Tonometry

 Parts of a Schiotz tonometer

 

REQUIREMENTS:

Anaesthetic eye drops (generally Paracaine), Schiotz tonometer with weight, Sterile cotton with spirit, Conversion chart

PROCEDURE: 

 

• Anaesthetize the patient using local anesthetic eye drops.
• The Schitoz tonometer is checked for zero error and its foot plate is cleaned by dabbing it against sterile cotton soaked in spirit.
• Let the alcohol evaporate. (to prevent corneal damage)
• POSITION- Patient in supine position, looking up at a fixation target with examiner at head end.
• Separate the two eyelids of the patient.
• Hold the tonometer as shown in figure (with the scale and handle/ holder of tonometer perpendicular to each other and the scale with readings is faced towards the examiner) and lower the tonometer plate so that it rests on the cornea & the plunger is free to move.
• Footplate of the tonometer should be held vertically on the center of cornea.
• The reading is noted (without any parallax).
• Similarly, IOP of the other eye is measured.
• The 5.5gm weight is initially used. If the scale reading is 3 or less, additional weight is added.
• Incase the needle oscillates, take the higher reading.
• Friedenwald conversion table is then used to derive the IOP in mmHg from the scale reading and the plunger weight.

REFERENCE VIDEO LINK: (** Spirit Lamp and antibiotic eye drops may not be required) https://youtu.be/4Hnzd_jaTmE

Written by our guest author Aishwarya Bagade
Illustrations by Devi Bavishi
#Ae(ONE)INTERN

Surgical scrubbing

 

APPROPRIATE DRESSING TO ENTER THE OPERATION THEATRE

- Cap

- Mask

- Eye shield 

- Surgical scrubs (bare hands below elbow)

- Protective footwear 

 

PREPARING TO SCRUB

- Pre-sterilized gown is generally kept on the sterile surface
- Peel the plastic glove packet open over the gown and drop the gloves onto the sterile gown without touching them
- This will ensure your gloves and gown are sterile
- Finally, put on a surgical mask and eyewear protection

PRE-SCRUB WASH

Run the tap to an adequate flow (to avoid water splashing) and temperature (Warm water makes antiseptics and soap work more effectively, while very hot water removes more of the protective fatty acids from the skin).

Povidone Iodine and Chlorhexidine are commonly used.

SCRUBBING

1. Wet hands and forearms

2. Back of hands

3. Palms

4. Fingers

5. Thumbs

6. Fingertips 

7. Forearms 

During each of the following steps keep hands (clean area) above the elbows (dirty area) allowing water to drain away, making sure to avoid splashing surgical attire.

Each step of surgical ‘scrubbing’ consists of five strokes rubbing backwards and forwards.

• Rinse keeping hands above elbow and repeat the above steps again.

• The second wash should only cover two-thirds of the forearms to avoid compromising cleanliness of hands.

• Local policy may include repeating these steps a third time but to wrists only.

• The scrub procedure should last for 5 minutes, with further scrubs during the day lasting 3 minutes.

• Rinse the hands.

• Turn the tap off (if necessary) with your elbow and keep your hands up, allowing water to drip from your elbows. Dry your hands with sterile towels.

** Some centres follow “Dry Scrubbing” – i.e., Scrubbing without water using by using Chlorhexidine gluconate 1 %+ Ethyl alcohol 61% w/w solution

GOWNING

- With one hand, pick up the entire folded gown by grasping the gown through all layers, being careful to touch only the inside top layer which is exposed

- Once your hands are securely pinching the gown in these slots, step back from the shelf and allow the gown to drop
- Keep at least 1 arm free space so that the gown does not touch any surrounding unsterile objects
- Grasp the inside shoulder seams and open the gown with the armholes facing you
- Carefully insert your arms part way into the gown one at a time, keeping hands at shoulder level away from the body
- Slide the arms further into the gown sleeves
- When the fingertips are level with the proximal edge of the cuff, grasp the inside seam at the cuff hem using thumb and index finger
- Be careful that no part of the hand protrudes from the sleeve cuff
- A theatre assistant will fasten the gown behind you, positioning it over the shoulders by grasping the inside surface of the gown at the shoulder seam and back. (The theatre assistant’s hands should only ever be in contact with the inside surface of the gown.)
- A sterile plastic gown is generally worn over it to avoid splash soiling

GLOVING

Pick up glove by the cuff touching only the inner side of the cuff. Pull back the sleeve only once you start wearing the glove on that particular hand.

• Keep your hands above your waist and in front of you

• Ensure you do not touch anything around you that is not sterile – this includes your face, mask, and hat!

** During Covid-19, donning and doffing of PPE is done inside the OT as shown here (REFER FIGURES 1, 3 & 4):

 https://docs.google.com/document/d/16uwMGAiXpYGAdPDcd_C4-e7azAULVIetOb-ODNd1W9A/edit?usp=drivesdk 

REFERENCE VIDEO LINK: (**NAIL BRUSH AND PICK MAY NOT BE AVAILABLE)

 (OPEN GLOVING TECHNIQUE AS SHOWN ABOVE MAY BE USED)

https://youtu.be/MPjA6Sx7_i8 

REFERENCES:

1. National Institute for Health and Care Excellence 2008 Clinical Guideline 74 – Surgical Site Infection: Prevention and treatment of surgical site infection London, NICE

2. World Health Organisation 2009 WHO Guidelines on Hand Hygiene in Health Care (revised Aug 2009) [online] www.who.int/gpsc/en [Accessed August 2018]

3. The Association for Perioperative Practice. A guide to surgical hand antisepsis 2014. [Accessed August 2018]

Information sourced from:

https://geekymedics.com/surgical-scrubbing-gowning-gloving-guide/ 

https://www.infectioncontroltoday.com/view/how-perform-surgical-hand-scrubs

 

Written by our guest author Pranav Survase

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IV cannulation and IV infusion

 Parts of IV Cannula

 Color coding of IV cannula

HOW DOES A 3 WAY STOPCOCK WORK - https://youtu.be/4TXQyv5_lGI

Usual sites of cannula insertion 

Dorsum of hand (Most commonly done), forearm, dorsum of foot in paediatric patients

Order of preferred vein for cannulation - the more distal the better, the straighter the better, the lesser on the joint the better. Your very last option on the arm should be the antecubital vein. 

REQUIREMENTS:

An appropriate size iv cannula (blue used usually for adults), a tourniquet, sterile gloves, alcohol swab, 3-way stopcock attached to 5ml syringe filled with normal saline (keep the 3- way such that one side-port is open and one is closed, as shown in the image below), dressing for the cannula.  If blood collection has to be done – vacutainers.

 

PROCEDURE: 

1. Wash hands and wear sterile gloves. 

2.  Apply a tourniquet proximal to the site of cannula insertion and ask the patient to close and open the fist a few times to make the veins visible. 

3.  The selected site is cleaned with an alcohol swab. 

4.  The cannula is opened from the sterile pack and held with two wings together with the bevel of the needle pointing upward. 

5. The vein to be punctured is steadied by slightly stretching the skin over it (also helps to see the direction of the vein clearly) and the skin is punctured with the cannula keeping the cannula at about 15 degrees to the skin. While doing this, decrease the angle between it and the hand (tilt needle upwards slightly) so that the vein is not counter-punctured. 

6. The needle with the cannula is advanced through the subcutaneous tissue into the vein.  As the cannula enters the vein blood will be seen flushed into the distal end of the cannula. 

7. The needle is further advanced few millimetres inside the vein. 

8. The cannula is held steady. The needle is withdrawn slightly and the plastic cannula is advanced into the vein over the metal needle. The metal needle and the tourniquet are removed. 

9. Blood collection from the open end of the cannula can be done at this point if it is required.

10. ** FLUSHING THE CANNULA – Immediately, the open end of the cannula is connected to the 3-way stopcock which is already attached to a 5ml saline syringe. Flush the cannula by injecting the normal saline.

11. ** ‘Turn off’ the 3 way (by aligning the blunt end of the 3 way knob with the iv cannula end), detach the syringe and close the ports of the 3 way stopcock with the caps.

12. The cannula is secured in place by an iv dressing.

** = DONE DIFFERENTLY FROM WHAT IS SHOWN IN THE VIDEO. 

PRACTICAL TIPS & TRICKS

1. As is mentioned before, keep the saline filled syringes already attached to the 3-way stopcocks during emergency. You won’t have time to attach them midway during the procedure. 

2. Tourniquet usually not available, so use a glove instead. 

3. During blood collection from the open end of the cannula, to prevent blood spillage between successive collections in different vacutainers, maintain a slight pressure with your hand over the end of the cannula which is entering the vein. This will prevent the blood from coming out. 

4. Remove vacutainer caps and keep the bulbs ready to collect blood in. Won’t have time to open and close each. 

5. During summer due to sweat, the iv dressing is more likely to come off and displace the iv cannula. Which will lead to repeated iv cannulations. So, make the cannula extra secure by additionally using micropore tape to keep it in place. 

6. Before putting IV sticking, put sanitiser on your gloves so that the sticking doesn't stick to your gloves.

7. Lower down the hand to be cannulated to make the vein more prominent.

8. Cannulate at the bifurcation point of the vein preferably (to prevent vein from rolling).

9. Vein may be tapped to make it more prominent (as it warms the area and releases vasodilators).

10. While stretching the skin over the vein, do it so by using your non-dominant hand's thumb placed below the patient's knuckle ridge.

 

VIDEO LINK:

https://youtu.be/h8DlRtqgh8c  (HAS SOME DIFFERENCES FROM WHAT IS DONE IN KEM HOSPITAL where I study. Those steps are highlighted above)

 

SETTING UP AN IV INFUSION 

Flow controller/Roller ball clamp: controls the rate of flow

Uppermost position: fastest flow

Lowermost position: CLOSED – no flow

REFERENCE VIDEO LINK:

https://youtu.be/Siy2cEMICE4

PROCEDURE OF SETTING UP THE I.V. INFUSION:

1. Collect all the requirements – bag containing the fluid/drug to be administered, iv set, pair of gloves

2. Explain the procedure to the patient and gain their consent

3. Check the fluid bag for any cloudiness or particulate matter present; do not use the bag if any such impurities are present

4. Remove the outer packing of the bag and hang it up on a drip stand

5. Wear sterile gloves

6. Open the iv set and keep the flow ‘off’ using the roller-ball clamp on the line

7. Remove the cover from the port on the bag containing the fluid/drug by twisting and breaking it off. Insert the spike (piercer) into the port, without touching the end of the spike

8. Half fill the drip chamber by squeezing it. Insert a needle at the top end of the bag and let it remain there.

9. Then release the roller ball clamp to allow the fluid to run through the giving set. Let the fluid come out through the open end of the line. Ensure there are no air bubbles in the line (to prevent air embolism). 

10. Attach the luer lock connector end of the iv set to the 3 way stopcock attached to the iv cannula which is already inserted in the patient’s arm

11. Set the infusion rate (as per instructions from the resident) by adjusting the roller ball.

Stopping the i.v. infusion:

1. Adjust the roller ball clamp to turn off the flow

2. Before disconnecting the iv set from the iv cannula, ‘switch off’ the 3-way stopcock

3. Disconnect the iv set from its insertion into the 3-way stopcock

 

 

Written by our guest author Mitali Shroff

Illustrations by Devi Bavishi
#Ae(ONE)INTERN

 

SCHIRMER'S TEST

The Schirmer test is used to test aqueous tear production. 

The test is performed in dim light with fans switched off.

Whatman filter paper no.41 is used with a dimension of 5 mm x 35 mm.

1. The test is performed by instilling a topical anaesthetic.

2. The 5 mm tab is folded at one end and then the bent end is placed at the junction of the lateral 1/3rd and medial 2/3rd of the lower conjunctival sac.

3. The corners of a soft tissue paper may be used to wick all liquid from the inferior fornix by capillary attraction without any wiping or direct irritation before the paper is placed. 

4. The patient's eyes are then closed for 5 minutes, and the amount of wetting in the paper strip is measured.

5. Less than 5 mm of wetting is abnormal; 5-10 mm is equivocal.

VIDEO LINK

https://youtu.be/cF2wocf6XWQ

Written by our guest author Jignesh Bhadarka

Illustrations by Ayushi Gupta
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Incision and drainage

 Incision and drainage (Hilton's Method)

 

REQUIREMENTS: Written informed consent, sterile gauze pieces, povidone-iodine, ethanol, sterile drape, syringe with needle filled with local anesthetic drug, scalpel with no.11 blade, 2 sterile syringes or 1 sterile syringe and 1 sterile swab, pre-labelled containers (for sending the sample for microscopy and culture and sensitivity), artery/ sinus forceps, roller gauze

• Area of abscess is cleaned with povidone iodine followed by ethanol and draped
• Local anesthesia (generally lignocaine) is injected
• Stab incision along long axis of abscess with no.11 blade is made over the most prominent part of the
swelling where the skin is red, thinned out & pointed OR over the most dependent part of abscess (to allow easy drainage)
• Skin incision is generally made along the Langer’s lines (vertically on limbs and horizontally on trunk) and it should be parallel to neurovascular bundle
• Squeeze out the pus
• Sample is collected by a syringe/ swab for microscopy and culture & sensitivity in a prelabelled sterile
container
• Explore the abscess cavity by introducing sinus forceps/ finger in the abscess cavity and breaking all loculi
• Base of the abscess, if unhealthy, is curetted
• Oozing of fresh blood indicates completion of process
• Cavity is irrigated by normal saline followed by antiseptic (e.g. Povidone-Iodine and H2O2)
• Pack the cavity with roller gauze (soaked in Povidone-iodine) and remove it after 24-48 hrs
• Keep the abscess open and do regular dressing. Allow healing by secondary intention
• Advice to patient: Keep the area clean and dry

 

Alternate day dressings (generally). Analgesics SOS.
Antibiotics and Tetanus immunization as indicated.

TIPS & TRICKS:
1. Incision should be large enough to allow artery forceps to enter. If required, extension of incision in the same axis may be done or a cruciate incision can be made
2. Sometimes a counter incision can be made in a the independent part to allow gravity- assisted drainage
3. Overpacking of abscess cavity should be avoided (to prevent ischemia of surrounding tissue)

Abscess at special sites:
I. For breast abscess, needle aspiration is done rather than incision and drainage. If it has to be done, incision should be radial
II. For some abscess like axillary abscess, drainage should be done under general anesthesia
III. Gluteal abscess requires a cruciate incision and de-roofing
IV. Tubercular lymph nodal abscesses are drained by non-dependent aspiration (To prevent non-healing of incision site)

 

VIDEO LINK
Equipment required: 2:28min
Preparation: 3:39 min
Procedure: 4:46 min to 7:27 min
https://youtu.be/MwgNdrA18fM

 

Written by our guest authors Tushar Mahajan and Anveshi Nayan

Illustrations by Devi Bavishi
#Ae(ONE)INTERN

 

Common steps to minor procedures

 

Steps common to all minor procedures

A) Pre- procedure:

1. Correct documentation with clinical photograph 

2. Informed written consent

3. Universal precautions  

4. Cleaning with betadine and spirit (or any other antiseptic) 

5. Infiltration of local anesthesia—Lignocaine with or without adrenaline. Check for the effect of anesthesia by gently poking the same needle in the periphery of the bleb raised by local anesthesia administration

B) Post-procedure: 

1. Dressing, antibiotics, TT injection when indicated

2. Advice to patient: The biopsy site should be kept clean and dry for a few days. The bandage should be changed at least once a day and should be changed if it should become wet or damp. Once a substantial scab has formed, or new skin begins to grow over the area and bleeding has stopped, the bandage can be removed

 

PRACTICAL TIPS AND TRICKS: 

1. While infiltrating, try to elevate the lesion by raising a wheal which allows the lesion to prop up

2. Keep a formalin filled pre-labelled container ready for putting the specimen in after its removal