24 Simple practical procedures
Urinary catheterisation (male)
Urinary catheters are made of latex or silicone rubber. A Foley catheter is shown in Figure 24.1. Common sizes for adults are 12–14F and for children 8–10F. The smallest feasible size should be used. You will need:
Procedure
• Wash hands and put on gloves
• Arrange everything needed on a sterile tray
• Drape the sterile towels to expose the penis
• Grasp penis with left hand with sterile swab
• Retract the foreskin (if present) and clean glans and urethral opening
• Squeeze lidocaine gel into urethra
• Open catheter, place kidney dish beneath urethral orifice
• Insert catheter with right hand (holding penis with left)
• Peel off plastic wrapping as you go
• Pulling the penis up and then down (Fig. 24.2) will help to traverse the prostatic urethra
• Insert catheter fully to ensure the balloon is in the bladder
• Check capacity of balloon and after urine is seen inflate 5–10 mL
Further details of technique may be found in Henry and Thomson, Clinical Surgery, 2005, Chapter 11.
Central venous line insertion – internal jugular vein
Many patients needing a central venous line insertion are quite unwell and unable to tolerate lying flat. Get everything ready before you put them into this position. The bed must be at 15° head-down tilt at the point of insertion of the needle. There are two methods for the internal jugular vein – high and low. The high method is shown in Figure 24.3. This procedure can result in serious complications (pneumothorax, carotid artery damage, haematoma) and should be done by, or under supervision of, an experienced doctor. It is common to utilise ultrasound to aid placement, as recommended in NICE guidelines, 2002.
Procedure
• If the patient is conscious, infiltrate the skin and proposed route of insertion with local anaesthetic at the level of the thyroid cartilage lateral to the carotid artery
• Open the CVP pack and flush all parts with heparinised saline
• Check the guidewire and practise advancing this
• Flush the needle and syringe to be used for cannulation with heparinised saline
• Make a small incision at the entry site
• Insert the needle and when deep to skin aspirate as you advance until venous blood is seen in the syringe
• Detach syringe and insert wire and introducer into end of needle
• When wire is halfway inserted withdraw needle
• Dilate the track with dilator
• Remove dilator and insert central line over the wire, remove wire
• The tip should lie in the superior vena cava
Details of the procedure can be found in Chapter 11 of Henry and Thomson, Clinical Surgery, 2005.
