Termination of pregnancy (TOP) Patients are referred by GPs or family planning centers. Fut ure contraception should be discussed. Methods medical (<9wk) mifepristone 600mg PO, then 1 mg gemeprost PV 36 \200\22348h later; surgical dilatation and evacuation or vacuum aspirati on. Complications hemorrhage, infection, retained products of conception, uterine perforati on, feelings of guilt, depression. _OHFP.indb 503 _OHFP.indb 503 30/05/2014 16:18 30/05/2014 16:18 504 CHAPTER 15 Emergency department Later pregnancy (2nd/3rd trimester) Table 15.23 Normal ranges in later pregnancy Parameter Range Parameter Range Haematocrit Hemoglobin WCC Platelets ESR Fibrinogen No change 95 \200\223150g/L 5 \200\22316 x 109/l 150 \200\223400 x 109/l 44 \200\223114mm/h 3000 \200\2236200mg/L Albumin Urea Creatinine PaO2 PaCO2 HCO \200\223 3 25 \200\22340g/l 1.6 \200\2236mmol/l 35 \200\22375 mol/l 11.0 \200\22314.0kPa 3.6 \200\223 4.2kPa 18 \200\22323mmol/l Hypertension in pregnancy1 (BP >140/90mmHg) Hypertension occurs in up to 20% of pregnancies ; 90% will be associated with known chronic hypertension, but some women will develop newly iBP, typi- cally after 20/40 gestation (pregnancy-induced or gestational). Pre-eclampsia i s hypertension with development of proteinuria (>0.3g/24h) and may develop from \211 20/40 gestation until 6wk post-partum. Risk factors for pre-eclampsia <18yr or >35yr, fi rst pre gnancy, BMI >30, chronic iBP, DM, SLE, thrombophilia, PMH or FH pre-eclampsia. Symptoms usu ally asymptomatic, headache, vomiting, visual disturbance. Signs evaluate for signs of 2 causes of iBP (b p263) or end-organ damage (b p265); pre-eclampsia: RUQ tenderness, oedema, papilloedema, hyper refl exia, clonus. Investigations urine M,C+S, 24h collection for prot ein (essential if dipstick \211 2+ protein); blds in chronic hypertension ensure secondary causes of hypertension excluded (b p263) and recent screening for baseline evidence of end -organ damage (b p265); if suspect pre-eclampsia: FBC (plts <100 109/l suggests pre-ecla mpsia, ITP or HELLP), U+E, iurate (sensitive but not specifi c for renal damage), LFT, clot ting (for DIC, b p405), G+S. See Table 15.23. Assess the fetus USS (fetus growth, size, pre sentation, liquor volume, fetal movements), umbilical artery Doppler, CTG. Management hyper tension stop any existing treatment with ACEi, ARB or chlorothiazide and refer to antenatal medical clinic for monitoring antihy- pertensive therapy; options include labetalol or Ca2+-channel antagonists; if suspect pre-eclampsia admit treat with IV hydralazine or lab etalol and MgSO4; consider expediting delivery. 3Eclampsia New onset tonic-clonic seizures or unexplained coma during pregnancy or postpartum; usually develops on background of pre-e clampsia. Signs and symptoms headache, hyperrefl exia, clonus, oedema, seizures Management 3Obstetric crash call move into left lateral position, protect airway, 15l/min O2, IV acces s (FBC, U+E, LFT, clotting, G+S), check BP, check glucose; MgSO4 4g over 20min IV, then mai ntenance dose of 2g/h IV; if diastolic >110mmHg give hydralazine or labetalol IV (b p266). Once stabilized, establish close fetal monitoring and consider urgent delivery. After deliv ery treat BP >160/110mmHg (b p266), strict fl uid balance, monitor FBC, U+E, LFT, observe f or \211 5d. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG107 OHFP.indb 504 OHFP.indb 504 30/05/2014 16:18 30/05/2014 16:18 505 LATER PREGNANCY (2ND/3RD TRIMESTER) 3HELLP (Haemolysis, Elevated liver enzymes, Low Platelets) Develops in 10% of cases of seve re pre-eclampsia. Symptoms upper abdominal pain, headache, malaise, vomiting. Signs RUQ ten derness, oedema, iBP. Results dHb, ibilirubin, iALT, dplts, proteinuria. Management resusci tate, FFP/plts/blood transfusion, urgent delivery. Complications DIC, hemorrhage (brain, li ver), eclampsia. Gestational diabetes mellitus (see also b p328) Any degree of glucose into lerance fi rst detected during pregnancy. Screening although some advocate universal screen ing, current NICE guid- ance1,2 is to off er a 2h 75g oral glucose tolerance test (OGTT) at booking to women with: previous gestational DM or baby >4.5kg, BMI >30, 1st-degree relativ e with DM, South Asian, black Caribbean or Middle Eastern ethnicity. Symptoms often asympto matic, glucose on urine dipstick. Signs large for dates, polyhydramnios. Investigations bld s plasma glucose \211 7.8mmol/l after OGTT (b p328); self- monitoring of capillary blood g lucose; regular USS to assess fetal growth. Treatment diet changes and exercise will achiev e good glycaemic control in 80%; start insulin or oral hypoglycaemics after 1 \200\2232wk i f this fails; stop treat- ment after birth and repeat OGTT at 6wk. Complications congenital abnormalities, stillbirth, pre-eclampsia, poly- hydramnios, large baby, traumatic delivery ; neonate birth injury (eg shoulder dystocia, brachial plexus trauma), respiratory distress syndrome, poly- cythaemia, hypoglycaemia, jaundice. 3Antepartum hemorrhage Vaginal bleedin g after 24/40 gestation. Causes placenta praevia, placental abruption; gynae causes see b p 486. Severe bleeding call senior help; lay fl at and elevate legs; O2 (15l/min); secure 2 l arge bore IV cannulae (take blood for FBC, clotting, G+S), 1l 0.9% saline STAT; urgent bloo d (O-negative, type specifi c, or full X-match, b p400); consider urgent delivery. Mild ble eding admit, IV access (FBC, clotting, G+S), monitor HR and BP, PV only if placental site k nown; USS; consider anti-D (b p502). Anemia in pregnancy Screening checked FBC at 12, 28 an d 36wk, treat if Hb <110g/L. Treatment ferrous sulfate 200mg/24h PO and folic acid 0.4mg/24 h PO. Breech presentation Should be noted from antenatal examination and scans. External ce phalic version can be attempted at 37/40 gestation (Rhesus \200\223ve mothers will need an ti-D b p502). Elective Cesarean section is often performed. Gestation >41/40 The risk of st illbirth increases after 42/40 gestation. If the baby has not been delivered by 41/40 then the mother should be seen in antenatal clinic to discuss induction. Induction methods inclu de: \200 Prostaglandin vaginal gel to \200\230ripen \200\231 the cervix \200 Artifi ci al rupture of membranes (AROM, amniotomy) \200 Oxytocin infusion. 1 NICE antenatal care guidelines available at (cid:27)guidance.nice.org.uk/CG62 2. NICE dia betes in pregnancy guidelines available at (cid:27)guidance.nice.org.uk/CG63 _OHFP.indb 505 _OHFP.indb 505 30/05/2014 16:18 30/05/2014 16:18 506 CHAPTER 15 Emergency department Delivery 1 See b p554 for the procedure for normal vaginal delivery. Prematurity Birth <37/ 40 gestation can have serious eff ects on the baby \200\231s survival and risk of disabilit y, especially <32/40. Key components of management of a woman in preterm labor include earl y and close liaison with obstetrics and pediatrics, maternal steroids (beclometasone 12mg/1 2h IM) if 24 \200\22334/40, consideration of tocolytics, consideration of transfer to a hos pital with neo- natal intensive care. Premature rupture of membranes (PROM) Rupture of membranes prior to onset of labor. Beyond 37/40 gestation, delivery should occur within 24h to reduce the risk of maternal/fetal infe ction; consider use of IV oxytocin or vaginal prostaglandin gel to induce labor. If <37/40 gestation, admit for IV antibiotics, close monitoring and specialist consideration of the u se of steroids, and induction of labor. Fetal monitoring \200 Doppler probe listen for decelerations at the end of a contraction \200 CTG (see box) \200 Fetal blood sampling (through a dilated cervix from the fetal s calp) to check for acidosis, representing hypoxia (normal pH >7.25). 3Fetal distress (worrying CTG, abnormal fetal blood sample) may indicate need for urgent de livery. Reading the cardiotocograph (CTG) CTGs measure fetal HR and uterine tone (contractions). Th ey are usually printed with a scale of 1cm/min. There are four features to note: \200 Bas eline fetal HR (should be 110 \200\223160bpm) \200 Variability (spikes and dips, should b e \211 5bpm) \200 Acceleration (transient increase in HR of >15bpm for >15s) \200 Dece lerations (transient decrease in HR of >15bpm for >15s). There are three types of decelerat ion: \200 Early occur with contractions; the lowest HR is when uterine tone is highest; these are physiological, refl ecting compression of the fetal head \200 Late occ ur after the contraction; the lowest fetal HR is 20 \200\22330s after the maximal uterine tone; these are abnormal Variable the relation to uterine tone and the degree of deceleration vary between contractions; these are abnormal. 3Worrying features baseline outside of normal, reduced variability, early decelerations of >40bpm, late decelerations, persistent variable decelerations, prolonged decelerations. Diffi cult deliveries Failure to progress if the baby is not coming out get senior help and con- sider: maternal position, maternal technique, episiotomy, instrumental delivery (forc eps/ventouse), emergency LSCS. Shoulder dystocia \200\230HELPERR \200\231: call Help, Epis iotomy, hyperextend the mother \200\231s Legs onto the abdomen, suprapubic Pressure, Enter (turn the shoulder with fi ngers), Remove the posterior arm, Roll onto all fours. 1 NICE in trapartum care guidelines available at (cid:27)guidance.nice.org.uk/CG55 OHFP.indb 506 OHFP.indb 506 30/05/2014 16:18 30/05/2014 16:18 507 AFTER DELIVERY (POST-PARTUM)1 After delivery (post-partum)1 3Post-partum hemorrhage Loss of >500ml blood during the fi rs t 24h after delivery. May be primary \200\223 loss of > 500ml blood during the fi rst 24h after delivery, or secondary \200\223 excessive bleeding >24h and <12wk postnatally. Cause s failure of uterine contraction, tears, retained placenta, clotting disorders. Severe blee ding call senior help; lay fl at and elevate legs; O2 (15l/min); secure 2 large-bore IV can nulae (take blood for FBC, clotting, G+S), 1l 0.9% saline STAT; urgent blood (O-negative, t ype specifi c, or full X-match, b p400); compress the uterus bimanually, give Syntocinon 10 units/h in 500ml 0.9% saline, deliver/check placenta, remove any retained placental tiss ue and repair tears; may need evacuation under anesthetic or emergency hysterectomy. Mild b leeding IV access (FBC, clotting, G+S), 0.9% saline, monitor HR and BP, vaginal examination . Pyrexia Causes endometritis, wound infection, mastitis, UTI, URTI, DVT. Ask about mode of d elivery, premature ruptured membranes, pyrexia in labor, pain, cough/SOB, PV bleeding/disch arge, dysuria, breast pain. Look for abdo/loin tenderness; PV uterine/adnexal tenderness, l ochia (period-like discharge), breast tenderness, leg swelling. Investigations urine M,C+S; blds FBC, CRP, G+S, bld cultures; culture high vaginal swab, sputum, wound swab. Managemen t according to the cause: \200 Wound infection of tear or episiotomy: antibiotics (eg fl ucloxacillin 500mg/6h PO and metronidazole 400mg/8h PO) Endometritis tender uterus, off ensive lochia (vaginal discharge): antibiotics (eg co-amoxiclav 625mg/8h PO; 1.2g/8h IV if signs of sepsis) Mastitis tender, red breast: encourage to continue breastfeeding (to prevent milk stagnatio n), NSAIDs (eg ibuprofen 400mg/6h PO), antibiotics (eg fl ucloxacillin 500mg/6h PO). Breast problems (see b p173 for prescribing in breastfeeding) Cracked nipples nipple shield s or emollient cream. Breast abscess refer to surgical team for incision and drainage. Post -natal psychiatric problems2 With the exertion and trauma of labor, dramatic hormone change s and the immediate demands of motherhood, it is perhaps unsurprising that 85% of women exp erience mood disturbance during the post-partum period. For most, this goes no further than transient and mild Postpartum \200\230Baby blues \200\231 1 \200\22310d after delivery, w ith rapidly fl uctuating mood and irritability. 10% may experience Postnatal depression, ty pically 6 \200\22316wk after delivery; this resembles depression in any other adult (b p367 ) and may necessitate antidepressants (eg SSRIs given for a minimum of 6mth), counseling or psychiatric referral. Puerperal psychosis aff ects 0.2% of women, typically presenting 3 \200\2237d after delivery with acute psychosis (b p365); this is a 3psychiatric emergency n ecessitating urgent referral and involvement of social services. g g 1 NICE postnatal care guidelines available at (cid:27)guidance.nice.org.uk/CG37 2 NICE obst etric mental health guidelines available at (cid:27)guidance.nice.org.uk/CG45 _OHFP.indb 507 _OHFP.indb 507 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 16 Procedures 509 Practical procedures 510 Laboratories 511 Achievement of Core Foundation Skills 512 Blood and injections Taking blood (venepuncture) 514 Femoral stab 516 Blood tubes 517 IV ca nnulation 518 Taking blood in children 520 Arterial blood gas (ABG) 522 SC/IM injections 52 4 IV injections 526 Cardiology ECGs and cardiac monitors 528 Exercise tolerance test 530 Chemical cardioversion (adenosine) 531 Cardioversion and defi brillation 532 Central lines 534 Thrombolysis 536 Respiratory Pleural tap 538 Chest drain (Seldinger method) 540 Endotracheal intubation (adu lt) 542 Laryngeal mask airway (LMA) 544 Urology Urethral catheterisation 546 Replacing a suprapubic catheter 548 Gastroenterology Replacing a PEG feeding tube 548 Nasogastric (NG) tubes 549 Ascitic tap (a bdominal paracentesis) 550 Neurology Lumbar puncture (LP) 552 Others Normal vaginal delivery 554 Joint aspiration and injection 556 Local anesthetic (LA) 558 Suturing 560 Reduction of fractures and dislocations 562 _OHFP.indb 509 _OHFP.indb 509 30/05/2014 16:18 30/05/2014 16:18 510 CHAPTER 16 Procedures Practical procedures In experienced hands procedures seem easy and highly rewarding, but it takes practice. Learning new procedures can make you feel frustrated, embarrassed, and gui lty about infl icting pain. When you are learning a new procedure, especially if it is your fi rst time, ask one of your seniors to take you through it and supervise you. Try to get as much practical experience as you can so that you can work more independently and eventua lly teach others. Before starting always introduce yourself and obtain informed consent (ve rbal or written, b p29) before carrying out the procedure. Explain in clear, simple languag e what the procedure involves, how it will feel, and why it is necessary and ask if they ha ve any questions. Mentally prepare yourself by thinking through each step of the procedure. The procedure as you perform the procedure take your time, plan ahead, and be confi dent i n your actions. Make sure you and the patient are as comfortable as possible and in the rig ht position. Ask for an assis- tant \200\223 useful if you have forgotten anything. If thi ngs go well at the end of the procedure always clean up and always dispose of your own shar ps. Check the patient is alert, comfort- able, and well. If things go wrong ask for help ea rly. Stay calm and reassure the patient while you wait for help to arrive. See b p30 if the re is a serious problem. Writing in the notes write your name, date, and time of the proced ure. Document that you obtained informed consent, why the procedure was undertaken, if ther e were any problems during it, who supervised and/or assisted you, and what your management plan is, eg sending CSF sample for M,C+S. You should also document the details of any equi pment used, such as putting the reference sticker from a urinary catheter wrapping in the n otes. Always write that the patient is comfortable afterwards, assuming this is true. Learn ing and assessment You will start to learn practical procedures as a medical student. Incre asingly, skills labs and simulated manikins are used for formal teaching, prior to your fi rst supervised eff orts on patients. Repetition and feedback will help shape your skills, a long with refl ection on your eff orts: think about what you did well, what you could do di ff erently and how you would teach someone else doing the procedure. By the end of F1, you will need to be signed off as competent for the core 15 procedures listed in Table 1.2 (b p 9) and maintain and improve these skills through F2. You can record your progress using the table on b p512. F1/F2 DOPS forms now receive much less emphasis, and are meant to provide feedback simply on the way you interact with a patient whilst performing the skill. Things to remember to put on a procedures trolley \200 Gloves sterile \200 Needles ( various sizes) \200 0.9% saline \200 Antiseptic solution \200 Syringes \200 Local a nesthetic Plenty of swabs \200\223 you can never have too many \200 Dressings and tape \200 Specimen pots/bottles \200 Kidney dishes/g alipots \200 Sharps bin. OHFP.indb 510 OHFP.indb 510 30/05/2014 16:18 30/05/2014 16:18 511 LABORATORIES Laboratories There are six main laboratories associated with a hospital: \200 Biochemistr y \200 Hematology and blood bank \200 Microbiology \200 Histopathology (including cyt ology) \200 Immunology \200 Genetics (only available in certain larger hospitals). Bioc hemistry this department deals with the processing of blood samples for salt and mineral le vels, eg U+E, LFT and hormone levels such as cortisol, TFT etc. It also deals with monitori ng drug levels, eg sodium valproate and ABG samples if there is not a blood gas machine in the clinical areas. In general \200\230gel \200\231 bottles are used for biochemistry samp les but check with your lab if you are unsure or taking blood for an unusual test (see b p5 17). Hematology this lab processes samples for FBC, ESR, clotting studies, G+S and crossmatching . It also examines blood fi lms if there is clinical suspicion of hematological disease, eg haemolytic anemia, leu- kaemia or malaria. Microbiology this specialty is concerned with identifying bacteria, viruses, fungi and para sites in samples of various bodily fl uids from patients. It examines specimens under the m icroscope to look for cells, cultures them in an incubator to try and grow pathogens and if any bugs grow, it investigates which antibiotics can be used to kill them or prevent their growth. It deals with specimens such as blood, urine, feces, CSF, and swabs taken from any site on the body. Microbiologists also use advanced molecular biology techniques to identi fy organisms that are dif- fi cult to culture, as well as assay antibiotic levels and are a useful source of advice when prescribing antibiotics for complex cases after discussion wi th your team \200\231s seniors. They usually produce the hospital antibiotic guideline poli cy in combination with the pharmacists. Histopathology this specialty deals with tissue samples, eg biop- sies and specimens remove d during operations or post-mortems. Pathologists examine these samples both macro- and mic roscopically to determine the nature of the tissue and the underlying disease process. They use diff erent slicing and staining techniques to examine specimens under the microscope t o determine the disease process or progression. Immunology performs tests to assess the immune system for under- activity (immunosuppressio n) or overactivity (autoimmune disease); many of these involve measuring antibody levels eg ANA. Samples for antibody analysis usually go in the plain tubes (b p517). Genetics this lab has two subdivisions: \200 Cytogenetics that look for chromosomal abnor malities eg assessing an amniocentesis sample for trisomy 21 (Down \200\231s) Molecular genetics that look for mutations in DNA, eg cystic fi brosis. The blood tube used for these tests varies between centers; the sample quality (fresh, free-fl owing) is espec ially important for cytogenetics. _OHFP.indb 511 _OHFP.indb 511 30/05/2014 16:18 30/05/2014 16:18 512 CHAPTER 16 Procedures Achievement of Core Foundation Skills This page is for you to record your personal progress towards achieving independence in all 15 of the key practical procedures identifi ed by the GMC as required by the end of F1. Du ring F2 you should maintain and build on these skills. Links to relevant pages in this book are shown. Skill Key dates and progress First attempted Signed off Venepuncture b p514 IV cannulation b p518 Giving IV medication and \202 uids b p526 ABG b p522 Blood culture b p515 IV \202 uid prescribing and infusion b p380 Blood transfusion b p398 Local anesthetic inj ection b p558 SC injection b p524 IM injection b p524 Perform and interpret an ECG b p528 Perform and interpret peak \202 ow b p130 Urethral ca theterisation (5) b p546 Urethral catheterisation (4) b p546 Airway care and adjuncts b p23 0 OHFP.indb 512 OHFP.indb 512 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 514 CHAPTER 16 Procedures Taking blood (venepuncture) Consent verbal Level F1 Diffi culty 1/5 Indications diagnosis, monitoring physiological state, therapeutic drug monitoring. Contrai ndications absolute competent patient refusal, ipsilateral AV fi stula. Site usually antecu bital fossa but can use any vein (eg hands, arms, feet, and groin (femoral stab b p516)); n ever use a limb with an AV fi stula ( (dialysis) or an IV infusion. y ) Equipment non-sterile gloves, tourniquet, antiseptic swab, vacutainer hub and needle, gauze , tape, sharps bin, blood bottles (see b p517). Checks patient comfortable, vein exposed, a ccessible and not pulsing, cotton wool to hand, no IV fl uids going into the limb of select ed vein. Patient position upper limb sit the patient upright, with arm extended and below t he heart; lower limb lay patient fl at on their back. Procedure wash hands and wear non-sterile gloves. Assess both arms and select an appropriat e vein. Tighten the tourniquet proximally and palpate along the course of the vein to asses s its direction and depth. Swab the skin and allow it to dry; and hold the vein steady with your non-dominant hand. Warn the patient and advance the needle into the vein at 20 to t he skin; feel for the slight \200\230give \200\231 as you enter the vein and hold your pos ition as you insert the blood bottle into the hub. Once the bottles are fi lled, unclip the tourniquet and gently cover the puncture site with cotton wool. Withdraw the needle, then apply pressure to the cotton wool. Press (or ask the patient to press) on the cotton wool f or 2min (longer if bleeding) then tape it in place. Dispose of the needle and hub into the sharps bin. Fill the blood tubes at the patient \200\231s bedside, label them, and complete the accompanying request forms. Con \201 rmation blood fl ows freely into the bottle. Complications pain, bleeding, haemat oma, failure, infection. Safety steady the patient \200\231s arm on a pillow to reduce move ment and risk of needle-stick injury, dispose of needles into a sharps bin immediately, do not resheath them. Alternatives \200 Blood samples can be taken from cannulae when they a re fi rst inserted. \200 Central venous lines can be used to sample blood. You will need 2 syringes and a 3rd with a suitable solution to fl ush the line (always check whether the li ne needs to be left with heparinised saline in it or just fl ushed with saline); wear steri le gloves, clean the port thoroughly with alcohol wipes, withdraw 5ml of blood in the fi rs t syringe and dispose of it; next withdraw the blood for your sample in the 2nd syringe, be fore fl ushing the line with the solution drawn up in 3rd syringe. Needle and syringes can be used for smaller veins which may collapse from the suction from vacutainers. For these veins use a small needle (eg blue, 23G) or \200\230butterfl y \200 \231 (Fig. 16.1; b p521) but beware of haemolysis causing artifi cially iK+ and iLDH. OHFP.indb 514 OHFP.indb 514 30/05/2014 16:18 30/05/2014 16:18 515 TAKING BLOOD (VENEPUNCTURE) Butterfly needle Fig. 16.1 Taking blood using a butterfl y needle. \200 If you are unable to obtain blood from the upper limb look at the veins in the leg/foot; if you still cannot fi nd veins ask your senior to try before consid ering a femoral stab. Hints and tips \200 In patients with poor veins spend a long time fi nding a suitable vei n rather than stabbing blindly In children use topical local anesthetic, see b p521 \200 In adults choose veins by palpa tion with the tourniquet on rather than their appearance; a bouncy vein is usually easy to take blood from \200 Tie the tourniquet tightly and ask the patient to clench their fi st repeatedly with their arm below their heart; tap the vein to make it more prominent \200 It is best to use a green (21G) vacutainer needle for U+E samples to prevent haemolysis an d spuriously iK+; if using a needle and syringe, aspirate blood slowly and gently. Only use blue (23G) needles for very fi ne veins Pull the skin and vein taut to prevent movement away from the needle, especially in older patients Going through the skin is the most painful bit, once under the skin you can take several attempts to maneuver the needle into the vein \200 If you can only o btain a small sample consider using pediatric tubes; see the minimum blood requirements on b p517 If you decide to use a needle and syringe, never force blood into blood tubes; the results are spectacular, messy, and embarrassing. Consider pulling the top off . Procedure for taking blood cultures Indicated by a repeated/persistent temp >37.5 C or one -off \211 38.3 C when a causative organism or source is not already known. In suspected b acterial endocarditis take 3 sets (6 bottles) from 3 separate veins. Procedure as for norma l blood-taking with needle and syringe except: \200 Wear sterile gloves (strict aseptic t echnique for central lines) \200 A set of blood cultures is two bottles (one aerobic and one anaerobic) \200 After using the chlorhexidine swab do not touch the vein again \200 Once the blood has been obtained replace the used needle with a fresh one \200 Flip off the culture bottle lids, swab the top with a clean chlorhexidine wipe, insert the needle and fi ll each bottle with 5 \200\22310ml. _OHFP.indb 515 _OHFP.indb 515 30/05/2014 16:18 30/05/2014 16:18 516 CHAPTER 16 Procedures Femoral stab Consent verbal Level F1 Diffi culty 2/5 Indications taking blood when alternative sites are not possible. Contraindications absolut e competent patient refusal; relative local infection, coagulopathy. ) Site either side of groin medial to the femoral artery (Fig. 16.2). g y ( g Equipment non-sterile gloves, antiseptic swab, 10 \200\22320ml syringe, 21G green needle, g auze, tape, sharps bin, appropriate blood bottles (see b p517). Checks patient comfortable, groin exposed, cotton wool to hand. Patient position patient fl at on their back with groi n exposed. Procedure wash hands and wear non-sterile gloves. Feel for the femoral pulse and choose the side where it is most prominent. Swab the skin thor- oughly then place your fi ngers over the artery; warn the patient and insert the needle vertically 1cm medial to your fi ngers. Pull back on the syringe as you advance and stop moving as soon as you get fl ashback. Fill the syringe then withdraw. Exert pressure over the area with cotton wool for at least 2min and dress it with a plaster once bleeding has subsided. Fill the blood tubes and label the m at the patient \200\231s bedside, dispose of the needle and syringe in a sharps bin and c omplete the accompanying request forms. Con \201 rmation blood fl ows freely into the syringe. Complications pain, bleeding, haema toma, infection, failure; bright red, pulsatile fl ashback suggests you hit the artery; con tinue to aspirate the required amount of blood as arterial blood can be used for all routin e tests, but press fi rmly for \211 5min after withdrawing the needle to ensure haemostasi s. Hints and tips to remember the anatomy of the femoral region, work in a lateral to media l direction and think \200\230NAVY \200\231: \200 Nerve (femoral nerve, most lateral) \200 Artery (femoral artery) \200 Vein (femoral vein) \200 Y-fronts (vital undergarmen t, best removed prior to procedure). Inguinal ligament Iliac crest Femoral nerve Femoral artery Femoral vein Pubic symphysis Pubic tubercle Fig. 16.2 Anatomy of the femoral region. OHFP.indb 516 OHFP.indb 516 30/05/2014 16:18 30/05/2014 16:18 517 BLOOD TUBES Blood tubes The colors and contents of the various blood bottles vary between suppliers and hospitals. Use Table 16.1 as a guide to which bottle is used for each test and to make sur e the sample is suitable. Fill in the color of blood bottles and specifi c blood tests used in your hospital. We have left space at the bottom for other blood tubes. Table 16.1 Blood tubes Color Contents Tests Special instructions 1ml minimum but aim to fi ll; gently mix to prevent clotting Always fi ll to the line and g ently mix to prevent clotting 4ml minimum; always handwrite \211 3 forms of patient identi fi cation Always fi ll to the line and gently mix to prevent clotting 1.5ml minimum but aim to fi ll; try to use a green vacutainer needle to prevent haemolysis and inaccurate K+ res ult EDTA FBC, reticulocytes, HbA1C, sickle screen, Hb electrophoresis, malaria screen ESR EDTA EDTA Blood transfusion (G+S, crossmatch) Sodium citrate D-dimer, APTT, PT/INR, thrombophilia screen, fi brinogen U+E, LFT, amylase, TFT, CRP, 3 \210\222, HCO \200\223 Cl \200\223, Mg2+, Ca2+, PO4 3, urate, LDH, total protein, digoxin, paracetamol and salicylate, lithium, other drug levels, tumor markers, B-hCG, protein elect rophoresis, cardiac markers Some endocrine tests, drug levels, serology Blood glucose, lact ate, alcohol; CSF glucose, protein, oligoclonal bands Some endocrine tests Glucose separating gel Plain 1.5ml minimum but aim to fi ll Blood fi ll to the line, mix gently; CSF 6 drops; mix gently Mix gently, may need to be transported on ice Fluoride oxalate Heparin _OHFP.indb 517 _OHFP.indb 517 30/05/2014 16:18 30/05/2014 16:18 518 CHAPTER 16 Procedures IV cannulation Consent verbal Level F1 Diffi culty 2/5 Indications unwell patients, shock, IV fl uids/drugs, blood product transfusions, other rou tes of drug administration not tolerated. Contraindications absolute competent patient refusal, ipsilateral AV fi stula. Site the forearm and back of the hand on the non-dominant arm are usually more convenient s ites for the patient, but any vein can be used (eg hands, arms, feet, legs), antecubital fo ssa in an emergency, never use a limb with an AV fi stula (dialysis). Equipment tourniquet, non-sterile gloves, antiseptic swab, cannulas (appropriate size, see Table 16.2), cannula dressing, 5ml syringe with saline fl ush, cotton wool, blood collectio n tubes and adaptor if blood sample required, sharps bin. Checks patient comfortable, skin is clean and free of infection, vein exposed, accessible and not pulsing, cotton wool sy ringe to hand. Patient position upper limb sit the patient upright, with arm extended and b elow the heart; lower limb lie patient fl at on their back. Procedure wash hands and wear non-sterile gloves. Assess both arms and select an appropriat e vein. Tighten the tourniquet proximally and palpate along the course of the vein to asses s its direction and depth. Local anesthetic can be given intradermally or topically prior t o this procedure. Swab the skin with 2% chlorhexidine, allow it to dry then hold the vein s teady with your non-dominant hand. Warn the patient and advance the cannula through the ski n at 20 with the bevel facing upwards and proximally. Look for fl ashback, then advance t he cannula and needle a little further before withdrawing the metal needle whilst fi rmly a dvancing the plastic cannula. Dispose of your sharp as soon as possible at the bed-side. Pr ess with your thumb over the tip of the cannula in the vein. \200 Taking blood if blood l eaks out try lifting the arm, if still leaking remove the tourniquet. Attach the adaptor and each blood tube in turn, then remove the tour niquet Not taking blood remove the tourniquet. Place the cap on the end of the cannula, secure wit h the adhesive dressing and fl ush with 2 \200\2235ml 0.9% saline through the side port. Da te the dressing and document date and time of insertion in the notes. Dispose of the needle into a sharps bin. Con \201 rmation fl ashback seen, saline fl ush requires minimal pressure and does not for m a proximal subcutaneous \200\230bleb \200\231 or cause pain. Complications early haematoma, tissuing (fl uid/drugs enter subcutaneous tissues), local da mage, air embolism; late thrombophlebitis, cellulitis. OHFP.indb 518 OHFP.indb 518 30/05/2014 16:18 30/05/2014 16:18 519 IV CANNULATION Safety never reinsert the metal needle into the plastic cannula once you have fully removed it as this increases the risk of needle-stick injuries and bits of the plastic cannula may shear off and embolise, steady the patient \200\231s arm on a pillow to reduce movement an d the risk of needle-stick injury, dispose of needles into a sharps bin immediately. Altern atives central venous cannulation (b p534), alternative route of drug administration (PO/IM /SC/PR). Hints and tips \200 See comments under \200\230Taking blood \200\231 \200 Start distal ly in a limb and work your way proximally if you fail to cannulate initially Veins are easier to cannulate at the junction of two veins \200 Try to avoid cannulae ove r a joint as these are uncomfortable and more likely to tissue If you go through the wall of the vein, withdraw a small distance until fl ashback recurs and try to advance the plastic cannula In confused patients and children, always cover the cannula with a cr pe bandage and tape the IV line to their skin to minimize auto-extraction and further cannulation practice. Table 16.2 Intravenous cannulae Color Size Flow rate (ml/min) Use Blue Pink Green White Gray Orange 22G 20G 18G 17G 16G 14G 31 55 90 135 170 265 Small fragile veins IV drugs and fl uids blood Blood, fl uids, drugs Blood, fl uids, drug s Rapid blood, fl uids, drugs Rapid blood, fl uids, drugs Cannula care \200 Inspect cannula daily, looking for infl ammation and replace it every 7 2h \200 If asked to replace it, check cannula is still necessary \200 If blocked, try f l ushing the line gently with 0.9% saline and check the giving set isn \200\231t kinked Remove the cannula if the surrounding skin becomes red, swollen or tender as a result of cannula insertion. _OHFP.indb 519 _OHFP.indb 519 30/05/2014 16:18 30/05/2014 16:18 520 CHAPTER 16 Procedures Taking blood in children Never use a needle and syringe, never use a snapped off broken needle. Diffi culty 3 \200 \2235/5 Consent verbal from parent child Level F1 Indications diagnosis, monitoring physiological state, drug monitoring. Contraindications r elative parental refusal, preserving veins. Planning before you take the blood get all the equipment ready, think about the amount of blood and which bottles you need, work out where the child, parent and staff will go, think about distraction and topical anesthesia (eg EM LA). Choosing a vein the appearance of the vein is more important than the feel in very you ng children (they can be too small to palpate); common sites include hands, feet and forear ms. Antecubital fossa and saphenous veins should only be used if there is no chance of a lo ng line being inserted. (a) (b) (c) Fig. 16.3 (a) Safe area for heel prick. (b) Use of a Tenderfoot for heel prick. (c) A cut -off butterfl y. Heel prick \200 Age range babies <10d; though works on fi ngers at all ages if desperate \200 Samples <1ml of blood, ie 2 bottles, not K+, clotting or blood cultures \200 Analg esia pacifi er dipped in 20% glucose, swaddling \200 Staff can be performed alone in babi es. \200 Advantages easy, usually quick, does not use up a site for cannulation \200 Di sadvantages small quantities, can take a long time, messy. Procedure grip the heel tightly between index fi nger and thumb. Choose a site on the outsi de of the heel (Fig. 16.3a) and wipe with an antiseptic swab then apply a small amount of V aseline . Hold the lancet (Fig. 16.3b) fi rmly against the skin and squeeze the heel as yo u release the lancet. Catch the blood as it drips out; you may need to gently squeeze the f oot. Apply cotton wool. Keeping it \200\230fun \200\231 it is essential to make the experience as pleasant as poss ible \200\223 not least of all to make it easier the next time. Use a special treatment ro om, involve the play therapist, keep their parents with them, smile, off er distraction, an d, most importantly, give out stickers. OHFP.indb 520 OHFP.indb 520 30/05/2014 16:18 30/05/2014 16:18 521 TAKING BLOOD IN CHILDREN Winged needle/cut-off butter \202 y (Fig. 16.3c) \200 Age range <1yr (but works at any a ge) \200 Samples not blood cultures \200 Analgesia pacifi er dipped in 20% glucose, swa ddling, Ametop /EMLA \200 Staff two extra \200\223 one to hold the child, one to act as tourniquet. \200 Advantages relatively easy to hit the vein, can get large quantities \200 Disadvantages very messy, can clot if fl owing slowly. Procedure locate suitable vein (between the knuckles can be surpris- ingly good if no other s are visible). Ask a colleague to act as a tourni- quet. Stretch the skin to fi x the vein ; a baby \200\231s fi st fi ts well between the thumb and index fi nger if their wrist is f l exed. Insert the needle slowly until blood drips out of the needle; catch suffi cient blo od then remove the needle and apply cotton wool. Butter \202 y \200 Age range >1yr \200 Samples not blood cultures \200 Analgesia Ame top /EMLA , cold spray, distraction (play therapist) \200 Staff two extra \200\223 one to hold the child, one as tourniquet and distraction. \200 Advantages clean, can get lar ge quantities \200 Disadvantages hard to hold butterfl y whilst drawing on syringe. Procedure locate suitable vein. Ask a colleague to act as a tourniquet. Stretch the skin to fi x the vein; insert the needle slowly until there is fl ashback. Hold the butterfl y in place whilst gently fi lling the syringe until there is suffi cient blood; remove the butte rfl y and apply cotton wool. Cannula \200 Age range any \200 Samples any including blood cultures \200 Analgesia p acifi er dipped in 20% glucose, swaddling, Ametop / EMLA , cold spray (ethyl chloride), d istraction (play therapist) Staff two extra \200\223 one to hold the child, one as tourniquet and distraction \200 A dvantages sterile, easy to obtain large samples, clean \200 Disadvantages makes future ca nnulation harder, can be diffi cult. Procedure locate suitable vein. Ask a colleague to act as a tourniquet. Stretch the skin to fi x the vein. Hold cannula between thumb and middle fi nger with bevel facing up. Gently insert the cannula until you see fl ash- back then use your index fi nger to gently advance the plastic cannula into the vein. Secure the cannula in place with a couple of steristrip s \204 then completely remove the needle (into a sharps bin at the bedside) and collect bl ood from the cannula by allowing it to drip into the tubes. Remove the tourniquet and secur e the cannula further with an adhesive dressing. Attach the extender to the cannula and fl ush with 2ml 0.9% saline. Wrap the surrounding area and the extender tube in gauze so that only the end of the extender is accessible. _OHFP.indb 521 _OHFP.indb 521 30/05/2014 16:18 30/05/2014 16:18 522 CHAPTER 16 Procedures Arterial blood gas (ABG) Consent verbal Level F1 Diffi culty 3/5