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Clinical Procedures - Clickhaler
Disposable dry-powder inhaler with dose meter which turns red when only 10 doses are left to use. The inhaler locks when empty so patients can be sure that they have taken a dose.
How to use
• Take only one dose at a time
• Remove the cap and shake
• Whilst holding inhaler upright, depress the button firmly and release until you hear a click
• Sit upright, breathe out completely, and insert mouthpiece sealing with lips
• Inhale deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose and repeat above as
necessary
• Replace cap.
Disposable dry-powder inhaler with dose meter which turns red when only 10 doses are left to use. The inhaler locks when empty so patients can be sure that they have taken a dose.
How to use
• Take only one dose at a time
• Remove the cap and shake
• Whilst holding inhaler upright, depress the button firmly and release until you hear a click
• Sit upright, breathe out completely, and insert mouthpiece sealing with lips
• Inhale deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose and repeat above as
necessary
• Replace cap.
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Clinical Procedures - HandiHaler
A dry-powder device with an integrated cap. This requires a lower inspiratory flow rate than other devices. However, a dose needs to be inserted via a capsule at each use requiring some dexterity. Patients may also find the cap rather hard to open as it requires a moderate amount of strength.
How to use
• Open cap by pulling upwards exposing mouthpiece
• Open the mouthpiece by pulling upwards exposing the dose chamber
• Take a capsule from the blister-pack and insert it into the chamber
• Replace the mouthpiece (it should click shut)
• Press the side button in a few times to pierce the capsule (you can watch through the small window
• Sit upright, hold head up, and breathe out
• Seal lips around mouthpiece
• Breathe in deeply to a full breath
• Remove inhaler and hold breath for as long as is comfortable
• Remove the used capsule and replace the cap.
A dry-powder device with an integrated cap. This requires a lower inspiratory flow rate than other devices. However, a dose needs to be inserted via a capsule at each use requiring some dexterity. Patients may also find the cap rather hard to open as it requires a moderate amount of strength.
How to use
• Open cap by pulling upwards exposing mouthpiece
• Open the mouthpiece by pulling upwards exposing the dose chamber
• Take a capsule from the blister-pack and insert it into the chamber
• Replace the mouthpiece (it should click shut)
• Press the side button in a few times to pierce the capsule (you can watch through the small window
• Sit upright, hold head up, and breathe out
• Seal lips around mouthpiece
• Breathe in deeply to a full breath
• Remove inhaler and hold breath for as long as is comfortable
• Remove the used capsule and replace the cap.
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Clinical Procedures - Spacer-Devices
A chamber through which the drug passes prior to inhalation, with a one-way valve at the mouthpiece. By slowing the velocity of aerosol ejected by the MDI, spacers reduce residue in the mouth and increase delivery to the lungs. They also reduce the coordination required for effective drug delivery using the MDI alone. They are, therefore, useful in children, the elderly and during acute exacerbations. Spacers can be bulky and need frequent cleaning.
Adult spacers
• Remove cap from inhaler and shake
• Insert into end of spacer
• Sit upright, breathe out completely, and insert mouthpiece of spacer, sealing with lips
• Depress the canister once
• Take a deep breath:
• Small volume spacers will whistle if inhaling too quickly
• Hold your breath for 10 seconds or as long as is comfortable
• Remove the spacer and exhale
• Recover before taking the next dose.
Spacer with mask (young children)
• Remove cap from inhaler and shake
• Insert into end of spacer
• Place mask over mouth and nose of child
• Encourage child to breathe normally
• Once breathing pattern established, depress the canister
once
• Allow child to breathe in and out a further 5 times
• Allow child time to recover before giving the next dose:
• D A similar 'multiple breath' technique can be used in adults.
A chamber through which the drug passes prior to inhalation, with a one-way valve at the mouthpiece. By slowing the velocity of aerosol ejected by the MDI, spacers reduce residue in the mouth and increase delivery to the lungs. They also reduce the coordination required for effective drug delivery using the MDI alone. They are, therefore, useful in children, the elderly and during acute exacerbations. Spacers can be bulky and need frequent cleaning.
Adult spacers
• Remove cap from inhaler and shake
• Insert into end of spacer
• Sit upright, breathe out completely, and insert mouthpiece of spacer, sealing with lips
• Depress the canister once
• Take a deep breath:
• Small volume spacers will whistle if inhaling too quickly
• Hold your breath for 10 seconds or as long as is comfortable
• Remove the spacer and exhale
• Recover before taking the next dose.
Spacer with mask (young children)
• Remove cap from inhaler and shake
• Insert into end of spacer
• Place mask over mouth and nose of child
• Encourage child to breathe normally
• Once breathing pattern established, depress the canister
once
• Allow child to breathe in and out a further 5 times
• Allow child time to recover before giving the next dose:
• D A similar 'multiple breath' technique can be used in adults.
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Clinical Procedures - Nasogastric Tube Insertion
Indications
• Feeding in patients with poor swallow (e.g. post cerebrovascular accident)
• Lavage of gastric contents in poisoning
• Postoperative for stomach decompression
• Bowel obstruction.
Contraindications
• Oesophageal stricture, obstructing tumour
• Tracheo-oesophageal fistula
• Achalasia cardia
• Deviated nasal septum
• Fractured base of skull
Risks
• Malpositioning in a lung
• Trauma to the nasal and/or pharyngeal cavities
• Perforation of esophagus.
Procedure Tips
•Medications such as proton pump inhibitors and acid suppressing drugs may elevate the pH of the aspirate giving a 'false-negative result.
If in doubt, request a chest radiograph before using
• Low pH-fluid may also be aspirated from the lung in cases of aspirated stomach contents. If in doubt, request a chest radiograph before using
• Chest radiography should be performed routinely in high-risk patients (those that are unconscious, intubated or have poor swallow)
• The absence of cough reflex does not rule out misplacement of the tube in the airways
• Auscultation for gurgling in the stomach is not a recommended method for confirming position.
Equipment
• Lubricant (e.g. Aquagel®)
• pH-testing strips
• 50mL syringe
• Gallipots
• Dressing pack
• Nasogastric tube (12-18 French size)
• Hypoallergenic tape
• Sterile gauze
• Gloves
• Disposable bowl.
Procedure
• Introduce yourself, confirm the patient's identity
• Explain the procedure to the patient, stating that it may be uncomfortable and can cause gagging, which is transient
• Make sure that the patient understands the procedure and agree a signal to be made if patient wants to you stop (e.g. raising hand)
• To estimate the length of the tube required, measure the distance from the bridge of the nose to the tip of the earlobe and then to the xiphoid process
• Position the patient semi-upright:
• If unconscious, place the patient on their side
• Check the patency of the nostrils and select a suitable side
• Wash hands and put on gloves
• Unwrap the tube and lubricate the tip by wiping it through a blob of lubricating gel
• Insert the tip of the tube in the nostril and advance the tube horizontally along the floor of the nasal cavity in a backward and downward direction
• As the tube passes into the nasopharynx, ask the patient to swallow if they are able to do so:
• Using a cup of water and straw often helps here
• If there is any obstruction felt during advancement, withdraw and try in the other nostril
• © Watch for any signs of distress; namely cough or cyanosis and remove the tube immediately if any of these occur
• Once the tube has reached the measured distance, secure it in place with the tape:
• The gastro-oesophageal junction is generally 38-42cm from the nostril so advancement of the tube 55-60cm from the nostril usually positions the nasogastric tube tip within the stomach.
• Aspirate a sample of fluid using a syringe
• Place the aspirate on a pH-testing strip:
• D A pH of 5.5 or less suggests that the tube is in the
stomach
• If no aspirate obtained, change position and try again. If still unsuccessful, perform chest radiography to confirm position:
• Be sure to leave the internal wire in the tube if you are sending the patient to x-ray. The tube itself is not radio-opaque and will be invisible on the resultant image
• Once satisfied that the tube lies within the stomach, remove the inner wire and secure the tube to the tip of the nose:
• It is sometimes helpful to curve the remainder of the tube towards the ear and secure to the cheek also.
Documentation
• Date, time, indication, informed consent obtained
• Size of tube inserted
• Length of tube internally (there are markings on the tube:
• This is important to allow other staff to assess whether the tube has moved in or out since insertion
• Method by which correct placement was confirmed
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Feeding in patients with poor swallow (e.g. post cerebrovascular accident)
• Lavage of gastric contents in poisoning
• Postoperative for stomach decompression
• Bowel obstruction.
Contraindications
• Oesophageal stricture, obstructing tumour
• Tracheo-oesophageal fistula
• Achalasia cardia
• Deviated nasal septum
• Fractured base of skull
Risks
• Malpositioning in a lung
• Trauma to the nasal and/or pharyngeal cavities
• Perforation of esophagus.
Procedure Tips
•Medications such as proton pump inhibitors and acid suppressing drugs may elevate the pH of the aspirate giving a 'false-negative result.
If in doubt, request a chest radiograph before using
• Low pH-fluid may also be aspirated from the lung in cases of aspirated stomach contents. If in doubt, request a chest radiograph before using
• Chest radiography should be performed routinely in high-risk patients (those that are unconscious, intubated or have poor swallow)
• The absence of cough reflex does not rule out misplacement of the tube in the airways
• Auscultation for gurgling in the stomach is not a recommended method for confirming position.
Equipment
• Lubricant (e.g. Aquagel®)
• pH-testing strips
• 50mL syringe
• Gallipots
• Dressing pack
• Nasogastric tube (12-18 French size)
• Hypoallergenic tape
• Sterile gauze
• Gloves
• Disposable bowl.
Procedure
• Introduce yourself, confirm the patient's identity
• Explain the procedure to the patient, stating that it may be uncomfortable and can cause gagging, which is transient
• Make sure that the patient understands the procedure and agree a signal to be made if patient wants to you stop (e.g. raising hand)
• To estimate the length of the tube required, measure the distance from the bridge of the nose to the tip of the earlobe and then to the xiphoid process
• Position the patient semi-upright:
• If unconscious, place the patient on their side
• Check the patency of the nostrils and select a suitable side
• Wash hands and put on gloves
• Unwrap the tube and lubricate the tip by wiping it through a blob of lubricating gel
• Insert the tip of the tube in the nostril and advance the tube horizontally along the floor of the nasal cavity in a backward and downward direction
• As the tube passes into the nasopharynx, ask the patient to swallow if they are able to do so:
• Using a cup of water and straw often helps here
• If there is any obstruction felt during advancement, withdraw and try in the other nostril
• © Watch for any signs of distress; namely cough or cyanosis and remove the tube immediately if any of these occur
• Once the tube has reached the measured distance, secure it in place with the tape:
• The gastro-oesophageal junction is generally 38-42cm from the nostril so advancement of the tube 55-60cm from the nostril usually positions the nasogastric tube tip within the stomach.
• Aspirate a sample of fluid using a syringe
• Place the aspirate on a pH-testing strip:
• D A pH of 5.5 or less suggests that the tube is in the
stomach
• If no aspirate obtained, change position and try again. If still unsuccessful, perform chest radiography to confirm position:
• Be sure to leave the internal wire in the tube if you are sending the patient to x-ray. The tube itself is not radio-opaque and will be invisible on the resultant image
• Once satisfied that the tube lies within the stomach, remove the inner wire and secure the tube to the tip of the nose:
• It is sometimes helpful to curve the remainder of the tube towards the ear and secure to the cheek also.
Documentation
• Date, time, indication, informed consent obtained
• Size of tube inserted
• Length of tube internally (there are markings on the tube:
• This is important to allow other staff to assess whether the tube has moved in or out since insertion
• Method by which correct placement was confirmed
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures - Ascitic Fluid Sampling (Tap)
Indications
• Diagnosing nature of new onset ascites (i.e. exudate or transudate)
• Diagnosis of spontaneous bacterial peritonitis
• Cytology to diagnose malignant :
ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site.
Risks
• Persistent leak of ascitic fluid:
• This is more likely if there is a large amount of fluid under tension
• Perforation of hollow viscera (e.g. bowel and bladder). This is very rare
• Peritonitis
• Abdominal wall hematoma
• Bleeding is very rare but may occur if there is injury to inferior epigastric artery (be careful to tap lateral abdominal wall as described).
Procedure Tips
• Check the patient's clotting and platelet count before the procedure and proceed with caution and senior advice if abnormal (correct if platelets <20 x 10°L, INR ≥2.5)
• Inform the laboratory especially during out of hours if cultures needed urgently and if SBP is suspected
• D If unable to obtain fluid despite correct technique, do not persist!
Stop and seek senior advice.
SAAG
Calculating the serum-ascites albumin gradient (SAAG) is a method of determining the cause of ascites.
SAAG = [serum albumin] - [ascites albumin]
>11g/L = portal hypertension (cirrhosis, alcoholic hepatitis, cardiac
ascites, Budd-Chiari syndrome, massive liver metastases).
<11g/L = infection, malignancy, nephrotic syndrome, pancreatic ascites.
Equipment
• Sterile gloves
• Dressing pack
• Antiseptic solution (e.g. iodine)
• 1% or 2% lidocaine
• 1 × 20mL syringe
• 2 × 5mL syringes
• 21G (green) and 25G (orange) needles
• Sterile containers
• Culture bottles
• Sterile dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Examine the abdomen and select a site for aspiration, 3 finger-breadths cranial to the anterior superior iliac spine:
• D Beware of positioning too medial as this risks hitting the inferior epigastric vessels
• D Be sure to identify and avoid any organomegaly which might interfere with procedure (in patients with massive splenomegaly, for example, avoid left iliac fossa)
• Clean the area with disinfectant and apply sterile drape
• Using the 25G (orange) needle and the 5mL syringe, administer local anaesthetic to the skin and subcutis, raising a wheal
• Using the 21G (green) needle, infiltrate deeper tissues, intermittently applying suction until the peritoneal cavity is reached, confirmed by flow of ascitic fluid into the syringe
• Note the depth needed to enter the peritoneal cavity
• Discard the used needles and attach a clean 21G needle to the 20mL syringe
• With the green needle perpendicular to the skin, insert carefully, aspirating continuously until you feel resistance give way
• Aspirate as much fluid as needed (usually 20mL is plenty)
• Withdraw needle and syringe and apply dressing
•Send sample for Gram stain and culture (in blood culture bottles), white cell count/neutrophils, biochemistry, cytology (if malignancy suspected):
• White cell count can be calculated in haematology lab; send fluid in EDTA-containing bottle. » (Total white cell count >500/mm' or neutrophils >250/mm3 suggests spontaneous bacterial peritonitis, SP)
• Neutrophil count is usually a manual procedure via microbiology and may take longer
• If malignancy is suspected, a large volume of ascites (e.g.
500mL) should be sent to cytology.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site aspirated
• Aseptic technique used?
• How many passes?
• Volume and colour of aspirate obtained
• Tests requested on samples
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Diagnosing nature of new onset ascites (i.e. exudate or transudate)
• Diagnosis of spontaneous bacterial peritonitis
• Cytology to diagnose malignant :
ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site.
Risks
• Persistent leak of ascitic fluid:
• This is more likely if there is a large amount of fluid under tension
• Perforation of hollow viscera (e.g. bowel and bladder). This is very rare
• Peritonitis
• Abdominal wall hematoma
• Bleeding is very rare but may occur if there is injury to inferior epigastric artery (be careful to tap lateral abdominal wall as described).
Procedure Tips
• Check the patient's clotting and platelet count before the procedure and proceed with caution and senior advice if abnormal (correct if platelets <20 x 10°L, INR ≥2.5)
• Inform the laboratory especially during out of hours if cultures needed urgently and if SBP is suspected
• D If unable to obtain fluid despite correct technique, do not persist!
Stop and seek senior advice.
SAAG
Calculating the serum-ascites albumin gradient (SAAG) is a method of determining the cause of ascites.
SAAG = [serum albumin] - [ascites albumin]
>11g/L = portal hypertension (cirrhosis, alcoholic hepatitis, cardiac
ascites, Budd-Chiari syndrome, massive liver metastases).
<11g/L = infection, malignancy, nephrotic syndrome, pancreatic ascites.
Equipment
• Sterile gloves
• Dressing pack
• Antiseptic solution (e.g. iodine)
• 1% or 2% lidocaine
• 1 × 20mL syringe
• 2 × 5mL syringes
• 21G (green) and 25G (orange) needles
• Sterile containers
• Culture bottles
• Sterile dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Examine the abdomen and select a site for aspiration, 3 finger-breadths cranial to the anterior superior iliac spine:
• D Beware of positioning too medial as this risks hitting the inferior epigastric vessels
• D Be sure to identify and avoid any organomegaly which might interfere with procedure (in patients with massive splenomegaly, for example, avoid left iliac fossa)
• Clean the area with disinfectant and apply sterile drape
• Using the 25G (orange) needle and the 5mL syringe, administer local anaesthetic to the skin and subcutis, raising a wheal
• Using the 21G (green) needle, infiltrate deeper tissues, intermittently applying suction until the peritoneal cavity is reached, confirmed by flow of ascitic fluid into the syringe
• Note the depth needed to enter the peritoneal cavity
• Discard the used needles and attach a clean 21G needle to the 20mL syringe
• With the green needle perpendicular to the skin, insert carefully, aspirating continuously until you feel resistance give way
• Aspirate as much fluid as needed (usually 20mL is plenty)
• Withdraw needle and syringe and apply dressing
•Send sample for Gram stain and culture (in blood culture bottles), white cell count/neutrophils, biochemistry, cytology (if malignancy suspected):
• White cell count can be calculated in haematology lab; send fluid in EDTA-containing bottle. » (Total white cell count >500/mm' or neutrophils >250/mm3 suggests spontaneous bacterial peritonitis, SP)
• Neutrophil count is usually a manual procedure via microbiology and may take longer
• If malignancy is suspected, a large volume of ascites (e.g.
500mL) should be sent to cytology.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site aspirated
• Aseptic technique used?
• How many passes?
• Volume and colour of aspirate obtained
• Tests requested on samples
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures - Abdominal Paracentesis (Drainage)
Indications
• To relieve symptoms in patients with tense ascites
• Refractory ascites in patients with cirrhosis of the liver
• Malignant ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site
• Caution is needed in the presence of omental or peritoneal metastatic disease. In these cases, drainage is often performed under imaging guidance by a radiologist.
Risks
• Haemodynamic instability, especially in cirrhotic patients; avoided by albumin replacement. (Usually 100mL 20% human albumin solution IV for every 2.5L fluid drained check local protocols with the Gastroenterology Department)
• Renal dysfunction (in those with abnormal baseline renal function. May need to withhold diuretics and limit drain volume to 5L)
• Wound infection
• Bleeding
• Perforation of bowel and bladder
• Abdominal wall hematoma.
Procedure Tips
• Avoid any area of skin which has a scar or engorged veins to minimize complications
• Low-grade coagulopathy is common in cirrhotic patients and use of fresh frozen plasma and platelets is not routinely recommended; seek senior advice
• Fluid leak can be minimized by the '-track' technique, moving the skin and subcutaneous tissue while insertion of drain, creating a zigzag path
• If no aspirate is obtained despite multiple attempts, liaise with Radiology and request an ultrasound and marking of a suitable site for aspiration.
Alternatively, ask the Radiology Department to insert the drain under ultrasound guidance.
The procedure below relates to a non-locking drainage kit from Rocket Medical -the essence is the same for other catheter kits although minor details may differ. You should refer to the kit's instructions.
Equipment
• Rocket abdominal catheter pack (catheter sleeve, puncture needle, and adaptor clamp)
• Catheter bag and stand
• 1 × 25G (orange) needle
• 1 x 21G (green) needle
• 3 x 10mL syringes
• 5mL 1% lidocaine
• lodine or antiseptic solution
• Sterile pack (including gloves, cotton balls, and bowl)
• Suitable adhesive dressing
• Scalpel/blade.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain informed consent
• Ensure that the patient has emptied their bladder
• Position the patient lying supine or semi-recumbent
• Percuss the extent of the ascitic dullness
• Mark your chosen spot in the region of the left iliac fossa within the area of dullness:
• Double-check clinical examination and imaging, if available.
If splenomegaly is present, right-sided drainage is recommended
• Wash hands and put the sterile gloves on
• Clean the area thoroughly with antiseptic
• Infiltrate the skin and subcutaneous tissues with lidocaine via the orange needle and 10mL syringe
• Attach the green needle to another 10mL syringe and insert into the abdomen, perpendicular to the skin. Advance the needle as you aspirate until fluid is withdrawn
• Prepare the catheter kit straighten the curled catheter using the plastic covering sheath provided
• Take the needle provided in the pack and pass through the sheath such that the needle bevel is directed along inside the curve of the catheter continue until the needle protrudes from the catheter tip
• Remove the plastic covering sheath
• Attach a 10mL syringe to the end of the catheter
• Make a small incision in the skin using the scalpel
• Grasp the catheter needle -10cm above the distal end and, with firm but controlled pressure, push the needle through the abdominal wall to ~3.5cm deep, aspirating with the syringe
• Aspiration of ascitic fluid confirms entry to the abdominal cavity
• Disengage needle from the catheter hub and advance catheter until the suture disc is flat against the skin
• Withdraw needle
• Connect adaptor-clamp to the catheter hub and securely attach the rubber portion of the clamp into a standard drainage catheter bag
• Secure the catheter to the abdomen using a suitable adhesive dressing
• Ensure the clamp is open to allow fluid to drain.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of drain
• Aseptic technique used?
• How many passes?
• Volume and colour of fluid obtained
• Any immediate complications
• Document the required albumin replacement (if appropriate) and when the catheter should be clamped.
• Signature, printed name and contact details.
Indications
• To relieve symptoms in patients with tense ascites
• Refractory ascites in patients with cirrhosis of the liver
• Malignant ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site
• Caution is needed in the presence of omental or peritoneal metastatic disease. In these cases, drainage is often performed under imaging guidance by a radiologist.
Risks
• Haemodynamic instability, especially in cirrhotic patients; avoided by albumin replacement. (Usually 100mL 20% human albumin solution IV for every 2.5L fluid drained check local protocols with the Gastroenterology Department)
• Renal dysfunction (in those with abnormal baseline renal function. May need to withhold diuretics and limit drain volume to 5L)
• Wound infection
• Bleeding
• Perforation of bowel and bladder
• Abdominal wall hematoma.
Procedure Tips
• Avoid any area of skin which has a scar or engorged veins to minimize complications
• Low-grade coagulopathy is common in cirrhotic patients and use of fresh frozen plasma and platelets is not routinely recommended; seek senior advice
• Fluid leak can be minimized by the '-track' technique, moving the skin and subcutaneous tissue while insertion of drain, creating a zigzag path
• If no aspirate is obtained despite multiple attempts, liaise with Radiology and request an ultrasound and marking of a suitable site for aspiration.
Alternatively, ask the Radiology Department to insert the drain under ultrasound guidance.
The procedure below relates to a non-locking drainage kit from Rocket Medical -the essence is the same for other catheter kits although minor details may differ. You should refer to the kit's instructions.
Equipment
• Rocket abdominal catheter pack (catheter sleeve, puncture needle, and adaptor clamp)
• Catheter bag and stand
• 1 × 25G (orange) needle
• 1 x 21G (green) needle
• 3 x 10mL syringes
• 5mL 1% lidocaine
• lodine or antiseptic solution
• Sterile pack (including gloves, cotton balls, and bowl)
• Suitable adhesive dressing
• Scalpel/blade.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain informed consent
• Ensure that the patient has emptied their bladder
• Position the patient lying supine or semi-recumbent
• Percuss the extent of the ascitic dullness
• Mark your chosen spot in the region of the left iliac fossa within the area of dullness:
• Double-check clinical examination and imaging, if available.
If splenomegaly is present, right-sided drainage is recommended
• Wash hands and put the sterile gloves on
• Clean the area thoroughly with antiseptic
• Infiltrate the skin and subcutaneous tissues with lidocaine via the orange needle and 10mL syringe
• Attach the green needle to another 10mL syringe and insert into the abdomen, perpendicular to the skin. Advance the needle as you aspirate until fluid is withdrawn
• Prepare the catheter kit straighten the curled catheter using the plastic covering sheath provided
• Take the needle provided in the pack and pass through the sheath such that the needle bevel is directed along inside the curve of the catheter continue until the needle protrudes from the catheter tip
• Remove the plastic covering sheath
• Attach a 10mL syringe to the end of the catheter
• Make a small incision in the skin using the scalpel
• Grasp the catheter needle -10cm above the distal end and, with firm but controlled pressure, push the needle through the abdominal wall to ~3.5cm deep, aspirating with the syringe
• Aspiration of ascitic fluid confirms entry to the abdominal cavity
• Disengage needle from the catheter hub and advance catheter until the suture disc is flat against the skin
• Withdraw needle
• Connect adaptor-clamp to the catheter hub and securely attach the rubber portion of the clamp into a standard drainage catheter bag
• Secure the catheter to the abdomen using a suitable adhesive dressing
• Ensure the clamp is open to allow fluid to drain.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of drain
• Aseptic technique used?
• How many passes?
• Volume and colour of fluid obtained
• Any immediate complications
• Document the required albumin replacement (if appropriate) and when the catheter should be clamped.
• Signature, printed name and contact details.
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Clinical Procedures - Sengstaken-Blakemore Tube Insertion
Indications
• Life-threatening variceal bleeding where facilities for endoscopy are not available or pending endoscopic therapy
• Life-threatening variceal bleeding where other modalities to control bleeding have failed.
Contraindications
• Variceal bleeding has ceased or significantly slowed
• Recent surgery to the GO]
• Known esophageal stricture (s).
Risks
• Mucosal necrosis due to inadvertent traction
• Oesophageal perforation. This may be due to a gastric balloon being inflated within the esophagus or can occur secondary to over- or prolonged inflation of the esophageal balloon
• Aspiration of fluid into the respiratory tract. The greatest risk occurs during insertion
• Asphyxiation due to superior migration of the tube and balloons. See last 'procedure tip' below.
Procedure Tips
• The tube can be used as a measure to control bleeding for about
12-18 hours. Generally, it should not be left in place for >24 hours
• Frequent aspirations from the gastric port are needed to assess the status of bleeding
• The tube has to remain in traction at the gastric balloon which will decompress the varices. However, direct pressure from the tube can cause mucosal ulceration. Examine frequently to ensure that excessive force is not being exerted
• If the balloons migrate superiorly, airway obstruction may occur. In this instance, as an emergency measure, the tube can be quickly cut with a pair of scissors and removed. Keep a pair of scissors handy.
This should be performed only by senior medical staff in close liaison with an anaesthetist and, ideally, with endotracheal intubation especially in agitated patients and those with hepatic encephalopathy.
• The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric lavage and maximal stomach evacuation prior to procedure.
Equipment
• Gloves, gown, and goggles
• Saline flush
• 2 x 50mL syringe.
• Local anaesthetic spray
• Sengstaken-Blakemore tube (usually kept in refrigerator to increase its stiffness)
• Lubricant jelly (e.g. Aquagel®
• Basin with sterile water
• Suction equipment
• Sphygmomanometer for pressure monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure to the patient, and obtain informed consent
• Position the patient at 45°
• Administer anaesthetic throat spray to the oropharynx
• Check the balloons in the tube for air leak by inflating them with an air-filled syringe and immersing in a basin of water.
Air leak is indicated by air bubbles appearing
• Deflate the balloons
• Apply lubricant over the tip of the tube and advance it through the oral cavity slowly until it crosses the gastro-oesophageal junction (GOJ):
• The GOJ is generally 38-42cm from the nostril so advancement of the tube 55-60cm usually positions the tip within the stomach
• Withdraw if the patient becomes breathless
• Inflate the gastric (not esophageal) balloon with 50mL air
• At this stage an abdominal radiograph may be performed to confirm the position of the tube in the stomach
• Once position is confirmed, inflate the gastric balloon to a total volume of 250mL air
• Pull gently on the tube until resistance is felt
• Secure with tape near the mouth with gauze pads, maintaining traction and tie the tube to a 500mL bag of saline. A pulley (e.g. a drip stand) is helpful in maintaining traction
• Mark the tube near the mouth which will serve as an indicator to whether the tube has migrated later
• Flush the gastric port with normal saline and aspirate at frequent intervals until it is clear, which indicates that bleeding has ceased
• • If bleeding continues, inflate the esophageal balloon with 40mL air and monitor the pressures using the sphygmomanometer at frequent intervals
• D After 12 hours of traction, relax the tension and push the tube into the stomach. If there is evidence of further bleeding, the gastric balloon can be re-inflated and traction re-applied with a view to repeat therapeutic endoscopy
• D During extubation (usually after 10-12 hours depending on clinical condition), deflate the gastric balloon first then the esophageal balloon and withdraw the tube slowly.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including anaesthetic support
• How many passes?
• Volume balloon inflated to and level of tube insertion
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Life-threatening variceal bleeding where facilities for endoscopy are not available or pending endoscopic therapy
• Life-threatening variceal bleeding where other modalities to control bleeding have failed.
Contraindications
• Variceal bleeding has ceased or significantly slowed
• Recent surgery to the GO]
• Known esophageal stricture (s).
Risks
• Mucosal necrosis due to inadvertent traction
• Oesophageal perforation. This may be due to a gastric balloon being inflated within the esophagus or can occur secondary to over- or prolonged inflation of the esophageal balloon
• Aspiration of fluid into the respiratory tract. The greatest risk occurs during insertion
• Asphyxiation due to superior migration of the tube and balloons. See last 'procedure tip' below.
Procedure Tips
• The tube can be used as a measure to control bleeding for about
12-18 hours. Generally, it should not be left in place for >24 hours
• Frequent aspirations from the gastric port are needed to assess the status of bleeding
• The tube has to remain in traction at the gastric balloon which will decompress the varices. However, direct pressure from the tube can cause mucosal ulceration. Examine frequently to ensure that excessive force is not being exerted
• If the balloons migrate superiorly, airway obstruction may occur. In this instance, as an emergency measure, the tube can be quickly cut with a pair of scissors and removed. Keep a pair of scissors handy.
This should be performed only by senior medical staff in close liaison with an anaesthetist and, ideally, with endotracheal intubation especially in agitated patients and those with hepatic encephalopathy.
• The threshold to perform endotracheal intubation should be low, as the risk of regurgitation and aspiration is extremely high. To minimize this risk, perform nasogastric lavage and maximal stomach evacuation prior to procedure.
Equipment
• Gloves, gown, and goggles
• Saline flush
• 2 x 50mL syringe.
• Local anaesthetic spray
• Sengstaken-Blakemore tube (usually kept in refrigerator to increase its stiffness)
• Lubricant jelly (e.g. Aquagel®
• Basin with sterile water
• Suction equipment
• Sphygmomanometer for pressure monitoring.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure to the patient, and obtain informed consent
• Position the patient at 45°
• Administer anaesthetic throat spray to the oropharynx
• Check the balloons in the tube for air leak by inflating them with an air-filled syringe and immersing in a basin of water.
Air leak is indicated by air bubbles appearing
• Deflate the balloons
• Apply lubricant over the tip of the tube and advance it through the oral cavity slowly until it crosses the gastro-oesophageal junction (GOJ):
• The GOJ is generally 38-42cm from the nostril so advancement of the tube 55-60cm usually positions the tip within the stomach
• Withdraw if the patient becomes breathless
• Inflate the gastric (not esophageal) balloon with 50mL air
• At this stage an abdominal radiograph may be performed to confirm the position of the tube in the stomach
• Once position is confirmed, inflate the gastric balloon to a total volume of 250mL air
• Pull gently on the tube until resistance is felt
• Secure with tape near the mouth with gauze pads, maintaining traction and tie the tube to a 500mL bag of saline. A pulley (e.g. a drip stand) is helpful in maintaining traction
• Mark the tube near the mouth which will serve as an indicator to whether the tube has migrated later
• Flush the gastric port with normal saline and aspirate at frequent intervals until it is clear, which indicates that bleeding has ceased
• • If bleeding continues, inflate the esophageal balloon with 40mL air and monitor the pressures using the sphygmomanometer at frequent intervals
• D After 12 hours of traction, relax the tension and push the tube into the stomach. If there is evidence of further bleeding, the gastric balloon can be re-inflated and traction re-applied with a view to repeat therapeutic endoscopy
• D During extubation (usually after 10-12 hours depending on clinical condition), deflate the gastric balloon first then the esophageal balloon and withdraw the tube slowly.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including anaesthetic support
• How many passes?
• Volume balloon inflated to and level of tube insertion
• Any immediate complications
• Signature, printed name, and contact details.
- Published on
Clinical Procedures – Basic Airway Manoeuvres
The following manoeuvres are performed with the patient lying supine and the attender positioned above the head.
The aim is to prevent the flaccid tongue from falling back and causing the epiglottis or tongue itself to occluding the airway.
These can be performed with no equipment.
Head Tilt
• Place your hands on the forehead and tilt the head backwards, extending the neck.
Chin Lift
• Place 2 fingertips below the mental protuberance of the mandible, with thumb in front
• Draw the mandible anteriorly.
Head tilt and chin lift are usually performed together.
• Head tilt and chin lift are not suitable if there is any suspicion of cervical spinal injury. Jaw thrust alone should be used in this situation.
Jaw Thrust
• Place your fingertips behind the angle of the mandible.
• The base of the thenar eminence of each hand should be rested on the cheek bones
• Use your fingers to pull the mandible anteriorly, whilst using your thumbs to open the mouth
• If performed with a mask, the thenar eminence may be used to maintain a good seal.
Procedure Tips
• After each manoeuvre, check for success
• It is worthwhile practicing these skills on resuscitation dummies prior to having to do them in real life!
• Use the above manoeuvres in conjunction with face masks or bag-valve mask ventilation.
The following manoeuvres are performed with the patient lying supine and the attender positioned above the head.
The aim is to prevent the flaccid tongue from falling back and causing the epiglottis or tongue itself to occluding the airway.
These can be performed with no equipment.
Head Tilt
• Place your hands on the forehead and tilt the head backwards, extending the neck.
Chin Lift
• Place 2 fingertips below the mental protuberance of the mandible, with thumb in front
• Draw the mandible anteriorly.
Head tilt and chin lift are usually performed together.
• Head tilt and chin lift are not suitable if there is any suspicion of cervical spinal injury. Jaw thrust alone should be used in this situation.
Jaw Thrust
• Place your fingertips behind the angle of the mandible.
• The base of the thenar eminence of each hand should be rested on the cheek bones
• Use your fingers to pull the mandible anteriorly, whilst using your thumbs to open the mouth
• If performed with a mask, the thenar eminence may be used to maintain a good seal.
Procedure Tips
• After each manoeuvre, check for success
• It is worthwhile practicing these skills on resuscitation dummies prior to having to do them in real life!
• Use the above manoeuvres in conjunction with face masks or bag-valve mask ventilation.
- Published on
Clinical Procedures - Oropharyngeal (Guedel) airway
A stiff tube with a fixed curvature is inserted through the mouth. A flange limits the depth of insertion.
• Use when the patient is semi-conscious.
Indications
• Airway compromise in the patient with reduced conscious level.
Contraindications
• Active gag reflex. Conscious patient.
Procedure
• Insert the airway initially with the curvature upwards
• Once inside the mouth, rotate it 180°
• Continue to insert, following the curvature of the tongue until the flange rests against the teeth or gums
• Ensure there is no gagging, snoring or vomiting and that air can move in and out freely.
Procedure Tips
• May be used for suction (size 10, 12, or 14 catheters).
• Insertion can be guided with a tongue depressor.
Airway Sizes
• Oropharyngeal airways come in many sizes and are colour-coded for convenience
• Select the correct size of airway for the patient by measuring it against the side of the patients face. The flange should sit at the corner of the patient's mouth and the tip at the angle of the jaw.
A stiff tube with a fixed curvature is inserted through the mouth. A flange limits the depth of insertion.
• Use when the patient is semi-conscious.
Indications
• Airway compromise in the patient with reduced conscious level.
Contraindications
• Active gag reflex. Conscious patient.
Procedure
• Insert the airway initially with the curvature upwards
• Once inside the mouth, rotate it 180°
• Continue to insert, following the curvature of the tongue until the flange rests against the teeth or gums
• Ensure there is no gagging, snoring or vomiting and that air can move in and out freely.
Procedure Tips
• May be used for suction (size 10, 12, or 14 catheters).
• Insertion can be guided with a tongue depressor.
Airway Sizes
• Oropharyngeal airways come in many sizes and are colour-coded for convenience
• Select the correct size of airway for the patient by measuring it against the side of the patients face. The flange should sit at the corner of the patient's mouth and the tip at the angle of the jaw.
- Published on
Clinical Procedures - Nasopharyngeal airway
A flexible tube is inserted through the nostril into the pharynx and is better tolerated than the oropharyngeal airway in semi-conscious patients.
Although there is a small flange at the end of the airway, a safety pin is usually inserted to prevent the device migrating into the patient's nose.
Indications
• Patients with reduced conscious level and/or airway compromise who will not tolerate an oropharyngeal airway (intact gag reflex).
Contraindications
• Known basal skull fracture (relative contraindication).
Procedure
• Lubricate the device
• Insert bevelled end into the wider nostril, passing it posteriorly and medially, aiming for the back of the opposite eyeball
• Use size 10 or 12 catheter for suction if required
• Advance until the flange is flush against the nostril.
Procedure Tips
• If insertion proves difficult, try the opposite nostril.
Airway sizes
• Nasopharyngeal airways come in several sizes; the size is usually stamped on the side
• Select the correct size for your patient by measuring the airway against the side of their face. The flange should lie at the patient's nostril and the tip at the tragus of the ear.
A flexible tube is inserted through the nostril into the pharynx and is better tolerated than the oropharyngeal airway in semi-conscious patients.
Although there is a small flange at the end of the airway, a safety pin is usually inserted to prevent the device migrating into the patient's nose.
Indications
• Patients with reduced conscious level and/or airway compromise who will not tolerate an oropharyngeal airway (intact gag reflex).
Contraindications
• Known basal skull fracture (relative contraindication).
Procedure
• Lubricate the device
• Insert bevelled end into the wider nostril, passing it posteriorly and medially, aiming for the back of the opposite eyeball
• Use size 10 or 12 catheter for suction if required
• Advance until the flange is flush against the nostril.
Procedure Tips
• If insertion proves difficult, try the opposite nostril.
Airway sizes
• Nasopharyngeal airways come in several sizes; the size is usually stamped on the side
• Select the correct size for your patient by measuring the airway against the side of their face. The flange should lie at the patient's nostril and the tip at the tragus of the ear.
