Being a new intern is a bit scary
23/08/2011 at 11:58 AM
Being a new intern is a bit scary. You are fresh out of med school, still not certain about your clinical knowledge, in a new place with plenty of responsibility and pressure to succeed.
The following blog series is dedicated to the new surgical intern, me being amongst them.
I gathered information from different web sites and forums which may be helpful for those of you who have been searching for some guidance to have all the necessary info in one spot. For all the med students out there, this may give some perspective as to what might be awaiting for you after med school.
Issues that will be raised include pre & post operative management, minor surgical procedures, proper dictation, important cheat sheets, info on the work load, tips on how to organize your time and links to important web pages.
Minor surgical procedures
The new intern will be expected to perform some minor invasive procedures which will most likely include the placement & removal of different catheters & tubes. These include: Foley catheters, nasogastric tubes, chest tubes, central lines & peritoneal drainage.
Central venous catheterization ("Central Line")
Intermediate term Peripherally Inserted Central Catheters ( PICCs) are mostly for home use in patients requiring antibiotics or total parenteral nutrition (TPN) for a period of up till 6 months. This catheter is inserted through a peripheral vein such as the Basilic v. and then advanced into the junction of the SVC and the right atrium. It has minimal complication risk, but since it is very small and long (60cm) it may be occluded easily.
Long term tunneled CVADs are used in patients requiring treatment of more than 6 months. A double cuff stabilizes the catheter in place and prevents bacterial migration. Two of the most commonly used catheters in this category are the Hickman & the Groshong.
The Groshong differs only by a valve which seals it from the bloodstream therefore not requiring daily heparinized saline wash and is suitable for heparin allergic or HITT patients.
Hickman
Groshong
Implanted venous ports are also used for a long term period of over 6 months. The internal jugular vein is usually used with this type of catheter and a subcutaneous reservoir is placed in the infraclavicular fossa. This type of catheter provides less maintenance and minimal infection risk.
Finding the veins may be a very difficult task. You may need to review your anatomy and if an US is nearby, don't hesitate to use it.
All catheter placements require the same patient preparation which includes placing the patient in Trendelenberg position, to prevent air emboli, skin preparation with 70% Propanal or 0.5% Chlorhexadine followed by 10% Povidone Iodine. 1% lidocaine is then administered subcutaneously.
The Seldinger Technique has made catheter placement relatively easy. A flexible guide wire is passed into the vein through a 14 gauge probe needle. Constant negative pressure on the syringe will show when the vein is found. The needle is then removed over the wire; a nick in the skin at the puncture site is made to make space for a dilator which creates a tract for the catheter. Always maintain control of the guide wire! The central venous catheter is then introduced over the wire & advanced to 15- 20 cm so that its tip is at the junction of the Superior vena cava (SVC) & the right atrium.
Aspiration of blood from all catheter lumens & then flushing with saline, confirms the catheter position in the vein & that all its parts are functional. The catheter is then sutured to the neck at 2 sites & a sterile dressing is put over it. A Chest X- Ray (CXR) is then preformed to confirm the location of the catheter and to rule out Pneumothorax (PTX).
Complications of CVAD insertion include PTX, injury to neighboring arteries injury, arrhythmias, especially when entering the r. atrium, air emboli and infection, usually due to coagulase negative staphylococcus.
The Subclavian vein is the preferred vein for cannulation. It is the most comfortable site for the patient, the easiest to maintain and has the lowest infection risk. Its disadvantages are the relatively rare complications such as pneumothorax and subclavian artery puncture, which are commoner at this site.
The Subclavian vein is posterior to the clavicle where it joins the Internal Jugular vein to form the SVC.
Find the SCM. This muscle splits into a medial part which inserts on the sternum and a lateral part which inserts on the clavicle. Find the spot where the lateral part inserts on the clavicle. The Subclavian vein lies under the clavicle at this point. The vein can be entered from above or below the clavicle. Avoid deep penetration.
The infraclavicular approach requires pointing the needle upward towards the ceiling and once the vein is entered, the needle should be rotated to 3 o'clock so that the guide wire enters the SVC.
The supraclavicular approach is easier. Find the angle between the clavicle and the lateral part of the SCM. The needle should be entered so that it bisects this angle. Direct the needle under the clavicle in direction of the opposite nipple. When entering the vein turn the needle to 9 o'clock so that the guide wire enters the SVC.
The Internal Jugular vein (IJV) is easy to access but uncomfortable for the patient. The right IJV is preferred due to a straighter course into the r. atrium, which also makes it the most suitable approach for temporary pacemaker placement. The IJV is also preferred when using US, since it is more identifiable than the Subclavian vein.
The common carotid pulse can be felt on the medial border of the SCM. The IJV is lateral to the common carotid artery. Find the triangle created by the two parts of the SCM. Insert the needle lateral to the carotid pulse at the apex of this triangle. The needle is advanced toward the ipsilateral nipple at a 45 degree angle with the skin surface. The vein should be encountered within 5cm of insertion.
The femoral vein is the easiest to find and preferred for trauma settings and cardiopulmonary resuscitation, except when there is an injury to the IVC. A major disadvantage for its elective use is the high risk for infection and venous thrombosis in this region.
Palpate the femoral artery pulse below the inguinal crease. Insert the needle 2cm medial to the pulse at a 30 degree angle. If the femoral pulse isn't palpable such as in shock situations, estimate the Femoral artery at midpoint between the anterior superior iliac spine and the pubic tubercle. The Femoral vein will be 2cm medial to this point.
Knowledge regarding catheter care is important to prevent post insertion complications.
Sterile occlusion dressing should be changed weekly and catheter lumens should be flushed regularly with heparinized saline to prevent thrombosis.
If thrombosis of the catheter is suspected, perform an n US Doppler/ venography. If confirmed, give antithrombotic to restore the catheter function. If this is unsuccessful remove the catheter & give systemic anticoagulation.
If catheter related bacteremia is suspected, take a blood culture from the catheter & another from a vein elsewhere. If the culture from the catheter grows bacteria
Many med students have probably been asked to draw blood samples from patients with CVADs and didn't really know the exact procedure. So here it goes….
Equipment:
Gloves, 1- 10 cc sterile syringe (to discard blood), 1- 5 cc or 10 cc sterile syringe for collection of blood sample, 1- 5 cc syringe with 5 ml of normal saline solution to flush the line after blood sampling, 1-3 cc syringe with 3 ml of Heparin Flush Solution (1:100), Blood tubes, Alcohol wipes.
Technique:
1. Wash hands.
2. Explain procedure to patient.
3. Apply gloves.
4. If the central line has a stopcock, blood should be drawn from the stopcock.
5. Attach a 10 cc syringe to the stopcock.
6. Gently aspirate 5 or 10 cc of blood.
7. Remove syringe and discard appropriately.
8. Attach a new 5 or 10-cc syringe to stopcock or buff cap port (depending on the amount of blood required).
9. Gently aspirate the amount of blood required for sampling.
10. Flush line and port with 5 cc of normal saline and followed by 3 cc of Heparin Flush solution.
11. Inject required amount of blood to the blood tube.
12. Remove and discard gloves and used supplies in appropriate receptacle.
13. Document the Heparin Flush in the patient's medical records.
CVAD removal also requires a special procedure.
Equipment:
A sterile suture removal set, sterile and nonsterile gloves, occlusive dressing, antimicrobial ointment, 4x4 sterile gauze pads, tape, and a measuring tape
Technique:
The following blog series is dedicated to the new surgical intern, me being amongst them.
I gathered information from different web sites and forums which may be helpful for those of you who have been searching for some guidance to have all the necessary info in one spot. For all the med students out there, this may give some perspective as to what might be awaiting for you after med school.
Issues that will be raised include pre & post operative management, minor surgical procedures, proper dictation, important cheat sheets, info on the work load, tips on how to organize your time and links to important web pages.
Minor surgical procedures
The new intern will be expected to perform some minor invasive procedures which will most likely include the placement & removal of different catheters & tubes. These include: Foley catheters, nasogastric tubes, chest tubes, central lines & peritoneal drainage.
Central venous catheterization ("Central Line")
The catheterization of a large vein can be done using the Internal Jugular vein, the Subclavian vein or the Femoral vein.
This type of catheterization is used both for diagnostics, such as central venous pressure & wedge pressure measurement, and for therapeutic purposes such as administration of medication, fluid resuscitation, nutrition, pacemaker & IVC filter insertion.
An absolute contraindication to insertion is venous thrombosis at the affected site and the relative contraindications include coagulopathies with an INR>2 or aPTT >2 times control and thrombocytopenia.
The different types of CVADs (Central Venous Access Device) are classified based on number of lumens, location, lifespan, subcutaneous tunneling, anti-infective features, heparin coating and tip structure.
Central venous catheters are usually 16 or 18 gauge and 15 cm long compared to peripheral venous catheters which are 18 or 22 gauge and 5 cm long.
Short term CVAD are cheap and easy to to insert. An example is the Mahurkar triple lumen catheter, commonly used for dialysis. It contains a lumen for transfusion, for blood feeding & removing.
This type of catheterization is used both for diagnostics, such as central venous pressure & wedge pressure measurement, and for therapeutic purposes such as administration of medication, fluid resuscitation, nutrition, pacemaker & IVC filter insertion.
An absolute contraindication to insertion is venous thrombosis at the affected site and the relative contraindications include coagulopathies with an INR>2 or aPTT >2 times control and thrombocytopenia.
The different types of CVADs (Central Venous Access Device) are classified based on number of lumens, location, lifespan, subcutaneous tunneling, anti-infective features, heparin coating and tip structure.
Central venous catheters are usually 16 or 18 gauge and 15 cm long compared to peripheral venous catheters which are 18 or 22 gauge and 5 cm long.
Short term CVAD are cheap and easy to to insert. An example is the Mahurkar triple lumen catheter, commonly used for dialysis. It contains a lumen for transfusion, for blood feeding & removing.
Intermediate term Peripherally Inserted Central Catheters ( PICCs) are mostly for home use in patients requiring antibiotics or total parenteral nutrition (TPN) for a period of up till 6 months. This catheter is inserted through a peripheral vein such as the Basilic v. and then advanced into the junction of the SVC and the right atrium. It has minimal complication risk, but since it is very small and long (60cm) it may be occluded easily.
Long term tunneled CVADs are used in patients requiring treatment of more than 6 months. A double cuff stabilizes the catheter in place and prevents bacterial migration. Two of the most commonly used catheters in this category are the Hickman & the Groshong.
The Groshong differs only by a valve which seals it from the bloodstream therefore not requiring daily heparinized saline wash and is suitable for heparin allergic or HITT patients.
Hickman
Groshong
Implanted venous ports are also used for a long term period of over 6 months. The internal jugular vein is usually used with this type of catheter and a subcutaneous reservoir is placed in the infraclavicular fossa. This type of catheter provides less maintenance and minimal infection risk.
Finding the veins may be a very difficult task. You may need to review your anatomy and if an US is nearby, don't hesitate to use it.
All catheter placements require the same patient preparation which includes placing the patient in Trendelenberg position, to prevent air emboli, skin preparation with 70% Propanal or 0.5% Chlorhexadine followed by 10% Povidone Iodine. 1% lidocaine is then administered subcutaneously.
The Seldinger Technique has made catheter placement relatively easy. A flexible guide wire is passed into the vein through a 14 gauge probe needle. Constant negative pressure on the syringe will show when the vein is found. The needle is then removed over the wire; a nick in the skin at the puncture site is made to make space for a dilator which creates a tract for the catheter. Always maintain control of the guide wire! The central venous catheter is then introduced over the wire & advanced to 15- 20 cm so that its tip is at the junction of the Superior vena cava (SVC) & the right atrium.
Aspiration of blood from all catheter lumens & then flushing with saline, confirms the catheter position in the vein & that all its parts are functional. The catheter is then sutured to the neck at 2 sites & a sterile dressing is put over it. A Chest X- Ray (CXR) is then preformed to confirm the location of the catheter and to rule out Pneumothorax (PTX).
Complications of CVAD insertion include PTX, injury to neighboring arteries injury, arrhythmias, especially when entering the r. atrium, air emboli and infection, usually due to coagulase negative staphylococcus.
The Subclavian vein is the preferred vein for cannulation. It is the most comfortable site for the patient, the easiest to maintain and has the lowest infection risk. Its disadvantages are the relatively rare complications such as pneumothorax and subclavian artery puncture, which are commoner at this site.
The Subclavian vein is posterior to the clavicle where it joins the Internal Jugular vein to form the SVC.
Find the SCM. This muscle splits into a medial part which inserts on the sternum and a lateral part which inserts on the clavicle. Find the spot where the lateral part inserts on the clavicle. The Subclavian vein lies under the clavicle at this point. The vein can be entered from above or below the clavicle. Avoid deep penetration.
The infraclavicular approach requires pointing the needle upward towards the ceiling and once the vein is entered, the needle should be rotated to 3 o'clock so that the guide wire enters the SVC.
The supraclavicular approach is easier. Find the angle between the clavicle and the lateral part of the SCM. The needle should be entered so that it bisects this angle. Direct the needle under the clavicle in direction of the opposite nipple. When entering the vein turn the needle to 9 o'clock so that the guide wire enters the SVC.
The Internal Jugular vein (IJV) is easy to access but uncomfortable for the patient. The right IJV is preferred due to a straighter course into the r. atrium, which also makes it the most suitable approach for temporary pacemaker placement. The IJV is also preferred when using US, since it is more identifiable than the Subclavian vein.
The common carotid pulse can be felt on the medial border of the SCM. The IJV is lateral to the common carotid artery. Find the triangle created by the two parts of the SCM. Insert the needle lateral to the carotid pulse at the apex of this triangle. The needle is advanced toward the ipsilateral nipple at a 45 degree angle with the skin surface. The vein should be encountered within 5cm of insertion.
The femoral vein is the easiest to find and preferred for trauma settings and cardiopulmonary resuscitation, except when there is an injury to the IVC. A major disadvantage for its elective use is the high risk for infection and venous thrombosis in this region.
Palpate the femoral artery pulse below the inguinal crease. Insert the needle 2cm medial to the pulse at a 30 degree angle. If the femoral pulse isn't palpable such as in shock situations, estimate the Femoral artery at midpoint between the anterior superior iliac spine and the pubic tubercle. The Femoral vein will be 2cm medial to this point.
Knowledge regarding catheter care is important to prevent post insertion complications.
Sterile occlusion dressing should be changed weekly and catheter lumens should be flushed regularly with heparinized saline to prevent thrombosis.
If thrombosis of the catheter is suspected, perform an n US Doppler/ venography. If confirmed, give antithrombotic to restore the catheter function. If this is unsuccessful remove the catheter & give systemic anticoagulation.
If catheter related bacteremia is suspected, take a blood culture from the catheter & another from a vein elsewhere. If the culture from the catheter grows bacteria
Many med students have probably been asked to draw blood samples from patients with CVADs and didn't really know the exact procedure. So here it goes….
Equipment:
Gloves, 1- 10 cc sterile syringe (to discard blood), 1- 5 cc or 10 cc sterile syringe for collection of blood sample, 1- 5 cc syringe with 5 ml of normal saline solution to flush the line after blood sampling, 1-3 cc syringe with 3 ml of Heparin Flush Solution (1:100), Blood tubes, Alcohol wipes.
Technique:
1. Wash hands.
2. Explain procedure to patient.
3. Apply gloves.
4. If the central line has a stopcock, blood should be drawn from the stopcock.
5. Attach a 10 cc syringe to the stopcock.
6. Gently aspirate 5 or 10 cc of blood.
7. Remove syringe and discard appropriately.
8. Attach a new 5 or 10-cc syringe to stopcock or buff cap port (depending on the amount of blood required).
9. Gently aspirate the amount of blood required for sampling.
10. Flush line and port with 5 cc of normal saline and followed by 3 cc of Heparin Flush solution.
11. Inject required amount of blood to the blood tube.
12. Remove and discard gloves and used supplies in appropriate receptacle.
13. Document the Heparin Flush in the patient's medical records.
CVAD removal also requires a special procedure.
Equipment:
A sterile suture removal set, sterile and nonsterile gloves, occlusive dressing, antimicrobial ointment, 4x4 sterile gauze pads, tape, and a measuring tape
Technique:
- Explain the procedure to the patient.
- Remove the dressing.
- Assess the catheter site for signs of infection.
- Turn off all infusions to the site.
- Open the suture removal kit and put on sterile gloves.
- Cut and remove the sutures, being very careful not to damage the catheter.
- Ask the patient to perform the Valsalva maneuver: Take a deep breath, hold it, and bear down until you tell him to stop.
- While he's bearing down, gently pull out the catheter.
- Hold a sterile 4x4 gauze pad over the site while you apply continuous pressure to stop bleeding and prevent air from entering the open tract.
- Tell him to breathe normally.
- Examine the catheter tip to make sure it's intact.
- Apply antimicrobial ointment and a sterile occlusive dressing to the insertion site.
- Measure the catheter and compare the length with the measurement documented in the patient's chart after insertion.
- Dispose of the catheter appropriately.
- Document the procedure, including the catheter insertion site, its condition, the catheter length, any difficulties removing the catheter, and the dressing you used to occlude the skin tract.
- Assess the site and change the dressing every 24 hours until epithelization occurs.
