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Clinical Procedures- Accuhaler
Dry powder device, superseding the Diskhaler and Rotahaler.
Has a dose counter. The several-step priming mechanism may be difficult for some to manage
How to use
• Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click
. With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed
• Sit upright, breathe out completely and insert mouthpiece, sealing with lips
• Inhale quickly and deeply
• (In contrast to breath-actuated devices)
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click
• Recover before taking the next dose.
Procedure Tips
• The Accuhaler must be closed and re-primed between successive doses.
• The dose counter indicates how many doses are left.
Dry powder device, superseding the Diskhaler and Rotahaler.
Has a dose counter. The several-step priming mechanism may be difficult for some to manage
How to use
• Hold the outer casing in one hand whilst pushing the thumb grip away, exposing the mouthpiece, until you hear a click
. With the mouthpiece towards you, slide the lever away from you until it clicks. The device is now primed
• Sit upright, breathe out completely and insert mouthpiece, sealing with lips
• Inhale quickly and deeply
• (In contrast to breath-actuated devices)
• Remove inhaler and hold your breath for 10 seconds or as long as is comfortable
• To close, pull the thumb grip towards you, hiding the mouthpiece in the cover, until you hear a click
• Recover before taking the next dose.
Procedure Tips
• The Accuhaler must be closed and re-primed between successive doses.
• The dose counter indicates how many doses are left.
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Clinical Procedures - Taking Cervical Smear
Indications
• Screening for cervical cancer
• Post-treatment follow-up for cervical dysplasia or malignancy
• After hysterectomy for neoplasia or dysplasia.
Contraindications
• There are no real contraindications but care is needed in circumstances in which an adequate sample may be difficult to obtain or interpret.
Risks
• (Minor) spotting
• Uterine cramps.
Procedure Tips
• Cervical smears should not be performed during pregnancy. The increase in cervical mucus (and resultant decrease in the number of cells obtained) usually renders the sample inadequate and the results unreliable
• Neither abnormal vaginal bleeding or discharge or a visible or palpate cervical lesion is an indication for a cervical smear per se as it is a test for cervical atypia which is asymptomatic. However, a speculum examination should be performed to inspect the cervix and infection screening offered. A cervical smear can be offered to women who have not had a normal test within the usual screening period
• Ensure the woman knows when and how she will receive the results of the test and who to contact in case of problems
The following describes the technique for obtaining a sample for 'liquid-based cytology (LBC), now used by the majority of Units in the UK
Equipment
• Cusco's specula of different sizes
• Disposable gloves
• Request form
• Sampling device: plastic broom (Cervex-Brush®)
• LBC vial: preservative for sample
• Patient information leaflet.
Procedure
• Introduce yourself, confirm the patient's identity, ensure the patient understands the purpose of the procedure and has been given a patient information leaflet
• Explain the procedure and obtain informed consent
• Ensure a chaperone is available during the examination
• Write the patient's identification details on LBC vial
• Ask the patient to lie on her back on an examination couch with both knees bent up and let her knees fall apart: either with her heels together in the middle or separated
• Warm the speculum under running water and lubricate it with a water-based lubricant
• Using the left hand, open the lips of the labia minora to obtain a good view of the introitus
• Hold the speculum in the right hand with the main beg of the speculum in the palm and the closed blades pre between index and middle fingers
• Gently insert the speculum into the vagina held with wrist turned such that the blades are in line with the opening between the labia
• The speculum should be angled downwards and backwards due to the angle of the vagina
• Maintain a posterior angulation and rotate the speculum through 90° to position handles anteriorly
• When it cannot be advanced further, maintain a downward pressure and press on the thumb piece to hinge the blades open exposing the cervix and vaginal walls
• Ensure entire cervix is clearly visualized and note any obvious abnormalities or irregularity
• Once in optimum position, tighten the thumbscrew
• Insert the plastic broom so that the central bristles of the brush are in the endocervical canal and the outer bristles in contact with the ectocervix
• Using pencil pressure, rotate the brush 5 times in a clockwise direction:
• The bristles are bevelled to scrape cells only on clockwise rotation
• Rinse the brush thoroughly in the preservative (Thin Prep® or break off brush into the preservative (SurePath®
• Undo the thumbscrew and withdraw the speculum
•The blades should be held open until their ends are visible distal to the cervix to avoid causing pain
• Rotate the open blades in an anticlockwise direction to ensure that the anterior and posterior walls of the vagina can be inspected
• Near the introitus, allow the blades to close taking care not to pinch the labia or hairs
• Allow the patient to re-dress in privacy.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including chaperone
• Date of last menstrual period and use of hormonal treatments
• Date of last smear and any abnormal results
• Any abnormalities identified
• Any immediate complications
Indications
• Screening for cervical cancer
• Post-treatment follow-up for cervical dysplasia or malignancy
• After hysterectomy for neoplasia or dysplasia.
Contraindications
• There are no real contraindications but care is needed in circumstances in which an adequate sample may be difficult to obtain or interpret.
Risks
• (Minor) spotting
• Uterine cramps.
Procedure Tips
• Cervical smears should not be performed during pregnancy. The increase in cervical mucus (and resultant decrease in the number of cells obtained) usually renders the sample inadequate and the results unreliable
• Neither abnormal vaginal bleeding or discharge or a visible or palpate cervical lesion is an indication for a cervical smear per se as it is a test for cervical atypia which is asymptomatic. However, a speculum examination should be performed to inspect the cervix and infection screening offered. A cervical smear can be offered to women who have not had a normal test within the usual screening period
• Ensure the woman knows when and how she will receive the results of the test and who to contact in case of problems
The following describes the technique for obtaining a sample for 'liquid-based cytology (LBC), now used by the majority of Units in the UK
Equipment
• Cusco's specula of different sizes
• Disposable gloves
• Request form
• Sampling device: plastic broom (Cervex-Brush®)
• LBC vial: preservative for sample
• Patient information leaflet.
Procedure
• Introduce yourself, confirm the patient's identity, ensure the patient understands the purpose of the procedure and has been given a patient information leaflet
• Explain the procedure and obtain informed consent
• Ensure a chaperone is available during the examination
• Write the patient's identification details on LBC vial
• Ask the patient to lie on her back on an examination couch with both knees bent up and let her knees fall apart: either with her heels together in the middle or separated
• Warm the speculum under running water and lubricate it with a water-based lubricant
• Using the left hand, open the lips of the labia minora to obtain a good view of the introitus
• Hold the speculum in the right hand with the main beg of the speculum in the palm and the closed blades pre between index and middle fingers
• Gently insert the speculum into the vagina held with wrist turned such that the blades are in line with the opening between the labia
• The speculum should be angled downwards and backwards due to the angle of the vagina
• Maintain a posterior angulation and rotate the speculum through 90° to position handles anteriorly
• When it cannot be advanced further, maintain a downward pressure and press on the thumb piece to hinge the blades open exposing the cervix and vaginal walls
• Ensure entire cervix is clearly visualized and note any obvious abnormalities or irregularity
• Once in optimum position, tighten the thumbscrew
• Insert the plastic broom so that the central bristles of the brush are in the endocervical canal and the outer bristles in contact with the ectocervix
• Using pencil pressure, rotate the brush 5 times in a clockwise direction:
• The bristles are bevelled to scrape cells only on clockwise rotation
• Rinse the brush thoroughly in the preservative (Thin Prep® or break off brush into the preservative (SurePath®
• Undo the thumbscrew and withdraw the speculum
•The blades should be held open until their ends are visible distal to the cervix to avoid causing pain
• Rotate the open blades in an anticlockwise direction to ensure that the anterior and posterior walls of the vagina can be inspected
• Near the introitus, allow the blades to close taking care not to pinch the labia or hairs
• Allow the patient to re-dress in privacy.
Documentation
• Date, time, indication, informed consent obtained
• Those present, including chaperone
• Date of last menstrual period and use of hormonal treatments
• Date of last smear and any abnormal results
• Any abnormalities identified
• Any immediate complications
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Surgery - Puch Skin Biopsy
Indications
• Punch biopsy is widely used for diagnosing lesions and rashes
• It is less helpful to confirm deep processes or for conditions that may be difficult to confirm histologically such as mycosis fungoides. Here, a larger incisional biopsy can be a better choice.
Contraindications
• Adrenaline-containing anesthetic should not be used on the fingers, toes, or penis, due to a potential risk of occluding an end-artery
• © Punch biopsy should usually be avoided if melanoma is suspected (excision biopsy is required
• © It is inadvisable to biopsy a patient if platelets < 50 × 10°/L or
INR >3.
Risks
• Take particular care when taking a punch biopsy from an area with important structures just beneath the skin. For example, the tendons on the dorsum of the hand, the facial nerve crossing the zygoma or temple:
• The risk can be reduced by raising a large bleb with the anaesthetic to put more depth between the surface and deeper structures
• D Patients should be warned that punch biopsy will always leave a scar
• In a patient prone to keloid scarring, try to avoid biopsying keloid-prone areas such as the upper trunk and back of the neck
• Infection
• Haemorrhage.
Procedure Tips
• Punch biopsy implements range in size from 3-8mm. For most diagnostic purposes, 4mm is appropriate; an 8mm punch biopsy defect requires a buried subcuticular suture in addition to surface sutures
• > Choice of biopsy site is very important for some lesias
Land rashes, as
the diagnostic histological features may only be press
ten lesions,
or in a particular part of a lesion. If in doubt, consult
ologist
• D Always mark the site of the biopsy. It can be surprise ricw, after blanching the skin with adrenaline and rubbing to clean the area, the obvious red, scaly plaque completely disappears!
• I Bulla: take the specimen across the edge of a fresh blister
• Ulcer: take the specimen from the edge of the lesion
• If for any reason suturing the wound is going to be difficult (e.g. very tight skin on the leg, markedly indurated lesion or patient won't keep still), the defect can be left to heal by secondary intention.
Equipment
• Surgical pack including sterile drape, gauze, small bowl
• Isopropyl alcohol swab
• Skin marker
• Non-sterile gloves
• Local anaesthetic (1 mL 1% lidocaine is usually plenty)
• 2mL syringe and fine bore (blue) needle
• Sterile gloves
• Sterile towel
• Sterile cleaning solution (e.g. iodine)
• Disposable punch biopsy implement (usually 4mm)
• Toothed forceps
• Scissors
• Histology pot
• Vaseline® or similar
• Plaster or other dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Mark the exact area to be biopsied with the skin marker
• Wipe the site to be biopsied with the alcohol swab
• Draw up the local anaesthetic (e.g. lidocaine 1% with adrenaline 1:200,000):
• If using anaesthetic containing adrenaline, warn the patient that the injection will sting
• Wearing the non-sterile gloves, inject the anaes around and beneath the biopsy site (into dermis and subcutis) to raise up a bleb:
• Keep gauze to hand to catch any drips.
• Wash hands using surgical scrub technique.
• Cleanse the area around the biopsy site with the cleaning solution and some gauze
• Position the sterile drape(s)
• Have gauze handy to mop up any bleeding:
• It can be helpful to place some adiacent to the biopsy site in the direction that any blood will flow
• Place the punch biopsy over the mark and push it through the skin with a rotating motion... penetrate through to subcutis, at which point a reduction in resistance can be felt
• Put down the punch biopsy implement
• Pick up the specimen without compressing it with the toothed forceps
• Harvest the specimen by cutting with the scissors through the connecting subcutaneous fat strands (sometimes this is unnecessary as the fat may just fall away)
• Place the specimen in the histology pot
• Place a smear of Vaseline® over the wound and cover with the plaster or dressing.
Documentation
• Date, time, indication, informed consent obtained
• Type and volume of local anaesthetic used
• Note the site and method of the biopsy (it can be helpful to draw a diagram)
• The type of suture used
• Instructions on the time for suture removal
• The pathology request form should provide the pathologist with information on the date, site, size type of biopsy.
• A brief history, description of the problem an differential is essential (lesion' or 'rash' does not
• Signature, printed name, and contact details.
Indications
• Punch biopsy is widely used for diagnosing lesions and rashes
• It is less helpful to confirm deep processes or for conditions that may be difficult to confirm histologically such as mycosis fungoides. Here, a larger incisional biopsy can be a better choice.
Contraindications
• Adrenaline-containing anesthetic should not be used on the fingers, toes, or penis, due to a potential risk of occluding an end-artery
• © Punch biopsy should usually be avoided if melanoma is suspected (excision biopsy is required
• © It is inadvisable to biopsy a patient if platelets < 50 × 10°/L or
INR >3.
Risks
• Take particular care when taking a punch biopsy from an area with important structures just beneath the skin. For example, the tendons on the dorsum of the hand, the facial nerve crossing the zygoma or temple:
• The risk can be reduced by raising a large bleb with the anaesthetic to put more depth between the surface and deeper structures
• D Patients should be warned that punch biopsy will always leave a scar
• In a patient prone to keloid scarring, try to avoid biopsying keloid-prone areas such as the upper trunk and back of the neck
• Infection
• Haemorrhage.
Procedure Tips
• Punch biopsy implements range in size from 3-8mm. For most diagnostic purposes, 4mm is appropriate; an 8mm punch biopsy defect requires a buried subcuticular suture in addition to surface sutures
• > Choice of biopsy site is very important for some lesias
Land rashes, as
the diagnostic histological features may only be press
ten lesions,
or in a particular part of a lesion. If in doubt, consult
ologist
• D Always mark the site of the biopsy. It can be surprise ricw, after blanching the skin with adrenaline and rubbing to clean the area, the obvious red, scaly plaque completely disappears!
• I Bulla: take the specimen across the edge of a fresh blister
• Ulcer: take the specimen from the edge of the lesion
• If for any reason suturing the wound is going to be difficult (e.g. very tight skin on the leg, markedly indurated lesion or patient won't keep still), the defect can be left to heal by secondary intention.
Equipment
• Surgical pack including sterile drape, gauze, small bowl
• Isopropyl alcohol swab
• Skin marker
• Non-sterile gloves
• Local anaesthetic (1 mL 1% lidocaine is usually plenty)
• 2mL syringe and fine bore (blue) needle
• Sterile gloves
• Sterile towel
• Sterile cleaning solution (e.g. iodine)
• Disposable punch biopsy implement (usually 4mm)
• Toothed forceps
• Scissors
• Histology pot
• Vaseline® or similar
• Plaster or other dressing.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain written consent if possible
• Mark the exact area to be biopsied with the skin marker
• Wipe the site to be biopsied with the alcohol swab
• Draw up the local anaesthetic (e.g. lidocaine 1% with adrenaline 1:200,000):
• If using anaesthetic containing adrenaline, warn the patient that the injection will sting
• Wearing the non-sterile gloves, inject the anaes around and beneath the biopsy site (into dermis and subcutis) to raise up a bleb:
• Keep gauze to hand to catch any drips.
• Wash hands using surgical scrub technique.
• Cleanse the area around the biopsy site with the cleaning solution and some gauze
• Position the sterile drape(s)
• Have gauze handy to mop up any bleeding:
• It can be helpful to place some adiacent to the biopsy site in the direction that any blood will flow
• Place the punch biopsy over the mark and push it through the skin with a rotating motion... penetrate through to subcutis, at which point a reduction in resistance can be felt
• Put down the punch biopsy implement
• Pick up the specimen without compressing it with the toothed forceps
• Harvest the specimen by cutting with the scissors through the connecting subcutaneous fat strands (sometimes this is unnecessary as the fat may just fall away)
• Place the specimen in the histology pot
• Place a smear of Vaseline® over the wound and cover with the plaster or dressing.
Documentation
• Date, time, indication, informed consent obtained
• Type and volume of local anaesthetic used
• Note the site and method of the biopsy (it can be helpful to draw a diagram)
• The type of suture used
• Instructions on the time for suture removal
• The pathology request form should provide the pathologist with information on the date, site, size type of biopsy.
• A brief history, description of the problem an differential is essential (lesion' or 'rash' does not
• Signature, printed name, and contact details.
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Clinical Procedures - Pleural Fluid Aspiration
Indications
• Diagnosis of cause of pleural effusion
• Relief of symptomatic pleural effusion.
Contraindications
• Recurrent effusion (chest drain, pleurodesis should be considered)
• Empyema (requires intercostal drain)
• Mesothelioma (tumour may spread down needle track)
• Bleeding diathesis.
Risks
• Pain
• Cough
• Failure to resolve
• Re-expansion pulmonary edema
• Pneumothorax.
Procedure Tips
• If unsuccessful, aspiration may be performed under ultrasound guidance:
discuss with your Radiology Department
• Passing a small fluid sample through a blood gas analyser may yield a rapid pH but should be avoided if the sample is purulent.
Alternative method
• An alternative method is to attach a fluid-giving set to one port of the
3-way tap and the 50mL syringe to the other. With this set up, you can aspirate 50mL into the syringe, turn the tap and empty it down the tubing into a container before turning the tap back to the syringe port.
The syringe, therefore, never needs to be disconnected and the risk of pneumothorax or other complication is reduced.
This describes the procedure for aspirating as much pleural fluid as possible. If only a small sample is required for diagnostic purposes, use a green needle and 20mL syringe and follow a similar method to that described under 'ascitic tap'.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/ gauze
• Selection of sterile containers and blood culture bottles
• Heparinized (ABG) syringe.
Procedure
• Fluid should be aspirated from a position 1-2 intercostal spaces below the highest level at which dullness is percussed.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning forward with arms rested on a table or over the back of a chair
• Percuss the effusion and choose a suitable spot for needle insertion
• Clean the area with chlorhexidine
• Using the blue needle and syringe, infiltrate local anaesthetic down to the pleura:
• © Insert needle just above a rib to avoid the neurovascular bundle
• Be sure to pull back on the syringe each time before injecting to ensure you are not in a blood vessel
• Once fluid is withdrawn, you have reached the pleura
Insert the cannula perpendicular to the chest wall, aspirating with another syringe as you advance until resistance reduces and pleural fluid is aspirated
• Remove the needle and attach the 3-way tap
• You may now aspirate fluid using the 50mL syringe. Once the syringe is full, close the tap, disconnect the syringe, and empty into a container. Re-attach the syringe, open the tap and repeat:
• The pleural space should never be in continuity with the environment or pneumothorax will occur
• Do not drain more than 2.5L at one time
• Remove the cannula and apply the dressing
• Send samples for:
• Microbiology: microscopy, culture, Auramine stain
TB culture
• Chemistry: protein, lactate dehydrogenase (LDH), pH, glucose, amylase
• Cytology
• Immunology: anti-nuclear antibody, rheumatoid factor, complement
• Take simultaneous venous blood for glucose, protein, LDH
• Request chest radiograph to confirm success and look for iatrogenic pneumothorax.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Colour, consistency, and volume of fluid aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
Indications
• Diagnosis of cause of pleural effusion
• Relief of symptomatic pleural effusion.
Contraindications
• Recurrent effusion (chest drain, pleurodesis should be considered)
• Empyema (requires intercostal drain)
• Mesothelioma (tumour may spread down needle track)
• Bleeding diathesis.
Risks
• Pain
• Cough
• Failure to resolve
• Re-expansion pulmonary edema
• Pneumothorax.
Procedure Tips
• If unsuccessful, aspiration may be performed under ultrasound guidance:
discuss with your Radiology Department
• Passing a small fluid sample through a blood gas analyser may yield a rapid pH but should be avoided if the sample is purulent.
Alternative method
• An alternative method is to attach a fluid-giving set to one port of the
3-way tap and the 50mL syringe to the other. With this set up, you can aspirate 50mL into the syringe, turn the tap and empty it down the tubing into a container before turning the tap back to the syringe port.
The syringe, therefore, never needs to be disconnected and the risk of pneumothorax or other complication is reduced.
This describes the procedure for aspirating as much pleural fluid as possible. If only a small sample is required for diagnostic purposes, use a green needle and 20mL syringe and follow a similar method to that described under 'ascitic tap'.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/ gauze
• Selection of sterile containers and blood culture bottles
• Heparinized (ABG) syringe.
Procedure
• Fluid should be aspirated from a position 1-2 intercostal spaces below the highest level at which dullness is percussed.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning forward with arms rested on a table or over the back of a chair
• Percuss the effusion and choose a suitable spot for needle insertion
• Clean the area with chlorhexidine
• Using the blue needle and syringe, infiltrate local anaesthetic down to the pleura:
• © Insert needle just above a rib to avoid the neurovascular bundle
• Be sure to pull back on the syringe each time before injecting to ensure you are not in a blood vessel
• Once fluid is withdrawn, you have reached the pleura
Insert the cannula perpendicular to the chest wall, aspirating with another syringe as you advance until resistance reduces and pleural fluid is aspirated
• Remove the needle and attach the 3-way tap
• You may now aspirate fluid using the 50mL syringe. Once the syringe is full, close the tap, disconnect the syringe, and empty into a container. Re-attach the syringe, open the tap and repeat:
• The pleural space should never be in continuity with the environment or pneumothorax will occur
• Do not drain more than 2.5L at one time
• Remove the cannula and apply the dressing
• Send samples for:
• Microbiology: microscopy, culture, Auramine stain
TB culture
• Chemistry: protein, lactate dehydrogenase (LDH), pH, glucose, amylase
• Cytology
• Immunology: anti-nuclear antibody, rheumatoid factor, complement
• Take simultaneous venous blood for glucose, protein, LDH
• Request chest radiograph to confirm success and look for iatrogenic pneumothorax.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Colour, consistency, and volume of fluid aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
- Published on
Clinical Procedures - Pneumothorax Aspiration
Indications
Simple pneumothorax
• Aspiration is indicated if the rim of pleural air visible on chest radiograph is >2cm or the patient is breathless
• If initial aspiration is unsuccessful, repeat aspiration may be successful in
>30% of cases and may avoid intercostal drain insertion
• The total volume aspirated should not exceed 2.5L.
Secondary pneumothorax
• That is, a pneumothorax in the presence of underlying lung disease
• Aspiration is only indicated in minimally symptomatic patients with small pneumothoraces (<2cm) aged <50 years.
Contraindications
• Previous failed attempts at aspiration
• Significant secondary pneumothorax
• Traumatic pneumothorax.
Risks
• Pain
• Cough
• Failure to resolve/recurrence
• Re-expansion pulmonary edema may theoretically occur if large volumes (>2.5L) are aspirated.
• Tension Pneumothorax
In the case of tension pneumothorax, a wide-bore cannula should be inserted into the 2nd intercostal space, midclavicular line without delay and left open to convert the tension pneumothorax to a simple pneumothorax.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/gauze.
Procedure
• Pneumothorax is usually aspirated from either the 2nd intercostal space at the midclavicular line or the 4th_ 6th intercostal spaces at the midaxillary line.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning back comfortably at about 45°
• Identify the site for needle insertion and double-check the radiograph to be certain you have the correct side. Confirm with clinical examination
• Clean the area with the chlorhexidine
• Infiltrate local anaesthetic down to the pleura using the blue needle and a 10mL syringe
• Attach the other 10mL syringe to the cannula and insert the cannula perpendicular to the chest wall, aspirating as you advance until resistance reduces:
• D Insert the cannula just above a rib to avoid the neurovascular bundle
• Remove the needle and quickly attach the 3-way tap and 50mL syringe
• Aspirate with the syringe; close the 3-way tap when the syringe is full, remove the syringe, and eject the air; reattach and open the 3-way tap to continue aspiration:
• © The pleural space should never be in continuity with the environment (i.e. tap open with syringe detached) or pneumothorax will re-accumulate
• Aspirate until resistance is felt, or up to a maximum of 2.5L
• Remove the cannula and apply the dressing
• Request chest radiograph to re-assess.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Volume of air aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
Indications
Simple pneumothorax
• Aspiration is indicated if the rim of pleural air visible on chest radiograph is >2cm or the patient is breathless
• If initial aspiration is unsuccessful, repeat aspiration may be successful in
>30% of cases and may avoid intercostal drain insertion
• The total volume aspirated should not exceed 2.5L.
Secondary pneumothorax
• That is, a pneumothorax in the presence of underlying lung disease
• Aspiration is only indicated in minimally symptomatic patients with small pneumothoraces (<2cm) aged <50 years.
Contraindications
• Previous failed attempts at aspiration
• Significant secondary pneumothorax
• Traumatic pneumothorax.
Risks
• Pain
• Cough
• Failure to resolve/recurrence
• Re-expansion pulmonary edema may theoretically occur if large volumes (>2.5L) are aspirated.
• Tension Pneumothorax
In the case of tension pneumothorax, a wide-bore cannula should be inserted into the 2nd intercostal space, midclavicular line without delay and left open to convert the tension pneumothorax to a simple pneumothorax.
Equipment
• Sterile pack
• Sterile gloves
• Cleaning solution (e.g. chlorhexidine)
• Large-bore (green) cannula
• 3-way tap
• 50mL syringe
• 5mL 1% lidocaine
• 23G (blue) needle
• 2 x 10mL syringe
• Dressing/gauze.
Procedure
• Pneumothorax is usually aspirated from either the 2nd intercostal space at the midclavicular line or the 4th_ 6th intercostal spaces at the midaxillary line.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient leaning back comfortably at about 45°
• Identify the site for needle insertion and double-check the radiograph to be certain you have the correct side. Confirm with clinical examination
• Clean the area with the chlorhexidine
• Infiltrate local anaesthetic down to the pleura using the blue needle and a 10mL syringe
• Attach the other 10mL syringe to the cannula and insert the cannula perpendicular to the chest wall, aspirating as you advance until resistance reduces:
• D Insert the cannula just above a rib to avoid the neurovascular bundle
• Remove the needle and quickly attach the 3-way tap and 50mL syringe
• Aspirate with the syringe; close the 3-way tap when the syringe is full, remove the syringe, and eject the air; reattach and open the 3-way tap to continue aspiration:
• © The pleural space should never be in continuity with the environment (i.e. tap open with syringe detached) or pneumothorax will re-accumulate
• Aspirate until resistance is felt, or up to a maximum of 2.5L
• Remove the cannula and apply the dressing
• Request chest radiograph to re-assess.
Documentation
• Date, time, indication, informed consent obtained
• Aseptic technique used?
• Local anaesthetic used
• Site needle inserted
• Volume of air aspirated
• Any immediate complications
• Investigations requested
• Signature, printed name, and contact details.
- Published on
Clinical Procedures - Non Invasive Ventilation ( CPAP)
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
CAP = continuous positive airways pressure. CAP traditionally
has its own equipment and 'set-up'. Recently more clinicians are delivering CPAP through the BiPAP Vision@. There is also a
'low-flow' version used mainly for transport of CPAP-dependent patients.
Equipment
)rd
• Mask (‡ T-piece), hood
• Head strap (mask), shoulder straps (hood)
• Oxygen circuit and humidification
• High flow generator (e.g. Whisper Flow®, Vital Signs®)
• Positive end-expiratory pressure (PEEP) valves (usually 5, 7.5, or 10cmH,O)
• 'Blow off' safety valve (10cmHO above the PEEP used).
Procedure
• Use available templates to assess appropriate sized interface and minimize air leaks (if using the BiPAP Vision
• Decide on level of PEEP to apply
• Attach PEEP valve to mask (if using traditional set-up, may need T-piece)
• Attach oxygen circuit with humidification including 'blow off' valve (for safety)
• Set inspired oxygen level
• Set flow rate to ensure the PEEP valve opens a small distance and never closes
• Titrate oxygen and PEEP in response to the patient's work of breathing, saturations, pH, Pa02, and PaCO2
• If appropriate, set alarms on ventilator (if using BiPAP Vision®
• Write a prescription chart of PEEP or ventilation settings and acceptable saturations, Pa02 and PaCO, continuous or intermittent.
Procedure Tips
• If valve closing fully, there is an air leak or patient requires higher PEEP
• May need to put more air into the mask rim for patient comfort and a better seal
• Better fit of mask if the patient keeps their dentures in!
• Large-bore nasogastric tubes will cause a leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 1 respiratory failure (e.g. lobar or bibasal collapse post surgery, pneumonia)
• Cardiogenic pulmonary edema
• Obstructive sleep apnoea
• Weaning.
Contraindications /Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• CO, retention if patient breathing small tidal volume against
Documentation
• Oxygen prescription chart
• Clear record of ABGs with evidence of time, inspired oxygen and PEEP
• Continuous or intermittent
• Good practice to document 'ceiling' of treatment in clinical environment (pressure and Fi02).
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
CAP = continuous positive airways pressure. CAP traditionally
has its own equipment and 'set-up'. Recently more clinicians are delivering CPAP through the BiPAP Vision@. There is also a
'low-flow' version used mainly for transport of CPAP-dependent patients.
Equipment
)rd
• Mask (‡ T-piece), hood
• Head strap (mask), shoulder straps (hood)
• Oxygen circuit and humidification
• High flow generator (e.g. Whisper Flow®, Vital Signs®)
• Positive end-expiratory pressure (PEEP) valves (usually 5, 7.5, or 10cmH,O)
• 'Blow off' safety valve (10cmHO above the PEEP used).
Procedure
• Use available templates to assess appropriate sized interface and minimize air leaks (if using the BiPAP Vision
• Decide on level of PEEP to apply
• Attach PEEP valve to mask (if using traditional set-up, may need T-piece)
• Attach oxygen circuit with humidification including 'blow off' valve (for safety)
• Set inspired oxygen level
• Set flow rate to ensure the PEEP valve opens a small distance and never closes
• Titrate oxygen and PEEP in response to the patient's work of breathing, saturations, pH, Pa02, and PaCO2
• If appropriate, set alarms on ventilator (if using BiPAP Vision®
• Write a prescription chart of PEEP or ventilation settings and acceptable saturations, Pa02 and PaCO, continuous or intermittent.
Procedure Tips
• If valve closing fully, there is an air leak or patient requires higher PEEP
• May need to put more air into the mask rim for patient comfort and a better seal
• Better fit of mask if the patient keeps their dentures in!
• Large-bore nasogastric tubes will cause a leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 1 respiratory failure (e.g. lobar or bibasal collapse post surgery, pneumonia)
• Cardiogenic pulmonary edema
• Obstructive sleep apnoea
• Weaning.
Contraindications /Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• CO, retention if patient breathing small tidal volume against
Documentation
• Oxygen prescription chart
• Clear record of ABGs with evidence of time, inspired oxygen and PEEP
• Continuous or intermittent
• Good practice to document 'ceiling' of treatment in clinical environment (pressure and Fi02).
- Published on
Clinical Procedures - Non Invasive Ventilation ( BiPAP)
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
BiPAP = bilevel positive airways pressure. Each machine varies
and some are more complicated than others. The steps outlined below are a guide only. All ventilated patients should be in a ward or unit with specialised staff who have been trained in the use of each ventilator.
Equipment
• Interface (face mask, nasal pillows, nasal mask etc.)
• Head straps
• Ventilation circuit (exhalation port unless on mask
• Humidification (if required)
• Ventilator (NIPPY 1/2/3/3+, BiPAP Vision® etc.)
• Entrained oxygen (unless with ventilator e.g. BiPAP Vision®.
Procedure
• Decide on which interface to use
• Use available templates to assess appropriate sized interface and minimize air leaks
• Start with low pressures (EPAP 4cmH,O, |PAP 12cmHO):
• Slowly increase pressures to levels agreed by multidisciplinary team, for patient comfort and in response to pH, PaO2 and PaCO2
• The aim being to reduce RR and work of breathing normalize ABGs (for the individual) using the minimal pressures possible
• Set inspiratory and expiratory times to those of the patient
• Continually reassess respiratory rates as this will change and therefore set times will have to change
• Titrate oxygen and pressures in response to the patient's saturations, pH, Pa0, and PaCO,
• If appropriate set alarms on ventilator
• Write a prescription chart of ventilation settings and acceptable saturations, Pa02, and PaCO2.
Procedure Tips
• Use full face masks usually in the acute setting as patients are usually mouth-breathing
• Better fit with dentures in!
• Large-bore nasogastric tubes will cause increased leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 2 respiratory failure (e.g. exacerbations of COPD, high spinal cord lesions, neuromuscular disease)
• Weaning
• Cardiogenic pulmonary oedema.
Contraindications/Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• Pulmonary barotraumas.
Documentation
• Oxygen prescription charts
• Ventilation prescription charts
• Clear record of ABGs with evidence of time, inspired oxygen, and ventilation levels
• Good practice to document the 'ceiling of pressures and FiO2, for the clinical environment.
Non-invasive ventilation should only be set up by experienced operators. The following is a guide only.
Background
BiPAP = bilevel positive airways pressure. Each machine varies
and some are more complicated than others. The steps outlined below are a guide only. All ventilated patients should be in a ward or unit with specialised staff who have been trained in the use of each ventilator.
Equipment
• Interface (face mask, nasal pillows, nasal mask etc.)
• Head straps
• Ventilation circuit (exhalation port unless on mask
• Humidification (if required)
• Ventilator (NIPPY 1/2/3/3+, BiPAP Vision® etc.)
• Entrained oxygen (unless with ventilator e.g. BiPAP Vision®.
Procedure
• Decide on which interface to use
• Use available templates to assess appropriate sized interface and minimize air leaks
• Start with low pressures (EPAP 4cmH,O, |PAP 12cmHO):
• Slowly increase pressures to levels agreed by multidisciplinary team, for patient comfort and in response to pH, PaO2 and PaCO2
• The aim being to reduce RR and work of breathing normalize ABGs (for the individual) using the minimal pressures possible
• Set inspiratory and expiratory times to those of the patient
• Continually reassess respiratory rates as this will change and therefore set times will have to change
• Titrate oxygen and pressures in response to the patient's saturations, pH, Pa0, and PaCO,
• If appropriate set alarms on ventilator
• Write a prescription chart of ventilation settings and acceptable saturations, Pa02, and PaCO2.
Procedure Tips
• Use full face masks usually in the acute setting as patients are usually mouth-breathing
• Better fit with dentures in!
• Large-bore nasogastric tubes will cause increased leak, change to small-bore or bulk up cheek tissue with granuflex.
Indications
• Type 2 respiratory failure (e.g. exacerbations of COPD, high spinal cord lesions, neuromuscular disease)
• Weaning
• Cardiogenic pulmonary oedema.
Contraindications/Cautions
• D Undrained pneumothorax (absolute contraindication)
• Facial fractures
• Life-threatening epistaxis
• Bullous pulmonary disease
• Proximal lung tumours (air trapping)
• Active TB (spread)
• Acute head injury
• Low blood pressure
• Uncontrolled cardiac arrhythmias
• Sinus/middle ear infection.
Risks
• Abdominal distension (secondary to 'swallowing' air)
• Decreased cardiac output (drop in blood pressure)
• Pressure sores from mask
• Aspiration of vomit
• Pulmonary barotraumas.
Documentation
• Oxygen prescription charts
• Ventilation prescription charts
• Clear record of ABGs with evidence of time, inspired oxygen, and ventilation levels
• Good practice to document the 'ceiling of pressures and FiO2, for the clinical environment.
- Published on
Clinical Procedures – Female 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. pad).
Contraindications
• Urethral injury.
Risks
• Urinary tract infection
• Septicaemia
• Pain
• Haematuria
• Urethral trauma
• © Beware latex allergy.
Procedure Tips
• Difficulty passing the catheter may be alleviated by slowly rotating the catheter whilst inserting
• Difficulty seeing the urethral meatus may be overcome by asking the patient to 'bear down'
• 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
• b 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 (female 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 with hips externally rotated and knees flexed. Uncover from waist down
• 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
• Use your non-dominant hand to part the labia
• Clean around the urethral meatus using the water/ chlorhexidine and a swab, moving from the centre of
• Instil local anaesthetic via urethral meatus:
• Wait at least 1 minute for the anaesthetic to act
• Place the kidney bowl between the patient's thighs
• Remove the tip of the plastic sheath containing the catheter, 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'
• At this point, urine may begin to drain. Let the end of the catheter rest in the kidney bowl to prevent 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)
• D 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
• 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
• 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. pad).
Contraindications
• Urethral injury.
Risks
• Urinary tract infection
• Septicaemia
• Pain
• Haematuria
• Urethral trauma
• © Beware latex allergy.
Procedure Tips
• Difficulty passing the catheter may be alleviated by slowly rotating the catheter whilst inserting
• Difficulty seeing the urethral meatus may be overcome by asking the patient to 'bear down'
• 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
• b 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 (female 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 with hips externally rotated and knees flexed. Uncover from waist down
• 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
• Use your non-dominant hand to part the labia
• Clean around the urethral meatus using the water/ chlorhexidine and a swab, moving from the centre of
• Instil local anaesthetic via urethral meatus:
• Wait at least 1 minute for the anaesthetic to act
• Place the kidney bowl between the patient's thighs
• Remove the tip of the plastic sheath containing the catheter, 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'
• At this point, urine may begin to drain. Let the end of the catheter rest in the kidney bowl to prevent 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)
• D 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
• 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
• Any immediate complications
• Signature, printed name, and contact details.
- Published on
Clinical Procedures –Suprapubic Catheterization
Indications
• Failed urethral catheterization in acute urinary retention
• Long-term catheterization (performed electively).
Contraindications
• Pregnancy
• Peritonism
• Clot retention (caused by underlying bladder malignancy)
• Previous lower abdominal surgery (bowel may stick to abdominal wall).
Risks
• Intra-abdominal injury (bowel perforation at insertion), peritonitis, infection, hemorrhage.
Procedure Tips
• D Bladder MUST be palpable and urine MUST be aspirated in order to safely insert catheter:
• Examine the patient. If the bladder is not palpable, consider other causes for the patient's symptoms
• Wear a disposable apron to avoid an unexpected shower
• Catheter balloon should be inflated with sterile water, not saline:
• Precipitation of saline can damage balloon and lead to difficult deflation and removal
• If unable to safely perform at bedside, abandon procedure
• Additional use of ultrasound is encouraged to facilitate safe catheter placement
• The first catheter change should be at 6 weeks to allow fistulous tract formation and thereafter 3-monthly changes.
Documentation
• Date, time, indication, informed consent obtained
• Volume and type of local anesthesia infiltrated
• Aspiration of urine?
• Size and type of catheter
• Urine drained freely once catheter placed?
• Amount of sterile water used to inflate the balloon
• Type of dressing used to anchor catheter
• Residual volume of urine drained
• Signature, printed name, and contact details.
Equipment
• lodine solution
• Catheter pack (containing sterile drape, sterile gauze, sterile receptacles)
• 2 x sterile gloves
• 21G (green) needle
• 2 x 10 mL syringe
• 10mL 1% lidocaine
• 10mL sterile water
• Scalpel
• Suprapubic catheter trocar
• 16Ch long-term Foley catheter (Silastic®)
• Catheter bag
• Adhesive dressing
• • Assistant.
Procedure
• Suprapubic catheterization has a mortality rate of
0.8-1.8%. It should only be performed by a suitably experienced individual, ideally a Urologist.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Place trolley on right-hand side of patient and position the patient supine with abdomen exposed
• Wash hands thoroughly
• Ask assistant to open catheter pack onto trolley
• Ask assistant to open first pair of sterile gloves. Put them
on
• Ask assistant to pour iodine into catheter pack receptacle
• Clean suprapubic area with gauze soaked in iodine, starting at site of incision (central and approximately 2-3 finger breadths above pubic symphysis) and working outwards
• Remove gloves and change for second sterile pair
• Attach green needle to 10mL syringe and draw up lidocaine
• Infiltrate skin at incision site and deeper layers of abdominal wall with 10mL of 1% lidocaine:
• Aspirate before each injection. If blood is aspirated, stop, change position of needle and recheck
• Using same needle and syringe attempt to aspirate urine
• If unsuccessful, alter angulation or even position of needle until urine is aspirated
• Use needle puncture site as marker for incision
• Ask assistant to open scalpel, trocar, catheter, and silk suture onto catheter pack
• D Test efficacy of anaesthesia using needle. If anaesthesia is not sufficient, wait a few minutes and recheck. If still not sufficient, infiltrate more anesthetic and repeat process
• Perform a 1cm vertical incision at needle site through skin, subcutaneous fat, and muscle layer
• Hold the trocar in the palm of the right hand (like a corkscrew), with middle finger outstretched for support and to limit depth of entry:
• Left hand is used to steady needle end of trocar
• Insert trocar through incision, in same direction as needle, using twisting motion:
• " You should feel a first 'give through linea alba and a second 'give on entering the bladder
• When urine issues from trocar, remove trocar holding attached sheath in place
• Block the end with right thumb to stop urine leakage
• Insert catheter via sheath
• Insert catheter as far as possible and inflate balloon
• Remove sheath by splitting apart
• Attach catheter bag
• Gently pull the catheter back until resistance is felt
• Secure catheter in place with suitable dressing
• Dress catheter site with gauze and adhesive dressing.
Indications
• Failed urethral catheterization in acute urinary retention
• Long-term catheterization (performed electively).
Contraindications
• Pregnancy
• Peritonism
• Clot retention (caused by underlying bladder malignancy)
• Previous lower abdominal surgery (bowel may stick to abdominal wall).
Risks
• Intra-abdominal injury (bowel perforation at insertion), peritonitis, infection, hemorrhage.
Procedure Tips
• D Bladder MUST be palpable and urine MUST be aspirated in order to safely insert catheter:
• Examine the patient. If the bladder is not palpable, consider other causes for the patient's symptoms
• Wear a disposable apron to avoid an unexpected shower
• Catheter balloon should be inflated with sterile water, not saline:
• Precipitation of saline can damage balloon and lead to difficult deflation and removal
• If unable to safely perform at bedside, abandon procedure
• Additional use of ultrasound is encouraged to facilitate safe catheter placement
• The first catheter change should be at 6 weeks to allow fistulous tract formation and thereafter 3-monthly changes.
Documentation
• Date, time, indication, informed consent obtained
• Volume and type of local anesthesia infiltrated
• Aspiration of urine?
• Size and type of catheter
• Urine drained freely once catheter placed?
• Amount of sterile water used to inflate the balloon
• Type of dressing used to anchor catheter
• Residual volume of urine drained
• Signature, printed name, and contact details.
Equipment
• lodine solution
• Catheter pack (containing sterile drape, sterile gauze, sterile receptacles)
• 2 x sterile gloves
• 21G (green) needle
• 2 x 10 mL syringe
• 10mL 1% lidocaine
• 10mL sterile water
• Scalpel
• Suprapubic catheter trocar
• 16Ch long-term Foley catheter (Silastic®)
• Catheter bag
• Adhesive dressing
• • Assistant.
Procedure
• Suprapubic catheterization has a mortality rate of
0.8-1.8%. It should only be performed by a suitably experienced individual, ideally a Urologist.
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Place trolley on right-hand side of patient and position the patient supine with abdomen exposed
• Wash hands thoroughly
• Ask assistant to open catheter pack onto trolley
• Ask assistant to open first pair of sterile gloves. Put them
on
• Ask assistant to pour iodine into catheter pack receptacle
• Clean suprapubic area with gauze soaked in iodine, starting at site of incision (central and approximately 2-3 finger breadths above pubic symphysis) and working outwards
• Remove gloves and change for second sterile pair
• Attach green needle to 10mL syringe and draw up lidocaine
• Infiltrate skin at incision site and deeper layers of abdominal wall with 10mL of 1% lidocaine:
• Aspirate before each injection. If blood is aspirated, stop, change position of needle and recheck
• Using same needle and syringe attempt to aspirate urine
• If unsuccessful, alter angulation or even position of needle until urine is aspirated
• Use needle puncture site as marker for incision
• Ask assistant to open scalpel, trocar, catheter, and silk suture onto catheter pack
• D Test efficacy of anaesthesia using needle. If anaesthesia is not sufficient, wait a few minutes and recheck. If still not sufficient, infiltrate more anesthetic and repeat process
• Perform a 1cm vertical incision at needle site through skin, subcutaneous fat, and muscle layer
• Hold the trocar in the palm of the right hand (like a corkscrew), with middle finger outstretched for support and to limit depth of entry:
• Left hand is used to steady needle end of trocar
• Insert trocar through incision, in same direction as needle, using twisting motion:
• " You should feel a first 'give through linea alba and a second 'give on entering the bladder
• When urine issues from trocar, remove trocar holding attached sheath in place
• Block the end with right thumb to stop urine leakage
• Insert catheter via sheath
• Insert catheter as far as possible and inflate balloon
• Remove sheath by splitting apart
• Attach catheter bag
• Gently pull the catheter back until resistance is felt
• Secure catheter in place with suitable dressing
• Dress catheter site with gauze and adhesive dressing.
- Published on
Clinical Procedures - Arterial Blood Sampling (ABG)
Indications
• Evaluation of arterial 02, COz, pH. etc.
• Measurement of response to therapeutic oxygen or diagnostic evaluation (e.g. exercise testing).
Contraindications
• Negative modified Allen's test
• Cutaneous or subcutaneous lesion at puncture site
• Surgical shunt (e.g. in a dialysis patient) in the limb proximal or distal to the puncture site
• Infection or known peripheral vascular disease in the limb
• Coagulopathy.
Risks
• Bleeding
• Haematoma
• Arteriospasm
• Infection
• False aneurysm formation
• Arterial occlusion.
Procedure Tips
• The key is carefully palpating the artery and lining the needle up to puncture it. Take your time!
• The majority of the pain comes from puncturing the skin. If no flash is seen immediately, try repositioning the needle by withdrawing without removing it from the skin
• If several attempts have failed, try a different location or ask for
• If there will be some delay in analysing the sample, store the blood filled syringe on ice
• Errors occur: if there is air in the syringe, if the sample is delayed in reaching the analyser (if this is anticipated, put the sample on ice), or if a venous sample is accidentally obtained.
Documentation
• Date, time, indication, consent obtained
• Artery punctured
• Modified Allen's test?
• How many passes?
• Any immediate complications
• Signature, printed name, contact details.
Equipment
• Gloves
• Sterile wipe (e.g. isopropyl alcohol)
• Cotton wool balls
• Tape
• Gauze
• Heparinized self-filling syringe and needle.
Choosing a Site
The radial artery at the level of the radial styloid is the usual site of choice as it is both superficial and easily accessible.
If the vessel is not obviously palpable, it is also possible to sample arterial blood at the brachial artery in the antecubital fossa or femoral artery just distal to the inguinal ligament.
Procedure: Radial Artery
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient appropriately: sitting comfortably with arm placed on a pillow, forearm supinated, wrist passively dorsiflexed
• D Confirm ulnar arterial supply to the hand before starting (modified Allen's test):
• Compress the radial and ulnar arteries with your thumbs
• Ask the patient to make a fist and to open it
• The hand should appear blanched
• Release pressure from the ulnar artery and watch the palm
• The palm should flush to its normal colour
• D If not, there may be inadequate ulnar arterial supply and damage to the radial artery during blood taking may result in critical ischaemia. Test the other side
• Put on your gloves
• Identify the radial artery with index and middle fingers of your non-dominant hand
• Clean the site, beginning centrally and spiralling outwards
• Whilst the sterilizing solution dries, remove the needle and syringe from packaging and attach the needle to the end of the syringe
• Eject excess heparin from the syringe through the needle:
• © Check local equipment. Some heparinized syringes contain a heparinized sponge and excess heparin/air should not be expelled
• Warn the patient to expect a 'sharp scratch
• Whilst palpating the artery (but not obliterating the pulsation), insert the needle just distal to your fingertips, bevel facing proximally, at an angle of 45-60° until a flashback is seen within the chamber of the needle
• Hold the syringe steady and allow it to fill itself with 1-2mL blood
• As you withdraw the needle, apply the gauze swab to the site, maintaining firm manual pressure over for at least 2 minutes
• Dispose of the needle and apply a vented cap, expelling any excess air:
• (This may not be necessary depending on your equipment see above).
Procedure: Brachial artery
• Similar procedure as above except...
• Position the elbow in extension. Angle the needle 60°
Procedure: Femoral Artery
• Position the patient with hip extended
• The pulse is felt 2cm below the midpoint between pubic symphysis and anterior superior iliac spine
• Angle the needle at 90° to the skin
• Pressure must be applied for at least 5 minutes.
Indications
• Evaluation of arterial 02, COz, pH. etc.
• Measurement of response to therapeutic oxygen or diagnostic evaluation (e.g. exercise testing).
Contraindications
• Negative modified Allen's test
• Cutaneous or subcutaneous lesion at puncture site
• Surgical shunt (e.g. in a dialysis patient) in the limb proximal or distal to the puncture site
• Infection or known peripheral vascular disease in the limb
• Coagulopathy.
Risks
• Bleeding
• Haematoma
• Arteriospasm
• Infection
• False aneurysm formation
• Arterial occlusion.
Procedure Tips
• The key is carefully palpating the artery and lining the needle up to puncture it. Take your time!
• The majority of the pain comes from puncturing the skin. If no flash is seen immediately, try repositioning the needle by withdrawing without removing it from the skin
• If several attempts have failed, try a different location or ask for
• If there will be some delay in analysing the sample, store the blood filled syringe on ice
• Errors occur: if there is air in the syringe, if the sample is delayed in reaching the analyser (if this is anticipated, put the sample on ice), or if a venous sample is accidentally obtained.
Documentation
• Date, time, indication, consent obtained
• Artery punctured
• Modified Allen's test?
• How many passes?
• Any immediate complications
• Signature, printed name, contact details.
Equipment
• Gloves
• Sterile wipe (e.g. isopropyl alcohol)
• Cotton wool balls
• Tape
• Gauze
• Heparinized self-filling syringe and needle.
Choosing a Site
The radial artery at the level of the radial styloid is the usual site of choice as it is both superficial and easily accessible.
If the vessel is not obviously palpable, it is also possible to sample arterial blood at the brachial artery in the antecubital fossa or femoral artery just distal to the inguinal ligament.
Procedure: Radial Artery
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Position the patient appropriately: sitting comfortably with arm placed on a pillow, forearm supinated, wrist passively dorsiflexed
• D Confirm ulnar arterial supply to the hand before starting (modified Allen's test):
• Compress the radial and ulnar arteries with your thumbs
• Ask the patient to make a fist and to open it
• The hand should appear blanched
• Release pressure from the ulnar artery and watch the palm
• The palm should flush to its normal colour
• D If not, there may be inadequate ulnar arterial supply and damage to the radial artery during blood taking may result in critical ischaemia. Test the other side
• Put on your gloves
• Identify the radial artery with index and middle fingers of your non-dominant hand
• Clean the site, beginning centrally and spiralling outwards
• Whilst the sterilizing solution dries, remove the needle and syringe from packaging and attach the needle to the end of the syringe
• Eject excess heparin from the syringe through the needle:
• © Check local equipment. Some heparinized syringes contain a heparinized sponge and excess heparin/air should not be expelled
• Warn the patient to expect a 'sharp scratch
• Whilst palpating the artery (but not obliterating the pulsation), insert the needle just distal to your fingertips, bevel facing proximally, at an angle of 45-60° until a flashback is seen within the chamber of the needle
• Hold the syringe steady and allow it to fill itself with 1-2mL blood
• As you withdraw the needle, apply the gauze swab to the site, maintaining firm manual pressure over for at least 2 minutes
• Dispose of the needle and apply a vented cap, expelling any excess air:
• (This may not be necessary depending on your equipment see above).
Procedure: Brachial artery
• Similar procedure as above except...
• Position the elbow in extension. Angle the needle 60°
Procedure: Femoral Artery
• Position the patient with hip extended
• The pulse is felt 2cm below the midpoint between pubic symphysis and anterior superior iliac spine
• Angle the needle at 90° to the skin
• Pressure must be applied for at least 5 minutes.
