PROCEDURES. INFORMED CONSENT DEFINITION: Process that fosters patients’ participation in the planning of their care. Required by hospital policy and Ohio.
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Slide 1
PROCEDURES
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INFORMED CONSENT DEFINITION: Process that fosters patients
participation in the planning of their care. Required by hospital
policy and Ohio law. Just signing a piece of paper leaves the
informed piece out of informed consent. You do not have to get
informed consent in an emergency
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INFORMED CONSENT Elements of Informed Consent 1. Purpose and
nature or procedure/treatment 2. Expectations of
procedure/treatment 3. Risks of procedure/treatment 4. Alternatives
to procedure/treatment and the risks/benefits of the alternatives
5. Names of physicians involved 6. Answer any questions 7.
Signature of patient or authorized individual
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INFORMED CONSENT Patients must have capacity to make decisions
in order to consent to procedure/treatment. Capacity is defined as
the ability to Understand information they are given Apply
information to their situation Reason/deliberate about the choices
available A patient who has capacity can refuse medical care. If
the patient does not have capacity, then the informed consent
process should be obtained from POA or next of kin.
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Central Venous Catheters Indications Administration of caustic
medications Invasive monitoring (CVP, SVO2) Large volume
resuscitation Dialysis Plasmapheresis Inability to obtain PIV
Contraindications Infection at insertion site Coagulopathy
Thrombocytopenia Thrombosis of target vessel
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Central Venous Catheters Complications Arterial stick or
cannulation Hematoma Pneumothorax Hemothorax Retained wire Air
embolism Bleeding Infection Arrhythmias Catheter related thrombosis
Vascular perforation Site Selection Minimize infection choose SC
> IJ > femoral Choose compressible site if concerned about
bleeding Avoid SC if bilateral lung pathology Avoid placement of
IJ/SC on side of unilateral lung pathology
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Arterial Lines Indications BP monitoring Titration of
vasopressors Frequent ABGs Contraindications Infection at insertion
site Failure to demonstrate collateral flow (Allen test)
Thoracentesis Indications Evaluation of new pleural effusion
Respiratory compromise Suspected infection Suspected malignancy
Contraindications Infection at insertion site Coagulopathy
Thrombocytopenia Bullous lung disease
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Thoracentesis Complications Pneumothorax (5-10%) Hemothorax
(1%) Re-expansion pulmonary edema Pleural Fluid Analysis LDH
Protein Cell count with diff Gram stain Culture Additional studies
as needed
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Thoracentesis INTERPRETATION OF RESULTS Lights Criteria for
exudative effusion = Protein (pleura) / Protein (serum) >0.5 LDH
(pleura) / LDH (serum) >0.6 LDH (pleura) >2/3 upper limit
normal Exudative neutrophil predominant = infection Exudative
lymphocytic predominant = TB, cancer Complicated parapneumonic =
+gram stain, pH
Lumbar Puncture Indication for Head CT prior to LP: Age >60
years h/o seizures or CNS disease Immunocompromised state Focal
neuro deficit Decreased LOC Papilledema Complications Post LP
Headache Backache at site of puncture Infection Bleeding Spinal
hematoma Brain herniation Neuropathic pain of lower
extremities
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Lumbar Puncture CSF Analysis Glucose Protein Cell count with
diff Gram stain & culture Additional studies as needed Viral
culture PCR ofr HSV, EBC, CMV, enterovirus VDRL/FTA Cytology
Oligoclonal bands Fungal and acid-fast stains/cultures
INTERPRETATION OF RESULTS Normal OP = 9-18cm Elevated with
infection, hydrocephalus, pseudotumor Normal Glucose = 50-70
Decreased in infection Normal Total Protein = 15-40 Elevated in
infection, MS, tumors, hemorrhage Can be artificially elevated if
RBC elevated (subtract 1mg protein/dL for every 1000 RBC count)
Normal WBC =
Paracentesis Complications Infection Hematoma Persistent leak
of ascites Bleeding Bowel perforation Renal failure Hemodynamic
instability including hypotension/ARF ***For large volume taps
(>4L) give 6-8g/L of 25% albumin Fluid analysis Cell count with
diff Gram stain & culture (direct innoculation of cx bottles at
bedside) Additional studies as needed Glucose (1 =cancer/infxn, 3
suggests pacreatitis) Triglycerides >200mg/dL suggests lymphatic
obstruction, cancer, TB Cytology
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Paracentesis INTERPRETATION OF RESULTS SAAG = serum albumin
ascites albumin 1.1 = portal HTN related 1.1 = non-portal HTN
related Ascites fluid total protein (use when SAAG >1.1) >
2.5 = suggests cirrhosis < 2.5 = suggests heart failure WBC >
500 or PMNs >250 = suggests infection
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Foley Catheter Indications Acute urinary retention Bladder
outlet obstruction Urine output measurement in critically ill
patients Continuous bladder irrigation During surgery Management of
open wounds in perineal region Intravesical pharmacologic therapy
Contraindications Urethral injury associated with pelvic trauma
Urethral stricture Artificial sphincter Complications Infection
Retained balloon fragments Bladder fistula Bladder perforation
Bladder stones
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Picc Line Indications Administration of caustic medications
Inability to obtain PIV Outpatient antibiotic administration
Contraindications Infection at insertion site Coagulopathy
Thrombocytopenia Active bacteremia Venous stenosis Complications
Arterial stick or cannulation Hematoma Pneumothorax Hemothorax
Retained wire Air embolism Bleeding Infection Arrhythmias Catheter
related thrombosis Vascular perforation
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Arthrocentesis Indications Diagnosis of joint effusion
Suspected septic joint Establish diagnosis in arthritis Drainage of
blood from hemarthrosis Pain relief with large effusion Suspected
inflammatory arthritis Contraindications Infection at the insertion
site Bacteremia Coagulopathy Thrombocytopenia
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Arthrocentesis Compliations Bleeding Infection Exacerbation of
arthritic pain Synovial fluid analysis WBC Gram stain and culture
Glucose Protein Crystal exam
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Arthrocentesis SYNOVIAL FLUID TEST NORMALNON- INFLAMMATOR Y
ARTHRITIS INFLAMMATORY ARTHRITIS INFECTION WBC50% PMN >50,000mm
with 75% PNM predominance GLUCOSE>25mg/dL with ratio of synovial
fluid to serum glucose