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Clinical Procedures - Vagal Maneouvres
Background
The Purpose
• Vagal manoeuvres can be used to determine the underlying rhythm or terminate SVT in haemodynamically stable patients. If the underlying rhythm is atrial flutter, slowing of the ventricular response by increasing vagal tone will reveal flutter waves
• Vagal manoeuvres are part of the adult peri-arrest algorithm for management of narrow complex tachycardia. They can be performed in a controlled clinical situation (i.e. attached to an ECG machine), or taught to the patient to perform at home if the sensation of the arrhythmia reoccurs.
Physiology
• Vagal manoeuvres increase vagal tone by activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve
• Increasing vagal tone impedes the AV node and so slows transmission of the electrical impulse from the atria to the ventricle. In this way any SVT that relies upon the AV node will be modified by an increase in vagal tone.
Background
The Purpose
• Vagal manoeuvres can be used to determine the underlying rhythm or terminate SVT in haemodynamically stable patients. If the underlying rhythm is atrial flutter, slowing of the ventricular response by increasing vagal tone will reveal flutter waves
• Vagal manoeuvres are part of the adult peri-arrest algorithm for management of narrow complex tachycardia. They can be performed in a controlled clinical situation (i.e. attached to an ECG machine), or taught to the patient to perform at home if the sensation of the arrhythmia reoccurs.
Physiology
• Vagal manoeuvres increase vagal tone by activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve
• Increasing vagal tone impedes the AV node and so slows transmission of the electrical impulse from the atria to the ventricle. In this way any SVT that relies upon the AV node will be modified by an increase in vagal tone.
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Clinical Procedures - The Valsalva manoeuvre
• This is forced expiration against a closed glottis. Increasing intrathoracic pressure stimulates baroreceptors in the aortic arch and results in increased vagal stimulation
• This can be successful in 25-50% of cases.
Procedure
• Ask the patient to take a deep breath in and then 'bear down' as if they are trying to open their bowels (or for women, as if they are in labour)
Some patients may struggle with this concept and so alternatively:
• Give them a 10mL syringe and ask them to blow into the tip, in an attempt to expel the plunger.
Showing off
The technique is named after Antonio Maria Valsalva a 17th-century physician from Bologna, who was mainly interested in the workings of the ear. He first described the manoeuvre with regard to testing the patency of the Eustachian tubes.
The Diving Reflex
• This involves either submerging the face in ice cold water (not very practical or covering the face with a towel soaked in ice cold water.
Carotid Sinus Massage
• This is described separately (see topic).
Eyeball Pressure
•This is not recommended as a clinical procedure as it can be both painful and damaging. Do NOT perform.
• This is forced expiration against a closed glottis. Increasing intrathoracic pressure stimulates baroreceptors in the aortic arch and results in increased vagal stimulation
• This can be successful in 25-50% of cases.
Procedure
• Ask the patient to take a deep breath in and then 'bear down' as if they are trying to open their bowels (or for women, as if they are in labour)
Some patients may struggle with this concept and so alternatively:
• Give them a 10mL syringe and ask them to blow into the tip, in an attempt to expel the plunger.
Showing off
The technique is named after Antonio Maria Valsalva a 17th-century physician from Bologna, who was mainly interested in the workings of the ear. He first described the manoeuvre with regard to testing the patency of the Eustachian tubes.
The Diving Reflex
• This involves either submerging the face in ice cold water (not very practical or covering the face with a towel soaked in ice cold water.
Carotid Sinus Massage
• This is described separately (see topic).
Eyeball Pressure
•This is not recommended as a clinical procedure as it can be both painful and damaging. Do NOT perform.
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Clinical Procedures – Defibrillation
Indications
• Elective cardioversion of atrial fibrillation
• Emergency cardioversion in a peri-arrest situation where a tachyarrhythmia is associated with adverse signs
• (See tachyarrhythmia algorithm by Resuscitation Council UK).
Equipment
The 'crash trolley' should contain all the equipment required:
• Gloves, aprons
• Defibrillator, pads, leads, ECG electrodes
• Oxygen, reservoir bag and mask with tubing, airways
• Intubation equipment
• IV fluids, giving sets, selection of syringes, needles, IV cannulas and fixation dressings
• Access to emergency drugs (e.g. atropine, adrenaline, amiodarone, magnesium sulphate).
Before You Start
The procedure is essentially the same whether it is performed electively or as an emergency. However, consider:
Elective procedure
• Obtain informed consent and save a copy of signed form
• Ensure patient fasted >6 hours
• Check serum potassium (>4.0mmol/L is associated with greater success)
• Confirm patient has been successfully anticoagulated for previous 4 weeks (INR >2):
• Warfarin is continued for 3 months post-procedure if successful
• The procedure should be performed in an anaesthetic room, following short-acting induction by an anaesthetist.
Emergency procedure
• Ensure a senior doctor is involved in the decision
• Ensure all other options have been tried or considered
• If possible, discuss with the patient or next of kin.
Procedure
• Ensure skin is dry, free of excess hair, jewellery is removed
• Attach the ECG electrodes; red under right clavicle, yellow under left clavicle, green at the umbilicus
• Switch on defibrillator
• Confirm the ECG rhythm
• Place the defibrillator gel pads on the patient's chest; one under the right clavicle and the other inferolateral to the cardiac ape
• Select the 'synchronous mode' on the defibrillator
• D Select the joules (J) required (see below)
• Place the paddles firmly on the chest on the gel pads
• Press the charge button on the paddles to charge the defibrillator and shout 'Stand clear! Charging!'
• Check all persons are standing well clear of the patient and bed (including yourself and that no one is touching the patient or bed (including yourself)
• Ensure the oxygen has been disconnected and removed
• I Check the monitor again to ensure a shockable rhythm
• Shout 'Stand clear! Shocking!'
• Press both discharge buttons on the paddles simultaneously to discharge the shock
• Return the paddles to the defibrillator or keep them on the chest if another shock is required.
Energy Selection
DC Cardioversion usually uses biphasic energies. A reasonable general guide is:
• 50] synchronized shock. If fails..
• 100] synchronized shock. If fails...
• 150] synchronized shock. If fails..
• 150J synchronized anteroposterior shock. If fails...
• Abandon procedure if elective, consult seniors if emergency (may need ICU input).
Contraindications
• Elective: patients unsuitable for general anesthetic, not anticoagulated or who have not signed a consent form
• Emergency: only performed when a tachyarrhythmia is associated with adverse events in the presence of a pulse (pulseless rhythms require management as per the resuscitation guidelines).
Risks
• General anaesthetic risk, if performed electively
• Embolic phenomenon, stroke, myocardial infarction.
Documentation
General
• Date, time and place. Name and grade of persons present
• ECG rhythm
• IV access secured
• Number, volume, dose of any drugs used, and any response noted
• Type of defibrillator machine used
• Method of sedation/anaesthetic
• Asynchronous or synchronous mode. Specify joules of each shock
• Confirm rhythm at end and 12-lead ECG findings
• Sign and bleep/contact details.
Elective
• Indication for DC cardioversion
• Informed consent obtained (retain copy of signed form)
• State time fasted from
• Document anticoagulation type and duration
• Serum potassium level
• Any drug allergies
• Name and grade of anaesthetist
• Type of anaesthetic used.
Emergency
• Events leading up to the peri-arrest situation
• HR, BP, Glasgow coma score on arrival and any deterioration
• Time of decision to shock, name and grade of decision-maker
• Verbal consent obtained?
• Type of sedation used
• Next of kin have been informed or if they are present or on route?
Indications
• Elective cardioversion of atrial fibrillation
• Emergency cardioversion in a peri-arrest situation where a tachyarrhythmia is associated with adverse signs
• (See tachyarrhythmia algorithm by Resuscitation Council UK).
Equipment
The 'crash trolley' should contain all the equipment required:
• Gloves, aprons
• Defibrillator, pads, leads, ECG electrodes
• Oxygen, reservoir bag and mask with tubing, airways
• Intubation equipment
• IV fluids, giving sets, selection of syringes, needles, IV cannulas and fixation dressings
• Access to emergency drugs (e.g. atropine, adrenaline, amiodarone, magnesium sulphate).
Before You Start
The procedure is essentially the same whether it is performed electively or as an emergency. However, consider:
Elective procedure
• Obtain informed consent and save a copy of signed form
• Ensure patient fasted >6 hours
• Check serum potassium (>4.0mmol/L is associated with greater success)
• Confirm patient has been successfully anticoagulated for previous 4 weeks (INR >2):
• Warfarin is continued for 3 months post-procedure if successful
• The procedure should be performed in an anaesthetic room, following short-acting induction by an anaesthetist.
Emergency procedure
• Ensure a senior doctor is involved in the decision
• Ensure all other options have been tried or considered
• If possible, discuss with the patient or next of kin.
Procedure
• Ensure skin is dry, free of excess hair, jewellery is removed
• Attach the ECG electrodes; red under right clavicle, yellow under left clavicle, green at the umbilicus
• Switch on defibrillator
• Confirm the ECG rhythm
• Place the defibrillator gel pads on the patient's chest; one under the right clavicle and the other inferolateral to the cardiac ape
• Select the 'synchronous mode' on the defibrillator
• D Select the joules (J) required (see below)
• Place the paddles firmly on the chest on the gel pads
• Press the charge button on the paddles to charge the defibrillator and shout 'Stand clear! Charging!'
• Check all persons are standing well clear of the patient and bed (including yourself and that no one is touching the patient or bed (including yourself)
• Ensure the oxygen has been disconnected and removed
• I Check the monitor again to ensure a shockable rhythm
• Shout 'Stand clear! Shocking!'
• Press both discharge buttons on the paddles simultaneously to discharge the shock
• Return the paddles to the defibrillator or keep them on the chest if another shock is required.
Energy Selection
DC Cardioversion usually uses biphasic energies. A reasonable general guide is:
• 50] synchronized shock. If fails..
• 100] synchronized shock. If fails...
• 150] synchronized shock. If fails..
• 150J synchronized anteroposterior shock. If fails...
• Abandon procedure if elective, consult seniors if emergency (may need ICU input).
Contraindications
• Elective: patients unsuitable for general anesthetic, not anticoagulated or who have not signed a consent form
• Emergency: only performed when a tachyarrhythmia is associated with adverse events in the presence of a pulse (pulseless rhythms require management as per the resuscitation guidelines).
Risks
• General anaesthetic risk, if performed electively
• Embolic phenomenon, stroke, myocardial infarction.
Documentation
General
• Date, time and place. Name and grade of persons present
• ECG rhythm
• IV access secured
• Number, volume, dose of any drugs used, and any response noted
• Type of defibrillator machine used
• Method of sedation/anaesthetic
• Asynchronous or synchronous mode. Specify joules of each shock
• Confirm rhythm at end and 12-lead ECG findings
• Sign and bleep/contact details.
Elective
• Indication for DC cardioversion
• Informed consent obtained (retain copy of signed form)
• State time fasted from
• Document anticoagulation type and duration
• Serum potassium level
• Any drug allergies
• Name and grade of anaesthetist
• Type of anaesthetic used.
Emergency
• Events leading up to the peri-arrest situation
• HR, BP, Glasgow coma score on arrival and any deterioration
• Time of decision to shock, name and grade of decision-maker
• Verbal consent obtained?
• Type of sedation used
• Next of kin have been informed or if they are present or on route?
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Clinical Procedures – Temporary External Pacing
This describes temporary transcutaneous pacing as an emergency.
Before You Start
• External pacing is usually performed in an emergency resuscitation situation following failure of response to initial management, as per the bradycardia algorithm from the Resuscitation Council (UK) at the end of this topic
• A senior doctor should be present and make the decision to proceed with external transcutaneous pacing
• There should be a plan in place for an experienced clinician to insert a temporary pacing wire within the next few hours. External pacing should only be a short-term management of decompensated bradycardia
• There should also be a bed available for the patient on a high-dependency unit or coronary care unit so that they can be closely monitored by experienced nursing staff whilst waiting for a temporary pacing wire. The patient should not be left on a general hospital ward.
Indications
• Symptomatic bradycardia unresponsive to treatment (see bradycardia algorithm)
• Mobitz type II block
• Complete heart block
• Heart block secondary to myocardial infarction
• Profound bradycardia secondary to drug overdose, e.g. beta blockers, digoxin
• systole or ventricular standstill
• External pacing can be used as overdrive pacing to terminate certain tachyarrhythmias that are unresponsive to initial treatment, e.g. polymorphic ventricular tachycardia (torsades de pointes) or refractory ventricular tachycardia.
Equipment
• Full resuscitation equipment: defibrillator with pacing setting
• Defibrillator pads
• Oxygen
• ECG monitoring
• Emergency drugs (including atropine and adrenaline)
• IV fluids
• Sedative drugs (e.g. midazolam or diazepam)
• Analgesia (e.g. morphine)
• Intubation equipment (in case indicated)
• Senior support.
Procedure
• The patient should already have:
• Large-bore IV access
• IV fluids running (unless in heart failure)
• Oxygen via a non-rebreathe mask at 15L/min
• ECG monitor connected and running
• Interval BP monitoring
• Place the pacing pads from the defibrillation kit on the patient's chest: one anteriorly in the V3 position and one posteriorly below the left scapula
• Sedation and analgesia may be required
• Attach the leads from the defibrillator to the pads
• Switch the defibrillator to its pacing mode.
Risks
• Failure and progression to temporary pacing wire insertion.
Documentation
Temporary external pacing is usually an emergency procedure so documentation may be delayed until the patient is stable. It should outline the resuscitation and external pacing simultaneously:
• Date and time
• Name and grade of persons present
•Events leading up to the need for external pacing
• Any drugs used, e.g. atropine or adrenaline, volume/ dose, and response
• Indication for external pacing
• If patient was conscious, document consent (usually verbal consent only)
• Any sedation used
• When external pacing commenced
• Details of plans for temporary pacing wire insertion
• Sign and bleep/contact details.
This describes temporary transcutaneous pacing as an emergency.
Before You Start
• External pacing is usually performed in an emergency resuscitation situation following failure of response to initial management, as per the bradycardia algorithm from the Resuscitation Council (UK) at the end of this topic
• A senior doctor should be present and make the decision to proceed with external transcutaneous pacing
• There should be a plan in place for an experienced clinician to insert a temporary pacing wire within the next few hours. External pacing should only be a short-term management of decompensated bradycardia
• There should also be a bed available for the patient on a high-dependency unit or coronary care unit so that they can be closely monitored by experienced nursing staff whilst waiting for a temporary pacing wire. The patient should not be left on a general hospital ward.
Indications
• Symptomatic bradycardia unresponsive to treatment (see bradycardia algorithm)
• Mobitz type II block
• Complete heart block
• Heart block secondary to myocardial infarction
• Profound bradycardia secondary to drug overdose, e.g. beta blockers, digoxin
• systole or ventricular standstill
• External pacing can be used as overdrive pacing to terminate certain tachyarrhythmias that are unresponsive to initial treatment, e.g. polymorphic ventricular tachycardia (torsades de pointes) or refractory ventricular tachycardia.
Equipment
• Full resuscitation equipment: defibrillator with pacing setting
• Defibrillator pads
• Oxygen
• ECG monitoring
• Emergency drugs (including atropine and adrenaline)
• IV fluids
• Sedative drugs (e.g. midazolam or diazepam)
• Analgesia (e.g. morphine)
• Intubation equipment (in case indicated)
• Senior support.
Procedure
• The patient should already have:
• Large-bore IV access
• IV fluids running (unless in heart failure)
• Oxygen via a non-rebreathe mask at 15L/min
• ECG monitor connected and running
• Interval BP monitoring
• Place the pacing pads from the defibrillation kit on the patient's chest: one anteriorly in the V3 position and one posteriorly below the left scapula
• Sedation and analgesia may be required
• Attach the leads from the defibrillator to the pads
• Switch the defibrillator to its pacing mode.
Risks
• Failure and progression to temporary pacing wire insertion.
Documentation
Temporary external pacing is usually an emergency procedure so documentation may be delayed until the patient is stable. It should outline the resuscitation and external pacing simultaneously:
• Date and time
• Name and grade of persons present
•Events leading up to the need for external pacing
• Any drugs used, e.g. atropine or adrenaline, volume/ dose, and response
• Indication for external pacing
• If patient was conscious, document consent (usually verbal consent only)
• Any sedation used
• When external pacing commenced
• Details of plans for temporary pacing wire insertion
• Sign and bleep/contact details.
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Clinical Procedures - Turbohaler
Dry powder device with preloaded tasteless drug. There is no dose counter, but a window that turns red after 20 doses.
The device is empty when there is red at the bottom of the window. Those with impaired dexterity may find the inhaler difficult to use.
How to use
• Unscrew and remove the white cover
• Hold the inhaler upright and prime the device by twisting the grip clockwise and anticlockwise as far as it will go (until you hear a click)
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• 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
• The device must be primed again between successive doses.
Procedure Tip
• Advise the patient that they will not feel the dose hit the back of their throat. Patients used to an MDI may find this off-putting.
Dry powder device with preloaded tasteless drug. There is no dose counter, but a window that turns red after 20 doses.
The device is empty when there is red at the bottom of the window. Those with impaired dexterity may find the inhaler difficult to use.
How to use
• Unscrew and remove the white cover
• Hold the inhaler upright and prime the device by twisting the grip clockwise and anticlockwise as far as it will go (until you hear a click)
• Sit upright, breathe out completely, and insert mouthpiece, sealing with lips
• 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
• The device must be primed again between successive doses.
Procedure Tip
• Advise the patient that they will not feel the dose hit the back of their throat. Patients used to an MDI may find this off-putting.
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Clinical Procedures - Clickhaler
Disposable dry-powder inhaler with dose meter which turns red when only 10 doses are left to use. The inhaler locks when empty so patients can be sure that they have taken a dose.
How to use
• Take only one dose at a time
• Remove the cap and shake
• Whilst holding inhaler upright, depress the button firmly and release until you hear a click
• Sit upright, breathe out completely, and insert mouthpiece sealing with lips
• Inhale deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose and repeat above as
necessary
• Replace cap.
Disposable dry-powder inhaler with dose meter which turns red when only 10 doses are left to use. The inhaler locks when empty so patients can be sure that they have taken a dose.
How to use
• Take only one dose at a time
• Remove the cap and shake
• Whilst holding inhaler upright, depress the button firmly and release until you hear a click
• Sit upright, breathe out completely, and insert mouthpiece sealing with lips
• Inhale deeply
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• Recover before taking the next dose and repeat above as
necessary
• Replace cap.
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Clinical Procedures - HandiHaler
A dry-powder device with an integrated cap. This requires a lower inspiratory flow rate than other devices. However, a dose needs to be inserted via a capsule at each use requiring some dexterity. Patients may also find the cap rather hard to open as it requires a moderate amount of strength.
How to use
• Open cap by pulling upwards exposing mouthpiece
• Open the mouthpiece by pulling upwards exposing the dose chamber
• Take a capsule from the blister-pack and insert it into the chamber
• Replace the mouthpiece (it should click shut)
• Press the side button in a few times to pierce the capsule (you can watch through the small window
• Sit upright, hold head up, and breathe out
• Seal lips around mouthpiece
• Breathe in deeply to a full breath
• Remove inhaler and hold breath for as long as is comfortable
• Remove the used capsule and replace the cap.
A dry-powder device with an integrated cap. This requires a lower inspiratory flow rate than other devices. However, a dose needs to be inserted via a capsule at each use requiring some dexterity. Patients may also find the cap rather hard to open as it requires a moderate amount of strength.
How to use
• Open cap by pulling upwards exposing mouthpiece
• Open the mouthpiece by pulling upwards exposing the dose chamber
• Take a capsule from the blister-pack and insert it into the chamber
• Replace the mouthpiece (it should click shut)
• Press the side button in a few times to pierce the capsule (you can watch through the small window
• Sit upright, hold head up, and breathe out
• Seal lips around mouthpiece
• Breathe in deeply to a full breath
• Remove inhaler and hold breath for as long as is comfortable
• Remove the used capsule and replace the cap.
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Clinical Procedures - Spacer-Devices
A chamber through which the drug passes prior to inhalation, with a one-way valve at the mouthpiece. By slowing the velocity of aerosol ejected by the MDI, spacers reduce residue in the mouth and increase delivery to the lungs. They also reduce the coordination required for effective drug delivery using the MDI alone. They are, therefore, useful in children, the elderly and during acute exacerbations. Spacers can be bulky and need frequent cleaning.
Adult spacers
• Remove cap from inhaler and shake
• Insert into end of spacer
• Sit upright, breathe out completely, and insert mouthpiece of spacer, sealing with lips
• Depress the canister once
• Take a deep breath:
• Small volume spacers will whistle if inhaling too quickly
• Hold your breath for 10 seconds or as long as is comfortable
• Remove the spacer and exhale
• Recover before taking the next dose.
Spacer with mask (young children)
• Remove cap from inhaler and shake
• Insert into end of spacer
• Place mask over mouth and nose of child
• Encourage child to breathe normally
• Once breathing pattern established, depress the canister
once
• Allow child to breathe in and out a further 5 times
• Allow child time to recover before giving the next dose:
• D A similar 'multiple breath' technique can be used in adults.
A chamber through which the drug passes prior to inhalation, with a one-way valve at the mouthpiece. By slowing the velocity of aerosol ejected by the MDI, spacers reduce residue in the mouth and increase delivery to the lungs. They also reduce the coordination required for effective drug delivery using the MDI alone. They are, therefore, useful in children, the elderly and during acute exacerbations. Spacers can be bulky and need frequent cleaning.
Adult spacers
• Remove cap from inhaler and shake
• Insert into end of spacer
• Sit upright, breathe out completely, and insert mouthpiece of spacer, sealing with lips
• Depress the canister once
• Take a deep breath:
• Small volume spacers will whistle if inhaling too quickly
• Hold your breath for 10 seconds or as long as is comfortable
• Remove the spacer and exhale
• Recover before taking the next dose.
Spacer with mask (young children)
• Remove cap from inhaler and shake
• Insert into end of spacer
• Place mask over mouth and nose of child
• Encourage child to breathe normally
• Once breathing pattern established, depress the canister
once
• Allow child to breathe in and out a further 5 times
• Allow child time to recover before giving the next dose:
• D A similar 'multiple breath' technique can be used in adults.
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Clinical Procedures - Nasogastric Tube Insertion
Indications
• Feeding in patients with poor swallow (e.g. post cerebrovascular accident)
• Lavage of gastric contents in poisoning
• Postoperative for stomach decompression
• Bowel obstruction.
Contraindications
• Oesophageal stricture, obstructing tumour
• Tracheo-oesophageal fistula
• Achalasia cardia
• Deviated nasal septum
• Fractured base of skull
Risks
• Malpositioning in a lung
• Trauma to the nasal and/or pharyngeal cavities
• Perforation of esophagus.
Procedure Tips
•Medications such as proton pump inhibitors and acid suppressing drugs may elevate the pH of the aspirate giving a 'false-negative result.
If in doubt, request a chest radiograph before using
• Low pH-fluid may also be aspirated from the lung in cases of aspirated stomach contents. If in doubt, request a chest radiograph before using
• Chest radiography should be performed routinely in high-risk patients (those that are unconscious, intubated or have poor swallow)
• The absence of cough reflex does not rule out misplacement of the tube in the airways
• Auscultation for gurgling in the stomach is not a recommended method for confirming position.
Equipment
• Lubricant (e.g. Aquagel®)
• pH-testing strips
• 50mL syringe
• Gallipots
• Dressing pack
• Nasogastric tube (12-18 French size)
• Hypoallergenic tape
• Sterile gauze
• Gloves
• Disposable bowl.
Procedure
• Introduce yourself, confirm the patient's identity
• Explain the procedure to the patient, stating that it may be uncomfortable and can cause gagging, which is transient
• Make sure that the patient understands the procedure and agree a signal to be made if patient wants to you stop (e.g. raising hand)
• To estimate the length of the tube required, measure the distance from the bridge of the nose to the tip of the earlobe and then to the xiphoid process
• Position the patient semi-upright:
• If unconscious, place the patient on their side
• Check the patency of the nostrils and select a suitable side
• Wash hands and put on gloves
• Unwrap the tube and lubricate the tip by wiping it through a blob of lubricating gel
• Insert the tip of the tube in the nostril and advance the tube horizontally along the floor of the nasal cavity in a backward and downward direction
• As the tube passes into the nasopharynx, ask the patient to swallow if they are able to do so:
• Using a cup of water and straw often helps here
• If there is any obstruction felt during advancement, withdraw and try in the other nostril
• © Watch for any signs of distress; namely cough or cyanosis and remove the tube immediately if any of these occur
• Once the tube has reached the measured distance, secure it in place with the tape:
• The gastro-oesophageal junction is generally 38-42cm from the nostril so advancement of the tube 55-60cm from the nostril usually positions the nasogastric tube tip within the stomach.
• Aspirate a sample of fluid using a syringe
• Place the aspirate on a pH-testing strip:
• D A pH of 5.5 or less suggests that the tube is in the
stomach
• If no aspirate obtained, change position and try again. If still unsuccessful, perform chest radiography to confirm position:
• Be sure to leave the internal wire in the tube if you are sending the patient to x-ray. The tube itself is not radio-opaque and will be invisible on the resultant image
• Once satisfied that the tube lies within the stomach, remove the inner wire and secure the tube to the tip of the nose:
• It is sometimes helpful to curve the remainder of the tube towards the ear and secure to the cheek also.
Documentation
• Date, time, indication, informed consent obtained
• Size of tube inserted
• Length of tube internally (there are markings on the tube:
• This is important to allow other staff to assess whether the tube has moved in or out since insertion
• Method by which correct placement was confirmed
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Feeding in patients with poor swallow (e.g. post cerebrovascular accident)
• Lavage of gastric contents in poisoning
• Postoperative for stomach decompression
• Bowel obstruction.
Contraindications
• Oesophageal stricture, obstructing tumour
• Tracheo-oesophageal fistula
• Achalasia cardia
• Deviated nasal septum
• Fractured base of skull
Risks
• Malpositioning in a lung
• Trauma to the nasal and/or pharyngeal cavities
• Perforation of esophagus.
Procedure Tips
•Medications such as proton pump inhibitors and acid suppressing drugs may elevate the pH of the aspirate giving a 'false-negative result.
If in doubt, request a chest radiograph before using
• Low pH-fluid may also be aspirated from the lung in cases of aspirated stomach contents. If in doubt, request a chest radiograph before using
• Chest radiography should be performed routinely in high-risk patients (those that are unconscious, intubated or have poor swallow)
• The absence of cough reflex does not rule out misplacement of the tube in the airways
• Auscultation for gurgling in the stomach is not a recommended method for confirming position.
Equipment
• Lubricant (e.g. Aquagel®)
• pH-testing strips
• 50mL syringe
• Gallipots
• Dressing pack
• Nasogastric tube (12-18 French size)
• Hypoallergenic tape
• Sterile gauze
• Gloves
• Disposable bowl.
Procedure
• Introduce yourself, confirm the patient's identity
• Explain the procedure to the patient, stating that it may be uncomfortable and can cause gagging, which is transient
• Make sure that the patient understands the procedure and agree a signal to be made if patient wants to you stop (e.g. raising hand)
• To estimate the length of the tube required, measure the distance from the bridge of the nose to the tip of the earlobe and then to the xiphoid process
• Position the patient semi-upright:
• If unconscious, place the patient on their side
• Check the patency of the nostrils and select a suitable side
• Wash hands and put on gloves
• Unwrap the tube and lubricate the tip by wiping it through a blob of lubricating gel
• Insert the tip of the tube in the nostril and advance the tube horizontally along the floor of the nasal cavity in a backward and downward direction
• As the tube passes into the nasopharynx, ask the patient to swallow if they are able to do so:
• Using a cup of water and straw often helps here
• If there is any obstruction felt during advancement, withdraw and try in the other nostril
• © Watch for any signs of distress; namely cough or cyanosis and remove the tube immediately if any of these occur
• Once the tube has reached the measured distance, secure it in place with the tape:
• The gastro-oesophageal junction is generally 38-42cm from the nostril so advancement of the tube 55-60cm from the nostril usually positions the nasogastric tube tip within the stomach.
• Aspirate a sample of fluid using a syringe
• Place the aspirate on a pH-testing strip:
• D A pH of 5.5 or less suggests that the tube is in the
stomach
• If no aspirate obtained, change position and try again. If still unsuccessful, perform chest radiography to confirm position:
• Be sure to leave the internal wire in the tube if you are sending the patient to x-ray. The tube itself is not radio-opaque and will be invisible on the resultant image
• Once satisfied that the tube lies within the stomach, remove the inner wire and secure the tube to the tip of the nose:
• It is sometimes helpful to curve the remainder of the tube towards the ear and secure to the cheek also.
Documentation
• Date, time, indication, informed consent obtained
• Size of tube inserted
• Length of tube internally (there are markings on the tube:
• This is important to allow other staff to assess whether the tube has moved in or out since insertion
• Method by which correct placement was confirmed
• Any immediate complications
• Signature, printed name, and contact details.
- Published on
Clinical Procedures - Ascitic Fluid Sampling (Tap)
Indications
• Diagnosing nature of new onset ascites (i.e. exudate or transudate)
• Diagnosis of spontaneous bacterial peritonitis
• Cytology to diagnose malignant :
ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site.
Risks
• Persistent leak of ascitic fluid:
• This is more likely if there is a large amount of fluid under tension
• Perforation of hollow viscera (e.g. bowel and bladder). This is very rare
• Peritonitis
• Abdominal wall hematoma
• Bleeding is very rare but may occur if there is injury to inferior epigastric artery (be careful to tap lateral abdominal wall as described).
Procedure Tips
• Check the patient's clotting and platelet count before the procedure and proceed with caution and senior advice if abnormal (correct if platelets <20 x 10°L, INR ≥2.5)
• Inform the laboratory especially during out of hours if cultures needed urgently and if SBP is suspected
• D If unable to obtain fluid despite correct technique, do not persist!
Stop and seek senior advice.
SAAG
Calculating the serum-ascites albumin gradient (SAAG) is a method of determining the cause of ascites.
SAAG = [serum albumin] - [ascites albumin]
>11g/L = portal hypertension (cirrhosis, alcoholic hepatitis, cardiac
ascites, Budd-Chiari syndrome, massive liver metastases).
<11g/L = infection, malignancy, nephrotic syndrome, pancreatic ascites.
Equipment
• Sterile gloves
• Dressing pack
• Antiseptic solution (e.g. iodine)
• 1% or 2% lidocaine
• 1 × 20mL syringe
• 2 × 5mL syringes
• 21G (green) and 25G (orange) needles
• Sterile containers
• Culture bottles
• Sterile dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Examine the abdomen and select a site for aspiration, 3 finger-breadths cranial to the anterior superior iliac spine:
• D Beware of positioning too medial as this risks hitting the inferior epigastric vessels
• D Be sure to identify and avoid any organomegaly which might interfere with procedure (in patients with massive splenomegaly, for example, avoid left iliac fossa)
• Clean the area with disinfectant and apply sterile drape
• Using the 25G (orange) needle and the 5mL syringe, administer local anaesthetic to the skin and subcutis, raising a wheal
• Using the 21G (green) needle, infiltrate deeper tissues, intermittently applying suction until the peritoneal cavity is reached, confirmed by flow of ascitic fluid into the syringe
• Note the depth needed to enter the peritoneal cavity
• Discard the used needles and attach a clean 21G needle to the 20mL syringe
• With the green needle perpendicular to the skin, insert carefully, aspirating continuously until you feel resistance give way
• Aspirate as much fluid as needed (usually 20mL is plenty)
• Withdraw needle and syringe and apply dressing
•Send sample for Gram stain and culture (in blood culture bottles), white cell count/neutrophils, biochemistry, cytology (if malignancy suspected):
• White cell count can be calculated in haematology lab; send fluid in EDTA-containing bottle. » (Total white cell count >500/mm' or neutrophils >250/mm3 suggests spontaneous bacterial peritonitis, SP)
• Neutrophil count is usually a manual procedure via microbiology and may take longer
• If malignancy is suspected, a large volume of ascites (e.g.
500mL) should be sent to cytology.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site aspirated
• Aseptic technique used?
• How many passes?
• Volume and colour of aspirate obtained
• Tests requested on samples
• Any immediate complications
• Signature, printed name, and contact details.
Indications
• Diagnosing nature of new onset ascites (i.e. exudate or transudate)
• Diagnosis of spontaneous bacterial peritonitis
• Cytology to diagnose malignant :
ascites.
Contraindications
• Acute abdomen that requires surgery
• Pregnancy
• Intestinal obstruction
• Grossly distended urinary bladder
• Superficial infection (cellulitis) at the potential puncture site
• Hernia at the potential puncture site.
Risks
• Persistent leak of ascitic fluid:
• This is more likely if there is a large amount of fluid under tension
• Perforation of hollow viscera (e.g. bowel and bladder). This is very rare
• Peritonitis
• Abdominal wall hematoma
• Bleeding is very rare but may occur if there is injury to inferior epigastric artery (be careful to tap lateral abdominal wall as described).
Procedure Tips
• Check the patient's clotting and platelet count before the procedure and proceed with caution and senior advice if abnormal (correct if platelets <20 x 10°L, INR ≥2.5)
• Inform the laboratory especially during out of hours if cultures needed urgently and if SBP is suspected
• D If unable to obtain fluid despite correct technique, do not persist!
Stop and seek senior advice.
SAAG
Calculating the serum-ascites albumin gradient (SAAG) is a method of determining the cause of ascites.
SAAG = [serum albumin] - [ascites albumin]
>11g/L = portal hypertension (cirrhosis, alcoholic hepatitis, cardiac
ascites, Budd-Chiari syndrome, massive liver metastases).
<11g/L = infection, malignancy, nephrotic syndrome, pancreatic ascites.
Equipment
• Sterile gloves
• Dressing pack
• Antiseptic solution (e.g. iodine)
• 1% or 2% lidocaine
• 1 × 20mL syringe
• 2 × 5mL syringes
• 21G (green) and 25G (orange) needles
• Sterile containers
• Culture bottles
• Sterile dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Examine the abdomen and select a site for aspiration, 3 finger-breadths cranial to the anterior superior iliac spine:
• D Beware of positioning too medial as this risks hitting the inferior epigastric vessels
• D Be sure to identify and avoid any organomegaly which might interfere with procedure (in patients with massive splenomegaly, for example, avoid left iliac fossa)
• Clean the area with disinfectant and apply sterile drape
• Using the 25G (orange) needle and the 5mL syringe, administer local anaesthetic to the skin and subcutis, raising a wheal
• Using the 21G (green) needle, infiltrate deeper tissues, intermittently applying suction until the peritoneal cavity is reached, confirmed by flow of ascitic fluid into the syringe
• Note the depth needed to enter the peritoneal cavity
• Discard the used needles and attach a clean 21G needle to the 20mL syringe
• With the green needle perpendicular to the skin, insert carefully, aspirating continuously until you feel resistance give way
• Aspirate as much fluid as needed (usually 20mL is plenty)
• Withdraw needle and syringe and apply dressing
•Send sample for Gram stain and culture (in blood culture bottles), white cell count/neutrophils, biochemistry, cytology (if malignancy suspected):
• White cell count can be calculated in haematology lab; send fluid in EDTA-containing bottle. » (Total white cell count >500/mm' or neutrophils >250/mm3 suggests spontaneous bacterial peritonitis, SP)
• Neutrophil count is usually a manual procedure via microbiology and may take longer
• If malignancy is suspected, a large volume of ascites (e.g.
500mL) should be sent to cytology.
Documentation
• Date, time, indication, informed consent obtained
• Type and amount of local anaesthetic used
• Site aspirated
• Aseptic technique used?
• How many passes?
• Volume and colour of aspirate obtained
• Tests requested on samples
• Any immediate complications
• Signature, printed name, and contact details.
