Common procedures in ward setting
- 2. NASOGASTRIC TUBES • Used: • • To decompress the stomach/gastrointestinal tract especially when there is obstruction, eg gastric outflow obstruction, ileus, intestinal obstruction. • • For gastric lavage. • • To administer feed/drugs, especially in critically ill patients or those with dysphagia, eg motor neuron disease, post CVA
- 3. HOW TO INSERT A NG TUBE • Wear non-sterile gloves and an apron to protect both you and the patient. • Explain the procedure. Take a new, cool (hence less flexible) tube. Have a cup of water to hand. Lubricate well with aqueous gel. • Use the tube, by holding it against the patient’s head, to estimate the length required to get from the nostril to the back of the throat. • Place lubricated tube in nostril with its natural curve promoting passage down, rather than up. The right nostril is often easier than the left but, if feasible, ask the patient for their preference. Advance directly backwards (not upwards). • When the tip is estimated to be entering the throat, rotate the tube by ~180° to discourage passage into the mouth. • Ask the patient to swallow a sip of water, and advance as they do, timing each push with a swallow. If this fails: Try the other nostril. • The tube has distance markings along it: the stomach is at ~35–40cm in adults, so advance > this distance, preferably 10 –20cm beyond. Tape securely to the nose. COMPLICATIONS •Pain, or, rarely: •Loss of electrolytes •Oesophagitis •Tracheal or duodenal intubation •Necrosis: retro- or nasopharyngeal •Stomach perforation.
- 4. PERIPHERAL VENOUS CANNULATION 24 22 20 18 16 24 22 20 18 16 14 Contraindications • Cannulae should not be placed unless intravenous access is required. • Caution in patients with a bleeding diathesis. Risks • Infection, which could be local or systemic. Sizing cannulae • Cannulae are colour-coded according to size. The ‘gauge’ is inversely proportional to the external diameter. • The standard size cannula is ‘green’ or 18G but for most hospital patients, a ‘pink’ or 20G cannula will suffice. Even blue cannulae are adequate in most circumstances unless fast flows of fluid are required.
- 5. CATHETERIZATION Size (in French gauge): 12=small; 16=large; 20=very large (eg 3-way). Indications • Relieve urinary retention. • Monitor urine output in critically ill patients. • Collect uncontaminated urine for diagnosis. It is contraindicated in urethral injury (eg pelvic fracture) and acute prostatitis.
- 7. PARACENTESIS • Place the patient flat and tap out the ascites, marking a point where fluid has been identified, avoiding vessels, stomas, and scars (adhesions to the anterior abdominal wall). The left side may be safer—less chance of nicking liver. • Clean the skin. Infiltrate some local anaesthetic, eg 1% lidocaine • Insert a 21G needle on a 20mL syringe into the skin and advance while aspirating until fluid is withdrawn, try to obtain 60mL of fluid. • Remove the needle, apply a sterile dressing. • Send fluid to microbiology (15mL) for microscopy and culture, biochemistry (5mL for protein), and cytology (40mL). Call microbiology to forewarn them if urgent analysis of the specimen is required
- 8. DIAGNOSTIC ASPIRATION OF A PLEURAL EFFUSION The conventional site for aspiration is posteriorly, approximately 10 cm lateral to the spine (mid-scapular line) and 1-2 intercostal spaces below the upper level of the fluid. • If not yet done, a CXR may help evaluate the side and size of the effusion. • Ideally use US guidance at the bedside (more chance of successful aspirate and less chance of organ puncture). If this is unavailable, ask an ultrasonographer to mark a spot, or percuss the upper border of the pleural effusion and choose a site1 or 2 intercostal spaces below it (usually posteriorly or laterally). • Clean the area around the marked spot with 2% chlorhexidine solution. • Infiltrate down to the pleura with 5–10mL of 1% lidocaine. • Attach a 21G needle to a syringe and insert it just above the upper border of the rib below the mark to avoid the neurovascular bundle (fi g 18.6). Aspirate whilst advancing the needle. Draw off 10–30mL of pleural fluid. Send fluid to the lab for chemistry (protein, glucose, pH, LDH); bacteriology (microscopy and culture,
- 10. LUMBAR PUNCTURE Contraindications • Infected skin or subcutis at the site of puncture. • Coagulopathy or thrombocytopenia. • Raised intracranial pressure with a differential pressure between the supra- and infra-tentorial compartments such as seen in space-occupying lesions. If in doubt, image first! Risks • Post-procedure headache. • Infection. • Haemorrhage (epidural, subdural, subarachnoid). • Dysesthesia of the lower limbs. • Cerebral herniation (always check local procedures regarding contraindication to LP and whether to perform CT head first).