Procedures Workshop 2012

8/2/2019 Procedures Workshop 2012

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Procedures Workshop

Joel Pasternack, MD, PhD

University of Rochester


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Core Procedures

1. Central Venous line - femoral vein, subclavian vein,

internal jugular vein

2. Lumbar puncture

3. Foley catheter

4. Nasogastric tube

5. Intravenous line*

6. Arterial Blood Gas* - radial artery, femoral artery

* These procedures are difficult to simulate on a cadaver.


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Additional Procedures

Endotracheal intubation - curved blade, straight blade

Digital blocks - fingers, thumb, toes

Joint aspiration - knee, elbow, ankle

Thoracentesis

Arterial lines* - radial artery, femoral artery

* This procedure is difficult to simulate on a cadaver.


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General Principles

Know the following:

1. Indications

2. Equipment sizes

3. Level of sterility

4. Anatomy and positioning which makesprocedure easiest for operator and patient.

5. Complications and modes of failure.

6. Anesthesia/analgesia


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Important Caveat for any procedure with a needle

**DO NOT SWING THE NEEDLE **

If you need to redirect needle, withdraw to just under the

skin, and redirect.

Otherwise, redirecting by swinging allows the needle tip to

act like a knife cutting tissue.


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Central Venous line

Indications:

- inability to obtain peripheral IV- need for multiple ports and repeated blood draws

- need for very large bore access

- central pressure monitoring or passage of Swan Ganz

catheter or cardiac pacer.


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Central Venous line

Adults:- standard 3-way central line is 7 French

(one 16 gauge port and two 18 gauge ports)

- Large bore introducer 9 French

Pediatrics:- double lumen catheter

4 French for < 10 kg

5 French for > 10 kg


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Central Venous line

- Needs to be sterile

- Use large drape to keep the wire

sterile.


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Central Venous line Positioning

Femoral vein:

- Leg extended at hip (difficult with hip flexed)

- Slight abduction and external rotation.

- Folded towel under buttocks helps in problem cases

Subclavian vein:

- Slight Trendelenburg (head & shoulders lower than heart)

Internal jugular:

- Slight Trendelenburg, right IJ preferred(no thoracic duct, straight shot at SVC, dome of right lung is lower)

- Sternocleidomastoid muscle defines the 3 approaches

(anterior, posterior, central)


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Central Venous line

Complications:- hemorrhage

- vascular injury

- cardiac arhythmia

- wire embolus

- catheter embolus- air embolus, infection

- thrombosis

- pneumothorax (subclavian or internal jugular)

- airway compromise (internal jugular).

Modes of failure:

- cant find vein

- cant pass wire

- catheterize artery

- misplacement of subclavian line up into neck


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Central Venous line

Anesthesia:

Local lidocaine


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Jugular Vein Size Variation

I l J l V i


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Internal Jugular Vein


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Femoral Vein and Artery


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Lumbar Puncture

Indications:

Evaluate for:

- meningitis- subarachnoid hemorrhage

- psuedo-tumor cerebri


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Lumbar Puncture

Sterile procedure

22 gauge needleLength: - adults 3 inch

- young children 1.5 inch

- Indicate top of iliac crests with line on skin- Position patient with back in forward flexion

(lying on side or sitting up)

- Enter skin at or cephalad to line demarcating iliac crest

(stay in mid sagital plane)


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Lumbar Puncture

Complications:

- paresthesias

- nerve root injury (rare)

Modes of Failure:

- inability to obtain CSF because puncture site over sacrum

- inability to obtain CSF because path of needle not inmid-sagital plane

- bloody tap


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Lumbar Puncture

Anesthesia:

- Local lidocaine

- Conscious sedation for children age 2-10


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Foley Catheter

Indications:

- monitor urinary output

- relieve urinary obstruction


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Foley Catheter

- Sterile technique

- Use 16 or 18 French in adults (larger if hematuria with clots)

- Coude catheter for difficult catheterization in males

Females - urethral meatus in midline.

Males - anatomic position of penis is erect

(catheter passes easier as U than S)Hypospadias - urethra is ventral in midline.


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Foley Catheter

Modes of failure:

- failure to visualize meatus in females

- failure to pass through prostate with or without catheter

looping around in posterior urethra


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Foley Catheter

Anesthesia:

Lidocaine Urojet for males


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Nasogastric tube

Indications:

- decompress stomach in bowel obstruction

- assess for UGI bleeding


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Nasogastric tube

Adults - Use 18 French

Babies - 8 or 10 French

- tube goes straight back in nasal cavity

- tilt head in extension to get around bend at nasopharynx

- flex head forward to keep tube out of trachea.


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Nasogastric tube

Modes of failure:

- Tube curling around in mouth

- Tube in trachea


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Nasogastric tube

Anesthesia: Problematic.

- LET or Lido w Epi or Cocaine in nose

- Cetacaine spray of throat.

(Alternative Lidocaine neb)


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Arterial Blood Gas

Indications:

- Assess acid/base status and ventilation


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Arterial Blood Gas

- 22 gauge sterile needle

- 21 or 23 butterfly w stop cock for additional blood tests

- clean gloves

Femoral arteryjust distal to inguinal ligament way

between pubic tubercle & ant. sup. iliac spine

but usually palpable pulse

Radial arteryradial to flex carpi radialis tendon

easiest to puncture with full supination forearm

and moderate extention wrist


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Arterial Blood Gas

Complications:

- arterial injury (hematoma, pseudoaneurysm, or thrombosis)

Modes of failure:

- inability to hit artery despite feeling pulse.

Suggested technique

- feel pulse with index and long finger slightly separated

-dont push down too hard with proximal finger

- keep needle in line of artery

- puncture between fingers


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Arterial Blood Gas

Anesthesia:

Lidocaine without epinephrine


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Arterial Lines

- Similar to ABG.

- 20 gauge IV catheter or

Seldinger technique (kits available)

- Radial line kit with enclosed wire

obviates need to sterile drape.


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Thoracentesis or

Chest tube insertion

Enter thoracic cavity just above a rib rather

than just below a rib. Remember the neuro-

vascular bundle is just below the rib.

Place chest tubes posterior to pectoralis major

in the anterior or mid axillary line.


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Documents

Procedures Workshop 2012