Procedurepalooza 2010 Day 2

1. Procedurepalooza 2010Day 2 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. Thoracentesis

5. Thoracentesis Indications Diagnostic • Has pleural effusion • May be something other than heart failure Therapeutic • Relief of dyspnea, oxygenation

6. Thoracentesis Contraindications • Patient uncooperative • Skin infection • Effusion too small (<1cm) • Known complex pleural disease • May need CT, U/S guidance • Mechanical ventilation • Coagulopathy • INR > 2 • PTT > 2X ULN • Thrombocytopenia (<50K) • Platelet dysfunction (uremia, anti-platelet agents)

7. Thoracentesis Complications • Pneumothorax • Hemopneumothorax • Hemorrhage • Re-expansion pulmonary edema

8. Complications

9. Thoracentesis Consent Preparation • Equipment • Positioning and Draping • Sterility Performance • Local anesthetic, including the periosteum • Walk the needle/catheter into the pleural space • Advance catheter, withdraw needle • Drain and collect sample • Sterile dressing

10. Location, Location, Location Tomsen et al. NEJM 355:e16, 2006

11. Rib Angle

12. Vein, Artery, and Nerve Lac des Pleura V A N

13. Please Note • Diagnostic thoracentesis does not help the patient • Nor does a diagnostic paracentesis • Nor a lumbar puncture • THESE ARE DIAGNOSTIC TESTS • WHAT YOU DO WITH THE RESULTS IS WHAT MATTERS TO THE PATIENT

14. Transudate vs Exudate • Key initial step in differential diagnosis • Light’s Criteria for exudative effusion (any 1 of 3): 1) Pleural fluid/Serum total protein > 0.5 OR 2) Pleural fluid/Serum LDH > 0.6 OR 3) Pleural fluid LDH > 2/3 the upper limit of normal serum • 98% sensitive/83% specific for exudate • 25% of transudates characterized as exudates • Typically in patients on diuretics Light, Ann Intern Med 77:507;1972/NEJM 346:1971;2002

15. Template Slide • Template Text Porcel and Light, Am. Fam. Physician 73:1211, 2006

16. Lumbar Puncture

17. Lumbar Puncture • Where is CSF produced? • Where is it stored? • What are some common indications and contraindications for an LP? • How do I perform an LP? • How do I interpret the results?

20. Lumbar Puncture Indications Diagnostic • Infectious • Inflammatory • Oncologic • SAH Therapeutic • Anesthesia • Antibiotic administration • Chemotherapy • Pseudotumor cerebri

21. Lumbar Puncture Contraindications • Cardiorespiratory compromise • Potentially increased ICP • Coagulopathy • Previous lumbar surgery

22. Who needs a CT before their LP?

23. CT indicated prior to LP • Altered mental status • Papilledema • Focal neurologic signs • Recent seizures • Immunocompromised • Elderly?

24. Technique Consent Preparation • Equipment • Positioning • Landmarks Performance • Local anesthesia • Procedure • Opening Pressure • Specimen handling

25. Positioning

26. Landmarks

27. Preparation • Mark desired point of entry • Sterile technique • Gloves • Gown • Clean area • Drapes • Local anesthetic

28. Procedure • Insert needle with stylus in place • Bevel in sagital plane • Angle toward umbilicus (15 degrees cephalad) • Needle will pass through: • Skin and subcutaneous tissue • Supraspinous ligament (c) • Interspinous ligament (b) • Ligamentum flavum (a) • Epidural space • Subarachnoid space CSF!!!

29. Opening pressure • Only obtained in lateral decubitus position • Attach stopcock to hub of needle • OP is highest number obtained by column • Normal is 9-18

30. Lumbar Puncture Specimen Handling • Collect 3-4 mL per tube • Use fluid in manometer first! • Cell count and diff • Protein and glucose • Gram stain and Cx • Special testing (e.g. HSV PCR, VDRL, etc.)

31. Lumbar Puncture Complications • Post LP Headache: ~25% • Back and radicular pain • Infection • Bleeding • CSF leak • Herniation

32. Lumbar Puncture Interpretation of Results • Appearance • Opening Pressure • Cells • Protein • Glucose • Gram stain and culture • Other tests

33. Normal CSF Results • Appearance • Clear, colorless • Opening Pressure • <19 • Cells • <5 WBCs, no RBCs • Protein • 15-45 • Glucose • ~2/3 serum • Gram stain and culture • Other tests

34. Abdominal Paracentesis

35. Paracentesis • Removal of intra-abdominal fluid through needle puncture of the abdominal cavity.

36. Paracentesis Indications • Determine etiology of an intra-abdominal fluid collection. • Infection, hemorrhage, urine, or other • Relief of symptoms related to abdominal fluid collection. • Abdominal distention, shortness of breath, est.. • Unexplained encephalopathy

37. Paracentesis Contraindications • Absolute • Profound hypotension • Relative • Coagulopathy • Renal dysfunction • Skin infection/Burns • Prior abdominal surgery

38. Technique Preparation • Landmarks • Equipment • Performance Procedure • Local anesthesia • Performance • How much to take • Specimen handling

39. Landmarks • Avoid the epigastric arteries and bladder.

40. Preparation • Mark desired point of entry • Sterile technique • Gloves • Gown • Clean area • Drapes • Local anesthetic • Paracentesis tray

41. Procedure • Insert needle through the skin and anterior abdominal wall, into the peritoneal fluid. • Z-line technique • Confirm aspiration of fluid • A catheter-over-needle assembly is used to place a catheter into the cavity for drainage. • Desired amount of fluid is drained • Catheter is removed and wound is dressed.

42. Z-line Technique • Needle is inserted perpendicular to the skin • Tension is maintained on the skin while the needle is advanced through the abdominal wall. • Lowers the risk of bleeding or fluid leakage.

43. Specimen handling • Cell count with differential • Protein, albumin, LDH • Bacterial culture/Gram stain • Cytology

44. Interpretation of Results • Serum-ascites albumin gradient (SAAG) ≥ 1.1 g/dl → portal hypertension related < 1.1 g/dl → non-portal HTN related

45. Complications • Bleeding • Persistent ascitic leak • Renal dysfunction • Transient Hypotension • Intestinal or bladder perforation • Localized infection at the puncture site • Abdominal wall blood clots or bruises • Spontaneous bacterial peritonitis

46. Naso-Gastric Tube Placement

47. Indications • Diagnostic • Evaluation of suspected upper GI bleeding • Aspiration of gastric fluid • Administration of contrast to the GI tract • Therapeutic • Gastric decompression • Administration of medications • Feeding • Bowel irrigation

48. Contraindications • Absolute • Severe midface trauma • Recent sinus surgery • Recent gastric or esophageal surgery • Relative • Coagulation abnormality • Esophageal varices or stricture • Recent banding or cautery of esophageal varices • Alkaline ingestion

49. Technique • Equipment • Positioning • Landmarks • Procedure • Confirmation

50. Equipment • Adult 16-18F Salem sump tubing • Lubricant • Toomey Syringe, 60 ml • Tape • Emesis Basin • Suction Tubing • Wall suction