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Basics of Emergency Medicine
Workshop V. Surgical vein preparation, Seldinger
technique, Urether catheterization, Nasogastric
tube insertion
Department of Anaesthesiology and Intensive
Therapy Institute of Surgical Research Department
of Emergency Medicine
Year 2015-2016 / 1st semester
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Surgical vein preparation

• Venous cutdown, that is surgical exposure of a
  peripheral vein, is necessary if it is impossible
  to insert a cannula into a satisfactory vein - or
  the percutaneous insertion of a vena cava
  catheter is contraindicated.
• Indications for catheterization of a vein
• Continuous CVP monitoring
• Replacement of fluids (infusion, transfusion)
• Iv. administration of drugs
• 4. Obtaining serial blood samples

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Surgical vein preparation I.

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

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Surgical vein preparation II.

• Implementation
• Performed by surgeon aseptic (operathing
  theatre) environment
• Under general anaesthesia (if contraindicated
  strong pain killers and infiltration of local
  anaesthetic)
• Skin incision above a superficial vein, blunt
  dissection of soft tissues, free dissection of
  the vein, small incision on the vessel,
  introduction of the catheter)

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Venasection - cannulation of a peripheral vein
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Removal of venous catheter
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Venous catheter can be introduced for CVP
measurement into the following veins 1. External
jugular vein 2. V. subclavia Arm veins (median
cubital vein, basilic vein)
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Central venous pressure (CVP)
The CVP indicates the right ventricular preload
(the rate of venous inflow). The CVP is
influenced by several factors, and in critically
ill patients its predictive value in giving a
measure of the filling of the intravascular space
is limited. In extreme situations, it
demonstrates the severity of hypo- or
hypervolemia.

• The CVP is elevated in cases of
• Increased intrathoracic pressure, at ventilation
  with positive pressure
• Impaired cardiac function (heart failure,
  pericardial tamponade)
• Hypervolemia (overfilling)
• Superior vena cava obstruction

• The CVP is decreased
• Reduced intrathoracic pressure (e.g.
  inspiration)
• In cases of obvious hypovolemia (if a volume
  challenge of 250500 ml of crystalloid causes an
  increase in CVP that is not sustained for more
  than 10 min, this is suggestive of (relative)
  hypovolemia)

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Seldinger technique (central vein insertion,
arterial and venous cathetarization)
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Seldinger technique I.

• Application
• minimally invasive procedures
• E.g.
• Common Interventional Radiology Procedures
• - procedures on arteries angiography
  percutaneous transluminal angioplasty arterial
  stenting, tu. embolisation..stb)
• - procedures on veins TIPS thrombolysis in
  DVT varicocele embolization, port insertion )
• 2. Central vein insertion for hemodynamics
• (fluid replacement, drug administration and
  parenteral feeding, intensive care monitoring
  etc)

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Seldinger technique II.
Insertion place Arteries femoral or brachial
artery (less frequently the radial or the
popliteal artery) In case of veins common
femoral vein, internal jugular or subclavian vein
Implementation with palpation of the pulse or by
means of ultrasound guidance
Venous port
Embolisation of uterinal artery
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Seldinger technique III.
1. Insert Braunüle into the lumen of the vessel
2. Remove the needle
3. Flexible guidewire into the central vein
4. Remove the sheat of Braunüle
5. Dilation device
6. Central vein canula
Removal of guide wire
Note In case of special, so called Seldinger
needle, the 1st and 2 nd steps are the same,
because there is no plastic sheat
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1. Measurement of central venous pressure
Centra venous catheter
Pressure transducer
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2. Measurement of arterial pressure in the
femoral artery
Arterial catheter
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Arterial/venous catheterization with percutaneous
punction
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Cardiac Output measurement with a transpulmonary
thermodilution method
Central venous catheter
Injectate saline temperature sensor housing
Temperature sensor
Pressure transducer
Arterial thermodilution catheter
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Scheme for the Transpulmonary Thermodilution
Method

Cold saline bolus injection
Lung
Thermistor catheter in aorta

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The thermodilution curve
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Measurement of Cardiac Output (CO)
A known volume of cold saline (5-10-20 ml) is
injected iv, as fast as possible. Saline
temperature is at least 10C lower than blood
temperature. The passage of the heat bolus
injected into the central vein is registered by a
thermistor catheter positioned in the femoral
artery. The temperature change recorded
downstream is depending on the flow and on the
volume through which the cold indicator has
passed. As a result, a thermodilution curve can
be obtained. The cardiac output is calculated
from the area under the thermodilution curve.
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Urinary system monitoringCatheterization of the
bladder
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Urether catheterization
Definition artificial emptying of the urinary
bladder. Aims therapeutic (urine retention,
incontinence, preoperative preparation)
diagnostic (monitoring fluid status,
urologic/microbiologic tests) Principles of
catheterization - catheterize only if it is
necessary - avoid catheterization in case of
urethral injuries - catheterize in accordance
with the rules of asepsis!
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Catheters Material synthetic, latex or
silicone. Size external diameter is given in
Charriére (1 Ch) or 1 French (1 F) (0.33 mm) The
most widely used 14-22 Ch Foley-catheter (with
balloon, easy fixation).
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Tools for catheterization - catheter in
appropriate size - urine container sack and
tube - sponges for cleaning of genital area -
disinfectant - saline (in syringe) to fill the
balloon - sterile lubricant (Instillagel) -
sterile gloves
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Male catheterization - Lift the penis (about 60
degrees) with left hand and retract the
foreskin - Clean the urethral meatus with
disinfectant 3 times - Inject some Instillagel to
the urethra - Insert the catheter into the
urethra withsterile forceps - Fill the balloon
with 10 ml saline - Pull back the catheter until
the balloonallows - Connect the urine container
sack to thecatheter.
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Male catheterization
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Removing the catheter in males
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Female catheterization - Spread the labia gently
with left hand - Clean the introitus with
disinfectant 3 times - Grasp the catheter with
sterile forceps at some cm-s from the end - Put
Instillagel onto the first some cm-s of the
catheter - Insert the catheter gently into
theurethra - Connect the urine container sackto
the catheter - Fill the catheter with 10 ml
saline - Pull the catheter back.
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Female catheterization
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Female catheter removal
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The aims of taking urine samples

• Simple examinations of the urine
• Inspection, and measurement of specific gravity
  and osmolarity
• Microscopic examinations
• Qualitative and quantitative lab tests
• Microbiological examination
• Assessment of the fluid status
• Urine collection for 24 h daily fluid balance.
  Determination of fluid intake and output
• Hour diuresis in patients in shock, or with
  burns, critical circulatory disorders, renal
  insufficiency

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• Enteral Feeding
• Nasogastric tube insertion

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Enteral feeding

• Parenteral feeding
• Enteral feeding (tubes)
• Planning gastroenteral feeding is preferred
  beacause it is more physiological

• Short term feeding
• (max. 2-3 weeks)
• Nasogastric tubes
• Orogastric tubes
• Nasoduodenal tubes
• Nasojejunal tubes

Long term feeding (stomas) Oesophagostoma Gastro
stoma Jejunostoma Percutan endoscopic
gastrostoma Percutan endoscopic jejunostoma
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Who needs an NG tube

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

Indicated for those clients who do not want/
cannot/ must not eat
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• Gather equipment for nasogastric tube insertion
• 14 0r 16 Fr NG tube
• Lubricating jelly
• Syringe 50-60 ml
• pH test strips
• Tongue blade
• Flashlight
• Emesis basin
• Catheter tipped syringe
• 1 inch wide tape or commercial fixation device
• Suctioning available and ready
• Preparation of the patient (high Fowler
  position)

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NG insertion-video
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NG tube insertion I.

• Inform the patient
• Patient is laid in a fowler, or in a semi-fowler
  position (in case of unconciuosness)

Semi-fowler position
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NG tube insertion II.

• Handwash
• Gloving
• Assess the patency of the tube
• Measure the required tube length (until the ear
  lobe and the xyphoid process)
• Preparation of the tube (bending, lubricant)

Measure the length of the tube
Lubricant
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NG tube insertion III.

• Introduce at an acute angle at first then push
  forward toward the nasopharynx
• After getting through the nasopharynx the patient
  should bend his head

introduction
After a few cm push parallel with the nose
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NG tube insertion IV.

• The patient take breath throuh his mouth during
  the whole procedure
• Tube can get through the oropharynx during
  swallowing (we pretend it by moving the
  epiglottis on the manikin)

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NG tube insertion V.

• After getting through the oropharynx, check the
  location of the tube (in case of breathing sounds
  take it out)
• Introduce the tube gradually during every
  swallowing
• Do not force the introcuction (in case of any
  obstruction take it out)
• Fix the tube with plaster around the nose

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Nasogastric tube insertion-video
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NG position
right
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Checking

• Confirm satisfactory tube positioning before
  starting tube feed
• aspirate for pH and color
• Stetoscope
• X-ray
• Monitor intake and output
• check the position of the tube before every
  feeding (at least in every 12h)

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• Task on the practice
• Applying Seldinger technique on dummy
• Male and female urinary catheterisation on
  manikin in pairs (physician and assistant)
• Insertion of nasogastric tube on manikin