Procedural Skills Flashcards
What are the procedures that I should be familiar with after finishing this block?
Blood transfusion (see separate cards) Bone marrow examination Urodynamic testing and urological procedures Thoracentesis Paracentesis Blood cultures Hickman line Mx
What are the indications for bone marrow aspiration?
- Suspected myelodysplastic syndromes (unexplained micro/macrocytosis)
- Unexplained anaemia
- Unexplained thrombocytopenia
- Pancytopenia
- Blood film showing leucoerythroblasts
- Suspected ALL/AML
- Assessment of remission of ALL/AML
- Ix and F/U of CML/CLL
- Myeloma
- Lymphomas
Why do we look at bone marrow?
It is where blood cells are made, so if a leukaemia is suspected, or another condition of the bone marrow, we can check the cell types, morphology, and number to assess the function of the bone marrow.
What should we check when consenting for a bone marrow aspirate?
- Travel hx to exclude exposure to parasites/fungi/mycobacterium
- Immune compromise
- Risk of bone fragility
- Previous malignancy diagnosis (breast and prostate esp.)
- Allergies
- Clotting disorders
Where are bone marrow biopsies taken from?
Iliac crest
Can a bone marrow aspirate be done with abnormal platelet count?
Yes
Can bone marrow aspirate be done on someone on anticoagulation?
Yes, providing INR is no severely abnormal i.e. over 5.
How is pain managed for a bone marrow biopsy?
Local anaesthetic usually, although general can be used on children and in very anxious patients.
How should the pt be positioned for a bone marrow biopsy?
Lateral decubitus position - lying on side with top leg flexed and lower leg straight.
May also be prone.
How is bone marrow aspiration/biopsy performed?
- Palpate iliac crest and mark site with pen.
- ANTT - sterile gloves and gown, prepare site with antiseptic, then drape surrounding area.
- Insert local anaesthetic to skin and subcut tissue to periosteum. Test adequacy with needle.
- Incision in skin, insert stylet locked in place and biopsy needle.
- Once contact with bone advance slowly rotating clockwise and anticlockwise until marrow cavity entered (sudden reduction in pressure).
- Do not advance beyond an initial 1cm.
- Remove stylet and aspirate 0.3mL of marrow. Depending on kit used, change to biopsy needle to take 1.6-3cm bone marrow biopsy.
- Remove needle and apply pressure to stop bleeding.
- Send sample off for processing.
What are the potential complications of bone marrow biopsy/aspiration?
Bleeding
Needle breaking
Infection
Chronic pain (rare)
What is a cystoscopy?
Endoscopy of the bladder via the urethra
What are the indications for cystoscopy?
Ix of: Cystitis Recurrent UTIs Haematuria Incontinence Prostate enlargement/urethral blockage
What is ureteroscopy?
Endoscopy of ureter
What are the indications for ureteroscopy?
Diagnosis and Rx of kidney stones
What is thoracentesis?
Procedure done to remove fluid from the pleural space for analysis.
What are the indications for thoracentesis?
Pleural effusion of unknown cause (?malignant cause)
Symptomatic relief of breathlessness (acute or repeated in palliative care)
When is thoracentesis contraindicated?
- Very small pleural effusion
- Bleeding disorders
- Anticoagulation
- Mechanical ventilation
- Derm condition on skin overlying puncture site
What techniques can we use to assist in the procedure of thoracentesis?
USS to reduce risk of complications
Tell me how thoracentesis is performed.
- Sit the pt as upright as possible and use ANTT.
- Percuss the upper level of the fluid and mark the site - typically 10cm lateral to spine (mid-scapular line) and 1-2 ICS lower than upper level of fluid.
- Clean the area with antiseptic
- Use local anaesthetic for skin and subcut tissues
- Insert smaller needle as a test just above the upper border of rib below the mark to avoid vessels and nerves that run along the inferior border. Test aspirating small vol. fluid.
- Insert 21G needle with 50ml syringe, and aspirate as advancing. Aspirate 50-100mls for diagnostic purposes.
- Look at fluid as it comes out and note colour, odour, and consistency. Separate into different sterile pots for analysis (biochem, micro, cytology etc.)
If for breathlessness or palliation, a greater volume of fluid is usually drained through a smaller gauge cannula (i.e. a wider cannula).
What are the potential complications of thoracentesis?
Pain during and after procedure Pneumothorax (12-30%) Persistent air leak Bleeding Infection/empyema Inadvertent liver/spleen rupture (if pt leans too far forward) Re-expansion pulmonary oedema Malignant metastatic seeding (rare)
What is paracentesis?
Tapping/draining of ascites for analysis and removal of large volumes
What are the indications for paracentesis?
Diagnostic - determine cause, transudate vs exudate, and detect cancerous cells
Therapeutic - relieve resp distress or abdo pain
What are the contraindications to paracentesis?
Skin infection over proposed insertion site
Pregnancy
Severe bowel distension
Coagulopathy (debated)
What are the complications of paracentesis?
Usually safe, but complications more common with significant co-morbidities.
Bleeding Infection Renal failure Hyponatraemia Hepatic encephalopathy Bowel perforation Leak
What is the main indication for taking blood cultures?
?sepsis
What are the 2 standard culture bottles?
Aerobic and anaerobic culture mediums.
How much blood does each blood culture bottle need?
10-15mL
What is the main problem with blood cultures?
Contamination of culture from patient or clinician
What special culture bottles are available?
Bottle to culture fungi or tuberculosis
Which blood culture bottle should be filled first?
Aerobic so that the anaerobic bottle is truly anaerobic.
What needs to be done to the blood culture bottles before a sample is taken?
The caps need to be removed, then the tops cleaned with a separate cleaning swab each before allowing them to dry.
Are blood cultures taken from a vein or an artery?
A vein… can you imagine taking it from an artery!!
Can blood for culture be taken from a central line?
Yes if you are invetsigating the source of an infection, but an additional peripheral sample should be taken first.
Blood cultures should always be taken via a FRESH STAB!!
What is a Hickman line?
A type of long term venous access device
Where does the tip of a Hickman line catheter sit?
It lies within the right atrium, the superior vena cava (SVC) or at the junction between them.
What other lines might be inserted other than a Hickman line?
- Groshong catheter
- Portacath
- TIVAS
- PICC
Why might a cancer patient have an indwelling venous access device?
Administering: -Chemotherapy -Long term IV medications -Parenteral nutrition -Recurrent blood product transfusions Drawing blood samples Temporary venous access for haemodialysis
What can pts with indwelling venous access devices do to care for them?
- Flush the line
- Hygiene
- Prevent air entry into tube
- Avoid damage
How frequently should a line be flushed?
Daily or every other day, but some devices like Groshong only need weekly flushing.
What should a line be flushed with?
Herparinised saline solution.
How should a Hickman line etc be kept clean?
- Clean venous access port
- Check access point for signs of infection
- Use alcohol wipes for external surfaces
- Keep dry when showing or bathing
How can air entry into a line be prevented?
Valves, or clamps on non-valved lines.
With what are the early complications of inserting a venous access line associated?
Insertion or the immediate aftermath
What are some of the early complications of inserting a venous access line?
Bruising Bleeding Pain Pneumothorax Venous thrombosis Air embolism Malpositioning Catheter migration Guidewire entrapment
What are some of the late complications of inserting a venous access line?
Intraluminal thrombus Fibrin sheath forms at catheter tip Malpositioning Pich-off of catheter between clavicle and first rib Thrombosis within vessel Infection
