Department of Anaesthesiology and Intensive TherapyInstitute of Surgical Research

Department of Emergency Medicine

Basics of Emergency Medicine

Workshop V.Surgical vein preparation, Seldinger technique,

Urether catheterization, Nasogastric tube insertion

Year 2013-2014 / 2nd semester

Surgical vein preparation

Seldinger technique (central vein insertion, arterial and venous

cathetarization)

Surgical vein preparation I.

Aim: to ensure a stable venous rout for fluid replacement, drug administration and parenteral feeding in case of insufficient peripheral veins

Implementation:

•Performed by surgeon; aseptic (operathing theatre) environment

•Under general anaesthesia (if containdicated: strong pain killers and infiltration of local anaesthetic)

•Skin incision above a superficial vein, blund dissection of soft tissues, free dissection of the vein, small incision on the vessel, introduction of the catheter)

Surgical vein preparation II.

Skin incision

Blunt dissection 1.

Blunt dissection 2.

Preparation of the vein 1.

Preparation of the vein 2.

Double thread below the vein 1.

Double thread below the vein 2.

Elevation of the vein

Seldinger technique I.Application: minimally invasive proceduresE.g.:1. Common Interventional Radiology Procedures: - procedures on arteries: angiography; percutaneous

transluminal angioplasty; arterial stenting, tu. embolisation..stb)

- procedures on veins: TIPS; thrombolysis in DVT; varicocele embolization, port insertion )

3. Central vein insertion (fluid replacement, drug administration and parenteral

feeding, intensive care monitoring etc)

Implementation: with palpation of the pulse or by means of ultrasound guidance

Insertion place:Arteries: femoral or brachial artery (less frequently: the radial or the popliteal artery) In case of veins: common femoral vein, internal jugular or subclavian vein

Seldinger technique II.

Venous portEmbolisation of uterinal artery

Seldinger technique III.1. Insert Braunüle into the lumen of the vessel

3. Flexible guidewire into the central vein

5. Dilation device

6. Central vein canula

2. Remove the needle

4. Remove the sheat of Braunüle

Removal of guide wire

Note: In case of special, so called Seldinger needle, the 1st and 2 nd steps are the same, because there is no plastic sheat

Seldinger.mpg

Seldinger technique- video

Urinary system monitoring

Catheterization of the bladder

Urether catheterization

Definition: artificial emptying of the urinary bladder.

Aims: therapeutic (urine retention, incontinence, preoperative preparation) diagnostic (monitoring fluid status, urologic/microbiologic tests)

Principles of catheterization

- catheterize only if it is necessary - avoid catheterization in case of urethral injuries - catheterize in accordance with the rules of asepsis!

Catheters

Material: synthetic, latex or silicone.Size: external diameter is given in Charriére (1 Ch) or

1 French (1 F) (=0.33 mm)The most widely used: 14-22 Ch Foley-catheter (with

balloon, easy fixation).

Tools for catheterization

- catheter in appropriate size- urine container sack and tube- sponges for cleaning of genital area- disinfectant- saline (in syringe) to fill the balloon- sterile lubricant (Instillagel)- sterile gloves

Male catheterization

Removing the catheter in males

Male catheterization- Lift the penis (about 60 degrees) with left hand

and retract the foreskin- Clean the urethral meatus with disinfectant 3

times- Inject some Instillagel to the urethra- Insert the catheter into the urethra with

sterile forceps- Fill the balloon with 10 ml saline- Pull back the catheter until the balloon

allows- Connect the urine container sack to the

catheter.

Female catheterization

Female catheter removal

Female catheterization

- Spread the labia gently with left hand- Clean the introitus with disinfectant 3 times- Grasp the catheter with sterile forceps at some cm-s

from the end - Put Instillagel onto the first some cm-s of the

catheter- Insert the catheter gently into the

urethra- Connect the urine container sack

to the catheter- Fill the catheter with 10 ml saline- Pull the catheter back.

Enteral Feeding

Nasogastric tube insertion

Enteral feeding1.Parenteral feeding2.Enteral feeding (tubes)

Planning: gastroenteral feeding is preferred beacause it is more physiological

Short term feeding(max. 2-3 weeks):

Nasogastric tubesOrogastric tubesNasoduodenal tubesNasojejunal tubes

Long term feeding(stomas):

OesophagostomaGastrostomaJejunostomaPercutan endoscopic gastrostomaPercutan endoscopic jejunostoma

Who needs an NG:

Assessment:•Surgical clients•Ventilated client•Neuromuscular impairment .•Clients who are unable to maintain adequate oral intake to meet metabolic demands.

Assess patency of nares.

„Indicated for those clients who do not want/ cannot/ must not eat”

Gather equipment for nasogastric tube insertion 14 0r 16 Fr NG tube

• Lubricating jelly• PH test strips• Tongue blade• Flashlight• Emesis basin• Catheter tipped syringe• 1 inch wide tape or commercial fixation device• Suctioning available and ready

Preparation of the patient (high Fowler position)

NG insertion-video

NG tube insertion I.– Inform the patient– Patient is laid in a fowler, or in a semi-fowler position (in case

of unconciuosness)

Semi-fowler position

NG tube insertion II.

– Handwash– Gloving– Assess the patency of the tube– Measure the required tube length (until the ear lobe

and the xyphoid process)– Preparation of the tube (bending, lubricant)

LubricantMeasure the length of the tube

– Introduce at an acute angle at first then push forward toward the nasopharynx

– After getting through the nasopharynx the patient should bend híds head

NG tube insertion III.

introduction After a few cm push parallel with the nose

• The patient take breath throuh his mouth during the whole procedure• Tube can get through the oropharynx during swelling (we pretend it

by moving the epiglottis on the manikin)

NG tube insertion IV.

• After getting through the oropharynx, check the location of the tube (in case of breathing sounds take it out)

• Introduce the tube gradually during every swelling

• Do not force the introcuction (in case of any obstruction take it out)

• Fix the tube with plaster around the nose

NG tube insertion V.

Nasogastric tube insertion-video

NG position

right

Checking:

Confirm satisfactory tube positioning before starting tube feed • aspirate for pH and color• Stetoscope• X-ray

Right product, right time, right client, right rate…..check and chart.

Monitor intake and output

check the position of the tube before every feeding (at least in every 12h)