INTRODUCTION TO

INPATIENT PROCEDURES

A Resident-to-Resident Guide

University of Minnesota Internal Medicine Residency

AHCC Ambulatory Rotation 2006

Second Edition, Revised October 2007

INTRODUCTION

Every procedure carries with it certain common risks; bleeding, potential structural damage, pain, potential for infection, etc. Many of these risks can be reduced or avoided altogether with careful attention to two major points. First, every patient represents an individual complex clinical picture; it is up to the provider to determine how the patient’s medical issues prior to the procedure may affect or hinder a positive outcome. Secondly, one must look at the procedure itself and weigh inherent potential complications against the overall benefit to the patient. Taking stock of these issues will help prepare the medical provider for potential complications before they happen, saving heartache and energy for both the patient and physician.

This handbook will serve to teach six of the common bedside procedures performed by residents on the General Medicine or ICU wards. While this book will teach you the basics, only time and experience will breed proficiency. Good luck!

AHCC 2006

JamesM.Abraham, MD

BaselAl-Aloul, MD

SyedSohailAli, MD

Patrick Foy, MD

JoEllenKohlman, MD

Haresh Kumar, MD

KatherineMarienfeld, MD

TABLE OF CONTENTS

  1. Before and After the Procedure
  2. Informed Consent
  3. Aseptic Guidelines
  4. Procedure Note Documentation
  5. Introduction to Central Venous Catheters
  6. Internal Jugular Central Venous Catheter Placement
  7. Femoral Central Venous Catheter Placement
  8. Arterial Line Placement
  9. Lumbar Puncture
  10. Bedside Paracentesis
  11. Bedside Thoracentesis

INFORMED CONSENT

James M. Abraham, MD

Every procedure, every time. Documentation is paramount particularly when considering performing a procedure. Every therapeutic procedure, despite the best intent, carries with it inherent risks along with the potential benefits. As healthcare providers it is our duty to adequately educate our patients regarding these risks and benefits, providing information and answering questions in lay terms so that the patient (or their surrogate) can make an informed medical decision.

“Informed consent” comprises several different aspects which should be documented in the chart prior to performing any procedure:

  1. Name of the procedure and the diagnosis for which it is being performed.
  2. Risks of the procedure and their likelihood of occurring.
  3. Benefits of the procedure as well as likelihood of information/advantages gained.
  4. Alternative therapies if available, as well as their risks and benefits.
  5. Opportunity for the patient (or surrogate) to ask questions and discuss other options.
  6. Documentation of the patient’s (or surrogate’s) ability to provide adequate informed consent.

Many institutions have “Informed Consent” templates available which help providers review and document each of these important aspects. Make sure these consents are signed and available in the chart prior to any procedure.

Dire situations may arise where a patient is unable to provide informed consent and a surrogate is unavailable; if the patient requires a potentially life-saving procedure emergently and may die without it, the procedure may be performed without informed consent. Once the acute emergency has been dealt with, informed consent from the patient or a designated surrogate should be obtained retroactively as soon as possible.

1Takimoto Y. Maeda S. Slingsby BT. Harada K. Nagase T. Nagawa H. Naga R. Akabayashi A.A template for informedconsent forms in medical examination and treatment: an intervention study.Medical Science Monitor. 13(8):PH15-8, 2007 Aug.

2 Gaeta T. Torres R. Kotamraju R. Seidman C. Yarmush J.The need for emergency medicine resident training in informedconsent for procedures.Academic Emergency Medicine. 14(9):785-9, 2007 Sep.

3Manthous CA. DeGirolamo A. Haddad C. Amoateng-Adjepong Y. Informedconsent for medical procedures: local and national practices. Chest. 124(5):1978-84, 2003 Nov.

4 Davis N. Pohlman A. Gehlbach B. Kress JP.McAtee J. Herlitz J. Hall J. Improving the process of informedconsent in the critically ill.JAMA. 289(15):1963-8, 2003 Apr 16.

ASEPTIC GUIDELINES

JamesM.Abraham, MD and BaselAl-Aloul, MD

One area of significant concern in healthcare today is the incidence of nosocomial infections, particularly those borne out of treatment delivered rather than the presenting illness. Hospitals and healthcare groups are now looking closely at the rate and incidence of infections arising from internally-performed procedures. Considering the vast amount of care delivered on daily basis and the growing bacterial resistance to antibiotics, maintaining sterility of bedside procedures is paramount.

Before opening your procedure kit, make sure to clearly identify the pertinent anatomy for your procedure. Clearly mark your planned point of entry. At this point, using Chloraprep or Betadine swabs (Chloraprep is now preferred given evidence it may in fact better disinfect and antagonize skin flora), gently sterilize the area starting at your point of entry and moving in concentric circles outward. Feel free to sterilize a wide area; this allows you more room to maneuver during the procedure. Repeat this process two or three times to ensure effective skin sterilization. For most procedures, maximum barriers should be used. These include a surgical cap, a face shield or goggles, sterile gloves, and a sterile gown. Maximum barriers also include washing your hands thoroughly before the procedure and using sterile drapes during the procedure. Oftentimes the draping provided in the procedure kits does not provide enough sterile workspace to comfortably perform the procedure. All wards should have packs of sterile towels stocked and available; do not hesitate to use these to extend the sterile workspace if necessary. If you require an assistant to perform the procedure, take time to ensure they are following proper aseptic technique as well.

While these steps may seem cumbersome, it is the responsibility of everyone delivering patient care to reduce infectious risk wherever and whenever possible. Take care to document that these guidelines were followed in your post-procedure note.

1Hu KK.Veenstra DL. Lipsky BA. Saint S. Use of maximal sterile barriers during central venous catheter insertion: clinical and economic outcomes. Clinical Infectious Diseases. 39(10):1441-5, 2004 Nov 15.

2Hu KK.Lipsky BA. Veenstra DL. Saint S. Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review. American Journal of Infection Control. 32(3):142-6, 2004 May.

PROCEDURE NOTE DOCUMENTATION

JamesM.Abraham, MD

The most important thing to do after completing any procedure is documenting how it was performed. The details of the procedure, including findings and complications, will never be as fresh as they are immediately following the procedure. After ordering any pertinent studies and attending to any patient needs after the procedure, take a few minutes to write a short note describing the findings and any treatment plans. Remember, the medical chart is a legal document; it is imperative to keep a clear record of everything that transpires during the medical encounter.

A clear but succinct procedure note includes a description of the procedure performed, the names and titles of the providers performing the procedure (always include the attending physician’s name), pertinent pre- and post-procedure diagnoses, and a mention of the type of anesthesia used (if any). Take care to document that informed consent was obtained (including placing the signed form in the chart). In an emergency, potentially life-saving or critical procedures may be performed without informed consent; informed consent can be obtained retroactively from the patient or a medical decision maker when the emergency is resolved.

Also take a moment to document that aseptic guidelines and sterile barriers were used during the procedure. In 2-3 sentences, briefly describe the procedure and what information was gathered. Document any specimens obtained and studies ordered; take note of any blood loss or complications during the procedure. If there are any post-procedure instructions, include them at the end of the note. The following is a sample procedure note:

PGY-2 Procedure Note

Procedure: Diagnostic/Therapeutic Paracentesis

Performed By: AbrahamMD, Attending Physician MD

Pre-procedure Diagnosis: ESLD/portal HTN with recurrent ascites

Post-procedure Diagnosis: Same

Anesthesia: Local

Informed consent was obtained from the patient/representative after discussion of risks, benefits, and alternatives; consent placed in chart. The abdomen was sterilized and draped per usual aseptic guidelines, sterile barriers were applied. Needle and catheter were introduced into the LLQ under local anesthesia; 5 liters of free-flowing clear yellow ascitic fluid were obtained, 15cc sent for further studies. Catheter was removed and a pressure dressing was placed.

Specimens: 3 tubes of ascitic fluid for routine studies

EBL: Minimal

Complications: None

Have patient lay on right side x2-3hrs, continue pressure bandage for now. Start 25% albumin IV for 40g x1 ASAP. Will await lab results; will reassess once results available.

(If applicable) Attending Physician MD was present/available during the critical elements of the procedure.

INTRODUCTION TO CENTRAL VENOUS CATHETERS

James M. Abraham, MD and Patrick Foy, MD

During your internship and residency, you will hear many different terms for central venous access, i.e. “Hickman”, “Quinton”, “ports”, “triple-lumens”, “IJs”, etc. The key to understanding catheters and their uses is to first understand that they are all just names. When these terms are used generically (as in the examples above), they simply refer to the eponym/brand name, type, size, and functionality of the central venous access. While this jargon may seem overwhelming at first, this basic guide hopefully should help remove some of the mystery.

  1. Types of Venous Access
  2. Peripheral Venous Access
  3. Bedside peripheral IV placement (“PIV”)
  4. Typically lasts for 3 days, should be changed regularly.
  5. Used for IV fluids, antibiotics, peripheral parenteral nutrition, chemotherapy, blood products, etc.
  6. Must be removed prior to discharge.
  7. Midline peripheral IV catheters (“Midlines”)
  8. Lasts for weeks given peripheral placement into a larger (though not central) vein.
  9. Essentially used for same therapies as a PIV.
  10. Must be removed prior to discharge.
  11. Peripherally-inserted central catheters (“PICCs”)
  12. Lasts for months to years if working properly.
  13. Provides central venous access similar to any other central line.
  14. Used for same therapies as a PIV; can also be used for blood draws and TPN.
  15. Placed under sterile conditions usually by a designated Vascular Access/PICC team.
  16. Patients may be discharged with these though this requires an absolute indication as well as specific arrangements for line care. Most PICCs are discontinued prior to discharge. Alert your Discharge Team/Discharge Coordinator ASAP if venous access may be required after discharge.
  17. Central Venous Access
  18. Tunneled catheters
  19. Refers to catheters that are tunneled under the skin prior entering a central vein.
  20. Hickman catheters (brand name; dual-lumen catheters used for TPN, blood products, chemotherapy, large-lumen Hickmans can be placed for dialysis/apheresis).
  21. Broviac catheters (brand name; similar to Hickmans).
  22. Groshong catheters (brand name; characterized by its valve-ended tip rather than an open-ended tip like all other catheters, requires less frequent line flushing).
  23. Tunneled catheters are often referred to by their brand names (Groshong, Hickman, etc.) as this also connotes their functionality.
  24. Typically have lesser rates of infection by taking advantage of dual barriers.
  25. Skin provides a natural barrier to infection.
  26. Dacron cuffs (or similar material) surround the catheter under the skin; this cuff induces fibrin and collagen deposition which stabilizes the catheter in place and provides a second internal barrier against infection.
  27. Generally placed by Interventional Radiology in an OR setting.
  28. Lasts for months to years if working properly.
  29. Never pull a tunneled cuffed catheter unless specifically directed or trained to do so. Pulling a cuffed catheter that has been in place for some time can cause significant pain, vessel injury, and soft tissue injury.
  30. If a tunneled catheter must be removed, contact the service (usually Interventional Radiology) that placed it to discuss/arrange removal.
  31. Tunneled catheters should only be accessed by certified experienced personnel and only after discussing with the primary service responsible for the access (Nephrology for tunneled dialysis catheters, Hematology/Oncology for tunneled chemotherapy catheters/ports, etc.).
  32. Patients may be discharged with these though this requires an absolute indication as well as specific arrangements for line care. Alert your Discharge Team/Discharge Coordinator ASAP if venous access may be required after discharge.
  33. Non-tunneled Catheters
  34. Placed for short-term central venous access for particular therapies (pressors, aggressive IV fluid resuscitation, central venous pressure monitoring).
  35. Can also be placed for short-term hemodialysis/apheresis (Quinton catheters) and hemodynamic monitoring (Cordis with Swan-Ganz catheter).
  36. Generally referred to by their site of placement (internal jugular, subclavian, femoral).
  37. Non-tunneled catheters are uncuffed and provide direct access into the vein; they may be removed at any time if indicated.
  38. Traditionally dual- or triple-lumen catheters; mildly increased thrombotic risk with larger lumen catheters (true for all catheters).
  39. Must be removed prior to discharge.
  40. Implanted Central Venous Access Catheters (“Ports”, “Port-a-Cath”)
  41. Ports are tunneled catheters implanted completely under the skin.
  42. Must be accessed through the skin with a special Huber needle in order to use.
  43. Placed for long-term though relatively infrequent venous access, particularly if treatment will be >6 months.
  44. Can last for years with proper care.
  45. Used primarily for weekly/monthly chemotherapy administration.
  46. Decreased infection and contamination risk given that all portions of the catheter are under the skin.
  47. Given the skin barrier, patients may exercise, swim, and perform most activities without risk of contamination unlike tunneled catheters.
  48. Usually placed by General Surgery in an OR setting.
  49. If a port must be removed, contact the service (usually General Surgery) that placed it to discuss/arrange removal.
  50. Patients may be discharged with these though this requires an absolute indication as well as specific arrangements for line care. Alert your Discharge Team/Discharge Coordinator ASAP if venous access may be required after discharge.
  51. Clinical Pearls
  52. Daily Assessment
  53. Check all lines (as well as any other devices) for evidence of infection or malfunction daily.
  54. Poor flushing (clot or impingement)
  55. Erythema, swelling, tenderness, fevers (infection, local vs. line sepsis)
  56. Change in external length (catheter fracture or migration)
  57. Take steps accordingly, including removing the device if indicated, if any of the above signs are present.
  58. Unless there is an absolute indication to keep central venous access in place, TAKE IT OUT.
  59. Frequent blood draws (relative indication, while inpatient only if absolutely required)
  60. Long-term chemotherapy
  61. Long-term IV antibiotics
  62. Frequent blood product transfusion
  63. Dialysis/apheresis

INTERNAL JUGULAR CENTRAL VENOUS CATHETER PLACEMENT

SyedSohailAli, MD

Indications

  1. Central venous, pulmonary artery, and pulmonary artery wedge pressure monitoring
  2. Access for hemodialysis/ultrafiltration, fluid resuscitation, pressors, inotropes, etc. that cannot be performed through a peripheral line
  3. Lack of peripheral access
  4. Frequent laboratory monitoring (relative)

Contraindications

  1. Relative contraindication if severe coagulopathy or platelets <50,000 (unless confirmed to be corrected)
  2. Suspected superior vena cava injury or DVT
  3. Distortion of landmarks (consider using ultrasound to identify vessels)
  4. Patient unable to cooperate/tolerate (relative, consider mild sedation/pain control)

Setup, Materials, and Pertinent Anatomy

Triple lumen central venous catheter kit

Ultrasound Site-RiteTM with sterile drape kit

3 Chloraprep swabs

Sterile saline flushes (may require 5-10 for flushing)

Sterile towels (to extend the sterile workspace)

Disposable chucks

Gauze dressing and tape

  1. Obtain patient’s informed consent and have consent available in chart; perform a “time-out” to confirm that this procedure will be performed on the correct site, on the correct patient.
  2. Place the patient in trendelenburg position slightly. This will facilitate filling of the internal jugular vein and make it more prominent on ultrasound.
  • Clearly identify the vessel by ultrasound before proceeding further; the vein should be fairly superficial and easily compressible by the ultrasound probe. Note the spatial relationship to the carotid by visualizing the pulsatile flow and incompressibility on the screen.

  1. Identify the sternal and clavicular heads of sternoclediomastoid (SCM) muscle; have the patient laterally flex neck against your hand if the landmarks are not readily apparent (see Figure above).
  2. Have the bed moved forward so that you can easily position yourself behind the patient’s head; this position allows for the easiest angle of entry when attempting to cannulate the vein.
  3. Sterilize and drape the area per aseptic guidelines; apply maximum barriers to reduce contamination risk (see Introduction).

Procedure

  1. Identify all sharps in the kit prior to starting your procedure. Check all syringes to make sure they draw back easily.
  • Make sure to have the guidewire, venous dilator, triple-lumen catheter, and flushes within close reach before starting the procedure. This will limit hand movement particularly while cannulating the vein and reduce risk of losing your entry point.
  1. Anesthetize the area per protocol taking care to aspirate before injecting to assure the needle is not in a vessel. If it is, retract the needle slowly and completely and apply pressure; reassess your placement and try again.
  2. Have an assistant hold the end of the ultrasound probe and drop it into the sterile probe sleeve. Make sure ultrasound gel is placed in the bottom of the sleeve inserting the probe. Secure the sleeve with the rubber bands provided; place the now sterile probe on the workspace until needed.
  3. Gently flush all ports of triple-lumen catheter with sterile saline to get rid of air; as you are flushing, secure the port clamps to prevent air from reentering.
  4. Under ultrasound guidance, insert the finder needle inferior to the junction of two heads of the SCM toward the IJ vein. Advance forward while directing the needle towards the ipsilateral nipple. Maintain an angle of 45 to the skin; the vein should be approximately 2-3 cm below the skin surface.
  • The ultrasound image does not take the place of monitoring anatomical landmarks, including feeling for the carotid pulse. While the ultrasound image may be appropriate, approaching too medially or inferiorly will increase risk for carotid puncture or other structural damage.
  1. Once a flash is obtained, stabilize your hand and check for good withdrawal of venous-appearing blood. Remove the syringe and thread the guidewire through the finder needle (modified Seldinger technique).
  • The guidewire should pass easily with little resistance. Never force the wire against resistance! This runs the risk of either coiling/irreversibly bending the wire (rendering it unusable) or perforating the vessel.
  • Heavy resistance against the wire may indicate that it is not in the venous lumen. Readjust the needle position to reestablish blood flow and try again.
  • Watch the monitor for PVCs while inserting the guidewire; this may occur when the wire is touching inside the right atrium. Pull back slowly and watch for the PVCs to cease.
  • Make sure to always have the guidewire secured in your hand while it is in the vein! This will prevent migration of the wire as well as reduce the risk of vessel perforation.
  • If the wire is lost in vein, contact Interventional Radiology immediately as it must be removed emergently.
  1. Once the wire is in place, remove the finder needle over the wire. Take your scalpel and make a 0.5cm nick in the skin right next to the wire.
  2. Thread the venous dilator over the guidewire through the nick in the skin. This will dilate your tract to the vessel. Expect an increase in bleeding once you have dilated the tract. Remove the dilator while leaving the wire in place.
  • If there is significant resistance to inserting the dilator, try making your skin nick a little bigger.
  • The dilator only needs to go in approximately 2-3cm; do not completely insert the dilator as this can cause severe vessel injury.
  1. Open the brown port of the triple-lumen catheter (blue port in Quinton catheters) and thread the catheter over the guidewire until the guidewire appears through the open port. Continue advancing the catheter to the desired depth and then remove the guidewire.
  2. Attach the sterile saline syringe to the brown port. Withdraw slightly to check the flow of blood. Once the flash is obtained flush forward until the lumen runs clear. Flush the remaining two ports until they run clear.
  • Make sure to unclamp the ports before flushing to prevent damage to the catheter.
  • Clamp the ports immediately after flushing to reduce risk of air embolism; replace the port caps.
  1. Suture the catheter in place per protocol and apply a clean dressing after cleansing the area to reduce infection risk.
  2. Obtain a STAT chest X-Ray to assess catheter placement. Ideal placement in mid-SVC or just superior to the SVC/right atrial junction.

Common Problems and Post-Procedural Complications