CERVICAL CAUTERIZATION

CERVICAL CAUTERIZATION

Introduction

            This is performed by electric cautery. In electrocautery there is simple burning of diseased tissue while with diathermy cautery there is electrocoagulation (i.e, both incision and coagulation) of diseased tissue. Electrocoagulatio (with high frequency monopolar electrode) is better than electrocautery because the penetration of heat and destruction of diseased gland tissue are uniform and controllable. As electrocautery is quite cheaper than diathermy cautery it is widely used.

Definition

Cervical cauterization is a procedure that is used to destroy abnormal (noncancerous or precancerous) cells on the opening to the womb (cervix). Cauterization is carried out through the use of heat, electricity, cold, corrosive chemicals or laser. The most common methods involve high frequency electric current (electrocoagulation) or freezing (cryocauterization, cryosurgery).

Indication

Cervical cauterization is commonly used ti treat inflammation of the cervix (cervicitis), liquid-filled sacs (cysts) and precancerous lesions of the cervix, such as small areas of  abnormal tissue (cervical dysplasia). Cauterization is used to treat cervical lesions caused by human papilloma virus (HPV) AS 80% of cervical cancers are associated with HPV. It may also be used to stop bleeding that is occurring either spontaneously or following a cervical procedure such as cervical biopsy, cervical polypectomy or cervical conization. Cervical cancer itself is not treated with cauterization but by more aggressive means including surgery and radiation therapy.

Contraindications

Acute cervicitis, vaginitis, pregnancy, acute pelvic inflammatory disease and suspected early invasion carcinoma of cervix under evaluation.

Procedure

Cauterization is performed in outpatient surgery centers and hospital. The woman lies on the exam table in lithotomy position. A speculum is inserted into vagina to hold it open to allow visualization of the cervix. The cervix is cleaned using a vaginal swab that is soaked in a salt solution (saline). Using a lighted, magnifying instrument (colposcope), the vagina and cervix are carefully examined for signs of inflammation or abnormal surface patterns. To allow visualization of abnormal surfaces, a solution of acetic acid is applied to the cervix. The acetic acid turns precancerous and cancerous regions of the cervix white (acetowhitening). A surface anesthetic or cervical nerve block may be administered a few minutes prior to cauterization. Cauterization is performed on any abnormal-appearing regions of the cervix. The method chosen depends on the experience of the physician, availability of necessary equipment and extent and location of lesion.

Electrocoagulation diatherapy uses electric current to destroy tissue. The current is delivered to the tissue through needle or ball electrodes. Electrocoagulation diathermy of deep cervical tissue requires general anesthesia. The most common office procedure for these conditions is Loop Electrical Excision Procedure (LEEP). The excision is done with an electrical wire so that precise control of the excision and electrocoagulation for hemostasis are accomplished. Injection of local anesthesia is necessary for this to be done in the office setting. Sometimes general anesthesia is required.

Chemical cautherization is used to treat cervical cysts, precancerous erosions of the cervix and cervicitis. The area to be cauterized must be dried using a cotton swab to prevent the chemical from trickling onto normal tissue. A cotton swab that has been moistened with the chemical cauterant (e.g biochloracetic acid) is touched to the cervical lesion. Cervical cysts would be punctured before application of the cauterant. After a few minutes the cauterized area is wiped with a dry swab to remove any residual chemical. Laser cauterization (laser vaporization) is an effective treatment of all cervical dysplasias including those that are too large for cryocauterizatiuonand those that slightly extend into the cervical canal (endocervix). Because of the expense of laser cautery equipment, most laser cauterizations are performed in outpatient surgery centers and hospitals and frequently involve general anesthesia. Laser cauterization is carried out by aiming a carbon dioxide laser beam at the cervical dysplasia. Because of the fine degree of control over the depth and width of tissue destruction, the laser can precisely vaporize the dysplasia while leaving adjacent normal tissue intact. A smoke evacuator is utilized to remove smoke from the vagina. Antibiotics and analgesics are prescribed as needed.

After-treatment

            Inform the patient that there will be excessive vaginal discharge for about 3 weeks. Abstinence from sexual intercourse for 3 weeks. Vaginal pessary or antiseptic cream is usually not necessary. Only if the discharge becomes infective they are indicated. Follow-up after 6 weeks: (1) If erosion has not healed completely repeat cauterization is indicated. (2) Pass a uterine sound to check that cervix is not stenosed.

Prognosis

            Electrocoagulation has a high success rate and is associated with a recurrence rate of 3% to 14%. Chemical cauterization has a high success rate for mild dysplasias. Laser cauterization has a high success rate and a recurrence rate of 4% to 23%.

Complications

            Complications associated with cervical cauterization include uterine cramping, lightheadedness, hot flashes and headaches (vasomotor reactions), profuse watery vaginal discharge, bleeding (hemorrhage), upwardly spreading (ascending) infection and narrowing (stenosis) of the cervical canal.  

NEONATAL CARE: ADMINISTRATION OF FLUIDS AND MEDICATION

NEONATAL CARE: ADMINISTRATION OF FLUIDS AND MEDICATION

Administration of oral medication

Adherence to the following principles in your professional and legal responsibility and will assist in safe practice (Griffith et al, 2003)

The Five Cs/Rs:

·        Correct/ Right Patient/ Child

·        Correct/ Right Medicine

·        Correct/ Right Dose

·        Correct/ Right Time

·        Correct/ Right Route

Double Checking

If double checking is required, all aspects of preparation, administration and documentation must be carried out from start to finish by both practitioners

Basic principles when administering oral medication

Child development considerations are important in the administration of medicines. Some basic principles include (Rationale 17).

·       Be confident

·       Approach the child/family with a positive attitude

·       Be honest and understanding

·       Allow the child to have control where appropriate.

·       Use appropriate language that the child understands.

·       Discuss with the child what they might taste/ smell/see/hear/feel.

·       Listen to all involved.

·       Explain the benefits of compliance with the medicine taking.

Age –appropriate considerations should always be taken into account during drug administration.

Drug Calculations

Paediatric dose calculation is usually based on either body surface area (mg/m²) or body weight (mg/ kg) of the child. Body weight is used more frequently for the case of calculation.

The calculation of body surface area (BSA) used to require body weight and height.

To calculate drug doses, use the following formula:

Dose required/ Present Standard Quantity of Drug  X  Present Quantity of Liquid in which Standard Quantity of Drug is Dissolved

In other words:

What you want/ What you have X What it is in (dilation)

For example: A child is prescribed 90mg of Paracetamol and the medication supplied is 120mg of Paracetamol in 5mls:

90 / 120 X 5 = 3.75mls

CONTRAINDICATIONS

o   Unconscious child

o   Absent gag reflex

o   Inability to swallow

o   Vomiting

CAUTIONS

R Digestive tract trauma/ illness

R Post gastro-intestinal surgery

R Nil-by-mouth

R Nausea

R Diarrhoea

IV CANNULAE INSERTION

Before cannula insertion, use aseptic techniques by doing the following:

     Wash hands aseptically

     Wear sterile gloves

     Disinfect the skin

     Use no-touch technique

IV THERAPY

Each NICU should designate persons to be trained in the preparation of IV fluids, peripheral additional fluids. They should establish a dedicated area for preparation of medications and IV fluids. This area should not be used to store/ place any biologic material (eg. tubes of blood, formula and others). Preparation of IV fluids, preparation of IV medications or drugs and administration of medications or drugs are important activities that have to be performed safely to prevent infections inside NICUs. Therefore, task analysis was performed where all steps required are described in details to avoid any contamination. Three main critical activities will be described:

A.    Preparation of IV fluids

B.    Preparation of IV medications or drugs

C.    Administration of IV medications or drugs

A.    Critical Steps in Preparation of IV fluids

1.     Perform routine/ hygienic hand wash.

2.     Prepare and clean working area with a disinfection

3.     Gather necessary materials (IV fluids, drugs, syringes, needles, disinfecting materials, etc) and place them in the clean area of possible on a clean cloth/ towel.

4.     Inspect IV fluid containers for expiry date, cracks, leaks, cloudy/turbid etc.

5.     Wash hands with an antiseptic for 2-3 minutes. Dry hands with paper towel or fresh cloth towel or perform alcohol hand rub.

6.     Disinfect the port of IV bottles/bags with appropriate disinfectant (70% alcohol) immediately before removing/adding fluids.

7.     Wear sterile gloves.

8.     Use a sterile base needle/syringe for each IV fluids (the container that has the largest volume of the mixture wanted i.e. adding the smaller amount of fluids to the larger amount which will be the base)

B.    Critical Steps in Preparation of IV medications or drugs

1.     Use single-dose ampoules rather than multi-dose vials. If multi-dose vials must be used, always pierce the septum with a sterile needle. Never enter multi-dose vials with a needle or syringe that has been used on a patient. Use a new needle every time you stick into the multi-dose vial.

2.     If a multi-dose vial needs to be resolved, the used needle/syringe must be disposed. For each draw from the vial a new sterile needle and syringe must be used.

3.     Before filling a syringe from an ampoule or multi-dose vial, inspect for any contamination, turbidity, cracks, leaks and expiry date.

4.     Between each draw the top of the vial should be wiped once with alcohol and a cotton pad.

5.     Use for each vial/ampoule a new sterile needle and syringe.

6.     Any medication left in the vital should be kept in a fridge for no more than 24 hours or less if the manufacturing instruction doesn’t allow 24 hours storage.

7.     Aseptic hand washing or alcohol rub should be performed before each use of a multi-dose vial/ampoule.

C.    Critical Steps in Administration of IV medications or drugs

A.    Every step must follow strict aseptic techniques.

B.    Maintain a closed system at all times.

C.    Do not mix medications together.

D.    If medications are not compatible with IV fluids, the IV line needs to be stopped and flushed before administration as follows:

a.      Stop the IV fluid first.

b.     Flush the cannula with saline solution.

c.      Infuse the medication.

d.     Flush again.

e.      If needed infuse the second medication and flush again.

f.      Restart the routine IV fluid.

BIBILIOGRAPHY

1.     Armitage G, Knapman H (2003). Adverse events in drug administration: a literature review. J Nurs Manag 11 (2): 130-140.

2.     Aronsen J (2003) Nurse Prescribers and Reporters, British Journal of Clinical Pharmacology 56 (6): 585-587.

3.     BMJ Group (2009) BNF for Children. London, RPS Publishing.

4.     Cope J (2006) Administration of medicines Operational Policy. London, Great Ormond Street Hospital

5.     Copping C (2005) Preventing and reporting drug administration errors. Nurs Times 101 (33): 32-34.

6.     Galbraith, A. Bullock, Sand Manias, E (2001) Fundamentals of Pharmacology, French Forest, Pearson Education Australia.

7.     Gibson F (2003) Nurse prescribing: children’s nurses views. Paediatr Nurs 15(1): 20-25.

8.     Griffith R, Griffith H, Jordan SD (2003) Administration of medicines. Part1: The law and nursing. Nurs Stand 18(2): 47-53; quiz 54, 56.

9.     Kanneh A (2002) Paediatric pharmacological principles: an update. Part 1: Drug development and pharmacodynamics. Paediatr Nurs 14 (8): 36-42.

10.  Kanneh A (2002 c) Paediatric pharmacological principles: an update. Part 3: Pharmacokinetics: metabolism and excretion. Paediatr Nurs 14 (10): 39-43.

11.  King RL (2004) Nurse perceptions of their pharmacology educational needs. J Adv Nurs 45 (4): 392-400.

12.  Leathard (2001) Understanding medicines: conceptual analysis of nurses needs for knowledge and understanding of pharmacology (Part 1). Nurse Education Today 21: 266-271.

13.  Manias E, Aitken R, Dunning T (2004) Medication management by graduate nurses: before, during and following medication administration. Nurs Health Sci 6 (2): 83-91.

RUBIN’S TEST (RT)

RUBIN’S TEST (RT)

It is tubal insufflations test which was introduced by Rubin 1920. It is not done now because other better diagnostic facilities are available.

Time

From 6^th to 10^th day of menstrual cycle ie soon after the period is over. At this time there is no risk of gas embolism or of disturbing the fertilized ovum.

Instruments

·       Rubin’s insufflaton cannula

·       Vaginal instruments

·       Kymographic apparatus or simple air insufflators

Procedure

ü  Outpatient procedure

ü  No anesthesia as normally no cervical dilatation is required

ü  Injection atropine, 0.6mg, half an hour before the procedure

ü  Emptying of bladder

ü  Lithotomy position, aseptic and antiseptic precautions

ü  Per vaginal examination

ü  Expose the cervix, catch its anterior lip by tinaculam

ü  Cannula is fitted to simple air insufflators or kymorphic apparatus (CO₂) gas is used.

Instrument is checked for patency as well as for abnormal leakage.

ü  Then introduce the cannula gently through the cervical canal

ü  In rubin’s cannula acorn (rubber color) is firmly pressed against external os and its tip lies beyond the internal os.

ü  Cervix is pulled by tinaculam for air tight fitting

ü  Rate of carbondioxide flow is 10-30cc/min. It should not exceed 60cc/minute. Total gas is usually sufficient, for single test.

Contraindications

1.     Local or pelvic infections

2.     Suspected pregnancy

3.     Uterine bleeding

4.     Recent curettage

5.     Heart or lung diseases

Complications

1)     Spreading or activating pelvic infection

2)     Collapse and vomiting

3)     Embolism

4)     Rupture of uterus or tubes

5)     Regurgitation

6)     Endometriosis.

Rubin’s test positive: patent tubes (atleast one is patent)

Rubin’s test negative: blocked tubes

Criteria for positive RT:

1.     Hissing, gurgling or bubbling sound heard on auscultation of the lower abdomen

2.     Post procedure pain in right shoulder and neck when the patient sits up

3.     X-rays abdomen in standing position after procedure shows gas under diaphragm

4.     Typical kymorphic tracing

False positive: 3-4% even when both tubes are blockes. Reasons include large hydrosalphinx, intravasation, leak in the apparatus, perforation of the uterus.

False negative: ie failure to pass gas in the peritoneal cavity even when the tubes are patent. 33% cases at first sitting. Reasons include tubal spasm, block in the instrument, functional closure at uterine end due to edema and hypertrophy of endometrium particularly in premenustral phase.

·       Besides its diagnostic value it has therapeutic effect in 20% cases, due to temporary clearance of secretions from the tubes.

·       A positive test ordinarly means that at least on tube is open but it does not exclude the presence of significant tubal damage and periorbital adhesions. In case of negative test it does not give the site of block.