Invasive procedures Ebrahim Alsaadoon

Invasive procedures

A medical procedure that invades (enters) the body, usually by cutting or puncturing the skin or by inserting instruments into the body or by coming into contact with inner mucosa.

Minimally invasive procedure Vs. İnvasive procedure

Examples: DRE, scopes, catheter insertion, Biopsies, lumpar puncture.

Nurse’s overall role

Admission and Labelling Procedure.

Consent & witness.

The Procedure check-List (Pt name, ward, procedure & site, Medications and Anesthesia, Doctor’s name, date and time, equıpments, pregnancy, etc.)

Documentation of procedure.

Ensure having a peripheral line before every procedure.

Handing over from ward to OT/ Procedure Room.

Ensuring safety of patient and confidentiality at all times.

Assist in procedure accordingly and as needed (equipment prep, patient positiıoning, meds prep,etc.)

On top of all that, always keep a smile, care for the patient like he is your own family, tolerate the annoying doctor who asks for impossible things!

Basically.. I’m asking you to be super heroes

Central Venous Catheters

Catheter insertion

• Sites of insertion:

Internal Jugular Vein (IJV)

Subclavian Vein (SCV)

External Jugular vein

Femoral veins

Peripherally inserted central catheter

Indications

Large-bore intravenous access.

Rapid fluid resuscitation

Rapid administration of blood replacement therapy

Infusion of therapeutic drugs

Vasoactive substances

Chemotherapy

Plasmapheresis, apheresis

Renal dialysis

Cardiac monitoring.

Types of Catheters

Types of catheters

Procedure

Start with explaining to the patient what you will do (where is the doctor?)*

Generally it is preferred that they take a shower using chlorhexidine soap!

Patient lying supine ( mild head tilt downwards).*

Make sure that everyone and everything is sterile.*

Give Local anesthesia at site of insertion.*

Make sure the equipment are working ( wire moves freely, Catheter flushes normally, all lumens work).*

Use the proper technique of insertion according to site of insertion until you aspirate blood using the needle.

Insert guidewire into the needle and advance smoothly (no muscles needed).. ~30cm of wire should go in.

Secure wire placement with one hand and pull needle out with the other.

Make a small incision where the wire enters the skin and dialate.

Insert Central Catheter over the wire until it is in place and then start removing the wire.

Sutures to secure the line, clean the area and keep dressing on the skin.*

Order a Chest X-ray (why?) *

Ensure you can aspirate blood from every lumen and you can flush every lumen. *

complications

Failure of procedure!

Arterial Puncture.

Hematoma

Infection

Arrhythmias

Pneumothorax

Thrombosis

Find another vein, find US machine.

Remove and Press for 5 minutes.

Usually reabsorbed spontaneously

Abx.

Call Cardiology!

Management of Pneumothorax.

Anticoagulations .. Removal?

Maintaining Central lines

Flush lumens on catheter with saline.

Obtain chest radiograph to confirm position of catheter and exclude pneumothorax.

Use sterile technique when injecting drugs or connecting tubing to lumens of catheter.

Routinely replace sterile dressings, cleansing the site with chlorhexidine before applying a new dressing.

Examine the insertion site daily for signs of infection.

While the catheter is in place, leave sterile caps in place at all times and cleanse ports with alcohol before connecting anything to them.

When preparing to remove the catheter, place the patient in Trendelenburg’s position. Ask the patient to exhale as the catheter is removed, to prevent air embolism, and apply pressure over the site for 1 to 2 minutes for hemostasis.

تمللتوا؟؟

معليش باقي بس

اسبىعين

Bone Marrow Biopsy and Harvest

What and where

A procedure to get a sample of the bone marrow in order to diagnose and follow up hematological disorders as well as evaluate the bone marrow environment & Cellularity.

In a child, you can get a sample from everywhere, but as you get older, function decreases and you ncan get it only from axial bones ( Sternum, Ribs, Vertebras, Pelvis, etc.)

Indications

Evaluation of unexplained anemia, leukopenia, thrombocytopenia, or pancytopenia.

Evaluation of unexplained elevations in peripheral blood counts (eg, polycythemia, thrombocytosis, leukocytosis).

Diagnosis and staging of lymphoma, Leukemia and Plasma Cell disorders.

Evaluation of unexplained splenomegaly.

Confirmation that the bone marrow is normal in a potential allogeneic hematopoietic cell donor in selected patients (rarely needed).

Contraindications

Severe Hemophila

DIC

Thrombocytopenia is not a contraindication, but usually we transfuse to ensure Plt at least 20,000.

?Anticoagulation (Doctor to Doctor)

Infection at the site of Collection.

Prep & Procedure

Informed Consent ( What a lazy doctor!) and Fasting.

Make sure which samples are needed ( Genetics, Flow Cyt., Biopsy, Smears, etc.)

All Equipment Available (needles, syringes, Gauze, Bx Needle, Sterile gloves and drapes, etc.)

Did you find that lazy doctor?

Pre-medications (Benzodiazepine & Fentanyl), O2 and Vitals.

Patient can lie in Decubitus or in the prone position.

Make sure everyone and Everything is Sterile!

Equipment is working.

Find the Posterior superior iliac Crest.

Give Local anesthesia into Skin & Periosteum

Insert Bx needle into the area ( incision?) in a rotational movement until you hit the bone and go into the bone ( Ouch!)

Prep & Procedure

Remove Stylet and aspirate bone marrow using a syringe. ( how do you know its BM? Also OUCH!!!)

Give to assistant ( yes you or Lab technician if you’re in SMC)

Assistant will make smears, put samples into CORRECT tubes.

The Lazy doctor will insert the bone further into the bone to get a biopsy in a rotational fashion.

Then he will look like he is fighting with the bone marrow.

Pull the needle out and drop biopsy into formalin tube.

Keep Pressure on area and then Clean it and keep dressing.

Ask patient to lie on his back (why?)and not to eat until fully awake.

Throughout the above procedure, you should keep an eye on the vitals.

complications

Bleeding -> Pressure

Infection -> Abx, Usually topical

Needle Breaking -> Find a surgeon

Pain and Discomfort-> Analgesia and Reassurance

Perforation?

Bone Marrow Harvest Indication: Failed Peripheral Mobilization, ? Pediatrics

Usually done in OT under GA.

Same technique of Bone marrow Bx, but repeat again and again in different Directions.

Collect 10-15ml/Kg of Recipient’s weight. ( Total of about 1.5-2L )

Use of Heparin and filtration.

Need Apheresis Team with you.

Complications: Usually same as BM Bx.

Your role: OT handover, reassure the patient, Make sure your checklist is there, OT Prep, Receive the patient and post-op orders.

LAZY DOC FOUND!

؟؟يعتوا

LUMBAR PUNCTURE

What is it

Procedure done to obtain a sample of the cerebrospinal fluid (CSF) to evaluate for signs of disease.

Usually at level L3/4 or L4/5. why?

Spine ends L1/L2

indications

Suspicion of CNS infections (Bacterial, Viral and Fungal)

Subarachnoid Hemorrhage diagnosis

Demyelinating diseases ( MS)

Gullian-Barre Syndrome

Intrathecal Medications ( Abx & Chemotherapy)

Spinal Anesthesia

Contraindications

Possible Raised intra-cranial pressure.

Thrombocytopenia or bleeding diathesis.

Anticoagulation use.

Suspected spinal epidural abscess.

Procedure

Informed Consent ( 5ala9 you found him)

Keep the patient in the lateral position and ask him to hug his knees with flexed neck (Fetal position)

Make sure everyone and everything is sterile & ready equipment.

Feel the area and palpate L4 .. L4 is at the level of the highest point of the iliac crest.

Insert the needle into the space between L4/L5, advance slowly towards umbilicus until you see clear fluid coming out.

Collect three tubes.. 10 drops into each tube .. All sterile! Remember which one is tube 1, 2, 3.

Pull the needle out slowly and keep pressure on the area after cleaning and keep dressing.

complications

Post LP headache -30% and can last for 2 days after.

Infection .. Meningitis!

Bleeding and Hemorraghic Tap.

Cerebellar herniation (conning) due to raised ICP.

...لكن اقول مالكم اال

و طبعا صالىنة

اللحم اللي ال غنى عنها

Liver & Kidney Biopsy

Liver Biopsy

Multiple types: Percutaneous, Transjugular, Laproscopic, Open, Ultrasound guided.

Indications:

●Diagnosis of multiple parenchymal liver diseases

●Abnormal liver tests of unknown etiology

●Focal or diffuse abnormalities on imaging studies

●Prognosis-staging of known parenchymal liver disease

●In BMT: differentiate between liver GVHD, infections and causes as well as diagnosing other complications such as VOD.

contraindications

Coagulopathy

NSAIDS and asprin use ( 7 days)

Dilated biliary tree

Suspected hemangioma, vascular tumor, or echinococcal cyst

Procedure

Informed consent and preliminary tests (LFTs, CBC, Coag) and NPO.

All equipment are ready ( Suction needle, Scalpel, Drapes, US machine, etc.)

Vital monitoring and medications ( sedative, anxiolytics and Local Anesthesia)

Patient supine with right hand under his head.

Make sure everyone and everything is sterile.

Doctor Percuss over the Liver until hears max. Dullness, and confirm with US machine.

Clean area, give local anesthesia and then make small incision.

Insert needle in incision and then ask patient to hold breath.

Obtain the sample and remove needle, Pt. can breath.

Keep pressure and dressing.

Patient should not move during procedure.

Post Bx care & Complications

Bedrest for minimum of 3-6 hours.

NPO until awake.

Generally left supine or right lateral side.

Vitals every 15 minutes in the first two hours, every 30 minutes next 2 hours and then hourly. Why?

Can be done as Outpatient and discharged on same day ( minimum 4 hours after Procedure).

Complications: Operator dependent, bleeding, pain, infection, perforation and Pneumothorax.

Renal Bx

Types: open, Laparoscopic, percutaneous.

Complicated indications and not always necessary. Often would not change course of management.

Indications include unexplained renal failure, suspected rare illnesses, acute nephritic syndrome.

Relative Contraindications: small kidney, bleeding risk, renal cysts, hydronephrosis, solitary native kidney.

Complications: bleeding risk, infection, perfotation, pain, hematuria.

Important things in procedure: Prone, lower renal pole, US guided.

متاكدين وحشتكم البحرين؟

حتى الشفتات و المنيجرية؟؟

SCOPES!

Upper and LOWER GI Scope

Procedures done in order to visualize the inner mucosa of the GI system from Oropharynx to cecum, with real-time assessment and interpretation of the findings encountered.

Needs to be done by expert hands and careful patient selection.

Common Indications: GI Sx not responding to treatment, Red flag Sx, suspicion of malignancy, Screening of high risk patient, Bleeding, GERD, IBD, Therapeutic.

Contraindications: not complying to previous instructions (NPO, Solution), inability to cooperate, perforation, hemodynamic instability.

Your role

Informed consent and reassurance as the procedure can be uncomfortable and Humiliating.

Ensure proper preparation of the patient (NPO & Bowel Prep)

Vitals, comorbidities, medications, allergies.

Proper handover to the Endoscope staff ( right patient, Labs, Comorbidities, meds and Allergies)

Generally the patient will receive Sedation and anxiolytics before procedure to help the patient cooperate and tolerate the procedure .. Or is it?

Experienced physician will proceed with endoscope to visualize the inner mucosa, sample taking and taking images which will help diagnose and assesse the patient.

Your role here is, keep an eye on the patient, assist the doctor with positioning and relaxing the patient, provide whatever equipment needed (biopsy, H.Pylori kit, ..) and vitals and prevent aspiration.

Following the procedure, ensure the patient is well, and follow post procedure order.

Try to find out what happened in the procedure.

complications

Sedation related

?aspiration

Bleeding

Perforation?

Pain and discomfort

Bronchoscope

Endoscopic procedure that visualizes the tracheobronchial tree by placing an optical instrument inside the airways.

Types: Flexible Vs. Rigid.

Indications: Pneumonia, persistent atelectasis, Lung mass, hemoptysis, Bronchiolitis obliterans.

What they generally do: Bronchial washing, Brushing, Sampling , Transbronchial Biopsy and Aspiration, Therapeutic (laser, Balloon and brachytherapy, Mucus clearance, foreign body removal)

Contraindications: hemodynamic instability, anticoagulation and bleeding diathesis, Cervical and mandibular injury.

Your role Informed consent and reassurance.

Ensure proper preparation of the patient , NPO and all labs required, optimum patient care.

Vitals, comorbidities, medications, allergies.

Proper handover to the brochoscope staff ( right patient, Labs, Comorbidities, meds and Allergies)

Generally the patient will receive Sedation and anxiolytics before procedure to help the patient cooperate and tolerate the procedure .. Or is it?

Experienced physician will proceed with bronchoscope to visualize the inner airway, sample taking and taking images which will help diagnose and assesse the patient.

Your role here is, keep an eye on the patient, assist the doctor with positioning and relaxing the patient, provide whatever equipment needed (biopsy, flush, ..) and vitals and prevent aspiration.

Following the procedure, ensure the patient is well, and follow post procedure order.

Try to find out what happened in the procedure.

complications

Sedation related.

Pneumothorax.

Bleeding & epistaxis.

Throat and nasal discomfort.

Bronchospasm

Hypoxia

infections