Prework Videos for Nov 30th 2022 Procedure Day are highlighted in red!
Goals for the following procedures:
Residents should…
-
Name the indications, contraindications and complications
-
Be familiar with the equipment used for the procedures
-
Perform the procedure below
Paracentesis:
Indications:
-
Diagnostic: where is fluid coming from, what is the fluid, is there an infection (takes 20cc fluid to do all tests)
-
Therapeutic: to alleviate symptoms
Contraindications:
Complications:
-
Risks: bleeding, infection, bowel perforation (watch for inferior epigastric artery, L preferred over R as may gather gas in ileo-cecal junction)
-
Most common complication: post-tap leak, treated with ostomy bag, pressure dressing or dermabond
Diagnostic Tests:
When to give albumin:
-
Large volume paracentesis, >5L recommendation is 6-8gm/L taken
-
SBP, 1.5gm/kg on day 1, 1gm/kg on day 3
Simulated Paracentesis Discussion Topics:
-
How to perform a z-line
-
Centimeter markings on catheter (how do these correlate with u/s image)
-
How do you create a wheal when anesthetizing the skin
-
How do you aspirate as you push a needle in (i.e. correct syringe holding technique)
-
Signs you have perforated bowel (pain, feces in tubing, air in tubing)
-
Common mistakes (not going deep enough with the needle/catheter setup)
-
How to troubleshoot air in tubing (place moistened gauze around catheter outside the body)
Paracentesis NEJM Online Video - 10 min
Paracentesis Ultrasound Video - 2 min
Thoracentesis:
Indications:
-
Diagnostic: transudate vs. exudate (Most patients with a new pleural effusion should undergo diagnostic thoracentesis unless there is a small amount of fluid and secure diagnosis or CHF with typical features).
-
Therapeutic: for symptom relief or for complicated pleural effusions (no more than 1-1.5L of fluid - more than this can precipitate flash pulmonary edema)
Contraindications:
Complications:
Diagnostic Tests:
-
Cell Count, Gram Stain, pH, Culture
-
TP/LDH for lights criteria - TP ratio >0.5, LDH ratio >0.6 or LDH>2/3 upper limit of normal
-
ADA for TB
-
Amylase for pancreatitis or Boerhaave
-
Triglycerides for chylothorax (>110 is diagnostic)
-
Turbidity (if debris filled, may be rheumatoid effusion)
-
Glucose (<60 suggests bacterial infection, unless patient is hypoglycemic)
Simulated Thoracentesis Discussion Topics:
-
How do you avoid the intercostal NAV bundle? (put needle into bone, then track over)
-
Common mistakes (not going deep enough with the needle/catheter setup)
-
Signs of pneumothorax (chest pain, air in tubing)
-
How to troubleshoot air in tubing (place petroleum gauze around catheter)
-
Controlled pressure removal of fluid
-
How do you aspirate as you push a needle in (i.e. correct syringe holding technique)
-
How to remove catheter (pt humming, petroleum gauze to cover hole)
Thoracentesis NEJM Video - Try this video first - esp. if you are on campus. 9min
Alternate Thoracentesis Video if you have trouble with the first. 6min
Thoracentesis Ultrasound Video - 2 min
Lumbar Puncture:
Indications:
-
Diagnostic: Infectious (meningitis, encephalitis, myelitis), multiple sclerosis, Guillain-Barre, leukemia, metabolic disease), anesthesia.
-
Therapeutic - chemotherapy, antibiotic administration
Contraindications:
-
Cardiorespiratory compromise
-
Cerebral herniation
-
Increased intracranial pressure
-
Focal neurologic deficits
-
INR>1.4, Plt<50K
-
Lumbar surgery
Complications:
-
Risks: bleeding, infection, herniation, headache, subarachnoid epidermal cyst, CSF leakage
Diagnostic Tests:
Simulated Lumbar Puncture Discussion Topics:
-
Finding L4 with the iliac crest
-
Positioning is key (spine should be parallel to the table and back should be arched)
-
Lateral recumbent position preferred for manometry but sitting position is often an easier position for the procedure.
-
15 degrees cephalad – "point to the umbilicus"
-
Bevel in the sagittal plane
-
only need about 2cc per tube
-
Replace stylet before removing the needle
NEJM LP Online Video - 11 min
5 Min Sono LP Video - 5 min
Ultrasound Basic Goals
(consider using any of the core POCUS exams to demonstrate these skills)
- Demonstrate how to orient the patient, transducer, and machine.
- Name some of the applications for the phase array, curvilinear and linear probes.
- Show how to change transducers and transducer settings (e.g. pulmonary setting VS cardiac VS MSK)
- Show how to use the gain, depth and various modes of the machine.
- Demonstrate how to enter patient information and save/print images.
- Show how to access archived images and videos
A little POCUS Intro Video - 4 min
POCUS Teaching Page with core POCUS exam examples and videos
Procedural Ultrasound Skill Basics
(looking at vasculature)
- identify a vein and artery
- demonstrate venous compression, arterial pulsatility, color mode and venous return with augmentation (compression of distal structures).
- Find the brachial, basilic,and cephalic veins.
- attempt a procedure under ultrasound guidance using the following approaches:
- in plane transverse
- in plane longitudinal
- out of plane transverse
Vascular Access Video - Please watch part 1 - 5 min
Comments (0)
You don't have permission to comment on this page.