introduction to inpatient procedures - fastly · web viewthis handbook will serve to teach six of...

INTRODUCTION TOINPATIENT PROCEDURES

A Resident-to-Resident Guide

University of Minnesota Internal Medicine ResidencyAHCC Ambulatory Rotation 2006

Second Edition, Revised October 2007

INTRODUCTION

Every procedure carries with it certain common risks; bleeding, potential structural damage, pain, potential for infection, etc. Many of these risks can be reduced or avoided altogether with careful attention to two major points. First, every patient represents an individual complex clinical picture; it is up to the provider to determine how the patient’s medical issues prior to the procedure may affect or hinder a positive outcome. Secondly, one must look at the procedure itself and weigh inherent potential complications against the overall benefit to the patient. Taking stock of these issues will help prepare the medical provider for potential complications before they happen, saving heartache and energy for both the patient and physician.

This handbook will serve to teach six of the common bedside procedures performed by residents on the General Medicine or ICU wards. While this book will teach you the basics, only time and experience will breed proficiency. Good luck!

AHCC 2006James M. Abraham, MD

Basel Al-Aloul, MDSyed Sohail Ali, MD

Patrick Foy, MDJoEllen Kohlman, MD

Haresh Kumar, MDKatherine Marienfeld, MD

TABLE OF CONTENTS

I. Before and After the ProcedureA. Informed ConsentB. Aseptic GuidelinesC. Procedure Note Documentation

II. Introduction to Central Venous Catheters

III. Internal Jugular Central Venous Catheter Placement

IV. Femoral Central Venous Catheter Placement

V. Arterial Line Placement

VI. Lumbar Puncture

VII. Bedside Paracentesis

VIII. Bedside Thoracentesis

INFORMED CONSENTJames M. Abraham, MD

Every procedure, every time. Documentation is paramount particularly when considering performing a procedure. Every therapeutic procedure, despite the best intent, carries with it inherent risks along with the potential benefits. As healthcare providers it is our duty to adequately educate our patients regarding these risks and benefits, providing information and answering questions in lay terms so that the patient (or their surrogate) can make an informed medical decision.

“Informed consent” comprises several different aspects which should be documented in the chart prior to performing any procedure:

1. Name of the procedure and the diagnosis for which it is being performed.2. Risks of the procedure and their likelihood of occurring.3. Benefits of the procedure as well as likelihood of information/advantages gained.4. Alternative therapies if available, as well as their risks and benefits.5. Opportunity for the patient (or surrogate) to ask questions and discuss other options.6. Documentation of the patient’s (or surrogate’s) ability to provide adequate informed consent.

Many institutions have “Informed Consent” templates available which help providers review and document each of these important aspects. Make sure these consents are signed and available in the chart prior to any procedure.

Dire situations may arise where a patient is unable to provide informed consent and a surrogate is unavailable; if the patient requires a potentially life-saving procedure emergently and may die without it, the procedure may be performed without informed consent. Once the acute emergency has been dealt with, informed consent from the patient or a designated surrogate should be obtained retroactively as soon as possible.

1 Takimoto Y. Maeda S. Slingsby BT. Harada K. Nagase T. Nagawa H. Naga R. Akabayashi A. A template for informed consent forms in medical examination and treatment: an intervention study. Medical Science Monitor. 13(8):PH15-8, 2007 Aug.

2 Gaeta T. Torres R. Kotamraju R. Seidman C. Yarmush J. The need for emergency medicine resident training in informed consent for procedures. Academic Emergency Medicine. 14(9):785-9, 2007 Sep.

3 Manthous CA. DeGirolamo A. Haddad C. Amoateng-Adjepong Y. Informed consent for medical procedures: local and national practices. Chest. 124(5):1978-84, 2003 Nov.

4 Davis N. Pohlman A. Gehlbach B. Kress JP. McAtee J. Herlitz J. Hall J. Improving the process of informed consent in the critically ill. JAMA. 289(15):1963-8, 2003 Apr 16.

ASEPTIC GUIDELINESJames M. Abraham, MD and Basel Al-Aloul, MD

One area of significant concern in healthcare today is the incidence of nosocomial infections, particularly those borne out of treatment delivered rather than the presenting illness. Hospitals and healthcare groups are now looking closely at the rate and incidence of infections arising from internally-performed procedures. Considering the vast amount of care delivered on daily basis and the growing bacterial resistance to antibiotics, maintaining sterility of bedside procedures is paramount.

Before opening your procedure kit, make sure to clearly identify the pertinent anatomy for your procedure. Clearly mark your planned point of entry. At this point, using Chloraprep or Betadine swabs (Chloraprep is now preferred given evidence it may in fact better disinfect and antagonize skin flora), gently sterilize the area starting at your point of entry and moving in concentric circles outward. Feel free to sterilize a wide area; this allows you more room to maneuver during the procedure. Repeat this process two or three times to ensure effective skin sterilization. For most procedures, maximum barriers should be used. These include a surgical cap , a face shield or goggles , sterile gloves , and a sterile gown . Maximum barriers also include washing your hands thoroughly before the procedure and using sterile drapes during the procedure. Oftentimes the draping provided in the procedure kits does not provide enough sterile workspace to comfortably perform the procedure. All wards should have packs of sterile towels stocked and available; do not hesitate to use these to extend the sterile workspace if necessary. If you require an assistant to perform the procedure, take time to ensure they are following proper aseptic technique as well.

While these steps may seem cumbersome, it is the responsibility of everyone delivering patient care to reduce infectious risk wherever and whenever possible. Take care to document that these guidelines were followed in your post-procedure note.

1 Hu KK. Veenstra DL. Lipsky BA. Saint S. Use of maximal sterile barriers during central venous catheter insertion: clinical and economic outcomes. Clinical Infectious Diseases. 39(10):1441-5, 2004 Nov 15.

2 Hu KK. Lipsky BA. Veenstra DL. Saint S. Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review. American Journal of Infection Control. 32(3):142-6, 2004 May.

PROCEDURE NOTE DOCUMENTATIONJames M. Abraham, MD

The most important thing to do after completing any procedure is documenting how it was performed. The details of the procedure, including findings and complications, will never be as fresh as they are immediately following the procedure. After ordering any pertinent studies and attending to any patient needs after the procedure, take a few minutes to write a short note describing the findings and any treatment plans. Remember, the medical chart is a legal document; it is imperative to keep a clear record of everything that transpires during the medical encounter.

A clear but succinct procedure note includes a description of the procedure performed, the names and titles of the providers performing the procedure (always include the attending physician’s name), pertinent pre- and post-procedure diagnoses, and a mention of the type of anesthesia used (if any). Take care to document that informed consent was obtained (including placing the signed form in the chart). In an emergency, potentially life-saving or critical procedures may be performed without informed consent; informed consent can be obtained retroactively from the patient or a medical decision maker when the emergency is resolved.

Also take a moment to document that aseptic guidelines and sterile barriers were used during the procedure. In 2-3 sentences, briefly describe the procedure and what information was gathered. Document any specimens obtained and studies ordered; take note of any blood loss or complications during the procedure. If there are any post-procedure instructions, include them at the end of the note. The following is a sample procedure note:

PGY-2 Procedure Note

Procedure: Diagnostic/Therapeutic ParacentesisPerformed By: Abraham MD, Attending Physician MD

Pre-procedure Diagnosis: ESLD/portal HTN with recurrent ascitesPost-procedure Diagnosis: SameAnesthesia: Local

Informed consent was obtained from the patient/representative after discussion of risks, benefits, and alternatives; consent placed in chart. The abdomen was sterilized and draped per usual aseptic guidelines, sterile barriers were applied. Needle and catheter were introduced into the LLQ under local anesthesia; 5 liters of free-flowing clear yellow ascitic fluid were obtained, 15cc sent for further studies. Catheter was removed and a pressure dressing was placed.

Specimens: 3 tubes of ascitic fluid for routine studiesEBL: MinimalComplications: None

Have patient lay on right side x2-3hrs, continue pressure bandage for now. Start 25% albumin IV for 40g x1 ASAP. Will await lab results; will reassess once results available.

(If applicable) Attending Physician MD was present/available during the critical elements of the procedure.

INTRODUCTION TO CENTRAL VENOUS CATHETERSJames M. Abraham, MD and Patrick Foy, MD

During your internship and residency, you will hear many different terms for central venous access, i.e. “Hickman”, “Quinton”, “ports”, “triple-lumens”, “IJs”, etc. The key to understanding catheters and their uses is to first understand that they are all just names. When these terms are used generically (as in the examples above), they simply refer to the eponym/brand name, type, size, and functionality of the central venous access. While this jargon may seem overwhelming at first, this basic guide hopefully should help remove some of the mystery.

I. Types of Venous AccessA. Peripheral Venous Access

1. Bedside peripheral IV placement (“PIV”)a. Typically lasts for 3 days, should be changed regularly.b. Used for IV fluids, antibiotics, peripheral parenteral nutrition, chemotherapy, blood products, etc.c. Must be removed prior to discharge.

2. Midline peripheral IV catheters (“Midlines”)a. Lasts for weeks given peripheral placement into a larger (though not central) vein.b. Essentially used for same therapies as a PIV.c. Must be removed prior to discharge.

3. Peripherally-inserted central catheters (“PICCs”)a. Lasts for months to years if working properly.b. Provides central venous access similar to any other central line.c. Used for same therapies as a PIV; can also be used for blood draws and TPN.d. Placed under sterile conditions usually by a designated Vascular Access/PICC team.e. Patients may be discharged with these though this requires an absolute indication as well as specific

arrangements for line care. Most PICCs are discontinued prior to discharge. Alert your Discharge Team/Discharge Coordinator ASAP if venous access may be required after discharge.

B. Central Venous Access1. Tunneled catheters

a. Refers to catheters that are tunneled under the skin prior entering a central vein.i. Hickman catheters (brand name; dual-lumen catheters used for TPN, blood products,

chemotherapy, large-lumen Hickmans can be placed for dialysis/apheresis).ii. Broviac catheters (brand name; similar to Hickmans).

iii. Groshong catheters (brand name; characterized by its valve-ended tip rather than an open-ended tip like all other catheters, requires less frequent line flushing).

b. Tunneled catheters are often referred to by their brand names (Groshong, Hickman, etc.) as this also connotes their functionality.

c. Typically have lesser rates of infection by taking advantage of dual barriers.i. Skin provides a natural barrier to infection.

ii. Dacron cuffs (or similar material) surround the catheter under the skin; this cuff induces fibrin and collagen deposition which stabilizes the catheter in place and provides a second internal barrier against infection.

d. Generally placed by Interventional Radiology in an OR setting.e. Lasts for months to years if working properly.

i. Never pull a tunneled cuffed catheter unless specifically directed or trained to do so. Pulling a cuffed catheter that has been in place for some time can cause significant pain, vessel injury, and soft tissue injury.

ii. If a tunneled catheter must be removed, contact the service (usually Interventional Radiology) that placed it to discuss/arrange removal.

f. Tunneled catheters should only be accessed by certified experienced personnel and only after discussing with the primary service responsible for the access (Nephrology for tunneled dialysis catheters, Hematology/Oncology for tunneled chemotherapy catheters/ports, etc.).

g. Patients may be discharged with these though this requires an absolute indication as well as specific arrangements for line care. Alert your Discharge Team/Discharge Coordinator ASAP if venous access may be required after discharge.

2. Non-tunneled Cathetersa. Placed for short-term central venous access for particular therapies (pressors, aggressive IV fluid

resuscitation, central venous pressure monitoring).b. Can also be placed for short-term hemodialysis/apheresis (Quinton catheters) and hemodynamic

monitoring (Cordis with Swan-Ganz catheter).c. Generally referred to by their site of placement (internal jugular, subclavian, femoral).d. Non-tunneled catheters are uncuffed and provide direct access into the vein; they may be removed at any

time if indicated.e. Traditionally dual- or triple-lumen catheters; mildly increased thrombotic risk with larger lumen catheters

(true for all catheters).

f. Must be removed prior to discharge.

3. Implanted Central Venous Access Catheters (“Ports”, “Port-a-Cath”)a. Ports are tunneled catheters implanted completely under the skin.

i. Must be accessed through the skin with a special Huber needle in order to use.ii. Placed for long-term though relatively infrequent venous access, particularly if treatment will

be >6 months.iii. Can last for years with proper care.

b. Used primarily for weekly/monthly chemotherapy administration.c. Decreased infection and contamination risk given that all portions of the catheter are under the skin.

i. Given the skin barrier, patients may exercise, swim, and perform most activities without risk of contamination unlike tunneled catheters.

d. Usually placed by General Surgery in an OR setting.i. If a port must be removed, contact the service (usually General Surgery) that placed it to

discuss/arrange removal.e. Patients may be discharged with these though this requires an absolute indication as well as specific

arrangements for line care. Alert your Discharge Team/Discharge Coordinator ASAP if venous access may be required after discharge.

II. Clinical PearlsA. Daily Assessment

1. Check all lines (as well as any other devices) for evidence of infection or malfunction daily.a. Poor flushing (clot or impingement)b. Erythema, swelling, tenderness, fevers (infection, local vs. line sepsis)c. Change in external length (catheter fracture or migration)

2. Take steps accordingly, including removing the device if indicated, if any of the above signs are present.

B. Unless there is an absolute indication to keep central venous access in place, TAKE IT OUT.1. Frequent blood draws (relative indication, while inpatient only if absolutely required)2. Long-term chemotherapy3. Long-term IV antibiotics4. Frequent blood product transfusion5. Dialysis/apheresis

Figure 1. The anatomic triangle formed by the clavicle and the two heads of the SCM; arrow indicates insertion point for needle directed towards the ipsilateral nipple.

INTERNAL JUGULAR CENTRAL VENOUS CATHETER PLACEMENTSyed Sohail Ali, MD

Indications

1. Central venous, pulmonary artery, and pulmonary artery wedge pressure monitoring2. Access for hemodialysis/ultrafiltration, fluid resuscitation, pressors, inotropes, etc. that cannot be performed through a peripheral line3. Lack of peripheral access4. Frequent laboratory monitoring (relative)

Contraindications

1. Relative contraindication if severe coagulopathy or platelets <50,000 (unless confirmed to be corrected)2. Suspected superior vena cava injury or DVT3. Distortion of landmarks (consider using ultrasound to identify vessels)4. Patient unable to cooperate/tolerate (relative, consider mild sedation/pain control)

Setup, Materials, and Pertinent Anatomy

Triple lumen central venous catheter kitUltrasound Site-RiteTM with sterile drape kit3 Chloraprep swabsSterile saline flushes (may require 5-10 for flushing)Sterile towels (to extend the sterile workspace)Disposable chucksGauze dressing and tape

1. Obtain patient’s informed consent and have consent available in chart; perform a “time-out” to confirm that this procedure will be performed on the correct site, on the correct patient.

2. Place the patient in trendelenburg position slightly. This will facilitate filling of the internal jugular vein and make it more prominent on ultrasound.

Clearly identify the vessel by ultrasound before proceeding further; the vein should be fairly superficial and easily compressible by the ultrasound probe. Note the spatial relationship to the carotid by visualizing the pulsatile flow and incompressibility on the screen.

3. Identify the sternal and clavicular heads of sternoclediomastoid (SCM) muscle; have the patient laterally flex neck against your hand if the landmarks are not readily apparent (see Figure above).

4. Have the bed moved forward so that you can easily position yourself behind the patient’s head; this position allows for the easiest angle of entry when attempting to cannulate the vein.

5. Sterilize and drape the area per aseptic guidelines; apply maximum barriers to reduce contamination risk (see Introduction).

Procedure

1. Identify all sharps in the kit prior to starting your procedure. Check all syringes to make sure they draw back easily. Make sure to have the guidewire, venous dilator, triple-lumen catheter, and flushes within close reach before starting the

procedure. This will limit hand movement particularly while cannulating the vein and reduce risk of losing your entry point.2. Anesthetize the area per protocol taking care to aspirate before injecting to assure the needle is not in a vessel. If it is, retract the needle

slowly and completely and apply pressure; reassess your placement and try again.3. Have an assistant hold the end of the ultrasound probe and drop it into the sterile probe sleeve. Make sure ultrasound gel is placed in the

bottom of the sleeve inserting the probe. Secure the sleeve with the rubber bands provided; place the now sterile probe on the workspace until needed.

4. Gently flush all ports of triple-lumen catheter with sterile saline to get rid of air; as you are flushing, secure the port clamps to prevent air from reentering.

5. Under ultrasound guidance, insert the finder needle inferior to the junction of two heads of the SCM toward the IJ vein. Advance forward while directing the needle towards the ipsilateral nipple. Maintain an angle of 45 to the skin; the vein should be approximately 2-3 cm below the skin surface.

The ultrasound image does not take the place of monitoring anatomical landmarks, including feeling for the carotid pulse. While the ultrasound image may be appropriate, approaching too medially or inferiorly will increase risk for carotid puncture or other structural damage.

6. Once a flash is obtained, stabilize your hand and check for good withdrawal of venous-appearing blood. Remove the syringe and thread the guidewire through the finder needle (modified Seldinger technique).

The guidewire should pass easily with little resistance. Never force the wire against resistance! This runs the risk of either coiling/irreversibly bending the wire (rendering it unusable) or perforating the vessel.

Heavy resistance against the wire may indicate that it is not in the venous lumen. Readjust the needle position to reestablish blood flow and try again.

Watch the monitor for PVCs while inserting the guidewire; this may occur when the wire is touching inside the right atrium. Pull back slowly and watch for the PVCs to cease.

Make sure to always have the guidewire secured in your hand while it is in the vein! This will prevent migration of the wire as well as reduce the risk of vessel perforation.

If the wire is lost in vein, contact Interventional Radiology immediately as it must be removed emergently.7. Once the wire is in place, remove the finder needle over the wire. Take your scalpel and make a 0.5cm nick in the skin right next to the

wire.8. Thread the venous dilator over the guidewire through the nick in the skin. This will dilate your tract to the vessel. Expect an increase in

bleeding once you have dilated the tract. Remove the dilator while leaving the wire in place. If there is significant resistance to inserting the dilator, try making your skin nick a little bigger. The dilator only needs to go in approximately 2-3cm; do not completely insert the dilator as this can cause severe vessel

injury.9. Open the brown port of the triple-lumen catheter (blue port in Quinton catheters) and thread the catheter over the guidewire until the

guidewire appears through the open port. Continue advancing the catheter to the desired depth and then remove the guidewire.10. Attach the sterile saline syringe to the brown port. Withdraw slightly to check the flow of blood. Once the flash is obtained flush forward

until the lumen runs clear. Flush the remaining two ports until they run clear. Make sure to unclamp the ports before flushing to prevent damage to the catheter. Clamp the ports immediately after flushing to reduce risk of air embolism; replace the port caps.

11. Suture the catheter in place per protocol and apply a clean dressing after cleansing the area to reduce infection risk.12. Obtain a STAT chest X-Ray to assess catheter placement. Ideal placement in mid-SVC or just superior to the SVC/right atrial junction.

Common Problems and Post-Procedural Complications

Carotid artery puncture Check blood return for bright red color and pulsatile flow. Pull the needle back slowly and apply firm pressure to the area for

10-15 minutes until bleeding has stopped.

Pneumothorax These tend to occur more often with subclavian catheter placements. Obtain a STAT chest X-Ray after catheter placement;

consider repeating if the patient becomes acutely short of breath, hypotensive, or drops his oxygen saturation.

Hematoma Can occur with multiple punctures, coagulopathy, or arterial/venous vessel disruption. Apply firm pressure to the area until

bleeding stops. If there is any indication of airway compromise from the hematoma, contact Surgery immediately for possible evacuation.

Thrombosis and superficial/line infection Can occur with inadequate flushing or in a catheter that has been in place for a long time. Monitor lines daily for these

complications which may require the line to be removed.

Air embolism Make sure all ports are flushed and clamped when not in use to reduce risk of air embolism, including during placement.

Catheter migration Ensure the line is sutured securely and dressed appropriately to prevent this complication.

References

1 Sauer W. Luft D. Risler T. Renn W. Eggstein M. Significance of ultrasonics in the placement of a central venous catheter. Deutsche Medizinische Wochenschrift. 113(37):1423-7, 1988 Sep 16.

2 McGee WT. Ackerman BL. Rouben LR. Prasad VM. Bandi V. Mallory DL. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Critical Care Medicine. 21(8):1118-23, 1993 Aug.

3 Moretti EW. Ofstead CL. Kristy RM. Wetzler HP. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. Journal of Hospital Infection. 61(2):139-45, 2005 Oct.

4 Deshpande KS. Hatem C. Ulrich HL. Currie BP. Aldrich TK. Bryan-Brown CW. Kvetan V. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Critical Care Medicine. 33(1):13-20; discussion 234-5, 2005 Jan.

FEMORAL CENTRAL VENOUS CATHETER PLACEMENTHaresh Kumar, MD

Indications

1. Central venous pressure monitoring2. Access for hemodialysis/ultrafiltration, fluid resuscitation, pressors, inotropes, etc. that cannot be performed through a peripheral line3. Lack of peripheral access4. Frequent laboratory monitoring (relative)

Contraindications

1. Relative contraindication if severe coagulopathy or platelets <50,000 (unless confirmed to be corrected)2. Suspected/known recent femoral vein injury or superficial femoral vein thrombus3. Distortion of landmarks (consider using ultrasound to identify vessels)4. Patient unable to cooperate/tolerate (relative, consider mild sedation/pain control)


Triple lumen central venous catheter kitUltrasound Site-RiteTM with sterile drape kit (if necessary)3 Chloraprep swabsSterile saline flushes (may require 5-10 for flushing)Sterile towels (to extend the sterile workspace)Disposable chucksGauze dressing and tape


2. Place the patient in reverse trendelenburg position slightly. This may facilitate filling of the femoral vein and make it more prominent on ultrasound.

Locate the femoral artery (usually just inferior to the inguinal ligament’s midpoint); the femoral vein lies medially to the femoral pulse.

Use the femoral pulse as a guide during the procedure; consider placing your fingers along the pulse as a point of reference.3. Sterilize and drape the area per aseptic guidelines (see Introduction); apply maximum barriers to reduce contamination risk.

Procedure

1. Identify all sharps in the kit prior to starting your procedure. Check all syringes to make sure they draw back easily. Make sure to have the guidewire, venous dilator, triple-lumen catheter, and flushes within close reach before starting the

procedure. This will limit hand movement particularly while cannulating the vein and reduce the risk of losing your entry point.

2. Anesthetize the area per protocol taking care to aspirate before injecting to assure the needle is not in a vessel. If it is, retract the needle slowly and completely and apply pressure; reassess your placement and try again.

3. Have an assistant hold the end of the ultrasound probe and drop it into the sterile probe sleeve. Make sure ultrasound gel is placed in the bottom of the sleeve inserting the probe. Secure the sleeve with the rubber bands provided; place the now sterile probe on the workspace until needed.

4. Gently flush all ports of triple-lumen catheter with sterile saline to get rid of air; as you are flushing, secure the port clamps to prevent air from reentering.

5. Insert the needle approximately 1cm medial to the femoral pulse and 1-3cm below the inguinal ligament. Aim toward the umbilicus while holding the needle at a 45 angle; the femoral vein is usually cannulated at 2-4cm of depth.

Be careful not to puncture above the level of the inguinal ligament; this can result in peritoneal perforation or inadvertent disruption of the pelvic vessels.

6. Once a flash is obtained, stabilize your hand and check for good withdrawal of venous-appearing blood. Remove the syringe and thread the guidewire through the finder needle (modified Seldinger technique).

The guidewire should pass easily with little resistance. Never force the wire against resistance! This runs the risk of either coiling/irreversibly bending the wire (rendering it unusable) or perforating the vessel.

Heavy resistance against the wire may indicate that it is not in the venous lumen. Readjust the needle position to reestablish blood flow and try again.

Make sure to always have the guidewire secured in your hand while it is in the vein! This will prevent migration of the wire as well as reduce the risk of vessel perforation.

If the wire is lost in vein, contact Interventional Radiology immediately as it must be removed emergently.7. Once the wire is in place, remove the finder needle over the wire. Take your scalpel and make a 0.5cm nick in the skin right next to the

wire.8. Thread the venous dilator over the guidewire through the nick in the skin. This will dilate your tract to the vessel. Expect an increase in

bleeding once you have dilated the tract. Remove the dilator while leaving the wire in place. If there is significant resistance to inserting the dilator, try making your skin nick a little bigger. The dilator only needs to go in approximately 2-3cm; do not completely insert the dilator as this can cause severe vessel

injury.

9. Open the brown port of the triple-lumen catheter (blue port in Quinton catheters) and thread the catheter over the guidewire until the guidewire appears through the open port. Continue advancing the catheter to the desired depth and then remove the guidewire.

10. Attach the sterile saline syringe to the brown port. Withdraw slightly to check the flow of blood. Once the flash is obtained flush forward until the lumen runs clear. Flush the remaining two ports until they run clear.

Make sure to unclamp the ports before flushing to prevent damage to the catheter. Clamp the ports immediately after flushing to reduce risk of air embolism; replace the port caps.

11. Suture the catheter in place per protocol and apply a clean dressing after cleansing the area to reduce infection risk.


Femoral artery puncture Check blood return for bright red color and pulsatile flow. Pull the needle back slowly and apply firm pressure to the area for

10-15 minutes until bleeding has stopped.

Hematoma Can occur with multiple punctures, coagulopathy, or arterial/venous vessel disruption. Apply firm pressure to the area until

bleeding has stopped.

Thrombosis and superficial/line infection Can occur with inadequate flushing or in a catheter that has been in place for a long time. Monitor lines daily for these

complications which may require the line to be removed.

Air embolism Make sure all ports are flushed and clamped when not in use to reduce risk of air embolism, including during placement.

Catheter migration Ensure the line is sutured securely and dressed appropriately to prevent this complication.

References

1 McGee WT. Ackerman BL. Rouben LR. Prasad VM. Bandi V. Mallory DL. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Critical Care Medicine. 21(8):1118-23, 1993 Aug.

2 Moretti EW. Ofstead CL. Kristy RM. Wetzler HP. Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia. Journal of Hospital Infection. 61(2):139-45, 2005 Oct.

3 Deshpande KS. Hatem C. Ulrich HL. Currie BP. Aldrich TK. Bryan-Brown CW. Kvetan V. The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population. Critical Care Medicine. 33(1):13-20; discussion 234-5, 2005 Jan.

ARTERIAL LINE PLACEMENTJoEllen Kohlman, MD

Indications

1. Need for close blood pressure monitoring (pressors, CHF decompensation, sepsis)2. Access to arterial blood (frequent ABGs)

Contraindications

1. Severe coagulopathy or platelet count <50,000 (unless confirmed to be corrected)2. Poor collateral circulation at proposed site (check Allen’s test)


Arterial line insertion kitChloraprep swabsDisposable chucksArterial line monitoring equipment (talk to RN to have ready)Ultrasound Site-RiteTM with sterile drape kit (if necessary)Pulse doppler (if necessary)


2. The arrow in the figure above denotes the radial artery. Perform the Allen’s test to confirm adequate collateral flow from the ulnar artery (occluding both the radial and ulnar artery until

the hand turns white, then releasing the ulnar artery to see if color returns in less than 7 seconds). If poor collateral flow (from arterial thrombus or PVD), consider using the other arm. Other sites of arterial access include

brachial, femoral, axillary, and dorsalis pedis.3. Flush the arterial line tubing with normal saline to reduce the risk of air embolism during placement.

Procedure

1. Restrain the patient’s arm palm up with the wrist in dorsiflexion by placing a rolled towel under the wrist. Make sure the blood pressure cuff is placed on the contralateral arm so it does not impede blood flow while placing the line.

2. Sterilize and drape the area per proper aseptic technique (see Introduction) and then adequately anesthetize the puncture site.3. Hold an 18 or 20 gauge needle like a pencil and puncture skin with needle bevel up at a 30-degree angle. If you are having difficulty

palpating the radial artery, use your index and middle finger to locate the artery by starting medially and slowly moving laterally until you feel the pulse.

If you are having difficulty finding the radial artery, consider using ultrasound or doppler to visualize the artery.4. Use other hand to palpate arterial pulse and then advance needle until a flash is obtained; once the flash is obtained slowly advance the soft

catheter while removing the stylet. There are often two catheters in each arterial line kit; make sure to use the longer catheter when possible. Arterial lines can also be placed via guidewire, similar to central line placement. Use whichever method is more comfortable or

easiest for you.5. Once the line is placed, hook up the flushed arterial line transducer tubing to the catheter tip. Evaluate your waveform to ensure an accurate

reading (see example below).

6. Secure your line to the skin with the suture provided.


Radial nerve injury Can occur with prolonged or forceful dorsiflexion of the wrist; limit the time spent in this position.

Superficial hematoma and wound infection Usually self-limited complications that require supportive care and antibiotics if concern for skin infection. Apply pressure to

the area if a hematoma develops given the arterial placement.

Difficulty locating pulse and vasospasm This can be made more difficult in a hypotensive patient or when pressors have been started as these cause the vessels to

constrict. Consider using doppler or ultrasound to visualize the artery; you may also want to consider placing the line via guidewire to

ensure stable access during the procedure. If the patient is severely hypotensive and you cannot place the line, you may need to volume resuscitate the patient more before

attempting again.

References

1 Shiver S. Blaivas M. Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Academic Emergency Medicine. 13(12):1275-9, 2006 Dec.

2 Chowet AL. Lopez JR. Brock-Utne JG. Jaffe RA. Wrist hyperextension leads to median nerve conduction block: implications for intra-arterial catheter placement. Anesthesiology. 100(2):287-91,2004 Feb.

Iliac crests

LUMBAR PUNCTUREKatherine Marienfeld, MD

Indications

1. CSF analysis to evaluate for subarachnoid hemorrhage, meningitis, etc.2. To evaluate for elevated ICP3. To drain CSF (such as in pseudotumor cerebri)4. For spinal anesthesia or to inject medications (i.e. chemo)

Contraindications

1. Relative contraindication if patient with coagulation defect or platelets <50,0002. Presence of intracranial mass3. Skin infection overlying area where LP is to be performed


Lumbar puncture kit3 Chloraprep swabsDisposable chucks4 Patient labels/stickers (collection date/time, initials)


2. Check the patient’s most recent labs, particularly CBCs and coagulation studies. Platelet count: Usually should be greater than 50,000 for any procedure to reduce bleeding risk. INR: Should be corrected with FFP if 2-3 times the normal limit to reduce bleeding risk.

3. If there is suspicion for increased ICP from an intracranial bleed or mass lesion (focal neurologic signs, papilledema, etc.), a Head CT should be performed prior to attempting the LP.

4. Arrange patient in appropriate position for lumbar puncture. The most common position entails that the patient be in a lateral recumbent position with both the knees and head flexed.

Placing a pillow under the head and between the knees can help keep the patient comfortable and the spine in one plane. If ICP measurement is required, it must be done in this position.

LP can also be performed with the patient sitting on the bed leaning onto a tray table with their back rounded. Often it is helpful to have an assistant help position/hold patient in place during the procedure to keep the spine aligned in one

plane.5. Identify your landmarks; palpate the superior iliac crests and “draw” a mental line between these points (this will be at about the L3/L4

interspace). Since the cord usually ends around L1/L2, entering below this site (L3/L4, L4/L5, L5/S1) reduces risk of spinal cord injury. Mark the planned entry site with a pen prior to sterilizing the area.

6. Use proper aseptic technique and barriers to prepare the procedure area and to reduce risk of contamination (see Introduction).

Procedure

1. Drape and anesthetize the entry site observing aseptic technique. Set up the manometer with the 3-way valve if planning to evaluate ICP.2. With the stylet in place, insert needle where mark was made. Make sure the beveled edge is facing upward (parallel to the long axis of the

spine, which helps separate the longitudinal dural fibers with less trauma).3. Advance needle slowly aiming slightly towards the head (in infants)/navel (in adults), and when you feel a “pop” (the sensation when the

needle pierces through the dura) withdraw the stylet watching for fluid (usually about 1.5 to 2 inch insertion). You may not feel a “pop” in all cases. If no fluid is visible in the needle hub, rotate the needle slightly. Otherwise, reinsert the

stylet and advance slightly.4. Continue this series of steps until fluid is visible or you feel you’ve gone too far. If you’ve gone too far, put the stylet back in and withdraw

the needle. Start again with a spare LP needle.5. If you feel that the needle has hit bone, pull the needle back a few centimeters to redirect and advance again. In elderly patients with

degenerative joint or disc disease, oftentimes the interspaces are quite small. Be aware of this before proceeding; if unable to obtain fluid consider a CT/fluoroscopy-guided procedure by Interventional Radiology.

If you are checking opening pressure make sure the manometer is set up and within reach. When you first see fluid in the needle hub, immediately attach the manometer to the end of the needle. Let fluid enter the manometer tube until it reaches a steady level and record that number (the level will rise and fall slightly with respiration).

To collect the fluid after using the manometer, simply twist the 3-way stopcock off to the patient and open to the side port. Collect 3-4 cc of fluid out of the manometer tube via the 3-way stopcock into each of 4 LP collection tubes

6. To collect the fluid without using the manometer, hold a collection tube just under the needle and let 3-4 cc of fluid drip into the tube. Repeat for a total of 4 tubes. If a number of studies are needed, up to 40cc of fluid can be removed at one time.

7. Once all fluid is collected, replace the stylet making sure the bevel is facing upward (parallel to the long axis of the spine) and withdraw the needle.

8. Carefully discard sharps and place a band-aid over the site; have the patient lay flat for at least 3-4 hours following the procedure to help reduce risk of spinal headache.


Spinal headache Usually occurs because of slightly reduced ICP following lumbar puncture. Having the patient lay flat for 3-4 hours after the LP may reduce the incidence though the literature is equivocal. Caffeine has

been used as a treatment for spinal headache but the efficacy is questionable. Spinal headaches are usually self-limited; treat with appropriate pain control as indicated.

Nerve root trauma Seen more often in patients with pre-existing scar tissue or previous spinal surgeries. Treat with appropriate pain control as indicated.

Subdural/subarachnoid bleed and hematoma Seen more often in patients with an underlying coagulopathy; treatment depends on the complication. Check CBC and coagulation studies prior to performing the procedure; correct abnormalities as indicated.

Meningitis (introduced) Observe proper aseptic technique to reduce contamination risk.

Herniation If there is any suspicion for increased intracranial pressure (focal neurologic signs, papilledema, etc.), obtain a Head CT prior to

attempting the LP.

Common Studies

Typical studies obtained for a diagnostic lumbar puncture include:

Tube #1: Cell count and differential Tube #2: Gram stain and culture Tube #3: Protein and glucose Tube #4: Hold for further studies

It is imperative that a tube be saved for studies to be ordered later, especially if the clinical picture or differential diagnosis changes. Studies that are often obtained after the initial procedure include: Cryptococcal antigen, bands, HSV, VDRL, cytology, etc. If you are concerned about a possible subarachnoid hemorrhage, obtain cell counts on both Tube #1 and Tube #4; if a hemorrhage is not present the RBC counts should decrease significantly from Tube #1 to Tube #4.

References

1 Lin et al. The Washington Manual. 2001

2 Waldman, Arthur. “Lumbar Puncture (CSF Examination).” eMedicine.com 2005

3 Johnson K and Sexton D. “Lumbar puncture: Technique; indications; contraindications; and complications in adults.” UpToDate.com 2005

4 Van de Beek et al. “Community-Acquired Bacterial Meningitis in Adults.” NEJM. Jan 5, 2006

5 Suarez et al. “Aneurysmal Subarachnoid Hemorrhage.” NEJM. Jan 26, 2006

BEDSIDE PARACENTESISJames M. Abraham, MD

Indications

1. Evaluation of new-onset ascites2. Evaluation of ascites of known etiology in the setting of acute decompensation3. Therapeutic drainage of large-volume or diuretic-resistant ascites

Contraindications

1. Relative contraindication if severe coagulopathy or platelets <50,000 (unless confirmed to be corrected)2. Multiple previous abdominal surgeries or previous intra-abdominal infections with adhesions(consider ultrasound-guided approach)3. Morbid obesity or hepatosplenomegaly (consider ultrasound-guided approach)4. Severe bowel distention5. Superficial cellulitis at proposed point of entry6. Inability of patient to cooperate with procedure


Combination Paracentesis/Thoracentesis kit (includes 1L cytology bag if needed)3 Chloraprep swabsDisposable chucks1L vacuum bottles (number needed based on expected drainage)4 Patient labels/stickers (collection date/time, initials)Foam tape (for pressure dressing)Ultrasound Site-RiteTM with sterile drape kit (if necessary)


2. Check the patient’s most recent labs, particularly CBCs and coagulation studies.1, 2

Platelet count: Usually should be greater than 50,000 for any procedure to reduce bleeding risk. INR: Should be corrected with FFP if 2-3 times the normal limit to reduce bleeding risk.

3. Perform a careful abdominal exam and mark your intended site prior to sterilizing the area. Be sure that you feel for an enlarged or low-lying liver and spleen as these may interfere with your site and increase risk of

significant bleeding. Preferred sites for paracentesis are below the lateral edge of the rectus muscles in the lower abdominal quadrants bilaterally.

This minimizes difficulty introducing the needle and usually offers the safest point of entry below the liver and spleen. If only a small amount of ascites is present or the patient has a complicated abdomen (multiple previous abdominal surgeries

with adhesions, multiple surgical scars, morbid obesity, loculated ascites), you may contact Radiology to mark the site by ultrasound. The patient must remain in the same position after the site is marked; paracentesis must be performed ASAP following marking to reduce risk of losing site and orientation due to patient movement or fluid shifts.

4. Make the work area as comfortable for yourself as possible, i.e. good lighting, elevate bed to a comfortable height, secure a work area and trash receptacle within easy reach to minimize movements during the procedure.

Place a pillow underneath the patient on the side opposite your intended puncture site tilting the patient toward you. Viscous bowel floats in fluid and, unless adhered to peritoneum from inflammation or scar tissue from previous surgery, should float away from the puncture site.

Consider using ultrasound to mark the site of entry if there is difficulty identifying an appropriate entry point by exam. Given literature that demonstrates a decrease in complications, using ultrasound to ensure proper entry may be recommended.

5. Prepare the area following proper aseptic technique (see Introduction); apply maximum barriers (sterile gloves/gown, face shield) to help reduce contamination risk.

Procedure

1. Identify all sharps in the kit prior to starting your procedure. Check all syringes to make sure they draw back easily.2. Anesthetize the area per protocol taking care to aspirate before injecting to assure the needle is not in a vessel. If it is, retract the needle

slowly and completely and apply pressure; reassess your placement and try again.3. After anesthetizing the area, take your scalpel and insert it approximately 0.5cm to create an opening for your catheter.4. Gently advance your catheter with the finder needle in place through the tract you have created. Make sure to slowly aspirate continuously

as you advance to make sure you are not entering a vessel; do NOT remove the syringe or flush forward as this can introduce air into the peritoneum.

5. Once the catheter is advanced to the black line, begin to advance the soft catheter OVER the finder needle in tandem; advance the soft catheter as far as it will go WITHOUT advancing the needle. Once the needle is retracted you will no longer be able to advance the soft catheter.

6. Once your soft catheter is in place, fill your 60cc syringe with ascites first. Use this to fill your specimen bottles. If only performing a diagnostic paracentesis, you may retract your catheter while covering the site and place a pressure dressing over the wound.

7. If you are performing a therapeutic paracentesis, connect the stopcock portion of the soft catheter to the vacuum tubing. With the stopcock turned to OFF, place the vacuum tubing needle into the vacuum bottle. Once secured, turn the stopcock to ON and let the bottle fill.

If you are not getting adequate flow, slowly twist the soft catheter until flow is restored.

As more fluid is obtained, the bowel may move forward and occlude the catheter. You may gently pull back the catheter to restore flow remembering that the catheter cannot be advanced again.

Turn the stopcock to OFF prior to changing vacuum bottles and hold the tubing upward to prevent spraying/leakage. Turn the flow back on once the tubing is secured into the new vacuum bottle.

8. Once a safe amount of ascites has been obtained or flow cannot be restored, slowly remove the soft catheter and apply pressure to the puncture site. Apply a pressure dressing to the wound and keep the patient turned onto the side opposite the puncture to reduce pressure on the forming clot.


Hypotension If performing/expecting a large-volume paracentesis (>5L), the patient should be intravascularly replaced with 8 grams of 25%

albumin solution per liter removed to reduce risk of post-paracentesis circulatory dysfunction.3, 4

Peritonitis (from introduced air, introduced infection, and bowel perforation) A common cause of free air and peritonitis following paracentesis is introduced air from catheter insertion or removal; this is

usually self-limited and resolves with time. If there are any symptoms of perforation (fever, elevated WBC count, hypotension, worsening pain, patient appears clinically ill), start the work-up for bowel perforation immediately.

If suspicion for perforation or peritonitis, obtain a STAT abdominal X-ray to evaluate for the presence of free air. If clinical suspicion is high for bowel perforation and X-ray is inconclusive, obtain a STAT CT abdomen without PO contrast

and contact General Surgery immediately. Start antibiotics immediately if there is any concern for introduced infection or bowel perforation.

Hemorrhage Usually occurs in the setting of coagulopathy though can also occur following traumatic paracentesis. Reverse the reversible (giving FFP and Vitamin K for elevated INR), replace the replaceable (giving PRBCs and IV fluid

for significant anemia and hypotension).

Wound dehiscence and persistent leakage Lay the patient on the side opposite the puncture site for 2-6 hours to reduce pressure on the wound and clot disruption. If leakage persists, a simple stitch can be placed to close the wound though closure usually occurs with conservative

management and time.

Superficial hematoma and wound infection Usually self-limited complications that require supportive care and antibiotics if concern for skin infection.

Common Studies

Typical studies obtained for a diagnostic paracentesis include: Tube #1: Cell count and differential Tube #2: Gram stain and culture Tube #3: LDH, albumin, glucose (serum-to-ascites albumin gradient is the most helpful) Tube #4 (if available): Held for further studies

Depending on appearance or differential diagnosis, other peritoneal fluid studies include amylase (poor study though may help assess if pancreatic in origin), cytology (sent in 1 liter cytology bag if concern for malignant ascites), and triglycerides (evaluation for chylous ascites).

Works Cited

1 Moore KP. Wong F. Gines P. Bernardi M. Ochs A. Salerno F. Angeli P. Porayko M. Moreau R. Garcia-Tsao G. Jimenez W. Planas R. Arroyo V. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology. 38(1):258-66, 2003 Jul.

2 McVay PA. Toy PT. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion. 31(2):164-71, 1991 Feb.

3 Sola-Vera J. Minana J. Ricart E. Planella M. Gonzalez B. Torras X. Rodriguez J. Such J. Pascual S. Soriano G. Perez-Mateo M. Guarner C. Randomized trial comparing albumin and saline in the prevention of paracentesis-induced circulatory dysfunction in cirrhotic patients with ascites. Hepatology. 37(5):1147-53, 2003 May.

4 Choudhury J, Sanyal AJ. Treatment of ascites. Curr Treat Options Gastroenterol. 6(6):481-91, 2003 Dec.

BEDSIDE THORACENTESISBasel Al-Aloul, MD

Indications

1. Diagnostic evaluation of pleural effusions of unknown etiology2. Therapeutic drainage of recurrent pleural effusions

Contraindications

1. Relative contraindication if severe coagulopathy or platelets <50,000 (unless confirmed to be corrected)2. Known bullous disease at site of insertion (relative)3. Patient on positive end-expiratory pressure/mechanical ventilation (relative)4. Known loculated pleural effusion (consider ultrasound or CT-guided approach)5. Superficial cellulitis at point of entry6. Inability of patient to cooperate with procedure


Thoracentesis/Paracentesis kit3 Chloraprep swabsDisposable chucksVaseline gauzeGauze padsFoam tape4 Patient labels/stickers (collection date/time, initials)Ultrasound Site-RiteTM with sterile drape kit (if necessary)


2. Perform a physical exam to localize the pleural effusion; also obtain a chest X-Ray to confirm your findings. Position the patient in a sitting position leaning forward over a tray table before performing your physical exam. Examine the patient’s chest by auscultation and percussion. Use percussion to locate the upper border of the effusion

(effusions,.consolidation, and masses sound dull to percussion). Mark 1-2 intercostal spaces below the upper border of the effusion as your entry point.

Always enter through the superior portion of the rib immediately below your chosen intercostal space. Remember, the intercostal neurovascular bundle runs along the inferior portion of each rib.

Consider using ultrasound to mark the site of entry if there is difficulty identifying an appropriate entry point by exam. Given literature that demonstrates a decrease in complications, using ultrasound to ensure entry into the effusion may be recommended.

If there is any concern for a mass causing the findings and the chest X-Ray is inconclusive, consider ordering a chest CT to better evaluate before attempting thoracentesis.

3. The ideal point of entry should be in the posterior thorax 6-7cm from the spine. Enter 1-2 intercostal spaces below the upper limit of the pleural effusion; make sure to enter over the superior portion of the rib so as to avoid the intercostal neurovascular bundle.

4. Sterilize and drape the area per aseptic guidelines as well as applying appropriate sterile barriers.

Procedure

1. Anesthetize the area per protocol taking care to aspirate periodically during insertion to ensure the needle is not in a vessel. Once the tract is anesthetized, continue to inject lidocaine into the intercostal muscle as the syringe is withdrawn.

2. Once the area is anesthetized, make a small incision through the skin with the scalpel provided to ease insertion of the needle/catheter apparatus.

3. With negative pressure applied to the syringe, advance the needle slowly over the top of the rib into the pleural cavity until fluid is returned.4. Aspiration of air bubbles may indicate puncture of the lung parenchyma; if this is seen the needle should be slowly removed under negative

pressure.5. Once the needle is in the pleural space, advance the catheter over the needle toward the diaphragm. Care should be taken not to advance the

needle during this step.6. Attach the drainage bag assembly to the stopcock to remove the pleural fluid.

For a diagnostic tap, 20-40cc of fluid should be sufficient. For a therapeutic tap, generally you can remove 1-1.5L of fluid before stopping. Removing more than this places the patient at

risk for developing pulmonary edema from the abrupt re-expansion of the lung. If at any time the patient complains of shortness of breath or starts coughing, stop withdrawing fluid immediately.

7. To remove the catheter, instruct the patient to expire forcefully to compress the lung and reduce risk of lung injury during removal. As the patient expires, quickly withdraw the catheter taking care to immediately occlude the entry site with Vaseline gauze.

8. Secure the Vaseline dressing with foam tape and obtain a chest X-Ray to evaluate for resolution of the pleural effusion and post-procedural pneumothorax.


Pneumothorax and hemothorax

Pneumothorax is a common complication following thoracentesis, often from introduced air. Pneumothoraces of 10-20% often are self-limited, however if larger or any evidence of hemodynamic compromise, place a chest tube immediately.

Hemothorax can occur in case of lung parenchymal injury during thoracentesis or intrusion into the intercostal vessels (particularly in the face of coagulopathy). Correct any coagulation abnormalities and place a chest tube immediately if indicated.

Neurovascular bundle injury Can occur with insertion through the inferior portion of the rib. Vessel rupture can result in a hemothorax, nerve injury can result intercostal neuritis/neuralgia.

Liver/spleen laceration These tend to occur when attempting to tap small pleural effusions; consider US/CT-guided approach instead.

Tumor seeding This can be seen with malignant effusions, particularly mesotheliomas.

Common Studies

Typical studies obtained for a diagnostic thoracentesis include: Tube #1: Cell count and differential Tube #2: Gram stain and culture Tube #3: LDH, albumin, glucose, pH (poor study, sample must be sent on ice) Tube #4 (if available): Held for further studies

Depending on appearance or the differential diagnoses, other pleural fluid studies include AFB stain/cultures, ANA, RF, amylase, lipase, cytology (sent in cytology bag), etc.

References

1 Mathew G. Mutch, Brent T. Allen. Common Surgical Procedures. The Washington Manual of Surgery. Second Edition. Lippincott Williams and Ailkins.

2 Mason: Murray & Nadel's. Textbook of Respiratory Medicine. Fourth Edition. Saunders.

3 Grogan DR. Irwin RS. Channick R. Raptopoulos V. Curley FJ. Bartter T. Corwin RW. Complications associated with thoracentesis. A prospective, randomized study comparing three different methods. Archives of Internal Medicine. 150(4):873-7, 1990 Apr.

4 Jones PW. Moyers JP. Rogers JT. Rodriguez RM. Lee YC. Light RW. Ultrasound-guided thoracentesis: is it a safer method? Chest. 123(2):418-23, 2003 Feb.

CREDITS

Front row (left to right): JoEllen Kohlman, Katherine Marienfeld, Patrick Foy, Haresh KumarBack row (left to right): Syed Sohail Ali, James Abraham, Basel Al-Aloul

The authors would like to thank several key people for their support during the development of this handbook. First and foremost, we would like to thank Dr. Paula Skarda and Dr. Kelly Frisch of Healthpartners Specialty Clinic/Regions Hospital, St. Paul, MN and Dr. Wesley Miller of the University of Minnesota Medical School for their constant encouragement and willingness to help us navigate the publication process. We would also like to thank Dr. Eric Korbach, Dr. Alain Broccard, and Dr. Avi Nahum of the Department of Pulmonology/Critical Care at Regions Hospital for their thoughtful review of our final manuscript. We hope that as a result of each of our colleagues’ advice and involvement, this manuscript can be used as an educational tool on the Medicine wards for years to come.

introduction to inpatient procedures - fastly · web viewthis handbook will serve to teach six of...

Documents