I&I Flashcards
Peripheral venous cannula
Tell me about
Indication
Features
Types
Method
Complications
Multiple different cannula systems are available:
Indication
= the peripheral administration of fluid and drugs
Types
Method
= Inserted into a vein under ANTT
- Newer ones don’t require saline prep and allow initial blood sample directly post insertion
- Lumens then need to be flushed to prevent clot formation
- Pre flushed octopus used as an adjunct
Types
Different sizes - 22G (Blue - 30ml/min) and 20G (pink - 60ml/min) are common on wards.
16G (Grey) are common in fluid resuscitations and trauma
- flow rate = 230ml/min
Poiseuille’s law
Flow rate =
- proportional to radius to the power of 4
- Inversely proportional to length
i.e. To give fluid quickly the cannula must be short and large bore.
Complications
- Haematoma
- Malplacement
- Blockage
- Superficial thrombophlebitis
Triple lumen central venous catheter
Indications
Kit
Complications
Other procedures using the same technique
Indication
1) CVP measurement: for fluid balance
2) Drugs requiring central administration e.g. Amiodarone, mannitol, chemo drugs, ?dialysis (vasopressors, inotropes)
3) TPN
The kit
The insertion kit for a central line includes
a 3-5 lumen cannula, guide wire, dilator, scalpel, and introducer needle
Central venous catheters are placed often into the subclavian or internal jugular veins (or femoral) via ultrasound
Method - Inserted using Seldinger technique under US
- Trendelenberg position
- Sterile
- LA
- US guidance
- Order a CXR afterwards
Complications on insertion
- Pneumothorax, sepsis, thrombosis, misplacement e.g. into an artery
Early complications
- Haematoma formation
- Infection
- Catheter obstruction
Late
- Thrombosis
- Sympathetic chain –> Horner’s syndrome
- Phrenic nerve damage –> hiccough, weak diaphragm
Other procedures also using Seldinger technique
- Angiography
- Chest drain insertion
- Percutaneous endoscopic gastrostomy
Picc line
Indications
Method
Complications
Peripheral IV central catheter - shares features of central and venous access
Indications Long-term vascular access for - blood sampling - Chemotherapy administration - Infusion of hyperosmolar solutions such as those used for total parenteral nutrition.
A PICC line is composed of a thin tube of biocompatible material and an attachment hub that is inserted percutaneously into peripheral veins and advanced into a large central vein.
Method
- Inserted into a peripheral vein e.g. cephalic
- Advanced until the tip sits in the SVX
- X-ray to confirm position
Complications
- Arrhythmias, Bleeding
- Late: Thrombosis, Catheter occlusion, Infection
Hickmann line
Indications
Method
Complications
This is a an example of a long term central venous line
Indicated for
- Long-term parenteral nutrition
- Long-term intravenous antibiotic therapy and
- Chemotherapy.
- Dialysis?
Method
Inserted in a similar way to a central line (usually subclavian).
The remnant of the line is tunnelled subcutaneously, which decreases the incidence of line infection.
Complications
- Early: Bleeding, Pneumothorax, Arrhythmia
- Late: Thrombosis, Infection, Catheter Occlusion
Tessio catheter
Pair of catheters, which are placed into the large central vein at the side of your neck (usually in the internal jugular vein) for haemodialysis.
- Arterial line takes blood to machine
- Venous limb takes blood back to pt
Indication
- Haemodialysis
Method
- Sterile insertion under x-ray guidance
- Arterial limb sits more proximally to reduce recirculation
- Tunnelled subcut
Complications
- Early: Peneumothorax, Bleeding, Arrhythmias
- Late: Thrombosis, Catheter infection, Occlusion
Blood culture bottles
These are two blood culture bottles
- one for aerobic bacteria (blue top) and
- one for anaerobic bacteria (purple top).
Indication
- Investigate pyrexia
Method
- Take blood using ANTT
- REPLACE needle with a clean one
- Wipe top of bottles with alcohol first
- Fill AEROBIC first
- Fill pt details and send to the lab
- Some hospitals have specific teams that take cultures
The blood is injected in a sterile manner into the bottles using a different needle from the one the blood was drawn with.
Blood cultures are a useful investigation in a case of pyrexia or suspected systemic sepsis.
Remember, fill the aerobic bottle first if you are using a vacutainer.
Blood bottles aka vacutainers
Blood bottles are colour coded to use for different tests.
Purple – contains EDTA.
Used for haematology - FBC, ESR, Blood film, reticulocytes, HbA1c
- Mix 8 times
- For ESR - need full bottle
Pink – contains EDTA. - sent to transfusion lab Used for G&S and crossmatch. DAT test - Invert 8 times - Special label to fill out by hand
Blue – contains buffered sodium citrate (chelates Ca2+, preventing clotting
Used for coagulation screening - PT/APTT, D-dimer, INR, specific factors
Yellow/gold – known as SST (serum separating tubes) Contains silica particles and serum separating gel. The silica particles work to activate clotting and cause the blood cells to clump together. The serum separatorconsists of an inert polymer gel which floats as a layer between the blood cells and plasma to form a physical barrierbetween them. This means that the sample can be centrifuged (spun) in the lab and the separated serum easily removed.
Used for a variety of tests that require separated serum for analysis,: U&Es, LFTs, CRP, TFTs, Bone profile, Amylase, Troponin, CK, Urate, Osmolality etc etc endo markers, tumour markers, drug levels
- Invert 5 times
Grey – contains sodium fluoride and potassium oxalate. Used for glucose and lactate tests.
- Invert 8 tumes
Red – contains silica particles.
Used for sensitive tests including toxicology, drug levels, antibodies, hormones and bacterial and viral serology.
- Invert 5 times
Dark green – contains sodium heparin.
Used for ammonia, renin, aldosterone and insulin tests.
- Invert 8 times
Light green – Known as PST. Contains lithium heparin and a plasma separator gel.
Used for routine biochemistry.
Rust Top- Viral Immunology.
Order of draw Cultures Blue Yellow Purple Pink Grey
Ryles NG tube
Ryles nasogastric tube which is primarily used for decompression (drip and suck) in bowel obstruction, but can also be used to insert drugs or contrast into the GI tract.
Features: Wide-bore, stiffer, radio-opaque line, Metal tip
- Metal tip weighs NGT down in stomach
Method
- Size tube by measuring from tip of pts nose to epigastrium, going around ear
- Gain consent and explain
- LUBRICATE tube with aqua gel
- Insert tube and ask pt swallow with water when they feel it at back of throat
- Check location
== The correct position of the tube is checked by aspirating gastric contents and checking for acidity on pH dipstick (<4), if this is unavailable then air can be inserted to the tube and the epigastrium auscultated for bubbling. Finally, an x-ray can be taken to identify the tube (below diaphragm)
-Once the tube is in the correct position a bag is attached and it is taped to the patients face.
Complications
- Nasal trauma
- Malposition: Airway, cranium (CI in cribriform plate fracture)
- Blockage
CI
- Any evidence of basal skull fractures
(After explaining what you are about to do to the patient, you will require a NG tube which has been in the fridge as it is stiffer, some lubricant, a bladder syringe, a drainage bag and pH dipstick.)
Feeding NG tube
This is a feeding nasogastric tube which is used for long term enteral nutrition in patients. It is thin bore and soft making it more comfortable for patients, it is also made of silastic which blocks less often.
Method
Size tube by measuring from tip of pts nose to epigastrium, going around ear
- Gain consent and explain
- LUBRICATE tube with aqua gel
- Insert tube and ask pt swallow with water when they feel it at back of throat
- Check location
== The correct position of the tube is checked by aspirating gastric contents and checking for acidity on pH dipstick (<4), if this is unavailable then air can be inserted to the tube and the epigastrium auscultated for bubbling. Finally, an x-ray can be taken to identify the tube (below diaphragm)
-Once the tube is in the correct position a bag is attached and it is taped to the patients face + remove the guide wire and the feed attached in a sterile manner.
Complications
NGT = Nasal trauma, malposition, blockage
Feeding = Refeeding syndrome, Electrolyte imbalance, Feed intolerance -> diarrhoea
CI:
Any evidence of basal skull fracture
Parenteral nutrition indications
Indications
- Unable to swallow e.g. oesophageal ca
- Prolonged obstruction/ileus
- High output fistula
- Short bowel syndrome
- Severe Chron’s
- Severe malnutrition
Delivery
Delivered centrally because HIGH OSMOLALITY = toxic to veins
- Short term: CV catheter
- Long term: Hickman or PICC line
Monitoring
- Standard: Weight, fluid balance and ruin glucose daily.
Blood glucose, FBC, U&Es, LFTs
Contents
2000 kcal: 50% fat, 50% carb
10-14g Nitrogen
Vitamins, minerals and trace elements
Complications
1) Line related: Pneumothorax, haemothorax, Arrhythmia, Line sepsis, Central venous thrombosis (-> PE, SVCO)
2) Feed related: Villous atrophy of GIT, Electrolyte disturbances e.g Refeeding syndrome, Hyperglycaemia, Vit and mineral deficiencies
Nasal cannulae
Percentage oxygen
Use
Nasal cannula are commonly used mode of oxygen delivery both in hospital and in the community.
It is widely used to carry 1-3L of oxygen per minute (can be up to 4L/min). This delivers between 28-44% of oxygen.
These cannulae differ from high-flow therapy (NIV).
Common issues are nasal sores and epistaxis, therefore patients are encouraged to apply water-based creams to moisturise.
Use: mildly hypoxic or non-acute situations
Hudson mask
Use
Delivers 30-40%
Flow rate 5-10L/min
Not commonly used any more
Venturi mask
% Oxygen
Use
Types
Delivers 24-60% oxygen depending on colour of fitting.
Flow rate (oxygen flow rate is set on the O2 wall tap) is shown on mask along with the % O2 delivery. Each colour must be used with a given flow rate (written on the mask) to give the correct oxygen percentage.
Use
Often used in COPD as it the most accurate way of giving variable percentage inspired oxygen.
Types: BLUE = 2-4L/min = 24% O2 WHITE = 4-6L/min = 28% O2 YELLOW = 8-10L/min = 35% O2 RED = 10-12L/min = 40% O2 GREEN = 12-15L/min = 60% O2
Non rebreather mask
% oxygen - flow rate?
Use
A non-rebreather mask (NRB) is used to assist in the delivery of oxygen therapy. It requires that the patient can breathe unassisted.
The non-rebreather mask covers both the nose and mouth of the patient and attaches with the use of an elastic cord around the patient’s head. The NRB has an ATTACHED RESERVOIR bag, that connects to an external oxygen tank or Bulk Oxygen Supply system.
- Ensure the reservoir bag has filled by temporarily obstructing the valve before positioning on the patient
The flow rate is 10-15 litres/minute and it can deliver up to 90% oxygen concentration.
Use
Used for acutely unwell patients BUT note that uncontrolled high flow oxygen is damaging (see notes opposite). As such, a non-rebreather is rarely indicated for long-term treatment.
non-invensive ventilation
Types
Use
CPAP= continuous positive airway pressure = high pressure air/oxygen with a tight fitting mask. Positive pressure all the time.
- Keeps airways open in sleep apnoea or heart failure.
BiPAP= bilevel positive airway pressure = high positive pressure on inspiration and lower positive pressure on expiration.
Used in COPD and atelectasis.
