Paracentesis

Indications

  • Evaluation of new-onset ascites
  • Evaluation of ascites of known etiology in the setting of acute decompensation
  • Therapeutic drainage of large volume or diuretic resistant ascites

Contraindications

  • Relative contraindication if severe coagulopathy or thrombocytopenia
  • Multiple previous abdominal surgeries or previous intra-abdominal infections with adhesions(consider ultrasound-guided approach)
  • Morbid obesity or hepatosplenomegaly (consider ultrasound-guided approach)
  • Severe bowel distention
  • Superficial cellulitis at proposed point of entry
  • Inability of patient to cooperate with procedure

Supplies list - CLICK HERE

  • Thoracentesis Tray with 8 Fr. Catheter and universal drainage set [contents]

Anatomic Considerations

  • Structural impediments to the safe introduction of a paracentesis needle can include the bladder, bowel, and pregnant uterus.
  • The bladder is normally tucked into the recess of the pelvis. However, neuropathically distended bladders caused by pharmacologic agents or medical conditions should preferably be emptied by voiding or by catheterization to avoid puncture.
  • Intestines typically float in ascitic fluid and will move safely away from a slowly advancing paracentesis needle. Even if penetrated by an 18- to 22-gauge needle, leakage of intestinal contents will not occur unless the intraluminal pressure is 5- to 10-fold greater than normal conditions. Therefore, US guidance may be indicated in cases of suspected adhesions or bowel obstruction.
  • In second- and third-term pregnancy, an open supraumbilical or US-assisted approach is preferred. The abdomen should be carefully inspected for evidence of abdominal hematoma, engorged veins, or superficial infection, and these sites should be strictly avoided.
  • The best site of entrance for repeat paracentesis is determined by the patient's prior experience, so this question should be asked of the patient.
  • In absence of prior experience, two sites are preferred. One site is approximately 2 cm below the umbilicus in the midline where the fasciae of the rectus abdominis join to form the fibrous, thin, avascular linea alba.  Large collateral veins may occasionally be present and should be avoided, as should suspected areas of skin infection.

 

 

  • If the patient has midline scarring, or if prior experience has been positive, the preferred alternate site is in either lower quadrant, approximately 4 to 5 cm cephalad and medial to the anterior superior iliac spine. The importance of remaining lateral to the rectus sheath is to avoid the inferior epigastric artery.
  • Patients with a large quantity of ascites can readily undergo the procedure in the supine position with the head of the bed slightly elevated.
  • Those with lesser amounts of fluid may profit from a lateral decubitus position with introduction of the needle into the midline or dependent lower quadrant. Some clinicians prefer to use the lateral decubitus position routinely because the bowel tends to float upward and away from the path of the needle.
  • Rarely, patients may need to be placed in a facedown, hands-on-knees position. In the patient with multiple abdominal scars or suspicion of compartmentalized abdominal fluid for any reason, US guidance is prudent. 

Technique

Informed consent

 

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.

  

Sterile Technique

 

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, aface 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. 

 

Catheter insertion

  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. Check the patient’s most recent labs, particularly CBCs and coagulation studies.
    • Ideally, platelets should be >50,000 and INR no more than 2-3 times the upper limit of normal
    • Remember that these are only relative contraindications and this procedure can be safely performed in the presence of thrombocytopenia and coagulopathy.
    • If you have any concerns about performing a procedure due to an uncorrected coagulopathy, you should discuss this with your supervising practitioner first.
  3. Perform a careful abdominal exam and mark your intended site prior to sterilizing the area.
  4. Be sure that you feel for an enlarged or low-lying liver and spleen as these may interfere with your site and increase risk of significant bleeding.
  5. Preferred sites for paracentesis are below the lateral edge of the rectus muscles in the lower abdominal quadrants bilaterally.  This minimizes difficulty introducing the needle and usually offers the safest point of entry below the liver and spleen.
  6. If only a small amount of ascites is present or the patient has a complicated abdomen (multiple previous abdominal surgeries with adhesions, multiple surgical scars, morbid obesity, loculated ascites), you may contact Radiology to mark the site by ultrasound.  The patient must remain in the same position after the site is marked; paracentesis must be performed ASAP following marking to reduce risk of losing site and orientation due to patient movement or fluid shifts.
  7. Make the work area as comfortable for yourself as possible, i.e. good lighting, elevate bed to a comfortable height, secure a work area and trash receptacle within easy reach to minimize movements during the procedure.
  8. Place a pillow underneath the patient on the side opposite your intended puncture site tilting the patient toward you.  Viscous bowel floats in fluid and, unless adhered to peritoneum from inflammation or scar tissue from previous surgery, should float away from the puncture site.
  9. Consider using ultrasound to mark the site of entry if there is difficulty identifying an appropriate entry point by exam.
  10. Prepare the area following proper aseptic technique; apply maximum barriers (sterile gloves/gown, face shield) to help reduce contamination risk.
  11. Identify all sharps in the kit prior to starting your procedure.  Check all syringes to make sure they draw back easily.
  12. Anesthetize the area 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. Once you enter the peritoneum (often denoted by a ‘pop’ and return of yellow ascitic fluid) deposit the remainder of the anesthetic.
  13. After anesthetizing the area, take your scalpel and insert it approximately 0.5cm to create an opening for your catheter.
  14. Gently advance your catheter with the finder needle in place through the tract you have created.  Make sure to slowly aspirate continuously as you advance to make sure you are not entering a vessel; do NOT remove the syringe or flush forward as this can introduce air into the peritoneum.
  15. Once the Caldwell catheter is advanced into the peritoneal space (again denoted by return of ascitic fluid) you can carefully remove the finder needle.
  16. Once your Caldwell catheter is in place, fill your 60cc syringe with ascites first.  Use this to fill your culture bottles if you are doing bedside inoculation (must apply a clean needle to the syringe before inoculating).  If only performing a diagnostic paracentesis, you may retract your catheter while covering the site and place a pressure dressing over the wound.
  17. If you are performing a therapeutic paracentesis, engage the slide lock on the tubing, connect the tubing to the Caldwell catheter and then connect the other end to the vacuum bottle. Release the slide lock and fluid should begin to flow.
  18. If you are not getting adequate flow, you can adjust the catheter or patient positioning until flow is restored.
  19. As more fluid is obtained, the bowel may move forward and occlude the catheter.  You may gently pull back the catheter to restore flow remembering that the catheter cannot be advanced again.
  20. Remember to engage the slide lock prior to changing vacuum bottles and hold the tubing upward to prevent spraying/leakage.  Turn the flow back on once the tubing is secured into the new vacuum bottle.
  21. Once a safe amount of ascites has been obtained or flow cannot be restored, slowly remove the soft catheter and apply pressure to the puncture site.  Apply a pressure dressing to the wound and keep the patient turned onto the side opposite the puncture to reduce pressure on the forming clot.

Specimen Handling

 

At least one 60 cc syringe should be reserved for laboratory analysis. You will need to put a red cap on this syringe before labeling and transport to the laboratory. If you choose to inoculate culture bottles at the bedside, use a clean needle (i.e. hasn’t been through skin) to place 10 ml of ascitic fluid in each of the culture bottles.

Results interpretation

Typical studies obtained for a diagnostic paracentesis include:

  • Cell count and differential

  • Gram stain and culture

  • LDH, albumin, glucose (serum-to-ascites albumin gradient is the most helpful)

  • Cytology

Depending on appearance or differential diagnosis, other peritoneal fluid studies include amylase (poor study though may help assess if pancreatic in origin), cytology (sent in 1 liter cytology bag if concern for malignant ascites), and triglycerides (evaluation for chylous ascites).


Recognizing & managing complications 

Peritonitis(from introduced air, introduced infection, and bowel perforation)

  • A common cause of free air and peritonitis following paracentesis is introduced air from catheter insertion or removal; this is usually self-limited and resolves with time.  If there are any symptoms of perforation (fever, elevated WBC count, hypotension, worsening pain, patient appears clinically ill), start the work-up for bowel perforation immediately.

  • If suspicion for perforation or peritonitis, obtain a STAT abdominal X-ray to evaluate for the presence of free air.

  • If clinical suspicion is high for bowel perforation and X-ray is inconclusive, obtain a STAT CT abdomen without PO contrast and contact General Surgery immediately.  Start antibiotics immediately if there is any concern for introduced infection or bowel perforation.

Hemorrhage

  • Usually occurs in the setting of coagulopathy though can also occur following traumatic paracentesis.

  • Reverse the reversible (giving FFP and Vitamin K for elevated INR), replace the replaceable (giving PRBCs and IV fluid for significant anemia and hypotension).

Wound dehiscence and persistent leakage

  • Lay the patient on the side opposite the puncture site for 2-6 hours to reduce pressure on the wound and clot disruption.

  • If leakage persists, a simple stitch can be placed to close the wound though closure usually occurs with conservative management and time.

Superficial hematoma and wound infection

  • Usually self-limited complications that require supportive care and antibiotics if concern for skin infection.

 Hypotension/Circulatory dysfunction/Renal failure

  • The following OHSU pharmacy protocol can be used to determine whether and how much albumin should be given following large volume paracentesis. 


References

This guide was adapted from:


Chapter 43: Peritoneal Procedures.  Clinical procedures in emergency medicine. Eds James Roberts and Jerris Hedges.  5th edition, 2004.


Introduction to Inpatient Procedures: A Resident-to-Resident Guide.University of Minnesota Internal Medicine Residency AHCC Ambulatory Rotation. Second Edition, Revised October 2007 (available via www.mededportal.org)

PARACENTESIS NOTE

Indications: ***

Consent obtained: ***

Operators:

1) ***
2) ***

Ultrasound guidance: Used
Images saved: No
Landmarks: percussion, U/S

Site of procedure (R or L): *** 

Pre-procedure diagnosis: ***

 Team pause:
At ***, prior to the beginning of the procedure, the team paused to verify the patient’s identity, the procedure to be performed (in accordance with the consent obtained prior to procedure,) and the correct side/site. This information was verified by the patient's nurse and the patient himself/herself.

Procedure:
Using sterile technique the abdomen was prepped with chlorhexidine and draped. *** mLs of 1% plain Lidocaine was used to raise a wheal and anesthetize the needle tract. Using an 11 scalpel, a nick was made in the skin. Using a caldwell needle the abdominal cavity was entered and ascitic fluid was withdrawn. The needle was withdrawn and a sterile pressure dressing was applied.

Findings:
Fluid appearance: ***
Volume of ascites removed: *** mL
Number of attempts: ***
Diagnostic studies:
- cell count and differential
- gram stain and culture
- albumin

***g of albumin was administered post-procedure. 

I was present for the entire procedure. There were no immediate or anticipated complications.

I spent 50 minutes with the patient. 

 

 

Indications

  • Evaluation of etiology of new pleural effusion
  • Relief of dyspnea associated with large pleural effusion

Contraindications

Absolute

  • None

Relative

  • Platelet <50
  • INR/PTT greater than 2 times upper limit normal
  • Cellulitis or herpes zoster overlying needle insertion site
  • Mechanical or manual ventilation

Supplies - click here for printable list

  • Thoracentesis Tray with 8 Fr. Catheter and universal drainage set [contents]
  • Extra 60 mL syringe (2)
  • Cultures bottles for bedside innoculation
  • EDTA (purple top) tube
  • Red syringe caps (3)
  • Sterile gloves
  • Alcohol preps
  • Towels/ABD pads

Anatomic Considerations

The visceral and parietal pleura are thin layers of connective tissue, and the space between the two linings is the pleural space.  The pleural space extends inferiorly to level of approximately the 10th intercostal space.  The intercostal vascular bundles are located along the inferior aspect of the ribs which is an important consideration during needle insertion due to the potential risk of injury to this bundle. 

 

Technique

Informed consent

Informed consent including a description of the procedure, as well as the procedure risks, benefits, and alternatives should be obtained and documented, and a copy of the consent placed in the patient’s paper chart. 

 

Patient and equipment preparation

Position the patient sitting upright on the edge of the bed with arms extended.  A table with pillow for the patient to lean upon is recommended in order to maximize comfort.  The effusion should be localized using auscultation, percussion, and tactile fremitus.  The thoracentesis site should be in the mid scapular or posterior axillary line (6-10 cm lateral to spine), and one to two intercostal spaces below the highest level of the effusion.  In order to minimize potential injury of the diaphragm, the lowest recommended level for thoracentesis is between the eighth and ninth ribs (eighth intercostals space).  Mark the area of needle insertion by pressing a pen or pen cap firmly on the skin creating an indentation that will remain after the ink is washed off. 

Using sterile technique, the skin is prepped with antiseptic (Chlorhexadine) in a wide area around the thoracentesis site.  A sterile drape should then be applied to create a sterile field. 

 

Catheter insertion

  1. Using a 16 gauge filtered needle, draw up 5 mL of 1% lidocaine without epinephrine into the 5 mL syringe.  Exchange the 16 gauge needle for a 25 guage needle and raise of skin wheel at the upper edge of the rib just below the marked intercostal space. 

  2. After a wheal is raised, exchange the 25 gauge needle for a 22 gauge needle to anesthetize the needle tract.  Needle insertion should target the upper edge of the rib in order to avoid injury to the neurovascular bundle which runs at the inferior margin of each rib. 

  3. Advance the 22 gauge needle at an angle perpendicular to the skin, aiming for the mid to upper edge of the rib.  For each 1 to 2 mm of needle advancement, aspirate, then inject 1 mL of anesthetic. 

  4. Once the needle is advanced to the depth of the rib, “walk” the needle superiorly until the intercostal space is reached, then advance the needle, under negative pressure, into the pleural space.

  1. Upon entering the pleural space, there will be some resistance, followed by aspiration of pleural fluid into the syringe.  Inject the remaining lidocaine into the pleural space, note the depth of needle insertion, and remove the needle under negative pressure.
  2. Using the scalpel, nick the skin at the area of needle insertion, creating a 2-3 mm incision.

  3. Utilizing identical technique, insert and advance the 8 Fr catheter over needle assembly, perpendicular to the skin and toward the upper edge of the rib, then walk the needle superiorly to the intercostal space.  Then, under negative pressure, advance the needle into the pleural space, keeping in mind the depth of the pleural space as determined by the anesthetic needle.  Once pleural fluid is returned in the syringe, advance the needle/catheter and additional 3-4 mm to ensure the catheter tip is inside the pleura.

  4. Keeping the needle assembly stable, advance the catheter over the needle and into the pleural space.

  5. Withdraw the needle, leaving the catheter in place.  As the needle is removed from the catheter hub, the hub will lock automatically.  Once the needle is removed, the hub cannot be unlocked and the needle cannot be reinserted.  This is designed to prevent accidental air entry into the pleural space.

  6. Attach the Y-tubing to the three way stopcock assembly on the catheter hub.  The short arm of the Y goes to the 60 mL syringe, the long arm to the collection bag, and the neck to the catheter hub. 

  7. Open the stopcock by moving the valve to the open position and, using the 60 mL syringe, aspirate 60 mL of fluid.  Remove the syringe and set aside to inoculate the culture tubes.

  8. Attach the spare 60 mL syringe and aspirate to fill the collection bag.  The tubing assembly contains a one way valve system that allows the operator to aspirate fluid into the syringe and then empty the syringe directly into the collection bag without reconfiguring the tubing. 

  9. Remove fluid by alternating pulling and pushing the syringe plunger until no additional fluid can be removed or a total of no more than 1,500 mL of fluid has been removed.  Limiting fluid removal to 1,500 mL is advised in order to theoretically reduce the risk of re expansion pulmonary edema.  Inform the patient that they may experience some chest discomfort and cough as the atelectatic lung re-expands with fluid removal.

  10. When fluid removal is complete, close the stopcock to the patient, and instruct the patient to hum in order to generate positive intrathoracic pressure.  While the patient hums, remove the catheter in a single, smooth movement and cover the entry site with a sterile bandage.

  11. Innoculate bedside culture tubes and EDTA tubes, label all specimens, and place in specimen bags for transportation to the lab.

Post procedure considerations

Post procedure radiographs have historically been obtained in order to rule out significant pneumothorax, however, studies have shown this to be unnecessary in patients with low risk for adhesions, require only a single needle pass, and have no new symptoms during or after the procedure. 

Results interpretation

Pleural fluid analysis

Diagnostic thoracentesis is useful for determining the cause of pleural effusions and for guiding therapeutic interventions.  Visual inspection of the fluid is the first step in analysis and can help guide the differential and need for advanced therapies.  Bloody fluid suggests trauma, malignancy, pulmonary infarct or pneumonia.  White or milky fluid suggests presence of lipids.  Grossly purulent fluid indicates empyema. 

 

Pleural fluid studies should always include lactate dehydrogenase (LDH), total protein, cell count with differential, culture with gram stain, glucose, and pH testing.  Concurrent serum LDH and protein levels should also be obtained.  The first step in fluid analysis is to determine if the fluid is an exudates (protein rich) or transudate.  This is accomplished using Light’s criteria.  The presence of any of of the following suggests the effusion to be exudative in nature:

 

1.) Pleural fluid to serum protein ratio >0.5

2.) Pleural fluid LDH > two thirds of the upper limit of serum reference range

3.) Pleural fluid to serum LDH ratio >0.6

 

Transudative effusions are caused by increased capillary hydrostatic pressure as seen most commonly in congestive heart failure and cirrhosis.  In general, transudative effusions typically require no further fluid analysis and therapy is directed at management of the underlying cause of effusion.

 

All exudative effusions should have additional pleural fluid studies including cell count with differential, glucose, pH, and cytology.  Consideration should be given to checking pleural fluid triglyceride levels if there is concern for chylous effusion.  The differential for exudates is broad, and includes trauma, malignancy, pneumonia, pulmonary infarction, connective tissue/autoimmune disease, tuberculous pleurisy, esophageal rupture, and pancreatitis. 

 

Drainage of the exudative effusion may be necessary if certain conditions are met.  In general, grossly purulent fluid on thoracentesis, a pH <7.2 or a glucose <60 mg/dL is an indication for drainage of the effusion.  The American College of Chest Physicians published guidelines for the evaluation and management of parapneumonic effusions in 2000 which emphasized that the estimated risk for poor outcome should be the basis for determining whether a parapneumonic effusion should be drained.  By the ACCP guidelines, category 3 and 4 parapneumonic effusions should undergo drainage, while category 1 and 2 effusions have lower risk for poor outcome and do not necessarily require drainage.

 

Recognizing & managing complications

Pneumothorax

Pneumothorax is the most common complication of thoracentesis, occurring in 5-20% of procedures.  Typically, pneumothoraces are small and asymptomatic, and require no interventions.  Occasionally, pneumothorax may result in increased respiratory symptoms and/or hypoxemia, and tube thoracostomy should be considered.  Tension pneumothorax, presenting as hypoxemia, hemodynamic instability is a medical emergency, and should be managed with immediate needle decompression by inserting a large bore needle into the anterior 2nd intercostal space of the affected lung. 

 

Cough

Cough resulting from re-expansion of atelectatic lung is a common complication of thoracentesis.  Termination of the procedure due to cough is not required unless the patient experiences significant discomfort or if cough is severe and persistent.

 

Infection

Risk of iatrogenic infection is estimated at 2%.  Attention to clinical signs and symptoms such as fever, leukocytosis, and respiratory signs and symptoms is recommended following thoracentesis.

 

References

Colice GL, Curtis A, Deslauriers J, et al.  Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.  Chest 2000; 118: 1158.

 

Roberts JR, Hedges JR. Clinical procedures in emergency medicine, 5th ed., (2004), 160-174.

 

Introduction to Inpatient Procedures: A Resident-to-Resident Guide.University of Minnesota Internal Medicine Residency AHCC Ambulatory Rotation. Second Edition, Revised October 2007 (available via www.mededportal.org)

THORACENTESIS NOTE

Indications: ***

Consent obtained: *** 

Operators:

1) ***
2) *** 

Imaging reviewed pre-procedure: ***

Landmarks: Percussion

Ultrasound guidance: ***
Images saved: ***

Site of procedure (R or L): *** 

Pre-procedure diagnosis: ***

Team pause:
At ***, prior to the beginning of the procedure, the team paused to verify the patient’s identity, the procedure to be performed (in accordance with the consent obtained prior to procedure,) and the correct side/site. This information was verified by the patient's nurse and the patient himself/herself. 

Procedure:
The patient was positioned appropriately. The site was prepped with chlorhexidine and sterilely draped. Using a 22 gauge needle *** mL of 1% lidocaine was injected subcutaneously to raise a wheel, and then anesthetize the needle tract over the superior border of the rib. The pleural space was entered and the pleura anesthetized. An 18 gauge needle was then advanced through the anesthetized tract. Once pleural fluid was aspirated, a catheter was advanced over the needle and into the pleural space and an adequate sample of pleural fluid was removed. The catheter was withdrawn at end-expiration with the patient holding his/her breath and covered with an occlusive dressing. The patient tolerated the procedure well and without complication. 

Findings:
Fluid appearance: ***
Volume of pleural fluid removed: *** mL
Number of attempts: ***
Studies sent:
- cell count and differential
- gram stain and culture
- protein
- albumin
- LDH
- cytology

 I was present for the entire procedure. There were no immediate or anticipated complications. There is no need for follow-up imaging unless indicated clinically. 

 I spent 50 minutes with the patient. 

 

Lumbar Puncture

Indications

  • Urgent: Suspected CNS infection
  • Urgent: Suspected SAH in patient with negative CT scan
  • Non-urgent: Diagnosis of suspected pseudotumor cerebri, NPH, CNS symphilis, CNS vasculitis, carcinomatous meningitis, TB meningitis, cancer staging
  • Therapeutic LP (such as in pseudotumor cerebri)
  • Therapeutic: Spinal anesthesia, intrathecal chemo, intrathecal antibiotics

Contraindications

  • Thrombocytopenia (platelets <50,000)
  • Elevated ICP  (signs include papilledema, decreased consciousness, focal deficits), consider CT prior to LP to rule out mass effect
  • Skin infection overlying area where LP is to be performed
  • Prior low back surgery – may require fluoro-guided procedure by IR

Supplies

Anatomic Considerations

  • The subarachnoid space must be entered below the termination of the spinal cord. The spinal cord terminates around the L2 body.
  • Identify the vertebral spinous processs in the midline. Draw an imaginary (or real) line connecting the superior iliac crests. These lines intersect at the L4 spinous process, or the L3/L4 interspace. You can select any interspace from L2-L3 to L5-S1 to perform the LP, but L3/L4 and L4/L5 are most commonly used.
  • You may want to mark your intended interspace with an indentation or the hub of a needle prior to beginning, so you don’t wash off your markings.

Technique

Informed consent

 

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.

 

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 (see above)

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.

Patient and equipment preparation

  • Arrange patient in appropriate position for lumbar puncture
  • The most common position entails that the patient be in a lateral recumbent position with both the knees and head flexed.  Placing a pillow under the head and between the knees can help keep the patient comfortable and the spine in one plane.  If ICP measurement is required, it must be done in this position.
  • LP can also be performed with the patient sitting on the bed leaning onto a tray table with their back rounded. ICP cannot be measured in this position.
  • Often it is helpful to have an assistant help position/hold patient in place during the procedure to keep the spine aligned in one plane.

Landmarks

  • Identify your landmarks; palpate the superior iliac crests and “draw” a mental line between these points (this will be at about the L3/L4 interspace). 
  • Since the cord usually ends around L1/L2, entering below this site (L3/L4, L4/L5, L5/S1) reduces risk of spinal cord injury.  Mark the planned entry site with a pen prior to sterilizing the area.

Pain Management / Local Anesthesia

  • Local anetsthetic: As below, using 1% lidocaine without epinephrine, infiltrate the the skin and intervertebral space using a 20 or 22 gauge needle.
  • Post-LP Headache prevention: Headache occurs in 10-30% of patients. Studies have shown that using smaller bore needles, and orienting the needle bevel parallel to longitudinal fibers of the dura will decrease the incidence of post-LP headache. Positioning of the patient prone vs supine after the procedure have not been shown to change the incidence of post-LP headache. Bedrest does not significantly decrease the risk of post-LP headache.

Sterile Technique

  1. Wash hands with soap and water prior to beginning the procedure
  2. While wearing non-sterile gloves, clean the overlying skin with chloraprep, starting at your point of entry and moving in concentric circles outward. Sterilize a wide area. Repeat 2-3 times. The antiseptic should be allowed to dry completely before the procedure begins.
  3. Use barrier precautions including:
    • Surgical cap
    • Face shield or goggles
    • Sterile gloves
    • Sterile gown
  4. Drape the patient with the sterile drape (with opening over lumbar spine). This is included in your LP kit. Consider using additional sterile towels to expand your sterile workspace.
  5. Ensure any assistants follow proper aseptic technique

Catheter insertion

  1. With the stylet in place, insert needle where mark was made.  Make sure the beveled edge is facing upward (parallel to the long axis of the spine, which helps separate the longitudinal dural fibers with less trauma).

  2. Advance needle slowly aiming slightly towards the head (in infants)/navel (in adults), and when you feel a “pop” (the sensation when the needle pierces through the dura) withdraw the stylet watching for fluid (usually about 1.5 to 2 inch insertion).

    • You may not feel a “pop” in all cases.  If no fluid is visible in the needle hub, rotate the needle slightly.  Otherwise, reinsert the stylet and advance slightly.

  3. Continue this series of steps until fluid is visible or you feel you’ve gone too far.  If you’ve gone too far, put the stylet back in and withdraw the needle.  Start again with a spare LP needle.

  4. If you feel that the needle has hit bone, pull the needle back a few centimeters to redirect and advance again.  In elderly patients with degenerative joint or disc disease, oftentimes the interspaces are quite small.  Be aware of this before proceeding; if unable to obtain fluid consider a CT/fluoroscopy-guided procedure by Interventional Radiology.

    • If you are checking opening pressure make sure the manometer is set up and within reach.  When you first see fluid in the needle hub, immediately attach the manometer to the end of the needle.  Let fluid enter the manometer tube until it reaches a steady level and record that number (the level will rise and fall slightly with respiration).

    • To collect the fluid after using the manometer, simply twist the 3-way stopcock off to the patient and open to the side port.  Collect 2-4 cc of fluid out of the manometer tube via the 3-way stopcock into each of 4 LP collection tubes

  5. To collect the fluid without using the manometer, hold a collection tube just under the needle and let 2-4 cc of fluid drip into the tube.  Repeat for a total of 4 tubes.  If a number of studies are needed, up to 40cc of fluid can be removed at one time.

  6. Once all fluid is collected, replace the stylet making sure the bevel is facing upward (parallel to the long axis of the spine) and withdraw the needle. 

Post procedure considerations

  • Carefully discard sharps and place a band-aid over the site.
  • Promptly enter your procedure note

Specimen Handling

 

Typical studies obtained for a diagnostic lumbar puncture include:

  • Tube #1:  Cell count and differential

  • Tube #2:  Gram stain and culture

  • Tube #3:  Protein and glucose

  • Tube #4:  Hold for further studies

It is imperative that a tube be saved for studies to be ordered later, especially if the clinical picture or differential diagnosis changes.  Studies that are often obtained after the initial procedure include:  Cryptococcal antigen, bands, HSV, VDRL, cytology, etc.  If you are concerned about a possible subarachnoid hemorrhage, obtain cell counts on both Tube #1 and Tube #4; if a hemorrhage is not present the RBC counts should decrease significantly from Tube #1 to Tube #4.

Results interpretation

Typical CSF Findings in Meningitis (Table adapted from Pocket Medicine, Fourth Edition):

 

Recognizing & managing complications

Spinal headache

  • Usually occurs because of slightly reduced ICP following lumbar puncture. Headache is typically mild and resolves spontaneously after 24 hours.

  • See Pain Mgmt section below regarding prevention of post-LP headache

  • Conservative treatment with bedrest and oral analgesics for the first 24 hours is recommended.

  • Caffeine has been used as a treatment for spinal headache but the efficacy is questionable.

  • Spinal headaches are usually self-limited; treat with appropriate pain control as indicated.

Nerve root trauma

  • Seen more often in patients with pre-existing scar tissue or previous spinal surgeries.

  • Treat with appropriate pain control as indicated.

Subdural/subarachnoid bleed and hematoma

  • Seen more often in patients with an underlying coagulopathy; treatment depends on the complication.

  • Check CBC and coagulation studies prior to performing the procedure; correct abnormalities as indicated.

Meningitis (introduced)

  • Observe proper aseptic technique to reduce contamination risk.

Herniation

  • If there is any suspicion for increased intracranial pressure (focal neurologic signs, papilledema, etc.), obtain a Head CT prior to attempting the LP.

References

UpToDate: Lumbar puncture: Technique; indications; contraindications; and complications in adults

 

UpToDate: Post-lumbar puncture headache

 

Roberts: Clinical Procedures in Emergency Medicine, 5th ed.- 2009 – Saunders

Introduction to Inpatient Procedures: A Resident-to-Resident Guide.University of Minnesota Internal Medicine Residency AHCC Ambulatory Rotation. Second Edition, Revised October 2007 (available via www.mededportal.org)

 

Sabatine, Marc.Pocket Medicine, Fourth Edition. Lippincott Williams & Wilkins, 2011, Philadelphia PA. Page 6-10.

LUMBAR PUNCTURE NOTE

Indications: ***

Consent obtained: ***

Operators:

1) ***
2) ***

Ultrasound guidance: ***

Images saved: ***

Landmarks: midline between superior iliac crests by palpation

Pre-procedure diagnosis: ***

 Team pause:
At ***, prior to the beginning of the procedure, the team paused to verify the patient’s identity, the procedure to be performed (in accordance with the consent obtained prior to procedure,) and the correct side/site. This information was verified by the patient's nurse and the patient himself/herself.

 Procedure:
Relevant imaging was reviewed and in combination with physical exam the patient was not thought to have increased intracranial pressure. The patient was positioned in the lateral decubitus position. Using anatomical landmarks by palpating the iliac crests a space was located in the midline between L3 and L4. The site was prepped with chlorhexidine and sterilely draped.

Using sterile technique *** mLs of 1% lidocaine was used to raise a wheal at the site of entry and the needle tract was anesthetized. Using a spinal needle the subarachnoid space was entered and *** mLs of CSF were withdrawn and sent for studies. A sterile dressing was applied. 

 Findings:
Opening pressure: *** cmH2O
CSF appearance: ***
Attempts: ***
Studies sent:
- cell count and differential
- CSF glucose
- CSF protein
- gram stain and culture
- additional studies: ***

 I was present for the entire procedure. There were no immediate or anticipated complications.

 I spent 50 minutes with the patient. 

 

Arthrocentesis

 

INDICATIONS

  • Arthrocentesis is used to establish the cause of an acute monoarthritis or polyarthritis.
  • Nongonococcal bacterial arthritis is a “do-not-miss” diagnosis, since a delay in identification and treatment may lead to clinically significant joint destruction and even death.
  • Other infectious causes include disseminated gonococcal infections, tuberculosis, fungal infections, and Lyme disease.
  • Crystal arthropathies (gout and pseudogout), rheumatic disorders, osteoarthritis, trauma, and hemarthrosis may also lead to acute joint effusions.
  • Arthrocentesis is also used as a therapeutic procedure, to drain large effusions or hemarthroses, and to instill corticosteroids or local anesthetic.

 

CONTRAINDICATIONS

  • Cellulitis overlying the site of needle entry.
  • Suspected bacteremia is a relative contraindication to arthrocentesis; if septic arthritis is suspected, however, the procedure should be performed.
  • The safety of arthrocentesis has not been established for patients with coagulopathy or patients who are receiving anticoagulant medications, and the use of reversal agents or products (e.g., fresh-frozen plasma or platelet concentrates) should be considered on a case-by-case basis.
     

COMPLICATIONS

  • Arthrocentesis is a relatively benign procedure, and if properly performed, complications are rare. Potential complications include iatrogenic infection, localized trauma, pain, and reaccumulation of the effusion

ANATOMY

 

 

SUPPLIES:

  • Skin permanent marker
  • Sterile gloves
  • Sterile fenestrated drape with aperture or sterile 5-towel pack to make sterile field
  • One 5-mL syringe for lidocaine injection with a 25g anesthetic needle and a 22g anesthetic needle
  • 1% lidocaine w/o epi (2 cc)
  • 18g x 1.5" needle for joint aspiration
  • One or two large 30-60cc syringes for joint aspiration depending on amount of fluid in the joint
  • chloraprep wand
  • Several 3x3 or 4x4 gauze packets
  • Sterile bandage
  • Consent form signed
  • Orders in EPIC for synovial fluid lab

 

PREPARATION

  • The knee may be tapped from either the medial or the lateral side.
  • The patient’s knee should be extended or flexed at an angle of 15 to 20 degrees.
  • The needle will enter the skin 1 cm medial (or lateral) to the superior third of the patella and is directed toward the intracondylar notch.
     

TECHNIQUE

  • Explain the procedure to the patient, obtain written informed consent, and then gather the equipment you will need.
  • Position the patient supine on a stretcher, with his or her knee extended or slightly flexed.
  • Identify the landmarks and demarcate the entry site with a skin-marking pen, or use another appropriate method. 
  • Prepare the skin with a cleansing agent such as povidone–iodine or chlorhexidine. You may place a sterile drape around the site.
  • Begin to anesthetize the region by placing a wheal of lidocaine in the epidermis, using a small (25-gauge) needle, and then anesthetize the deeper tissues in the anticipated trajectory of the arthrocentesis needle. Intermittently pull back on the plunger during the injection of the anesthetic to exclude intravascular placement.
  • Using an 18-gauge needle and large syringe, direct the needle behind the patella and toward the intracondylar notch. Resist the temptation to “walk” the needle along the inferior surface of the patella, since this practice may damage the delicate articular cartilage.
  • Constantly pull back on the plunger while you advance the needle; you will know when the needle enters the synovial cavity, because fluid will enter the syringe.
  • You should remove as much fluid as possible. “Milking” the effusion, by gently compressing the suprapatellar region with the opposite hand, may aid in this endeavor. In cases of large effusions, you may need a second syringe to complete the aspiration.
  • Once the aspiration is completed, remove the needle, cleanse the skin, and apply a bandage. You may apply a woven elastic bandage or knee immobilizer to reduce post procedural swelling and discomfort.
     

TROUBLESHOOTING

  • Failure to aspirate synovial fluid results in a “dry tap.” Misdiagnosis of knee effusion, obesity, obstruction of the needle lumen by particulate matter or a plica, or hypertrophy of the synovium (owing to chronic inflammation) may all result in a dry tap. If the medial approach was used initially, a lateral approach should be attempted, since this may overcome difficulties presented by a medial plica or thick medial fat pad.

 

SYNOVIAL-FLUID ANALYSIS

  • Collected fluid should immediately be placed into appropriate containers and analyzed expediently. Check with the laboratory regarding specific submission procedures (e.g., the correct tubes and the volume of fluid required for each test). If only minute volumes of synovial fluid are obtained, discussions with laboratory personnel are indicated to prioritize testing. As little as one drop of fluid may be sufficient for crystal analysis, and 1 ml may suffice for a cell count and a differential count.
  • Gram’s Staining and Culture
    • Gram’s staining and culture of synovial fluid provide the most definitive evidence of septic arthritis. The sensitivity of these techniques is much higher for nongonococcal infections (50 to 75 percent for Gram’s staining and 75 to 95 percent for culture) than for disseminated gonococcal disease (less than 10 percent and 10 to 50 percent, respectively.) If gonococcus is suspected, cultures of the blood and of urethral, rectal, or oropharyngeal swabs should be considered. To minimize the risk of contamination, the synovial fluid is often submitted for testing in the syringe used for the arthrocentesis.
  • Cell Count and Differential Count
    • The cell count and differential count are used to differentiate between non inflammatory effusions (e.g., osteoarthritis and trauma) and inflammatory conditions (e.g., septic and crystal-induced arthritis). A cutoff of 2000 white cells per milliliter and 75 percent polymorphonuclear cells is generally used. It should be emphasized that the cell count and differential count cannot reliably differentiate among various inflammatory entities. For example, up to 33 percent of patients with septic arthritis may have white-cell counts below 50,000 per milliliter, and patients with acute gouty arthritis may have counts exceeding 100,000 per milliliter. Synovial fluid is usually submitted for cell and differential counts in specimen tubes treated with EDTA.
  • Crystal Analysis
    • Evaluation of synovial fluid under a polarizing-light microscope may reveal the presence of monosodium urate crystals (seen in gout) or calcium pyrophosphate dihydrate crystals (seen in pseudogout). Gout will appear as negatively birefringent needles whereas pseudogout will appear as positively birefringent rhomboids. The sensitivity of crystal analysis is relatively high (80 to 95 percent for gout and 65 to 80 percent for pseudogout). It should be noted that the presence of crystals does not exclude the possibility of septic arthritis, since the two conditions may coexist. Synovial fluid is usually submitted for crystal analysis in a lithium heparin–treated specimen tube.
  • Other Tests
    • Although often ordered, biochemical assays such as for glucose, protein, and lactate dehydrogenase have little discriminatory value and should not be included in routine synovial-fluid analysis. Other tests, such as specific stains and cultures for atypical infectious agents and cytologic evaluation for suspected malignant effusions, may be indicated in certain situations.

Adapted from Roberts JR, Hedges JR. Clinical procedures in emergency medicine, 5th ed., (2004), 160-174.

ARTHROCENTESIS NOTE

Indications: ***

Consent obtained: ***

Operators:

1) ***
2) ***

Site of procedure: ***

Pre-procedure diagnosis: ***

 Team pause:
At ***, prior to the beginning of the procedure, the team paused to verify the patient’s identity, the procedure to be performed (in accordance with the consent obtained prior to procedure,) and the correct side/site. This information was verified by the patient's nurse and the patient himself/herself.

 Procedure:
By physical exam an effusion was located, and using landmarks the knee was positioned accordingly. The site was prepped with chlorhexidine and sterilely draped. Using sterile technique a 27 gauge needle the site was anesthetized with *** mLs of 1% lidocaine. The joint space was entered with an 18 gauge and synovial fluid was aspirated via lateral/medial approach. A clean dressing was applied.

 Findings:
Volume of synovial fluid aspirated: ***mL
Synovial fluid appearance: ***
Diagnostic studies:
- cell count and differential
- crystal analysis
- gram stain and culture

 I was present for the entire procedure. There were no immediate or anticipated complications.

 I spent 50 minutes with the patient. 

Central Venous Catheter Placement - Internal Jugular Vein

 

INDICATIONS

  • Central venous access for infusion of vasoactive drugs, TPN, high dose KCl, etc.
  • Hemorrhagic disorder where large volumes blood/blood products needed
  • Measurement of central venous pressure
  • Need for frequent blood draws where peripheral access limited.
  • Lack of peripheral venous access
     

CONTRAINDICATIONS

  • Severe coagulopathy; INR > 1.5-1.6; platelets < 50 K (relative contraindication). The femoral or IJ site is preferred with a coagulopathy or anticoagulation due to the ability to compress the vein in the event of serious hemorrhage.
  • Infected skin site
  • In patients with higher risks for pneumothorax or inability to tolerate pneumothorax, the IJ or femoral sites may also be preferred.
  • Thrombosis of target vein
     

RISKS

  • The risk of complications of central line placement varies with the experience of the operator and the conditions (emergency vs. elective) under which the line is placed. Nonetheless, some general statements can be made and used when obtaining consent from a patient. Risks associated with central venous catheterization include infectious, mechanical, and thrombotic complications. A chest radiograph should be obtained to confirmplacement and to assess for complications.
  • Infectious Complications
    • Catheter infections occur by means of one of three mechanisms: local insertion siteinfection, which travels down the catheter externally; or hub colonization followed by infection via the intralumenal route or via hematogenous seeding of the catheter.
    • The Institute for Healthcare Improvement recommends five steps to reduce central-line infections: hand hygiene, adherence to maximal barrier precautions, chlorhexidine skin antisepsis, selection of an optimal catheter site, and daily review of the necessity of the catheter, with prompt removal when the catheter is no longer needed. Implementation of these steps has been conclusively shown to decrease the rate of catheter-related bloodstream infection. Scheduled changing of a catheter over a guide wire or moving a catheter to a new site can increase mechanical and infectious complications, and neither is recommended. Antiseptic containing hubs and antimicrobial-impregnated catheters have been shown to decrease the rate of catheter-related bloodstream infections. Topical antibiotic ointments are ineffective, promote antibiotic-resistant bacteria, and increase fungal colonization.
  • Mechanical Complications
    • Mechanical complications include arterial puncture, hematoma, pneumothorax, hemothorax,arrhythmia, and improper location of the catheter, whether in an accessory vein or in the other vessels of the upper vascular system. Insertion of a catheter into the femoral vein, not shown in this video, has the highest risk of mechanical complications, but the rates of serious mechanical complications for femoral and subclavian insertion are similar. If an artery is punctured, further attempts at that site should be abandoned, and access to an alternative site should be attempted. Internal jugular and subclavian cannulation sites are preferred because of their lower overall rate of mechanical complications. However, these sites carry a small risk of hemothorax and pneumothorax. Ultrasound guidance for internal jugular cannulation significantly reduces the number of attempts required and the risk of complications.
  • Thrombotic Complications
    • Central venous cannulation increases the risk of central venous thrombosis, with the concomitant potential risk of venous thromboembolism. Thrombosis may occur as early as the first day after cannulation. The site with the lowest risk for thrombotic complications is the subclavian vein. Prompt removal of the catheter when it is no longer needed decreases the risk of catheter-related thrombosis.

 
INDWELLING CENTRAL VENOUS CATHETER REMOVAL GUIDELINES

  • No specific time interval for changing or removal. Catheter site and need should be reassessed daily. If site becomes infected, removal and if needed, replace at a different site.
  • If line is to be removed because of suspicion of a catheter-related infection, and the skin site is not infected-looking, guide wire exchange with blood cultures through the line and culture of the tip should be performed
  • Catheter removal may not be required with coagulase-negative Staph line infection without infected skin site, but most other catheter related infections require removal and antibiotics.
     

SUPPLIES:

  • Triple lumen catheter pack (20cm catheter for most) **If pt may need ct pulmonary angio or rapid contrast bolus, a "Pressure injectable" triple lumen should be placed (stored on station 20)
  • Towel pack – sterile
  • Sterile gown, mask, hat, gloves
  • Ultrasound, if available with sterile probe cover
  • 3 quick blue hubs with saline flushes in 3 separate syringes
  • CVP setup at bedside
  • Line cart in room
  • INR, plts if indicated
  • Consent form signed

ANATOMY

  • The two heads of the sternocleidomastoid muscle and clavicle form a triangle, at the apex of which is located the internal jugular vein.
  • The carotid artery is located medial to the internal jugular, usually medial to the medial head of the sternocleidomastoid muscle. 
  • The right IJ is preferred over the left for cannulation because of its more direct line to the atrium and lower risk of potential injury to the thoracic duct during cannulation. 
  • On ultrasound, the IJ located lateral to the carotid artery and is easily collapsible when pressure is applied with the ultrasound probe.  Often, the carotid artery is easily recognized by its pulsatility.  On occasions, the IJ can be found in close approximation, even overriding the carotid artery, highlighting the importance of correctly identifying these vesses prior to attempts at cannulation.

 

SITE PREPARATION & ANESTHESIA

  • Cleanse a 15-20 cm area over the side of the mid- to lower neck with povidone-iodine solution; the right side is preferred due to more direct line to the atrium and avoids injuring the thoracic duct. If you are using ultrasound guidance, do a quick look prior to preparing your sterile field to localize the IJ and its relationship to the carotid artery.
  • The site of entry should be at the top of the triangle formed by the two heads of the sternocleidomastoid muscle and clavicle.
  • Drape the patient with the provided paper/plastic drape with center cutout.
  • Estimate the length of catheter to be placed to end up with tip above right atrium
  • Using the 25 ga needle, make a wheal under the skin at the desired spot, and anesthetize the subcutaneous tissue
  • Using the 20 ga needle, anesthetize deeper.
  • Always pull back before injecting to avoid intravascular injection of lidocaine.
     

TECHNIQUE

  • Place the guide wire, dilator, catheter, and scalpel on the sterile drape for easy reach when needed.
  • Have the patient turn head in the opposite direction
  • Using the 18 ga finder needle (largest needle in the kit) and a small syringe, enter the skin at the top of the jugular triangle. In obese patients where the landmarks are not discernable, a reasonable rule of thumb is to go three finger breadths lateral from the tracheal midline, and three finger breadths up from the clavicle.
  • Alternatively use ultrasound guidance with the portable ultrasound in a sterile sleeve to localize the vein and follow your needle into its lumen.
  • Ultrasound Guidance: In numerous studies, ultrasound guidance has been shown to increase the success of first-time catheter placement and to decrease the risk of complications. When using ultrasound guidance, enlist an assistant either to handle the probe or to remove it when it is no longer needed. The vein and artery appear circular and black on the ultrasound image; the vein is much more compressible when gentle pressure is applied to the skin via the probe. The needle appears echogenic and can be followed into the image of the vein
  • Palpate for the carotid impulse an make sure you are lateral to this.
  • Insert the needle at 30 degrees and aim for the ipsilateral nipple.
  • Gradually advance the needle, always gently pulling back on the plunger as you progress; a flash and easy withdrawal of dark blood, this indicates entrance into the vein.
  • If you bury the needle without blood, gradually withdraw; you may still get into the vein as you may have collapsed it on the way in.
  • Once in the vessel, steady the needle and remove the syringe, holding a thumb over it to prevent air embolism.
  • Insert j-tipped guide wire into needle; if resistance is felt do not force it.
  • Watch monitor as guide wire is advanced. Ventricular ectopy indicates placement in RV, and guide wire should be pulled back a few cm.
  • Holding guide wire, remove needle from skin.
  • Make a small nick with the number 11 blade where wire enters skin.
  • Advance dilator over guide wire with a twisting motion; there will be resistance.
  • Remove dilator, holding guide wire and having some gauze 4x4 in your hand to apply pressure to a site that will now bleed after dilation.
  • Place catheter over guide wire; it should advance easily. Hold guide wire at skin entrance and feed it back through distal port of central line (brown cap). When wire comes out, grab it at the end and finish advancing catheter.
  • Remove guide wire and flush line through all 3 ports.
  • Suture catheter in place via flange with holes. If more than a cm or 2 of catheter is exposed due to length, either suture the catheter down or use the snap-on flange provided in the kit.
  • Order a stat CXR to evaluate for line placement and complication.
    • The tip of the catheter should be at the junction of the SVC and right atrium on chest xray.
    • New data would suggest that this is 2cm below the superior right cardiac sillhouette which is made up by the right atrial appendage. (Verhey P.T., Gosselin M.V., Primack S.L., Blackburn P.L. and Kraemer A.C. (2008).  Advancement beyond this point can lead to arrythmia and unlikely myocardial perforation.

Adapted from Roberts JR, Hedges JR. Clinical procedures in emergency medicine, 5th ed., (2004), 160-174.

PROCEDURE:
Internal jugular central venous catheter, U/S guided.

 

INDICATION:

***

 

PROCEDURE OPERATOR:

***

 

CONSENT:

***

 

PROCEDURE SUMMARY:
A time-out was performed. The patient's <LEFT/RIGHT> neck region was prepped and draped in sterile fashion using chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine. The <LEFT/RIGHT> internal jugular vein was accessed under ultrasound guidance using a finder needle and sheath. U/S images were permanently documented. Venous blood was withdrawn and the sheath was advanced into the vein and the needle was withdrawn. A guidewire was advanced through the sheath. A small incision was made with a 10 blade scalpel and the sheath was exchanged for a dilator over the guidewire until appropriate dilation was obtained. The dilator was removed and an 8.5 French central venous quad-lumen catheter was advanced over the guidewire and secured into place with 4 sutures at <__> cm. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure x-ray shows the tip of the catheter within the superior vena cava.

 

COMPLICATIONS:

***

 

ESTIMATED BLOOD LOSS:

***