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PROCEDURES
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
INFORMED CONSENT
 Elements of Informed Consent
1.
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Purpose and nature or procedure/treatment
Expectations of procedure/treatment
Risks of procedure/treatment
Alternatives to procedure/treatment and the risks/benefits
of the alternatives
Names of physicians involved
Answer any questions
Signature of patient or authorized individual
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.
Central Venous Catheters
 Indications
 Contraindications
 Administration of caustic
 Infection at insertion site
medications
 Invasive monitoring (CVP,
SVO2)
 Large volume resuscitation
 Dialysis
 Plasmapheresis
 Inability to obtain PIV
 Coagulopathy
 Thrombocytopenia
 Thrombosis of target vessel
Central Venous Catheters
 Complications
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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
Arterial Lines
 Indications
 Contraindications
 BP monitoring
 Infection at insertion site
 Titration of vasopressors
 Failure to demonstrate
 Frequent ABGs
collateral flow (Allen test)
Arterial lines
 Complications
 Retained guide-wire
 Infection
 Hematoma
 Limb ischemia
Thoracentesis
 Indications
 Contraindications
 Evaluation of new pleural
 Infection at insertion site
effusion
 Respiratory compromise
 Suspected infection
 Suspected malignancy
 Coagulopathy
 Thrombocytopenia
 Bullous lung disease
Thoracentesis
 Complications
 Pleural Fluid Analysis
 Pneumothorax (5-10%)
 LDH
 Hemothorax (1%)
 Protein
 Re-expansion pulmonary edema
 Cell count with diff
 Gram stain
 Culture
 Additional studies as needed
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%
Lumbar Puncture
 Indications
 Contraindications
 Suspected CNS infection
 Infection at insertion site
 Suspected SAH
 Elevated ICP
 Suspected CNS malignancy
 Mass lesion of spinal cord or
 Evaluation of demyelinating
brain
 Coagulopathy
 Thrombocytopenia
/inflammatory CNS process
 Therapeutic reduction of CNS
pressure
 Delivery of intrathecal
chemotherapy
 Unexplained headache
Lumbar Puncture
 Indication for Head CT prior to
 Complications
LP:
 Post LP Headache
 Age >60 years
 Backache at site of puncture
 h/o seizures or CNS disease
 Infection
 Immunocompromised state
 Bleeding
 Focal neuro deficit
 Spinal hematoma
 Decreased LOC
 Brain herniation
 Papilledema
 Neuropathic pain of lower
extremities
Lumbar Puncture
 CSF Analysis
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Glucose
Protein
Cell count with diff
Gram stain & culture
Additional studies as needed
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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
Paracentesis
 Indications
 Contraindications
 Evaluation of new ascites
 Infection at insertion site
 Suspected spontaneous or
 Coagulpathy (controversial)
secondary bacterial peritonitis
 Symptomatic control of
shortness of breath in massive
ascites
 Thrombocytopenia (controversial)
 Severe bowel distention
 Full bladder
Paracentesis
 Complications
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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
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
Foley Catheter
 Indications
 Acute urinary retention
 Bladder outlet obstruction
 Urine output measurement in
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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
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Infection
Retained balloon fragments
Bladder fistula
Bladder perforation
Bladder stones
Picc Line
 Indications
 Administration of caustic
medications
 Inability to obtain PIV
 Outpatient antibiotic
administration
 Contraindications
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Infection at insertion site
Coagulopathy
Thrombocytopenia
Active bacteremia
Venous stenosis
 Complications
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Arterial stick or cannulation
Hematoma
Pneumothorax
Hemothorax
Retained wire
Air embolism
Bleeding
Infection
Arrhythmias
Catheter related thrombosis
Vascular perforation
Arthrocentesis
 Indications
 Contraindications
 Diagnosis of joint effusion
 Infection at the insertion
 Suspected septic joint
site
 Bacteremia
 Coagulopathy
 Thrombocytopenia
 Establish diagnosis in
arthritis
 Drainage of blood from
hemarthrosis
 Pain relief with large
effusion
 Suspected inflammatory
arthritis
Arthrocentesis
 Compliations
 Synovial fluid analysis
 Bleeding
 WBC
 Infection
 Gram stain and culture
 Exacerbation of arthritic
 Glucose
pain
 Protein
 Crystal exam
Arthrocentesis
SYNOVIAL
FLUID TEST
NORMAL
NONINFLAMMATOR
Y
ARTHRITIS
INFLAMMATORY
ARTHRITIS
INFECTION
WBC
<200/mm³
200-2,000/mm³
with <25% PMN
2,000-20,000/mm³
with >50% PMN
>50,000mm³
with 75% PNM
predominance
>25mg/dL
with ratio of synovial
fluid to serum glucose
<1
<25mg/dL
<3g/dL
>3g/dL
>3g/dL
n/a
GOUT:
n/a
GLUCOSE
PROTEIN
CRYSTAL
EXAM
n/a
negatively birerefringent
urate crystals
PSEUDOGOUT:
positively birerefringetn
calcium pyrophosphate
crystals
OTHER
 For invasive procedures goal INR <1.5 and platelets
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>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