SUTURES & LIGATURES 2 catgut plain & chromic

ABSORBABLE SUTURE

Catgut (Plain)

The origin is from the intestine of animals and after processing 98% of the extracted material is collagen. Each of the strands is then graded and separated into six metric size: from the thinnest to the thickest, 2(4/0), 3(3/0), 3.5(2/0), 4(0), 5(1), and 6(2)
(The sizes refer to metric gauge, the sizes in brackets are the USP equivalents). The metric size approximates the diameter of the strand in millimeters × 10.

Uses (Fig. above)

The finished catgut is cut into lengths of about 70 cm (30 in) or 1.52 m (5 ft) to form ligatures or ‘needled’ sutures.

         The attachment of nontrau­matic suture needles is a machine procedure.

         There are two basic methods of needle attachment. A hole may be drilled into the blunt end of the needle shaft, or the needle can be flanged at this end to form a groove. Machines are used to close the prepared needle and tightly around the suture material, which is the “pull tested” to ensure that it is firmly attached to the needle. This material is then sterilized and package in a fluid in small easy to handle packages.

Catgut passes through tissues smoothly and easily.

•       It swells and loses its strength at the end of one week, there is loss of 70% of its strength

•       It disintigrates by proteolysis and is rapidly absorbed.

•       There is an inflammatory response to its presence in the tissues.

         It is used as ligature for small vessels and also as a suture for a subcutaneous stitch under the skin.

Catgut (Chromic)

The origin of this suture material is the same as catgut (plain). The material obtained from animal intestine is treated by immersion in a dichromate bath. It is sterilized and package in a similar manner as plain catgut. Its treatment in a chromic bath delays its disintegration and this suture loses 70% of its strength by the end of second week.

Uses

It is used as a ligature from blood vessels and also for suturing the mucosa of the GI tract, urinary tract, respiratory tract, peritoneum and muscle.

         Surgical catgut is wet packaged in alcohol in hermetical sealed pack and presterilized.

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SUTURES & LIGATURE 1

Ligature and Suture Materials

SUTURES AND LIGATURES

In surgery all tissue layers are cut to reach the required organ. On closure all these layers must be stitched back in position accurately to its opposing layer to provide anatomical continuity which was interrupted while opening up the body. Surgeons have made use of sutures and ligatures for achieving closure the following are some available techniques for skin closure.

1.      Needle and suture

2.      Metal ligature

3.      Skin clips

4.      Staples

5.      Adhesive closure

         A suture or a stitch holds cut tissue layers or structure together to help the process of healing.

         A ligature or metal ligature is the use of the material to encircle a cut end of a blood vessel so as to control bleeding. Staples have been used to anastemose hollow organs and vessels. Suture can be:

1.      Absorbable or

2.      Nonabsorbable

         And both these varieties may be made of either natural or synthetic fiber.

NEEDLES

•       These can be with an eye where thread has to be passed through so that two strands pass through the tissues causing trauma.

•       The same is true of spring eye needles.

•       Shapes of needles vary from quarter circle to straight and the shape of the tip of the needle shown in Figures above.

•       A traumatic needle come with the suture material (single strong) attached to the needle .

•           These are presterilized and come in double wraps

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Duties Anesthesia Assistant check lists and musts

INSTRUCTIONS FOR OPERATION ROOM ASSISTANTS (ORA)

Check-list I for Continuous Flow (Boyle’s Anesthetic Apparatus or any Anesthesia Machine) (see Fig. AIII.1)

•       All anesthetic apparatus must be checked before beginning of anesthesia.

•       A suitable resuscitation device (for example a self-inflating bag or bellows) to ventilate the lungs of the patient in case the gas supply fails should be available at all times.

Oxygen Supplies

For Machines Fitted with Cylinder Supply 

•       Turn on the oxygen supply from the cylinder in use and check the pressure (Full 2000 lb/in2)

•       Turn on the supply from the reserve cylinder, check the pressure and turn it off again

•       Check that a third cylinder is available to replace the cylinder in use when it is exhausted

•       Keep marker slip on the cylinders as ‘Full’, ‘empty’ or ‘inuse’.

For Machine Fitted with a Piped Gas Supply

•       Check the source of piped gas whether supply is on or not

•       Check that there is a full cylinder of oxygen fitted to your machine in case the pipeline supply fails.

Turn off All Machine Gas Supplies Except One Oxygen Cylinder or Pipeline Supply

•       Open all rotameters. Only oxygen should flow through oxygen rotameter tube

•       If this does not happen, do not use the machine.

If the Machine has an Oxygen-failure Warning Device

Test it as follows:

•       Turn on the gas supply from one oxygen cylinder (pipeline disconnected if fitted) and one nitrous oxide cylinder (if fitted)

•       Open rotameter taps to give a flow of oxygen and nitrous oxide of 5 litres/min

•       Turn off the oxygen supply at the cylinder. If a functioning warning device is fitted, an alarm should sound, and automatically nitrous oxide supply cuts off

•       After the test remember to open the oxygen cylinder valve again

•       Avoid using a machine that does not have a functioning oxygen-failure alarm

•       If there is no alternative, one must record the oxygen cylinder pressure every 5 min throughout anesthesia and change cylinders when the cylinder pressure drops below 220 psic

•       Never begin anesthesia with a machine that has only a single source of oxygen, i.e. only one cylinder or the pipeline.

Nitrous Oxide

•       Check the labels, keep reserve cylinder

•       The amount present in the cylinder can only be ascertained by weighing as the gas is in liquid form and the gas pressure above the liquid level remains reasonably constant as long as any liquid remains

•       Till the exhaustion of the cylinder, the pressure will show high. Only when all the liquid is vaporized, there will be drop in pressure

•       So keep a watch on the fall in pressure and the approxi­mate time a cylinder lasts

•       Cylinders should be labelled as “full”, “in use”, “empty.”

Rotameters

•       Inspect visually for cracks

•       Make sure that the bobbins do not stick in the tubes.

Emergency Oxygen

•       Turn on the emergency oxygen (bypass) button or tap

•       A high flow of oxygen should be delivered from the gas outlet

•       Note that this supply does not pass through the oxygen rotameter.

Vaporizer

•       Check that all vaporizers are firmly connected and filled with the correct anesthetic agent

•       Check that all filling ports are firmly closed and con­centration dials are set to zero

•       A Boyle’s bottle should have the lever in off position and the plunger pulled up.

Leaks

•       Check machine once a month for leaks or when you suspect. Apply suspected area with soapy water and watch for bubbles from suspected site

•       Possible site for leak are the joints, in the bag and breathing circuit.

Breathing System

•       Check for correct assembly.

•       Check the inner tube of bain circuit before each use.

Make Sure that You have

•       Face mask of suitable size

•       Oropharyngeal or nasopharyngeal airway of suitable size

•       Tested laryngoscope

•       Endotracheal tube of suitable size (test cuff by inflating)

•       Tested suction apparatus and suction catheters

•       Table or trolley that can be tilted head-down

•       All emergency and routine drugs

•           All electrical points to ventilator, monitors and suction apparatus to be checked for any loose contact

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CAUDAL BLOCK Anesthesia 12 Objectives Position Steps of Procedure

Caudal Extradural Sacral Block

Objectives

•   To provide anesthesia and analgesia for perineal, pelvic and abdominal operation by introducing the local anesthetic or opioid analgesic into the caudal epidural space

•   Consent to be taken for this procedure.

Position

•   Lateral position.

•   Prone position with hips slightly flexed over two pillows; legs slightly abducted and toes turn in.

•   Knee chest position.

•   Knee elbow position.

Premedication

Patient is premedicated with oral drugs.

Procedure

   1.  Intravenous line secured.

   2.  In children-under light general anesthesia (with O2, N2O, Halothane).

   3.  Clean the lower back

   4.  Drape the part with sterile towels leaving the sacrococcygeal region exposed.

   5.  Tip of coccyx identified.

   6.  Triangular sacral hiatus palpated 3.5 to 5 cm above it (Local infiltration not given to preserve landmarks).

   7.  Five cm needle, 22 G is inserted through the sacrococcygeal membrane at an angle of 20° (no need to use epidural needle).

   8.  Once through the membrane, the needle is depressed to    further 45° towards the intergluteal cleft and the needle is advanced further 2 to 3 cm in the midline. The needle should not go beyond the level of postsuperior iliac spine.

   9.  Ten ml syringe with air attached to the needle and test for loss of resistance and aspiration test done.

10.  If no crepitus over the skin or no CSF, drug injected into the space after a test dose slowly

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EPIDURAL anesthesia 11 objectives position procedure

Epidural Anesthesia

Objectives

•   To provide anesthesia for procedures and surgical inter­ventions (i.e., urological, gynecological, obstetrics, abdominal and orthopedic surgeries) by giving local anesthesia into the epidural space.

•   This technique is also used for providing postoperative analgesia.

•   Written consent for procedure is required.

Position

Same as for spinal anesthesia.

Premedication

•   Oral premedication given.

Procedure

   1.  Procedure explained to the patient.

   2.  On a tiltable table.

   3.  Performed at any level of spinal cord according to the desired level of analgesia.

   4.  Thoracic, lumbar or caudal epidural practiced.

   5.  The duration of action can be prolonged by intermittent injections through an epidural catheter.

   6.  Epidural needles are thick and curved tips (16, 18, 20 G Tuophy).

   7.  Intravenous line started.

   8.  Patient attached to ECG, SpO2 and NIBP, monitor.

   9.  Scrub and wear sterile gown and gloves.

10.  Check the epidural set on the sterile trolley for the items required, proper size needle and catheter; proper fitting of syringe into the hub of epidural needle.

11.  Fill in a 20 ml syringe the local anesthesia to be injected into the epidural space.

12.  Read the label of drug vial carefully for the name, percentage, baricity, expiry date. Confirm it with assistant.

13.  Local anesthetic to be used for skin infiltration taken into a 2 ml syringe (2 cc, 2% xylocaine).

14.  Cover the drug tray with a sterile towel to avoid spilling of antiseptic solution during cleaning.

15.  Clean the back with antiseptic swab same as spinal procedure.

16.  At L4 space, skin is infiltrated with local anesthetic with a 24/25 G needle - A skin puncture is made with a 18 G needle.

17.  Epidural needle is introduced in the above point upto supraspinous ligament.

18.  Stylet is withdrawn and attach a 10 ml syringe with 5 to
6 ml of air.

19.  Needle advanced further using firm but gentle pressure on the plunger of the syringe till there is a sudden loss of resistance to pressure on the plunger.

20.  The epidural space correct position is further checked by adding a drop of local anesthetic deposited at the hub which will be sucked in if in correct place.

21.  The drug slowly injected attaching the 20 ml syringe into the epidural space, directly after a test dose of 2 ml or

22.  Epidural catheter is inserted through the needle (if intermittent dosage is required).

23.  The catheter is introduced upto 3rd mark.

24.  Needle is carefully withdrawn.

25.  Catheter is adjusted upto 2nd mark .

26.  It is strapped to the back of the patient.

27.  Drug is given through the catheter slowly.

28.  Onset of action after 15-20 minutes.

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