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Practical Guide to Common Clinical Procedures and
Emergencies 1st Edition Chandra M. Kumar Digital
Instant Download
Author(s): Chandra M. Kumar, Chris Dodds
ISBN(s): 9789026519710, 9026519710
Edition: 1
File Details: PDF, 11.11 MB
Year: 2005
Language: english
Practical Guide to Common
Clinical Procedures and
Emergencies
Practical Guide to Common
Clinical Procedures and
Emergencies

Professor Chandra M. Kumar, MBBS, DA,

FFARCS, FRCA, MSc
Professor of Anaesthesia,
School of Health, University of Teeside
The James Cook University Hospital
Middlesbrough TS4 3BW, UK

Professor Chris Dodds, MB, MRCGP, FRCA

Professor of Anaesthesia,
School of Health, University of Teeside
The James Cook University Hospital
Middlesbrough TS4 3BW, UK
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2005 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20130703

International Standard Book Number-13: 978-0-203-09018-3 (eBook - PDF)

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sonable efforts have been made to publish reliable data and information, neither the author[s] nor the
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Contents

Contributors xi
Preface xxi

Section 1 Basic Skills 1

1. Setting up an intravenous infusion 3
Gerry Appleton
2. Intravenous drugs 7
Gerry Appleton
3. How to perform a venous cannulation 12
Chris Dodds
4. Cannulation of peripheral arteries 17
Fiona L. Clarke
5. Maintaining an airway 21
Tim Meek
6. Intubation skills 28
Tim Meek
7. Assessment of consciousness 34
Roger Strachan
8. Taking consent 40
Barry Nicholls
9. Taking an ECG 49
Chandrika Roysam
10. Interpreting the ECG 53
Chandrika Roysam
11. Simple local anaesthetic techniques 60
Dave Murray
12. Basic suturing techniques 70
Philip A. Corbett and William A. Corbett
13. Scrub/sterile techniques 78
Gillian Davies
14. Simple patient monitoring 86
Nigel Puttick
15. Urinary catheterisation 94
David Chadwick
16. Using a medical simulator 102
Ronnie J. Glavin
17. How to prepare to speak at an educational meeting 108
J. David Greaves
18. Using audio-visual material in presentations 114
J. David Greaves
19. Electrical safety 123
Steve Graham
20. Writing a discharge letter 131
Philip A. Corbett and William A. Corbett

Section 2 Higher Skills 137

21. Sedation 139
Mike G. Bramble
22. Intravenous regional anaesthesia (Bier’s Block) 145
Chandra M. Kumar
23. Central venous access 151
Fiona L. Clarke
24. Ultrasound and its application in venous access 157
Oliver Weldon
25. Acute pain assessment and patient controlled analgesia 164
Christine Sinclair
26. Inserting a naso-gastric tube 172
Ian Conacher
27. Paediatric vascular access 177
Christopher J. Vallis
28. Removing a foreign body from the eye 184
John R. Clarke

Section 3 Respiratory Skills 193

29. Oxygen therapy 195
Praveen Kalia
30. Airway assessment 203
Simon Gardner and Dave Ryall
31. Drainage of a pleural effusion 208
Ian Conacher
32. Insertion of a chest drain 211
Kyee H. Han
33. CPAP therapy 219
Chris Dodds
34. Practical guide to non-invasive ventilation 223
E. Sowden and Stephen Murphy

vi Contents
35. Pulmonary function tests 228
Mark Weatherhead and George Antunes
36. Lumbar puncture 235
Roger Strachan

Section 4 Cardiovascular Skills 243

37. Drainage of a pericardial effusion 245
Robert J.R. Meikle
38. Pulmonary artery catheterization 250
Emilio Garcia
39. Cardiac output measurement 256
Khalid J. Khan
40. Intra-aortic balloon counter-pulsation 264
James Park
41. Temporary pacing 274
Deepak Kejariwal and Basant K. Chaudhury

Section 5 Anaesthetic Skills 281

42. Checking an anaesthesia machine 283
Nigel Puttick
43. Monitoring and anaesthesia 292
Stephen Bonner
44. Difficult intubation 302
Simon Gardner and David Ryall
45. Spinal anaesthesia 308
Tim Meek and John Hughes
46. Epidural anaesthesia 315
Tim Meek and John Hughes
47. Major peripheral nerve blocks 322
Martin Herrick

Section 6 Critical Care Skills 333

48. Ventilators 335
Fiona L. Clarke
49. Conventional tracheostomy 341
Derek A. Bosman
50. Percutaneous dilatational tracheostomy 348
Stephen Chay
51. Bronchoscopy 355
Harry Gribbin

Contents vii
52. Intracranial pressure measurement 362
Kathryn A. Price
53. Intravenous feeding lines and total parenteral nutrition 368
Judith C. Wright
54. Diagnostic peritoneal lavage 374
Jonathan R. Easterbrook and Robert Wilson
55. Haemodialysis and haemofiltration 378
David Reaich
56. Brain stem death testing 383
Stephen Bonner

Section 7 Specific Advanced Skills 389

57. Echocardiography—requesting an echocardiogram 391
Mike J. Stewart
58. Neonatal resucitation 401
Samir Gupta and Sunil Sinha
59. Fetal heart rate monitoring in labour 409
Helen R. Simpson

Section 8 Emergencies 417

60. Hypovolaemia 419
L. Jeyaraj and Gerard Danjoux
61. Acute asthma 426
Harry Gribbin
62. Anaphylaxis 432
Jacqui Gedney
63. Epilepsy 440
Peter Newman and Maureen Pearce
64. The management of near-drowning 446
Jason Easby
65. Hypothermia 451
Diane Monkhouse
66. Overdose 456
Samit Mitra and Gaynor Creaby
67. Stridor 463
Mike Tremlett
68. The immediate management of head injuries 471
Roger Strachan
69. Adult cardio-respiratory resuscitation 477
Carol Tennant

viii Contents
Section 9 Algorithms 487
Appendix 1: Adult basic life support 489
Appendix 2: Advanced life support algorithm for the 490
management of cardiac arrest in adults
Appendix 3: Paediatric basic life support 491
Appendix 4: Paediatric advanced life support 492
Appendix 5: Newborn life support 493
Appendix 6: Consent 494
Appendix 7: Adverse reaction form 495

Index 497

Contents ix
Contributors

Dr George Antunes
Consultant Chest Physician
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mrs Gerry Appleton

Director of Nursing
Freeman Hospital
Freeman Road
Newcastle upon Tyne, NE7 7DN, UK

Dr Stephen Bonner
Consultant in Anaesthesia and Intensive Care Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mr Derek A. Bosman
Consultant Otolaryngologist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3PW, UK

Professor Mike G. Bramble

Department of Gastrointestinal Unit
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mr David Chadwick
Consultant Urologist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK
Dr Stephen Chay
Staff Grade Doctor
Intensive Care Unit
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Basant Chaudhury
Consultant Physician
University Hospital of Hartlepool
Holdforth Road
Hartlepool TS24 9AH, UK

Dr Fiona Clarke
Consultant Intensivist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mr John R. Clarke
Consultant Ophthalmic Surgeon
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Ian Conacher
Consultant Anaesthetist
Freeman General Hospital
Freeman Road
Newcastle upon Tyne NE7 7DN, UK

Dr Philip A. Corbett
Surgical SHO
Mersey Deanery
8 Oakdale Road
Liverpool L18 1EP, UK

Professor William A. Corbett

Consultant Colorectal Surgeon
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

xii Contributors
Dr Gaynor Creaby
Specialist Registrar Accident and Emergency
St James’s Hospital
15 Hyde Terrace
Leeds LS2 9LT, UK

Dr Gerard Danjoux
Consultant in Anaesthesia
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Sister Gillian Davies

General Theatre
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Professor Chris Dodds

Department of Anaesthesia
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Jason Easby
Specialist Registrar in Anaesthesia
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mr Jonathan R. Easterbrook
SpR General Surgery
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Emilio Garcia
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Contributors xiii
Dr Simon Gardner
Specialist Registrar in Anaesthesia and Intensive Care Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Jacqui Gedney
Consultant in Anaesthesia and Intensive Care Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Ronnie J. Glavin
Consultant Anaesthetist
Educational Co-director
Scottish Clinical Simulation Centre
Stirling Royal Infirmary
Stirling FK8 2AU, UK

Dr Steve Graham
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr J. David Greaves
Consultant Anaesthetist
Royal Victoria Infirmary
Victoria Road
Newcastle upon Tyne NE1 4LP, UK

Dr Harry Gribbin
Consultant in Respiratory Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Samir Gupta
Neonatal Fellow
Directorate of Neonatology
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

xiv Contributors
Mr Kyee H. Han
Consultant in Accident and Emergency Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Martin Herrick
Consultant Anaesthetist
Perioperative Care Services
Addenbrooke’s Hospital
PO Box 93
Cambridge, UK

Dr John Hughes
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr L. Jeyaraj
Specialist Registrar in Anaesthesia
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Praveen Kalia
Consultant Anaesthetist
University Hospital of Hartlepool
Holdforth Road
Hartlepool TS24 9AH, UK

Dr Deepak Kejariwal
Department of Medicine
University Hospital of Hartlepool
Holdforth Road
Hartlepool TS24 9AH, UK

Dr Khalid J. Khan
Consultant Cardiothoracic Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Contributors xv
Professor Chandra M. Kumar
Professor of Anaesthesia
Department of Anaesthesia
The James Cook University Hospital
Marton Road
Middlesbrough, TS4 3BW, UK

Dr Tim Meek
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Robert J.R. Meikle

Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Samit Mitra
Consultant in Accident and Emergency
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Diane Monkhouse
Specialist Registrar in Intensive Care Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Stephen Murphy
Consultant Respiratory Physician
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Dave Murray
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS3 4BW, UK

xvi Contributors
Dr Peter Newman
Consultant Neurologist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Barry Nicholls
Consultant Anaesthetist
Tauton and Somerset Hospital
Musgrove Park
Taunton TA1 5DA, UK

Dr James Park
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mrs Maureen Pearce

Neurology Clinical Nurse Specialist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Kathryn A. Price
Consultant in Anaesthesia and Intensive Care
Newcastle General Hospital
Newcastle upon Tyne NE1 4LP, UK

Dr Nigel Puttick
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr David Reaich
Consultant Nephrologist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Contributors xvii
Dr Chandrika Roysam
Consultant Anaesthetist
Freeman Hospital
Newcastle-upon-Tyne NE7 7DN, UK

Dr David Ryall
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Miss Helen R. Simpson

Consultant in Fetal Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Mrs Christine Sinclaire

Acute Pain Clinical Nurse Specialist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Professor Sunil Sinha

Professor of Paediatrics and Neonatal Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr E. Sowden
Specialist Registrar in Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Mike J. Stewart
Consultant Cardiologist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

xviii Contributors
Mr Roger Strachan
Consultant Neurosurgeon
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Miss Carol Tennant

Resuscitation Department Manager
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Mike Tremlett
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Christopher J. Vallis
Consultant Paediatric Anaesthetist
Royal Victoria Infirmary
Newcastle upon Tyne NE1 4LP, UK

Dr Mark Weatherhead
SpR Respiratory Medicine
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Dr Oliver Weldon
Consultant Anaesthetist
Freeman Hospital
Freeman Road
Newcastle upon Tyne NE7 7DN, UK

Professor Robert Wilson

Professor of Surgery
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

Contributors xix
Dr Judith C. Wright
Consultant Anaesthetist
The James Cook University Hospital
Marton Road
Middlesbrough TS4 3BW, UK

xx Contributors
Preface

Many practical procedures are performed in the management of

patients in the operating department, intensive care, high dependency
and immediate postoperative care units. Most of the practical proce-
dures are described in major textbooks of anaesthesia and intensive
care but these books may be heavy and immediate access may be dif-
ficult when the procedure is carried out on patients.

The purpose of this thin and light book is to include everyday prac-
tical that are performed in the management of patients. Each chapter
is organised by introduction, relevant anatomy, physiology, how to
do the procedure, indications, contraindication and complications.
The ‘how to do’ sections will contain practical tips with photographic
and other illustrative materials so that readers can easily understand
the procedures.

The book is intended for those involved in the conduct of anaes-

thesia and the management of patients in the intensive care, high
dependency and postoperative care units. Practicing anaesthetists,
trainee anaesthetists, examinees, intensive care nurses, anaesthetic
nurses, recovery nurses, operating department assistants and medical
students will find this book of immense value. The book should also
be of interest to others in surgical and other medical specialities.

Professor Chandra M. Kumar

Professor Chris Dodds
Section 1
Basic Skills
1
Setting up an intravenous infusion
Gerry Appleton

Most patients in hospital environments receive medication, fluids

and electrolytes by intravenous (IV) infusion. Volumetric pumps and
syringe drivers are used to deliver these medications and to control the
flow and rate at which they are infused.

In some clinical areas such as the Intensive Care Unit it is not uncom-
mon to have multiple infusions in progress with ten or more pumps
controlling patient medication and fluid delivery.

IV infusions are the avenue for delivery of many high risk drugs
such as morphine, heparin, potassium and insulin and therefore
safety is paramount in all aspects of the preparation and manage-
ment of intravenous infusion therapy.

Preparation of infusions

Practitioners are required to adhere to and apply their local drug

administration policy to their practice, what we suggest in this section
is good practice and technique that should underpin and compliment
the requirements of that policy.

Any infusions should be drawn up and prepared in a clean environ-

ment. Sterile needles and syringes should be used and practitioners
should thoroughly wash their hands prior to beginning of the proced-
ure. The use of filter needles is the optimum method of avoiding
contaminants in the prepared infusions such as glass splinters.
Evidence suggests that the use of an in-line-filter can help in redu-
cing the incidence of infection from fungi and bacteria. It is good
and safe practice that two practitioners make certain safety checks
before even preparing the drugs for administration.
• The patient’s details should be checked on the prescription chart
and identification band. Name, date of birth, hospital identifica-
tion number and any patient allergies should also be checked.
• The drug should clearly be prescribed using its generic name.
• The amount and type of diluents should be checked along with
any further IV fluid that may be required to administer the drug.
• Any special instructions should also be clearly documented on
the prescription chart and checked e.g. rate of administration.

Labelling of infusion syringes and bags

Infusions should be labelled in accordance with hospital drug policy

but again good practice is suggested here that can compliment local
procedure. The patient’s name, the generic name of the drug or drugs
and doses within the infusion, the type and amount of diluents used
should be clearly printed on the infusion label.

The time that the infusion was prepared and when it will expire
should also be documented on the drug added label along with the
initials of the practitioner that prepared the infusion and the one who
checked it. It is essential that the strength/concentration of the
infusion is also clearly identified on the label; this enables more
accuracy in ensuring the patient receives correct dosage over the
correct time (e.g. 1 mL  1 mg or 1 mL  80 mcg).

Sometimes higher concentrations are required to be infused if a

patient is being fluid restricted. In these circumstances especially
if standard regimens for infusions are used, there is a potential risk
of drug errors occurring. If a higher strength infusion is prepared
this should be clear on the label—writing the strength in red ink
and starring it to ensure that it is immediately noticeable to practi-
tioners checking the infusion prior to starting it off.

The infusion line should also be labelled at the point where it

connects to the patient’s intravenous access. This is done using
a ‘flag’—the name of what is infusing through that line and again
the concentration per mL should be clearly seen on the label. This
tells practitioners immediately what is being infused on each line/
lumen of the available access. It is particularly useful when mul-
tiple infusions are in progress and essential if inotropic drugs are
being infused.

4 Setting up an intravenous infusion

Inotrope infusions

Some infusions can have a profound effect on a patient’s haemo-

dynamic status and they can become very sensitive to changes in
rate or breaks in the infusion of the drug. Accidental bolus can cause
episodes of extreme hypertension and tachycardia and breaks in infu-
sion can cause severe hypotension and cardiac instability.

There are several safety aspects in the management of inotropic

infusions that must be followed:

• All inotropes should be managed on a labelled dedicated

inotrope lumen on a central or long line.
• Three way taps should be closed to infusions that are not running.
• Inotropes should not be managed on a peripheral line.
• Never give a bolus of inotrope infusion.
• An infusion should be checked by two practitioners prior to
being inserted into the infusion pump and if not started imme-
diately by two practitioners again prior to starting the infusion.
• Always follow the guidelines for safe ‘piggy backing’ of inotrope
infusions.

Piggy backing of inotrope infusions

Because of the potential haemodynamic compromise and instability

associated with inotrope infusions it is essential that they are not
allowed to run out and then be changed as other infusions are. To pre-
vent problems occurring piggy backing of infusions is required. This
simply means establishing the next infusion before the expiring infu-
sion has run out with minimum impact on the patients haemodynamic
status.

Guidelines

Ensure that the infusion is checked by two practitioners prior to start-

ing it even if it is already in the pump and was checked earlier. Check
not only the drug but also the concentration.

Start the new infusion at the same rate as the existing infusion.

Gerry Appleton 5
Slowly reduce the rate of the expiring infusion intermittently, observ-
ing the patients clinical haemodynamic status. A transient increase in
the new infusion may be required if the patients blood pressure does
become compromised by the changeover.

Once the expiring infusion is stopped switch off the infusion pump
and turn off its respective three way tap on the central line.

6 Setting up an intravenous infusion

2
Intravenous drugs
Gerry Appleton

Intravenous (IV) drug therapy is now seen as an everyday procedure

used in all areas and aspects of the clinical environment. The skill is
now so widely used across the spectrum of the multidisciplinary team
there can sometimes be a tendency to assume that that the procedure
is routine and without associated clinical problems.

Although relatively infrequent complications can and do occur,

in this chapter we will examine the safe and correct methods for
preparing and administering IV drug therapy therefore minimising
the risks of potential complications occurring.

Benefits of intravenous administration

There are many benefits for administering prescribed medication intra-

venously, first and foremost that it enables far greater control over both
dosage of the required drug but also over the rate of administration and
bioavailability. The venous circulation facilitates an equal distribution
of the drug administered throughout the blood stream enabling a quicker
onset of the required effect. This makes IV administration the method
of choice in emergency situations such as cardiac arrests.

Intravenous administration ensures an effective absorption into the

body and is also used where patients have gut absorption problems
or who may be nil by mouth.

Safety

Safety is paramount in all aspects of this procedure; it is essential that

practitioners know fully their Trust’s drug administration policy.
The skill is performed within the individual boundaries of their own
scope of professional practice and ultimately they are accountable.

Always ensure that you know the drug you are giving, its
effect and its possible side effects

If not… do not give it!

Trust drug administration policies differ from area to area but

safety aspects of the technique are emphasised throughout. It is
good and safe practice that two practitioners make certain safety
checks before even preparing the drugs for administration.
• The patient’s details should be checked on the prescription
chart and identification band. (Name, date of birth, hospital
identification number and any patient allergy.)
• The drug should be clearly prescribed using its generic name.
• The amount and type of dilutant should be checked along with
any further IV fluid that may be required to administer the drug.
• Any special instructions should also be clearly documented on
the prescription chart and checked, i.e. the rate of administration.

Preparation and administration

Infection control
Along with safety, measures to ensure prevention of infection should
be utilised at all times through each stage of the procedure. The
following good practice tips can ensure this:
• Always wear an apron and gloves.
• Aseptic technique throughout is the key preventative measure in
reducing the likelihood of infection associated with IV therapy.
• All cannula, ports and taps should be occluded with an obturat-
ing cap when not in use.
• Evidence suggests that the use of in line filters can reduce the
incidence of infection from fungi and bacteria.
• Always draw up drugs using sterile needles and syringes, this
can minimise contaminants such as glass splinters. The use of
filter needles can eradicate contaminants.
• Keep dressings clean and dry to cannulae and lines and observe
the site for signs of infection.

8 Intravenous drugs
Procedure
• It is important to select the most appropriate port for adminis-
tration, there may just be a single, peripheral cannula or there
may be a multi lumen central line with several ports to choose
from. Therapies in progress on various lines obviously will
affect which administration port is selected.
• If using an in line filter check that it is patent and within its
useable date, if there is debris present or visible blockages the
filter should be renewed.
• Check the line site to ensure the cannula or line is in place and
that there is no sign of infection or inflammation.
• All drugs to be administered should be drawn up separately in
individual syringes; they should never be mixed together.
• Documentation with each drug recommends the appropriate
volume of dilutant to use and which ones are compatible when
mixing. Some trusts have local standardised regimes for dilut-
ing drugs such as antibiotics.
• Ensure that drugs are completely dissolved in the dilutant before
drawing up, do not give the drug if a cloudy precipitate is seen
or an unexpected change in colour occurs.
• Use an alcohol swab to clean the port prior to giving the drugs.
• The line/cannula should be flushed prior to administration to
ensure patency.
• Drugs should be infused slowly one at a time with the patient’s
condition observed/monitored continually throughout the admin-
istration process.
• To avoid any chemical interaction between drugs being given
(this is rare) it is recommended that the line is flushed with
saline between each administration.

Stop administration immediately if:

• There is any sudden change in the patients visible

condition.
• There is any sudden change in the patient’s vital signs.
Draw back on the line to remove as much of the infused
drug as possible and get medical assistance immediately

• Once all the drugs have been administered the filter and line
should be flushed with saline to infuse any remaining medication

Gerry Appleton 9
 and maintain line patency. Check that all connections on taps,
lines and filters are secure and that ports are capped off.
• If the line or cannulae is not in permanent use it is recom-
mended that it is flushed with a heparin saline solution in order
to maintain patency.

Allergy and anaphylaxis

Allergic and anaphylactic reactions can occur extremely quickly because

substances are being infused directly into the circulation. It is important
to be able to recognise an evolving reaction and know what to do
about it.

In an allergic reaction the patient may develop a rash with gener-

alised itching, their breathing may become wheezy and in severe
allergic reactions they may also develop acute dyspnoea.

An anaphylactic reaction is life threatening, it will have a sudden

onset with the patient complaining of feeling faint, short of breath
and developing bronchospasm. Acute hypotension can present very
quickly along with classic signs such as facial swelling, rash and
itching.

If a suspected reaction occurs you need to act quickly. Stop the

drug administration and get senior help immediately. IM adrena-
line is usually the first line treatment.

Drug errors

You may make a drug error… you may find a drug error.

Don’t panic!

Check the patient is OK, then inform the senior medical and
nursing staff.

Psychological aspects

Don’t forget to think about your patients. They may be anxious and
worried about what you are doing or giving them. A few words from
you can make a big difference.

10 Intravenous drugs
• Always inform the patient of what you are doing and why.
• Remember some drugs can be painful when administered through
peripheral lines e.g. Propofol.
• Warn the patient of any effects that a drug may have on them.

Summary

• Always adhere to your Trusts drug administration policy.

• Ensure you are confident and competent in this area before
using this technique in practice. You are accountable.
• Never give a drug that you don’t know.
• Safety is paramount at all times.
• Measures must be taken to prevent cross infection.
• Act quickly and get help in the event of an adverse reaction.
• Keep patients informed.

Gerry Appleton 11
3
How to perform a venous
cannulation
Chris Dodds

Introduction

Venous access is one of the most fundamental skills in clinical prac-

tice. It is essential for resuscitation of ill patients, for many types of
drug administration and for the maintenance of fluid balance in fasted
patients.

The anatomy of the venous system is an important element on the

road to success and should be remembered prior to trying to cannu-
late a vein. The veins are low pressure vessels with a series of valves
within the lumen to encourage venous return to the heart. The ves-
sel wall is muscular and has an autonomic supply as has the arterial
vasculature. The veins in the limbs are arranged in arcades for the
counter-current temperature control, and their flow is regulated as
one of the bodies’ mechanisms to maintain core temperature. This
implies that cold will lead to venous constriction (harder to cannu-
late) whilst warmth will lead to vasodilatation (easier to cannulate).

Access to the vein is through a series of barriers of variable resistance

and with discrete functions. The first is obvious, but its function is
often ignored. The skin acts as a very effective barrier to infection
and this is enhanced by the keratin layer remaining desiccated. It also
acts to warn of dangerous environments by nocioception, and whilst
the degree varies with the site, all procedures on the skin cause pain.
Below the skin is the vascular sub-cutaneous fat layer. It is of low
resistance but may be large enough to hide the veins!

Direct puncture of the skin breaks this protective barrier and

increases the risk of infection, whilst occlusive dressings will
hydrate the keratin layer and reduce its effectiveness in this area.
The pain of cannulation is related to the site chosen and the size
of the cannula. Movement of the cannula once inserted remains
painful for the entire duration of the cannulation—fix it securely.

Equipment

Non-slip gloves—they do not need to be sterile

2 mL syringe with 1% lidocaine and a 25G needle
5–10 mL syringe with normal saline
Tourniquet—capable of one-handed use
A range of venous cannulae
A fixation dressing—non-occlusive
Good light

Technique

• Wear gloves.
• Clean the skin if it is dirty.
• Keep the limb dependent at all time.
• Apply the tourniquet—it does not need to be very tight!

Figure 1. Position of hand to help gravity fill the vein.

Chris Dodds 13
• Identify a junction of the veins.
• Raise a dermal wheal with the local anaesthetic (instant anaesthe-
sia) or a subcutaneous bleb (this takes over a minute to work—
wait for it).
• Keep traction in the line of cannulation—to prevent folding of
the skin.
• Approach the vein parallel to the surface of the skin (the veins
usually stand out).
• Smoothly insert to needle through the skin, though the subcuta-
neous fat and into the vein.
• A sensation of a ‘pop’ may be felt, there may be a flashback of
blood into the cannula, and visualisation of the cannula in the
vein are all key end-points.
• Lift the tip of the cannula to prevent it going straight through the
back of the vein, and whilst lifting, glide the cannula further into
the vein. The larger the gauge of the cannula, the longer the dis-
tance between the needle tip and the plastic cannula.
• Once in the vein, release the tourniquet.
• Lift the limb above the heart—this limits the need to press over
the cannula tip, an action which can perforate the vein in frail,
elderly patients.

Figure 2. Venepuncture.

14 How to perform a venous cannulation

• Remove the needle and either cap or connect the IV infusion to
the cannula.
• Secure the cannula with the dressing.
• Safely dispose of the sharps yourself!

Key points

• Skin barrier
• Vascular damage
• Neuronal damage
• Embolic problems
• Errors of administration

• Use gravity to fill the vein

• Warm the limb
• Avoid multiple stabs—venous constriction will occur!
• Choose the correct size cannula for the task—the bigger
ones are easier to insert!
• Use local anaesthesia
• Transilluminate
• Use saline not water to test the vein.
• Fast and smooth entry
• Always flush the cannula with saline after every drug
administration

Factors to consider

Cannula size
The use of the cannula will determine the size you use. If drug therapy
is the priority then placing the smallest cannula into the largest vein
will limit the potential vasculitis that commonly occurs and means the
system will last longer. The relatively high blood flow through the vein
will dilute the drug. If rapid fluid therapy is necessary then the largest
gauge cannula should be used. There is little indication for using a
medium gauge cannula—‘just in case’.

Smaller cannulae are harder to insert because they can flex at the
skin boundary and enter the vein at an acute angle, and go straight
through.

Chris Dodds 15
Local anaesthesia

This should always be used for any cannula above a 22G cannula
(Blue) because the pain caused by inserting cannulae of greater
gauge is increasingly worse than that of injecting the local anaes-
thesia. 1% lidocaine should be used because 2% is painful. Topical
gels and creams are useful in children and some adults, but they take
a minimum of 30 minutes to work, and because of the occlusive
dressings used to keep them in place, the skin become hydrated and
thickened.

16 How to perform a venous cannulation

4
Cannulation of peripheral arteries
Fiona L. Clarke

The most commonly used site is the radial artery at the wrist. The ulnar
artery is used infrequently, and should be avoided if the ipselateral radial
artery has already been cannulated. The dorsalis pedis artery is usually
used in the foot. The tibialis anterior artery can be used, but is again best
avoided if the dorsalis pedis on that side has already been used, because
of the risk to peripheral perfusion from thrombosis. More proximal arter-
ies can be used if peripheral cannulation fails e.g. brachial or femoral
arteries. Femoral arterial lines are the most likely to become infected.
Cannulation of central arteries assumes that collateral arterial supply will
perfuse the distal limb if thrombosis occurs.

Modified Allen test

This should be used to check that ulnar artery flow is sufficient to per-
fuse the hand before attempting to cannulate the radial artery. It is not
a completely reliable test and false positive and false negative results
can be obtained. Ask the patient to clench their fist tightly, and then
apply sufficient digital pressure to the radial and ulnar artery to
occlude both of them. In an unconscious patient, elevate the arm to
reduce blood flow, and then occlude the arteries. Extend the fingers.
After the hand is open, release the pressure over the ulnar artery, and
look for a blush of blood returning to the hand and fingers through
the palmer arch arteries. If the hand remains pale, release the pres-
sure over the radial artery and look for changes in perfusion. Make
sure that the fingers and hand are not hyperextended as this can give
misleading results. The original Allen test was performed on both
hands simultaneously with one artery occluded in each hand.

Complications of cannulation

Major complications occur in less than 1% of cases.

Early
Technical failure
Haematoma and bleeding
Radial artery spasm and peripheral ischaemia
Intimal dissection and peripheral ischaemia
Embolic phenomena and peripheral ischaemia
Infection

Late
Infection
Peripheral gangrene from prolonged ischaemia or emboli
Pseudoaneurysm formation
Arteriovenous malformation

Choice of cannula
A 20G cannula should be used in adults, 22G or 24G in children. These
can be inserted as a cannula over needle or using a Seldinger tech-
nique. The cannula should have no injection port and may or may not
have wings depending on personal preference. Cannulae are available
with devices to prevent the spillage of arterial blood e.g. Flo-switch®.

Technique

Palpate the radial artery at the wrist to identify a point where the pulse
is strongest. It is helpful to extend the hand slightly by placing a bag
of intravenous fluid under the wrist, or a rolled up towel. Hanging a
bag of fluid from several fingers with the hand extended at the side of
the bed or trolley has also been recommended. Overextension should be
avoided as this may make pulsations more difficult to feel.

Wash your hands and wear sterile gloves.

Disinfect the skin, and use a sterile drape, especially if using a

Seldinger technique.

Infiltrate the skin and subcutaneous tissues on either side of the

artery with 2–5 mL of plain lidocaine. Lidocaine will anaesthetise
the skin and also cause a sympathetic block of the nerves around the
artery, reducing the chance of arterial spasm, so should also be used
in the unconscious sedated patient. If time permits (e.g. a planned

18 Cannulation of peripheral arteries

change of cannula in an awake ICU patient) amethocaine gel
(Amitop) or EMLA cream may to placed over the site and covered
with an occlusive dressing for 30–60 min before cannulation. Insert
the cannula at a 30–45˚ angle to the skin. The artery is a peripheral
structure, and if you miss it and go deeply into the wrist, you will hit
the periosteum of the radius and cause pain. When a flashback of
blood is obtained, advance the cannula over the needle before with-
drawing the needle. The walls of arteries are thicker than vein walls,
and it is possible to get an initial flashback of blood before the whole
bevel of the needle is within the lumen of the artery. If you feel resist-
ance, try gently rotating the cannula on the needle, or altering the
angle of the needle relative to the skin and then try to advance the
cannula. The cannula should slide in as easily as a venous cannula.

If you have decided to use a Seldinger technique, you will be able to

see if pulsatile blood spurts out of your needle. This helps show if
you are in the correct position in the correct vessel, but is messy.
Advance the guide wire up the needle, making sure to insert the
softer, more flexible end first. The guide wire should slide smoothly
into the artery. You may feel the change in resistance as it leaves the
tip of the needle, but nothing further. Remove the needle over the
guidewire, and then insert the cannula over the guidewire, making
sure that a small part of the guidewire sticks out of the end of the
cannula. You should hold this part of the guidewire, and then slide
the cannula over the guidewire into the artery. Remove the guide-
wire, and connect to a pressurised flush system or a syringe of saline
with three-way tap and short extension set. Check that you can aspir-
ate blood, and then flush the line. The cannulae should be secured in
place by stiches or thin tape, and then covered by transparent sterile
dressings. The line should be clearly identified as an arterial line,
and colour coded three-way taps used, to try to minimise the risk of
inadvertent intra-arterial injection of drugs.

• Use peripheral arteries first.

• Do not use both co-lateral arteries on the same limb.
• Arteries are rarely deep structures.
• Always use local anaesthesia.
• Avoid hyperextension if using the radial artery.
• There should be no resistance once the cannula is
intraluminal.

Fiona L. Clarke 19
 • Always check the entire pressure system for air bubbles.
• Use a sterile technique especially if using a Seldinger
technique.
• Colour code the lines and connections.
• Secure the cannula.
• Cover with occlusive dressings.

Further reading

1 Furhman TM, Pippin WD, Talmage LA, Reilley TE. Evaluation

of the collateral circulation of the hand. J Clin Monit. 1992;
8:28–32.
2 Scheer BV, Perel A, Pferffer UJ. Clinical Review: Complications
and risk factors of peripheral arterial catheters used for haemo-
dynamic monitoring in anaesthesia and intensive care medicine.
Crit Care. 2002;6:199–204.

20 Cannulation of peripheral arteries

5
Maintaining an airway
Tim Meek

Introduction

Maintaining an airway in a patient is a core skill useful to anyone

working in a clinical environment. Patients may need airway mainte-
nance as a result of an unexpected event such as cardiac or respiratory
arrest, or as a part of the anaesthetic sequence, at any time from
induction to recovery. Airway maintenance is needed if a patient is
not breathing, or if a patient is breathing, but has an obstructed airway.
Generally, you will perform this manoeuvre either in a highly super-
vised environment (e.g. anaesthetic room, recovery room), or whilst
‘holding the fort’ waiting for help to arrive (e.g. cardiac arrest). Depend-
ing upon the location, the equipment to hand will vary slightly, but the
principles are the same. Whatever the situation, a patent airway is a
basic physiological requirement. Without it, oxygenation, and there-
fore life, is impossible. Manikin-based training is useful, but there is
no substitute for demonstration in the calm environment of the anaes-
thetic room and recovery room.

Airway maintenance can be divided into four parts:

Providing oxygen
Optimising position
Opening the airway
Supporting ventilation (if required)

Providing oxygen
Initiating oxygen administration should be a reflex action. This will
be delivered either via an oxygen mask, or via a breathing circuit,
depending upon the location and the patient’s condition.
Figure 1. By changing a flat pillow (left) for a larger one (right) the
head becomes more extended on the neck and the neck
becomes more flexed on the thorax. The oral and pharyngeal
axes (superimposed) are brought more nearly into line.

Optimising position
In order to make ventilation easier, the patient should have the neck
flexed on the thorax, and the head extended on the neck. This position
is often likened to ‘sniffing the morning air’, or ‘sipping a pint of
beer’. It requires proper positioning of the patient’s head on the pil-
low. In this position, the axes of the mouth and pharynx are brought
more into line than when the patient is lying flat (Figure 1).

Opening the airway

This step aims to create an unobstructed airway for breathing/ventila-
tion. If appropriate, remove any obstructing matter from the mouth
and pharynx under direct vision. Use suction apparatus if necessary.
Perform a chin lift and/or a jaw thrust; this lifts the tongue from the
soft palate. It is best performed by hooking fingers of one, or both
hands behind the angles of the jaw (Figure 2).

If needed, an oropharyngeal airway can be inserted: The appropri-

ate size airway is the same length as the distance from the angle of
the mouth to the tragus of the ear (or alternatively from the centre
of the mouth to the angle of the jaw).

Insertion should be performed gently. Sometimes it is necessary to

insert the airway upside down and rotate it, being careful not to
damage or dislodge the front teeth (Figure 3).

22 Maintaining an airway
Figure 2. Opening the airway. The fingers are hooked behind the angle
of the jaw, and the jaw is lifted forward as gently as possible.
It is possible to hold a facemask and perform a jaw thrust at
the same time (right).

Figure 3. Inserting an oro-pharyngeal airway. The appropriate size of

airway is as long as the distance from the angle of the mouth
to the tragus of the ear (top left). The airway is inserted
upside down (top right) and is rotated through 180˚ (bottom
left), whilst being gently advanced into its resting position
(bottom right).

Tim Meek 23
These measures should provide a clear airway. If the patient is
breathing, this should be evident—look, feel and listen:
You should see the chest rise and fall.
You may feel breath if you place your face close to the patient’s.
At the same time, you may also hear breathing.
You may hear breath sounds on auscultation with a stethoscope.
If there is no evidence of breathing, either the airway is still
obstructed, or the patient is not making respiratory efforts. If the
airway is still obstructed, repeat the above steps.

Obstruction of the airway is suggested by:

Noisy, stirtorous breathing (snoring).
‘Tracheal tug’ (watch the front of the neck—the trachea can be
seen to move down on inspiration).
Paradoxical movement of the chest and abdomen (normally the
chest and abdomen move out during inspiration; if obstruction
is present, the abdomen moves out, but the chest moves in—
also called ‘see-sawing’).
If the patient has a patent airway and is not making respiratory
efforts, you will need to consider how to support ventilation.

Supporting ventilation
Slightly different equipment will be available for bag and mask ven-
tilation, depending upon the location. Generally, the choice will be:
Anaesthetic circuit (anaesthetic room or operating theatre).
‘C-circuit’ (recovery room).
Self-inflating bag and mask (resuscitation trolley).
Whichever is used, the principles are the same.

Bag and mask ventilation should be considered a two-person

manoeuvre until you are experienced:
One person maintains the airway and holds the mask, as above.
A second person squeezes the bag to ventilate the lungs
(Figure 4).

A ventilatory rate of 12/min, with a tidal volume of 10 mL/kg is

appropriate.

As part of cardiopulmonary resuscitation, there should be two

breaths to fifteen chest compressions but with no pause between the
compressions for the breaths. Look for evidence of ventilation—the

24 Maintaining an airway
Figure 4. Supporting ventilation. This photo shows two person bag
and mask ventilation, using a self-inflating bag.

chest should rise with each breath. Beware of inflating the stomach,
which increases the risk of regurgitation. Inflation of the stomach is
usually due to:
Failure to position the patient’s head correctly or open the air-
way adequately (see above), or:
Over-enthusiastic squeezing of the bag.

The Laryngeal Mask AirwayTM (LMA)

The LMA (Figure 5) is an airway device with an inflatable cuff, which

sits in the hypopharynx, above the laryngeal inlet.

It may provide easier airway control in situations where facemask

ventilation is difficult or impossible. It has the additional benefit
of freeing the operator’s hands. It can be used for spontaneous res-
piration or for controlled ventilation. It is important to recognise
however that it does not protect the airway from aspiration of
regurgitated stomach contents. Insertion of the LMA is often quite
straightforward (Figure 6), but just like other airway maintenance
techniques, requires supervised practice.

Tim Meek 25
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