Tips on procedures a trainee medical SHO is expected to do in the NHS
Please be aware that the procedures explained here are only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust.
Please also note that there are simulation sessions in almost every trust to enable health care professionals become more confident in their skills.
As a SHO ( trainee/non trainee) you are expected to learn and do the following procedures independently:
1. Ascetic taps
2. Lumbar punctures
3. NGT placement and checking
4. Pleural aspiration for pneumothorax or pleural fluid
5. Cardioversion, advanced CPR
These are mentioned in the ARCP decision aid for IMT here:
https://www.jrcptb.org.uk/training-certification/arcp-decision-aids
This is the rule I use for procedures:
Always observe, then assist , then do it under supervision, do it independently but under supervision and then do it independently and finally, teach your colleagues.
I am going to go through each procedure and my tips I have learnt over the past few years.
ADVANCED CPR
You will do this multiple times when you are on call when there is a CRASH call. Once you are ALS trained ( http://omarsguidelines.blogspot.com/2017/12/my-guideline-for-als.html ), you are expected to lead CRASH calls as well.
My suggestion would be to observe a registrar lead a CRASH call. Then try to lead it next time. Also get used to the RESUS trolley in your trust and try to participate actively in the CRASH call. Reflect upon it in your portfolio so that you can link it to the relevant competencies. Also try to lead a CRASH call and ask the registrar to sign a CBD/mini CEX for that.
ASCETIC TAPS and DRAINS
https://patient.info/doctor/ascites-tapping
Thanks to the common problem of alcohol abuse, the acute and gastro wards are always full of decompensated alcoholic liver disease patients.
You will get plenty of opportunities to do taps and drains.
Some nurses, ACPs can do them as well so you will have plenty of people to teach you.
Before the procedure:
Platelets- these can be low in decompensated liver disease and may need a senior decision regarding the risk vs. benefit of sticking a needle in.
Check patients old letters:
If the patient has disseminated cancer causing ascites or ascites ? malignant in origin, there can be a risk of seeding the malignant cells in the abdominal wall. Hence, this needs to be a senior decision regarding whether it is reasonable to tap or not.
If the patient has had a huge mesh repair for bilateral hernias - you do not want to penetrate the mesh or cause further complications. Such cases are usually drained via USS guidance.
Preparation
1.ONLY FOR DRAINS
Usually it is 100 ml for every 1.5 to 2 litres drained ( but this varies from trust to trust and even from patient to patient. So ALWAYS read the old letters of the patient to see if any particular regime is followed).
Make sure the patient is cannulated
Some trusts have a ascetic tap trolley/kit. This is what it includes:
Explain the procedure to the patient in detail. Some trusts have patient information leaflets on this as well.
Explain why you have to do it and what the benefits are.
Then go through the risks which include:
Bleeding, infection, pain, injury to surrounding structures - especially bowels, failure of procedure, multiple attempts, dry tap, unable to get a diagnosis ( if it is a diagnostic tap), reaction to local anaesthetic ( always check allergy status)
Fill out a consent form 1 ( if the patient has capacity) and fill the relevant details. Sign it and then ask the patient to countersign it. Give the carbon copy to the patient and put the original one in the patients notes.
If the patient lacks capacity, fill out a form 4, discuss the above with the next of kin and ask the next of kin to sign if available or otherwise just sign it on your own.
THE PROCEDURE:
FOR ASCITIC TAP
FOR ASCITIC DRAINS:
Ask the patient to lie on their back. Get everything ready and prepare your sterile field. Ask your assistant to open the lidocaine (and if required, bottles for you) when you request him/her, ensuring that (s)he/ the bottles/lidocaine do not touch the sterile field.
Percuss the abdomen and confirm the spot you want to go in -usually lateral to the rectus abdominis muscle and go approximately 5 cm superior and medial to the anterior superior iliac spines. You must observe this and then do it under supervision and you will know the exact spot to go in.
Put on sterile gloves
Open the syringe, drawing up needle, blue and green needles, bannno catheter
Set up the Bannano catheter - take it out of its pack, guide the needle through the plastic tubing and then remove the plastic sheath. This may sound a bit complicated if you are reading this for the first time and have not done one before. Hence, it is advised to observe a procedure first.
Clean the area with the chloraprep.
Put a sterile sheet on the areas surrounding the point of insertion.
Ask your assistant to open the lidoacaine solution and check the dose and date of expiry again. Draw it up using the drawing up needle.
Remove the drawing up needle and attach the orange needle.
Inject a small amount of local - enough to make a bleb at the point of insertion. Remove the orange needle and attach a green needle.
Insert this perpendicular to the abdominal pain ( just like you would be doing a diagnostic abdominal tap) and aspirate , inject ( keep repeating till you go deep enough to aspirate ascetic fluid). Then inject a bit more by going deeper and remove the needle and syringe.
Put a gauze on the insertion site to prevent any leak.
Wait for a few seconds for it work and then insert the sheathed Bannano catheter.
Keep a gauze/sterile gallipot handy because as soon as the needle hits the ascetic fluid, it will come out and may soil you and the bed if you are not careful.
Remove the needle whilst holding the catheter in place.
If required, connect a syringe and aspirate fluid to send to the lab.
Quickly connect the clamped tubing to the catheter.
Connect the drainage bag to the clamped tubing
Unclamp the tubing and let the fluid drain
Secure the catheter in place by sticking on cannula dressings.
Ensure that the drainage bag is below the level of the patient but is NOT pulling on the catheter as it may fall out.
Inform the nursing staff to strictly document the output and once the bag is 1.5 - 2 litres full, start the HAS solution. This may need to repeated ( up to 4 to 5 times depending on what the plan of target fluid volume removal is)
Document the procedure and document a clear plan:
- Aim to remove 1.5 to 2 litres and then administer 20% 100 ml HAS.
- Monitor BP, urine output, pulse.
- Remove drain after 4 to 6 hours.
- If any concerns, bleep your gastro reg (from 9 AM to 5 PM) and bleep the medical registrar on call if out of hours. Hand this over to the on call SHO/FY1 to ensure that the drain is removed in case the nurses get busy.
PEOPLE WHO CAN HELP BUILD YOUR SKILLS:
Gastro registrars
Gastro ACPs who do drains on a regular basis.
LUMBAR PUNCTURES
https://www.nhs.uk/conditions/lumbar-puncture/
As a SHO, you will do these a lot. Not only in your neurology placement but also when you are on call.
SHOs initially shy away from it so I am going to give you some tips:
1. Always observe, assist , then do it under supervision, do it independently but under supervision and then do it independently.
2. When you are doing one for the first time under supervision, make sure that you have a patient who is thin and ha a very good spine. There is nothing like getting disappointed because you cannot puncture the subarachnoid space due to a lot of fat.
3. Take your time to get used to the lumbar puncture kit.
This is what you will need
Palpate for the anterior superior iliac spines and then draw an imaginary line from both to the spine - this is the point you would want to go in- This is L4/5, You can go here,1 space above it or 2 spaces above it .
Some people like to mark the insertion point by drawing an X with the centre of the X at the insertion point.
Ask the patient to relax and go to the toilet as they will have to lie flat for 45 min after the procedure. I usually make sure they have their phones/a book to read beforehand as they get bored and then start mobilizing after a few minutes.
5. Always read the notes the notes to see if the consultant/registrar need any additional tests - they may request test like HMDS, cytology, CJD, TB, atypical bacteriae, fungi, viral PCR, oligoclonal bands, etc. Also check ( and confirm if not clear) if we need to check the opening pressure.
Ensure that the CT head, clotting and platelets are normal.
6. Consent the patient- explain the procedure, why you are doing it and what are the complications which include:
Pain, headache, bleeding, infection, sharp shooting pain down the legs which is very intermittent and will last a few seconds, failure of procedure, multiple attempts, dry tap, unable to get diagnosis, reaction to local anaesthetic(always check allergy status).
7. Label the bottles beforehand- Always take an extra sample especially if the patient has seen by neurology as the team invariably adds on more tests to the existing CSF samples.
8. Take your trolley and get an assistant. Ask the assistant to reassure the patient if necessary, open the lidocaine for you and hand you opened CSF collection bottles. If it is for xanthochromia in additional to the usual investigations, ensure that the assistant hands you the bottle in a black bag to avoid exposure to sunlight.
9. Get a chair and set the level of the bed so that you are at a comfortable level.
10. Ask the patient to get into the same position you asked him/her to go into ( see point 4 ).
11. Repeat the same process- keep palpating till you know for certain that you have found the right space. I usually warn these patients that I will be prodding their hips and lower spines a lot. Make sure that if it a young female and you are a male doctor, she knows why you are doing this.
12. Open all the necessary equipment in your sterile area and put on sterile gloves. Check the lumbar puncture needle and ensure the stylet is moving freely in the needle.
If you need to check pressures, play around with the manometer and ensure that the stop cock is such a position that the fluid will go up the tube and not out of it.
13. Put sterile drapes on the patients hips ( as you will be palpating the anterior superior iliac spines again) and put a sterile drape under the patient ( in case there is bleeding- avoid soiling the bed PLUS it is aseptic)
14. Palpate the space again.
15. Clean the area with Chloraprep - start at the insertion point and then move in a circle. Make sure that the patients back is exposed as much as possible.
16. Draw up lidocaine after checking the dose and expiry date.
17. Attach an orange needle and after palpating the space again, inform the patient that you are about to inject local anaesthetic, inject enough to make a superficial bleb. Then go slightly deeper.
18. Attach a green needle to the same syringe and then go deeper. Again, inform the patient of what you are doing and inject some, then aspirate ( to ensure you have not hit a vessel), keep repeating the process.
19. Wait for a few seconds to let the local anaesthetic take effect. Explain to the patient that you are now to insert a long but very thin needle. They will feel a pressure and if you injure a nerve they may feel a sharp shooting pain down their legs which will last a few seconds. It is important that they do not move and let you know immediately - the pain will settle as soon as pull out the needle.
20. Palpate the space again. Let your assistant know that you will need the bottles soon. again remind your assistant to hand you a bottle in a black bag to avoid exposure to sunlight if you are checking for xanthochromia.
21. Insert the LP needle - go perpendicular, in the same tract as the local anaesthetic injection and you will feel a give- That is the subarachnoid space.
22. Puncture the subarachnoid space and you will see clear colourless fluid in the LP needle. Take the stylet out and if you need to check pressures, connect the manometer to it. You will see fluid rising in it. Wait till the fluid stops rising and say the figure out loud ( you have no idea how many times people forget what it was later on - your assistant will always remember). Open the stopcock and ask your assistant to give you the bottles - put in 10 to 20 drops ( or as per protocol) in each bottle. Then remove the manometer and immediately put in the stylet.
23. If you are not checking pressures, ask your assistant to hand you the opened bottles.
24. It is a good idea to count the number of drops going into each bottle loudly so that you do not forget.
25. Once the samples have been collected, put the stylet in ASAP and then remove the needle.
26. Put a dressing on, thank the patient and ask them to lie on their back.
27. Get rid of the sharps, clean your mess ( please do not leave it at the bedside)
28. Document everything in the notes, thank your assistant and then call the lab- in some trusts you have to inform the lab ASAP.
29. Hand deliver the samples to the lab or request a porter to take them
DOING A LUMBAR PUNCTURE WITH THE PATIENT SITTING UP
This CANNOT be used to check CSF pressure.
The anaesthetic team is particularly keen on doing lumbar punctures in this position - especially if it is a difficult one.
You ask the patient to fold their arms and put them on a table ( with a pillow) and bend forwards as much as possible. This makes the intervertebral spaces even wider. The rest of the technique is the same.
COMMON PROBLEMS:
1. Hitting bone constantly.
Take the needle out. Confirm position again - read point 4. Sometimes you can change the angle of the needle whilst it is in the spine especially in the elderly who have degenerative bone diease.
2. Post LP headache - always ensure you put the stylet into the needle before taking it out.
Tips:
PEOPLE WHO CAN HELP BUILD YOUR SKILLS:
Neurology registrars
Neurology physician associates/specialist nurses who do LPs on a regular basis
Medical registrars
ITU registrars
NG TUBE INSERTIONS
As a SHO, you may not get to do these a lot. Which is why you tend to get deskilled easily. It is a good idea to continue doing NGT insertions whenever you get the chance.
Every trust has its own protocols.
These are the important indications to be aware of:
1. Feeding - in decompensated liver disease, anorexia.
2. Poor swallow - stroke, neurological conditions like MND, Parkinson's, Myasthenia.
3. Gastric dysmotility.
1. Patient refusal - ensure that you have checked their capacity to refuse a NGT and they understand how important this is.
2. Gastric surgery - like gastric bypass. There is high risk of perforation. Usually the endoscopists pass a NJ tube with endoscope guidance
3. Varices ( Usually the endoscopists pass a NJ tube with endoscope guidance).
4. Chemical ingestion - high risk of perforation.
1. NG tube with guide wire
2. Lubricating jelly
3. Enteric syringe to aspirate fluid
4. pH strips to check if the aspirate is acidic.
5. A sick bowl
6. An assistant to hold the patients hands- as this is a very uncomfortable procedure and it can make things worse for an already agitated patient.
7. Any local hospital NGT insertion protocols ( stickers, booklets, etc).
1. It is advisable to have an assistant who can reassure the patient.
2. Open the NG tube packet and measure the distance from the tip of the nose, around the ear to the xiphisternum. The marking on the NG tube is the minimum mark the NG tube should be inserted.
3. If the local protocol allows it, lubricate the tip using lubricating jelly ( some trusts have lubricated NG tubes)
4. Ask the patient to sit up as much as possible.
5. Remember the anatomy of the nose- the tube should be angled very slightly through the nostrils ( towards the ears rather than the head)
6. When you insert the tube in the nostril, ask the patient to swallow ( if not nil by mouth, allow them to have a sip of water, if nil by mouth ask them to swallow their saliva)
7. Pass the NGT as quick as possible. The quicker you go, the less is the chance of the patient feeling any discomfort.
8. It should easily pass.
9. Stop at the marking you measured before and then insert it 5 to 6 cm more to leave enough leeway in case it dislodges.
10. Tape it to the nose and aspirate fluid out of the NG tube
11. Check the fluid against pH paper - if it is aciditc, you can be assured that it is in the right place.
12. You can then remove the guidewire.
13. If you do not get an aspirate, request an urgent CXR to ensure that the NGT tip is below the diaphragm. LEAVE THE GUIDE WIRE IN till the CXR confirms the position.
14. Document in the patients notes.
Common problems:
1. The NGT comes out of the mouth
This is because of an uncooperative patient, poor positioning. You could try some mild sedation if appropriate.
2. There is no aspirate - this may mean 2 things- The NGT is in the wrong place or the patient does not have a lot of gastric contents. A CXR is necessary.
3. Unable to pull the guidewire out. This happens when the NGT is kinked. Just pull it out ever so slightly ( ensuring the mark at the nostril is still more than what the nose to xiphisternum distance is) and then see if the guide wire can be pulled out.
4. The patient keeps pulling the NGT out.
In this case, a bridle may be appropriate which is a piece of string attached to 2 plastic rods with magnetic tips used to secure the NGT in place.
HOW TO INSERT A BRIDLE:
This may vary from trust to trust.
You can ONLY insert a bridle once the guide wire has been removed - Ie the NGT is in position as confirmed by acidic aspirate or a CXR.
Open the bridle kit and see if the magnetic tips of the rods are functioning ( ie are the tips sticking to each other?)
You will see a piece of string going through one of the rods.
Insert one of the rods with the string going through it into the nostril which has the NGT inserted- magnetic tip inwards.
Insert the free rod through the other nostril.
You will feel the magnetic tips click.
When that happens, pull the rod in the NG free nostril out and the string will automatically come out.
Then remove the first rod by pulling on it and holding the string at the other nostril.
Now you will have a piece of string coming out of both nostrils, secured to the back of the nose ( around the vomer bone)
You then attach a clip to secure both strings and NG tube, then make a knot on the string distal to the clip to prevent the string from slipping out.
Cut the extra pieces of string and then document in the notes.
PEOPLE WHO CAN HELP BUILD YOUR SKILLS
Gastro registrars
Gastro specialist nurses/ACPs/Physician associates
Stroke nurses
Stroke registrars
Medical registrars
I am going to skip pleural aspiration and chest drain insertions for now and will discuss these later. Please contact your local respiratory team as you will learn more by seeing these procedures plus the protocols vary from trust to trust.
Please also note that there are simulation sessions in almost every trust to enable health care professionals become more confident in their skills.
As a SHO ( trainee/non trainee) you are expected to learn and do the following procedures independently:
1. Ascetic taps
2. Lumbar punctures
3. NGT placement and checking
4. Pleural aspiration for pneumothorax or pleural fluid
5. Cardioversion, advanced CPR
These are mentioned in the ARCP decision aid for IMT here:
https://www.jrcptb.org.uk/training-certification/arcp-decision-aids
Always observe, then assist , then do it under supervision, do it independently but under supervision and then do it independently and finally, teach your colleagues.
I am going to go through each procedure and my tips I have learnt over the past few years.
ADVANCED CPR
You will do this multiple times when you are on call when there is a CRASH call. Once you are ALS trained ( http://omarsguidelines.blogspot.com/2017/12/my-guideline-for-als.html ), you are expected to lead CRASH calls as well.
My suggestion would be to observe a registrar lead a CRASH call. Then try to lead it next time. Also get used to the RESUS trolley in your trust and try to participate actively in the CRASH call. Reflect upon it in your portfolio so that you can link it to the relevant competencies. Also try to lead a CRASH call and ask the registrar to sign a CBD/mini CEX for that.
https://patient.info/doctor/ascites-tapping
Thanks to the common problem of alcohol abuse, the acute and gastro wards are always full of decompensated alcoholic liver disease patients.
You will get plenty of opportunities to do taps and drains.
Some nurses, ACPs can do them as well so you will have plenty of people to teach you.
Check relevant investigations:
Clotting ( which could be markedly deranged in decompensated liver disease) - however the patient should have received some treatment for it ( Vitamin K)
Hb - make sure the patient is not bleeding. The last thing you want is to stick a needle in an anaemic patient, injure a vessel and make things worse. Platelets- these can be low in decompensated liver disease and may need a senior decision regarding the risk vs. benefit of sticking a needle in.
If the patient has disseminated cancer causing ascites or ascites ? malignant in origin, there can be a risk of seeding the malignant cells in the abdominal wall. Hence, this needs to be a senior decision regarding whether it is reasonable to tap or not.
If the patient has had a huge mesh repair for bilateral hernias - you do not want to penetrate the mesh or cause further complications. Such cases are usually drained via USS guidance.
1.ONLY FOR DRAINS
If it is decompensated liver disease, the patient will have a low albumin. When you remove the ascetic fluid, the fluid from his blood vessels will third space and hence there is a risk of the patient dropping his/her blood pressure and going into shock.
Hence, ALWAYS arrange human albumin solution - the doses may vary from trust to trust but usually it is 20% 100 ml human albumin solution. In my trust, you have to request it on a blood products request card, send it to the transfusion team who can arrange it urgently within 10 to 15 minutes. Group and cross match IS NOT required for this. You also need to prescribe it on a blood transfusion prescription form ( may vary from trust to trust). Remember, ensure that it is available and ready to attach when you are about to perform the ascetic drain. Usually it is 100 ml for every 1.5 to 2 litres drained ( but this varies from trust to trust and even from patient to patient. So ALWAYS read the old letters of the patient to see if any particular regime is followed).
Make sure the patient is cannulated
2. Prepare your equipment:
FOR ASCETIC TAPS- 1 Green needle
- 3 10 ml syringes
- Sterile gloves
- Chloraprep applicators
- A wound care pack - which has sterile gauzes, sheets, sterile gallipot and dressings.
- 3 bottles for collection; usually this includes WCC, C+S, albumin and any tests which have been requested by the consultant ( ie cytology, HMDS, sample for AAFB, etc)- Ensure that they are labelled.
- An assistant (who should be wearing non sterile gloves)
Some trusts have a ascetic tap trolley/kit. This is what it includes:
- Bonanno Catheter - which basically a needle, a guiding sheath and a rubber tubing with a clamp.
- Lidocaine - 1% ( check the date of expiry).
- 3 10 ml syringes
- Orange, green needles
- Drawing up needle
- Catheter bag
- Dressing to secure the Bonanno catheter in place once inserted- Some trusts use cannula dressings ( 2 to 3 )
- A sick bowl ( in case you make a mess)
- 3 bottles for collection (ensure that they are labelled)
- Chloraprep applicators
- A wound care pack
- A trolley
- An assistant (who should be wearing non sterile gloves)
Explain the procedure to the patient in detail. Some trusts have patient information leaflets on this as well.
Explain why you have to do it and what the benefits are.
Then go through the risks which include:
Bleeding, infection, pain, injury to surrounding structures - especially bowels, failure of procedure, multiple attempts, dry tap, unable to get a diagnosis ( if it is a diagnostic tap), reaction to local anaesthetic ( always check allergy status)
Fill out a consent form 1 ( if the patient has capacity) and fill the relevant details. Sign it and then ask the patient to countersign it. Give the carbon copy to the patient and put the original one in the patients notes.
If the patient lacks capacity, fill out a form 4, discuss the above with the next of kin and ask the next of kin to sign if available or otherwise just sign it on your own.
THE PROCEDURE:
FOR ASCITIC TAP
- Ask the patient to lie on their back. Get everything ready and prepare your sterile field. Ask your assistant to open the bottles for you when you request him/her to ensuring that (s)he/ the bottles do not touch the sterile field.
- Percuss the abdomen and confirm the spot you want to go in -usually lateral to the rectus abdominis muscle and go approximately 5 cm superior and medial to the anterior superior iliac spines. You must observe this and then do it under supervision and you will know the exact spot to go in.
- Put on sterile gloves and clean the area with the chloraprep.
- Put a sterile sheet on the areas surrounding the point of insertion.
- Ask your assistant to open a syringe and needle ( (s)he should not touch either- just the plastic wrapper).
- Insert the needle perpendicular to the abdominal wall and aspirate 10 ml. Then remove the syringe and give it to your assistant to flush the fluid into the bottles. Make sure you have a gauze on the needle opening to prevent fluid leaking out and making a mess on the bed (the nurses will not be pleased).
- Insert another syringe into the needle and take 10 ml more. If required, take more ( depending how many sample tests are needed).
- Remove the needle with syringe ( the last one you have aspirated )- carefully hand it over to your assistant to flush into the sample collection bottle.
- Place a gauze on the puncture site ASAP to prevent it from leaking
- Remove gauze and put sterile dressing on.
- Monitor BP, urine output, pulse.
- Remove drain after 4 to 6 hours.
- If any concerns, bleep your gastro reg (from 9 AM to 5 PM) and bleep the medical registrar on call if out of hours. Hand this over to the on call SHO/FY1 to ensure that the drain is removed in case the nurses get busy.
COMPLICATIONS:
Other than the usual, there can be a constant leak from the puncture site. In this case, some consultants suggest putting a stoma bag however there can always be a risk of infection this way. Hence run it past your seniors.
Other than the usual, there can be a constant leak from the puncture site. In this case, some consultants suggest putting a stoma bag however there can always be a risk of infection this way. Hence run it past your seniors.
PEOPLE WHO CAN HELP BUILD YOUR SKILLS:
Gastro registrars
Gastro ACPs who do drains on a regular basis.
LUMBAR PUNCTURES
https://www.nhs.uk/conditions/lumbar-puncture/
As a SHO, you will do these a lot. Not only in your neurology placement but also when you are on call.
SHOs initially shy away from it so I am going to give you some tips:
1. Always observe, assist , then do it under supervision, do it independently but under supervision and then do it independently.
2. When you are doing one for the first time under supervision, make sure that you have a patient who is thin and ha a very good spine. There is nothing like getting disappointed because you cannot puncture the subarachnoid space due to a lot of fat.
3. Take your time to get used to the lumbar puncture kit.
This is what you will need
- Surgical gown
- Sterile gloves ( make sure you have at least 2 pairs- I always manage to rip one pair)
- Sterile gauze pieces
- Dressing
- Sterile drape
- Sterile sheets
- Chloraprep applicators- 2
- 1% lidocaine
- Orange, blue needles, drawing up needles
- LP needle
- Labelled bottles - usually for CSF protein, glucose, WCC, C+S, Xanthochromia and anything additional (like HMDS, cytology, CJD, TB, atypical bacteriae, fungi, viral PCR, oligonclonal bands etc)- it is always advised to send an EXTRA sample for storage purposes ( in case any more tests need to be added).
- An assistant who is wearing non sterile gloves.
Palpate for the anterior superior iliac spines and then draw an imaginary line from both to the spine - this is the point you would want to go in- This is L4/5, You can go here,1 space above it or 2 spaces above it .
Some people like to mark the insertion point by drawing an X with the centre of the X at the insertion point.
Ask the patient to relax and go to the toilet as they will have to lie flat for 45 min after the procedure. I usually make sure they have their phones/a book to read beforehand as they get bored and then start mobilizing after a few minutes.
5. Always read the notes the notes to see if the consultant/registrar need any additional tests - they may request test like HMDS, cytology, CJD, TB, atypical bacteriae, fungi, viral PCR, oligoclonal bands, etc. Also check ( and confirm if not clear) if we need to check the opening pressure.
Ensure that the CT head, clotting and platelets are normal.
6. Consent the patient- explain the procedure, why you are doing it and what are the complications which include:
Pain, headache, bleeding, infection, sharp shooting pain down the legs which is very intermittent and will last a few seconds, failure of procedure, multiple attempts, dry tap, unable to get diagnosis, reaction to local anaesthetic(always check allergy status).
7. Label the bottles beforehand- Always take an extra sample especially if the patient has seen by neurology as the team invariably adds on more tests to the existing CSF samples.
8. Take your trolley and get an assistant. Ask the assistant to reassure the patient if necessary, open the lidocaine for you and hand you opened CSF collection bottles. If it is for xanthochromia in additional to the usual investigations, ensure that the assistant hands you the bottle in a black bag to avoid exposure to sunlight.
9. Get a chair and set the level of the bed so that you are at a comfortable level.
10. Ask the patient to get into the same position you asked him/her to go into ( see point 4 ).
11. Repeat the same process- keep palpating till you know for certain that you have found the right space. I usually warn these patients that I will be prodding their hips and lower spines a lot. Make sure that if it a young female and you are a male doctor, she knows why you are doing this.
12. Open all the necessary equipment in your sterile area and put on sterile gloves. Check the lumbar puncture needle and ensure the stylet is moving freely in the needle.
If you need to check pressures, play around with the manometer and ensure that the stop cock is such a position that the fluid will go up the tube and not out of it.
13. Put sterile drapes on the patients hips ( as you will be palpating the anterior superior iliac spines again) and put a sterile drape under the patient ( in case there is bleeding- avoid soiling the bed PLUS it is aseptic)
14. Palpate the space again.
15. Clean the area with Chloraprep - start at the insertion point and then move in a circle. Make sure that the patients back is exposed as much as possible.
16. Draw up lidocaine after checking the dose and expiry date.
17. Attach an orange needle and after palpating the space again, inform the patient that you are about to inject local anaesthetic, inject enough to make a superficial bleb. Then go slightly deeper.
18. Attach a green needle to the same syringe and then go deeper. Again, inform the patient of what you are doing and inject some, then aspirate ( to ensure you have not hit a vessel), keep repeating the process.
19. Wait for a few seconds to let the local anaesthetic take effect. Explain to the patient that you are now to insert a long but very thin needle. They will feel a pressure and if you injure a nerve they may feel a sharp shooting pain down their legs which will last a few seconds. It is important that they do not move and let you know immediately - the pain will settle as soon as pull out the needle.
20. Palpate the space again. Let your assistant know that you will need the bottles soon. again remind your assistant to hand you a bottle in a black bag to avoid exposure to sunlight if you are checking for xanthochromia.
21. Insert the LP needle - go perpendicular, in the same tract as the local anaesthetic injection and you will feel a give- That is the subarachnoid space.
22. Puncture the subarachnoid space and you will see clear colourless fluid in the LP needle. Take the stylet out and if you need to check pressures, connect the manometer to it. You will see fluid rising in it. Wait till the fluid stops rising and say the figure out loud ( you have no idea how many times people forget what it was later on - your assistant will always remember). Open the stopcock and ask your assistant to give you the bottles - put in 10 to 20 drops ( or as per protocol) in each bottle. Then remove the manometer and immediately put in the stylet.
23. If you are not checking pressures, ask your assistant to hand you the opened bottles.
24. It is a good idea to count the number of drops going into each bottle loudly so that you do not forget.
25. Once the samples have been collected, put the stylet in ASAP and then remove the needle.
26. Put a dressing on, thank the patient and ask them to lie on their back.
27. Get rid of the sharps, clean your mess ( please do not leave it at the bedside)
28. Document everything in the notes, thank your assistant and then call the lab- in some trusts you have to inform the lab ASAP.
29. Hand deliver the samples to the lab or request a porter to take them
DOING A LUMBAR PUNCTURE WITH THE PATIENT SITTING UP
This CANNOT be used to check CSF pressure.
The anaesthetic team is particularly keen on doing lumbar punctures in this position - especially if it is a difficult one.
You ask the patient to fold their arms and put them on a table ( with a pillow) and bend forwards as much as possible. This makes the intervertebral spaces even wider. The rest of the technique is the same.
COMMON PROBLEMS:
1. Hitting bone constantly.
Take the needle out. Confirm position again - read point 4. Sometimes you can change the angle of the needle whilst it is in the spine especially in the elderly who have degenerative bone diease.
2. Post LP headache - always ensure you put the stylet into the needle before taking it out.
- Position is everything
- If you cannot palpate a space, inform your registrar that you will have a go if you are certain that you will get it but you may need his/her assistance. So request him/her to be aware ( ask your assistant to bleep him/her if you struggle).
- Always read the notes to see what investigations are needed
- Take this opportunity to teach your assistant - be it a medical student, a fellow colleague, a nurse or a HCA. Everyone is keen to learn. Ask them to palpate the space before you make it all sterile
- Talk your patient through the procedure, before doing it and after doing it.
- Do not rush - never do a LP if you have a few minutes before handover.
- Avoid doing LPs overnight - the on call team is very busy and this process may take a good 30 minutes
- Hand over your on call bleep to a colleague when you are doing the procedure.
- Document the whole procedure in detail.
- If you cannot palpate a space, do not try to attempt the procedure. This holds true for people with a high BMI ( who may need a longer needle ).
- Know who can help in case you cannot get a sample. If you as a SHO cannot get a sample, ask your reg. If (s)he struggles, then ask the anaesthetics team ( you need to talk to them - preferably face to face and book the patient into theatres. Ensure that you have informed them if you want to check CSF pressure and what they need to do if it is high, how many samples they need to send and please label all the bottles, consent the patient and be prepared to go with the patient as they need someone to take the bottles to the lab, plus you get to learn how to do difficult lumbar punctures). If the anaesthetic team cannot do it, the interventional radiologist can do it under X ray guidance. Some can also do it under USS guidance as well.
- If this is the first actual LP you are doing ( under supervision), make sure you have a compliant, thin patient. This will make you more confident.
- Keep doing lumbar punctures.
PEOPLE WHO CAN HELP BUILD YOUR SKILLS:
Neurology registrars
Neurology physician associates/specialist nurses who do LPs on a regular basis
Medical registrars
ITU registrars
NG TUBE INSERTIONS
As a SHO, you may not get to do these a lot. Which is why you tend to get deskilled easily. It is a good idea to continue doing NGT insertions whenever you get the chance.
Every trust has its own protocols.
These are the important indications to be aware of:
1. Feeding - in decompensated liver disease, anorexia.
2. Poor swallow - stroke, neurological conditions like MND, Parkinson's, Myasthenia.
3. Gastric dysmotility.
1. Patient refusal - ensure that you have checked their capacity to refuse a NGT and they understand how important this is.
2. Gastric surgery - like gastric bypass. There is high risk of perforation. Usually the endoscopists pass a NJ tube with endoscope guidance
3. Varices ( Usually the endoscopists pass a NJ tube with endoscope guidance).
4. Chemical ingestion - high risk of perforation.
1. NG tube with guide wire
2. Lubricating jelly
3. Enteric syringe to aspirate fluid
4. pH strips to check if the aspirate is acidic.
5. A sick bowl
6. An assistant to hold the patients hands- as this is a very uncomfortable procedure and it can make things worse for an already agitated patient.
7. Any local hospital NGT insertion protocols ( stickers, booklets, etc).
1. It is advisable to have an assistant who can reassure the patient.
2. Open the NG tube packet and measure the distance from the tip of the nose, around the ear to the xiphisternum. The marking on the NG tube is the minimum mark the NG tube should be inserted.
3. If the local protocol allows it, lubricate the tip using lubricating jelly ( some trusts have lubricated NG tubes)
4. Ask the patient to sit up as much as possible.
5. Remember the anatomy of the nose- the tube should be angled very slightly through the nostrils ( towards the ears rather than the head)
6. When you insert the tube in the nostril, ask the patient to swallow ( if not nil by mouth, allow them to have a sip of water, if nil by mouth ask them to swallow their saliva)
7. Pass the NGT as quick as possible. The quicker you go, the less is the chance of the patient feeling any discomfort.
8. It should easily pass.
9. Stop at the marking you measured before and then insert it 5 to 6 cm more to leave enough leeway in case it dislodges.
10. Tape it to the nose and aspirate fluid out of the NG tube
11. Check the fluid against pH paper - if it is aciditc, you can be assured that it is in the right place.
12. You can then remove the guidewire.
13. If you do not get an aspirate, request an urgent CXR to ensure that the NGT tip is below the diaphragm. LEAVE THE GUIDE WIRE IN till the CXR confirms the position.
14. Document in the patients notes.
Common problems:
1. The NGT comes out of the mouth
This is because of an uncooperative patient, poor positioning. You could try some mild sedation if appropriate.
2. There is no aspirate - this may mean 2 things- The NGT is in the wrong place or the patient does not have a lot of gastric contents. A CXR is necessary.
3. Unable to pull the guidewire out. This happens when the NGT is kinked. Just pull it out ever so slightly ( ensuring the mark at the nostril is still more than what the nose to xiphisternum distance is) and then see if the guide wire can be pulled out.
4. The patient keeps pulling the NGT out.
In this case, a bridle may be appropriate which is a piece of string attached to 2 plastic rods with magnetic tips used to secure the NGT in place.
HOW TO INSERT A BRIDLE:
This may vary from trust to trust.
You can ONLY insert a bridle once the guide wire has been removed - Ie the NGT is in position as confirmed by acidic aspirate or a CXR.
Open the bridle kit and see if the magnetic tips of the rods are functioning ( ie are the tips sticking to each other?)
You will see a piece of string going through one of the rods.
Insert one of the rods with the string going through it into the nostril which has the NGT inserted- magnetic tip inwards.
Insert the free rod through the other nostril.
You will feel the magnetic tips click.
When that happens, pull the rod in the NG free nostril out and the string will automatically come out.
Then remove the first rod by pulling on it and holding the string at the other nostril.
Now you will have a piece of string coming out of both nostrils, secured to the back of the nose ( around the vomer bone)
You then attach a clip to secure both strings and NG tube, then make a knot on the string distal to the clip to prevent the string from slipping out.
Cut the extra pieces of string and then document in the notes.
PEOPLE WHO CAN HELP BUILD YOUR SKILLS
Gastro registrars
Gastro specialist nurses/ACPs/Physician associates
Stroke nurses
Stroke registrars
Medical registrars
I am going to skip pleural aspiration and chest drain insertions for now and will discuss these later. Please contact your local respiratory team as you will learn more by seeing these procedures plus the protocols vary from trust to trust.
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