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Clinical Procedures – Laryngeal Mask Airway
A laryngeal mask airway (LMA) is a tube with an inflatable cuff ('mask) around its base to create a seal around the laryngeal inlet.
• This does not prevent aspiration of stomach contents.
Indications
• Unconscious patient requiring ventilation.
Contraindications
• Conscious patient (absolute)
• Maxillofacial trauma
• Risk of aspiration
• >16 weeks pregnant.
Procedure
• Ensure that the cuff inflates and deflates satisfactorily
• For insertion, the mask should be completely deflated
• Deflate the cuff with a 20mL syringe. Lubricate the outer cuff with aqueous gel
• Gently extend the head and flex the neck (except in possible cervical trauma)
• Hold the LMA tubing near the cuff, like a pen
• With the mask facing down, pass along the under-surface of the palate until it reaches the posterior pharynx
• Guide the tube backwards and downwards (using a finger if necessary) until resistance is felt
• Remove your hand and fill the mask with the required amount of air (usually 20-30mL):
• The tube should lift out of the mouth slightly and the larynx is pushed forward if it is in the correct position
• Connect the bag-valve mask and ventilate
• Auscultate in both axillary regions to confirm ventilation
• Insert a bite block/Guedel airway next to the tube in case the patient bites down
• Secure in place with tape/ribbon.
A laryngeal mask airway (LMA) is a tube with an inflatable cuff ('mask) around its base to create a seal around the laryngeal inlet.
• This does not prevent aspiration of stomach contents.
Indications
• Unconscious patient requiring ventilation.
Contraindications
• Conscious patient (absolute)
• Maxillofacial trauma
• Risk of aspiration
• >16 weeks pregnant.
Procedure
• Ensure that the cuff inflates and deflates satisfactorily
• For insertion, the mask should be completely deflated
• Deflate the cuff with a 20mL syringe. Lubricate the outer cuff with aqueous gel
• Gently extend the head and flex the neck (except in possible cervical trauma)
• Hold the LMA tubing near the cuff, like a pen
• With the mask facing down, pass along the under-surface of the palate until it reaches the posterior pharynx
• Guide the tube backwards and downwards (using a finger if necessary) until resistance is felt
• Remove your hand and fill the mask with the required amount of air (usually 20-30mL):
• The tube should lift out of the mouth slightly and the larynx is pushed forward if it is in the correct position
• Connect the bag-valve mask and ventilate
• Auscultate in both axillary regions to confirm ventilation
• Insert a bite block/Guedel airway next to the tube in case the patient bites down
• Secure in place with tape/ribbon.
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Clinical Procedures – Basic Spirometry
Basic spirometry is a simple lung function test which can aid diagnosis of a number of conditions, but is primarily used to distinguish between restrictive and obstructive lung diseases.
Different spirometers vary in their operation, but most are now hand-held computerized devices with an easy-to-use interface, able to calculate normal values and print a spirometry report. The following describes the use of this device.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• The patient should be standing or sitting upright
° Input the data requested by the spirometer if appropriate: age, gender, and height
• Ask the patient to take a deep breath and wrap their lips around the mouthpiece, making an airtight seal
• Ask the patient to breathe out as hard and as long as possible until they feel they have completely emptied their lungs
• Three satisfactory breaths should be obtained:
• D The volume-time graph should be smooth, subsequent
FEV1 and FVC results should be within 100mL of each other
• Save and print the report.
Procedure Tips
• If the patient is having difficulty performing correctly, a brief demonstration often proves very useful
• Performing the test seated may be easier for elderly or infirm patients.
Documentation
• Record the FVC, FEV , the FEV/FVC ratio and relevant predicted values. Also document the quality and reproducibility of blows and whether pre- or post-treatment.
Key Values
• FEV: forced expiratory volume in the first second
• FVC: forced vital capacity (the total lung volume from maximum inspiration to maximum expiration, in forced exhalation).
Common patterns of abnormality
Obstructive
Although FVC may be reduced, FEV is much more reduced, hence the FEV/FVC ratio falls. It can also take much longer to fully exhale
Restrictive
The airway patency is not affected in restrictive lung conditions but the
FEV and FVC are reduced due to the restrictive picture
Basic spirometry is a simple lung function test which can aid diagnosis of a number of conditions, but is primarily used to distinguish between restrictive and obstructive lung diseases.
Different spirometers vary in their operation, but most are now hand-held computerized devices with an easy-to-use interface, able to calculate normal values and print a spirometry report. The following describes the use of this device.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• The patient should be standing or sitting upright
° Input the data requested by the spirometer if appropriate: age, gender, and height
• Ask the patient to take a deep breath and wrap their lips around the mouthpiece, making an airtight seal
• Ask the patient to breathe out as hard and as long as possible until they feel they have completely emptied their lungs
• Three satisfactory breaths should be obtained:
• D The volume-time graph should be smooth, subsequent
FEV1 and FVC results should be within 100mL of each other
• Save and print the report.
Procedure Tips
• If the patient is having difficulty performing correctly, a brief demonstration often proves very useful
• Performing the test seated may be easier for elderly or infirm patients.
Documentation
• Record the FVC, FEV , the FEV/FVC ratio and relevant predicted values. Also document the quality and reproducibility of blows and whether pre- or post-treatment.
Key Values
• FEV: forced expiratory volume in the first second
• FVC: forced vital capacity (the total lung volume from maximum inspiration to maximum expiration, in forced exhalation).
Common patterns of abnormality
Obstructive
Although FVC may be reduced, FEV is much more reduced, hence the FEV/FVC ratio falls. It can also take much longer to fully exhale
Restrictive
The airway patency is not affected in restrictive lung conditions but the
FEV and FVC are reduced due to the restrictive picture
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Clinical Procedures - Metered Dose Inhaler
Requires coordination to use effectively and lacks a dose counter. May be unsuitable for the very young, elderly, or those with arthritis affecting the hands.
How to use
• Take only one dose at a time
• Remove the cap and shake the inhaler several times
• Sit upright, breathe out completely
• Insert mouthpiece in mouth, sealing with lips
• Take a deep breath in; just after you begin to breathe in depress the canister whilst continuing to inhale:
• The canister should be pressed just after the start of inhalation, not before
• Inhale slowly and 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.
Requires coordination to use effectively and lacks a dose counter. May be unsuitable for the very young, elderly, or those with arthritis affecting the hands.
How to use
• Take only one dose at a time
• Remove the cap and shake the inhaler several times
• Sit upright, breathe out completely
• Insert mouthpiece in mouth, sealing with lips
• Take a deep breath in; just after you begin to breathe in depress the canister whilst continuing to inhale:
• The canister should be pressed just after the start of inhalation, not before
• Inhale slowly and 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 - Autohaler
This is a 'breath-actuated' inhaler, releasing a dose automatically as a breath is taken. No hand coordination is required. The priming lever, however, can prove difficult to use and requires priming before each dose.
How to use
• Remove cap and shake inhaler several times
• Prime by pushing the lever into the vertical position whilst keeping the inhaler upright
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• Inhale slowly and deeply:
• • Don't stop when the inhaler clicks
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Push lever down and allow time to recover before taking the next dose
• Once doses are taken, replace cap.
Procedure Tips
• Patients unable to operate the lever by hand may be able to use a hard surface such as the edge of a table for assistance
• Use inhaler only for the number of doses written on the label
This is a 'breath-actuated' inhaler, releasing a dose automatically as a breath is taken. No hand coordination is required. The priming lever, however, can prove difficult to use and requires priming before each dose.
How to use
• Remove cap and shake inhaler several times
• Prime by pushing the lever into the vertical position whilst keeping the inhaler upright
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• Inhale slowly and deeply:
• • Don't stop when the inhaler clicks
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Push lever down and allow time to recover before taking the next dose
• Once doses are taken, replace cap.
Procedure Tips
• Patients unable to operate the lever by hand may be able to use a hard surface such as the edge of a table for assistance
• Use inhaler only for the number of doses written on the label
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Clinical Procedures - Easi-breathe
Breath-actuated inhaler, as autohaler only primed by opening the cap hence this must be closed and opened again between successive doses.
How to use
• Shake the inhaler several times
• Hold upright and prime by opening the cap
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips:
• Make sure that your fingers are not covering the air holes at the top
• Inhale slowly and deeply
• © Don't stop when the inhaler puffs
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Close the cap, with the inhaler upright
• Recover before taking the next dose.
Procedure Tips
• It is essential to close and then open the cap between successive doses. This primes the inhaler
• Advise the patient not to dismantle the inhaler. Patients used to using MDIs may be tempted to take the top off and attempt to depress the canister manually.
Breath-actuated inhaler, as autohaler only primed by opening the cap hence this must be closed and opened again between successive doses.
How to use
• Shake the inhaler several times
• Hold upright and prime by opening the cap
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips:
• Make sure that your fingers are not covering the air holes at the top
• Inhale slowly and deeply
• © Don't stop when the inhaler puffs
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Close the cap, with the inhaler upright
• Recover before taking the next dose.
Procedure Tips
• It is essential to close and then open the cap between successive doses. This primes the inhaler
• Advise the patient not to dismantle the inhaler. Patients used to using MDIs may be tempted to take the top off and attempt to depress the canister manually.
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Clinical Procedures- Accuhaler
Dry powder device, superseding the Diskhaler and Rotahaler.
Has a dose counter. The several-step priming mechanism may be difficult for some to manage
How to use
• Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click
. With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed
• Sit upright, breathe out completely and insert mouthpiece, sealing with lips
• Inhale quickly and deeply
• (In contrast to breath-actuated devices)
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click
• Recover before taking the next dose.
Procedure Tips
• The Accuhaler must be closed and re-primed between successive doses.
• The dose counter indicates how many doses are left.
Dry powder device, superseding the Diskhaler and Rotahaler.
Has a dose counter. The several-step priming mechanism may be difficult for some to manage
How to use
• Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click
. With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed
• Sit upright, breathe out completely and insert mouthpiece, sealing with lips
• Inhale quickly and deeply
• (In contrast to breath-actuated devices)
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click
• Recover before taking the next dose.
Procedure Tips
• The Accuhaler must be closed and re-primed between successive doses.
• The dose counter indicates how many doses are left.
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Clinical Procedures - Taking Cervical Smear
Indications
• Screening for cervical cancer
• Post-treatment follow-up for cervical dysplasia or malignancy
• After hysterectomy for neoplasia or dysplasia.
Contraindications
• There are no real contraindications but care is needed in circumstances in which an adequate sample may be difficult to obtain or interpret.
Risks
• (Minor) spotting
• Uterine cramps.
Procedure Tips
• Cervical smears should not be performed during pregnancy. The increase in cervical mucus (and resultant decrease in the number of cells obtained) usually renders the sample inadequate and the results unreliable
• Neither abnormal vaginal bleeding or discharge or a visible or palpate cervical lesion is an indication for a cervical smear per se as it is a test for cervical atypia which is asymptomatic. However, a speculum examination should be performed to inspect the cervix and infection screening offered. A cervical smear can be offered to women who have not had a normal test within the usual screening period
• Ensure the woman knows when and how she will receive the results of the test and who to contact in case of problems
The following describes the technique for obtaining a sample for 'liquid-based cytology (LBC), now used by the majority of Units in the UK
Equipment
• Cusco's specula of different sizes
• Disposable gloves
• Request form
• Sampling device: plastic broom (Cervex-Brush®)
• LBC vial: preservative for sample
• Patient information leaflet.
Procedure
• Introduce yourself, confirm the patient's identity, ensure the patient understands the purpose of the procedure and has been given a patient information leaflet
• Explain the procedure and obtain informed consent
• Ensure a chaperone is available during the examination
• Write the patient's identification details on LBC vial
• Ask the patient to lie on her back on an examination couch with both knees bent up and let her knees fall apart: either with her heels together in the middle or separated
• Warm the speculum under running water and lubricate it with a water-based lubricant
• Using the left hand, open the lips of the labia minora to obtain a good view of the introitus
• Hold the speculum in the right hand with the main beg of the speculum in the palm and the closed blades pre between index and middle fingers
• Gently insert the speculum into the vagina held with wrist turned such that the blades are in line with the opening between the labia
• The speculum should be angled downwards and backwards due to the angle of the vagina
• Maintain a posterior angulation and rotate the speculum through 90° to position handles anteriorly
• When it cannot be advanced further, maintain a downward pressure and press on the thumb piece to hinge the blades open exposing the cervix and vaginal walls
• Ensure entire cervix is clearly visualized and note any obvious abnormalities or irregularity
• Once in optimum position, tighten the thumbscrew
• Insert the plastic broom so that the central bristles of the brush are in the endocervical canal and the outer bristles in contact with the ectocervix
• Using pencil pressure, rotate the brush 5 times in a clockwise direction:
• The bristles are bevelled to scrape cells only on clockwise rotation
• Rinse the brush thoroughly in the preservative (Thin Prep® or break off brush into the preservative (SurePath®
• Undo the thumbscrew and withdraw the speculum
•The blades should be held open until their ends are visible distal to the cervix to avoid causing pain
• Rotate the open blades in an anticlockwise direction to ensure that the anterior and posterior walls of the vagina can be inspected
• Near the introitus, allow the blades to close taking care not to pinch the labia or hairs
• Allow the patient to re-dress in privacy.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including chaperone
• Date of last menstrual period and use of hormonal treatments
• Date of last smear and any abnormal results
• Any abnormalities identified
• Any immediate complications
Indications
• Screening for cervical cancer
• Post-treatment follow-up for cervical dysplasia or malignancy
• After hysterectomy for neoplasia or dysplasia.
Contraindications
• There are no real contraindications but care is needed in circumstances in which an adequate sample may be difficult to obtain or interpret.
Risks
• (Minor) spotting
• Uterine cramps.
Procedure Tips
• Cervical smears should not be performed during pregnancy. The increase in cervical mucus (and resultant decrease in the number of cells obtained) usually renders the sample inadequate and the results unreliable
• Neither abnormal vaginal bleeding or discharge or a visible or palpate cervical lesion is an indication for a cervical smear per se as it is a test for cervical atypia which is asymptomatic. However, a speculum examination should be performed to inspect the cervix and infection screening offered. A cervical smear can be offered to women who have not had a normal test within the usual screening period
• Ensure the woman knows when and how she will receive the results of the test and who to contact in case of problems
The following describes the technique for obtaining a sample for 'liquid-based cytology (LBC), now used by the majority of Units in the UK
Equipment
• Cusco's specula of different sizes
• Disposable gloves
• Request form
• Sampling device: plastic broom (Cervex-Brush®)
• LBC vial: preservative for sample
• Patient information leaflet.
Procedure
• Introduce yourself, confirm the patient's identity, ensure the patient understands the purpose of the procedure and has been given a patient information leaflet
• Explain the procedure and obtain informed consent
• Ensure a chaperone is available during the examination
• Write the patient's identification details on LBC vial
• Ask the patient to lie on her back on an examination couch with both knees bent up and let her knees fall apart: either with her heels together in the middle or separated
• Warm the speculum under running water and lubricate it with a water-based lubricant
• Using the left hand, open the lips of the labia minora to obtain a good view of the introitus
• Hold the speculum in the right hand with the main beg of the speculum in the palm and the closed blades pre between index and middle fingers
• Gently insert the speculum into the vagina held with wrist turned such that the blades are in line with the opening between the labia
• The speculum should be angled downwards and backwards due to the angle of the vagina
• Maintain a posterior angulation and rotate the speculum through 90° to position handles anteriorly
• When it cannot be advanced further, maintain a downward pressure and press on the thumb piece to hinge the blades open exposing the cervix and vaginal walls
• Ensure entire cervix is clearly visualized and note any obvious abnormalities or irregularity
• Once in optimum position, tighten the thumbscrew
• Insert the plastic broom so that the central bristles of the brush are in the endocervical canal and the outer bristles in contact with the ectocervix
• Using pencil pressure, rotate the brush 5 times in a clockwise direction:
• The bristles are bevelled to scrape cells only on clockwise rotation
• Rinse the brush thoroughly in the preservative (Thin Prep® or break off brush into the preservative (SurePath®
• Undo the thumbscrew and withdraw the speculum
•The blades should be held open until their ends are visible distal to the cervix to avoid causing pain
• Rotate the open blades in an anticlockwise direction to ensure that the anterior and posterior walls of the vagina can be inspected
• Near the introitus, allow the blades to close taking care not to pinch the labia or hairs
• Allow the patient to re-dress in privacy.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including chaperone
• Date of last menstrual period and use of hormonal treatments
• Date of last smear and any abnormal results
• Any abnormalities identified
• Any immediate complications
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Surgery - Puch Skin Biopsy
Indications
• Punch biopsy is widely used for diagnosing lesions and rashes
• It is less helpful to confirm deep processes or for conditions that may be difficult to confirm histologically such as mycosis fungoides. Here, a larger incisional biopsy can be a better choice.
Contraindications
• Adrenaline-containing anesthetic should not be used on the fingers, toes, or penis, due to a potential risk of occluding an end-artery
• © Punch biopsy should usually be avoided if melanoma is suspected (excision biopsy is required
• © It is inadvisable to biopsy a patient if platelets < 50 × 10°/L or
INR >3.
Risks
• Take particular care when taking a punch biopsy from an area with important structures just beneath the skin. For example, the tendons on the dorsum of the hand, the facial nerve crossing the zygoma or temple:
• The risk can be reduced by raising a large bleb with the anaesthetic to put more depth between the surface and deeper structures
• D Patients should be warned that punch biopsy will always leave a scar
• In a patient prone to keloid scarring, try to avoid biopsying keloid-prone areas such as the upper trunk and back of the neck
• Infection
• Haemorrhage.
Procedure Tips
• Punch biopsy implements range in size from 3-8mm. For most diagnostic purposes, 4mm is appropriate; an 8mm punch biopsy defect requires a buried subcuticular suture in addition to surface sutures
• > Choice of biopsy site is very important for some lesias
Land rashes, as
the diagnostic histological features may only be press
ten lesions,
or in a particular part of a lesion. If in doubt, consult
ologist
• D Always mark the site of the biopsy. It can be surprise ricw, after blanching the skin with adrenaline and rubbing to clean the area, the obvious red, scaly plaque completely disappears!
• I Bulla: take the specimen across the edge of a fresh blister
• Ulcer: take the specimen from the edge of the lesion
• If for any reason suturing the wound is going to be difficult (e.g. very tight skin on the leg, markedly indurated lesion or patient won't keep still), the defect can be left to heal by secondary intention.
Equipment
• Surgical pack including sterile drape, gauze, small bowl
• Isopropyl alcohol swab
• Skin marker
• Non-sterile gloves
• Local anaesthetic (1 mL 1% lidocaine is usually plenty)
• 2mL syringe and fine bore (blue) needle
• Sterile gloves
• Sterile towel
• Sterile cleaning solution (e.g. iodine)
• Disposable punch biopsy implement (usually 4mm)
• Toothed forceps
• Scissors
• Histology pot
• Vaseline® or similar
• Plaster or other dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Mark the exact area to be biopsied with the skin marker
• Wipe the site to be biopsied with the alcohol swab
• Draw up the local anaesthetic (e.g. lidocaine 1% with adrenaline 1:200,000):
• If using anaesthetic containing adrenaline, warn the patient that the injection will sting
• Wearing the non-sterile gloves, inject the anaes around and beneath the biopsy site (into dermis and subcutis) to raise up a bleb:
• Keep gauze to hand to catch any drips.
• Wash hands using surgical scrub technique.
• Cleanse the area around the biopsy site with the cleaning solution and some gauze
• Position the sterile drape(s)
• Have gauze handy to mop up any bleeding:
• It can be helpful to place some adiacent to the biopsy site in the direction that any blood will flow
• Place the punch biopsy over the mark and push it through the skin with a rotating motion... penetrate through to subcutis, at which point a reduction in resistance can be felt
• Put down the punch biopsy implement
• Pick up the specimen without compressing it with the toothed forceps
• Harvest the specimen by cutting with the scissors through the connecting subcutaneous fat strands (sometimes this is unnecessary as the fat may just fall away)
• Place the specimen in the histology pot
• Place a smear of Vaseline® over the wound and cover with the plaster or dressing.
Documentation
• Date, time, indication, informed consent obtained
• Type and volume of local anaesthetic used
• Note the site and method of the biopsy (it can be helpful to draw a diagram)
• The type of suture used
• Instructions on the time for suture removal
• The pathology request form should provide the pathologist with information on the date, site, size type of biopsy.
• A brief history, description of the problem an differential is essential (lesion' or 'rash' does not
• Signature, printed name, and contact details.
Indications
• Punch biopsy is widely used for diagnosing lesions and rashes
• It is less helpful to confirm deep processes or for conditions that may be difficult to confirm histologically such as mycosis fungoides. Here, a larger incisional biopsy can be a better choice.
Contraindications
• Adrenaline-containing anesthetic should not be used on the fingers, toes, or penis, due to a potential risk of occluding an end-artery
• © Punch biopsy should usually be avoided if melanoma is suspected (excision biopsy is required
• © It is inadvisable to biopsy a patient if platelets < 50 × 10°/L or
INR >3.
Risks
• Take particular care when taking a punch biopsy from an area with important structures just beneath the skin. For example, the tendons on the dorsum of the hand, the facial nerve crossing the zygoma or temple:
• The risk can be reduced by raising a large bleb with the anaesthetic to put more depth between the surface and deeper structures
• D Patients should be warned that punch biopsy will always leave a scar
• In a patient prone to keloid scarring, try to avoid biopsying keloid-prone areas such as the upper trunk and back of the neck
• Infection
• Haemorrhage.
Procedure Tips
• Punch biopsy implements range in size from 3-8mm. For most diagnostic purposes, 4mm is appropriate; an 8mm punch biopsy defect requires a buried subcuticular suture in addition to surface sutures
• > Choice of biopsy site is very important for some lesias
Land rashes, as
the diagnostic histological features may only be press
ten lesions,
or in a particular part of a lesion. If in doubt, consult
ologist
• D Always mark the site of the biopsy. It can be surprise ricw, after blanching the skin with adrenaline and rubbing to clean the area, the obvious red, scaly plaque completely disappears!
• I Bulla: take the specimen across the edge of a fresh blister
• Ulcer: take the specimen from the edge of the lesion
• If for any reason suturing the wound is going to be difficult (e.g. very tight skin on the leg, markedly indurated lesion or patient won't keep still), the defect can be left to heal by secondary intention.
Equipment
• Surgical pack including sterile drape, gauze, small bowl
• Isopropyl alcohol swab
• Skin marker
• Non-sterile gloves
• Local anaesthetic (1 mL 1% lidocaine is usually plenty)
• 2mL syringe and fine bore (blue) needle
• Sterile gloves
• Sterile towel
• Sterile cleaning solution (e.g. iodine)
• Disposable punch biopsy implement (usually 4mm)
• Toothed forceps
• Scissors
• Histology pot
• Vaseline® or similar
• Plaster or other dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Mark the exact area to be biopsied with the skin marker
• Wipe the site to be biopsied with the alcohol swab
• Draw up the local anaesthetic (e.g. lidocaine 1% with adrenaline 1:200,000):
• If using anaesthetic containing adrenaline, warn the patient that the injection will sting
• Wearing the non-sterile gloves, inject the anaes around and beneath the biopsy site (into dermis and subcutis) to raise up a bleb:
• Keep gauze to hand to catch any drips.
• Wash hands using surgical scrub technique.
• Cleanse the area around the biopsy site with the cleaning solution and some gauze
• Position the sterile drape(s)
• Have gauze handy to mop up any bleeding:
• It can be helpful to place some adiacent to the biopsy site in the direction that any blood will flow
• Place the punch biopsy over the mark and push it through the skin with a rotating motion... penetrate through to subcutis, at which point a reduction in resistance can be felt
• Put down the punch biopsy implement
• Pick up the specimen without compressing it with the toothed forceps
• Harvest the specimen by cutting with the scissors through the connecting subcutaneous fat strands (sometimes this is unnecessary as the fat may just fall away)
• Place the specimen in the histology pot
• Place a smear of Vaseline® over the wound and cover with the plaster or dressing.
Documentation
• Date, time, indication, informed consent obtained
• Type and volume of local anaesthetic used
• Note the site and method of the biopsy (it can be helpful to draw a diagram)
• The type of suture used
• Instructions on the time for suture removal
• The pathology request form should provide the pathologist with information on the date, site, size type of biopsy.
• A brief history, description of the problem an differential is essential (lesion' or 'rash' does not
• Signature, printed name, and contact details.
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Clinical Procedures - Pleural Fluid Aspiration
Indications
• Diagnosis of cause of pleural effusion
• Relief of symptomatic pleural effusion.
Contraindications
• Recurrent effusion (chest drain, pleurodesis should be considered)
• Empyema (requires intercostal drain)
• Mesothelioma (tumour may spread down needle track)
• Bleeding diathesis.
Risks
• Pain
• Cough
• Failure to resolve
• Re-expansion pulmonary edema
• Pneumothorax.
Procedure Tips
• If unsuccessful, aspiration may be performed under ultrasound guidance:
discuss with your Radiology Department
• Passing a small fluid sample through a blood gas analyser may yield a rapid pH but should be avoided if the sample is purulent.
Alternative method
• An alternative method is to attach a fluid-giving set to one port of the
3-way tap and the 50mL syringe to the other. With this set up, you can aspirate 50mL into the syringe, turn the tap and empty it down the tubing into a container before turning the tap back to the syringe port.
The syringe, therefore, never needs to be disconnected and the risk of pneumothorax or other complication is reduced.
This describes the procedure for aspirating as much pleural fluid as possible. If only a small sample is required for diagnostic purposes, use a green needle and 20mL syringe and follow a similar method to that described under 'ascitic tap'.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/ gauze
• Selection of sterile containers and blood culture bottles
• Heparinized (ABG) syringe.
Procedure
• Fluid should be aspirated from a position 1-2 intercostal spaces below the highest level at which dullness is percussed.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning forward with arms rested on a table or over the back of a chair
• Percuss the effusion and choose a suitable spot for needle insertion
• Clean the area with chlorhexidine
• Using the blue needle and syringe, infiltrate local anaesthetic down to the pleura:
• © Insert needle just above a rib to avoid the neurovascular bundle
• Be sure to pull back on the syringe each time before injecting to ensure you are not in a blood vessel
• Once fluid is withdrawn, you have reached the pleura
Insert the cannula perpendicular to the chest wall, aspirating with another syringe as you advance until resistance reduces and pleural fluid is aspirated
• Remove the needle and attach the 3-way tap
• You may now aspirate fluid using the 50mL syringe. Once the syringe is full, close the tap, disconnect the syringe, and empty into a container. Re-attach the syringe, open the tap and repeat:
• The pleural space should never be in continuity with the environment or pneumothorax will occur
• Do not drain more than 2.5L at one time
• Remove the cannula and apply the dressing
• Send samples for:
• Microbiology: microscopy, culture, Auramine stain
TB culture
• Chemistry: protein, lactate dehydrogenase (LDH), pH, glucose, amylase
• Cytology
• Immunology: anti-nuclear antibody, rheumatoid factor, complement
• Take simultaneous venous blood for glucose, protein, LDH
• Request chest radiograph to confirm success and look for iatrogenic pneumothorax.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Colour, consistency, and volume of fluid aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
Indications
• Diagnosis of cause of pleural effusion
• Relief of symptomatic pleural effusion.
Contraindications
• Recurrent effusion (chest drain, pleurodesis should be considered)
• Empyema (requires intercostal drain)
• Mesothelioma (tumour may spread down needle track)
• Bleeding diathesis.
Risks
• Pain
• Cough
• Failure to resolve
• Re-expansion pulmonary edema
• Pneumothorax.
Procedure Tips
• If unsuccessful, aspiration may be performed under ultrasound guidance:
discuss with your Radiology Department
• Passing a small fluid sample through a blood gas analyser may yield a rapid pH but should be avoided if the sample is purulent.
Alternative method
• An alternative method is to attach a fluid-giving set to one port of the
3-way tap and the 50mL syringe to the other. With this set up, you can aspirate 50mL into the syringe, turn the tap and empty it down the tubing into a container before turning the tap back to the syringe port.
The syringe, therefore, never needs to be disconnected and the risk of pneumothorax or other complication is reduced.
This describes the procedure for aspirating as much pleural fluid as possible. If only a small sample is required for diagnostic purposes, use a green needle and 20mL syringe and follow a similar method to that described under 'ascitic tap'.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/ gauze
• Selection of sterile containers and blood culture bottles
• Heparinized (ABG) syringe.
Procedure
• Fluid should be aspirated from a position 1-2 intercostal spaces below the highest level at which dullness is percussed.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning forward with arms rested on a table or over the back of a chair
• Percuss the effusion and choose a suitable spot for needle insertion
• Clean the area with chlorhexidine
• Using the blue needle and syringe, infiltrate local anaesthetic down to the pleura:
• © Insert needle just above a rib to avoid the neurovascular bundle
• Be sure to pull back on the syringe each time before injecting to ensure you are not in a blood vessel
• Once fluid is withdrawn, you have reached the pleura
Insert the cannula perpendicular to the chest wall, aspirating with another syringe as you advance until resistance reduces and pleural fluid is aspirated
• Remove the needle and attach the 3-way tap
• You may now aspirate fluid using the 50mL syringe. Once the syringe is full, close the tap, disconnect the syringe, and empty into a container. Re-attach the syringe, open the tap and repeat:
• The pleural space should never be in continuity with the environment or pneumothorax will occur
• Do not drain more than 2.5L at one time
• Remove the cannula and apply the dressing
• Send samples for:
• Microbiology: microscopy, culture, Auramine stain
TB culture
• Chemistry: protein, lactate dehydrogenase (LDH), pH, glucose, amylase
• Cytology
• Immunology: anti-nuclear antibody, rheumatoid factor, complement
• Take simultaneous venous blood for glucose, protein, LDH
• Request chest radiograph to confirm success and look for iatrogenic pneumothorax.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Colour, consistency, and volume of fluid aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
- Published on
Clinical Procedures - Pneumothorax Aspiration
Indications
Simple pneumothorax
• Aspiration is indicated if the rim of pleural air visible on chest radiograph is >2cm or the patient is breathless
• If initial aspiration is unsuccessful, repeat aspiration may be successful in
>30% of cases and may avoid intercostal drain insertion
• The total volume aspirated should not exceed 2.5L.
Secondary pneumothorax
• That is, a pneumothorax in the presence of underlying lung disease
• Aspiration is only indicated in minimally symptomatic patients with small pneumothoraces (<2cm) aged <50 years.
Contraindications
• Previous failed attempts at aspiration
• Significant secondary pneumothorax
• Traumatic pneumothorax.
Risks
• Pain
• Cough
• Failure to resolve/recurrence
• Re-expansion pulmonary edema may theoretically occur if large volumes (>2.5L) are aspirated.
• Tension Pneumothorax
In the case of tension pneumothorax, a wide-bore cannula should be inserted into the 2nd intercostal space, midclavicular line without delay and left open to convert the tension pneumothorax to a simple pneumothorax.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/gauze.
Procedure
• Pneumothorax is usually aspirated from either the 2nd intercostal space at the midclavicular line or the 4th_ 6th intercostal spaces at the midaxillary line.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning back comfortably at about 45°
• Identify the site for needle insertion and double-check the radiograph to be certain you have the correct side. Confirm with clinical examination
• Clean the area with the chlorhexidine
• Infiltrate local anaesthetic down to the pleura using the blue needle and a 10mL syringe
• Attach the other 10mL syringe to the cannula and insert the cannula perpendicular to the chest wall, aspirating as you advance until resistance reduces:
• D Insert the cannula just above a rib to avoid the neurovascular bundle
• Remove the needle and quickly attach the 3-way tap and 50mL syringe
• Aspirate with the syringe; close the 3-way tap when the syringe is full, remove the syringe, and eject the air; reattach and open the 3-way tap to continue aspiration:
• © The pleural space should never be in continuity with the environment (i.e. tap open with syringe detached) or pneumothorax will re-accumulate
• Aspirate until resistance is felt, or up to a maximum of 2.5L
• Remove the cannula and apply the dressing
• Request chest radiograph to re-assess.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Volume of air aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
Indications
Simple pneumothorax
• Aspiration is indicated if the rim of pleural air visible on chest radiograph is >2cm or the patient is breathless
• If initial aspiration is unsuccessful, repeat aspiration may be successful in
>30% of cases and may avoid intercostal drain insertion
• The total volume aspirated should not exceed 2.5L.
Secondary pneumothorax
• That is, a pneumothorax in the presence of underlying lung disease
• Aspiration is only indicated in minimally symptomatic patients with small pneumothoraces (<2cm) aged <50 years.
Contraindications
• Previous failed attempts at aspiration
• Significant secondary pneumothorax
• Traumatic pneumothorax.
Risks
• Pain
• Cough
• Failure to resolve/recurrence
• Re-expansion pulmonary edema may theoretically occur if large volumes (>2.5L) are aspirated.
• Tension Pneumothorax
In the case of tension pneumothorax, a wide-bore cannula should be inserted into the 2nd intercostal space, midclavicular line without delay and left open to convert the tension pneumothorax to a simple pneumothorax.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/gauze.
Procedure
• Pneumothorax is usually aspirated from either the 2nd intercostal space at the midclavicular line or the 4th_ 6th intercostal spaces at the midaxillary line.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning back comfortably at about 45°
• Identify the site for needle insertion and double-check the radiograph to be certain you have the correct side. Confirm with clinical examination
• Clean the area with the chlorhexidine
• Infiltrate local anaesthetic down to the pleura using the blue needle and a 10mL syringe
• Attach the other 10mL syringe to the cannula and insert the cannula perpendicular to the chest wall, aspirating as you advance until resistance reduces:
• D Insert the cannula just above a rib to avoid the neurovascular bundle
• Remove the needle and quickly attach the 3-way tap and 50mL syringe
• Aspirate with the syringe; close the 3-way tap when the syringe is full, remove the syringe, and eject the air; reattach and open the 3-way tap to continue aspiration:
• © The pleural space should never be in continuity with the environment (i.e. tap open with syringe detached) or pneumothorax will re-accumulate
• Aspirate until resistance is felt, or up to a maximum of 2.5L
• Remove the cannula and apply the dressing
• Request chest radiograph to re-assess.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Volume of air aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
