1. Intro to Medical Procedures
Intern bootcamp
Paul m. Shaniuk, md
Med/peds chief resident

2. Objectives
Learn the basic steps that should be done prior to any procedure
Go over the program requirements for procedure competency
Review Procedures common in Internal Medicine
Paracentesis
Thoracentesis
Lumbar Puncture

3. Before doing any procedure…

4. Before doing any procedure…
Know the indications/contraindications/potential complications
Am I signed off?
Is the patient consented?
Do I have my equipment?
Have I informed the RN & completed a Time Out?

5. After doing any procedure
Hemostasis?
Are my samples labelled and sent to the lab?
Please clean the room/site
Clean the chucks, put away sharps
Your RNs and the janitorial staff will love you!
Have I written my procedure note?

6. Am I signed off? – Log in MyEvaluations
Abdominal Paracentesis = 5
ABG, draw and interpret = 5
Arterial Line Placement = 5 for competency, 10 for credentialing
Arthrocentesis/Joint Aspiration = 3 for competenc, 6 for credentialing
Bladder Cath = 5
Breast exam = 5
Central Line
Femoral = 5
IJ = 8
ECG interpretation = 1
I&D = 2
Lumbar Puncture = 5
NG tube placement = 3
Rectal Exam = 5
Thoracentesis = 5
Venipuncture = 5
Wound Care & Laceration Repair = 10

7. Transducers
Slide from CCF Ultrasound Course

8. Transducer Configuration
Slide from CCF Ultrasound Course

9. Abdominal Paracentesis

10. Abdominal Paracentesis - Indications
Evaluation of new onset ascites
R/O Spontaneous Bacterial Peritonitis
Evaluation of a hospitalized patient with ascites
Diagnosis of source of sepsis in a patient with ascites
Symptom relief in patients with refractory ascites
i.e. Therapeutic or Large Volume Paracentesis

11. Abdominal Paracentesis - Contraindications
Massive ileus
Disseminated intravascular coagulation
Primary fibrinolysis

12. Abdominal Paracentesis – Potential Complications
Bleeding
Deep space hematoma
Infection
Bowel perforation

13. Anatomic Considerations

14. Ultrasound Images
Ideally start w/curvilinear to find a pocket, then switch to linear to r/o blood vessels.

15. Paracentesis - Technique
Necessary Tools:
1.Kits: In clean utility room. Vacutainers help for therapeutic, but are sometimes in short supply. Ask RN or division secretary and they can send up from central supply. Have gauze, gloves, gown, mask, chlorhex prep. Instead of kit, a 20 gauge needle can be used for quick diagnostic taps, but often easier to use the kit.
2. Prep
Can have patient void first to not confuse bladder w/ascites.
Lay patient at degrees.

16. Paracentesis - Technique
Modified Z-Line technique
3. U/S Guidance: Visualize ascites in RLQ or LLQ. Avoid superficial blood vessels using Doppler mode (come to think of it, avoid all blood vessels). Hematoma can develop if hit the inferior epigastric artery, which runs just lateral to the midline. Remember, patients with ascites often also have hepatosplenomegaly, avoid upper quadrants.
4. Prep:
Arrange room, position ultrasound.
Chlorhex the area. Sterile drape. Chlorhex again.
Assistant to help get sterile probe cover on and find area again.
5. Use lidocaine to inject along area of expected needle course (aspirate before each injection, often will aspirate ascites fluid, which is ok!).
6. Pull skin up slightly so hole in skin does not match entry site to ascites (avoid lots of leakage when done). Called the Z-Line technique
7. Insert needle (90 degree angle with skin, parallel to the floor).
8. Withdraw fluid. If diagnostic fill all 4 tubes (easily done with one piston syringe, need multiple regular syringes if not using a kit)
9. If therapeutic, set up kit to either drain to gravity or via vacutainer (ask your resident, better seen than written).
10. Remove needle, clean area, apply 4x4. Tell the patient to expect some leakage.
11. If therapeutic, decide if your patient meets criteria for albumin to avoid post procedure hypotension. (usually 6-8g. albumin (25% conc.) for every 4-5 L removed (rounded to multiple of 25). i.e. 50g. albumin for 8 L removed)

17. Paracentesis – Therapeutic Large Volume Ascites Removal
Removal of > 5 L of fluid at once.
Upper limit is usually felt to be L as long as you aggressively replete Albumin. (probably safest to stop around 8-10L)
6 – 8 grams of Albumin is recommended for every liter removed when you remove > 5 L at once.
Round to multiple of 25g (i.e. – give 50g. Albumin for 8L of ascites removed)

18. Paracentesis – Routine Lab Orders
Always Send:
Cell count with differential (r/o SBP)
Albumin, Total Protein (calculate SAAG)
May also want to send:
Gram Stain & Bacterial Culture
LDH (increased in secondary bacterial peritonitis)
Amylase (increased in acute pancreatitis)
Glucose (decreased in SBP or 2ndary bacterial peritonitis)
Cytology
Rarely may need to send:
Fungal smear and culture, Adenosine Deaminase Activity, Triglyceride, bilirubin, Ascitic AFB

19. Paracentesis - Ascitic Fluid Orders

21. Paracentesis – IR Procedure Order

23. Paracentesis – Serum Albumin-Ascites Gradient (SAAG)
High SAAG (> 1.1 g/dL)
Cirrhosis/Alcoholic Hepatitis
Heart Failure
Massive Hepatic Mets
Constrictive Pericarditis
Budd - Chiari Syndrome
Portal Vein Thrombosis
Low SAAG (</= 1.1 g/dL)
Pancreatitis
Serositis
Nephrotic Syndrome TB
Peritoneal Carcinomatosis

24. Paracentesis – Spontaneous Bacterial Peritonitis
Elevated neutrophils (> 250 cells/mm3), positive ascitic fluid culture and absence of secondary peritonitis.
Absolute PMN cells can be calculated with total cell count and percentage of PMNs.
1 PMN is subtracted from the absolute PMN count for every 500 red blood cells/mm3, especially if there is concern for traumatic paracentesis.
Antibiotic treatment for SBP should not be delayed for paracentesis to be performed or cultures to return.

25. Paracentesis - Secondary Bacterial Peritonitis
Ascitic fluid infection with positive ascitic fluid bacterial culture, and PMN count >250 cells/mm3 in the setting of a surgically treatable intra-abdominal source of infection.
Why do we need to differentiate between SBP?
Mortality of secondary bacterial peritonitis approaches 100% if treatment only consists antibiotics without surgical interventions.
Mortality of spontaneous bacterial peritonitis is about 80% if a patient receives an unnecessary exploratory laparotomy.
How to differentiate from SBP?
Runyon’s Laboratory Criteria (2 or more): total protein < 1 g/DL, glucose <50 mg/dL and LDH greater than upper limit of normal serum.
Polymicrobial growth in culture
Order CT A/P if the patient meets these criteria and/or your clinical suspicion is high.

26. Thoracentesis

27. Thoracentesis - Indications
Evaluate a pleural effusion (Exudative? Transudative? Malignant?)
Most, if not all new onset pleural effusions need at least a diagnostic thoracentesis
Therapeutic intervention for dyspnea or hypoxemia in a patient w/unilateral pleural effusion

28. Thoracentesis - Contraindications
Severe coagulopathy (likely safe with mild)
Use with caution in patients on mechanical ventilation

29. Thoracentesis – Potential complications
Bleeding (always go OVER the rib to avoid the neurovascular bundle)
Pneumothorax
Infection

30. Thoracentesis - Technique
Patient position
Ultrasound evaluation
Needle insertion site
Positioning: Patients who are alert and cooperative are most comfortable in a seated position, leaning slightly forward and resting the head on the arms or hands or on a pillow, which is placed on an adjustable bedside table. This position facilitates access to the posterior axillary space, which is the most dependent part of the thorax. Unstable patients and those who are unable to sit up may be supine for the procedure.
Ultrasound: Performed to confirm the pleural effusion, assess its size, look for loculations, and determine the optimal puncture site. Either a curvilinear transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) may be used. The diaphragm is brightly echogenic and should be clearly identified. Its exact location throughout the respiratory cycle should be determined. It is important to select a rib interspace into which the diaphragm does not rise up at end-exhalation (usually 7-9 in mid-clavicular line)
Technique:
Standard sterile technique (chlorhex prep, sterile drape, chlorhex prep)
Anesthesize with 2-3 cc’s of lidocaine. May aspirate some pleural fluid, it’s ok!
Under ultrasound guidance (or if site is marked by radiology), place needle/catheter into the space, aspirating back until pleural fluid obtained, use small skin nick to facilitate entry.
Palpate rib during needle entry! Go OVER the rib to avoid neurovascular bundle.
Enter to black line under ultrasound guidance, then pull back needle and advance catheter.
Obtain sample for diagnostic samples, then place in sample syringes
Connect to 3-way connector for therapeutic thoracentesis
After 1-1.5L fluid removed, withdraw needle while applying adhesive bandage (limits PTX risk)

31. Thoracentesis - Technique
Avoid removing > 1500 mL at a time to avoid post-expansion edema
LABS:
Routine:
Serum & Pleural LDH & total protein (Light’s Criteria)
Cell count & differential
Gram stain & culture pH
Glucose
Other labs:
Cytology, cholesterol, triglycerides, amylase, ADA
Triglycerides = chylothorax
Amylase = esophageal rupture or acute/chronic panc

33. Thoracentesis – IR Procedure Order

35. Thoracentesis – Light’s Criteria

36. Thoracentesis - Interpretation
Complicated Pleural Effusion/Empyema:
Malignancy:
TB Pleurisy:
Esophageal Rupture:
Chylothorax:
Hemothorax:

37. Thoracentesis - Interpretation
Complicated Pleural Effusion/Empyema: pH < 7.2
Malignancy: Positive Cytology
TB Pleurisy: +ADA
Esophageal Rupture: High Amylase
Chylothorax: TGs > 110 mg/dL
Hemothorax: ratio of pleural fluid to blood hematocrit > 0.5

38. Lumbar Puncture http://www.nejm.org/doi/full/10.1056/NEJMvcm054952

39. Lumbar Puncture - Indications
URGENT:
Suspected CNS infection/meningitis
Suspected subarachnoid hemorrhage in a patient with a negative CT scan
NON-URGENT:
Diagnose pseudotumor cerebri, NPH, carcinomatous meningitis
Diagnose neurosyphilis
Treatment:
Intrathecal antibiotics/chemotherapy/anesthesia (epidural)
Drainage for NPH/pseudotumor cerebri

40. Lumbar Puncture - Contraindications
Increased ICP/Intracranial mass lesion
Bleeding disorders
Coagulopathy (INR > 1.4)
Thrombocytopenia (platelets < 50,000))
Suspected epidural abscess

41. Lumbar Puncture - Complications
Post-Lumbar Puncture headache
Bleeding
Uncal herniation
Infection
Back pain

42. LP - Technique
Patient position (sitting upright or lateral recumbent position*)
Needle insertion site (highest points of iliac crests; L3/L4 or L4/L5 interspace)
CSF collection
Prep:
Theoretically patients without neuro signs don’t need a CT prior to LP, in practice it’s often difficult to fully examine a patient with concern for meningitis and a CT head is usually indicated prior to LP(noncontrast) to prevent herniation from mass lesion.
Obtain LP kit, chlorhexadine, gloves, facemasks, gowns. Lidocaine is in most of the kits at the VA and UH.
We usually use the lateral decubitus position. Have the patient positioned on the bed with their knees pulled towards their chest (an assistant may need to help).
Technique:
Palpate the vertebra at the level of the iliac crest. Identify the intervertebral space. (Better seen than described)
Cleanse the area with chlorhexadine.
Put on sterile gear, open the kit, place the sterile drape over the area.
Inject lidocaine in area to be instrumented.
Insert needle at 90 degree angle with skin. Advance in general direction of umbilicus in a direction perpendicular to the iliac crest line > you’ll either hit bone (at that point, pull back and redirect) or feel a pop as you enter the subarachnoid space.
Diagnostic Samples:
Obtain opening pressure if desired.
Collect spinal fluid in the kit’s tubes.
Label the tubes and send to lab with order requisitions.
Withdraw needle and clean site. Tell patient to lay flat as much as possible for 6-8 hours to reduce risk for post-LP headache. Can also give high dose caffeine.

43. LP – Lab Orders

45. LP – IR Procedure Order

47. Lumbar Puncture – Diagnostic Testing
Routine Labs:
Total Protein/Glucose
Cell count with differential
Gram stain and culture
Bacterial antigens
Viral PCR/Culture
Enterovirus, HSV/VZV, arboviral panel
Uncommonly:
Cytology
VDRL/FTA
Fungal stain & culture

48. Lumbar Puncture – Laboratory Testing
Tube 1
Cell count & Diff
Tube 2
Glucose, Protein, VDRL/FTA, other special labs
Tube 3
Culture
Tube 4
Repeat Cell Count & Diff

49. Lumbar Puncture – Interpretation
Normal CSF:
Glucose: CSF to serum glucose ratio of 0.6
Protein: mg/dL
Cell count: < 5 WBCs and < 5 RBCs

50. Lumbar Puncture – Interpretation
Glucose (mg/dL)
< 10
10-45
More common
Bacterial Meningitis
Less common
TB, Fungal Meningitis
Neurosyphillis
Protein (mg/dL)
> 250
50-250
More common
Bacterial Meningitis
Viral Meningitis, Lyme’s Disease and Neurosyphillis
Less common
TB Meningitis
Total WBC #
> 1000
More common
Bacterial Meningitis
Bacterial, Viral or TB Meningitis
Viral, TB, Neurosyphillis or Early Bacterial
Less common
Some cases of Mumps
Encephalitis

51. References Thank you to Dr. Aniket Rali
Thank you to the Ultrasound Course from CCF
NEJM Videos
Paracentesis
Thoracentesis
Lumbar Puncture