Procedures Workshop

Joel Pasternack, MD, PhD University of Rochester

Core Procedures
1. Central Venous line - femoral vein, subclavian vein, internal jugular vein 2. Lumbar puncture 3. Foley catheter 4. Nasogastric tube 5. Intravenous line* 6. Arterial Blood Gas* - radial artery, femoral artery
* These procedures are difficult to simulate on a cadaver.

Additional Procedures
Endotracheal intubation - curved blade, straight blade Digital blocks - fingers, thumb, toes Joint aspiration - knee, elbow, ankle Thoracentesis Arterial lines* - radial artery, femoral artery
* This procedure is difficult to simulate on a cadaver.

General Principles
Know the following: 1. Indications 2. Equipment sizes 3. Level of sterility 4. Anatomy and positioning which makes procedure easiest for operator and patient. 5. Complications and modes of failure. 6. Anesthesia/analgesia

Important Caveat for any procedure with a needle **DO NOT SWING THE NEEDLE **

If you need to redirect needle, withdraw to just under the skin, and redirect.

Otherwise, redirecting by swinging allows the needle tip to act like a knife cutting tissue.

Central Venous line

Indications:
- inability to obtain peripheral IV - need for multiple ports and repeated blood draws - need for very large bore access - central pressure monitoring or passage of Swan Ganz catheter or cardiac pacer.

Central Venous line

Adults:
- standard 3-way central line is 7 French (one 16 gauge port and two 18 gauge ports)
- Large bore introducer 9 French

Pediatrics:
- double lumen catheter 4 French for < 10 kg 5 French for > 10 kg

Central Venous line

- Needs to be sterile
- Use large drape to keep the wire sterile.

Central Venous line Positioning

Femoral vein: - Leg extended at hip (difficult with hip flexed) - Slight abduction and external rotation. - Folded towel under buttocks helps in problem cases Subclavian vein: - Slight Trendelenburg (head & shoulders lower than heart) Internal jugular: - Slight Trendelenburg, right IJ preferred (no thoracic duct, straight shot at SVC, dome of right lung is lower) - Sternocleidomastoid muscle defines the 3 approaches (anterior, posterior, central)

Central Venous line

Complications: - hemorrhage - vascular injury - cardiac arhythmia - wire embolus - catheter embolus - air embolus, infection - thrombosis - pneumothorax (subclavian or internal jugular) - airway compromise (internal jugular). Modes of failure: - cant find vein - cant pass wire - catheterize artery - misplacement of subclavian line up into neck

Central Venous line

Anesthesia:
Local lidocaine

Jugular Vein Size Variation

Internal Jugular Vein

Femoral Vein and Artery

Lumbar Puncture
Indications:
Evaluate for: - meningitis - subarachnoid hemorrhage - psuedo-tumor cerebri

Lumbar Puncture
Sterile procedure 22 gauge needle Length: - adults 3 inch - young children 1.5 inch - Indicate top of iliac crests with line on skin - Position patient with back in forward flexion (lying on side or sitting up) - Enter skin at or cephalad to line demarcating iliac crest (stay in mid sagital plane)

Lumbar Puncture
Complications: - paresthesias - nerve root injury (rare)

Modes of Failure: - inability to obtain CSF because puncture site over sacrum - inability to obtain CSF because path of needle not in mid-sagital plane - bloody tap

Lumbar Puncture
Anesthesia: - Local lidocaine

- Conscious sedation for children age 2-10

Foley Catheter
Indications:
- monitor urinary output - relieve urinary obstruction

Foley Catheter
- Sterile technique - Use 16 or 18 French in adults (larger if hematuria with clots) - Coude catheter for difficult catheterization in males

Females - urethral meatus in midline. Males - anatomic position of penis is erect (catheter passes easier as U than S) Hypospadias - urethra is ventral in midline.

Foley Catheter
Modes of failure:

- failure to visualize meatus in females

- failure to pass through prostate with or without catheter looping around in posterior urethra

Foley Catheter
Anesthesia:

Lidocaine Urojet for males

Nasogastric tube
Indications: - decompress stomach in bowel obstruction - assess for UGI bleeding

Nasogastric tube
Adults - Use 18 French Babies - 8 or 10 French - tube goes straight back in nasal cavity - tilt head in extension to get around bend at nasopharynx - flex head forward to keep tube out of trachea.

Nasogastric tube
Modes of failure: - Tube curling around in mouth - Tube in trachea

Nasogastric tube
Anesthesia: Problematic. - LET or Lido w Epi or Cocaine in nose

- Cetacaine spray of throat. (Alternative Lidocaine neb)

Arterial Blood Gas

Indications:
- Assess acid/base status and ventilation

Arterial Blood Gas

- 22 gauge sterile needle - 21 or 23 butterfly w stop cock for additional blood tests - clean gloves
Femoral artery just distal to inguinal ligament way between pubic tubercle & ant. sup. iliac spine but usually palpable pulse Radial artery radial to flex carpi radialis tendon easiest to puncture with full supination forearm and moderate extention wrist

Arterial Blood Gas

Complications: - arterial injury (hematoma, pseudoaneurysm, or thrombosis)

Modes of failure: - inability to hit artery despite feeling pulse. Suggested technique - feel pulse with index and long finger slightly separated -dont push down too hard with proximal finger - keep needle in line of artery - puncture between fingers

Arterial Blood Gas

Anesthesia: Lidocaine without epinephrine

Arterial Lines
- Similar to ABG. - 20 gauge IV catheter or Seldinger technique (kits available)

- Radial line kit with enclosed wire obviates need to sterile drape.

Thoracentesis or Chest tube insertion

Enter thoracic cavity just above a rib rather than just below a rib. Remember the neurovascular bundle is just below the rib. Place chest tubes posterior to pectoralis major in the anterior or mid axillary line.