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 2013-2014 / 2nd semester
Surgical vein preparation
Seldinger technique (central vein
insertion, arterial and venous
cathetarization)
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
Surgical vein preparation II.
Implementation:
Performed by surgeon; aseptic (operathing theatre)
environment
Under general anaesthesia (if containdicated: strong
pain killers and infiltration of local anaesthetic)
Skin incision above a superficial vein, blund dissection
of soft tissues, free dissection of the vein, small
incision on the vessel, introduction of the catheter)
Skin incision
Blunt dissection 1.
Blunt dissection 2.
Preparation of the vein 1.
Preparation of the vein 2.
Double thread below the vein 1.
Double thread below the vein 2.
Elevation of the vein
Seldinger technique I.
Application:
minimally invasive procedures
E.g.:
1. 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 )
3. Central vein insertion
(fluid replacement, drug administration and parenteral
feeding, intensive care monitoring etc)
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
Embolisation of uterinal artery
Venous port
Seldinger technique III.
1. Insert Braunle into the lumen of the vessel
2. Remove the needle
3. Flexible guidewire into the
central vein
4. Remove the sheat of Braunle
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
Seldinger technique- video
Seldinger.m pg
Urinary system monitoring
Catheterization of the bladder
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!
Catheters
Material: synthetic, latex or silicone.
Size: external diameter is given in Charrire (1 Ch) or
1 French (1 F) (=0.33 mm)
The most widely used: 14-22 Ch Foley-catheter (with
balloon, easy fixation).
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
Male catheterization
Removing the catheter in males
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 with
sterile forceps
- Fill the balloon with 10 ml saline
- Pull back the catheter until the balloon
allows
- Connect the urine container sack to the
catheter.
Female catheterization
Female catheter removal
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 the
urethra
- Connect the urine container sack
to the catheter
- Fill the catheter with 10 ml saline
- Pull the catheter back.
Enteral Feeding
Nasogastric tube insertion
Enteral feeding
[Link] feeding
[Link] 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
Gastrostoma
Jejunostoma
Percutan endoscopic gastrostoma
Percutan endoscopic jejunostoma
Who needs an NG:
Assessment:
Surgical clients
Ventilated client
Neuromuscular impairment .
Clients who are unable to maintain adequate oral
intake to meet metabolic demands.
Assess patency of nares.
Indicated for those clients who
do not want/ cannot/ must not eat
Gather equipment for nasogastric tube insertion
14 0r 16 Fr NG tube
Lubricating jelly
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)
NG insertion-video
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
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
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 hds head
introduction
After a few cm push parallel with the nose
NG tube insertion IV.
The patient take breath throuh his mouth during the whole procedure
Tube can get through the oropharynx during swelling (we pretend it
by moving the epiglottis on the manikin)
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 swelling
Do not force the introcuction (in case of any
obstruction take it out)
Fix the tube with plaster around the nose
Nasogastric tube insertion-video
NG position
right
Checking:
Confirm satisfactory tube positioning before starting tube feed
aspirate for pH and color
Stetoscope
X-ray
Right product, right time, right client, right rate..check and
chart.
Monitor intake and output
check the position of the tube before every feeding (at least
in every 12h)