* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download PROCEDURES
Survey
Document related concepts
Transcript
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. 2. 3. 4. 5. 6. 7. 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 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 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 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 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 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 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 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 >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