02 lab skill preparing patient

7/27/2019 02 Lab Skill Preparing Patient

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Preparing patientPreparing patient

ByBy

ArifArifMuttaqinMuttaqin


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PreparationPreparation

Pleural biopsyPleural biopsy

BronchoscopyBronchoscopy

PeritonealPeritoneal paracentesisparacentesis

Liver biopsyLiver biopsy

Lumbar punctureLumbar puncture


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Preparation of:Preparation of:

NurseNursePatientPatient

RoomRoomEquipmentEquipment


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Preparation of Nurse :Preparation of Nurse :KnowledgeKnowledge

Anatomy and physiologyAnatomy and physiology

Procedural institutionsProcedural institutions

Skill :Skill :CognitiveCognitiveInterpersonalInterpersonal

PsychomotorPsychomotor

AttitudeAttitudeProfessionalProfessional


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Preparation of Patient :Preparation of Patient :

Assessment:Assessment:Orders,Orders,

Cooperative levels.Cooperative levels.

Diagnostics.Diagnostics.

Informed consentInformed consent

PrivacyPrivacyPhysicalPhysical

PositionPosition


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Preparation of Room :Preparation of Room :

Operation tableOperation tableTemperatureTemperature

NoiseNoise


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Preparation ofPreparation of EquipmentEquipment ::

Technical procedureTechnical procedureProcedural institutionsProcedural institutions

PatientPatient


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Pleural biopsy PreparationPleural biopsy Preparation


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Definition:Definition:

The pleura is the membrane that linesThe pleura is the membrane that linesthe lungs and chest cavity. A pleuralthe lungs and chest cavity. A pleuralbiopsybiopsy is the removal of pleural tissueis the removal of pleural tissue

for examination and eventual diagnosisfor examination and eventual diagnosis

Alternative Names:Alternative Names:Closed pleural biopsy; Needle biopsy of theClosed pleural biopsy; Needle biopsy of the

pleurapleura


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PurposePurpose Pleural biopsyPleural biopsy

Pleural biopsy is performed to differentiatePleural biopsy is performed to differentiate

between benign (between benign (noncancerousnoncancerous) and) andmalignant (cancerous) disease, tomalignant (cancerous) disease, todiagnose viral, fungal, ordiagnose viral, fungal, or parasiticparasitic

diseasesdiseases, and to identify a condition called, and to identify a condition calledcollagen vascular disease of the pleura.collagen vascular disease of the pleura.

It is also ordered when a chestIt is also ordered when a chest x rayx rayindicates a pleuralindicates a pleural--basedbased tumortumor, reaction,, reaction,or pleural thicknessor pleural thickness
http://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/adamcontent/tumorhttp://www.healthline.com/adamcontent/tumorhttp://www.healthline.com/adamcontent/tumorhttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infectionshttp://www.healthline.com/galecontent/parasitic-infections


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Preparations for this procedure vary,Preparations for this procedure vary,

depending on the type of proceduredepending on the type of procedurerequested.requested.

ClosedClosed needle biopsyneedle biopsy requires little or norequires little or no

preparation.preparation.Open pleural biopsyOpen pleural biopsy, which is performed in a, which is performed in a

hospital, requires fasting (no solids or liquids)hospital, requires fasting (no solids or liquids)

for 8for 8--12 hours before the procedure because12 hours before the procedure becausethe stomach must be empty beforethe stomach must be empty before generalgeneralanesthesiaanesthesia is administered.is administered.
http://www.healthline.com/adamcontent/biopsyhttp://www.healthline.com/adamcontent/biopsyhttp://www.healthline.com/adamcontent/open-pleural-biopsyhttp://www.healthline.com/adamcontent/open-pleural-biopsyhttp://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/galecontent/anesthesia-general-2http://www.healthline.com/adamcontent/open-pleural-biopsyhttp://www.healthline.com/adamcontent/biopsy


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ThoracentesisThoracentesis

DefinitionDefinitionAA pleural biopsypleural biopsy is a procedure to remove a sample of the tissueis a procedure to remove a sample of the tissue

lining the lungs and the inside of the chest wall to check forlining the lungs and the inside of the chest wall to check fordisease or infection.disease or infection.

Alternative NamesAlternative Names

Closed pleural biopsy; Needle biopsy of the pleuraClosed pleural biopsy; Needle biopsy of the pleura

How the test is performedHow the test is performed This test does not have to be done in the hospital. It may beThis test does not have to be done in the hospital. It may be

done at a clinic or doctor's office.done at a clinic or doctor's office. Patient will be sitting up for the biopsy. The health care proviPatient will be sitting up for the biopsy. The health care providerder

will cleanse the skin at the biopsy site, and inject a local numwill cleanse the skin at the biopsy site, and inject a local numbingbingdrug (anesthetic) through the skin and into the lining of the ludrug (anesthetic) through the skin and into the lining of the lungsngs

and chest wall (pleural membrane).and chest wall (pleural membrane).
http://www.healthline.com/galecontent/pleural-biopsy-1http://www.healthline.com/galecontent/pleural-biopsy-1http://www.healthline.com/galecontent/pleural-biopsy-1


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ThoracentesisThoracentesis PreparationPreparation

ThoracentesisThoracentesis (also referred to as Pleural(also referred to as Pleural

fluid aspiration or Pleural tap) is afluid aspiration or Pleural tap) is aprocedure to remove fluid from the spaceprocedure to remove fluid from the spacebetween the lining of the outside of thebetween the lining of the outside of the

lungs (pleura) and the wall of the chest.lungs (pleura) and the wall of the chest.Normally, very little fluid is present in thisNormally, very little fluid is present in thisspace. An accumulation of excess fluidspace. An accumulation of excess fluidbetween the layers of the pleura is called abetween the layers of the pleura is called apleural effusion.pleural effusion.


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THE THORACENTESISTHE THORACENTESIS

PROCEDUREPROCEDUREA small area of skin onA small area of skin on PatientrPatientrchest or back ischest or back is

washed with a sterilizing solution. Somewashed with a sterilizing solution. Somenumbing medicine (local anesthetic) is injectednumbing medicine (local anesthetic) is injected

in this area.in this area.

A needle is then placed through the skin of theA needle is then placed through the skin of thechest wall into the space around the lungs calledchest wall into the space around the lungs called

the pleural space. Fluid is withdrawn andthe pleural space. Fluid is withdrawn and

collected and may be sent to a laboratory forcollected and may be sent to a laboratory foranalysis (pleural fluid analysis).analysis (pleural fluid analysis).


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In a pleural biopsy, a small piece of

pleural tissue in the chest is removedwith a needle. The biopsy may

distinguish between a cancerous and

noncancerous disease. It also can

help to detect whether a viral, fungalor parasitic disease is present.


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PREPARING FOR THEPREPARING FOR THE

PROCEDUREPROCEDURENo special preparation is needed beforeNo special preparation is needed before

the procedure. A chest xthe procedure. A chest x--ray is may beray is may beperformed before and after the test.performed before and after the test.

Do not cough, breathe deeply, or moveDo not cough, breathe deeply, or moveduring the test to avoid injury to the lung.during the test to avoid injury to the lung.


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DURING THE PROCEDUREDURING THE PROCEDURE

Patient will sit on the edge of a chair or bed withPatient will sit on the edge of a chair or bed withPatient head and arms resting on a table. ThePatient head and arms resting on a table. The

skin around the procedure site is disinfected andskin around the procedure site is disinfected andthe area is draped. A local anesthetic is injectedthe area is draped. A local anesthetic is injectedinto the skin. Theinto the skin. The thoracentesisthoracentesis needle isneedle is

inserted above the rib into the pleural space.inserted above the rib into the pleural space.There will be a stinging sensation when the localThere will be a stinging sensation when the localanesthetic is injected, and Patient may feel aanesthetic is injected, and Patient may feel asensation of pressure when the needle issensation of pressure when the needle isinserted into the pleural space.inserted into the pleural space.Assess develop shortness of breath or chestAssess develop shortness of breath or chestpain.pain.


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POTENTIAL RISKSPOTENTIAL RISKS

PneumothoraxPneumothorax (collapse of the lung)(collapse of the lung)

Fluid reFluid re--accumulationaccumulation Pulmonary edemaPulmonary edema

BleedingBleeding InfectionInfection

Respiratory distressRespiratory distress


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open pleural biopsyopen pleural biopsy

DefinitionDefinition

An open pleural biopsy is a procedure toAn open pleural biopsy is a procedure toremove and examine the tissue that lines theremove and examine the tissue that lines the

inside of the chest. This tissue is called theinside of the chest. This tissue is called the

pleura.pleura.

Alternative NamesAlternative NamesBiopsyBiopsy -- open pleuraopen pleura


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In an open pleural biopsy, a small piece of the pleural tissue is removed

through a surgical incision in the chest. After the sample is obtained, a

chest tube is placed and the incision is closed with stitches. Abnormal

results may indicate tuberculosis, abnormal growths, viral, fungal, andparasitic diseases.


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BronchoscopyBronchoscopy PreparationPreparation


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RSUD Soetomo, 1994


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BronchoscopyBronchoscopy is a procedure in which ais a procedure in which ahollow, flexible tube called a bronchoscope ishollow, flexible tube called a bronchoscope is

inserted into the airways through the nose orinserted into the airways through the nose or

mouth to provide a view of themouth to provide a view of thetracheobronchialtracheobronchial tree. It can also be used totree. It can also be used to

collect bronchial and/or lung secretions and tocollect bronchial and/or lung secretions and to

perform tissue biopsy.perform tissue biopsy.


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PurposePurpose

During aDuring a bronchoscopybronchoscopy, the physician can, the physician canvisually examine the lower airways, includingvisually examine the lower airways, including

the larynx, trachea, bronchi, and bronchioles.the larynx, trachea, bronchi, and bronchioles.

The procedure is used to examine theThe procedure is used to examine themucosal surface of the airways formucosal surface of the airways for

abnormalities that might be associated with aabnormalities that might be associated with a

variety of lung diseases. Its use may bevariety of lung diseases. Its use may be

diagnostic or therapeutic.diagnostic or therapeutic.


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BronchoscopyBronchoscopy may be used to examine and help diagnose:may be used to examine and help diagnose: diseases of the lung, such as cancer or tuberculosisdiseases of the lung, such as cancer or tuberculosis

congenital deformity of the lungscongenital deformity of the lungs

suspected tumor, obstruction, secretion, bleeding, or foreign bosuspected tumor, obstruction, secretion, bleeding, or foreign body in thedy in theairwaysairways

airway abnormalities, such as trachealairway abnormalities, such as tracheal stenosesstenoses

persistent cough, orpersistent cough, or hemoptysishemoptysis, that includes blood in the sputum, that includes blood in the sputum

BronchoscopyBronchoscopy may also be used for the following therapeuticmay also be used for the following therapeuticpurposes:purposes: to remove a foreign body in the lungsto remove a foreign body in the lungs

to remove excessive secretionsto remove excessive secretions

BronchoscopyBronchoscopy can also be used to collect the following biopsycan also be used to collect the following biopsyspecimens:specimens: sputumsputum

tissue samples from the bronchi or bronchiolestissue samples from the bronchi or bronchioles

cells collected from washing the lining of the bronchi or bronchcells collected from washing the lining of the bronchi or bronchiolesioles


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If the purpose of theIf the purpose of the bronchoscopybronchoscopy is to takeis to take

tissue samples or biopsy, a forceps ortissue samples or biopsy, a forceps orbronchial brush are used to obtain cells.bronchial brush are used to obtain cells.

Alternatively, if the purpose is to identify anAlternatively, if the purpose is to identify an

infectious agent, ainfectious agent, a bronchoalveolarbronchoalveolarlavagelavagecan be performed to gather fluid for culturecan be performed to gather fluid for culture

purposes. If any foreign matter is found inpurposes. If any foreign matter is found in

the airways, it can be removed as well.the airways, it can be removed as well.


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The instrument used inThe instrument used in bronchoscopybronchoscopy, a bronchoscope, is a slender,, a bronchoscope, is a slender,flexible tube less than 0.5 in (2.5 cm) wide and approximately 2flexible tube less than 0.5 in (2.5 cm) wide and approximately 2 ftft(0.3 m) long that uses(0.3 m) long that uses fiberopticfiberoptic technology (very fine filaments thattechnology (very fine filaments that

can bend and carry light). There are two types of bronchoscopes,can bend and carry light). There are two types of bronchoscopes, aastandard tube that is more rigid and astandard tube that is more rigid and a fiberopticfiberoptic tube that is moretube that is moreflexible.flexible.

The rigid instrument does not bend, does not see as far down intThe rigid instrument does not bend, does not see as far down intoothe lungs as the flexible one, and may carry a greater risk of cthe lungs as the flexible one, and may carry a greater risk of causingausinginjury to nearby structures. Because it can cause more discomforinjury to nearby structures. Because it can cause more discomforttthan the flexible bronchoscope, it usually requires generalthan the flexible bronchoscope, it usually requires generalanesthesia. However, it is useful for taking large samples of tianesthesia. However, it is useful for taking large samples of tissuessueand for removing foreign bodies from the airways.and for removing foreign bodies from the airways.

During the procedure, the airway is never blocked since oxygen cDuring the procedure, the airway is never blocked since oxygen cananbe supplied through the bronchoscope.be supplied through the bronchoscope.


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BronchoscopyBronchoscopy fiberopticsfiberoptics

BronchoscopyBronchoscopy is usually performed in anis usually performed in an endoscopyendoscopy room, but mayroom, but mayalso be performed at the bedside. The patient is placed on his balso be performed at the bedside. The patient is placed on his backackor sits upright. Aor sits upright. A pulmonologistpulmonologist, a specialist trained to perform the, a specialist trained to perform the

procedure, sprays an anesthetic into the patient's mouth or throprocedure, sprays an anesthetic into the patient's mouth or throat.at.When anesthesia has taken effect and the area is numb, theWhen anesthesia has taken effect and the area is numb, thebronchoscope is inserted into the patient's mouth and passed intbronchoscope is inserted into the patient's mouth and passed intoothe throat. If the bronchoscope is passed through the nose, anthe throat. If the bronchoscope is passed through the nose, ananesthetic jelly is inserted into one nostril. While the bronchoanesthetic jelly is inserted into one nostril. While the bronchoscopescope

is moving down the throat, additional anesthetic is put into theis moving down the throat, additional anesthetic is put into thebronchoscope to anesthetize the lower airways.bronchoscope to anesthetize the lower airways.

The physician observes the trachea, bronchi, and the mucosal linThe physician observes the trachea, bronchi, and the mucosal liningingof these passageways looking for any abnormalities that may beof these passageways looking for any abnormalities that may be

present. If samples are needed, a bronchialpresent. If samples are needed, a bronchial

lavagelavage

may bemay be

performed, meaning that a saline solution is introduced to flushperformed, meaning that a saline solution is introduced to flush thethearea prior to collecting cells for laboratory analysis. Very smaarea prior to collecting cells for laboratory analysis. Very smallllbrushes, needles, or forceps may also be introduced through thebrushes, needles, or forceps may also be introduced through thebronchoscope to collect tissue samples from the lungs.bronchoscope to collect tissue samples from the lungs.


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Bronchoscopy can be performed via the patient's mouth (A) or through the nose (C).During the procedure, the scope is fed down the trachea and into the bronchus leading

to the lungs (B), providing the physician with a view of internal structures (D).


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The patient should fast for six to 12 hours prior to the proceduThe patient should fast for six to 12 hours prior to the procedure andre andrefrain from drinking any liquids the day of the procedure.refrain from drinking any liquids the day of the procedure.

Smoking should be avoided for 24 hours prior to the procedure anSmoking should be avoided for 24 hours prior to the procedure anddpatients should also avoid taking anypatients should also avoid taking any aspirinaspirin or ibuprofenor ibuprofen--typetypemedications.medications.

TheThe bronchoscopybronchoscopy itself takes about 45itself takes about 4560 minutes. Prior to the60 minutes. Prior to thebronchoscopybronchoscopy, several tests are usually done, including a, several tests are usually done, including a chest xchest x

rayray and blood work.and blood work.Sometimes aSometimes a bronchoscopybronchoscopy is done under general anesthesia, inis done under general anesthesia, inwhich case the patient will have an intravenous (IV) line in thewhich case the patient will have an intravenous (IV) line in the arm.arm.More commonly, the procedure is performed under local anesthesiaMore commonly, the procedure is performed under local anesthesia,,which is sprayed into the nose or mouth. This is necessary to inwhich is sprayed into the nose or mouth. This is necessary to inhibithibit

the gag reflex. A sedative also may be given. A signed consent fthe gag reflex. A sedative also may be given. A signed consent formormis necessary for this procedure.is necessary for this procedure.
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PurposePurpose

During aDuring a bronchoscopybronchoscopy, the physician can, the physician canvisually examine the lower airways, includingvisually examine the lower airways, including

the larynx, trachea, bronchi, and bronchioles.the larynx, trachea, bronchi, and bronchioles.

The procedure is used to examine theThe procedure is used to examine themucosal surface of the airways formucosal surface of the airways for

abnormalities that might be associated with aabnormalities that might be associated with a

variety of lung diseases. Its use may bevariety of lung diseases. Its use may bediagnostic or therapeutic.diagnostic or therapeutic.


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AftercareAftercare BronchoscopyBronchoscopy

After theAfter the bronchoscopybronchoscopy, the, the vital signsvital signs (heart rate, blood pressure,(heart rate, blood pressure,and breathing) are monitored. Sometimes patients have anand breathing) are monitored. Sometimes patients have anabnormal reaction to anesthesia. Any sputum should be collectedabnormal reaction to anesthesia. Any sputum should be collected inin

an emesis basin so that it can be examined for the presence ofan emesis basin so that it can be examined for the presence ofblood.blood.

If a biopsy was taken, the patient should not cough or clear theIf a biopsy was taken, the patient should not cough or clear thethroat as this might dislodge any blood clot that has formed andthroat as this might dislodge any blood clot that has formed andcause bleeding. No food or drink should be consumed for about twcause bleeding. No food or drink should be consumed for about twoohours after the procedure or until the anesthesia wears off.hours after the procedure or until the anesthesia wears off.There is a significant risk for choking if anything (including wThere is a significant risk for choking if anything (including water) isater) isingested before the anesthetic wears off, and the gag reflex hasingested before the anesthetic wears off, and the gag reflex hasreturned. To test if the gag reflex has returned, a spoon is plareturned. To test if the gag reflex has returned, a spoon is placed onced on

the back of the tongue for a few seconds with light pressure. Ifthe back of the tongue for a few seconds with light pressure. Iftherethereis no gagging, the process is repeated after 15 minutes.is no gagging, the process is repeated after 15 minutes.

The gag reflex should return in one to two hours. Ice chips or cThe gag reflex should return in one to two hours. Ice chips or clearlearliquids should be taken before the patient attempts to eat solidliquids should be taken before the patient attempts to eat solid food.food.
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AftercareAftercare BronchoscopyBronchoscopy

Patients are informed that after the anestheticPatients are informed that after the anesthetic

wears off the throat may be irritated for severalwears off the throat may be irritated for several

days.days.

Patients should notify their health care provider ifPatients should notify their health care provider if

they develop any of these symptoms:they develop any of these symptoms: hemoptysishemoptysis (coughing up blood)(coughing up blood)

shortness of breath, wheezing, or any troubleshortness of breath, wheezing, or any trouble

breathingbreathing chest painchest pain

fever, with or without breathing problemsfever, with or without breathing problems


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RisksRisks

Use of the bronchoscope mildly irritates theUse of the bronchoscope mildly irritates thelining of the airways, resulting in some swellinglining of the airways, resulting in some swelling

and inflammation, as well as hoarseness causedand inflammation, as well as hoarseness causedfrom abrading the vocal cords. If this abrasion isfrom abrading the vocal cords. If this abrasion ismore serious, it can lead to respiratory difficultymore serious, it can lead to respiratory difficulty

or bleeding of the lining of the airways.or bleeding of the lining of the airways.

TheThe bronchoscopybronchoscopy procedure is also associatedprocedure is also associatedwith a small risk of disordered heart rhythmwith a small risk of disordered heart rhythm(arrhythmia), heart attacks, low blood oxygen(arrhythmia), heart attacks, low blood oxygen

(hypoxemia), and(hypoxemia), and pneumothoraxpneumothorax (a puncture of(a puncture ofthe lungs that allows air to escape into the spacethe lungs that allows air to escape into the spacebetween the lung and the chest wall).between the lung and the chest wall).


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RisksRisks

These risks are greater with the use of a rigid bronchoscope thaThese risks are greater with the use of a rigid bronchoscope thannwith awith a fiberopticfiberoptic bronchoscope. If a rigid tube is used, there is also abronchoscope. If a rigid tube is used, there is also arisk of chipped teeth. The risk of transmitting infectious disearisk of chipped teeth. The risk of transmitting infectious disease fromse from

one patient to another by the bronchoscope is also present.one patient to another by the bronchoscope is also present.There is also a risk of infection from endoscopes inadequatelyThere is also a risk of infection from endoscopes inadequatelyreprocessed by the automated endoscope reprocessing (AER)reprocessed by the automated endoscope reprocessing (AER)system. The Centers for Disease Control (CDC) reported cases ofsystem. The Centers for Disease Control (CDC) reported cases ofpatientpatient--toto--patient transmission of infections followingpatient transmission of infections following bronchoscopicbronchoscopicprocedures using bronchoscopes that were inadequatelyprocedures using bronchoscopes that were inadequatelyreprocessed byreprocessed byAERsAERs..

Investigation of the incidents revealed inconsistencies betweenInvestigation of the incidents revealed inconsistencies between thethereprocessing instructions provided by the manufacturer of thereprocessing instructions provided by the manufacturer of the

bronchoscope and the manufacturer of the AER; or that thebronchoscope and the manufacturer of the AER; or that thebronchoscopes were inadequately reprocessed.bronchoscopes were inadequately reprocessed.


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Normal resultsNormal results

If the results of theIf the results of the bronchoscopybronchoscopy are normal, the windpipe (trachea)are normal, the windpipe (trachea)appears as smooth muscle with Cappears as smooth muscle with C--shaped rings of cartilage atshaped rings of cartilage atregular intervals. There are no abnormalities either in the tracregular intervals. There are no abnormalities either in the trachea orhea or

in the bronchi of the lungs.in the bronchi of the lungs.BronchoscopyBronchoscopy results may also confirm a suspected diagnosis. Thisresults may also confirm a suspected diagnosis. Thismay include swelling, ulceration, or deformity in the bronchialmay include swelling, ulceration, or deformity in the bronchial wall,wall,such as inflammation,such as inflammation, stenosisstenosis, or compression of the trachea,, or compression of the trachea,neoplasm, and foreign bodies. Theneoplasm, and foreign bodies. The bronchoscopybronchoscopy may also revealmay also revealthe presence of atypical substances in the trachea and bronchi.the presence of atypical substances in the trachea and bronchi. IfIfsamples are taken, the results could indicate cancer, diseasesamples are taken, the results could indicate cancer, disease--causing agents, or other lung diseases. Other findings may inclucausing agents, or other lung diseases. Other findings may includedeconstriction or narrowing (constriction or narrowing (stenosisstenosis), compression, dilation of), compression, dilation ofvessels, or abnormal branching of the bronchi. Abnormalvessels, or abnormal branching of the bronchi. Abnormalsubstances that might be found in the airways include blood,substances that might be found in the airways include blood,secretions, or mucous plugs.secretions, or mucous plugs.


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PeritonealPeritoneal paracentesisparacentesis

I t d ti


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IntroductionIntroduction

ParacentesisParacentesis is ais a

procedure in whichprocedure in whicha needle ora needle orcatheter is insertedcatheter is inserted

into the peritonealinto the peritonealcavity to obtaincavity to obtainasciticascitic fluid forfluid for

diagnostic ordiagnostic ortherapeutictherapeuticpurposespurposes

I di iI di ti


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IndicationsIndications

Diagnostic:Diagnostic:

New onsetNew onset ascitesascites::To determineTo determine aetiologyaetiology..

To differentiateTo differentiate transudatetransudate versusversus exudateexudate..

To detect cancerous cells.To detect cancerous cells.

Suspected spontaneous or secondary bacterialSuspected spontaneous or secondary bacterialperitonitisperitonitis

Therapeutic:Therapeutic:

To relieve respiratory distress secondary toTo relieve respiratory distress secondary to ascitesascites..To relieve abdominal pain or pressure secondary toTo relieve abdominal pain or pressure secondary to

ascitesascites..

C t i di tiC t i di ti


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ContraindicationsContraindications

Uncooperative patientUncooperative patient

Skin infection at the proposed punctureSkin infection at the proposed puncturesitesite

PregnancyPregnancySevere bowel distensionSevere bowel distension

CoagulopathyCoagulopathy (opinion divided(opinion divided -- some feelsome feelonly precluded where there is clinicallyonly precluded where there is clinically

evidentevident fibrinolysisfibrinolysis or DIC)or DIC)

E i tE i t


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EquipmentEquipment

The equipment required can be found in a disposableThe equipment required can be found in a disposableparacentesis/thoracentesisparacentesis/thoracentesis kit. It includes the following:kit. It includes the following: Antiseptic swab sticksAntiseptic swab sticks

Fenestrated drapeFenestrated drape LidocaineLidocaine 1%, 51%, 5--mLmL ampuleampule

Syringe, 10Syringe, 10 mLmL

Injection needles, 22 gauge (Injection needles, 22 gauge (gaga), 2), 2

Injection needle, 25Injection needle, 25 gaga

Scalpel, No. 11 bladeScalpel, No. 11 blade Catheter, 8F, over 18Catheter, 8F, over 18 gaga x 7 1/2" needle with 3x 7 1/2" needle with 3--way stopcock, selfway stopcock, self--sealing valve,sealing valve,

and a 5and a 5--mLmL LuerLuer--Lock syringeLock syringe


Introducer needle, 20Introducer needle, 20 gaga

Tubing set with roller clampTubing set with roller clamp Drainage bag or vacuum containerDrainage bag or vacuum container

Specimen vials or collection bottles, 3Specimen vials or collection bottles, 3

Gauze, 4 X 4 inchGauze, 4 X 4 inch

Adhesive dressingAdhesive dressing


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P iti iP iti i


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PositioningPositioning

The two recommended areas of abdominal wall entry forThe two recommended areas of abdominal wall entry forparacentesisparacentesis are as follows (see photo):are as follows (see photo):

Two centimeters below the umbilicus in the midline (through theTwo centimeters below the umbilicus in the midline (through thelinealinea alba)alba)

Five centimeters superior and medial to the anterior superior ilFive centimeters superior and medial to the anterior superior il iaciacspines on either sidespines on either side

The authors recommend the routine use ofThe authors recommend the routine use ofultrasonographyultrasonography to verify the presence of a fluid pocketto verify the presence of a fluid pocketunder the selected entry site in order to increase the rateunder the selected entry site in order to increase the rateof success.of success.66 The ultrasound also helps the practitionerThe ultrasound also helps the practitioneravoid a distended urinary bladder or small bowelavoid a distended urinary bladder or small boweladhesions below the selected entry point. To minimizeadhesions below the selected entry point. To minimizecomplications, avoid areas of prominent veins (caputcomplications, avoid areas of prominent veins (caputmedusa), infected skin, or scar tissue.medusa), infected skin, or scar tissue.


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TechniqueTechnique


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TechniqueTechnique

Explain the procedure, benefits, risks,Explain the procedure, benefits, risks,complications, and alternative options tocomplications, and alternative options tothe patient or the patient's representativethe patient or the patient's representativeand obtain signed informed consent.and obtain signed informed consent.

Empty the patient's bladder, eitherEmpty the patient's bladder, eithervoluntarily or with a Foley catheter.voluntarily or with a Foley catheter.

Position the patient and prepare the skinPosition the patient and prepare the skinaround the entry site with an antisepticaround the entry site with an antisepticsolution.solution.

TechniqueTechnique


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TechniqueTechnique

Explain the procedure,Explain the procedure,benefits, risks, complications,benefits, risks, complications,

and alternative options to theand alternative options to thepatient or the patient'spatient or the patient'srepresentative and obtainrepresentative and obtainsigned informed consent.signed informed consent.

Empty the patient's bladder,Empty the patient's bladder,either voluntarily or with aeither voluntarily or with aFoley catheter.Foley catheter.

Position the patient andPosition the patient andprepare the skin around theprepare the skin around theentry site with an antisepticentry site with an antisepticsolution.solution.

TechniqueTechnique


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TechniqueTechnique

Apply a sterile fenestrated drapeApply a sterile fenestrated drapeto create a sterile field.to create a sterile field.

Use the 5Use the 5--mL syringe and the 25mL syringe and the 25--

ga needle to raise a smallga needle to raise a smalllidocainelidocaine skin wheal around theskin wheal around theskin entry site.skin entry site.

Switch to the longer 20Switch to the longer 20--ga needlega needleand administer 4and administer 4--55 mLmL ofoflidocainelidocaine along the catheteralong the catheterinsertion tract. Make sure toinsertion tract. Make sure toanesthetize all the way down toanesthetize all the way down tothe peritoneum. The authorsthe peritoneum. The authorsrecommend alternating injectionrecommend alternating injectionand intermittent aspiration downand intermittent aspiration down

the tract untilthe tract until asciticascitic fluid isfluid isnoticed in the syringe. Note thenoticed in the syringe. Note thedepth at which the peritoneum isdepth at which the peritoneum isentered. In obese patients,entered. In obese patients,reaching the peritoneum mayreaching the peritoneum may

involve passing through ainvolve passing through asignificant amount of adiposesignificant amount of adiposetissue.tissue.

TechniqueTechnique


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TechniqueTechnique

Use the No. 11 scalpel bladeUse the No. 11 scalpel bladeto make a small nick in theto make a small nick in the

skin to allow an easierskin to allow an easiercatheter passage.catheter passage.

Insert the needle directlyInsert the needle directlyperpendicular to the selectedperpendicular to the selectedskin entry point. Slowskin entry point. Slowinsertion in increments of 5insertion in increments of 5mm is preferred to minimizemm is preferred to minimize

the risk of inadvertentthe risk of inadvertentvascular entry or puncture ofvascular entry or puncture ofthe small bowel.the small bowel.

TechniqueTechnique


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TechniqueTechnique

Continuously apply negative pressure to the syringe as the needlContinuously apply negative pressure to the syringe as the needle ise isadvanced. Upon entry to the peritoneal cavity, loss of resistancadvanced. Upon entry to the peritoneal cavity, loss of resistance is felte is feltandand asciticascitic fluid can be seen filling the syringe. At this point, advancefluid can be seen filling the syringe. At this point, advance

the device 2the device 2--5 mm into the peritoneal cavity to prevent misplacement5 mm into the peritoneal cavity to prevent misplacementduring catheter advancement. In general, avoid advancing the needuring catheter advancement. In general, avoid advancing the needledledeeper than the safety mark that is present on most commerciallydeeper than the safety mark that is present on most commerciallyavailable catheters or deeper than 1 cm beyond the depth at whicavailable catheters or deeper than 1 cm beyond the depth at whichhasciticascitic fluid was noticed in thefluid was noticed in the lidocainelidocaine syringe.syringe.

TechniqueTechnique


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TechniqueTechnique

Use one hand to firmly anchor theUse one hand to firmly anchor theneedle and syringe securely in place toneedle and syringe securely in place toprevent the needle from enteringprevent the needle from enteringfurther into the peritoneal cavity.further into the peritoneal cavity.

Use the other hand to hold theUse the other hand to hold thestopcock and catheter and advancestopcock and catheter and advancethe catheter over the needle and intothe catheter over the needle and intothe peritoneal cavity all the way to thethe peritoneal cavity all the way to theskin. If any resistance is noticed, theskin. If any resistance is noticed, the

catheter was probably misplaced intocatheter was probably misplaced intothe subcutaneous tissue. If this is thethe subcutaneous tissue. If this is thecase, withdraw the device completelycase, withdraw the device completelyand reattempt insertion. Whenand reattempt insertion. Whenwithdrawing the device, always removewithdrawing the device, always remove

the needle and catheter together as athe needle and catheter together as aunit in order to prevent the bevel fromunit in order to prevent the bevel fromcutting the catheter.cutting the catheter.

TechniqueTechnique


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TechniqueTechnique

While holding the stopcock,While holding the stopcock,pull the needle out. The selfpull the needle out. The self--

sealing valve prevents fluidsealing valve prevents fluidleak.leak.

Attach the 60Attach the 60--mL syringe tomL syringe tothe 3the 3--way stopcock andway stopcock and

aspirate to obtainaspirate to obtain asciticascitic fluidfluidand distribute it to theand distribute it to thespecimen vials. Use the 3specimen vials. Use the 3--

way valve, as needed, toway valve, as needed, tocontrol fluid flow and preventcontrol fluid flow and preventleakage when no syringe orleakage when no syringe ortubing is attached.tubing is attached.

TechniqueTechnique


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TechniqueTechnique

Connect one end ofConnect one end of

the fluid collectionthe fluid collectiontubing to the stopcocktubing to the stopcock

and the other end to aand the other end to a

vacuum bottle or avacuum bottle or adrainage bag.drainage bag.

TechniqueTechnique


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TechniqueTechnique

The catheter can become occludedThe catheter can become occludedby a loop of bowel orby a loop of bowel or omentumomentum. If. Ifthe flow stops, kink or clap thethe flow stops, kink or clap the

tubing to avert loss of suction, thentubing to avert loss of suction, thenbreak the seal and manipulate thebreak the seal and manipulate thecatheter slightly, then reconnectcatheter slightly, then reconnectand see if flow resumes. Rotatingand see if flow resumes. Rotatingthe catheter about the long axisthe catheter about the long axis

can sometimes reinstitute flow incan sometimes reinstitute flow inmodels with side ports.models with side ports.

Remove the catheter after theRemove the catheter after thedesired amount ofdesired amount of asciticascitic fluid hasfluid hasbeen drained. Apply firm pressure,been drained. Apply firm pressure,

as necessary, to stop bleeding, ifas necessary, to stop bleeding, ifpresent. Place a bandage over thepresent. Place a bandage over theskin puncture site.skin puncture site.

AftercareAftercare


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AftercareAftercare

Within 48 hours, blood tests should be repeatedWithin 48 hours, blood tests should be repeatedalthough withalthough with terminal careterminal care, such rigidity is not always, such rigidity is not always

necessary.necessary.AscitesAscites will tend to rewill tend to re--form and can be tapped again.form and can be tapped again.

A major concern is the introduction of infection. This mayA major concern is the introduction of infection. This may

not be associated with signs of peritoneal irritation andnot be associated with signs of peritoneal irritation andso if the temperature rises over the next few days, thenso if the temperature rises over the next few days, thenantibiotics should be given to cover such infection.antibiotics should be given to cover such infection.

If a large amount of protein has been removed, a highIf a large amount of protein has been removed, a high

protein diet is in orderprotein diet is in order -- drainingdraining ascitesascites may havemay haverelieved pressure on the stomach but the underlyingrelieved pressure on the stomach but the underlyingcondition is usually such that appetite remains poor.condition is usually such that appetite remains poor.
http://www.patient.co.uk/DisplayConcepts.asp?WordId=PALLIATION%20AND%20TERMINAL%20CARE&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=PALLIATION%20AND%20TERMINAL%20CARE&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=PALLIATION%20AND%20TERMINAL%20CARE&MaxResults=50


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Liver biopsyLiver biopsy

ByBy

ArifArifMuttaqinMuttaqin


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Liver Biopsy

A liver biopsy is not a routine procedure, but is performed when it

is necessary to determine the presence of liver disease and tolook for malignancy, cysts, parasites, or other pathology. The

actual procedure is only slightly uncomfortable. Most of the

discomfort arises from being required to lie still for several hoursafterwards to prevent bleeding from the biopsy site.



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The liver is a pyramidThe liver is a pyramid--shaped organ that lies within the upper rightshaped organ that lies within the upper rightside of the abdomen. In a typical liver biopsy, a needle is inseside of the abdomen. In a typical liver biopsy, a needle is insertedrtedthrough the rib cage or abdominal wall and into the liver to obtthrough the rib cage or abdominal wall and into the liver to obtain aain a

sample for examination.sample for examination.The procedure can also be performed by inserting a needle into tThe procedure can also be performed by inserting a needle into thehe

jugular vein in the neck and passing a catheter through the veinjugular vein in the neck and passing a catheter through the veins downs downto the liver to obtain the sample.to the liver to obtain the sample.

The biopsy helps diagnose a number ofThe biopsy helps diagnose a number of liver diseasesliver diseases. The biopsy. The biopsyalso helps in the assessment of the stage (early, advanced) of talso helps in the assessment of the stage (early, advanced) of the liverhe liverdisease. This is especially important in hepatitis C infection.disease. This is especially important in hepatitis C infection.

The biopsy also helps detect:The biopsy also helps detect: cancercancer

infectionsinfections the cause of an unexplained enlargement of the liverthe cause of an unexplained enlargement of the liver

abnormal liver enzymes that have been detected in blood testsabnormal liver enzymes that have been detected in blood tests

Core AssessmentCore Assessment
http://health.allrefer.com/health/liver-disease-info.htmlhttp://health.allrefer.com/health/liver-disease-info.htmlhttp://health.allrefer.com/health/liver-disease-info.html


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Core AssessmentCore Assessment

drug allergiesdrug allergies

medicationsmedicationsbleeding problemsbleeding problems

pregnantpregnant


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Lumbar puncturep

Lumbar puncture is aLumbar puncture is aprocedure that is oftenprocedure that is oftenperformed in the emergencyperformed in the emergency

department to obtaindepartment to obtaininformation about theinformation about thecerebrospinal fluid (CSF)cerebrospinal fluid (CSF)

Although usually used forAlthough usually used fordiagnostic purposes to rule outdiagnostic purposes to rule out

potential lifepotential life--threateningthreateningconditions such asconditions such as bacterialbacterialmeningitismeningitis oror subarachnoidsubarachnoidhemorrhagehemorrhage, lumbar puncture, lumbar punctureis also sometimes performedis also sometimes performed

for therapeutic reasons, suchfor therapeutic reasons, suchas the treatment ofas the treatment ofpseudotumorpseudotumorcerebricerebri..

http://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/1164341-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overviewhttp://emedicine.medscape.com/article/961497-overview


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u ba pu c u ep

CSF fluid analysis can also aidCSF fluid analysis can also aidin the diagnosis of variousin the diagnosis of variousother conditions, such asother conditions, such as

demyelinatingdemyelinating diseases anddiseases andcarcinomatouscarcinomatous meningitis.meningitis.

Lumbar puncture should beLumbar puncture should beperformed only after aperformed only after aneurological examination andneurological examination and

should never delay potentiallyshould never delay potentiallylifesaving interventions suchlifesaving interventions suchas the administration ofas the administration ofantibiotics and steroids toantibiotics and steroids topatients with suspectedpatients with suspected

bacterial meningitis.bacterial meningitis.

IndicationsIndications


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Suspicion ofSuspicion of meningitismeningitis

Suspicion ofSuspicion of subarachnoidsubarachnoid hemorrhagehemorrhageSuspicion of central nervous systemSuspicion of central nervous system

diseases such asdiseases such as GuillainGuillain--BarrBarr

syndromesyndrome33 andand carcinomatouscarcinomatous meningitismeningitis

Therapeutic relief ofTherapeutic relief of pseudotumorpseudotumorcerebricerebri

ContraindicationsContraindications
http://emedicine.medscape.com/article/232915-overviewhttp://emedicine.medscape.com/article/232915-overviewhttp://emedicine.medscape.com/article/794076-overviewhttp://emedicine.medscape.com/article/794076-overviewhttp://emedicine.medscape.com/article/794076-overviewhttp://emedicine.medscape.com/article/794076-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/1143167-overviewhttp://emedicine.medscape.com/article/1143167-overviewhttp://emedicine.medscape.com/article/1143167-overviewhttp://emedicine.medscape.com/article/1143167-overviewhttp://emedicine.medscape.com/article/1143167-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/792008-overviewhttp://emedicine.medscape.com/article/794076-overviewhttp://emedicine.medscape.com/article/232915-overview


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Absolute contraindications to lumbar puncture are as follows:Absolute contraindications to lumbar puncture are as follows:

Unequal pressures between theUnequal pressures between the supratentorialsupratentorial andand infratentorialinfratentorial compartments, usually inferredcompartments, usually inferredby characteristic findings on the brain CT scan:by characteristic findings on the brain CT scan:

Midline shiftMidline shiftLoss ofLoss of suprachiasmaticsuprachiasmatic and basilar cisternsand basilar cisterns

PosteriorPosterior fossafossa massmass

Loss of the superiorLoss of the superior cerebellarcerebellarcisterncistern

Loss of theLoss of the quadrigeminalquadrigeminal plate cisternplate cistern

Infected skin over the needle entry siteInfected skin over the needle entry site

Relative contraindications to lumbar puncture are as follows:Relative contraindications to lumbar puncture are as follows: Increased intracranial pressure (ICP)Increased intracranial pressure (ICP)

CoagulopathyCoagulopathy

Brain abscessBrain abscess

Indications for brain CT scan prior to lumbar puncture include tIndications for brain CT scan prior to lumbar puncture include the following:he following:44 Patients who are older than 60 yearsPatients who are older than 60 years

Patients who arePatients who are immunocompromisedimmunocompromised Patients with known CNS lesionsPatients with known CNS lesions

Patients who have had a seizure within 1 week of presentationPatients who have had a seizure within 1 week of presentation

Patients with abnormal level of consciousnessPatients with abnormal level of consciousness

Patients with focal findings on neurological examinationPatients with focal findings on neurological examination

Patients withPatients with papilledemapapilledema seen on physical examination with clinical suspicion of elevateseen on physical examination with clinical suspicion of elevated ICPd ICP

PreparePrepare


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pp

Lumbar puncture, commonly called a spinal tap, is theLumbar puncture, commonly called a spinal tap, is themost common method. The test is usually done like this:most common method. The test is usually done like this:

The patient lies on his or her side, with knees pulled up towardThe patient lies on his or her side, with knees pulled up towardthe chest, and chin tucked downward. Sometimes the test isthe chest, and chin tucked downward. Sometimes the test isdone with the person sitting up, but bent forward.done with the person sitting up, but bent forward.

After the back is cleaned, the health care provider will injectAfter the back is cleaned, the health care provider will inject aalocal numbing medicine (anesthetic) into the lower spine.local numbing medicine (anesthetic) into the lower spine.

A spinal needle is inserted, usually into the lower back area.A spinal needle is inserted, usually into the lower back area.

Once the needle is properly positioned, CSF pressure isOnce the needle is properly positioned, CSF pressure ismeasured and a sample is collected.measured and a sample is collected.

The needle is removed, the area is cleaned, and a bandage isThe needle is removed, the area is cleaned, and a bandage isplaced over the needle site. The person is often asked to lieplaced over the needle site. The person is often asked to liedown for a short time after the test.down for a short time after the test.


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PreparePrepare


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p

Occasionally, special xOccasionally, special x--rays are used to help guide the needle into therays are used to help guide the needle into theproper position. This is called fluoroscopy.proper position. This is called fluoroscopy.

Lumbar puncture with fluid collection may also be part of otherLumbar puncture with fluid collection may also be part of other procedures,procedures,particularly aparticularly a myelogrammyelogram (x(x--ray or CT scan after dye has been inserted intoray or CT scan after dye has been inserted intothe CSF).the CSF).Alternative methods of CSF collection are rarely used, but may bAlternative methods of CSF collection are rarely used, but may beenecessary if the person has a back deformity or an infection.necessary if the person has a back deformity or an infection.

CisternalCisternal puncture uses a needle placed below the occipital bone (back ofpuncture uses a needle placed below the occipital bone (back ofthe skull). It can be dangerous because it is so close to the brthe skull). It can be dangerous because it is so close to the brain stem. It isain stem. It isalways done with fluoroscopy.always done with fluoroscopy.Ventricular puncture is even more rare, but may be recommended iVentricular puncture is even more rare, but may be recommended in peoplen peoplewith possiblewith possible brainbrain herniationherniation. This test is usually done in the operating. This test is usually done in the operatingroom. A hole is drilled in the skull, and a needle is inserted droom. A hole is drilled in the skull, and a needle is inserted directly into oneirectly into oneof brain's ventricles.of brain's ventricles.

CSF may also be collected from a tube that's already placed in tCSF may also be collected from a tube that's already placed in the fluid,he fluid,such as a shunt or asuch as a shunt or a venitricularvenitriculardrain. These sorts of tubes are usuallydrain. These sorts of tubes are usuallyplaced in the intensive care unit.placed in the intensive care unit.

Prepare for the TestPrepare for the Test
http://www.nlm.nih.gov/medlineplus/ency/article/003807.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003807.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003807.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003807.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001421.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003807.htm


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p

The patient (or guardian) must give theThe patient (or guardian) must give the

health care team permission to do the test.health care team permission to do the test.

Afterward, you should plan to rest forAfterward, you should plan to rest for

several hours, even if you feel fine. Youseveral hours, even if you feel fine. You

won't be required to lie flat on your backwon't be required to lie flat on your backthe entire time, but rest is advised tothe entire time, but rest is advised to

prevent additional leakage of CSF aroundprevent additional leakage of CSF aroundthe site of the puncture.the site of the puncture.

RisksRisks


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Risks of lumbar puncture include:Risks of lumbar puncture include: Bleeding into the spinal canalBleeding into the spinal canal

Discomfort during the testDiscomfort during the test

Headache after the testHeadache after the test Hypersensitivity (allergic) reaction to the anestheticHypersensitivity (allergic) reaction to the anesthetic

Infection introduced by the needle going through the skinInfection introduced by the needle going through the skin

There is an increased risk of bleeding in people who take bloodThere is an increased risk of bleeding in people who take bloodthinners.thinners.

BrainBrain herniationherniation may occur if this test is done on a person with a massmay occur if this test is done on a person with a massin the brain (such as a tumor or abscess). This can result in brin the brain (such as a tumor or abscess). This can result in brainaindamage or death. This test is not done if an exam or test revealdamage or death. This test is not done if an exam or test reveals signss signsof a brain mass.of a brain mass.

Damage to the nerves in the spinal cord may occur, particularlyDamage to the nerves in the spinal cord may occur, particularly if theif theperson moves during the test.person moves during the test.

CisternalCisternal puncture or ventricular puncture carry additional risks of braipuncture or ventricular puncture carry additional risks of brainnor spinal cord damage and bleeding within the brain.or spinal cord damage and bleeding within the brain.

Instructions for PatientsInstructions for Patients


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Basic InstructionsBasic Instructions Please arrange for a ride home after your lumbar puncture.Please arrange for a ride home after your lumbar puncture.

Drink extra fluids the day beforeDrink extra fluids the day before

No solid foods from midnight on, if lumbar puncture is scheduledNo solid foods from midnight on, if lumbar puncture is scheduled for thefor themorning.morning.

Drink extra fluids (no caffeine) up to 2 hours before exam.Drink extra fluids (no caffeine) up to 2 hours before exam.

2 hours before exam2 hours before examNPO (If medications needed, take only withNPO (If medications needed, take only withswallow of water.)swallow of water.)

Please arrive 45 minutes before scheduled lumbar puncturePlease arrive 45 minutes before scheduled lumbar punctureappointment. Go to theappointment. Go to theLobbyLobby Registration office first then report to the 2nd floor OutpatienRegistration office first then report to the 2nd floor OutpatienttDepartment.Department.

Plan on 2 to 3 hours from arrival to discharge.Plan on 2 to 3 hours from arrival to discharge.

On the ride home, the back of the seat should be in the full recOn the ride home, the back of the seat should be in the full recliningliningposition ratherposition ratherthan straight up. It is important to lie as flat as possible tothan straight up. It is important to lie as flat as possible to help preventhelp prevent aabad headache.bad headache.

EquipmentEquipment


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Spinal or lumbar puncture tray (including the items listed belowSpinal or lumbar puncture tray (including the items listed below))

Sterile glovesSterile gloves

Antiseptic solution with skin swabsAntiseptic solution with skin swabs

Sterile drapeSterile drapeLidocaineLidocaine 1% without epinephrine1% without epinephrine


Needles, 20 and 25 gauge (Needles, 20 and 25 gauge (gaga))

Spinal needles, 20 and 22Spinal needles, 20 and 22 gagaThreeThree--way stopcockway stopcock

ManometerManometer

Four plastic test tubes, numbered 1Four plastic test tubes, numbered 1--4, with caps4, with caps

Sterile dressingSterile dressing

Optional:Optional: Syringe, 10Syringe, 10 mLmL


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Lumbar puncture lateralrecumbent position.



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Position the patientPosition the patient

in the lateralin the lateral

recumbent positionrecumbent positionwith hips, knees,with hips, knees,

and chin flexedand chin flexed

toward the chest intoward the chest in

order to open theorder to open the

interlaminarinterlaminarspaces.spaces.A pillow can be usedA pillow can be used

to support the head.to support the head.



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The sitting position mayThe sitting position maybe a helpful alternativebe a helpful alternativeposition, especially inposition, especially in

obese patients (easierobese patients (easierto confirm the midline).to confirm the midline).In order to open theIn order to open theinterlaminarinterlaminarspaces, thespaces, the

patient should leanpatient should leanforward and beforward and besupported by a Mayosupported by a Mayostand with a pillow on it,stand with a pillow on it,

by hunching over theby hunching over theback of a stool, or byback of a stool, or byanother person.another person.

Lumbar puncture sitting position.

TechniqueTechnique


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Explain the procedure, benefits,Explain the procedure, benefits,risks, complications, and alternativerisks, complications, and alternativeoptions to the patient or the patient'soptions to the patient or the patient'srepresentative and obtain a signedrepresentative and obtain a signedinformed consent.informed consent.

WearingWearing nonsterilenonsterile gloves, locategloves, locatethe L3the L3--L4L4 interspaceinterspace by palpatingby palpatingthe right and left posterior superiorthe right and left posterior superioriliac crests and moving the fingersiliac crests and moving the fingersmedially toward the spine. Palpatemedially toward the spine. Palpate

thatthat interspaceinterspace (L3(L3--L4) as well asL4) as well asone above (L2one above (L2--L3) and one belowL3) and one below(L4(L4--L5) to find the widest space.L5) to find the widest space.Mark the entry site with a thumbnailMark the entry site with a thumbnailor a marker. To help open theor a marker. To help open theinterlaminarinterlaminarspaces, the patient canspaces, the patient canbe asked to practice pushing thebe asked to practice pushing theentry site area out toward theentry site area out toward thepractitioner.practitioner.

L3-L4 interspace palpation.

TechniqueTechnique


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Open the spinal tray,Open the spinal tray,change to sterilechange to sterile

gloves, and prepare thegloves, and prepare theequipment. Open theequipment. Open thenumbered plastic tubesnumbered plastic tubesand place them upright,and place them upright,

assemble the stopcockassemble the stopcockon the manometer, andon the manometer, anddraw thedraw the lidocainelidocaine intointothe 10the 10--mL syringe.mL syringe.

TechniqueTechnique


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Use the skin swabs and antiseptic solution to cleanUse the skin swabs and antiseptic solution to cleanthe skin in a circular fashion starting at the L3the skin in a circular fashion starting at the L3--L4L4interspaceinterspace and moving outward to include at leastand moving outward to include at least11 interspaceinterspace above and below. Just beforeabove and below. Just beforeapplying the skin swabs, warn the patient that theapplying the skin swabs, warn the patient that thesolution is very cold, since this can be unnerving tosolution is very cold, since this can be unnerving to

the patient.the patient.Place a sterile drape below the patient and aPlace a sterile drape below the patient and afenestrated drape on the patient. Most spinal traysfenestrated drape on the patient. Most spinal trayscontain fenestrated drapes with an adhesive tapecontain fenestrated drapes with an adhesive tapethat keeps the drape in place.that keeps the drape in place.

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Use the 10Use the 10--mL syringe to administer local anesthesia. Raise amL syringe to administer local anesthesia. Raise askin wheal using the 25skin wheal using the 25--ga needle and then switch to the longerga needle and then switch to the longer2020--ga needle to anesthetize the deeper tissue. Insert the needlega needle to anesthetize the deeper tissue. Insert the needleall the way to the hub, aspirate to confirm that the needle is nall the way to the hub, aspirate to confirm that the needle is not inot ina blood vessel, and then inject a small amount as the needle isa blood vessel, and then inject a small amount as the needle iswithdrawn a few centimeters. Continue this process above,withdrawn a few centimeters. Continue this process above,below, and to the sides very slightly (using the same puncturebelow, and to the sides very slightly (using the same puncturesite).site).

This process anesthetizes the entire immediate area so that, ifThis process anesthetizes the entire immediate area so that, ifredirection of the spinal needle is necessary, the area will stiredirection of the spinal needle is necessary, the area will sti ll bell beanesthetized. For this reason, a 10anesthetized. For this reason, a 10--mL syringe may be moremL syringe may be morebeneficial than the usual 3beneficial than the usual 3--mL syringe supplied with the standardmL syringe supplied with the standard

lumbar puncture kit. The 20lumbar puncture kit. The 20--ga needle can also be used as aga needle can also be used as aguide for the general direction of the spinal needle. In otherguide for the general direction of the spinal needle. In otherwords, the best direction in which to aim the spinal needle canwords, the best direction in which to aim the spinal needle can bebeconfirmed if the 20confirmed if the 20--ga needle encounters bone in one directionga needle encounters bone in one directionbut not in another.but not in another.

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Stabilize the needle (20 or 22Stabilize the needle (20 or 22 gaga) with the index fingers and) with the index fingers andadvance it through the skin wheal using the thumbs. Orient the badvance it through the skin wheal using the thumbs. Orient the bevelevelparallel to the longitudinalparallel to the longitudinal duraldural fibers to increase the chances of thefibers to increase the chances of theneedle separating the fibers rather than cutting them (bevel facneedle separating the fibers rather than cutting them (bevel facingingup in the lateral recumbent position and facing to either side iup in the lateral recumbent position and facing to either side in then thesitting position).sitting position).

Insert the needle at a slightlyInsert the needle at a slightly cephaladcephalad angle toward the umbilicus.angle toward the umbilicus.Advance the needle slowly but smoothly. Occasionally, theAdvance the needle slowly but smoothly. Occasionally, the

practitioner feels a characteristic "pop" when the needle penetrpractitioner feels a characteristic "pop" when the needle penetratesatesthethe duradura. Otherwise, the. Otherwise, the styletstylet should be withdrawn aftershould be withdrawn afterapproximately 4approximately 4--5 cm and observed for fluid return. If no fluid5 cm and observed for fluid return. If no fluidreturns, replace thereturns, replace the styletstylet, advance or withdraw the needle a few, advance or withdraw the needle a fewmillimeters, and recheck for fluid return. Continue this processmillimeters, and recheck for fluid return. Continue this process untiluntil

fluid is successfully returned.fluid is successfully returned.

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To measure the opening pressure, the patient must be inTo measure the opening pressure, the patient must be inthe lateral recumbent position. After fluid returns from thethe lateral recumbent position. After fluid returns from theneedle, attach the manometer through the stopcock andneedle, attach the manometer through the stopcock andnote the height of the fluid column. The patient's legsnote the height of the fluid column. The patient's legsshould be straightened when measuring open pressureshould be straightened when measuring open pressureor a falsely elevated pressure will be obtained.or a falsely elevated pressure will be obtained.

Collect at least 10 drops of CSF in each of the 4 plasticCollect at least 10 drops of CSF in each of the 4 plastictubes, starting with tube #1. The CSF that is in thetubes, starting with tube #1. The CSF that is in themanometer should be used (if possible) for tube #1.manometer should be used (if possible) for tube #1.

Replace theReplace the styletstylet and remove the needle. Clean off theand remove the needle. Clean off theskin preparatory solution. Apply a sterile dressing andskin preparatory solution. Apply a sterile dressing andplace the patient in the supine position.place the patient in the supine position.

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If the patient is dehydrated, a falsely negative dry tap may beIf the patient is dehydrated, a falsely negative dry tap may beobtained as a result of very low CSF volume and pressure. If thiobtained as a result of very low CSF volume and pressure. If this iss issuspected, attempt tosuspected, attempt to rehydraterehydrate the patient prior to the procedure.the patient prior to the procedure.

If the procedure is performed in the sitting position and an opeIf the procedure is performed in the sitting position and an openingningpressure is required (pressure is required (egeg,, pseudotumorpseudotumorcerebricerebri), replace the), replace the styletstyletand have an assistant help the patient into the left lateral recand have an assistant help the patient into the left lateral recumbentumbentposition. No data suggest increased risk of spinal headache orposition. No data suggest increased risk of spinal headache ortransectiontransection of the spinal nerves with position change. Take care notof the spinal nerves with position change. Take care not

to change the orientation of the spinal needle during this maneuto change the orientation of the spinal needle during this maneuver.ver.The amount ofThe amount of lidocainelidocaine provided in most kits is often inadequate.provided in most kits is often inadequate.The authors recommend supplementing the kit with a 10The authors recommend supplementing the kit with a 10--mL syringemL syringeand a bottle of 1%and a bottle of 1% lidocainelidocaine. Make sure not to exceed the maximal. Make sure not to exceed the maximalrecommend dose of 4.5 mg/kg ofrecommend dose of 4.5 mg/kg of lidocainelidocaine. A smaller (27. A smaller (27 gaga, 1 1/4"), 1 1/4")

needle may be used for infiltration. Smaller needles are shown tneedle may be used for infiltration. Smaller needles are shown to beo beassociated with less pain during local anesthesia.associated with less pain during local anesthesia.

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IfIfthe CSF flow is too slow, ask the patient to cough or bear downthe CSF flow is too slow, ask the patient to cough or bear down as in theas in theValsalvaValsalva maneuver, or ask an assistant to intermittently press on themaneuver, or ask an assistant to intermittently press on thepatientpatients abdomen to increase the flow. Alternatively, the needle can bes abdomen to increase the flow. Alternatively, the needle can berotated 90 degrees such that the bevel facesrotated 90 degrees such that the bevel faces cephaladcephalad..

Never delay intravenous antibiotics for a lumbar puncture or a pNever delay intravenous antibiotics for a lumbar puncture or a prere--lumbarlumbarpuncture CT scan. Meningitis can usually be inferred from the cepuncture CT scan. Meningitis can usually be inferred from the cell count,ll count,antigen detection, or both.antigen detection, or both.

The smaller the needle used for the lumbar puncture, the lower tThe smaller the needle used for the lumbar puncture, the lower the riskhe riskofofthe patient developing a postthe patient developing a postlumbar puncture headache. Data suggest alumbar puncture headache. Data suggest a

inverse linear relationship to gauge, and the authors recommendinverse linear relationship to gauge, and the authors recommend using ausing a2222--ga needle, regardless of what size needle is supplied with the kga needle, regardless of what size needle is supplied with the kit.it.55

The use ofThe use of atraumaticatraumatic needles has been shown to significantly reduce theneedles has been shown to significantly reduce theincidence of postincidence of postlumbar puncture headache (3%) when compared tolumbar puncture headache (3%) when compared tostandard spinal needles (approximately 30%).standard spinal needles (approximately 30%).66,,77 Obtaining pressures canObtaining pressures can

be more difficult with these needles.be more difficult with these needles.Prophylactic bed rest following lumbar puncture has not been shoProphylactic bed rest following lumbar puncture has not been shown to bewn to beof benefit and should not be recommended.of benefit and should not be recommended.88,,99,,1010

02 lab skill preparing patient

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