Procedures
Central Line
Central line
kit (single or triple lumen)
Blue IV
adapter caps (3 for triple lumen)
Suture 2-0
silk Needle driver
Chlorhexidine
scrub Saline flushes
SiteRite
& sleeve Mask, gown and
gloves
Helpful Subclavian Hints: Place
patient in Trendelenburg (15-20 degrees) and turn their head away from the
target vessel. Identify the lateral
margin of the posterior belly of the SCM muscles as it inserts into the clavicle. Your needle insertion site is 1 cm inferior
and 1 cm lateral to the inferior aspect of the clavicle at this point. Be sure to anesthetize the periosteum with
Lidocaine. Advance the needle until it
hits the clavicle, pass the needle under the clavicle (keeping it parallel to
the patient’s back…don’t dive in, there’s lung under there!) As you pass the needle point towards the
suprasternal notch…and you should hit the vein. Check to make sure the blood is dark and not red and pulsatile
(arterial). Insert the catheter 15 cm
for a Right sided subclavian, and 17 cm for the Left side. If you hit the Subclavian artery, remove the
needle and hold pressure above and below the clavicle (pinch the clavicle).
Helpful Internal Jugular Hints: Place
patient in Trendelenburg (15-20 degrees) and turn their head away from the
target vessel. Identify the triangle
formed by the anterior and posterior bellies of the SCM muscle and the
clavicle. Your insertion site is near
the apex of this triangle. Use the Site Rite in obese patients or in
patients you suspect may have clots in this area (ie. frequently instrumented
patients). On the Site Rite, the vein
will be compressible, while the artery will not be. Palpate the carotid artery in the triangle and retract it
medially. Insert the needle at a
45-degree angle to the skin into the triangle apex just lateral to the carotid
pulsation, advancing toward the ipsilateral nipple. Insert the catheter 15 cm for a Right IJ, and 17 cm for a Left
IJ. If you hit the Carotid, remove
needle and hold pressure.
If IJ or
subclavian call for STAT CXR to
confirm placement and r/o PTX
Basic tray +/-Lidocaine
Chlorhexidine
scrub Arrow-ART line Suture
Needle
driver Tape to tape down
hand
Ask Nurse to
“set up for an A-line”
Helpful Radial Art-Line Hints: Be
sure to place patient’s hand in a hyperextended position (may have to tape down
their hand to achieve this). Palpate the radial artery with 2
fingertips placed 2 cm apart. Delineate
a line b/n the fingertips, and insert the angiocatheter along this line at a 45
degree angle from the skin, into the radial artery. Once you get a flash of blood in the needle hub, advance the
whole apparatus until the artery is transfixed. Then withdraw the needle and leave the cannula in place. Attach to the transducer and be sure to
suture the cannula down.
Single lumen
central line kit Basic tray
Suture Needle driver Chlorhexidine
Ask Nurse to
“set up for an A-line”
Helpful
Femoral Art-Line Hints: Identify
the pulsation of the femoral artery.
This is your insertion site.
Attach to the transducer, and suture the site down.
LP kit,
Betadine (do not use chlorhexidine!), Band aid, Extra CSF tubes
The minimal
CSF volumes needed for the following tests:
Cell and
differential 1.0
cc
Oligoclonal
bands 5.0
cc
Glucose 0.3
cc
Mycobacteria/AFB 5.0 cc
Protein 0.4 cc
Mycology
cx/Crypto Ag 0.5
cc
Bacteriology 0.5 cc
Virology 0.5
cc
Immunology/Meningitis
screen 1.0 cc
VDRL 0.5 cc
IgG Index
(for multiple sclerosis) 0.5
cc
Cytopath 3.0
cc
You can
often combine several of these tests together in one tube: e.g. tube #1 and
tube #4 (1 cc each) for cell count and diff; tube #2 (1 cc) for
protein/glucose; tube #3 (8 cc) for all of the microbiology which will later be
distributed among the labs, except for VDRL which needs a separate tube. Always remember to collect 1-2 extra “Did
you” tubes for second-thought tests.
Labs can be ordered via ordernet or on a pager path rec (easier)
Helpful Lumbar Puncture Hints: Position
the patient either sitting on the edge of the bed leaning over a table, or
lying on their side in a tight fetal position.
Palpate the superior edge of the iliac crests and create a line b/n it
and the L4-L5 area. After prep and
local anesthesia, insert the needle deeper, anesthetizing the periosteum. Insert the spinal needle between the spinous
processes, angled towards the umbilicus.
Withdraw the stylet periodically, and you should get spinal fluid
(generally this occurs after you feel a “pop”…the entry of the needle into the
dura)
Caldwell
needle Basic tray Lidocaine
Chlorhexidine 10 or 20cc syringe Vacuum Bottles
Angio-cath
tubing- “custom angiographic kit by NAMIC”
Lavender
top, port-a-cult vial, red top, green top
In
general, diagnostic (and many therapeutic) paracentesis fluid should be sent
for:
(1) cell
count and differential (green top (or
lavender top), minimum 1 cc),
(2) gram
stain and bacterial culture, as well as fungal and AFB when indicated (special
green-top, agar-based aerobic port-a-cult
culture bottle, or specimen cup,
or regular blood culture bottles
[blood culture bottles give the best yield]
(3) albumin (to calculate the serum-ascites
albumin gradient, see SBP section below for interpretation) (red top, minimum 1 cc),
(4) consider
total protein, LDH, amylase (if you suspect pancreatitis), cholesterol (if you
suspect chylous ascites), depending on your diagnostic concern (red top).
(5)
cytopath, depending on your diagnostic concern (any container: the more the
better); add 5,000 U heparin/1 L bottle to prevent clotting. If you are doing a procedure on the weekend, you can call the Pathology
resident on call to pick up bottles for cytology, or you can place them in the
refrigerator as soon as possible to preserve the cytology and deliver the
bottles to cytology on Monday to the cytology department 4th floor.
Helpful Paracentesis Hints: The
lower quadrant approach is most often used.
Place the patient in a supine position.
Percuss to find the level of dullness.
Insert the needle along the anterior axillary line, lateral to the
rectus sheath (halfway b/n the umbilicus and the anterior superior iliac spine)
or 1-2 cm below the level of percussed dullness.
Single lumen
central line kit OR Thoracentesis kit with turkel needle
Basic tray Chlorhexidine scrub
Vacuum
bottles (don’t need if using thoracentesis kit, it has a 2 liter bag in it)
Red top,
lavender top, culture bottle
STAT CXR
after procedure
In general,
diagnostic +/- therapeutic thoracentesis fluid should be sent for:
(1) cell
count and diff (green or lavender top),
(2) gram
stain +/- culture (bacteriology, virology, mycology, AFB) (port-a-cult or specimen cup),
(3) glucose,
protein*, LDH*, cholesterol (if you suspect chylous effusion) (red top),
(4) pH (green top) which should be walked to
the critical care lab immediately,
(5)
cytopath, depending on your diagnostic concern (in any container: the more the
better); add 5,000 U heparin/1 L bottle to prevent clotting.
Look
for specialized thoracentesis kits with nearly all the equipment needed. Otherwise, the high-pressure angiographic
tubing, with Kelly clamp and angiocath from the triple lumen kit is a good
alternative.
*Send
corresponding serum tests to calculate fluid to serum ratios.