Therapeutic procedures

A review of some imp ward and icu procedures.

1. THERAPEUTIC PROCEDURES PRESENTED BY: DR DURGESH KUMAR JUNIOR RESIDENT DEPARTMENT OF RADIOTHERAPY

2. VARIOUS THERAPEUTIC PROCEDURE I V CANNULATION INJECTION TECHNIQUES RYLE TUBE INSERTION FOLEY CATHETERIZATION ABDOMINAL PARACENTESIS INTRA PERITONEAL CHEMOTHERAPY PLEURAL FLUID ASPIRATION LUMBAR PUNCTURE CENTRAL VENOUS ACCESS CPR ENDOTRACHEAL INTUBATION

3. INTRAVENOUS CANULATION . A cannula is a flexible tube that can be inserted into the body.

4. INDICATIONS Repeated blood sampling Intravenous fluid administration Intravenous medications administration Intravenous chemotherapy administration Intravenous nutritional support Intravenous blood or blood products administration Intravenous administration of radiological contrast agents for computed tomography, magnetic resonance imaging, or nuclear imaging THE SITES TO BE AVOIDED Wrist Legs, feet, ankles Veins below a previous IV infiltration Vein below a phlebitic area Sclerosed or thrombosed veins Areas of skin inflammation An arm affected by a radial mastectomy, edema, blood clot, or infection. An arm with an arteriovenous shunt of fistula local complication: -Infiltration. -Extravasation. -Thrombosis. -Cellulitis. -Phlebitis. systemic complication: -Embolism. -Hematoma. -Systemic infection -Allergic reaction.

5. INJECTION It is an infusion method of putting fluid into the body, usually with a syringe and a hollow needle which is pierced through the skin to a sufficient depth for the material to be administered into the body. Syringe – a device made of a hollow tube and a needle that is used to force fluids into or take fluids out of the body Needle- larger the gauge smaller is the needle.

6. INTRADERMAL INJECTION Indications: For diagnostic purposes (allergies and sensitivities to drugs) For administering tuberculin testing Most commonly used site: Inner surface of the forearm Subscapular region of the back can be used as well as the deltoid region. Intradermal literally means “between the skin layers” and injection is administered just under the epidermis . Syringe is positioned at15 ˚ angle .

7. SUBCUTANEOUS INJECTION Common sites used for SQ route: Outer aspect of the upper arm Abdomen(from below the costal margin to the iliac crests) Anterior aspects of the thigh Upper back Upper ventral or dorsogluteal area Indications: Used commonly for insulin injections Heparin Filgrastim Anti rabies TECHNIQUE Hold syringe in the dominant hand between the thumb and forefinger. Inject the needle quickly at an angle of 45 to 90 degree, depending on the amount and turgor of the tissue and the length of the needle

8. INTRAMUSCULAR INJECTION SITE Deltoid muscle Dorsoglutea l Ventrogluteal Vastus lateralis Rectus femoris PROCEDURE 3cc syringe can be used for IM injection with g22 or 23 needle; 1-2 inches long Position the needle at 90˚ angle. Do not forget to aspirate the plunger once injected to check for blood. Inject medication slowly (To minimize pain) Apply pressure to site and massage after.

9. INTRATHECAL INJECTION four agents are licensed for intrathecal chemotherapy. are methotrexate, cytarabine (Ara-C), hydrocortisone, and, rarely, thiotepa

10. Lumbar Puncture Procedure : Lying down L2/L3 level downwards Needle between 2 spinal processes with cutting edge of the bevel in direction parallel to ligamentum flavum . Needle is introduced sligthly upward and forward. At about 4-7 cm firmer resistence of ligamentum flavum & give in sensation is felt when dura is breached . Contraindications Infection or wound at the site of LP Bleeding tendency. Intracranial or intraspinal mass lesions Complications Low pressure H/A. Hematoma. Cerebral herniation. Infections. Neural injury. LBP.

11. Nasogastric Intubation (RYLE’s Tube)   One meter long 3 lead shots in the tip – radio opaque Level markings I marking – 40 cm – O-G junction II marking – 50 cm - Body of stomach III marking – 60 cm – Pylorus of stomach Diagnostic indications Evaluation of upper gastrointestinal (GI) bleeding ( ie , presence, volume) Aspiration of gastric fluid content Identification of the esophagus and stomach on a chest radiograph Therapeutic indications Gastric decompression, including maintenance of a decompressed state after endotracheal intubation, often via the oropharynx Relief of symptoms and bowel rest in the setting of small-bowel obstruction Aspiration of gastric content for poisoning cases Administration of medication Feeding Bowel irrigation

12. PROCEDURE

13. CONTRAINDICATIONS Absolute contraindications - Severe midface trauma Recent nasal surgery Relative contraindications - Coagulation abnormality Esophageal varices or stricture Recent banding or cautery of esophageal varices Alkaline ingestion COMPLICATIONS Rhinitis Pharyngitis Esophageal ulceation Aspiration pneumonia if inserted in trachea STOMACH WASH It is done in cases of poisoning . A large no . Ryle tube 22 or 24 is inserted and clean water is pushed into the stomach rapidly and let the gastric content flow out after wards , repeat it till fluid is clear . Collect the first sample for medicolegal and testing purposes .

14. URINARY CATHETERIZATION Catheterization of the urinary bladder is the insertion of a hollow tube through the urethra into the bladder for removing urine. It is an aseptic procedure for which sterile equipment is required. Diagnostic indications Collection of uncontaminated urine specimen Monitoring of urine output Imaging of the urinary tract Therapeutic indications Acute urinary retention ( eg ,   BPH , blood clots)  Chronic obs truction Initiation of continuous bladder irrigation Intermittent decompression for  neu rogenic bladder Hygienic care of bedridden patients SIZE The French scale (Fr.) is used to denote the size of catheters. Each unit is roughly equivalent to 0.33 mm in diameter (that is, 18 Fr. indicates a diameter of 6 mm). Catheters come in several sizes: a. Number 8 Fr. and 10 Fr. are used for children. b. Number 14 Fr. and 16 Fr. are used for adults. c. Number 20 Fr. and 22 Fr. are usually used for adults with gross hematuria .

15. EQUIPMENT REQUIRED Catheter 10cc syringe Sterile water Cotton balls with betadine Lubricant Sterile gloves. Flashlight or lamp. Urine collection bag. Velcro leg strap or anchoring tape. Disposal bag. PROCEDURE Explain the Procedure to the Patient. Provide for Privacy and Adequate Lighting. Positioning female patient - dorsal recumbant male patient - supine position

16. INSERTING FOLEY IN MALE INSERTING FOLEY IN A FEMALE

17. ABDOMINAL PARACENTESIS INDICATIONS For evaluation of new onset ascites. Testing of ascitic fluid. For evaluation of patient with ascitis who has signs of clinical deterioration like fever , abdominal pain,hepatic encephalopathy , decreased renal function n metabolic acidosis. Paracentesis can identify unexpected diagnosis such as chylous , hemorrhagic or esinophilic ascites useful to know etiology n antibiotic susceptibility. Abdominal paracentesis is a bed side clinical procedure in which needle is inserted into peritoneal cavity and ascitic fluid is removed. CONTRAINDICATIONS Pt with DIC – risk is decreased by administering platelets or FFPs. Primary fibrinolysis ( pt with 3 dimensional bruises) treat with aminocaproic acid or IV tranexamic acid. Massive ileus with bowel distension. Near the surgical scar bcoz scars are asso . With tethering of bowel to abd.wall n will cause bowel perforation. Infections

18. PROCEDURE CHOICE OF NEEDLE DIAGNOSTIC: 1.5 Inch, 22 Gauge needle THERAPEUTIC: 15/ 16 Gauge POSITION Mostly Supine Head may be elevated SITE Lt lower Quadrant (Dullness on percussion) 3cm medial & 3cm above the ant. Sup. Iliac spine TECHNIQUE Choose the site & sterilise with Iodine or Chlorhexidine and than pass the needle tangentially, raising a wheal with Lignocaine. “Z” track creates a non linear pathway b/n Skin& Ascitic fluid & minimise the chance of leakage.

19. INTRA PERITONEAL CHEMOTHERAPY Used in advanced ovarian tumor or where disese is less than 1 cm . Taxane & platinum based chemotherapy compounds are used. It can be deliverd by using portacath , grosshong catheter or single use percutaneous catheter . Before IP therapy peritoneal cavity must be drained as completely as possible .

20. PLEURAL FLUID ASPIRATION INDICATIONS DIAGNOSTIC LARGE PLEURAL EFFUSION CARDIO RESPIRATORY EMBARASSMENT INFECTED PLEURAL FLUID ACUTE PULMONARY EDEMA PERSISTENT PLEURAL EFFUSION INSPITE OF ANTI TUBERCULOUS TREATMENT . CONTRAINDICATIONS Local infection over proposed site of thoracentesis (e.g. cellulitis, herpes zoster). Select another entry site . Uncontrolled bleeding ,Coagulopathy is a relative contraindication. Caution must be exerted when performing thoracentesis in mechanically ventilated patients. The positive pressure of the ventilator may expand the lung to greater than normal volumes, increasing the potential risk of pneumothorax. Ultrasound-guided thoracentesis is recommended in this situation Defer thoracentesis in patients with severe hemodynamic or respiratory compromise until the underlying condition is stabilized

21. PROCEDURE POSITION : patient sit up against a back rest or leans forward resting the arms on the tip of a bed table. SITE : 7 th or 8 th intercostal space in midaxillary or scapular line .The part is prepared with cetavlon or iodine and spirit . LOCAL ANAESTHETIC : skin , subcutaneous tissue and parietal pleura are infiltrated with 2% lignocaine . PUNCTURE: The aspiration needle is introduced at right angles to the skin , midway between two rib near the upper border of lower rib and advanced till pleura is ruptured whih is indicated by GIVE IN . The needle is now attached with 50 ml syringe and two way stop cork and about 500-1000ml of fluid is removed at a time. Aspiration must be stopped if patient coughs .

22. Central Venous Catheter PICC (Peripherally inserted Central Catheter) Percutaneous(Subclavian) Percutaneous (IJ-Int. Jugular) Tunnelled (Hickman) Implanted Port (single or double lumen) Catheters inserted into large veins in central circulation SITES

23. Central Venous Access INDICATION Patients requiring multiple sites for IV access Patients lacking useable peripheral IV sites Patients requiring central venous pressure monitoring Patients requiring total parenteral nutrition Patients receiving incompatible medications Patients requiring multiple infusions of fluids, medications, or chemotherapy Patients requiring long term antibiotic therapy Patients subject to frequent blood sampling or receiving blood transfusions Patients requiring a temporary access site for hemodialysis Patients receiving infusions that are hypertonic, hyperosmolar or infusions that have divergent pH value

24. Relative Contraindications Bleeding disorders Anticoagulation or thrombolytic therapy Distorted local anatomy Cellulitis, burns, severe dermatitis at site Vasculitis COMPLICATIONS Vascular Air embolus Arterial puncture Arteriovenous fistula Hematoma Blood clot Infectious Sepsis, cellulitis, osteomyelitis, septic arthritis Miscellaneous Dysrhythmias Catheter knotting or malposition Nerve injury Pneumothorax, hemothorax , hydrothorax, hemomediastinum Bowel or bladder perforation

25. Location Advantage Disadvantage Internal Jugular Bleeding can be recognized and controlled Malposition is rare Less risk of pneumothorax Risk of carotid artery puncture pneumothorax possible Femoral Easy to find vein No risk of pneumothorax Preferred site for emergencies and CPR Fewer bad complications Highest risk of infection Risk of DVT Not good for ambulatory patients Subclavian Most comfortable for conscious patients Highest risk of pneumothorax, should not do on intubated pts Should not be done if < 2 years Vein is non-compressible

26. PICC Overview Peripherally Inserted Central Catheters Designed for patients that need moderate intravenous therapy (5 days - 1 year) Bedside placement Lower infection rate than IVs or CVCs (3% infection rate) less stenosis or phlebitis VEINS TO BE SELECTED Basilic vein Cephalic vein Median cubital vein Brachial vein Greater sapheous vein in neonates

27. Implantable Ports Devices Ports are usually placed in the upper chest, just below the clavicle . Similar to tunneled catheter except access obtained through s/c reservoir (port) which lies in a minor surgically devised pocket Reservoir connected to tunneled catheter and tip position at the junction of the superior vena cava and the right atrium The port reservoir is constructed from either plastic or metal ( stainless steel or titanium) Has a centrally positioned silicone diaphragm (septum) Accessing device involves puncturing the septum with a non-coring needle Successful access is confirmed by aspiration of blood Silicone septum is typically designed to withstand 1K – 2K punctures during lifetime of port

28. Device selection Type of VAD Dwell time Tip placement Conventional peripheral catheters 48 - 72 hrs Peripherally below axillary vein Midline catheters 2 – 4 weeks Basilic or cephalic PICC Over 48 hrs to 1 year SVC tip placement Tunnelled catheter & ports Over 6 weeks to over 1 year SVC tip placement

29. CARDIOPULMONARY RESUSCITATION) Cardio pulmonary resuscitation (CPR) is a technique of basic life support for the purpose of oxygenation to the heart, lungs and brain until and unless the appropriate medical treatment can come and restore the normal cardiopulmonary function. BASIC STEPS OF CAB C-COMPRESSION A-AIRWAY B-BREATHING

30. CHEST COMPRESSION TECHNIQUE The palm of one hand is placed in the concavity of the lower half of the sternum 2 fingers above the xiphoid process. ( AVOID xiphisternal junction → fracture & injury). The other hand is placed over the hand on the sternum. Shoulders should be positioned directly over the hands with the elbows locked straight and arms extended. Use your upper body weight to compress. Sternum must be depressed atleast 5 cm in adults, and 2-4 cm in children, 1-2 cm in infants . Must be performed at a rate of 100-120/min During CPR the ratio of chest compressions to ventilation should be as follows: Single rescuer = 30:2 In the presence of 2 rescuers chest compressions must not be interrupted for ventilation

31. AIRWAY HEAD TILT AND CHIN LIFT JAW THURST BREATHING BAG AND MASK VENTILATION MOUTH TO MOUTH

32. ENDOTRACHEAL INTUBATION INDICATIONS Respiratory arrest Failure or contraindication to NPPV Hemodynamic instability Decreased level of consciousness Severe dyspnea with use of accessory muscles and paradoxical abdominal motion Respiratory rate greater than 35 breaths per minute Life threatening hypoxemia (PaO2<40 MM Hg) Severe acidosis (pH<7.25)and or hypercapnia (PaCO2>60 MM HG)

33. ENDOTRACHEAL INTUBATION