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Procedurepalooza 2010 Day 3

Procedurepalooza 2010 Day 3. Jason Poston Section of Pulmonary and Critical Care Department of Medicine University of Chicago. Source: ABIM Website 3/31/09 http://www.abim.org/certification/policies/imss/im.aspx#procedures. Goals. Remind you of what you already know

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Procedurepalooza 2010 Day 3

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  1. Procedurepalooza 2010Day 3 Jason Poston Section of Pulmonary and Critical Care Department of Medicine University of Chicago

  2. Source: ABIM Website 3/31/09 http://www.abim.org/certification/policies/imss/im.aspx#procedures

  3. Goals • Remind you of what you already know • Encourage a systematic approach to procedures • Should we do it? • Will we get in trouble? • How do we do it? • What happens once we’ve done it?

  4. Incision and Drainage of an Abscess

  5. Indications • Primary therapy for cutaneous abscesses • Often obviates need for antibiotics • Exam shows tender, indurated, fluctuant area • Needle aspiration • US • Amenable for I & D if > 5mm in diameter

  6. Contraindications • Extremely large abscesses • Deep or difficult to access lesions • Areas of cosmetic concern • Cellulitis without abscess

  7. Complications • Pain • Bleeding • Progression or recurrence of abscess • Endocarditis?

  8. I & D Abscess: Technique NEJM: Videos in Clinical Medicine http://content.nejm.org/cgi/video/357/19/e20/

  9. Questions?

  10. Peripheral Intravenous Cannulation and Venous Blood Draw

  11. Peripheral Intravenous Cannulation • Indications: • IV drug administration and fluid hydration • IV hydration • Transfusions of blood and blood products • Surgery and Emergency Care • Contraindications: • Site specific: • Infection • Phlebitis • AV fistula in the extremity • Previous surgical procedures in the extremity (ex: LN dissection)

  12. Peripheral Intravenous Cannulation • Complications: • Pain • Bruising • Bacterial Infection • Extravasation • Phlebitis • Thrombosis • Embolism • Nerve Damage

  13. PIC: Equipment • Gloves, Eye Protection • Tourniquet • Chlorhexidine antiseptic solution • Saline Flush • 2 x 2 Gauze • Transparent Tape • Catheter

  14. PIC: Catheter Size • Ranges 14 gauge - 24 gauge • Choose smallest effective catheter • 14 G and 16 G for emergent resuscitation

  15. PIC:Choosing a Site • Preferred: Forearm • Antecubital fossa in emergencies • Dorsal veins in foot or saphenous have a higher incidence of thrombosis and embolism

  16. The Procedure • Position the patient supine with the arm supported • Tie tourniquet with 1/2 knot 8-10 cm above targeted insertion site • Inspect and palpate veins • Clean selected site with chlorhexadine • Spin the hub of the catheter to ensure it slides easily around needle • Use nondominant hand to apply traction to the vein distal to insertion site

  17. The Procedure • Hold catheter with dominant thumb and index finger • Insert Catheter with bevel up at 5 - 30 degree angle through the skin and into the vein • Less angle is required for more superficial veins • When flash of blood enters catheter, lower catheter to angle almost parallel to the skin and advance catheter • Remove Tourniquet • Apply pressure to vein proximal to the end of the catheter to prevent blood loss as you remove needle from catheter

  18. The Procedure • Flush with saline to confirm patency Never reinsert needle into catheter! • Check for swelling, redness, leakage or discomfort around insertion site • Attach IV tubing • Secure catheter with transparent occlusive dressing at the hub. • Loop IV tubing and secure to the skin

  19. Drawing Venous Blood • Indications • To obtain a variety of blood values • Contraindications • Site Specific • Areas of burns or scarring • Area with hematoma or edema • Extremity with previous surgical intervention (ex: Mastectomy) • Area near an IV (distal draw is acceptable)

  20. Drawing Venous Blood • Complications: • Bleeding • Hematoma • Swelling • Infection

  21. Drawing Venous Blood • Equipment: • Gloves, Eye Protection • Chlorhexidine antiseptic solution • Needles • Gauze and adhesive bandage

  22. Drawing Venous Blood • Choosing a Site • Upper Extremity Ideal • Avoid areas listed in contraindications

  23. Drawing Venous Blood • Follow the same steps as PIC to choose, sterilize and apply traction to a vein • Insert needle at 15 - 30 degree angle • With flash, attach evacuated collection tube (in series if more than one) • Remove tourniquet before the last container fills. • Apply pressure at insertion site as needle is removed • Hold pressure to prevent hematoma formation; Cover with occlusive bandage

  24. Questions?

  25. Arthrocentesis

  26. Indications • Aspiration for diagnostic testing • Aspiration for relief from pressure • Injection of Medication • Glucocorticoids • Local anesthetic

  27. Contraindications

  28. Complications • Bleeding • Leakage of joint fluid • Infection • Post-injection flare • Flushing (with Kenalog)

  29. The Procedure • Position and palpate • Sterilization • Iodine • Chlorhexidine • Anesthesia • Ethyl chloride • 1% lidocaine

  30. The Procedure • More about sterility • Because you never touch prepped skin, sterile gloves are not a necessity • Equipment • Needle (22 gauge default) • Syringe (6 cc default)

  31. Knee Anatomy

  32. Fluid Analysis • Gram stain and culture • Remember low sensitivity for gonococcus • Cell count and differential • Crystal analysis

  33. Monosodium urate crystals

  34. CPPD crystals

  35. Injection • Own set of contraindications • Possible infection • DM • One joint worse than others • Early osteoarthritis, candidate for repair

  36. What do you inject? • Glucocorticoids • Triamcinolone acetonide (Kenalog) • Methylprednisolone (Depo-Medrol) • Triamcinolone hexacetonide (Aristospan) • Analgesics • Lidocaine

  37. Questions?

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