1. PROCEDURES

2. INFORMED CONSENT DEFINITION: Process that fosters patients’ participation in the planning of their care. Required by hospital policy and Ohio law. Just signing a piece of paper leaves the “informed” piece out of informed consent. You do not have to get informed consent in an emergency

3. INFORMED CONSENT Elements of Informed Consent 1. Purpose and nature or procedure/treatment 2. Expectations of procedure/treatment 3. Risks of procedure/treatment 4. Alternatives to procedure/treatment and the risks/benefits of the alternatives 5. Names of physicians involved 6. Answer any questions 7. Signature of patient or authorized individual

4. INFORMED CONSENT Patients must have capacity to make decisions in order to consent to procedure/treatment. Capacity is defined as the ability to… Understand information they are given Apply information to their situation Reason/deliberate about the choices available A patient who has capacity can refuse medical care. If the patient does not have capacity, then the informed consent process should be obtained from POA or next of kin.

5. Central Venous Catheters Indications Administration of caustic medications Invasive monitoring (CVP, SVO2) Large volume resuscitation Dialysis Plasmapheresis Inability to obtain PIV Contraindications Infection at insertion site Coagulopathy Thrombocytopenia Thrombosis of target vessel

6. Central Venous Catheters Complications Arterial stick or cannulation Hematoma Pneumothorax Hemothorax Retained wire Air embolism Bleeding Infection Arrhythmias Catheter related thrombosis Vascular perforation Site Selection Minimize infection choose SC > IJ > femoral Choose compressible site if concerned about bleeding Avoid SC if bilateral lung pathology Avoid placement of IJ/SC on side of unilateral lung pathology

7. Arterial Lines Indications BP monitoring Titration of vasopressors Frequent ABGs Contraindications Infection at insertion site Failure to demonstrate collateral flow (Allen test)

8. Arterial lines Complications Retained guide-wire Infection Hematoma Limb ischemia

9. Thoracentesis Indications Evaluation of new pleural effusion Respiratory compromise Suspected infection Suspected malignancy Contraindications Infection at insertion site Coagulopathy Thrombocytopenia Bullous lung disease

10. Thoracentesis Complications Pneumothorax (5-10%) Hemothorax (1%) Re-expansion pulmonary edema Pleural Fluid Analysis LDH Protein Cell count with diff Gram stain Culture Additional studies as needed

11. Thoracentesis INTERPRETATION OF RESULTS Light’s Criteria for exudative effusion = Protein (pleura) / Protein (serum) >0.5 LDH (pleura) / LDH (serum) >0.6 LDH (pleura) >2/3 upper limit normal Exudative neutrophil predominant = infection Exudative lymphocytic predominant = TB, cancer Complicated parapneumonic = +gram stain, pH <7.2 or glucose <60 ADA >70 = suggests TB Glucose <60 = suggests infection, cancer, RA Hemothorax = effusion Hct/serum Hct >50%

12. Lumbar Puncture Indications Suspected CNS infection Suspected SAH Suspected CNS malignancy Evaluation of demyelinating /inflammatory CNS process Therapeutic reduction of CNS pressure Delivery of intrathecal chemotherapy Unexplained headache Contraindications Infection at insertion site Elevated ICP Mass lesion of spinal cord or brain Coagulopathy Thrombocytopenia

13. Lumbar Puncture Indication for Head CT prior to LP: Age >60 years h/o seizures or CNS disease Immunocompromised state Focal neuro deficit Decreased LOC Papilledema Complications Post LP Headache Backache at site of puncture Infection Bleeding Spinal hematoma Brain herniation Neuropathic pain of lower extremities

14. Lumbar Puncture CSF Analysis Glucose Protein Cell count with diff Gram stain & culture Additional studies as needed Viral culture PCR ofr HSV, EBC, CMV, enterovirus VDRL/FTA Cytology Oligoclonal bands Fungal and acid-fast stains/cultures INTERPRETATION OF RESULTS Normal OP = 9-18cm Elevated with infection, hydrocephalus, pseudotumor Normal Glucose = 50-70 Decreased in infection Normal Total Protein = 15-40 Elevated in infection, MS, tumors, hemorrhage Can be artificially elevated if RBC elevated (subtract 1mg protein/dL for every 1000 RBC count) Normal WBC = <5 PMN = bacterial Lymphocytes = TB, fungal, aseptic Can be elevated with elevated RBC (subtract 1 WBC from measured WBC for every 700 RBC’s in CSF) Normal RBC = 0 Elevated in traumatic tap, SAH

15. Paracentesis Indications Evaluation of new ascites Suspected spontaneous or secondary bacterial peritonitis Symptomatic control of shortness of breath in massive ascites Contraindications Infection at insertion site Coagulpathy (controversial) Thrombocytopenia (controversial) Severe bowel distention Full bladder

16. Paracentesis Complications Infection Hematoma Persistent leak of ascites Bleeding Bowel perforation Renal failure Hemodynamic instability including hypotension/ARF ***For large volume taps (>4L) give 6-8g/L of 25% albumin Fluid analysis Cell count with diff Gram stain & culture (direct innoculation of cx bottles at bedside) Additional studies as needed Glucose (<50mg/dL suggests perforated viscus) LDH ratio of ascites:serum (1=SBP, >1 =cancer/infxn, <1 = uncomplicated cirrhosis) Amylase ratio of ascites:serum (>3 suggests pacreatitis) Triglycerides >200mg/dL suggests lymphatic obstruction, cancer, TB Cytology

17. Paracentesis INTERPRETATION OF RESULTS SAAG = serum albumin – ascites albumin ≥ 1.1 = portal HTN related ≤ 1.1 = non-portal HTN related Ascites fluid total protein (use when SAAG >1.1) > 2.5 = suggests cirrhosis < 2.5 = suggests heart failure WBC > 500 or PMNs >250 = suggests infection

18. Foley Catheter Indications Acute urinary retention Bladder outlet obstruction Urine output measurement in critically ill patients Continuous bladder irrigation During surgery Management of open wounds in perineal region Intravesical pharmacologic therapy Contraindications Urethral injury associated with pelvic trauma Urethral stricture Artificial sphincter Complications Infection Retained balloon fragments Bladder fistula Bladder perforation Bladder stones

19. Picc Line Indications Administration of caustic medications Inability to obtain PIV Outpatient antibiotic administration Contraindications Infection at insertion site Coagulopathy Thrombocytopenia Active bacteremia Venous stenosis Complications Arterial stick or cannulation Hematoma Pneumothorax Hemothorax Retained wire Air embolism Bleeding Infection Arrhythmias Catheter related thrombosis Vascular perforation

20. Arthrocentesis Indications Diagnosis of joint effusion Suspected septic joint Establish diagnosis in arthritis Drainage of blood from hemarthrosis Pain relief with large effusion Suspected inflammatory arthritis Contraindications Infection at the insertion site Bacteremia Coagulopathy Thrombocytopenia

21. Arthrocentesis Compliations Bleeding Infection Exacerbation of arthritic pain Synovial fluid analysis WBC Gram stain and culture Glucose Protein Crystal exam

22. Arthrocentesis SYNOVIAL FLUID TEST NORMALNON- INFLAMMATOR Y ARTHRITIS INFLAMMATORY ARTHRITIS INFECTION WBC<200/mm³200-2,000/mm³ with <25% PMN 2,000-20,000/mm³ with >50% PMN >50,000mm³ with 75% PNM predominance GLUCOSE>25mg/dL with ratio of synovial fluid to serum glucose <1 <25mg/dL PROTEIN<3g/dL>3g/dL CRYSTAL EXAM n/a GOUT: negatively birerefringent urate crystals PSEUDOGOUT: positively birerefringetn calcium pyrophosphate crystals n/a

23. OTHER For invasive procedures goal INR 50,000 Remove invasive lines/tubes as soon as possible to prevent infection Be aware of blood and body fluid exposure guideline Be aware of Universal precautions Review videos of procedures on New England Journal of Medicine website