Department of Anaesthesiology and Intensive TherapyInstitute of Surgical Research

Department of Emergency Medicine

Basics of Emergency Medicine

Workshop V.Surgical vein preparation, Seldinger technique,

Urether catheterization, Nasogastric tube insertion

Year 2015-2016 / 1st semester

Surgical vein preparation

Venous cutdown, that is surgical exposure of a peripheral vein, is necessary if it is impossible to insert a cannula into a satisfactory vein - or the percutaneous insertion of a vena cava catheter is contraindicated.

Indications for catheterization of a vein

1. Continuous CVP monitoring2. Replacement of fluids (infusion, transfusion)3. Iv. administration of drugs4. Obtaining serial blood samples

Surgical vein preparation I.

Aim: to ensure a stable venous rout for fluid replacement, drug administration and parenteral feeding in case of insufficient peripheral veins

Implementation:

• Performed by surgeon; aseptic (operathing theatre) environment

• Under general anaesthesia (if contraindicated: strong pain killers and infiltration of local anaesthetic)

• Skin incision above a superficial vein, blunt dissection of soft tissues, free dissection of the vein, small incision on the vessel, introduction of the catheter)

Surgical vein preparation II.

Venasection - cannulation of a peripheral vein

Removal of venous catheter

Venous catheter can be introduced for CVP measurement into the following veins

1. External jugular vein;

2. V. subclavia; Arm veins (median cubital vein, basilic vein);

The CVP indicates the right ventricular preload (the rate of venous inflow).The CVP is influenced by several factors, and in critically ill patients its predictive value in giving a measure of the filling of the intravascular space is limited.In extreme situations, it demonstrates the severity of hypo- or hypervolemia.

Central venous pressure (CVP)

The CVP is elevated in cases of:• Increased intrathoracic pressure, at ventilation with positive pressure;

• Impaired cardiac function (heart failure, pericardial tamponade);

• Hypervolemia (overfilling);

• Superior vena cava obstruction;

The CVP is decreased:• Reduced intrathoracic pressure (e.g. inspiration)

• In cases of obvious hypovolemia (if a volume challenge of 250–500 mℓ of crystalloid causes an increase in CVP that is not sustained for more than 10 min, this is suggestive of (relative) hypovolemia)

Seldinger technique

(central vein insertion, arterial and venous cathetarization)

Seldinger technique I.Application: minimally invasive proceduresE.g.:1. Common Interventional Radiology Procedures: - procedures on arteries: angiography;

percutaneous transluminal angioplasty; arterial stenting, tu. embolisation..stb)

- procedures on veins: TIPS; thrombolysis in DVT; varicocele embolization, port insertion )

2. Central vein insertion for hemodynamics (fluid replacement, drug administration and parenteral

feeding, intensive care monitoring etc)

Implementation: with palpation of the pulse or by means of ultrasound guidance

Insertion place:Arteries: femoral or brachial artery (less frequently: the radial or the popliteal artery) In case of veins: common femoral vein, internal jugular or subclavian vein

Seldinger technique II.

Venous portEmbolisation of uterinal artery

Seldinger technique III.1. Insert Braunüle into the lumen of the vessel

3. Flexible guidewire into the central vein

5. Dilation device

6. Central vein canula

2. Remove the needle

4. Remove the sheat of Braunüle

Removal of guide wire

Note: In case of special, so called Seldinger needle, the 1st and 2 nd steps are the same, because there is no plastic sheat

Centra venous catheter

1. Measurement of central venous pressure

Pressure transducer

Arterial catheter

Thermosensor for cold saline bolus

Arterial pressure transducer

2. Measurement of arterial pressure in the femoral artery

Arterial/venous catheterization with percutaneous punction

PiCCO Monitor

Arterial thermodilution catheter

Temperature sensor

Pressure transducer

Central venous catheter

Injectate saline temperature sensor housing

Cardiac Output measurement with a transpulmonary thermodilution method

Cold saline bolus injection

Lung

Thermistor catheter in aorta

Scheme for the Transpulmonary Thermodilution Method

The thermodilution curve

A known volume of cold saline (5-10-20 ml) is injected iv, as fast as possible. Saline temperature is at least 10°C lower than blood temperature.

The passage of the heat bolus injected into the central vein is registered by a thermistor catheter positioned in the femoral artery.

The temperature change recorded downstream is depending on the flow and on the volume through which the cold indicator has passed. As a result, a thermodilution curve can be obtained.

The cardiac output is calculated from the area under the thermodilution curve.

Measurement of Cardiac Output (CO)

Urinary system monitoring

Catheterization of the bladder

Urether catheterization

Definition: artificial emptying of the urinary bladder.

Aims: therapeutic (urine retention, incontinence, preoperative preparation) diagnostic (monitoring fluid status, urologic/microbiologic tests)

Principles of catheterization

- catheterize only if it is necessary - avoid catheterization in case of urethral injuries - catheterize in accordance with the rules of asepsis!

Catheters

Material: synthetic, latex or silicone.

Size: external diameter is given in Charriére (1 Ch) or 1 French (1 F) (=0.33 mm)

The most widely used: 14-22 Ch Foley-catheter (with balloon, easy fixation).

Tools for catheterization

- catheter in appropriate size

- urine container sack and tube

- sponges for cleaning of genital area

- disinfectant

- saline (in syringe) to fill the balloon

- sterile lubricant (Instillagel)

- sterile gloves

Male catheterization- Lift the penis (about 60 degrees) with left hand

and retract the foreskin

- Clean the urethral meatus with disinfectant 3 times

- Inject some Instillagel to the urethra

- Insert the catheter into the urethra withsterile forceps

- Fill the balloon with 10 ml saline

- Pull back the catheter until the balloonallows

- Connect the urine container sack to thecatheter.

Male catheterization

Removing the catheter in males

Female catheterization

- Spread the labia gently with left hand

- Clean the introitus with disinfectant 3 times

- Grasp the catheter with sterile forceps at some cm-s from the end

- Put Instillagel onto the first some cm-s of the catheter

- Insert the catheter gently into theurethra

- Connect the urine container sackto the catheter

- Fill the catheter with 10 ml saline

- Pull the catheter back.

Female catheterization

Female catheter removal

Simple examinations of the urine:

• Inspection, and measurement of specific gravity and osmolarity

• Microscopic examinations

• Qualitative and quantitative lab tests

• Microbiological examination

Assessment of the fluid status:

• Urine collection for 24 h; daily fluid balance. Determination of fluid intake and output;

• Hour diuresis: in patients in shock, or with burns, critical circulatory disorders, renal insufficiency;

The aims of taking urine samples

Enteral Feeding

Nasogastric tube insertion

Enteral feeding

1.Parenteral feeding2.Enteral feeding (tubes)

Planning: gastroenteral feeding is preferred beacause it is more physiological

Short term feeding(max. 2-3 weeks):

Nasogastric tubesOrogastric tubesNasoduodenal tubesNasojejunal tubes

Long term feeding(stomas):

OesophagostomaGastrostomaJejunostomaPercutan endoscopic gastrostomaPercutan endoscopic jejunostoma

Who needs an NG tube:

Assessment:• Surgical clients• Ventilated client• Neuromuscular impairment .• Clients who are unable to maintain adequate oral

intake to meet metabolic demands.

„Indicated for those clients who do not want/ cannot/ must not eat”

Gather equipment for nasogastric tube insertion

• 14 0r 16 Fr NG tube• Lubricating jelly• Syringe 50-60 ml• pH test strips• Tongue blade• Flashlight• Emesis basin• Catheter tipped syringe• 1 inch wide tape or commercial fixation device• Suctioning available and ready

Preparation of the patient (high Fowler position)

NG insertion-video

NG tube insertion I.– Inform the patient– Patient is laid in a fowler, or in a semi-fowler

position (in case of unconciuosness)

Semi-fowler position

NG tube insertion II.

– Handwash– Gloving– Assess the patency of the tube– Measure the required tube length (until the ear lobe

and the xyphoid process)– Preparation of the tube (bending, lubricant)

LubricantMeasure the length of the tube

– Introduce at an acute angle at first then push forward toward the nasopharynx

– After getting through the nasopharynx the patient should bend his head

NG tube insertion III.

introduction After a few cm push parallel with the nose

• The patient take breath throuh his mouth during the whole procedure

• Tube can get through the oropharynx during swallowing (we pretend it by moving the epiglottis on the manikin)

NG tube insertion IV.

• After getting through the oropharynx, check the location of the tube (in case of breathing sounds take it out)

• Introduce the tube gradually during every swallowing

• Do not force the introcuction (in case of any obstruction take it out)

• Fix the tube with plaster around the nose

NG tube insertion V.

Nasogastric tube insertion-video

NG position

right

Checking:

Confirm satisfactory tube positioning before starting tube feed

• aspirate for pH and color• Stetoscope• X-ray

Monitor intake and output

check the position of the tube before every feeding (at least in every 12h)

Task on the practice:

1. Applying Seldinger technique on dummy;

2. Male and female urinary catheterisation on manikin in pairs (physician and assistant);

3. Insertion of nasogastric tube on manikin;