Advanced Clinical Procedures

Question 1

Esophagostomy tube

Answer 1

Feeding tube for in appetent patients

Question 2

Advantages?

Esophagostomy tube

Answer 2

Use right away, simple, minimal equipment, relatively low risk, well-tolerated.

Question 3

Esophagostomy tube

Indications:

Answer 3

Inappetance, hyporexia
Maxillofacial injury
Dental/oral pain or disease
Pharyngeal disease

Question 4

Esophagostomy tube

Contraindications?

Answer 4

Vomiting, regurgitation, esophageal disease, inability to protect airway.

Question 5

Esophagostomy tube

Materials needed

Answer 5

Feeding tube (red rubber, MILA) adapters if needed
Scalpel blade
Curved large forceps (Rochester-carmalts)
Sharpie or other marking pen
Needle holders and non-absorbable suture

Question 6

Esophagostomy tube

Preparation

Answer 6

Induce general anesthesia and intubate
Clip and scrub lateral neck from ramus to caudal cervical region
Measure tube from cervical point of insertion to mid thorax.
*CUT off the tip of the red rubber catheter.

Question 7

Esophagostomy tube

Placing the tube

Answer 7

Pass carmalt from the mouth to the mid-cervical region, press the tips laterally against the skin.
Incise over the tip of the carmalt through the skin, SC, fascia and esophagus.
Push carmalt through the incision.
Grasp the tip of the feeding tube.
Pull the tube out through the mouth.
Reverse the tip and pass down the esophagus
-Tube will FLIP
Take a radiograph!

Question 8

Esophagostomy tube

Securing the tube

Answer 8

Variety of methods..
Deep bite of the atlas periosteum
Finger trap suture.

Question 9

Thoracocentesis

Indications

Answer 9

Diagnostic and therapeutic for pleural space disease

• Pleural effusion
• Pneumothorax

Question 10

Thoracocentesis

Contraindications?

Answer 10

Coagulopathy

Question 11

Thoracocentesis

Materials needed

Answer 11

20-22 g IV catheter (alt. butterfly)
Three way stopcock
IV extension tubing
Syringe
Collection materials (basin, tubes, culture)

Question 12

Thoracocentesis

Preparation

Answer 12

+/- sedation, LA
Clip and scrub the area in the middle of the chest
-may need to prep and tap bilaterally
Sterile gloves and handling of the materials.

Question 13

Thoracocentesis

Technique

Answer 13

Insert catheter through the skin
-perpendicular to the body wall
-cranial aspect of rib
--avoid intercostal aa. on caudal aspect
Remove needle (if using catheter)
Direct needle/catheter parallel to the body wall to avoid iatrogenic lung injury
-bevel up-air, bevel down (fluid)
Attach a fluid line, 3 way stop cock and syringe
Put assistant to work!

Question 14

Thoracostomy tube

Indications

Answer 14

Indications:

• Continuous pneumothorax
• Post op thoracic surgery
• Pyothorax

Question 15

Thoracostomy tube

Materials needed

Answer 15

Local anesthetic
Sterile surgical pack (towels, needle holder, blade, towel clamp, forceps and hemostats)
Thoracic drainage tube
Christmas tree adapter
Three way stopcock
Non-absorbable suture
Cerclage wire or zip tie, metal clamp.

Question 16

Thoracostomy tube

Preparation

Answer 16

General anesthesia
Clip thoracic wall, scrub
Intercostal nerve block
Assistant advance skin cranially
Drape and use aseptic technique.

Question 17

Thoracostomy tube

Technique

Answer 17

Small incision at approximately 10th ICS
Tunnel tube with trocar cranially under skin
Direct tube through the thoracic wall (cranial aspect of the rib)
Advance the tube off trocar into thorax.

Question 18

Thoracostomy tube

Securing the tube

Answer 18

Attach Christmas tree adapter and evacuate the chest
Place purse string suture (grab muscle)
Finger trap suture
Bandage
Secure with wire/zip tie/clamp to prevent accidental loss of negative pressure.

Question 19

Purse string suture

Answer 19

Take bites around the stoma, wound, tube

Clinch closed around opening.

Question 20

Finger trap suture

Answer 20

Bite of skin, muscle (get muscle in cats!) OR continuation of purse string
Tie knot with equal length of suture on either side.
Cross strands of suture underneath tube.
Surgeons throw - enough to indent tube.
Cross strands behind (surgeons throw, repeat 4-5x)
Finish with knot, some take a final bite of skin.