pneumothorax
• SSP PSP not resolving with needle aspiration
• Hydropneumothorax
• Haemothorax
• Empyema
• Malignant effusion

56. Insulin syringe

60. Miller Straight Blade

64. In general, for average adult males, 7.5 mm to 8.5
mm, and females, 7.0 mm to 7.5 mm are
preferred.

65. • ETTs have an inflatable balloon at the distal end of the tube to form a
seal when inflated against the tracheal wall that prevents air leaking
around the tube to allow for adequate gas exchange.
• The cuff also maintains the ETT in proper position and prevents
oropharyngeal and gastrointestinal secretions from entering the
lower respiratory tract.
• A pilot balloon is present on the proximal end of the ETT outside of
the patient and has a one-way valve to allow for monitoring the cuff
pressure.
• all tested for cuff leaks

66. • A cuff pressure of 20 cm to 30 cm is usually recommended to provide an
adequate seal without causing injury to tracheal wall.
• Another key feature of standard ETTs includes a radiopaque marking all
along the length of the tube to allow for tip identification and tube location
on plain chest radiographs.
• During intubation, an indwelling stylet must be present within the ETT
before inserting the ETT into the airway.
• Oral intubation is the recommended route of choice for placing ETTs in
emergent and rapid sequence intubation.
• Nasal intubation may only rarely be considered for those with oral or
mandibular trauma or facial deformities

68. • All laryngoscopes should be checked for a functioning light source.
Bedside suction devices should be easily accessible.
• Of note, even if airway assessment does not reveal any obvious
evidence of difficulty, a backup plan should be readily available.
Adequate nursing staff and respiratory therapists must be present to
assist with intubation, monitoring, administering drugs and to
prepare the ventilator.

69. • The upper airway patency needs to be maintained with chin lift or
jaw thrust maneuvers that facilitate oxygen entry into the airways.
• Sniffing position: Flexion of neck on body and Extension of head on
neck to align 3 axes (oral, phayngeal and laryngeal)

72. • Direct laryngoscopy should be performed, and once glottis is visualized definitively, an appropriate size
endotracheal tube with stylet should be placed through the vocal cords under direct visualization.
• After that, the endotracheal tube cuff is inflated with 10 ml of air and the stylet removed.
• Placement should be confirmed by end tidal carbon dioxide detection, quantitative or colorimetric methods.
• Auscultation over both lung fields and the epigastric region should also be performed to ensure equal breath
sounds on both sides in the chest and absent in epigastric region.
• Post-intubation management involves securing the endotracheal tube, connecting endotracheal tube to a
mechanical ventilator and evaluating and managing potential post-intubation complications
• A chest radiograph should be performed to determine the depth of airway intubation. Endotracheal tube tip
should be located more than 2 cm but less than 5 cm from the carina on chest radiography.

74. Indications
• Type 1 & 2 Respiratory failure
• Shock
• Low GCS
• Elective for GA
• OPP
• Snake bite with neurotoxicity
• GBS with neuromuscular weakness
• MG crisis

75. Complications
• Immediate
• Esophageal intubation
• Right brochus intubation
• Trauma to teeth and ither oropharyngeal structures
• Delayed
• Tracheal injury stenosis
• TOF
• Vocal cord palsy
• VAP

76. Contraindications
• Laryngeal spasm ( tentanus , anaphylaxis )- emergency tracheostomy
or cricothyroidotomy

77. Guedel Airway

78. AMBU

79. • A one-person technique requires the "E-C seal" method where the first and
second digits form a "C" over the mask with the thumb pressing down by
the nasal bridge, the second digit over the bottom of the mask by the
mouth, and your remaining three digits forming an "E" over the mandible
to hold the mask tight. There should be no gaps between the mask and the
face. You can also perform the “head-tilt chin lift” maneuver or a “jaw-
thurst” if indicated to maintain airway patency.
• In a two-person technique, the second rescuer squeezes the bag while the
first rescuer uses the same E-C technique with both hands. This is more
effective in delivering the required tidal volume and also creates a better
seal

80. • An oropharyngeal airway may be inserted to prevent airway occlusion
when the patient is supine.
• The rescuer should be at the patient’s head. A good seal must be
achieved with the mask and the face. The pointed end of the mask
must be over the nose, and the curved end just below the lower lip.
• It is indicated for hypercapnic respiratory failure, hypoxic respiratory
failure, apnea, or altered mental status with the inability to protect
the airway.
• It's usage is advocated while delivering breaths during
cardiopulmonary resuscitation.

81. Ryles NG Tube -nose-to-ear-to-
xiphisternum (NEX) method

82. • Length: 125 cm
• Size: Ranges from 6-18 Fr (Adult 14-18 Fr and Child 10-14 Fr)
• Near tip end:
• Numerous side holes
• Radiopaque lead-shots (helps confirm position of NG tube in X-ray
and also makes the tip end heavier which helps in insertion of the
tube)

85. Left: Estimating length of the tube required
Right: Confirming the correct position of tube

87. Indications
NG lavage poisoning
Feeding – comatose , lower CN palsy
Dependent drainage

88. Contraindications
• Basilar skull fractures (Risk of NG reaching brain)
• Facial fractures (risk of cribiform plate disruption and NG reaching
brain)
• Obstructed nasal passages (if needed orogastric intubation is
considered)
• Caustic ingestion or esophageal strictures (risk of perforation)
• Coagulopathy (Risk of uncontrollable epistaxis)