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Procedure Day Syllabus

Page history last edited by dstromberg@salud.unm.edu 1 year, 4 months ago

 

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:

  • Overlying cellulitis/zoster

  • Limited or no fluid

  • DIC (There is technically no INR/Platelet contraindication level)

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:

  • SAAG - >1.1 suggests portal HTN

  • SBP analysis with cell count - >250 absolute PMNs shows SBP (>100 PMNs if peritoneal dialysis catheter is present)

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:

  • Overlying cellulitis

  • Limited or no fluid

  • Empyema/complicated effusion should be done by IR

  • INR>2, Plt<50K

  • On positive pressure ventilation

Complications:

  • Risks: bleeding, infection, pneumothorax (ultrasound has been shown to reduce this risk)

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

    • Trick to remember the ratios: LDH has more letters and has a higher ratio

  • 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:

  • Cell count with differential

  • Gram stain & culture

  • Glucose, total protein

  • Cytology & AFB stains if indicated.

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

 

 

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