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Introduction of a percutaneous catheter into a large vein (jugular or femoral).
Indications
Peripheral venous collapse requiring rapid vacular perfusion.
Material
Large bore needles and catheters (16 to 24 G) and intravenous fluids are needed.
Technique
External jugular vein
· Lower and turn the patient's head to the opposite side of the chosen vein.
· Rigorous asepsis: clean with polyvidone iodine (see table page 7).
· Compress the base of the neck to dilate the vein which crosses the sternomastoid muscle.
Internal jugular vein
· Gently lower and turn the patient's head to the opposite side of the chosen vein.
Rigorous asepsis: clean with polyvidone iodine and use sterile gloves.
Place a large bore needle and catheter (e.g. 16 G for an adult) on a syringe.
Puncture the head of the triangle formed by the two heads of the sternocleidomastoid and the clavicle.
Direct the needle behind, parallel to the median fine (ATTENTION: the CAROTID !) and at an angle of 30° to the horizontal.
Gently advance the needle while aspirating on the syringe. ATTENTION: do not advance too far under the clavicle because of the risk of a pneumothorax.
When blood appears, ask the patient to hold his/her breath, and
slowly advance the catheter.
- Apply a sterile dressing.
Femoral Vein
· The technique is easier than for the internal jugular vein but the region is septic.
· Rigorous asepsis.
· Place a large bore catheter on a syringe.
· Mark the crural arc; the line in the groin joining the antero-superior iliac spine and the spine of the pubis (the spine of the pubis is marked by palpating the superior border of the bone).
· Mark the edges of the femoral artery in the crural arc and fix the vessel beneath two fingers of the left hand.
· In adults, puncture lcm on the inside of the wall of the artery and 2cm below the crural arc.
· Puncture almost vertically and a little obliquely while continuously aspirating on the syringe.
· If bone is struck, withdraw while continuing to aspirate.
· When in the vein, gently lower the syringe towards the buttocks and advance the catheter. Ensure that the catheter is in the vein by aspirating blood into the syringue and then remove the introducer.
· Apply a sterile dressing.
· In the case of an arterial puncture, apply pressure for 10 minutes.
Removal of cerebrospinal fluid (CSF) for diagnostic purposes.
Indications
Suspicion of meningitis (fever, vomiting, nuchal rigidity.)
Contraindications
Intracranial hypertension, Pott's disease.
Material
Lumbar puncture needle with a stylette (for adults, 20G; for children, 23G).
Position of the patient
If possible, the patient should be sitting, back rounded, vertebral column rectilinear, head bent, chin on the sternum, and arms across the knees. If this is not possible, put the patient in the fetal position with back rounded and head flexed.
Technique
· Cleanse the lumbar region with polyvidone iodine(see table page 7) and if possible use sterile gloves.
Mark the spinous process of the 4th lumbar vertebra by a horizontal line between the superior iliac crests (in adults, the spinal cord descends to the second lumbar vertebra; in children, it descends to the 4th).
· Place the tip of the left index finger on this spine.
· Inject exactly between the two spines (L3 and L4 or L4 and L5) rapidly traversing the skin, then horizontally or obliquely towards the head.
· In adults, at a depth of 3 to 4 cm, there is resistance due to the transverse ligaments: if a needle is advanced a little further, the epidural space is reached.
· Remove the stylette and if the puncture is successful, liquid will appear. Do not aspirate the syringe, but collect the liquid in a bottle.
· Replace the stylette in the needle and withdraw together, then compress the puncture wound with a dressing of polyvidone iodine (see table page 7).
· After the lumbar puncture, confine to bed for 24 hours.
Incidents
· Failed puncture
Start again
(the axis of the needle is incorrect, there has been contact with bone, the
position of the patient is incorrect, the needle has not been advanced
sufficiently).
· Bloody puncture
Start again
(puncture of a peridural vein, or subarachnoid hemorrhage).
· Sudden pain in the inferior
limb
Occasionally a caudal nerve is hit; do nothing but ensure that the CSF
is
examined.
Puncture between the two pleural layers.
Indications
Drainage of pleural fluid for exploratory and diagnostic purposes.
Material
The same material as for a lumbar puncture: needle with stylette 20 to 23G.
Technique
Rigorous asepsis: clean the area with large quantities of polyvidone iodine (see table 1), sterilised equipment and sterile gloves if possible.
The patient should be seated, bending forward with hands on
knees.
Place a long, large bore needle on a syringe (the wall thickness is
about 3cm).
For an exploratory puncture, avoid the cardiac region, the section above the axillary crease, and do not inject below the 9th rib.
Puncture the superior brim of the inferior rib marked with the index finger of the left hand.
Gently advance the needle perpendicular to the surface, while aspirating the syringe, until fluid is collected. If the puncture fails, remove the needle aspirating all the time, and start again in an adjacent space.
In the case of a puncture for drainage of fluid or for diagnostic collection, enter the 8th intercostal space in the posterior axillary line. When the fluid has been collected, connect the needle to a large diameter drainage tube (a perfusion tube) which can be clamped with forceps and attached to a large aspirating syringe (30 to 50mls).
Drainage of fluid must be slow and not more than 700 to 800ml per episode.
ALWAYS ASPIRATE while removing the needle and compress the puncture point with a sterile dressing.
Accidents
· Pulmonary edema and syncope: rarely.
· Pneumothorax created by the entry of air at the time of puncture; prevented by ensuring a tight fit between the needle and syringe and by ensuring that continuous aspiration occurs as the needle is withdrawn.
· Accidental puncture of the vascular/nerve bundles due to a puncture at the inferior rather than the superior border of the rib.
Drainage of liquid or air between the two pleural layers.
Indications
Pneumothorax, hemothorax, empyema.
Material
· For local anesthetic
· Drapes and sterile gloves
· 2 Kelly forceps, 1 scalpel
· 1 thoracic drain with trochar (type Monod) or a tubular catheter
· Connecting pipe
· Bottle containing an antiseptic solution (chlorhexidine (+ cetrimide), see table page 7)
· Non resorbable suture material (Dec 3 or 2/0).
Technique with or without a trochar
Figure 54
· Patient in sitting position
· Disinfect the skin with polyvidone iodine (see table page 7).
· Puncture point: on the anterior axillary fine, posterior to pectoralis major, above the nipple, which corresponds to the 4th intercostal space, 4 finger breadths from the axilla, at the superior edge of the inferior rib. (This point is considered the least dangerous, avoiding organ puncture. Theoretically it is too low for treatment of a pneumothorax and too high for treatment of a purulent pleural discharge).
· ATTENTION: there is often a tendency to longer the needle and therefore to risk a hepatic or splenic puncture.
· Inject local anesthetic (lidocaine 1 %) at the site of the puncture, cross all tissue plains until the discharging site is reached and then remove the needle while aspirating.
· Make a transverse incision of 1 cm with a scalpel in the cutaneous and subcutaneous tissues at the superior border of the inferior rib.
FIGURE
Drain without a trocar
· Introduce a pair of Kelly forceps into the incision at the smooth border of the rib and gently separate the intercostal muscle fibres, then perforate the pleura. Next, introduce the drain (with intrapleural perforations) between the clasps of the Kellys. ensuring that the other end of the drain is clamped.
· Introduce the drain until it is estimated that the perforations are within the pleura, knowing that the thickness of the well is about 3 cm (figure 55).
FIGURE
Drain with trocar
Figures 56, 57, 58
· Push firmly, until the pleura is reached, rotating the trocar with one hand and using the index finger on the trocar as a guard to prevent rapid entry.
· Remove the stylette and cover the end of the trochar with a finger. Then introduce the clamped drain.
· Remove the trocar as far as the chest wall and clamp the drain above the trocar.
· ATTENTION: during the few seconds when air can enter through the trochar, ask the patient to stop breathing in order to prevent air entry.
· Attach the drain to a drainage tube connected by an airtight seal to a bottle containing an antiseptic solution. The tube should be placed in the solution.
FIGURE
FIGURE
FIGURE
The drain must be fixed to the skin:
· Use non resorbable suture material (Dec 3 or 2/0).
· Suture the drain to one of the edges of the wound and make a knot to ensure that the connection is airtight. Then criss-cross the suture material along the drain and fasten with a knot.
Additional suture
Attach another suture to the skin and around the drain, leave it long and knotted.
FIGURE
Anti-reflux system
Figures 60, 61
A sterilised anti-reflux valve is normally used, but if not available in the case of a pneumothorax, the end of a surgical glove attached to the drain acts as a valve.
FIGURE
FIGURE
FIGURE
Removal of the drain
When the draininage is complete:
· Cut the knot of the additional suture and the knot fixed to the drain.
· Make a bow with the additional suture.
· Ask the patient to stop breathing while an assistant removes the drain.
· Tie the knot and the additional suture will close the puncture wound.
Puncture between the two layers of the pericardium to evacuate fluid (blood or serous).
Indication
Tamponade, massive cardiac collapse.
Diagnostic signs
· Dyspnea, anxiety, syncope.
· Distended juguler veins.
· Tachycardia and disappearing heart sounds.
· Falling blood pressure, reduce difference between systolic and diastolic blood pressure, systolic pressure falling with deep inspiration.
Material
· Short bevel catheter of 16 G
· 50 ml syringe
· Sterile drapes with a hole
· Sterile gloves
· Polyvidone iodine (see table page 7)
Technique
· Rigorous asepsis.
· Fix the needle to the syringe.
· Introduce the needle to the left of the xyphoid process at an angle of 45° to the skin.
· Point the needle towards the right shoulder advancing and aspirating until blood appears.
Incident
Perforation of the inferior wall of the heart: withdraw the needle a little.
FIGURE
FIGURE
· Drainage of fluid in the peritoneum ù Injection of intra-peritoneal perfusion
Indications
· Drainage of ascitic fluid is indicated principally for diagnostic purposes or when respiration is impaired. Drain slowly. Attach a drainage tube and container to the trochar, do not remove more than 1 liter per episode.
· Intra - peritoneal perfusion: indicated when there is difficult access to a vein, to avoid loosing time while waiting for venous access, for example in children with acute dehydration. Do not perfuse more than 70 ml/kg, perfuse slowly and use only sodium chloride or ringer lactate.
Material
Large trocar or short large bore catheter (18 G for exemple).
Technique
Figure 66
· Rigorous asepsis: clean the abdomen with polyvidone iodine (see table page 7).
· Single puncture, perpendicular to the abdomen, on a line joining the umbilicus and the anterior superior iliac spine, usually on the left, to avoid perforation of the cecum; on the right in the case of massive splenomegaly.
FIGURE
Drainage of fluid in the articular cavity of the knee.
Indications
· Painful hemarthroses in cases of knee torsion: wait 24 to 48 hours before puncture and drainage to allow the hematoma to collect and to prevent recurrence.
· Hydarthrosis: injection of diagnostic fluid or removal of post-trauma serous fluid.
If pus is found in the joint space, surgical drainage is necessary.
Material
Large bore needle and syringe or trochar.
Technique
Figures 67, 68
· Rigorous asepsis: drapes and sterile gloves, clean with polyvidone iodine (see table page 7).
· Puncture with a trocar or large needle at an angle above and lateral to the knee cap, and 1/2 cm above and behind.
· Advance at an angle of 45° to the horizontal and sagittal planes, and push the needle behind the knee cap.
· To empty the cavity, squeeze the quadriceps muscle with the left hand while aspirating on the syringe with the other hand.
FIGURE
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