Bedside procedures
Supervised byDR HISHAM
Prepared byANWARIAH ARIS NOOR MOHAMMAD SAFWANBEDSIDE
PROCEDURES
OUTLINESClassificationPre-procedureProceduresTake home
messages
OBJECTIVESTo identify indication/contraindicationTo be able to
performTo be aware of complication and how to avoid or
minimalize
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CLASSIFICATIONDiagnosticTherapeuticBoth
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PRE- PROCEDUREConsentAseptic technique- hand wash, sterile
glove, mask, apron, povidoneMonitoring SpO2 in chest tube, CVC,
intubationVerify the correct siteLocal anaesthesia
Consent indication C/I, complicationAseptic handwashing, ppe,
glove, maskMonitoring pulse oxy spo2 PRVerify the abnormal site
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LOCAL ANAESTHESIAMechanism of ActionToxicityAgents
CVSCNS
Alters sodium membrane permeabilityNo action
potentialLidocaineBupivacainePrilocaine
MOA: altering membrane sodium permeability resulting in a block
to the transmission of impulses along the nerve fibreAgents :
Lidocaine & Bupivacaine less common be used PrilocaineMax
doses: 4mg/kgNeurological: drowsiness, slurred speech, numbness of
the tongue or mouth, convulsions & comaCVS: early tachycardia,
, hypertension, late bradycardia, hypotension, cardiac arrythmias,
and cardiac arrest6
Lidocaine/lignocaineInjection, gel, spray1% /2%/with epinephrine
80000uMax dose 4mg/kg to 300 mg (2%:- 0.2ml/kg -15ml)Max dose with
epinephrine:7mg/kg to 500mg
Central venous catheterNasogastric tubeCatheter bladder
drainageEndotracheal intubationToilet and suturingParacentesis/
Peritoneal tappingChest tubeHemorrhoid bandingSuprapubic
catheterization
PROCEDURESPractice makes perfect
Common ones From head to toeConsent, preparationAsepticWash
hand, wear gown and sterile glvoesAssemble the instrument and
flush8
1. Central venous catheterIndications:Volume
resuscitationCentral venous pressure monitoringEmergent venous
accessNutritional supportInotropesHemodialysis
Contraindications:Coagulopathy (INR> 1.5, aPTT ratio> 1.5,
plt < 50,000)Vein thrombosis
CVP require strict input/output charting aggressive hydration to
prevent fluid overload or AKIE.g: Acute pancreatitis, ascending
cholangitis, major GI surgery or patients with underlying heart
failure or renal failure9
Approach:Peripheral Cephalic / basilic /brachial veinIJV Between
2 heads of SCM muscleSubclavian - 1 2cm below the junction of
middle and medial third of the clavicleEquipments:Central venous
catheter (long line) setManometer setAccessory : Dressing set,
syringe, hep saline
Size: 45/70cm10
Peripheral approachposition: supinePlace tourniquet & choose
a veinClean and drapeInfiltrate LA around entry point Puncture at
entry point using introducer needle into the vein while gently
withdrawing the plunger of the syringe
When theres venous blood backflow, remove the needle Insert the
catheter+guide wire through the needle into the vein Split the
protective catheter sheath.Remove the guidewire.Measure length
using the guidewire and pull the catheter back using the
measurementFlush with hep saline & apply flavine
dressingCXR
Complications: BleedingAir
embolusPneumothoraxMalpositioningArrythmias
Bleeding : rupture the vessels / artery punctureAir embolus :
Pneumothorax sudden gush of air aspirated confirm clinically and
CXRMalpositioning too deep or highDysarrthmias - 13
2. Nasogastric tube insertionIndications:GI decompressionGastric
lavageEnteral feedingPrevention of aspiration
Contraindications:Recent esophageal/gastric surgeryBase of skull
fractureSevere facial trauma
GI decompression: obstruction, ileus, postoperative,
pancreatitisGastric lavage : UGIB or to drain alleged ingestion of
poisonEnteral feeding : unable to swallowPrevention of aspiration :
stroke or neuro d/o affecting swallowing
C/I : may go intracraniallyMay cause perforate or puncture the
op site
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Equipment:NG tube 8,10Accessory : Gel, syringe, gauze,
stethoscope, glass of water
Length:Measure: tip of nose to earlobe to midpoint between
xiphisternum and umbilicus
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procedurePosition : sit up straightLubricate the NGT with
gelInsert through the nasal opening until the tip hits pts throat -
swallow sips of waterAdvanced the NGT gently while asking the
patient to keep swallowing until desired lengthSecure with tape
Confirm position:Inject air while auscultate the stomach and
compare with lungAspirate gastric contentCXR
Complications: Erosion of narisEpistaxisNasotracheal
intubation
3. Urethral catheterizationIndications:DiagnosticCollection of
uncontaminated urine specimenUrinary output monitoringUrodynamic
studies
TherapeuticAcute urinary retentionFor bladder
irrigationIntermittent decompression forneurogenic
bladderIntravesical chemotherapy
EquipmentFoleys catheter16 -18F, CBD set, lignocaine gel,
syringe with 10cc water for injection,
Non touching techniqueUse forceps in the cbd set
For female patients
For male patients
ComplicationsPainUTIUrethritisUrethra strictureTraumatic
urethral injury
4. Endotracheal intubationIndicationsAirway management during
resuscitationGeneral anaesthesiaRespiratory failureAirway
obstruction Multiple trauma, head injury and abnormal mental status
Inhalation injury with erythema/edema of the vocal cords
ContraindicationsFractured larynxMassive maxillofacial
traumaSuspected cervical spinal cord injury
EquipmentEndotracheal tube (7-9), laryngoscope handle and blade,
10cc syringe, suction, ambubagMedication Midazolam-morphine 2.5, 5
,10 mg IVEsmeron - 0.6-1.2 mg/kg IV Scoline 0.3-1.1 mg/kg IV
procedureVentilate pt before attempting procedure(100% O2)Check
the light and et tube cuffPosition pts head tilt and jaw liftAfter
adequate ventilation, insert laryngoscope with left handuse the
blade to push the tounge to pts leftAdvance the blade until
epiglottis visualized,
place the blade anterior to epiglottis and lift anteriorly to
visualize vocal cords (Gentle pressure to cricoid cartilage helps
visualizitaion)
Insert the et tube with right hand while maintain visualization
of the chordsSuction to clear the airwayInflate the cuff with 10cc
syringeCheck chest movement and auscultate both lungs to
compareSecure with tape
ComplicationsBleedingOral or pharnygeal traumaImproper tube
positioningTube kinking or obstruction
5.Toilet and suturingIndicationsAll wounds need some kind of
toilet. Contraindications to a radical toilet are signs of
established infection, such as a foul discharge, lymphangitis,
lymphadenitis, or fever.
EquipmentT&S set, blade or scalpel, suture, plenty of
sterile water, syringe 10cc,50 cc, lignocaine 2% injection
procedureAssess the wound: depth, foreign body, sign of
infection, active bleeding, necrotic tissue, underlying structural
injury (bone fracture, tendon injury, organ
perforation)HemostasisSkin preparation and wound toiletClean
surrounding skin with povidoneGive adequate local
anaesthesiaIrrigation with copious amount of salineRemove foreign
body and necrotic tissueDebride ragged, nonviable skin edges.
ClosureTiming Primary closure: immediate closure for simple
wounds
