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Clinical Procedures – Intravenous Infusion
Equipment
• Gloves
• An appropriate fluid bag
• Giving set
• Drip stand
• 10mL syringe with saline flush.
Procedure
• ©Intravenous infusions require intravenous access
• Check the fluid in the bag and fluid prescription chart
• Ask a colleague to double-check the prescription and the fluid and sign their name on the chart
• Flush the patient's cannula with a few mL of saline to ensure there is no obstruction. If there is evidence of a blockage, swelling at the cannula site, or if the patient experiences pain, you may need to replace the cannula
• Open the fluid bag and giving set, which come in sterile packaging
• Unwind the giving set and close the adjustable valve
• Remove the sterile cover from the bag outlet and from the sharp end of the giving set
• Using quite a lot of force, push the giving set end into the bag outlet
• Invert the bag and hang on a suitable drip-stand
• Squeeze the drip chamber to half fill it with fluid
• Partially open the valve to allow the drip to run, and watch fluid run through to the end (it might be best to hold the free end over a sink in case of spills)
• If bubbles appear, try tapping or flicking the tube
• Once the giving set is filled with liquid, connect it to the
cannula
• Adjust the valve and watch the drips in the chamber
• Adjust the drip rate according to the prescription.
Drip Rate
• Most infusions tend to be given with electronic devices which pump the fluid in at the prescribed rate. However, it is still important that healthcare professionals are able to set up a drip at the correct flow rate manually
• Using a standard giving set, clear fluids will form drips of about 0.05mL. that is, there will be approximately 20 drips/mL. You can then calculate
Equipment
• Gloves
• An appropriate fluid bag
• Giving set
• Drip stand
• 10mL syringe with saline flush.
Procedure
• ©Intravenous infusions require intravenous access
• Check the fluid in the bag and fluid prescription chart
• Ask a colleague to double-check the prescription and the fluid and sign their name on the chart
• Flush the patient's cannula with a few mL of saline to ensure there is no obstruction. If there is evidence of a blockage, swelling at the cannula site, or if the patient experiences pain, you may need to replace the cannula
• Open the fluid bag and giving set, which come in sterile packaging
• Unwind the giving set and close the adjustable valve
• Remove the sterile cover from the bag outlet and from the sharp end of the giving set
• Using quite a lot of force, push the giving set end into the bag outlet
• Invert the bag and hang on a suitable drip-stand
• Squeeze the drip chamber to half fill it with fluid
• Partially open the valve to allow the drip to run, and watch fluid run through to the end (it might be best to hold the free end over a sink in case of spills)
• If bubbles appear, try tapping or flicking the tube
• Once the giving set is filled with liquid, connect it to the
cannula
• Adjust the valve and watch the drips in the chamber
• Adjust the drip rate according to the prescription.
Drip Rate
• Most infusions tend to be given with electronic devices which pump the fluid in at the prescribed rate. However, it is still important that healthcare professionals are able to set up a drip at the correct flow rate manually
• Using a standard giving set, clear fluids will form drips of about 0.05mL. that is, there will be approximately 20 drips/mL. You can then calculate
Documentation
• Ensure fluid and/or drug is clearly timed and signed for as per local policy
• Nursing notes should be completed to include the reason for the infusion
• Medical notes should be used to record any causes for concern arising from administration of the infusion
• Cannula site (and cannula documentation) should be dated and signed on insertion
• Ensure any fluid-monitoring chart is complete and updated as appropriate
• Ensure fluid and/or drug is clearly timed and signed for as per local policy
• Nursing notes should be completed to include the reason for the infusion
• Medical notes should be used to record any causes for concern arising from administration of the infusion
• Cannula site (and cannula documentation) should be dated and signed on insertion
• Ensure any fluid-monitoring chart is complete and updated as appropriate
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Clinical Procedures - Arterial Line Insertion (Radial Artery)
Indications
• Continuous beat-to-beat measurement of arterial blood pressure (inotrope therapy, intraoperatively for major surgery, transfer of critically ill)
• Repeated blood gas sampling.
Contraindications
• Infection at insertion site
• Working AV fistula
• Traumatic injury proximal to the insertion site
• Vascular insufficiency in the distribution of the artery to be cannulated
• Significant clotting abnormalities.
Risks
• Non-vascular: superficial bleeding, infection, inadvertent arterial injection
. Vascular: vasospasm, thrombosis, thromboembolism, air embolism,
blood vessel injury, distal ischaemia
Procedure Tips
• Good positioning is vital. Make sure both you and the patient are comfortable
• © Do not force the guidewire. If there is resistance, try lowering the needle to a shallower angle without removing it from the artery
• © Cover the floor with spill sheets as the procedure can be messy!
• D The modified Allen's test should be used for assessment of the collateral supply to the hand before the radial artery is punctured but may not be completely reliable in predicting ischaemic injury.
Modified Allen's test
• Compress the radial and ulnar arteries at the wrist and ask the patient to clench their fist
• Ask the patient to open the hand
• Release pressure over the ulnar artery
• Watch the palm for return of colour:
• Return of colour should normally occur in 5-10 seconds
• Return of colour taking >15 seconds suggests an inadequate collateral supply by the ulnar artery and radial artery cannulation should not be performed.
Equipment
• Arterial catheter set:
• Arterial catheter (20G), needle, guidewire
• Sterile gloves, sterile gown (‡ surgical hat and mask)
• Dressing pack including a sterile drape
• Sterile preparation solution (e.g. 2% chlorhexidine)
• Local anaesthetic (e.g. 1% lidocaine), 22G needle, and 5mL syringe
• (Optional) A 3-way tap with a short extension (flushed with normal saline) connected to a 10mL syringe containing normal saline
• Suture
• Transducer set with pressurized bag of heparinized saline.
Procedure (Modified Seldinger Technique)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Choose a site for arterial line insertion (e.g. radial artery)
• Position the forearm so that it is supported from underneath and hyperextend the wrist
• Set up a trolley keeping everything sterile:
• Open the dressing pack onto the trolley creating a sterile field
• Open the arterial catheter set and place onto the sterile field
• Wash hands using a surgical scrub technique and put on the sterile gown and gloves
• Clean the wrist, hand, and forearm with a sterile preparation solution and create a sterile field with the drape
• Palpate the radial artery with your non-dominant hand and infiltrate the skin overlying the pulsation with some local
anaesthetic
• Insert the arterial needle, directing it towards the radial pulsation at a 30-45° angle. (Do not attach to a syringe.)
• You can also use a syringe with the plunger removed.
This allows identification of the arterial pulsation without excess spillage
• On hitting the artery, blood will spurt out of the hub of the needle
• Keeping the needle still, insert the guidewire through the hub of the needle. © Don't force the guidewire
• Remove the needle leaving the guidewire in place
• Thread the arterial catheter over the guidewire making sure that guidewire is seen at all times through the distal end of the catheter
• Holding the distal end of the guidewire with one hand, push the arterial catheter through the skin with the other
• Remove the guidewire
• Blood should spill out of the end of the catheter if it is within the artery
• Connect to the short extension of the 3-way tap, aspirate and flush with normal saline, and close off the tap:
• Alternatively, connect immediately to a pressurized transducer set, aspirate, and flush
•Do not delay connection to transducer and flush-bag
• Take extreme care not to allow any air bubbles to flush into the artery (risk of distal embolization)
• Suture in place
• Label catheter as arterial and inform relevant staff.
Documentation
• Time, date, indication and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempts)
• Aseptic technique: gloves, gown, hat, mask, sterile solution
• Local anaesthetic: type and amount infiltrated
• Technique used: modified Seldinger, cannula over needle
• Catheter size used: 20G
• Aspirated and flushed
• Signature, printed name, and contact details.
Indications
• Continuous beat-to-beat measurement of arterial blood pressure (inotrope therapy, intraoperatively for major surgery, transfer of critically ill)
• Repeated blood gas sampling.
Contraindications
• Infection at insertion site
• Working AV fistula
• Traumatic injury proximal to the insertion site
• Vascular insufficiency in the distribution of the artery to be cannulated
• Significant clotting abnormalities.
Risks
• Non-vascular: superficial bleeding, infection, inadvertent arterial injection
. Vascular: vasospasm, thrombosis, thromboembolism, air embolism,
blood vessel injury, distal ischaemia
Procedure Tips
• Good positioning is vital. Make sure both you and the patient are comfortable
• © Do not force the guidewire. If there is resistance, try lowering the needle to a shallower angle without removing it from the artery
• © Cover the floor with spill sheets as the procedure can be messy!
• D The modified Allen's test should be used for assessment of the collateral supply to the hand before the radial artery is punctured but may not be completely reliable in predicting ischaemic injury.
Modified Allen's test
• Compress the radial and ulnar arteries at the wrist and ask the patient to clench their fist
• Ask the patient to open the hand
• Release pressure over the ulnar artery
• Watch the palm for return of colour:
• Return of colour should normally occur in 5-10 seconds
• Return of colour taking >15 seconds suggests an inadequate collateral supply by the ulnar artery and radial artery cannulation should not be performed.
Equipment
• Arterial catheter set:
• Arterial catheter (20G), needle, guidewire
• Sterile gloves, sterile gown (‡ surgical hat and mask)
• Dressing pack including a sterile drape
• Sterile preparation solution (e.g. 2% chlorhexidine)
• Local anaesthetic (e.g. 1% lidocaine), 22G needle, and 5mL syringe
• (Optional) A 3-way tap with a short extension (flushed with normal saline) connected to a 10mL syringe containing normal saline
• Suture
• Transducer set with pressurized bag of heparinized saline.
Procedure (Modified Seldinger Technique)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Choose a site for arterial line insertion (e.g. radial artery)
• Position the forearm so that it is supported from underneath and hyperextend the wrist
• Set up a trolley keeping everything sterile:
• Open the dressing pack onto the trolley creating a sterile field
• Open the arterial catheter set and place onto the sterile field
• Wash hands using a surgical scrub technique and put on the sterile gown and gloves
• Clean the wrist, hand, and forearm with a sterile preparation solution and create a sterile field with the drape
• Palpate the radial artery with your non-dominant hand and infiltrate the skin overlying the pulsation with some local
anaesthetic
• Insert the arterial needle, directing it towards the radial pulsation at a 30-45° angle. (Do not attach to a syringe.)
• You can also use a syringe with the plunger removed.
This allows identification of the arterial pulsation without excess spillage
• On hitting the artery, blood will spurt out of the hub of the needle
• Keeping the needle still, insert the guidewire through the hub of the needle. © Don't force the guidewire
• Remove the needle leaving the guidewire in place
• Thread the arterial catheter over the guidewire making sure that guidewire is seen at all times through the distal end of the catheter
• Holding the distal end of the guidewire with one hand, push the arterial catheter through the skin with the other
• Remove the guidewire
• Blood should spill out of the end of the catheter if it is within the artery
• Connect to the short extension of the 3-way tap, aspirate and flush with normal saline, and close off the tap:
• Alternatively, connect immediately to a pressurized transducer set, aspirate, and flush
•Do not delay connection to transducer and flush-bag
• Take extreme care not to allow any air bubbles to flush into the artery (risk of distal embolization)
• Suture in place
• Label catheter as arterial and inform relevant staff.
Documentation
• Time, date, indication and informed consent obtained
• Site and side of successful insertion
• Site, side, and complications of unsuccessful attempts)
• Aseptic technique: gloves, gown, hat, mask, sterile solution
• Local anaesthetic: type and amount infiltrated
• Technique used: modified Seldinger, cannula over needle
• Catheter size used: 20G
• Aspirated and flushed
• Signature, printed name, and contact details.
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Surgery - Knee Joint Injection
Indications
• Iniection of corticosteroids are performed to relieve:
•Acute attack of crystal arthritis (gout, pseudogout)
• Flare of inflammatory arthritis (seronegative arthritis, rheumatoid arthritis, reactive arthritis)
• Pain in patients with osteoarthritis.
Other substances administered by an intra-articular injection
• Yttrium: for chronic monoarticular synovitis
• Hyaluronic acid: for pain in patients with osteoarthritis of the knee.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia and a high IN should be discussed with a rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France)
• Subcutaneous atrophy: rare but may be permanent
• Side effects from systemic absorption of corticosteroids: including facial flushing and transient worsening of diabetic control (uncommon)
• Increased pain: this usually lasts for 2-3 days.
Procedure Tips
• It is good practice to send the joint aspirate for routine crystal study Ch stain, and culture. This establishes if the joint was infected before joins aspiration and corticosteroid injection
• Microbiology request forms should provide information on the date, time, and site of joint aspirated.
Injecting smaller joints
• Hydrocortisone (short acting) should be used for small superficial joints rather than triamcinolone
• For MCP joints, 25mg of hydrocortisone and 0.5mL of 2% lidocaine will suffice
• Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• Corticosteroid injection:
• Triamcinolone (long acting) for large joints (knee, shoulder)
• Lidocaine 1% or 2%
• 21G (green) needles
• 10mL syringe
• 5mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• Draw up 40mg triamcinolone and 2mL of 2% lidocaine
• A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• If there is no suspicion of septic arthritis and, once a significant proportion of synovial fluid has been aspirated, attach the syringe containing a mixture of corticosteroids and lidocaine to the needle
• Aspirate a little more to confirm intra-articular, extra-vascular placement and inject the steroid mixture
• • If there is any suspicion of septic arthritis, injection of corticosteroids should not be carried out in the same sitting as synovial fluid aspiration:
•Signs and symptoms of septic arthritis may be indolent in the immunosuppressed and a high index of suspicion needs to be maintained. The clinical suspicion of septic arthritis is further strengthened by aspirating cloudy or purulent fluid
• Withdraw the needle and dress the site with a suitable plaster
• Advise the patient to rest the injected area for 24 48 hours.
Procedure (Superolateral Approach)
For large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be aimed inferiorly and medially.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested
• Type and amount of anaesthetic and steroid used
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Iniection of corticosteroids are performed to relieve:
•Acute attack of crystal arthritis (gout, pseudogout)
• Flare of inflammatory arthritis (seronegative arthritis, rheumatoid arthritis, reactive arthritis)
• Pain in patients with osteoarthritis.
Other substances administered by an intra-articular injection
• Yttrium: for chronic monoarticular synovitis
• Hyaluronic acid: for pain in patients with osteoarthritis of the knee.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia and a high IN should be discussed with a rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France)
• Subcutaneous atrophy: rare but may be permanent
• Side effects from systemic absorption of corticosteroids: including facial flushing and transient worsening of diabetic control (uncommon)
• Increased pain: this usually lasts for 2-3 days.
Procedure Tips
• It is good practice to send the joint aspirate for routine crystal study Ch stain, and culture. This establishes if the joint was infected before joins aspiration and corticosteroid injection
• Microbiology request forms should provide information on the date, time, and site of joint aspirated.
Injecting smaller joints
• Hydrocortisone (short acting) should be used for small superficial joints rather than triamcinolone
• For MCP joints, 25mg of hydrocortisone and 0.5mL of 2% lidocaine will suffice
• Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• Corticosteroid injection:
• Triamcinolone (long acting) for large joints (knee, shoulder)
• Lidocaine 1% or 2%
• 21G (green) needles
• 10mL syringe
• 5mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• Draw up 40mg triamcinolone and 2mL of 2% lidocaine
• A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• If there is no suspicion of septic arthritis and, once a significant proportion of synovial fluid has been aspirated, attach the syringe containing a mixture of corticosteroids and lidocaine to the needle
• Aspirate a little more to confirm intra-articular, extra-vascular placement and inject the steroid mixture
• • If there is any suspicion of septic arthritis, injection of corticosteroids should not be carried out in the same sitting as synovial fluid aspiration:
•Signs and symptoms of septic arthritis may be indolent in the immunosuppressed and a high index of suspicion needs to be maintained. The clinical suspicion of septic arthritis is further strengthened by aspirating cloudy or purulent fluid
• Withdraw the needle and dress the site with a suitable plaster
• Advise the patient to rest the injected area for 24 48 hours.
Procedure (Superolateral Approach)
For large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be aimed inferiorly and medially.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested
• Type and amount of anaesthetic and steroid used
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures – Knee Joint Aspiration
Indications
• Differential diagnosis of acute hot swollen joint
• Recurrent aspiration for joint sepsis.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia or a high IN should be discussed with rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint. This is a relative contraindication. A prosthetic joint should be aspirated by an orthopedic surgeon in a theatre using full surgical sterile precautions.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France).
Procedure Tips
• If you are unable to aspirate synovial fluid:
•Simply withdraw the needle and insert at a different angle (aiming inferomedially)
• Change the position of the patient. Ask them to sit on the edge of a bed with their feet on a stool or chair and repeat the procedure in this position
• Other joints may be aspirated using a similar technique. Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Aspiration of a prosthetic joint should be performed by an Orthopaedic Surgeon in a theatre with full surgical sterility.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• 21G (green) needles
• 10mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• ( A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• Withdraw the needle and dress the site with a suitable plaster
• Send the samples for crystal study, Gram stain, and culture.
Procedure (Superolateral Approach)
Used for large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be inserted at a 45° angle and aimed inferiorly and medially under the patella
• Continue to advance the needle with negative pressure on the plunger until fluid is aspirated.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested:
• The pathology request form should provide the pathologist with information on the date, time, and site of joint aspirate
• The sample should be sent to the laboratories and analysed fresh for crystals, Gram stain, and culture.
The laboratory should be alerted if septic arthritis is suspected
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Differential diagnosis of acute hot swollen joint
• Recurrent aspiration for joint sepsis.
Contraindications
• Superficial infection or broken skin
• Coagulopathy: patients with thrombocytopenia or a high IN should be discussed with rheumatologist or orthopedic surgeon before a joint injection is attempted
• Prosthetic joint. This is a relative contraindication. A prosthetic joint should be aspirated by an orthopedic surgeon in a theatre using full surgical sterile precautions.
Risks
• Discomfort: usually short lived and minor
• Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France).
Procedure Tips
• If you are unable to aspirate synovial fluid:
•Simply withdraw the needle and insert at a different angle (aiming inferomedially)
• Change the position of the patient. Ask them to sit on the edge of a bed with their feet on a stool or chair and repeat the procedure in this position
• Other joints may be aspirated using a similar technique. Use 23-25G (blue, orange) for small joints such as wrist, MCP.
Aspiration of a prosthetic joint should be performed by an Orthopaedic Surgeon in a theatre with full surgical sterility.
Equipment
• Sterile gloves
• Isopropyl alcohol swabs
• 21G (green) needles
• 10mL syringe
• White-capped universal containers
• Elastoplast or cotton wool and sticky tape.
Procedure (Medial Approach)
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps)
• Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe
• Wash hands and put on the gloves
• ( A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier
• Wipe the site with alcohol swabs
• Attach a 10mL syringe to a green needle
• Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side
• Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid
• If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid
• Withdraw the needle and dress the site with a suitable plaster
• Send the samples for crystal study, Gram stain, and culture.
Procedure (Superolateral Approach)
Used for large effusions that distend the suprapatellar pouch.
• The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch
• The needle should be inserted at a 45° angle and aimed inferiorly and medially under the patella
• Continue to advance the needle with negative pressure on the plunger until fluid is aspirated.
Documentation
• Date, time, indication, informed consent obtained
• Site and approach taken
• Aseptic technique used?
• How many passes?
• Volume and nature of fluid aspirated and tests requested:
• The pathology request form should provide the pathologist with information on the date, time, and site of joint aspirate
• The sample should be sent to the laboratories and analysed fresh for crystals, Gram stain, and culture.
The laboratory should be alerted if septic arthritis is suspected
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures - Fine Needle Aspiration
Indications
• Diagnosis of a lump; commonly thyroid and lymph node.
Contraindications
• Bleeding diathesis
• Overlying infection
• Adjacent vital structures. Image-guidance should always be used if available.
Risks
• Bleeding
• Local infection
• Damage to surrounding structures depending on site, e.g. blood vessels, nerves.
Procedure Tips
• © Radiological guidance should always be used if available
• Contact the histopathology department in advance to ensure appropriate transport medium is used. It may be possible to arrange immediate analysis, allowing diagnosis and repeat FNA if insufficient cells are obtained.
A method for obtaining a cytological sample of a mass lesion.
• This procedure should only be performed by, or under strict supervision of, an experienced practitioner.
• Fine-needle aspiration (FNA) usually takes place in the Radiology Department and is performed by an experienced Radiologist under ultrasound or CT guidance. The following describes the older, 'blind' technique.
Equipment
• Local anaesthetic (e.g. 1% lidocaine)
• Small-gauge (blue) needle and 10mL syringe
• Sterile pack
• Cleaning solution (e.g. chlorhexidine)
• Medium-gauge (green) needle
• 10mL or 20mL syringe for aspiration
• Sterile gloves.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient according to the biopsy site, allowing easy palpation of the mass
• Expose appropriately
• Wash your hands and put on sterile gloves
• Clean the area with the cleaning solution and apply drapes
• Instil local anesthetic to the skin and subcutaneous tissues withdrawing the plunger prior to each injection to avoid intravenous injection and warning the patient to expect a
'sharp scratch'
• Immobilize the mass with your non-dominant hand
• Using your dominant hand, insert the needle through the skin into the lump, maintaining negative pressure on the plunger as you go
• Once in the lump, the needle may be moved gently back and forth to obtain a greater volume of cells
It may be necessary to insert the needle several times to obtain a sufficient sample
• Do not expect a large amount of material within the syringe! A tiny sample within the needle will usually suffice
• Remove the needle and send the sample for cytology (you will need to gently expel the sample from the needle into a suitable container)
• Apply a sterile dressing to the site.
Alternative Method
• There are two schools of thought in FNA
• Some practitioners use a small (blue) needle without a syringe attached. This is moved in and out very quickly within the mass whilst also applying rotation. Capillary action deposits a cellular sample within the needle which can then be gently expelled using an empty syringe
• This capillary action technique may result in a larger number of intact cells in the resultant sample as the negative pressure created when using a syringe can disrupt cell membranes.
Documentation
• Date and time
• Indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of puncture
• Aseptic technique used?
• How many passes?
• Volume and colour of sample obtained
• Any immediate complications
• Tests requested on resultant sample
• Signature, printed name, and contact details.
Indications
• Diagnosis of a lump; commonly thyroid and lymph node.
Contraindications
• Bleeding diathesis
• Overlying infection
• Adjacent vital structures. Image-guidance should always be used if available.
Risks
• Bleeding
• Local infection
• Damage to surrounding structures depending on site, e.g. blood vessels, nerves.
Procedure Tips
• © Radiological guidance should always be used if available
• Contact the histopathology department in advance to ensure appropriate transport medium is used. It may be possible to arrange immediate analysis, allowing diagnosis and repeat FNA if insufficient cells are obtained.
A method for obtaining a cytological sample of a mass lesion.
• This procedure should only be performed by, or under strict supervision of, an experienced practitioner.
• Fine-needle aspiration (FNA) usually takes place in the Radiology Department and is performed by an experienced Radiologist under ultrasound or CT guidance. The following describes the older, 'blind' technique.
Equipment
• Local anaesthetic (e.g. 1% lidocaine)
• Small-gauge (blue) needle and 10mL syringe
• Sterile pack
• Cleaning solution (e.g. chlorhexidine)
• Medium-gauge (green) needle
• 10mL or 20mL syringe for aspiration
• Sterile gloves.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient according to the biopsy site, allowing easy palpation of the mass
• Expose appropriately
• Wash your hands and put on sterile gloves
• Clean the area with the cleaning solution and apply drapes
• Instil local anesthetic to the skin and subcutaneous tissues withdrawing the plunger prior to each injection to avoid intravenous injection and warning the patient to expect a
'sharp scratch'
• Immobilize the mass with your non-dominant hand
• Using your dominant hand, insert the needle through the skin into the lump, maintaining negative pressure on the plunger as you go
• Once in the lump, the needle may be moved gently back and forth to obtain a greater volume of cells
It may be necessary to insert the needle several times to obtain a sufficient sample
• Do not expect a large amount of material within the syringe! A tiny sample within the needle will usually suffice
• Remove the needle and send the sample for cytology (you will need to gently expel the sample from the needle into a suitable container)
• Apply a sterile dressing to the site.
Alternative Method
• There are two schools of thought in FNA
• Some practitioners use a small (blue) needle without a syringe attached. This is moved in and out very quickly within the mass whilst also applying rotation. Capillary action deposits a cellular sample within the needle which can then be gently expelled using an empty syringe
• This capillary action technique may result in a larger number of intact cells in the resultant sample as the negative pressure created when using a syringe can disrupt cell membranes.
Documentation
• Date and time
• Indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site of puncture
• Aseptic technique used?
• How many passes?
• Volume and colour of sample obtained
• Any immediate complications
• Tests requested on resultant sample
• Signature, printed name, and contact details.
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Clinical Procedures - Lumbar Puncture
Indications
• In the diagnosis of meningitis, subarachnoid hemorrhage and other diseases including non-infective meningitis and Guillain- Barré syndrome
• Treatment (short term) of idiopathic intracranial hypertension:
• In this case, consider removing between 10-20mL of CSF.
Contraindications
• Infected skin or subcutis at the site of puncture
• Coagulopathy or thrombocytopenia
• Raised intracranial pressure, particularly where there is a differential pressure between the supra- and infratentorial compartments such as seen in space-occupying lesions. If in doubt, image first!
Risks
• Post-procedure headache
• Infection
• Haemorrhage (epidural, subdural, subarachnoid)
• Dysaesthesia of the lower limbs
• Cerebral herniation (always check local procedures regarding contraindication to lumbar puncture and whether to perform CT head first).
Procedure Tips
• Always use the smallest gauge spinal needle available:
• In some centres, 'pencil-point' needles are used which are associated with a much reduced incidence of post-procedure headache
• If the needle strikes bone and cannot be advanced, withdraw slightly, re-angle, and advance in a stepwise fashion until the gap is found
• Lumbar puncture can be performed with the patient sitting, leaning forwards. This is particularly useful if the patient is obese. However, pressure measurements will be erroneous if taken in this position.
Documentation
• Date, time, indication, and informed consent obtained
• Vertebral level needle inserted
• Number of passes before SF obtained
• Initial ('opening) pressure and final ('closing') pressure
• Amount and appearance of CSF
• Tests samples sent for
• Any immediate complications
• Signature, printed name and contact details.
Equipment
• Sterile gloves
• Sterile pack (containing drape, cotton balls, small bowl)
• Antiseptic solution (e.g. iodine)
• Sterile gauze dressing
• 1 × 25G (orange) needle
• 1 × 21G (green) needle
• Spinal needle (usually 22G)
• Lumbar-puncture manometer
• Three-way tap (may be included in a lumbar puncture kit)
• 5-10mL 1% lidocaine
• 2 × 10mL syringes
• 3 x sterile collection tubes and 1 biochemistry tube for glucose measurement.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Position the patient lying on their left-hand side with the neck, knees, and hips flexed as much as possible:
Ensure that the patient can hold this position comfortably
• Place a pillow between the patient's knees to prevent the pelvis tilting
• Label the collections tubes *1, 2°, and '3"
• Identify the iliac crest. The disc space vertically below this (as you are looking) will be ~L3-L4
• Mark the space between the vertebral spines at this point with a pen
• Wash hands and put on the sterile gloves
• Unwrap all equipment and ensure it fits together correctly:
• It is usually useful to give the 3-way tap a few twists as it can stick
• Apply the drapes around the area and sterilize with the antiseptic solution and cotton balls in outward-spiral motion
• Inject the lidocaine (using a 10mL syringe and the orange needle) at the marked site to raise a small wheal
• Swap the orange needle for the green one and infiltrate the lidocaine deeper. © Take care to aspirate before injecting to ensure blood vessels are avoided
• Wait for ~1 minute for the anaesthetic to take effect
• Introduce the spinal needle through the marked site at about 90° to the skin, heading slightly toward the umbilicus.
Keep the bevel facing cranially
• Gently advance the needle to ~5 cm depth
• At this point, a further slight push of the needle should produce a 'give as the needle enters the subarachnoid space (this takes a little practice to feel with confidence)
• Withdraw the stilette from the needle. CSF should begin to drip out
• Measure the CSF pressure: connect the manometer to the end of the needle via the 3-way tap (the CSF will rise up the manometer allowing you to read off the number)
• Turn the tap such that the CSF within the manometer pours out in a controlled manner and further CS can drip freely
• Collect about 5 or 6 drops into each collection tube in the order in which they have been labelled
• Collect a few more drops into the biochemistry tube for glucose measurement
• Close the tap so that the manometer will measure the pressure at the end of the collection ('closing pressure)
• Remove the needle, tap, and manometer in one action
• Apply a sterile dressing
• Send the fluid for analysis:
• Cell count (bottles 1 and 3)
• Microscopy, culture and sensitivities (bottles 1 and 3)
• Biochemistry: glucose (biochemistry tube), protein (bottle 2)
• Advise the patient to lie flat for ~1 hour and ask nursing staff to check CNS observations
Clinical Procedures - Lumbar Puncture
Indications
• In the diagnosis of meningitis, subarachnoid hemorrhage and other diseases including non-infective meningitis and Guillain- Barré syndrome
• Treatment (short term) of idiopathic intracranial hypertension:
• In this case, consider removing between 10-20mL of CSF.
Contraindications
• Infected skin or subcutis at the site of puncture
• Coagulopathy or thrombocytopenia
• Raised intracranial pressure, particularly where there is a differential pressure between the supra- and infratentorial compartments such as seen in space-occupying lesions. If in doubt, image first!
Risks
• Post-procedure headache
• Infection
• Haemorrhage (epidural, subdural, subarachnoid)
• Dysaesthesia of the lower limbs
• Cerebral herniation (always check local procedures regarding contraindication to lumbar puncture and whether to perform CT head first).
Procedure Tips
• Always use the smallest gauge spinal needle available:
• In some centres, 'pencil-point' needles are used which are associated with a much reduced incidence of post-procedure headache
• If the needle strikes bone and cannot be advanced, withdraw slightly, re-angle, and advance in a stepwise fashion until the gap is found
• Lumbar puncture can be performed with the patient sitting, leaning forwards. This is particularly useful if the patient is obese. However, pressure measurements will be erroneous if taken in this position.
Documentation
• Date, time, indication, and informed consent obtained
• Vertebral level needle inserted
• Number of passes before SF obtained
• Initial ('opening) pressure and final ('closing') pressure
• Amount and appearance of CSF
• Tests samples sent for
• Any immediate complications
• Signature, printed name and contact details.
Equipment
• Sterile gloves
• Sterile pack (containing drape, cotton balls, small bowl)
• Antiseptic solution (e.g. iodine)
• Sterile gauze dressing
• 1 × 25G (orange) needle
• 1 × 21G (green) needle
• Spinal needle (usually 22G)
• Lumbar-puncture manometer
• Three-way tap (may be included in a lumbar puncture kit)
• 5-10mL 1% lidocaine
• 2 × 10mL syringes
• 3 x sterile collection tubes and 1 biochemistry tube for glucose measurement.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Position the patient lying on their left-hand side with the neck, knees, and hips flexed as much as possible:
Ensure that the patient can hold this position comfortably
• Place a pillow between the patient's knees to prevent the pelvis tilting
• Label the collections tubes *1, 2°, and '3"
• Identify the iliac crest. The disc space vertically below this (as you are looking) will be ~L3-L4
• Mark the space between the vertebral spines at this point with a pen
• Wash hands and put on the sterile gloves
• Unwrap all equipment and ensure it fits together correctly:
• It is usually useful to give the 3-way tap a few twists as it can stick
• Apply the drapes around the area and sterilize with the antiseptic solution and cotton balls in outward-spiral motion
• Inject the lidocaine (using a 10mL syringe and the orange needle) at the marked site to raise a small wheal
• Swap the orange needle for the green one and infiltrate the lidocaine deeper. © Take care to aspirate before injecting to ensure blood vessels are avoided
• Wait for ~1 minute for the anaesthetic to take effect
• Introduce the spinal needle through the marked site at about 90° to the skin, heading slightly toward the umbilicus.
Keep the bevel facing cranially
• Gently advance the needle to ~5 cm depth
• At this point, a further slight push of the needle should produce a 'give as the needle enters the subarachnoid space (this takes a little practice to feel with confidence)
• Withdraw the stilette from the needle. CSF should begin to drip out
• Measure the CSF pressure: connect the manometer to the end of the needle via the 3-way tap (the CSF will rise up the manometer allowing you to read off the number)
• Turn the tap such that the CSF within the manometer pours out in a controlled manner and further CS can drip freely
• Collect about 5 or 6 drops into each collection tube in the order in which they have been labelled
• Collect a few more drops into the biochemistry tube for glucose measurement
• Close the tap so that the manometer will measure the pressure at the end of the collection ('closing pressure)
• Remove the needle, tap, and manometer in one action
• Apply a sterile dressing
• Send the fluid for analysis:
• Cell count (bottles 1 and 3)
• Microscopy, culture and sensitivities (bottles 1 and 3)
• Biochemistry: glucose (biochemistry tube), protein (bottle 2)
• Advise the patient to lie flat for ~1 hour and ask nursing staff to check CNS observations
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Clinical Procedures - Male Urethral Catheterization
Indications
• Relief of acute urinary retention
• Accurate monitoring of urine output in the acutely unwell/those undergoing surgery
• Prevention of complications of chronic urinary retention (e.g. neurological; consider long-term alternatives)
• Urinary incontinence (consider alternatives e.g. convene/pad).
Contraindications
• Urethral/prostatic injury.
Risks
• Urinary tract infection
• Septicaemia
Pain
• Haematuria
• Creation of a 'false passage' through prostate
• Urethral trauma
• © Beware latex allergy.
Procedure Tips
• Difficulty passing an enlarged prostate is a common problem. Tricks to try to ease the catheter past include:
• Ensure the catheter is adequately lubricated
• Try moving the penis to a horizontal position between the patient's legs as prostatic resistance is reached
• Ask the patient to wiggle his toes
• Rotate the catheter back and forth as it advances
• If catheter fails to pass, consider using larger bore catheter (e.g. 16F
instead of 14F) as this may prevent coiling in the urethra
• If urine fails to drain despite the catheter being fully advanced:
•Palpate the bladder: if palpable, the catheter is inappropriately placed
• Manual pressure on the bladder may express enough urine from a near-empty bladder to show itself
• Aspirate with a bladder syringe, or flush with a little sterile saline
• D If it is impossible to pass the catheter, ask for help. If all else fails, it may be necessary to proceed to suprapubic catheterization.
Equipment
• Foley catheter (male) of appropriate French, usually 12-14
• 10mL syringe of sterile water
• Syringe of lidocaine gel 1% (e.g. Instilligel®
• Catheter bag
• Sterile gloves
• Catheter pack containing drape, kidney dish, swabs/cotton balls. and a small dish
• Sterile water/chlorhexidine sachet.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient lying supine with the external genitalia uncovered:
• Uncover from umbilicus to knees
• Using aseptic technique, unwrap the equipment and pour the chlorhexidine or sterile water into the dish
• Wash your hands and put on the sterile gloves
• Tear a hole in the middle of the drape and place it over the genitals so as to allow access to the penis
• Use your non-dominant hand to hold the penis upright
• Withdraw the foreskin and clean around the urethral meatus using the water/chlorhexidine and a swab, moving from the centre outwards
• Instil local anaesthetic via urethral meatus, with the penis held vertically. Wait at least 1 minute for the anaesthetic to act
• Place the kidney bowl between the patient's this
• Remove the tip of the plastic sheath containing being careful not to touch the catheter itself
• Insert catheter into urethra, feeding it out of the plastic wrapper as it is advanced
• Insert the catheter to the 'hilt':
• If the catheter will not advance fully, don't force it.
Withdraw a little, extend the penis fully and carefully try again. See 'tips' for more advice
• At this point, urine may begin to drain:
• Let the end of the catheter rest in the kidney bowl to catch any spills
• Inflate the balloon using sterile water inserted into the catheter side-arm according to the balloon's capacity (written on the cuff of the balloon lumen)
• Watch the patient's face and ask them to warn you if they feel pain
• Once the balloon is inflated, remove the syringe and attach the catheter bag
• Gently pull the catheter until you feel resistance as the balloon rests against the bladder neck
• Replace the foreskin (this is essential to prevent paraphimosis)
• Re-dress the patient appropriately.
Documentation
• Date and time
• Indication, informed consent obtained
• Size of catheter inserted
• Aseptic technique used?
• Volume of water used to inflate the balloon
• Residual volume of urine obtained
• Foreskin replaced?
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Relief of acute urinary retention
• Accurate monitoring of urine output in the acutely unwell/those undergoing surgery
• Prevention of complications of chronic urinary retention (e.g. neurological; consider long-term alternatives)
• Urinary incontinence (consider alternatives e.g. convene/pad).
Contraindications
• Urethral/prostatic injury.
Risks
• Urinary tract infection
• Septicaemia
Pain
• Haematuria
• Creation of a 'false passage' through prostate
• Urethral trauma
• © Beware latex allergy.
Procedure Tips
• Difficulty passing an enlarged prostate is a common problem. Tricks to try to ease the catheter past include:
• Ensure the catheter is adequately lubricated
• Try moving the penis to a horizontal position between the patient's legs as prostatic resistance is reached
• Ask the patient to wiggle his toes
• Rotate the catheter back and forth as it advances
• If catheter fails to pass, consider using larger bore catheter (e.g. 16F
instead of 14F) as this may prevent coiling in the urethra
• If urine fails to drain despite the catheter being fully advanced:
•Palpate the bladder: if palpable, the catheter is inappropriately placed
• Manual pressure on the bladder may express enough urine from a near-empty bladder to show itself
• Aspirate with a bladder syringe, or flush with a little sterile saline
• D If it is impossible to pass the catheter, ask for help. If all else fails, it may be necessary to proceed to suprapubic catheterization.
Equipment
• Foley catheter (male) of appropriate French, usually 12-14
• 10mL syringe of sterile water
• Syringe of lidocaine gel 1% (e.g. Instilligel®
• Catheter bag
• Sterile gloves
• Catheter pack containing drape, kidney dish, swabs/cotton balls. and a small dish
• Sterile water/chlorhexidine sachet.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient lying supine with the external genitalia uncovered:
• Uncover from umbilicus to knees
• Using aseptic technique, unwrap the equipment and pour the chlorhexidine or sterile water into the dish
• Wash your hands and put on the sterile gloves
• Tear a hole in the middle of the drape and place it over the genitals so as to allow access to the penis
• Use your non-dominant hand to hold the penis upright
• Withdraw the foreskin and clean around the urethral meatus using the water/chlorhexidine and a swab, moving from the centre outwards
• Instil local anaesthetic via urethral meatus, with the penis held vertically. Wait at least 1 minute for the anaesthetic to act
• Place the kidney bowl between the patient's this
• Remove the tip of the plastic sheath containing being careful not to touch the catheter itself
• Insert catheter into urethra, feeding it out of the plastic wrapper as it is advanced
• Insert the catheter to the 'hilt':
• If the catheter will not advance fully, don't force it.
Withdraw a little, extend the penis fully and carefully try again. See 'tips' for more advice
• At this point, urine may begin to drain:
• Let the end of the catheter rest in the kidney bowl to catch any spills
• Inflate the balloon using sterile water inserted into the catheter side-arm according to the balloon's capacity (written on the cuff of the balloon lumen)
• Watch the patient's face and ask them to warn you if they feel pain
• Once the balloon is inflated, remove the syringe and attach the catheter bag
• Gently pull the catheter until you feel resistance as the balloon rests against the bladder neck
• Replace the foreskin (this is essential to prevent paraphimosis)
• Re-dress the patient appropriately.
Documentation
• Date and time
• Indication, informed consent obtained
• Size of catheter inserted
• Aseptic technique used?
• Volume of water used to inflate the balloon
• Residual volume of urine obtained
• Foreskin replaced?
• Any immediate complications
• Signature, printed name, and contact details.
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Clinical Procedures- Intravenous (via cannula)
Intravenous injections can be administered by puncturing the vein with a needle and syringe and injecting directly. The procedure below describes injecting via an intravenous cannula. If no cannula in place, cannulate first.
Ensure that you comply with the local policy regarding drug administration. In hospital, two healthcare professionals should usually check and administer medication.
Equipment
• Appropriate syringe (dependent upon quantity of drug to be administered)
• Prescribed drug
• Saline flush (10mL syringe with sterile saline)
• Prescription chart
• Antiseptic swab.
Procedure
• Assess patient for drugs required (i.e. for pain relief, vomiting etc.)
• Refer to prescription chart, double-checking the appropriate drugs and dosage to be given:
•Always ensure you are fully aware of any possible side effects of any drugs you are due to administer
•Double-check the prescription chart for date and appropriate route for administration
•Check administration of previous dose not tOn after last dose?
•Ensure that the drug to be given is within its use
•Check patient and chart for any evidence of allergie relevant drug reactions
• Always comply with the local hand-hygiene practices
Once checked by suitably qualified staff take drug and prescription chart to the patient
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Check with patient: name and date of birth (if capable):
• If incapable, check name band with another healthcare professional
• © The patient may need to be assisted to change position, if unable to move themselves, and to enable access to an appropriate site
• Cleanse the cannula port with the antiseptic wipe
• Attach the saline flush to the syringe port and inject a few mL to check patency of the cannula:
• D Watch for a bleb forming as consequence of extravasation
• If no problems are encountered, swap the flush for the drug-containing syringe and inject drug slowly
• To finish, inject a few more mL of saline into the cannula port and re-attach the bung
• Once the procedure is completed without complication, withdraw needle and discard into a sharps bin
• Monitor patient for any negative effects of the drug.
Intravenous injections can be administered by puncturing the vein with a needle and syringe and injecting directly. The procedure below describes injecting via an intravenous cannula. If no cannula in place, cannulate first.
Ensure that you comply with the local policy regarding drug administration. In hospital, two healthcare professionals should usually check and administer medication.
Equipment
• Appropriate syringe (dependent upon quantity of drug to be administered)
• Prescribed drug
• Saline flush (10mL syringe with sterile saline)
• Prescription chart
• Antiseptic swab.
Procedure
• Assess patient for drugs required (i.e. for pain relief, vomiting etc.)
• Refer to prescription chart, double-checking the appropriate drugs and dosage to be given:
•Always ensure you are fully aware of any possible side effects of any drugs you are due to administer
•Double-check the prescription chart for date and appropriate route for administration
•Check administration of previous dose not tOn after last dose?
•Ensure that the drug to be given is within its use
•Check patient and chart for any evidence of allergie relevant drug reactions
• Always comply with the local hand-hygiene practices
Once checked by suitably qualified staff take drug and prescription chart to the patient
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Check with patient: name and date of birth (if capable):
• If incapable, check name band with another healthcare professional
• © The patient may need to be assisted to change position, if unable to move themselves, and to enable access to an appropriate site
• Cleanse the cannula port with the antiseptic wipe
• Attach the saline flush to the syringe port and inject a few mL to check patency of the cannula:
• D Watch for a bleb forming as consequence of extravasation
• If no problems are encountered, swap the flush for the drug-containing syringe and inject drug slowly
• To finish, inject a few more mL of saline into the cannula port and re-attach the bung
• Once the procedure is completed without complication, withdraw needle and discard into a sharps bin
• Monitor patient for any negative effects of the drug.
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Clinical Procedures - Venous Sampling from a Central Venous Catheter
The following describes venous blood sampling from a line in the internal jugular vein. The principles are the same for a line at any site.
Equipment
• 3 × 10mL syringes
• 0.9% isotonic or heparinized saline
• Chlorhexidine or iodine solution
• Sterile gauze
• Sterile gloves and apron
• Sterile drape.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Stop any infusions (if possible) for at least 1 minute before sampling
• Place the patient in a supine position
• Ask the patient to turn their head away from the line site during the procedure
• Drape the site and put on a pair of sterile gloves and apron
• Spray the line end with the chlorhexidine solution or wipe with gauze dipped in iodine
• Clamp the line port and remove the cap, if present
• Connect a 10mL syringe to the port and then unclamp
• Withdraw 5-10mL of blood, clamp the line and ren syringe
• Discard the blood
• Repeat the procedure with a new syringe, withdrawing tomL.
• Clamp the line, disconnect the syringe. Keep this sample!
• Fill the final syringe with saline and attach it to the port
• Unclamp the port and instil the saline. Clamp the port again before disconnecting the syringe
• Replace the port cap.
Risks
• Clot or infection in the line
• Air embolus
• Physical damage to the line: burst or torn port.
Central venous lines should only be used for blood sampling if it is not possible to obtain a sample via the peripheral route. Do not risk catheter sepsis or a clotted line unless there are no alternatives!
Procedure Tips
• Always be sure to clamp the port before removing the syringe and unclamp before withdrawing blood or instilling the saline
• Most central lines have several ports: which should I use?
• Blood should ideally be sampled from the port with its hole at the tip of the line this is often the brown port
• Check the ports: most will have the gauge printed on them, choose the largest gauge port available
• Be sure to remove any bubbles from the saline before instilling
• Infusions must be stopped: otherwise a significant portion of the sample obtained may be the solution that is entering via the other port giving inaccurate results at analysis!
The following describes venous blood sampling from a line in the internal jugular vein. The principles are the same for a line at any site.
Equipment
• 3 × 10mL syringes
• 0.9% isotonic or heparinized saline
• Chlorhexidine or iodine solution
• Sterile gauze
• Sterile gloves and apron
• Sterile drape.
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Stop any infusions (if possible) for at least 1 minute before sampling
• Place the patient in a supine position
• Ask the patient to turn their head away from the line site during the procedure
• Drape the site and put on a pair of sterile gloves and apron
• Spray the line end with the chlorhexidine solution or wipe with gauze dipped in iodine
• Clamp the line port and remove the cap, if present
• Connect a 10mL syringe to the port and then unclamp
• Withdraw 5-10mL of blood, clamp the line and ren syringe
• Discard the blood
• Repeat the procedure with a new syringe, withdrawing tomL.
• Clamp the line, disconnect the syringe. Keep this sample!
• Fill the final syringe with saline and attach it to the port
• Unclamp the port and instil the saline. Clamp the port again before disconnecting the syringe
• Replace the port cap.
Risks
• Clot or infection in the line
• Air embolus
• Physical damage to the line: burst or torn port.
Central venous lines should only be used for blood sampling if it is not possible to obtain a sample via the peripheral route. Do not risk catheter sepsis or a clotted line unless there are no alternatives!
Procedure Tips
• Always be sure to clamp the port before removing the syringe and unclamp before withdrawing blood or instilling the saline
• Most central lines have several ports: which should I use?
• Blood should ideally be sampled from the port with its hole at the tip of the line this is often the brown port
• Check the ports: most will have the gauge printed on them, choose the largest gauge port available
• Be sure to remove any bubbles from the saline before instilling
• Infusions must be stopped: otherwise a significant portion of the sample obtained may be the solution that is entering via the other port giving inaccurate results at analysis!
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Surgery - Arteriovenous Fistulae and Malformations
Introduction
An irregular link between an artery and vein that avoids the capillary bed is called an arteriovenous fistula.
vascular malformations: Deformity exhibiting typical endothelium.
Angioma/hemangioma: Deformity characterized by endothelial hyperplasia.
Etiology
Congenital: categorized into malformations (AVMs) and haemangiomas (strawberry naevi, for example). The latter is separated into high flow and low flow types (such as pulmonary or hepatic AVM;
genetic: AVMs and haemangiomas are linked to a variety of genetic disorders, including hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) and Klippel–Trenaunay, Kasabach–Merritt, Sturge–Weber, and von Hippel–Lindau.
Aorto-venocaval fistula, glomus tumor, hypernephroma, sarcomas, infections, inflammations, or iatrogenic conditions (e.g., Brescia-Cimino fistula for hemodialysate or portocaval shunt in portal hypertension) are examples of acquired conditions.
Epidemiology
The others are less prevalent than cutaneous haemangiomas.
History
Depending on the location and extent of the AVM, symptoms might manifest differently and may result from either local or systemic effects (see Complications).
Congenital cutaneous haemangiomas frequently become apparent at birth or shortly thereafter.
Typically, malformations enlarge with aging, puberty, or pregnancy.
Internal organs may not exhibit symptoms until issues arise.
Other symptoms could be discomfort or swelling in the limbs, or varicose veins.
Examination
Cutaneous haemangiomas, also known as Campbell de Morgan spots, are often firm, crimson in color, and blood-filled when compressed.
An overlaying bruit or palpable thrill, possibly accompanied by decreased distal pulses and increased pulse pressure, may indicate the presence of internal AVMs.
Investigational studies
AVM imaging: Depending on where the lesion is located. Among the modalities employed are invasive angiography, CT or MRI scanning, and duplex scanning.
SPECT scan: Radiolabelled microspheres that are too big to go through capillaries are injected into an artery to quantify AV shunting. Using a gamma camera, those going through AVMs are trapped in the lungs and measured.
Management
Conservative: By the end of the first year of life, cutaneous haemangiomas typically spontaneously recede. Internal organ AVMs can be watched and may not require treatment.
Interventional radiology: Metal coils, tissue adhesive, or particles can be used to embolize internal AVMs or fistulae.
Surgery: Excision (following pre-operative embolization) is often challenging, although it is a possibility for small and easily accessible AVMs.
Useful for tiny AVMs, stereotactic radiosurgery may take years to fully manifest.
Complications
Cutaneous: bleeding, ulcers, and cosmetic deformity.
Organ-specific: For example, lung AVMs might result in hemoptysis or paradoxical embolism; brain AVMs can induce localized neurological impairments, convulsions, or stroke.
Peripheral tissue ischemia is considered distal.
Systemic: When there are significant AVMs, high-output heart failure may occur.
Prognosis
Depending on the aetiology and site. 90% of haemangiomas regress over a period of 5 to 10 years, while cerebral AVMs carry a 1-4 percent yearly risk of hemorrhage.
Introduction
An irregular link between an artery and vein that avoids the capillary bed is called an arteriovenous fistula.
vascular malformations: Deformity exhibiting typical endothelium.
Angioma/hemangioma: Deformity characterized by endothelial hyperplasia.
Etiology
Congenital: categorized into malformations (AVMs) and haemangiomas (strawberry naevi, for example). The latter is separated into high flow and low flow types (such as pulmonary or hepatic AVM;
genetic: AVMs and haemangiomas are linked to a variety of genetic disorders, including hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) and Klippel–Trenaunay, Kasabach–Merritt, Sturge–Weber, and von Hippel–Lindau.
Aorto-venocaval fistula, glomus tumor, hypernephroma, sarcomas, infections, inflammations, or iatrogenic conditions (e.g., Brescia-Cimino fistula for hemodialysate or portocaval shunt in portal hypertension) are examples of acquired conditions.
Epidemiology
The others are less prevalent than cutaneous haemangiomas.
History
Depending on the location and extent of the AVM, symptoms might manifest differently and may result from either local or systemic effects (see Complications).
Congenital cutaneous haemangiomas frequently become apparent at birth or shortly thereafter.
Typically, malformations enlarge with aging, puberty, or pregnancy.
Internal organs may not exhibit symptoms until issues arise.
Other symptoms could be discomfort or swelling in the limbs, or varicose veins.
Examination
Cutaneous haemangiomas, also known as Campbell de Morgan spots, are often firm, crimson in color, and blood-filled when compressed.
An overlaying bruit or palpable thrill, possibly accompanied by decreased distal pulses and increased pulse pressure, may indicate the presence of internal AVMs.
Investigational studies
AVM imaging: Depending on where the lesion is located. Among the modalities employed are invasive angiography, CT or MRI scanning, and duplex scanning.
SPECT scan: Radiolabelled microspheres that are too big to go through capillaries are injected into an artery to quantify AV shunting. Using a gamma camera, those going through AVMs are trapped in the lungs and measured.
Management
Conservative: By the end of the first year of life, cutaneous haemangiomas typically spontaneously recede. Internal organ AVMs can be watched and may not require treatment.
Interventional radiology: Metal coils, tissue adhesive, or particles can be used to embolize internal AVMs or fistulae.
Surgery: Excision (following pre-operative embolization) is often challenging, although it is a possibility for small and easily accessible AVMs.
Useful for tiny AVMs, stereotactic radiosurgery may take years to fully manifest.
Complications
Cutaneous: bleeding, ulcers, and cosmetic deformity.
Organ-specific: For example, lung AVMs might result in hemoptysis or paradoxical embolism; brain AVMs can induce localized neurological impairments, convulsions, or stroke.
Peripheral tissue ischemia is considered distal.
Systemic: When there are significant AVMs, high-output heart failure may occur.
Prognosis
Depending on the aetiology and site. 90% of haemangiomas regress over a period of 5 to 10 years, while cerebral AVMs carry a 1-4 percent yearly risk of hemorrhage.
