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Procedurepalooza 2010 Day 3. Jason Poston Section of Pulmonary and Critical Care Department of Medicine University of Chicago. Source: ABIM Website 3/31/09 http://www.abim.org/certification/policies/imss/im.aspx#procedures. Goals. Remind you of what you already know

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procedurepalooza 2010 day 3

Procedurepalooza 2010Day 3

Jason Poston

Section of Pulmonary and Critical Care

Department of Medicine

University of Chicago

slide2

Source: ABIM Website 3/31/09

http://www.abim.org/certification/policies/imss/im.aspx#procedures

goals
Goals
  • Remind you of what you already know
  • Encourage a systematic approach to procedures
    • Should we do it?
    • Will we get in trouble?
    • How do we do it?
    • What happens once we’ve done it?
indications
Indications
  • Primary therapy for cutaneous abscesses
  • Often obviates need for antibiotics
  • Exam shows tender, indurated, fluctuant area
    • Needle aspiration
    • US
  • Amenable for I & D if > 5mm in diameter
contraindications
Contraindications
  • Extremely large abscesses
  • Deep or difficult to access lesions
  • Areas of cosmetic concern
  • Cellulitis without abscess
complications
Complications
  • Pain
  • Bleeding
  • Progression or recurrence of abscess
  • Endocarditis?
i d abscess technique
I & D Abscess: Technique

NEJM: Videos in Clinical Medicine

http://content.nejm.org/cgi/video/357/19/e20/

peripheral intravenous cannulation
Peripheral Intravenous Cannulation
  • Indications:
    • IV drug administration and fluid hydration
    • IV hydration
    • Transfusions of blood and blood products
    • Surgery and Emergency Care
  • Contraindications:
    • Site specific:
      • Infection
      • Phlebitis
      • AV fistula in the extremity
      • Previous surgical procedures in the extremity

(ex: LN dissection)

peripheral intravenous cannulation1
Peripheral Intravenous Cannulation
  • Complications:
    • Pain
    • Bruising
    • Bacterial Infection
    • Extravasation
    • Phlebitis
    • Thrombosis
    • Embolism
    • Nerve Damage
pic equipment
PIC: Equipment
  • Gloves, Eye Protection
  • Tourniquet
  • Chlorhexidine antiseptic solution
  • Saline Flush
  • 2 x 2 Gauze
  • Transparent Tape
  • Catheter
pic catheter size
PIC: Catheter Size
  • Ranges 14 gauge - 24 gauge
  • Choose smallest effective catheter
  • 14 G and 16 G for emergent resuscitation
pic choosing a site
PIC:Choosing a Site
  • Preferred: Forearm
  • Antecubital fossa in emergencies
  • Dorsal veins in foot or saphenous have a higher incidence of thrombosis and embolism
the procedure
The Procedure
  • Position the patient supine with the arm supported
  • Tie tourniquet with 1/2 knot 8-10 cm above targeted insertion site
  • Inspect and palpate veins
  • Clean selected site with chlorhexadine
  • Spin the hub of the catheter to ensure it slides easily around needle
  • Use nondominant hand to apply traction to the vein distal to insertion site
the procedure1
The Procedure
  • Hold catheter with dominant thumb and index finger
  • Insert Catheter with bevel up at 5 - 30 degree angle through the skin and into the vein
    • Less angle is required for more superficial veins
  • When flash of blood enters catheter, lower catheter to angle almost parallel to the skin and advance catheter
  • Remove Tourniquet
  • Apply pressure to vein proximal to the end of the catheter to prevent blood loss as you remove needle from catheter
the procedure2
The Procedure
  • Flush with saline to confirm patency

Never reinsert needle into catheter!

  • Check for swelling, redness, leakage or discomfort around insertion site
  • Attach IV tubing
  • Secure catheter with transparent occlusive dressing at the hub.
  • Loop IV tubing and secure to the skin
drawing venous blood
Drawing Venous Blood
  • Indications
    • To obtain a variety of blood values
  • Contraindications
    • Site Specific
      • Areas of burns or scarring
      • Area with hematoma or edema
      • Extremity with previous surgical intervention (ex: Mastectomy)
      • Area near an IV (distal draw is acceptable)
drawing venous blood1
Drawing Venous Blood
  • Complications:
    • Bleeding
    • Hematoma
    • Swelling
    • Infection
drawing venous blood2
Drawing Venous Blood
  • Equipment:
    • Gloves, Eye Protection
    • Chlorhexidine antiseptic solution
    • Needles
    • Gauze and adhesive bandage
drawing venous blood3
Drawing Venous Blood
  • Choosing a Site
    • Upper Extremity Ideal
    • Avoid areas listed in contraindications
drawing venous blood4
Drawing Venous Blood
  • Follow the same steps as PIC to choose, sterilize and apply traction to a vein
  • Insert needle at 15 - 30 degree angle
  • With flash, attach evacuated collection tube (in series if more than one)
  • Remove tourniquet before the last container fills.
  • Apply pressure at insertion site as needle is removed
  • Hold pressure to prevent hematoma formation; Cover with occlusive bandage
indications1
Indications
  • Aspiration for diagnostic testing
  • Aspiration for relief from pressure
  • Injection of Medication
    • Glucocorticoids
    • Local anesthetic
complications1
Complications
  • Bleeding
  • Leakage of joint fluid
  • Infection
  • Post-injection flare
  • Flushing (with Kenalog)
the procedure3
The Procedure
  • Position and palpate
  • Sterilization
    • Iodine
    • Chlorhexidine
  • Anesthesia
    • Ethyl chloride
    • 1% lidocaine
the procedure4
The Procedure
  • More about sterility
    • Because you never touch prepped skin, sterile gloves are not a necessity
  • Equipment
    • Needle (22 gauge default)
    • Syringe (6 cc default)
fluid analysis
Fluid Analysis
  • Gram stain and culture
    • Remember low sensitivity for gonococcus
  • Cell count and differential
  • Crystal analysis
injection
Injection
  • Own set of contraindications
    • Possible infection
      • DM
      • One joint worse than others
    • Early osteoarthritis, candidate for repair
what do you inject
What do you inject?
  • Glucocorticoids
    • Triamcinolone acetonide (Kenalog)
    • Methylprednisolone (Depo-Medrol)
    • Triamcinolone hexacetonide (Aristospan)
  • Analgesics
    • Lidocaine