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PDF eBook Study Guide
This page intentionally left blank
Practical Procedures
in Anaesthesia and
Critical Care

Dr Guy Jackson
Consultant Anaesthetist,
Royal Berkshire Hospital,
Reading, UK

Dr Neil Soni
Consultant Anaesthetist and Intensivist,
Chelsea and Westminster Hospital,
London, UK

Dr Christopher Whiten
Consultant Anaesthetist,
Charing Cross Hospital,
London, UK

Illustrations by
Jesse Brown

1
This page intentionally left blank
 v

Acknowledgments

We would like to thank the following for their permissions: Association of Anaesthetists
of Great Britain and Ireland; Difficult Airway Society; National Patient Safety Agency;
Portex; Resuscitation Council (UK).
Thank you also to: the microbiology and infection control departments at the Royal
Berkshire Hospital; Jesse Brown for his great illustrations and patience dealing with us;
Mark Bryant, Radiology Specialist Registrar in the Wessex Deanery, for supplying many
of the x-ray and ultrasound images; Gary Croucher for his help with photography; all the
patients who kindly consented to photography.
GJ, CW, NS
Finally, a big thank you to my wife, Georgia, and my children who put up with me during
the hours of writing!
GJ
This page intentionally left blank
 vii

Contents

Abbreviations xi
Introduction xiii

Chapter 1 Basic Principles 1

Hand washing 2
Aseptic technique 7
Consent 11
Environment, safety and additional equipment 12
Ultrasound in anaesthesia and intensive care 13
Cardiopulmonary resuscitation 14

Chapter 2 Intravascular Access 21

Peripheral venous cannulation 22
Central venous access 26
Ultrasound guidance for intravenous central line insertion 30
Seldinger technique 33
Railroading 36
Internal jugular vein CVC insertion 38
Subclavian vein CVC insertion 42
Femoral vein CVC insertion 45
External jugular vein cannulation 48
Tunnelled central venous lines 50
Peripheral sites for central venous access: peripherally inserted central catheter
(PICC) lines 52
‘Special’ lines 56
Pulmonary artery catheter 56
Intraosseous needle insertion 59
Lines for haemofiltration/dialysis 62
Dialysis 64
Arterial line insertion 66
Rapid infusion devices 68
Transducers 70

Chapter 3 Monitoring 71
‘Routine’ anaesthetic monitoring 72
12-lead ECG 73
Cardiac output monitoring 75
Intra-abdominal pressure measurement 77
Arterial blood gas sampling 78
viii
Chapter 4 Airway Procedures 81
Airway maintenance 82
Positioning 82
Oropharyngeal airway (aka Guedel Airway) 84
Nasopharyngeal airway 86
Facemasks 88
Laryngeal mask airways 90
Tracheal intubation 95
Oral tracheal intubation 95
Nasal intubation 101
Bougies and other intubation aids 104
Contents

Rapid sequence induction (RSI) 106

Double lumen tube insertion 111
Airway devices and ‘special’ airways 117
Video-laryngoscopes 118
Difficult intubation 120
Retrograde tracheal intubation 125
Emergency airway access 129
Cricothyroidotomy 129
Fibreoptic intubation 135
Percutaneous tracheostomy 142
Insertion of a tracheostomy 144
Changing a tracheostomy 149
Bronchoscopy 151
Ventilation 156
Mechanical ventilation 156

Chapter 5 Thoracic Procedures 163

Needle thoracostomy for chest aspiration 164
Aspiration of tension pneumothorax 164
Aspiration of pleural effusion/haemothorax 166
Intercostal drain insertion 169
Surgical chest drain insertion 169
Seldinger chest drain insertion 173
Removal of a chest drain 175
Pericardiocentesis 177
Temporary cardiac pacing 179
External temporary cardiac pacing: percussion pacing 179
External temporary cardiac pacing: transcutaneous pacing 181
Internal temporary cardiac pacing 182

Chapter 6 Abdominal Procedures 185

Nasogastric and nasojejunal tube placement 186
Nasogastric tubes 186
Nasojejunal tubes 192
Sengstaken–Blakemore and Minnesota tube placement 194
Urethral catheterization 198
Abdominal paracentesis 202
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 ix
Chapter 7 Neurological and Related Procedures 207
Local anaesthesia 208
Lumbar puncture 210
Spinal anaesthesia 214
Epidural anaesthesia analgesia 219
Epidural analgesia troubleshooting 227
Intracranial pressure monitoring 229

Index 233

Contents
This page intentionally left blank
 xi

Abbreviations

AAGBI – Association of Anaesthetists of Great Britain and Ireland

ANTT – aseptic non-touch technique
ARDS – acute respiratory distress syndrome
ASB – assisted spontaneous breathing
BAL – bronchoalveolar lavage
BiPAP – bi-level positive airway pressure
BP – blood pressure
C-spine – cervical spine
CBF – cerebral blood flow
CMV – controlled mandatory ventilation
CNS – central nervous system
COPD – chronic obstructive pulmonary disease
CPAP – continuous positive airway pressure
CPP – cerebral perfusion pressure
CPR – cardiopulmonary resuscitation
CRRT – continuous renal replacement therapy
CSF – cerebrospinal fluid
CVC – central venous catheter
CVS – cardiovascular system
CVVH – continuous venovenous haemofiltration
CVVHD – continuous venovenous haemodialysis
CVVHDF – continuous venovenous haemodiafiltration
CXR – chest X-ray
DAS – Difficult Airway Society
ECG – electrocardiogram
ENT – ear, nose and throat
ETCO2 – end-tidal carbon dioxide
FRC – functional residual capacity
GCS – Glasgow coma scale
GI – gastrointestinal
HCWs – healthcare workers
HDF – haemodiafiltration
HF – haemofiltration
HFJV – high-frequency jet ventilation
HFO – high-frequency oscillation
ICP – intracranial pressure
LMA – laryngeal mask airway
LP – lumbar puncture
MAP – mean arterial pressure
NG – nasogastric
NICE – National Institute of Clinical Excellence
NIV – non-invasive ventilation
xii
NJ – nasojejunal
PAC – pulmonary artery catheter
PCV – pressure-controlled ventilation
PAoP – pulmonary artery occlusion pressure
PEEP – positive end-expiratory pressure
PICC – peripherally inserted central catheter
PPCD – post-paracentesis circulatory dysfunction
PRAM – pressure recording analytical method
PS – pressure support
RS – respiratory system
RSI – rapid sequence induction
Abbreviations

SAH – subarachnoid haemorrhage

SIMV – synchronized intermittent mandatory ventilation
SIRS – systemic inflammatory response syndrome
TIVA – total intravenous anaesthesia
TPN – total parenteral nutrition
TT – tracheal tube
UF – ultrafiltration
USS – ultra-sound scan
 xiii

Introduction

A book on practical procedures may seem to some superfluous in the era of the
Internet, but not to us. A practical procedures book is a familiar friend to be kept at
hand; one needs to know the book and where to find the information one wants. As
doctors we need to be familiar with a particular approach to a technique. What we do
not want to do is to try something new, a variation on a theme, which appeared on the
internet, in the early hours of the morning. The ability to perform a wide variety of
practical procedures safely and competently is essential for any doctor involved in the
practice of anaesthesia and intensive care. Not all of us do all of them regularly, but
most of us get called upon to do most of them at some time, often a time not of our
choosing. We were taught that one cannot escape statistics and that some procedures
carry an intrinsic complication rate but we also believe that attention to detail can keep
those complications at the lowest level possible. That is your responsibility to your
patients. This book, we hope, will be a helpful companion to those practising proce-
dures and a reassuring safeguard for those undergoing procedures.
The morbidity associated with many procedures may be minimized by ensuring prac-
titioners have familiarity and competence. Historically this has been achieved through
long hours at work and learning by example – ‘see one, do one, teach one’. However,
the reduced hours and changing work patterns of recent times have made the acquisi-
tion of practical skills more difficult. In our experience it is still not uncommon for junior
anaesthetists and intensivists to be faced with having to perform certain procedures
with which they have little familiarity. This is especially true ‘out of hours’. One of the
authors performed admirably on his first night as a house officer by teaching himself
how to record a 12-lead ECG when all around refused to help! It is clear that a book
cannot replace practical instruction and formal clinical supervision when it comes to
learning practical procedures and none of the techniques described hereafter should be
attempted without proper training. However, having a familiar aide-memoire is not only
reassuring but also sensible.
To ensure safety, there is no substitute for adequate preparation. Preparation starts
with a careful risk/benefit analysis, requires knowledge, which may need refreshing, and
needs skill, which implies practice or at least experience. Attention to detail encom-
passes checking equipment before starting, meticulous attention to cleanliness, and care
throughout the performance of a procedure. Post-procedural follow up is also very
important and requires a checklist of the potential problems to look out for, a checklist
that most of us do not carry, supratentorially, at all times.
We have written this book in the hope that it will be of use to trainees when familiar-
izing themselves with procedures they are being taught to perform, and also as a refer-
ence tool for use at the bedside when performing those procedures alone. We have
endeavoured to keep the emphasis on the practical nature of the techniques, hence the
use of pictures and illustrations. In addition, we have included many ‘handy hints’ that
xiv
we have picked up over the years, which may help others to achieve success with diffi-
cult procedures. We cannot take credit for these and therefore send our thanks to all
of the wise folk with whom we have worked in the past.
We would welcome your feedback on the book. Please do let us know of any tips or
advice you might have for any of the procedures in this book. All comments are grate-
fully received and can be emailed to us at ost@oup.com.

Guy Jackson
Neil Soni
Chris Whiten
2010
Introduction

Note:
Please note that some of the photos are intended to demonstrate surface anatomy and
have therefore been taken with no attempt to achieve sterility. We promote the highest
standards of sterility as demonstrated by our text on the subject.
 1

Chapter 1
Basic Principles
 2
Hand washing
• There has been huge interest in this topic recently, both within medical publications
and the media.
• Hands are the most common way in which micro-organisms, particularly bacteria,
can be transmitted and subsequently cause infection, especially to those with
increased susceptibility. In order to prevent the spread of micro-organisms via this
route to those who might develop serious infections while receiving care, hand
hygiene must be performed adequately and consistently. This is considered to be
the single most important practice in reducing the transmission of infectious agents,
1 Basic Principles

and preventing healthcare-associated infections, during delivery of care.

• Every person encountered could be carrying potentially harmful micro-organisms
that might be transmitted and cause harm to others. For this reason, hand hygiene is
one precaution that must be applied as standard.
• Many hospital trusts now operate a “bare below the elbow” policy following
guidance from the Department of Health (Department of Health, 2007).
• The term hand hygiene (decontamination) refers to a process for the physical
removal of blood, body fluids and removal or destruction of microorganisms from
the hands by hand washing with liquid soap and water and hand decontamination
achieved using an alcohol based hand rub.
• Be aware that different techniques may be applicable to different organisms.
For example, MRSA requires alcohol-based hand cleaning while Clostridium difficile
spores need soap and water handwashing.
Definitions
• Social Hand Hygiene
 This aims to render the hands physically clean and to remove micro-organisms

picked up during social activities (transient micro-organisms).

 Transient flora, which colonize the superficial layers of the skin, are more

amenable to removal by routine hand washing. They are often acquired by health
care workers (HCWs) during direct contact with patients or contact with
contaminated environmental surfaces within close proximity to the patients.
Transient flora includes the organisms most frequently associated with healthcare
associated infections.
• Hygienic Hand Hygiene
 Used to remove or destroy transient micro-organisms and to provide residual

protection at times when hygiene is particularly important in protecting yourself

and others, by reducing resident micro-organisms.
 Resident flora, which are attached to deeper layers of the skin, are more resistant

to removal. In addition, resident flora can cause infections when they are
introduced during invasive procedures such as the insertion of intravenous (IV)
lines or during surgery.
• Surgical Hand Hygiene
 Aims to remove or destroy transient micro-organisms and substantially reduce

those micro-organisms which normally live on the skin (resident micro-organisms)

at times when surgical procedures are being carried out.
 See ‘aseptic technique’ section.
 3
Indications
• Before:
 entering/leaving clinical areas

 patient contact

 handling a patient device

 putting on gloves

 preparing/giving medications

 moving from a contaminated body site to a clean body site during

1 Basic Principles
patient care
 using a computer keyboard or mouse (in a clinical area)

 eating/handling of food/drinks

 aseptic procedures

 different care activities for the same patient.

• After:
 patient contact

 hands becoming visibly/potentially soiled

 visiting the toilet

 using computer keyboard (in a clinical area)

 handling laundry/equipment/waste

 blowing/wiping/touching nose

 any contact with inanimate objects (e.g. equipment, items around the patient) and

the patient environment

 handling body substances

 removing gloves

 contact with patients being cared for in isolation

 being in wards during outbreaks of infection.

Contraindications
• None
Complications
• Contact dermatitis
Equipment
• Alcohol based hand gel:
 must only be used on visibly clean hands. It offers a quick and effective hand

decontamination option between care tasks not involving body fluids.

• Liquid soap and water:
 must be used when hands are visibly/potentially soiled with blood or other body

fluids.
• Combination of the above:
 where infection with a spore forming organism e.g. Clostridium difficile is

suspected/proven.
 where infection with viral gastroenteritis e.g. Norovirus is suspected.

Sites
• As indicated in Figures 1.1−1.2.
• Commonly missed sites during hand cleaning can be seen in Figure 1.3.
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