SLIDE BASIC PRACTICAL PROCEDURES 2024.pptx

SLIDE BASIC PRACTICAL PROCEDURES 2024.pptx

1. BASIC PRACTICAL PROCEDURES IN CT SURGERY

2. Classification Procedures on blood vessels - Venepuncture -Peripheral venous cannulation -Central venous cannulation -Central venous manometry -Venous cutdown cannulation -Arterial puncture

3. Intubation -Nasogastric intubation - Oesephageal tamponade -Endotracheal intubation Urethral/Suprapubic catheterization Abdominal paracentesis Pleural aspiration Pleural biopsy Intercostal tube drainage

4. Indications Diagnostic Therapeutic

5. SEQUENCE Indications /Contra-indications Equipment Informed Consent Sites Antisepsis Anaesthesia /Sedation Procedure Complications

6. Venepuncture Size of needles: 21-gauge for an adult and 23-gauge for a child. Lighting Latex gloves Clench, flicking LA cream 2-step fashion; Y- junction Labelling , disposal

7. VENEPUNCTURE

8. Venepuncture for blood culture Aseptic technique Hand wash, sterile towel Assistant applies torniquet ‘no touch’ technique Substitute another needle for injection into 2 culture bottles – aerobic and anaerobic.

9. Peripheral venous cannulation For intravenous infusions and medications Cannula – different sizes with colour code.

10. Peripheral venous cannulation

11. Central venous cannulation Forsmann 1929 Infusions, inotropes , chemo, TPN, dialysis, manometry Aseptic technique. Scrub, gown. Basilic , subclavian , internal jugular, femoral vein. LA or when patient is under GA Seldinger technique; variety of catheters

12. Central venous cannulation/manometry

13. Venous cut down cannulation Infusions, pacemaker Long saphenous vein, cephalic vein at the wrist and deltopectoral groove

14. Venous cut down cannulation

15. Arterial puncture Sampling for Paco 2, Pao 2 , pH, bicarbonate Haemodynamic monitoring Arteriography Heparinized syringe Seldinger technique for indwelling cathether if BP is to be monitored.

16. Arterial puncture

17. Nasogastric intubation - tube

18. Nasogastric intubation

19. NG intubation

20. Oesephageal tamponade

21. Endotracheal intubation

22. Urethral/suprapubic catheterization

23. Abdominal paracentesis

24. Thoracentesis Diagnostic Therapeutic

25. Indications Thoracentesis is indicated for the symptomatic treatment of large pleural effusions or for treatment of empyemas . It is also indicated for pleural effusions of any size that require diagnostic analysis.

26. Thoracentesis ( thoracocentesis ) Before the procedure, bedside ultrasonography can be used to determine the presence and size of pleural effusions and to look for loculations . During the procedure, it can be used in real time to facilitate anesthesia and then guide needle placement. Pleural biopsy may be required

27. Pleural aspiration

28. Contraindications - relative Uncorrected bleeding diathesis Chest wall cellulitis at the site of puncture

29. Pleural biopsy Abram’s needle Cope’s needle Ultrasound- guided

30. Indications for pleural biopsy Undiagnosed exudative lymphocytic pleural effusions Pleural mass, thickening, or nodularity Recurrent pleural effusion of unknown etiology

31. Pleural biopsy techniques Once pleural biopsy is indicated, various biopsy techniques are available to diagnose pleural disease. These range from older techniques, such as “blind” or closed pleural biopsy, to image-guided and thoracoscopic biopsy. The latter techniques have higher diagnostic yield and provide better diagnostic sensitivity. In addition, the use of immunohistochemistry provides increased diagnostic accuracy.

32. Biopsy techniques Closed Needle Pleural Biopsy: Cope needles and Abram’s needles are most commonly used for blind or closed needle biopsy. This procedure is generally performed in the setting of a large pleural effusion without any imaging other than chest radiography. Image – guided needle biopsy

33. Triangle of Safety Anterior axillary line Midaxillary line 5 th intercostal space

34. TRIANGLE OF SAFETY

35. Consent Consent should be obtained from the patient or family member. The indications, risks, benefits, and alternatives of the procedure; and the risk and benefits of not undergoing the procedure. Allow the patient the opportunity to ask any questions and address any concerns they may have.

36. Procedure - anaesthesia , position Anesthesia In addition to local anesthesia, mild sedation may also be considered. IV midazolam or lorazepam can attenuate the anxiety that may be associated with any invasive procedure. Analgesia is critically important, in that pain is the most common complication of thoracentesis . Local anesthesia is achieved with generous local infiltration of lidocaine . The skin, subcutaneous tissue, rib periosteum , intercostal muscle, and parietal pleura should all be well infiltrated with local anesthetic. It is particularly important to anesthetize the deep part of the intercostal muscle and the parietal pleura because puncture of these tissues generates the most pain. Pleural fluid is often obtained via aspiration during anesthetic infiltration of these deeper structures; this helps confirm proper needle location.

37. Positioning Patients who are alert and cooperative are most comfortable in a seated position (see the image below), leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure.

38. Pleural biopsy Pleural diseases involve the parietal and visceral pleura and may be of infectious, inflammatory, or malignant origin, often resulting in pleural effusions. The diagnostic evaluation of pleural effusions should include pertinent history, clinical course, and radiographic abnormalities and take into account the patient’s desire to pursue aggressive workup. Initial evaluation begins with a thoracentesis and characterization of the fluid as a transudate or exudate , its appearance, turbidity, and even odor ( ie , urinothorax ).

39. Pleural biopsy .. Further analysis includes chemical, microbiological, cytological, and disease-specific analyses depending on the suspected etiology. Transudative pleural fluid is misclassified as an exudate in up to 25% of cases. In order to reduce misclassification, special attention should be paid to the serum-to-pleural protein and serum-to-pleural albumin differences. Differences of more than 3.1 g/ dL and more than 1.2 g/ dL , respectively, indicate a transudate . Rarely, neoplastic pleural diseases can present as a transudate .

40. Pleural biopsy - malignancy Primary pleural malignancies tend to originate from the parietal pleura and spread to the visceral pleura, while metastatic disease ( ie , bronchogenic carcinoma) starts on the visceral pleura and spreads to the parietal pleura. Contrast-enhanced CT scanning of the thorax is indicated for an undiagnosed exudative effusion to assess for parenchymal abnormalities and the extent of pleural involvement..

41. Pleural biopsy – Rheumatoid dx Subsequent pleural biopsy is indicated to evaluate and exclude infectious and malignant aetiologies , particularly malignant mesothelioma . Connective tissue disorders such as rheumatoid disease can also present with pleural involvement, requiring pleural biopsy for diagnosis. In addition, pleural thickening in the absence of pleural effusion may require further histological evaluation. Despite extensive workup, the etiology of pleural effusion remains unclear in nearly 20%-25% of cases

42. Chest drains - Indications Chest drains are inserted as an invasive procedure to; Remove fluid/air from the pleural space/ mediastinum , and/or Re-expand the lungs and restore negative intrapleural pressure and respiratory function. Conditions that require a chest drain include; Pneumothorax - "Air in the pleural cavity". This occurs when there is a breach of the lung surface or chest wall which allows air to enter the pleural cavity and consequently cause the lung to collapse. Pleural Effusion - a collection of fluid abnormally present in the pleural space, usually resulting from excess fluid production and/or decreased lymphatic absorption.

43. Chest drains - Indications… Haemothorax - the presence of blood in the pleural space. The source of blood may be the chest wall, lung parenchyma, heart, or great vessels. Chylothorax - is a type of pleural effusion. It results from lymph formed in the digestive system called chyle accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct. Empyema - is a collection of pus within a naturally existing anatomical cavity. For example, pleural empyema is empyema of the pleural cavity. It must be differentiated from an abscess, which is a collection of pus in a newly formed cavity. Post Cardiac or thoracic surgery

44. Chest Drains - Basics of Breathing Breathing is stimulated by the build up of CO2 levels in the bloodstream. When the diaphragm descends there is an increase in interthoracic space and a decrease in interthoracic pressure. Intrapulmonary pressure also decreases which draws air into the lungs as the pressure outside of the lungs is greater than the pressure inside. Weak diaphragm decreases the available volume making it harder to draw air in and also increases the risk of developing pneumonia . Lungs are surrounded by pleura which have a layer of fluid between them.

45. Basics of breathing… The visceral pleura is attached to the lungs while the parietal pleura is attached to the ribs. The lungs are elastic and want to recoil with the pleura, this elasticity creates the negative pressure which causes the lungs to inflate. Intrapleural pressure is always negative however during inspiration it is more negative (-8cm H2O) whilst during expiration when the diaphragm relaxes it’s less negative (-4cm H2O). If this intrapleural pressure is lost e.g. during a stabbing, the loss of negative pressure will cause the lung to collapse and a chest drain will be needed to restore the correct pressures.

46. Chest drains Chest drains or under water sealed drains (UWSD) provide a method of removing air & fluid from the pleural space. The idea is to create a one-way mechanism (valve) that will let air/fluid out of the pleural space and prevent outside air/fluid from entering into the pleural space. This is accomplished by the use of an underwater seal. The distal end of the drainage tube is submerged in 2cm of H2O. They use flexible plastic tubes which are inserted through the chest wall and into the pleural space between the 5th and 6th intercostal space in the mid-axillary line, venting the space which allows air back out.

47. Principles of UWSD The underwater seal prevents air re-entering the pleural space. Usually, the distal end of the drain tube is submerged 2cm under the surface level of the water in the drainage (or collection) chamber. This creates a hydrostatic resistance of +2cmH20 in the drainage chamber. Normal intrapleural pressure is negative. However, if air or fluid enters the pleural space, intrapleural pressure becomes positive. Air is eliminated from the pleural space into the drainage chamber when intrapleural pressure is greater than +2cmH20. Thus, air moves from a higher to lower pressure along a pressure gradient. The drainage chamber has a vent to allow air to escape the chamber, and not build up within the chamber.

48. Principles.. Fluids will drain by gravity into the drainage chamber, and will not spill back into the pleural space if the bottle is always kept below the level of the patient's chest. If the bottle needs to be lifted above the chest, the tubing should be briefly double clamped as close to the patient as possible. The movement and unclamping should take place as quickly as possible to minimise clamping time.

49. Drainage systems Underwater seal chest drainage. A- Single-bottle system. B- Two bottle system. C- three bottle system Systems Glass Bottle System: 1 bottle: The simplest form of underwater seal drainage systems. This system can drain both fluid and air. The distal end of the drainage tube must remain under the water surface level.There is always an outlet to the atmosphere to allow air to escape.It is suitable for use with a simple pneumothorax , when the vent is left open to the atmosphere, or following a pneumonectomy when the tubing is clamped and released hourly

50. Drainage systems.. 2 bottle : This system is suitable for the drainage of air and fluid. The first chamber is for collection of fluid and the second is for the collection of air. As the two are separate, fluid drainage does not adversely affect the pressure gradient for evacuation of air from the pleural space. A separate chamber for fluid collection enables monitoring of volume and expelled matter. 3 bottle: Suction is required when air or fluid needs a greater pressure gradient to move from the pleural space to the collection system. Suction may be applied via a third bottle or a suction chamber. Plastic System: Thoraseal or Pleuravac  

51. One bottle system

52. Y-Connector

53. 2 bottle system

54. ATRIUM drainage system

55. 'The BTS Guidelines for the insertion of a chest drain, Establish patient on continuous cardiac monitoring and pulse oximetry Place conscious patient in a sitting position at 45 degrees with arm of same side placed above head Palpate the fourth or fifth intercostal space just anterior to the mid- axillary line Surgically prepare the area. Ensure local anaesthetic is infiltrated from subcutaneous tissue down to pleura. Select the appropriate size tube and remove stylet . Incise the skin parallel to the upper border of the rib below the chosen intercostal space. Incise down to the fascia.

56. Guidelines… "Blunt dissect" (using an artery forceps) down to the pleura, enter the pleural space, and then widen the hole by opening the forceps. Sweep the pleural space with a gloved finger to widen the hole and push the lung away from the hole (only possible in older children, beware of rib fractures in injured child). Hold the tip of the catheter with a curved artery clamp and advance it into the pleural space, directing the catheter posteriorly and superiorly. Advance so that all apertures of the tube are in the chest. Attach the tube to UWSD below the patient's chest level. Anchor the drain and suture the wound. Tape in place with tegaderm sandwich and anchor the tube to the patient's side. - Connect to the UWSD. Watch for "swinging" of water in tube connection. [6]

57. Complications Pain – chest wall/ neck / shoulder Failure to enter the pleural space Infection at insertion site or intrapleurally Penetration / lacerations to lungs Penetration of peritoneal space - laceration of the diaphragm Haemorrhage Blocked drains Pleural sepsis Subcutaneous emphysema Tumor seeding

58. Minor complications Dry tap Cough Subcutaneous hematoma Subcutaneous seroma Vasovagal syncope

59. Assessment of a Chest Drain Important aspects that should be noted include: Location: Anterior Basal Right or Left side etc Pain Swing/Oscillation - Normal – reflects the changes in pleural pressure on breathing (if not on suction). Will gradually lessen and stop as lung re-expands. If drain is not swinging; Gradual : lung re-expanded, Sudden : ?obstructed or ?lung collapse, Check for suction : Wall suction – no swing

60. Assessment … Draining- Denotes volume of fluid draining from pleural space. Dependent on pathology; Post op – mostly occurs in first few hours, Fluid – slow drainage, Pneumothorax – minimal. If amount in bottle is excessive, its more difficult for air to be expelled. If there is a lack of drainage – check for kinks or obstruction Bubbling- Reflects the amount of air draining out of the pleural space. Usually occurs during expiration or coughing. May also occur on inspiration if big air leak present. Large volume air leaks may require suction to remove air; if persistent may require pleurodesis . Continuous bubbling – means there is a connection between the lung and intra pleural space. If bubbling stops check for; Kink, Blockage, Disconnection.

61. Assessment… Suction - Application of a negative pressure (3-5kPa) to restore negative pressure in the pleural space. Typically used if there is a large volume of air or fluid to be removed from the pleural space CXR Auscultation

62. Handling of Chest Drain Familiarise yourself with the location of the clamps in case of emergency or breaking of the bottle. Drains should be on the floor on their stand for gravity drainage Keep bottles/drains below the level of the patient’s chest – if you need to move the patient from lying to sitting this should be done on the side the chest drain is on Clamping should be avoided if at all possible – can cause a tension pneumothorax which leads to compression of the heart and a mediastinal shift which can be fatal. Don’t pass the chest drain over the patient – loss of gravity could cause contents to spill back into the pleural space. If you knock over the chest drain: put it back upright, check the levels and perform the necessary tests to make sure it’s still working properly. If theres a suction port attached to the chest drain and you need to mobilise the patient you have to get surgical permission to temporarily disconnect the suction

63. Accidental Disconnection of Tube Part of the system becomes disconnected or drain/bottle breaks; Clamp the tubing close to the patients chest Reconnect with sterile tubing or new drain Unclamp and restore drainage Report the incident

64. Removal of chest drains Criteria for removal of chest drains Less than 100ml of drainage in 24hours Minimal swing Chest X-ray establishing full lung expansion Breath sounds present over the whole thorax on auscultation No air leak