IInntteerrnnaall MMeeddiicciinnee

PPrroocceedduurreess MMaannuuaall

JJoooo--MMeenngg SSoohh

PPrroocceedduurreess MMaannuuaall

TTaabbllee ooff CCoonntteennttss PPaaggee Introduction 1 General Principles, Sedation & Pain Control 2 Sterile Technique, Local Anesthetic 3 Needles, Syringes, and Angiocatheters 4 Paracentesis 5 - 7 Thoracentesis 8 - 11 Lumbar Puncture (Spinal Tap) 12 - 16 Central Venous Catheter Insertion 17 - 21 Knee Arthrocentesis and Injection 22 - 25 Bone Marrow Aspiration and Biopsy 26 - 30 References 31

IINNTTRROODDUUCCTTIIOONN

The technical skills acquired by Internal Medicine residents have largely been dictated by the patients encountered during clinical rotations. The quality of teaching with respect to these skills has traditionally been dependent on the senior resident teaching these skills. The above two factors have lead to wide variations in the experience and competence among graduating internal medicine residents in performing the technical skills which are deemed necessary at the time of graduation. The objectives of the Department of Medicine’s “Medical Procedures” day in the University of Toronto Surgical Skills Lab are the following: • To provide formal instruction on techniques in performing common procedures in Internal Medicine

• To understand the indications, contra-indications, and complications associated with these procedures

• To give hands-on practice and experience at performing these procedures on models

• To reduce anxiety/discomfort in performing these procedures and ultimately, to enhance the confidence level in residents performing these procedures on live patients

HHOOWW TTOO UUSSEE TTHHIISS MMAANNUUAALL The general outline for each procedure will assume the following format:

• Introduction & Indications for the Procedure • Precautions & Risks of the Procedure • Materials Required • Anatomy, Positioning, and Landmarking • Technique • Diagnostic Tests This manual was developed to complement and reinforce the skills taught during the practical sessions at the skills lab. The techniques described in this manual have been derived from various sources including expert opinion and should not be interpreted as being the only method of performing these procedures. The author assumes no liability for any injury or complications arising from the performance of these technical skills on patients.

AACCKKNNOOWWLLEEDDGGEEMMEENNTTSS

• Production of Manual Dr. J. Soh • Contributions to Manual Dr. C. Jaigobin, Dr. R. Wax, Dr. C. Chan, Dr. N. Girgrah Dr. K. Imrie, Dr. L. Albert • Surgical Skills Centre Personnel - Lisa Satterthwaite, Dezan Rego, Shunne Leung, Marina Romanova

1

GGEENNEERRAALL PPRRIINNCCIIPPLLEESS

BBeeffoorree tthhee PPrroocceedduurree

• Be aware of the potential complications • Obtain informed consent by explaining:

- the purpose of the procedure, its inherent risks and benefits - implications of having the procedure as well as refusing to have the procedure done

TThhee EEnnvviirroonnmmeenntt

• Materials - take the time to collect all necessary equipment/labels/requisition forms before starting - bring extra materials just in case (ie. gloves, needles, syringes, gauze) • Lighting - ensure optimal lighting around the area of interest • Miscellaneous: - Pads under the patient to absorb Betadine (so sheets don’t have to be changed) - Waste disposal container on the side to quickly throw out waste materials - Bedside table to hold your materials

TThhee PPaattiieenntt

• Ensure proper positioning of the patient and patient comfort • Draping - maintain patient dignity by draping appropriately and exposing only necessary areas • Know the anatomy of the area you will be working around • Carefully landmark the area of interest with ink or make a depression with your pen or needle base

YYoouu,, tthhee PPhhyyssiicciiaann

• Be as comfortable as possible (get a chair to sit on if needed) • Roll up your sleeves, remove your stethoscope and any unnecessary jewelry • Put bedrails down and adjust height of bed to suit your needs • Ask for assistance from nurses or fellow housestaff/medical students • Communicate with the patient

- What you are doing and what they can expect - Determine if there is adequate anesthesia - Ensure the patient is in a comfortable position before and throughout the procedure - Provide reassurance and encouragement throughout the procedure

SSEEDDAATTIIOONN && PPAAIINN CCOONNTTRROOLL

• Always consider patient comfort AND safety • May be appropriate to give pre-sedation, if their vital signs are stable and they can be monitored • Recall that most sedatives/analgesics are also cardio-respiratory depressants

MMeeddiiccaattiioonnss UUsseedd MMaatteerriiaallss rreeqquuiirreedd

Anxiolytics • IV access • Versed (midazolam) 0.5-1.0 mg IV increments • Oxygen • Ativan (lorazepam) 0.5-1.0 mg SL increments • O2 Saturation Monitor • Valium (diazepam) 1.0-2.0 mg IV increments

Analgesics • Fentanyl 50-100 µg IV increments • Demerol 25 mg IV increments • Morphine 1-3 mg IV increments

2

SSTTEERRIILLEE TTEECCHHNNIIQQUUEE

MMaatteerriiaallss RReeqquuiirreedd ffoorr aa SStteerriillee FFiieelldd

• Dressing Tray (should contain the following) - Cotton Balls/gauze - Forceps - Sterile Draping (2-3/tray) - Compartment trays for cleaning solutions • Betadine (10% Povidine-Iodine) • Isopropyl Alcohol 70% may be used after Betadine to clean off some of the Betadine

TTeecchhnniiqquuee

• Prep the area of interest with Betadine – start from the center of the desired field and work your way outward; After repeating this 2-3 times, you may use the same technique with Isopropyl Alcohol to wash away some of the Betadine • Put on sterile gloves (gown and mask if indicated) • Drape the area with sterile towels or the drapes included in the dressing trays (or use the drapes included in individual Procedural Kits) • Instruct the patient to not contaminate the sterile field • Admit to breaks in sterility (by yourself or the patient) and start the process over if this occurs (never put the patient at risk)

LLOOCCAALL AANNEESSTTHHEETTIICCSS

• Lidocaine (1:100 = 1% = 1gm in 100 mLs = 10mg/mL) • Maximum doses of lidocaine = 5 mg/kg without epinephrine; 7mg/kg with epinephrine • Epinephrine – used for local hemostasis (by vasoconstriction) and prevents distribution of local anesthetic away from the injected site, resulting in a prolonged local effect • Using the 25 gauge needle, insert the needle bevel up until the bevel is no longer seen, then raise a small bleb slowly (intradermal injection – as in a TB skin test); Once this outer layer is anesthetized, deeper layers will be easier to freeze • When freezing deeper layers, aspirate before injecting to ensure the needle is not in a blood vessel

MMaatteerriiaallss RReeqquuiirreedd SSyymmppttoommss ooff ttooxxiicciittyy

• Lidocaine 1%-2% (5-10 cc’s) • peri-oral numbness/tingling, • 5-10 cc Syringe • light-headedness, tinnitus, disorientation • 25 gauge needle (freezing needle) • muscle twitching, tremors seizures • 20 gauge needle (to draw up lidocaine and • respiratory depression; cardiac arrest to freeze deeper layers)

3

NNEEEEDDLLEESS,, SSYYRRIINNGGEESS,, AANNDD AANNGGIIOOCCAATTHHEETTEERRSS

• Become comfortable using a one-handed technique: - dominant hand for injecting or aspirating - non-dominant hand to make the skin taut before injecting to stabilize the syringe & needle from excessive movement to ensure the needle does not go deeper than desired to landmark (arteries, bony structures, etc) • Use the freezing needle to help landmark internal bony structures • Insert needles with “Bevel up” and ensure the bevel is up throughout the procedure • Angiocaths: Once the stylet is withdrawn from the plastic catheter, never re-insert the needle back as this may tear the catheter (making it difficult to remove from the patient) “Bevel Up”

Angiocatheter

Catheter

Needle

4

PPAARRAACCEENNTTEESSIISS

IInnttrroodduuccttiioonn && IInnddiiccaattiioonnss

• Used as a diagnostic (etiology of ascites) and therapeutic procedure (large volume paracentesis) • Any patient with new onset ascites or suspected Spontaneous Bacterial Peritonitis (SBP) should undergo a diagnostic paracentesis

PPrreeccaauuttiioonnss && RRiisskkss • There is no cutoff of coagulation parameters beyond which the procedure should not be performed (ie. FFP/platelets not required unless the patient is already spontaneously bleeding) • There is no set “maximum” amount of fluid that can be drained for therapeutic purposes • Be cautious with large volume paracentesis in the very end-stage cirrhotic patient with impaired renal function (due to fluid shifts) → If attempting paracentesis, maximum of 6L should be removed • Consider the use of IV Albumin (8-12 gm / Litre drained) during the paracentesis (approximately equivalent to 50 cc’s of 25% Albumin per Litre drained) • <1% chance of bowel puncture if highly suspicious, start patient on appropriate antibiotic therapy • <1% risk of abdominal wall hematoma

MMaatteerriiaallss RReeqquuiirreedd

• Dressing Tray, Sterilization Solutions, Sterile gloves • Local Anesthetic Materials • Extra Gauze • Multiple syringes (20cc, 30cc, or 60cc) • 18 gauge Angiocath (for diagnostic taps) or 14-16 gauge Angiocath (for therapeutic taps) 1.5-2 inches long; for larger individuals, consider using a Thoracentesis Kit (see next section for more details) • Vacuum Bottles & Tubing (to hook up angiocath to the bottles) • Bandaid

Other Materials for Diagnostic Taps Other Materials for Therapeutic Taps • Specimen bottles for - Biochemistry • Urometer or bucket to drain the fluid - Hematology • Tape to secure tubes for drainage set up - Pathology • Blood culture bottles for Microbiology

PPaattiieenntt PPoossiittiioonniinngg && TTeecchhnniiqquuee –– SSuuppiinnee AApppprrooaacchh

LLaannddmmaarrkkiinngg (See Diagram marked by X) • Percuss area of dullness on both flanks • On either flank, landmark a point midway between the level of the umbilicus and iliac crests • Avoid previous surgical incisions as a landmark; be cautious of hepatomegaly or splenomegaly

• Use sterile technique to clean the area off; Drape appropriately • Freeze the skin with Lidocaine using 25 gauge needle • Replace 25 gauge needle with 20 gauge needle and advance the needle slowly (while intermittently aspirating) until fluid is aspirated • Withdraw needle while continuing to inject lidocaine • Attach Angiocath to a syringe and re-insert into the peritoneal space • When fluid returns, withdraw the needle & syringe as a single unit, leaving the plastic catheter in the peritoneum • Reattach new syringes and withdraw required samples

5

x • x

•• TThheerraappeeuuttiicc TTaappss - connect Angiocath to Vacuum bottle via tubing (See below for diagram) OR connect Angiocath to Urometer (Foley bag) via tubing and drain by positive pressure (for large volume taps)

•• ““ZZ--TTrraacctt”” TTeecchhnniiqquuee - minimizes fluid leakage after the procedure - Displace the skin few cm in any direction, then insert the angiocath as above - Release the skin tension only when the angiocath enters the peritoneal space

and fluid is flowing PPaattiieenntt PPoossiittiioonniinngg && TTeecchhnniiqquuee –– SSeeaatteedd AApppprrooaacchh

LLaannddmmaarrkkiinngg: Caudad to the umbilicus (See Diagram on previous page marked •)

• Use the same technique described above • Ensure the patient has an empty bladder and there are no signs of bladder outlet obstruction • This technique is contra-indicated with midline scars (bowel loops may be fixed to the wall) **** Consider Ultrasound Guidance in obese patients or if having difficulty obtaining fluid ****

TTiippss

• If no fluid withdrawn, try different angle or site (may be loculated) • If fluid draining well into vacuum bottle but it then stops, try removing the tubing from the vacuum bottle and hold the tubing below the patient to allow the fluid to drain out by positive pressure (gravity) - the bowel loops may be stuck up against the catheter secondary to the vacuum bottle’s high negative pressure

DDiiaaggnnoossttiicc TTeessttss

• Hematology: Fluid Cell count & Differential • Biochemistry: Albumin (obtain serum albumin to calculate the Serum-Ascites Albumin Gradient) Optional Tests: total protein, amylase, LDH • Microbiology: Place 10cc’s of fluid into each blood culture bottle Use an ordinary specimen container for other cultures/AFBs/gram stain • Cytology: Provide large samples with the vacuum bottles if concerned about malignant cause of ascites (try to send sample in the morning on weekdays only)

AngioCatheter with tubing to the Vacuum Bottle (Consider using a Urometer/bag for large volume paracenteses)

6

AASSCCIITTIICC FFLLUUIIDD AANNAALLYYSSIISS

EEttiioollooggyy ooff AAsscciitteess SSeerruumm--AAsscciitteess AAllbbuummiinn GGrraaddiieenntt

(Serum Albumin – Ascitic Albumin) ≥ 11 g/L < 11 g/L

• Cirrhosis, Hepatitis • CHF • Portal vein thrombosis • Hepatic vein thrombosis • Veno-occlusive disease • Massive liver metastases → ↑Hydrostatic Pressure (Portal Hypertension)

• Peritoneal Carcinomatosis (Malignancy/mets) • Pancreatic Ascites • TB Peritonitis • Serositis (SLE, Familial Mediterranean Fever, etc) • Nephrotic Syndrome • Bowel obstruction or infarction

Fluid Production > Fluid Resorption

SSppoonnttaanneeoouuss BBaacctteerriiaall PPeerriittoonniittiiss -- DDeeffiinniittiioonnss

• Spontaneous Bacterial Peritonitis - PMN ≥ 250 cells/mm3 PLUS positive ascitic fluid culture, in the absence of a surgically treatable intra-abdominal source of infection • Culture Negative Neutrocytic Ascites – PMN ≥ 250 cells/mm3 BUT negative ascitic fluid culture • Monomicrobial Non-neutrocytic Ascites – PMN <250 cells/mm3 BUT positive ascitic fluid culture OOtthheerr TTeessttss • Amylase – elevated levels seen in pancreatic ascites and gut perforation into the peritoneal cavity

7

TTHHOORRAACCEENNTTEESSIISS

IInnttrroodduuccttiioonn && IInnddiiccaattiioonnss

• Used as a diagnostic (etiology of pleural effusion) and therapeutic procedure • Confirm level of Pleural Effusion with a CXR (may be beneficial to get a lateral decubitus to ensure the effusion “layers out” (ie. free flowing and not loculated) • The presence of a clinically significant pleural effusion (> 10mm on ultrasound or lateral decubitus X-ray) with no known cause should be tapped; Patients presenting with definite CHF, bilateral effusions without fever or chest pain may be given a trial of diuresis, with resolution/improvement expected within 48 hours of diuresis

PPrreeccaauuttiioonnss • Avoid removal of more than 1 Litre risk of re-expansion pulmonary edema (due to rapid increase in the pulmonary capillary pressure and blood flow with subsequent transudation of fluid) • Check & correct coagulation/platelet deficits prior to performing the procedure

RRiisskkss • Pneumothorax may be caused by: - Lung laceration by needle OR entrance of air through the needle during the procedure - If small pneumothorax on CXR, may be reasonable to just observe Routine Post-Thoracentesis X-rays are not indicated unless: - air is obtained during the thoracentesis - coughing occurs - chest pain or dyspnea develops - tactile fremitus over the superior part of the aspirated hemithorax is lost - if pneumothorax < 30% of hemithorax, then observe and repeat X-ray - if pneumothorax > 30% of hemithorax, requires chest tube drainage • Hemothorax (if large enough, requires drainage with a closed thoracostomy) • Pulmonary Laceration • Hypoxemia - V/Q Mismatching (from perfusion of atelectatic lung areas)

- Pulmonary Edema (Re-expansion) • Hemoperitoneum, Liver or spleen puncture

MMaatteerriiaallss RReeqquuiirreedd

• Dressing Tray, Sterilization Solutions, Sterile gloves • Local Anesthetic Materials • 16-18 gauge Angiocath (1.5-2 inches long) • Syringes (20 cc, 30 cc, or 60cc) • Vacuum Bottles & Tubing (to hook up angiocath to the bottles) → for Therapeutic taps • Bandaid Other Materials: • Specimen bottles for: - Biochemistry - Hematology - Pathology - Microbiology • Arterial Blood Gas syringe for pH (and ice)

8

• Alternatively, one may use a conventional thoracentesis kit (see contents in diagram below) - these kits prevent air from entering the pleural cavity; Also have multiple side-ports and end-port to ensure effective drainage of fluid (angiocaths have only one end-port which may become blocked)

- they are significantly longer (19cm) than an angiocatheter and may be more difficult to manipulate

TThhoorraacceenntteessiiss KKiitt && NNeeeeddllee

Aspirating Syringe

Connection Tubing Connection for

Aspirating Syringe

Needle Connector to Vacuum Bottle

Scalpel

3 Way Stop-Cock

Thoracentesis Needle & Catheter

PPaattiieenntt PPoossiittiioonniinngg

LLaannddmmaarrkkiinngg:: (See Diagram below marked by X) • Patient should be seated upright with arms over a bedside table; Back should be fully exposed • Percuss for dullness to find the top of the fluid level • Horizontal landmark: Scapular line (preferred) or posterior axillary line • Vertical landmark: 1-2 interspaces below the top of the fluid level but above the 8th Interspace

Insert needle just above the edge of the rib (to avoid neurovascular bundle)

X

9

TTeecchhnniiqquuee –– UUssiinngg AAnnggiiooccaatthheetteerr

• Use sterile technique to clean the area off & drape appropriately (use tape to secure drapes to back) • Freeze skin with Lidocaine using 25 gauge needle; then replace needle with 20 gauge needle and penetrate into the deeper layers (while freezing), hitting the top of the rib, then “marching over” the rib until pleural fluid is obtained; then withdraw freezing needle • Attach Angiocath to syringe and re-insert in similar fashion • Advance while aspirating when fluid returns, fill syringe with fluid and then withdraw the syringe & needle as one unit, leaving the plastic catheter in the pleural space

* Always cap off the opening (with your thumb or other object) of the plastic catheter or else air will enter pleural space and cause a pneumothorax *

• Re-attach new syringes for more specimens (or tubing & vacuum bottles for therapeutic tap → remember to clamp off tubing when changing vacuum bottles) • Ask pt. to exhale or hum/Valsalva while removing the catheter to reduce risk of pneumothorax

TTeecchhnniiqquuee –– UUssiinngg TThhoorraacceenntteessiiss NNeeeeddllee KKiitt

• Clean, drape, and inject local anesthetic as described above • Attach the aspirating syringe to the “Connection for aspirating syringe” and insert the thoracentesis needle as described above (hit the top of the rib, then “march over” the rib until fluid is obtained) • Once fluid is obtained, advance the plastic catheter (without the needle component) until all the side- ports are deep to the skin layer, then remove the needle & aspirating syringe as a single unit • Attach new syringes to the 3-way stopcock (or tubing & vacuum bottles for therapeutic tap) to continue removing fluid - see diagram below for direction of stopcock)

*** When removing fluid, turn the stopcock “off” (see diagram and direction of arrows) to face away from the direction of the catheter; When changing syringes or tubing, ensure the stopcock is directed “off” to the open port - this will prevent air from entering the system ***

DDiiaaggnnoo

• Hema • Bioch

• Micro • Cytol * Obtain

Removing Fluid

ssttiicc TTeessttss tology: Fluid Cell Count & Differential emistry: Protein*

LDH, Glucose* pH (in ABG syringe place on Optional Tests: - Amylase, Trig

- Rheumatoid F - Specific Grav

biology: Place fluid into Aerobic & Anaeogy, Flow Cytometry

Serum values for Protein, LDH, and G

Changing Syringes/Tubes

ice) lycerides actor, ANA, Complement levels

ity robic Blood Culture Tubes (10 cc’s/bottle)

lucose to make comparisons

10

PPLLEEUURRAALL FFLLUUIIDD AANNAALLYYSSIISS Sensitivity Specificity

Light’s Criteria for Exudative effusion ≥ one of the following: 98 83 • Ratio of (pleural fluid protein) : (serum protein) > 0.5 86 84 • Ratio of (pleural fluid LDH) : (serum LDH) > 0.6 90 82 • Pleural fluid LDH > 2/3 upper limit of normal for Serum LDH 82 89 Other Criteria • Pleural fluid cholesterol > 1.55 mmol/L 54 92 • Pleural fluid cholesterol > 1.10 mmol/L 75 80 • Ratio of (pleural fluid cholesterol) : (serum cholesterol) > 0.3 89 81 • Serum albumin – pleural fluid albumin ≤ 12 g/L 87 92

Low Pleural Fluid glucose (<3.3 mmol/L) seen in: • Complicated Parapneumonic effusion (see below) • Hemothorax • Malignant effusion • Lupus pleuritis • Rheumatoid pleuritis • Churg-Strauss Syndrome • TB • Paragonimiasis

Elevated Amylase Elevated Cholesterol • pancreatic diseases • chylothorax • ruptured esophagus EEttiioollooggyy ooff TTrraannssuuddaattiivvee PPlleeuurraall EEffffuussiioonnss • Congestive Heart Failure • Cirrhosis/Liver failure • Pulmonary Embolism

EEttiioollooggyy ooff EExxuuddaattiivvee PPlleeuurraall EEffffuussiioonnss Inflammatory Etiology

• Infectious – parapneumonic effusion (secondary to pneumonia), empyema • Serositis – SLE, Rheumatoid Arthritis, Familial Mediterranean Fever • Pulmonary Embolism

Malignancy

CCllaassssiiffiiccaattiioonn ooff PPaarraappnneeuummoonniicc EEffffuussiioonnss aanndd EEmmppyyeemmaass

Nomenclature Biochemistry Cultures Management Typical Parapneumonic Effusion

• pH > 7.2 • LDH < 1000

• Gram stain −ve • Antibiotics only

Complicated – Borderline • pH 7.0 – 7.2 • LDH > 1000

• Gram stain −ve • Antibiotics ± Drainage

Complicated – Simple • pH < 7.0 • ↓↓ glucose

• Gram stain +ve OR C&S +ve

• Antibiotics + Chest Tube

Complicated – Complex • as above • as above with loculated fluid (no pus)

• Antibiotics + Chest Tube ± intrapleural thrombolytics if unsuccessful

Empyema – Simple • as above • Free flowing pus

• Antibiotics + large Chest Tube • Consider decortication if empyema remains > 1 wk

Empyema – Complex • as above • Multi-loculated pus

• Antibiotics + large Chest Tube • ± lytic therapy/decortication

11

LLUUMMBBAARR PPUUNNCCTTUURREE

IInnttrroodduuccttiioonn • Total CSF in adults is ~ 150cc’s; 400-500 cc’s per day is produced in a normal individual. • Distance between the skin and subarachnoid space is ~ 4cm in the average individual • Check & correct coagulation/platelet parameters before performing the procedure (to avoid causing an epidural or subdural hematoma)

PPrreeccaauuttiioonnss • Patients with a decreased level of consciousness, focal neurological deficits, or papilledema must have a CT scan prior to a lumbar puncture to rule out a mass lesion causing increased ICP • Patients with none of the above features generally do not require a CT scan prior to a lumbar puncture • If suspecting meningitis, NEVER delay antibiotic therapy while awaiting for a CT scan

CCoonnttrraaiinnddiiccaattiioonnss ttoo LLuummbbaarr PPuunnccttuurree • Signs of impending herniation • Papilledema or CNS mass lesion • Soft tissue infection at the site of needle entry point • Uncorrected thrombocytopenia (<50 000) or Coagulopathy

RRiisskkss • Post-lumbar puncture headache, caused by continuous drainage of CSF into tissues outside of the subarachnoid space through a dural tear, may be prevented by:

- Inserting bevel of needle parallel to the dural fibers (ie. bevel “up” if patient is lying in lateral decubitus → causes less dural tear) - Replacing the stylet at the end of the procedure before withdrawing the needle

• Bedrest post-lumbar puncture has not been proven to reduce the incidence of post-LP headaches • Volume of fluid removed is not a risk factor for developing post-LP headaches • Pt. may complain of electrical shock going down the back/leg/toes should be transient • Persistent CSF drainage from puncture site repaired by anesthesia by inserting a blood patch over the site of leakage • Brain herniation see “Introduction” section and need for CT scans pre-procedure

AAnnaattoommyy ooff aa LLuummbbaarr PPuunnccttuurree

LLAAYYEERRSS PPEENNEETTRRAATTEEDD DDUURRIINNGG AA LLUUMMBBAARR PPUUNNCCTTUURREE

Skin Subcutaneous Tissues Supraspinous Ligament Interspinous Ligament Cauda Equina Ligamentum Flavum Dura Subarachnoid Needle with Stylet Space removed

12

MMaatteerriiaallss RReeqquuiirreedd

Manometer with Extension

Free &

Spinal Needle

• Steriliz PPaattiieenn

LLaannddmm • Identify • May us medull

Bandaid Sponge Sticks

Connector Tube between Needle and Manometer

Gauze

Sterile Field

Lidocaine

20 gauge Needle

zing Needle Syringe Collection Bottles

(Labelled 1 to 4)

3 Way Stop Cock

ation Solutions, Sterile Gloves, Dressing Tray (if stand

tt PPoossiittiioonniinngg && TTeecchhnniiqquuee

aarrkkiinngg:: (See Diagram) the L4-L5 space (L4 lies at the level between iliac cree the L3-4, L4-5, or L5-S1 space (do not use the L2-3 spaaris terminates at L2) ensure your landmark is in the

Iliac Crest Spinal L4-L5 Space

Basin for Sterile Solution

ard LP tray is not available)

sts) ce or higher because the conus midline

Needle Stylet

13

PPaattiieenntt PPoossiittiioonniinngg

LLaatteerraall DDeeccuubbiittuuss AApppprrooaacchh • Position the patient horizontally with maximal flexion of the hips, knees, and back. • Patient’s spine should not be twisted/rotated; Knees should be close to the chest (↑back flexion will result in ↑intervertebral disk space between L3-L4 and L4-L5 allows easier passage of the needle – See diagram below) • Position patient close to the edge of the bed • Palpate the iliac crests and identify the L4-L5 space at that same level, as demonstrated in the diagram

SSeeaatteedd AApppprrooaacchh • Sitting at the edge of the bed, have the patient curl their back as much as possible by leaning over a bedside table with their head flexed (similar to thoracentesis position)

Effects of Flexion on opening the Intervertebral Disk Space

TTeecchhnniiqquuee

• Use sterile technique to clean the area off; Drape appropriately using the draping provided in the kit • Freeze the skin with lidocaine using the 25 gauge needle • Replace the needle with the 20 gauge needle and penetrate into deeper layers while injecting lidocaine (< 2-3 cc’s of lidocaine needed) do not infiltrate the subarachnoid space with lidocaine • Insert the Spinal needle at an angle 100-150 cephalad (alternatively, aim for the umbilicus). It is critical that the needle be in line with the spinous processes (a few degrees off will result in missing the target); guide the needle and stylet in while using your non-dominant hand to landmark the spinous processes above and below your entry point (you will feel resistance from the ligamentous structures as you enter deeper layers) • If encountering bone - ensure the patient is flexed maximally - ensure needle is angled appropriately and in line with the spinous processes - attempt to maneuver between the spinous processes by using different angles • When you feel you have penetrated the Ligamentum flavum (may feel a “pop” or give) and are into the subarachnoid space, remove the stylet to see if CSF drains out (wait for a few seconds). If no CSF is obtained, replace the stylet and advance by 2mm increments, each time withdrawing the stylet to check for CSF drainage; If you feel you are too deep, withdraw the needle and re-landmark

14

MMeeaassuurriinngg OOppeenniinngg PPrreessssuurreess • If CSF is obtained, measure opening pressures by attaching the 3-way stopcock and manometer (assemble the manometer & 3-way stopcock before beginning the procedure) • Ensure that the stopcock is directed away from the Spinal Needle – See diagram below • Patient should be allowed to extend their hips and knees to allow accurate measurement of pressures • Turn the stopcock dial to collect the fluid in the manometer; then turn the stopcock dial to collect fluid from the patient (See Diagram below for directions of stopcock)

• F S • W

Measuring Opening Pressures

ill each specimen bottle in order (lpecimens for Cytology and unusuhen finished, re-insert stylet, then

Collecting CSF from Manometer

abel each container from #1 - #4): al micro-organisms may require a f remove the spinal needle slowly.

Collecting CSF from Spinal Needle

each bottle requires 1-2 cc’s; ull bottle (~10cc’s)

15

DDiiaaggnnoossttiicc TTeessttss

• Hematology- Cell Count & Differential (Avoid sending Tube #1 for this) - If suspecting Subarachnoid Hemorrhage, send specimen bottles #1 & #4 for Cell Count (if traumatic, RBCs in #4 should be less than #1; if SAH, RBC’s in #4 should not be significantly less than #1

• Biochemistry -Glucose, Protein (obtain serum samples as well) • Microbiology - C&S, STAT Gram stain if suspecting bacterial meningitis - Fungal, TB, India Ink stain & Cyptococcal Antigen (if suspecting Cryptococcus) - PCR (Herpes encephalitis, viral meningitides, and bacterial antigens) - VDRL, FTA-ABS (Fluorescent Treponemal Antibody Absorption Test), MHA-TP (MicroHemagglutination-Treponema Pallidum) for Syphilis • Cytology - Send full specimen bottle in a.m. on weekdays only (if suspecting malignancy) • Special Tests- Oligoclonal bands (≥ 2 IgG Oligoclonal bands in MS) - Myelin Basic Protein (disorders resulting in myelin breakdown) - Xanthochromia (Subarachnoid hemorrhage) - ACE levels (Neurosarcoidosis) - Antibodies in paraneoplastic syndromes (Anti-Yo, Anti-Hu, Anti-Ri, etc…) Tube #1: Gram Stain, C&S Tube #2: Glucose, Protein Tube #3: Cell Count and Differential Tube #4: Special Studies (Fungal, Viral, Others)

SSPPIINNAALL FFLLUUIIDD AANNAALLYYSSIISS

CELL COUNT & DIFFERENTIAL

GLUCOSE PROTEIN

Normal • <5 WBC/mm3

• <5 RBC/mm3

• If traumatic tap (ie. +++ RBC’s), then CSF WBC ↑ by 1/mm3 for every 700 RBC’s/mm3

• 2.5 – 4.5 mmol/L • should be >60% serum glucose

• 0.2 – 0.45 g/L • if traumatic tap (ie. +++ RBC’s), then CSF protein ↑ by 0.1g/L for every 1000 RBC/mm3

Bacterial Meningitis

• > 250-500 (often > 1000 WBC/mm3) • > 50% PMN

• < 2.2 mmol/L • CSF:serum glucose ratio < 30%

• > 2.2 g/L

Viral Meningitis • <250-500 WBC/mm3

• lymphocyte predominance • normal – slightly ↓ • 0.5 – 2.2 g/L

TB Meningitis • 10-500 WBC/mm3

• lymphocyte predominance • decreased • 1.0 – 5.0 g/L

Fungal Meningitis

• lymphocyte pleocytosis • decreased • elevated

16

CCEENNTTRRAALL VVEENNOOUUSS CCAATTHHEETTEERR IINNSSEERRTTIIOONNSS

IInnttrroodduuccttiioonn

• These lines may be used for - Hemodynamic monitoring (CVP, PCWP, etc) - Administering IV fluids & multiple medications (through multiple ports) - Administering Inotropes/Vasopressors - Venous blood sampling, Hemodialysis • Sterile technique with gowns, masks, gloves, and sterile drapes (field should be 3X length of catheter) is a MUST to prevent catheter-related infections • Check and correct any Coagulation defects • Be aware of the potential complications of performing a central line insertion NOTE: In the event that rapid resuscitation with fluid or blood is needed, a short and fat catheter (eg. 14 gauge peripheral angiocath) is better than a long and thin catheter (eg. Central line)

PPrreeccaauuttiioonnss && RRiisskkss

GGeenneerraall CCoommpplliiccaattiioonnss • Air embolism – if suspect this has happened, immediately place patient in Trendelenburg position, left

lateral decubitus and aspirate the air • Infection (Line sepsis) – draw retrograde cultures and peripheral cultures to confirm this • Guide-wire embolism – requires vascular surgery or interventional radiology to remove • Thrombosis, Hemorrhage • Arterial puncture → “How do I know I am in the Vein and not the Artery?”

- If you are not sure, don’t dilate the vessel - may attach a sterile tubing to the end of the needle; hold up tubing and see how high the blood

rises → if <10-15cm, then likely venous - can also attach tubing to pressure transducer (if available) to determine the pressure - send a blood sample off for Arterial Blood Gas measurements → Once you are sure it is venous, proceed with dilating the vessel and the Seldinger Technique

IInntteerrnnaall JJuugguullaarr LLiinneess • Lower incidence of pneumothorax; hematomas can be compressed;not as comfortable as subclavian) • Carotid artery puncture/Hematoma remove needle and apply pressure - do not attempt cannulation of the other side (bilateral hematomas may compromise airway) • Pneumothorax CXR to confirm this ± need for other intervention • Hemothorax SSuubbccllaavviiaann LLiinneess • Higher incidence of pneumothorax; hematomas cannot be compressed;more comfortable for patients) • Subclavian artery puncture watch for hemothorax with CXR; if significant, may need arterial repair • Pneumothorax FFeemmoorraall LLiinneess (Not ideal for mobile patients) • Femoral nerve damage (approach too lateral) • Septic arthritis of the hip (needles inserted too deep in setting of non-sterile technique) • Viscus penetration (patient with a previously unknown femoral hernia) • Risk of Retroperitoneal Hematoma if puncture site is above the inguinal ligament

17

MMaatteerriiaallss RReeqquuiirreedd

Alternate

• • • • •

Angiocatheter

Freezing Needle

Finder Needle

Catheterizing Needle

Vessel Dilator

Styrofoam for sharps

Catheter Clamp for suturing

Triple-Lumen Catheter

Scalpel

Suture Needle

Guide Wire

Dressing Tray, Sterilization Solutions, Sterile gloves Local Anesthetic Materials IV Solutions to hook up to the lines (or flushes if capping off the line) Sterile drapes to protect the area (usually included in the central line kit) Dressings to be applied to the site after the central line is sutured in place

18

PPaattiieenntt PPoossiittiioonniinngg && TTeecchhnniiqquuee

• Check and correct coagulation/platelet parameters prior to proceeding • Position the patient in Trendelenburg (head down) by 150-200 and turn the head slightly to the opposite side (for Internal jugular and Subclavian Line insertions) • Use sterile technique to clean the area off; drape appropriately (see intro. section) • May consider using a 22 gauge “finder” needle to locate the Internal Jugular Vein before using the larger bore needle/catheter provided (if carotid artery is punctured, a smaller hole is made and bleeding is less than if the larger bore needle is used) IInntteerrnnaall JJuugguullaarr VVeeiinn:: AAnntteerriioorr AApppprrooaacchh ((AArrrrooww AA -- See next page))

• Vein runs medial to the sternomastoid at the top of the neck, passes under the muscle, then exits at the apex of a triangle (defined by the medial edge of the sternal head, the lateral edge of the clavicular head, and the clavicle) to travel lateral to the sternal head to join the subclavian vein behind the medial clavicle (See Diagram on next page) • Insert the needle at the apex of the triangle described above • May use non-dominant hand to palpate carotid artery and retract it medially from insertion site • Angle the needle at 200-300 to the skin, aiming toward the ipsilateral nipple • Advance while aspirating until venous blood returns (~ 1-4cm) Proceed to Seldinger technique • If no vessel is encountered, withdraw needle while aspirating – vein may be found in this way IInntteerrnnaall JJuugguullaarr VVeeiinn:: PPoosstteerriioorr AApppprrooaacchh ((AArrrrooww BB))

• Must turn the head further away from the operator than with the anterior approach • Insert the needle 4-5 cm above the clavicle, lateral to the clavicular muscle head (Insertion site is ~ 1cm superior to the point where the external jugular vein crosses the lateral edge of the sternocleidomastoid muscle • Needle should be advanced in a plane parallel to the bed, aiming for the suprasternal notch • Advance while aspirating until venous blood returns (~5 cm) Proceed to Seldinger technique • If no vessel is encountered, withdraw needle while aspirating – vein may be found in this way SSuubbccllaavviiaann VVeeiinn AApppprrooaacchh ((AArrrrooww CC))

• Vein lies posterior to the lateral part of the clavicle, crosses under it at the distal third of the clavicle, and then joins the internal jugular vein at the base of the neck (See Diagram) • Insert the needle at a point 1cm inferior to the distal third of the clavicle • Angle the needle at 200-300 to the skin, aiming toward the suprasternal notch • Aim to hit the clavicle, then “march” down along the bone and pass under it while aspirating • Advance while aspirating until venous blood returns (~5 cm) • Rotate bevel to 3 o’clock (directs guide wire into SVC) Proceed to Seldinger technique • If no vessel is encountered, withdraw needle while aspirating – vein may be found in this way

19

In C NNoottee:: Arrows indicate FFeemmoorraall VVeeiinn AApppprroo

• Vein is found 1-2 cm • If unable to palpate t and the Symphysis P The femoral artery lie most medial segmen • Structures lateral to t • Structures medial to Remember from Late

Nerve Artery

Vein Empty space Lymphatics • Insert the needle just • Angle the needle at 3 • Advance while aspira • If no vessel is encoun

ternal Jugular Vein B A

Sternocleidomastoid Muscle

Suprasternal Notch

Subclavian Vein

direction of needle insertion

aacchh medial to the palpated Femoral Artery he arterial pulse, draw a line between the ASIS ubis, divide the line into three equal segments. s at the intersection between the middle and ts (as illustrated) Symphysis he femoral vein: femoral artery, then nerve Pubis the femoral vein: lymphatics

ral to Medial: Nerve Artery Vein

below the inguinal ligament, 1-2 cm medial to the femoral arterial pulse 00-400 to the skin, aiming toward the umbilicus ting until venous blood returns (~4-5 cm) Proceed to Seldinger technique tered, withdraw needle while aspirating – vein may be found in this way

20

SSeellddiinnggeerr TTeecchhnniiqquuee

• Once venous blood is aspirated (1), untwist the syringe (2) from the needle. Venous blood should 1 flow out easily. (If unsure if blood is venous or arterial, see above section on

“Arterial Puncture – How do I know I am in the vein and not the artery?”) 2 • Insert the guide-wire through the needle (should meet minimal resistance while doing so), leaving a few inches of guide wire external to the needle (3) • Withdraw the needle over the wire (4), leaving the wire in place 4 3 5

Guide Wire

• Use scalpel (5) to make a small skin incision along the path of the guide-wire Note: Direct the scalpel away from the guide wire Dilator • Thread the vessel dilator (6) over the guide wire to dilate the skin, soft-tissues, and blood vessel and make a passage 6 7 for the catheter • Remove the dilator (7) over the wire *** Hold on to the guide-wire at all times to prevent it from entering the circulation *** • Thread the Catheter over the wire (8) wire will pass through the distal/end port of a multi-lumen catheter; Before starting the procedure, close off the other ports and open the distal/end port to allow the wire to pass through

9 8 Triple-Lumen Catheter Cathether Anchor Guide Wire • Remove the wire (9); aspirate air from the lumens of the catheter, then hook up to IV solutions (or cap off with saline or heparin flushes) • Secure the line by suturing the Catheter Anchor to the skin; (May also use Catheter Clamps provided in the Kit). Clean the area and apply sterile dressings • Order CXR to confirm placement with Internal Jugular & Subclavian Lines: Tip of the catheter should be in the SVC (not the right atrium)

21

KKNNEEEE AARRTTHHRROOCCEENNTTEESSIISS && IINNJJEECCTTIIOONNSS

IInnttrroodduuccttiioonn

• The knee is probably the most common joint to be aspirated; Knee aspiration is also felt to be a procedure that a graduating Internal Medicine resident should be competent in performing; Other joint aspirations (eg. shoulder, wrist, elbow, ankle, etc.) are considered optional to master • Diagnosis of a knee effusion depends mainly on the physical exam +/- ultrasound of the joint space

IInnddiiccaattiioonnss Diagnostic Indications • Undiagnosed Knee Effusion • Suspected Septic arthritis • Evaluation of response to therapy with septic arthritis • Suspected crystal-induced arthritis

Therapeutic Indications • Relief of tense effusions causing elevated intra-articular pressure • Drainage of a septic joint • Injection of corticosteroids or hyaluronic acid derivatives

PPrreeccaauuttiioonnss

• Correct any platelet and coagulation defects prior to aspirating any joint space • Inject corticosteroids only after septic arthritis has been adequately ruled out

CCoonnttrraaiinnddiiccaattiioonnss ttoo KKnneeee AAssppiirraattiioonn • Soft tissue infection at the site of aspiration • Uncorrected Thrombocytopenia or Coagulopathy - Note: the risk of iatrogenic hemarthrosis with an experienced operator is probably low. Knee

aspiration in the setting of possible septic arthritis is crucial in this setting, correction of platelet/coagulation abnormalities may not be completely necessary – pressure should be applied over the aspiration sight for several minutes

RRiisskkss • Hemorrhage into joint space • Iatrogenic septic arthritis (Incidence < 1:10,000) • Joint injury – this may be avoided by aspirating slowly and preventing excessive movement of the

needle while in the joint space • Risks with Injection of Corticosteroids - Tendon Rupture (if injection directly into tendon) - Acceleration of joint damage if undiagnosed septic joint - Subcutaneous fat atrophy if injection is too superficial - Cartilage injury with repeated corticosteroid injections (limit steroid injections to 3/joint/year) - Flushing reaction in patients receiving triamcinolone acetonide (Kenalog)

MMaatteerriiaallss RReeqquuiirreedd • 3 or more Alcohol swabs OR povidone-iodine prep solution; Gloves (need not be sterile) • 18 gauge needle (or smaller bore needle) -- a large bore needle may create too much negative suction pressure and bring debris into the needle, physically blocking further aspiration • Multiple syringes (5-10cc for diagnostic purposes, 20-60cc for therapeutic drainage) • Specimen collection bottles & Bandaid • OOPPTTIIOONNAALL - Hemostat or “clamp” to stabilize needle while changing syringes - Local Anesthetic Materials (Lidocaine, Needle & Syringe) - Polarized Microscope & Glass slides for examination of crystals NOTE: Performing an arthrocentesis does not require a full sterile set-up (ie. betadine, dressing tray, sterile drapes, sterile gloves, etc) provided the operator is comfortable in the technique and can ensure that the skin around the injection site AND the needle barrel will not be touched If this

is not the case, then a full sterile set-up is recommended

22

PPaattiieenntt PPoossiittiioonniinngg

• Patient should be positioned comfortably lying down with knee held in the extended position with a slight amount of flexion (approximately 100–200) to relax the quadriceps muscle (a small pillow or roll can be placed under the knee to provide support) • Instruct the patient to NOT tighten their quadriceps muscle

LLaannddmmaarrkkiinngg (See Diagram below)

• Locate the patellar borders by palpation • Lateral approach Needle entry point ~ 1/3 of the way down from the superior pole of the patella (A) • Medial approach Needle entry point ~ 1/3 of the way down from the superior pole of the patella (B)

A

TTeecchhnniiqquuee • Mark the proposed site of n • Sterilize the area with 3 co • Use of local anesthetic is o not used, then a small bor Note: Lidocaine may redu

included in the cultu • Insert the needle just below After the needle has enter continuing to advance - un Lateral Approa • Once synovial fluid is aspir iatrogenic joint damage • After the syringe is full, use syringe to collect further sa

B

eedle entry (with a pen or indentation in the skin) ncentric outward spirals with an iodine disinfectant or alcohol swabs ptional (depending on the patient and the physician); If Local anesthetic is

e needle should be used with quick “sure” puncture of the joint space ce the sensitivity of synovial fluid cultures if some of the lidocaine is re sample (ie. posterior to) the patella, aiming slightly posteriorly and downwards;

ed the subcutaneous tissue, exert negative pressure on the syringe while til fluid is aspirated

ch – Aerial View

ated, minimize needle moveme

a clamp/hemostat or gauze tomples if needed

Lateral Approach – Lateral View

nt within the joint space to prevent

secure the needle position and apply a new

23

TTIIPPSS • If fluid is initially aspirated but the flow subsequently stops: - the bevel of the needle may be obstructed with synovium release the suction, slightly reposition the needle, then try again; alternatively, inject some of the aspirated fluid to relieve the obstruction - the majority of fluid may be in the suprapatellar bursa apply pressure to the suprapatellar bursa (or ask an assistant to apply pressure) to move fluid into the joint cavity, as you continue to aspirate • Ultrasound guidance may be required for small/difficult effusions IINNTTRRAA--AARRTTIICCUULLAARR IINNJJEECCTTIIOONN OOFF CCOORRTTIICCOOSSTTEERROOIIDDSS

CHOICE OF STEROIDS - Methylprednisolone Acetate (Depo-medrol) - Triamcinolone Acetonide (Kenalog) - Triamcinolone Hexacetonide (Aristospan) • Before injecting steroids, it is mandatory to rule out a septic arthritis (by cell count and/or cultures) • With a 22 gauge needle attached to a 5-10cc syringe, load the needle with the steroid selected • Applying the same technique described above, insert the needle into the knee joint • Once fluid is aspirated, inject the steroid into the joint cavity (minimal resistance should be felt) NOTE: Some physicians may dilute the steroid with an equal volume of Lidocaine to help provide

immediate relief of pain from the inflammation (this also confirms proper placement of the injection)

TTWWOO--SSYYRRIINNGGEE TTEECCHHNNIIQQUUEE • This technique may reduce the incidence of steroid-induced subcutaneous fat atrophy • Two syringes are used: one for anesthetic, one for the steroid • Applying the same method described under “Technique”, enter the joint space with the anesthetic needle – once fluid is aspirated, inject a few cc’s of Lidocaine • Next, stabilize the needle at its base with a hemostat/clamp or sterile gauze, remove the anesthetic syringe and attach the syringe containing corticosteroids • Inject the Steroid into the joint cavity; after this is done, re-attach the anesthetic syringe, inject a few more cc’s of Lidocaine, then remove the needle from the joint cavity PPOOSSTT CCOORRTTIICCOOSSTTEERROOIIDD--IINNJJEECCTTIIOONN IINNSSTTRRUUCCTTIIOONNSS • Instruct the patient to rest and avoid weight-bearing on the injected knee for 48 hours • Warn the patient of a steroid flare – pain that occurs 6-12 hours after injection that may last 2-3 days (thought to be caused by the precipitation of steroid crystals within the synovial fluid) self-limiting condition • Application of ice, Tylenol, or NSAIDs may be of benefit for pain relief

24

DDiiaaggnnoossttiicc TTeessttss

BBEEDDSSIIDDEE TTEESSTTSS • Examine fluid for colour, clarity, and viscosity (normal fluid is clear, straw-coloured, and viscous)

LLAABBOORRAATTOORRYY TTEESSTTSS • Cell Count & Differential • Gram Stain, Culture & Sensitivity (if suspecting septic arthritis); AFBs - If Gonococcal arthritis suspected, chocolate (Thayer-Martin) agar should be inoculated with the fluid • Crystal examination (under Light & Polarized Microscopy) • Optional Tests: LDH, Glucose, Rheumatoid Factor, ANA, Complement levels, Cytology

JJOOIINNTT FFLLUUIIDD AANNAALLYYSSIISS

CELL COUNT &

DIFFERENTIAL GLUCOSE

Normal • <200 WBC/mm3 Non-Inflammatory Arthritis

• 200 – 2000 WBC/mm3

• < 50% PMNs

Inflammatory Arthritis • > 2000 WBC/mm3

• PMN predominance ↓

Septic Arthritis • > 100 000 WBC/mm3

• PMN predominance ↓↓

NOTES: • WBC Cell counts of 50,000 – 100,000 may be inflammatory and/or septic • Glucose measurements reflect an increase in glucose consumption by cells in the joint and a decrease in effective circulation to the joint reflects the degree of inflammation and NOT its etiology • Protein measurements not useful with joint fluids

25

BBOONNEE MMAARRRROOWW AASSPPIIRRAATTIIOONN && BBIIOOPPSSYY

IInnttrroodduuccttiioonn • Each hospital has its own protocol for the collection of bone marrow samples (some hospitals have technologists to perform smears of aspirate samples to determine the suitability of the sample); other hospitals may require you to collect aspirate samples into special test tubes, and only perform them in the mornings check your hospital’s protocols before performing this procedure • The most common site of sampling is the Posterior Superior Iliac Spine (PSIS). Sternal samples can also be obtained but this should only be performed by an experienced physician • A CBC with Peripheral Blood Film should be ordered on the same day of the procedure

IInnddiiccaattiioonnss • Unexplained Cytopenias (anemia, leukopenia, thrombocytopenia) • Lymphoproliferative or Myeloproliferative Disorders; Abnormal cells seen in Peripheral Blood Film • Myelodysplastic Syndromes • Metastatic Disease • Search for Infectious Processes (eg. TB, Histoplasmosis) or Granulomatous Disorders (eg. Sarcoid) • Quantification of Iron Stores (Gold standard for diagnosing Iron Deficiency Anemia) • Fever of Unknown Origin

PPrreeccaauuttiioonnss • Coagulation defects should be corrected prior to the procedure (INR preferably < 1.5) • Thrombocytopenia is not a contra-indication to the procedure and does not require prophylactic platelet transfusions

RRiisskkss • Hemorrhage, bruising, and infection at the sampling site • Pain after the procedure • Bowel injury or retroperitoneal hemorrhage if needle extends past the anterior cortex of the iliac crest • Breaking bone marrow needle if improper technique used

MMaatteerriiaallss RReeqquuiirreedd • Dressing Tray (or Bone Marrow Kit), Sterilization solutions, Sterile gloves, Local Anesthetic Materials • Bone Marrow Aspiration & Biopsy N dle, Stylet – see below

Bone marrow Aspiration Needle

• Scalpel • Multiple 3cc (or larger) syringes for c • Appropriate Test Tubes for aspiratio • Sterile specimen bottle with fixative • Specific culture mediums if TB or Fu • Bandaid

ee

Stylet

Bone Marrow Biopsy Needle (Jamshidi Needle) ollection of Aspirate samples

n samples for collection of Biopsy sample (check with lab for the fixative) ngal infection suspected

26

PPaattiieenntt PPoossiittiioonniinngg && TTeecchhnniiqquuee

• Patient can be positioned lying prone on the bed OR in the horizontal position with knees and hips flexed, and the side being sampled furthest away from the bed

LLaannddmmaarrkkiinngg • First palpate the Iliac Crest • Then “walk your fingers down” to the PSIS (See X on diagram) This will be felt as a prominent bump • Alternatively, start at the intergluteal cleft and palpate three finger-widths cephalad, and three finger-widths to the right/left PSIS will be felt as a prominent bump • Place a pen-mark or indentation at the landmarked sp • Use sterile technique to clean the area off; Drape app • Freeze the skin with lidocaine using the 25 gauge nee and penetrate into deeper layers (while still freezing); • Once bone is encountered (ie. PSIS), freeze the perio anesthesia of this pain sensitive area; Use the freezi the PSIS • Remove the freezing needle and proceed with the As

XX XX

ot ropriately dle; then replace needle with 20 gauge needle

steum in a circular fashion to ensure adequate

ng needle to help you landmark the borders of

piration and/or Biopsy

27

BBoonnee MMaarrrrooww AAssppiirraattiioonn TTeecchhnniiqquuee

• Remove the Sternal Guard from the Aspiration Needle • After making a small incision over the biopsy site with the scalpel, insert the Aspirating needle and penetrate the skin and subcutaneous tissues with a slight rotating motion; If the horizontal position is used, your free hand may be used to exert counter-pressure on the pelvis to aid in boring through the bone • Once bone is encountered, continue advancing the needle, passing through the cortical bone with a rotating motion until a slight “give” is felt This is when the marrow cavity has been entered • Remove the needle cap and obturator

• Attach the needle to a 3cc syringe • Use a rapid suctioning motion to quickly obtain 1cc of marrow aspirate • NOTE: This part of the procedure may cause a sharp pain w proceeding with the aspiration) • If a Bone Marrow Technologist is present, he/she will make sme adequacy of the sample based on the presence of marrow spic the aspirated material should be examined for adequacy (ie. ho floating particles), then placed into the appropriate Specimen B • Additional samples may be aspirated depending on the diagnos Flow Cytometry, Special Cultures, etc.)

arn the patient of this before

ars of the aspirate and determine the ules; If a Technologist is not present, ld the tube under light and look for ottles tic tests desired (ie. Cytogenetics,

28

BBoonnee MMaarrrrooww BBiiooppssyy TTeecchhnniiqquuee

• Using the same skin incision, insert the Jamshidi Biopsy Needle • Advance the Jamshidi Needle with a slight rotating motion until bone is encountered • Be careful NOT to sample the same area where the Bone Marrow Aspirate was taken – such a specimen may contain artifact arising from the aspiration procedure • Once bone is encountered, remove the cap and obturator • Continue advancing the Jamshidi Needle (now with a hollow bore) using a twisting motion until approximately 1 inch of bone marrow is obtained • The stylet or obturator may be gently inserted at this time to give an estimate of the size of marrow sample contained in the hollow needle, without crushing the sample • To dislod • Gently ro • Hold the • Insert the Marrow b • If a Bone to determ • After com over the • Place the for ~60 m

Marrow Sample

Stylet

gck

ba sio Min

psi bin

e the marrow sample, rotate the Jamshidi Needle clockwise, then counter-clockwise the Jamshidi needle to free the biopsy sample, then withdraw the needle SLOWLY

se of the Jamshidi needle over the Specimen Container tylet through the tip of the Jamshidi needle and push the psy sample into the collection container arrow Technologist is present, he/she will examine the sample e if it is adequate

leting the Aspiration and/or Biopsy, apply manual pressure te for several minutes to achieve hemostasis andage over the biopsy site and have the patient lie supine utes to apply further pressure

29

DDiiaaggnnoossttiicc TTeessttss

•• MMoorrpphhoollooggiicc eexxaammiinnaattiioonn ooff bboonnee mmaarrrrooww - gives information on marrow cellularity and abundance of hematopoietic precursor cells - presence of myelodysplasia or granulomas - detection of metastases

•• FFllooww CCyyttoommeettrryy - analyzes Myeloid B and T cell surface markers in leukemias & lymphomas - determines lineage of abnormal cells and stage of differentiation

•• CCyyttooggeenneettiicc AAnnaallyyssiiss - detects chromosomal changes in leukemias, lymphomas, and myelodysplastic syndromes - eg) changes in number of chromosomes (eg. trisomy 8), translocations (eg. t(9,22) seen in the Philadelphia Chromosome), and inversions of genetic material (eg. inv(16) - these chromosomal changes have prognostic significance

•• MMoolleeccuullaarr GGeenneettiiccss - allows analysis of molecular changes within tumour cells as a result of alterations in genes - establishes clonality of a cell population, determines cell lineage

•• IIrroonn SSttuuddiieess

•• CCuullttuurree && SSeennssiittiivviittyy,, AAcciidd FFaasstt BBaacciillllii,, VViirraall,, FFuunnggaall

30

RReessoouurrcceess

Bresnick S, Adams G. On Call Procedures, 2000; WB Saunders Hasselbacher P. Synovial Fluid Tests of Proven Value. In Schumacher HR., Klippel JH, Koopman WJ: Primer on Rheumatic Diseases 10th edition. Atlanta, Arthritis Foundation, 1993. Hoffman’s Hematology: Basic Principles and Practice, Philadelphia, Pennsylvania; Churchill Livingstone Inc. 2000Marino PL, The ICU Book, 1998; Williams & Wilkins Joynt R, Griggs R. Clinical Neurology. Philadelphia, Pennsylvania: Lippincott-Raven, 1998 Kelly’s Textbook of Rheumatology, Philadelphia, Pennsylvania, W.B. Saunders Co. Kopplin et al. Procedures Manual, St. Michael’s Hospital; Toronto, ON. Light R.W., Pleural Effusion, NEJM 2002; 346(25): 1971-1977. Murray J, Nadel J. Textbook of Respiratory Medicine. Philadelphia, Pennsylvania: W.B. Saunders Co., 1994 Roberts, W.N.; Owen, D.S.; Joint Aspiration or Injection in Adults: Technique and Indications, UpToDate 2002 Roberts, W,N; Hauptman, H.W.; Joint Aspiration or Injection in Adults: Complications, UpToDate 2002 Runyon B,A; Care of Patients with Ascites, NEJM 1994; 330(5):337 – 341. Schumacher H.R.; Primer on the Rheumatic Diseases, Atlanta, Georgia; William Byrd Press, 1993 Simon R, Brenner B. Emergency Procedures & Techniques. Baltimore, Maryland: Williams & Wilkins, 1994 Wintrobe’s Clinical Hematology; Baltimore, Maryland. Williams & Wilkins 1999 Yamada T et al. Textbook of Gastroenterology. Philadelphia, Pennsylvania: J.B. Lippincott Co., 1995 Trewhitt K.G., Bone Marrow Aspiration & Biopsy: Collection and Interpretation, Oncology Nursing Forum 2001; 28(9): 1409-1417 http://www.emedicine.com/med/topic2971.htm#target2 http://www.echo.uqam.ca/mednet/anglais/hermes_a/knee/part_6.html#Answer_32_01 http://uwcme.org/courses/rheumatology/knee/arthrocentesis.html

31