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:

Figure 24.1 A Foley urinary catheter.

Procedure

• Wash hands and put on gloves

• Arrange everything needed on a sterile tray

• Position the patient flat

• 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

• FORCE MUST NOT BE USED

• Insert catheter fully to ensure the balloon is in the bladder

• Check capacity of balloon and after urine is seen inflate 5–10 mL

• Painful? – STOP

• Withdraw catheter to lodge against bladder neck

• Replace foreskin

• Attach drainage apparatus.

Figure 24.2 Technique for male catheterisation.

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.

Figure 24.3 The approach used for cannulation of the internal jugular vein.

Insertion of a chest drain

Chest drains are inserted for a variety of reasons including pneumothorax, haemothorax, pleural effusion (large) and empyema.

You will need:

Procedure

• Position patient as shown in Figure 24.4

• Check physical signs, correct side and CXR

• Mark site of insertion (it is surprisingly easy to lose your bearings once the drapes are on). This will also ensure that you insert the drain at the same site you anaesthetised: the patient will appreciate this

• Prepare skin and drape

• Anaesthetise skin and proposed track down to rib

• Make a 2–3 cm incision at marked site

• Bluntly dissect down to superior border of rib with artery forceps

• Continue to parietal pleura (more local anaesthetic may be needed)

• Puncture pleura, insert finger and sweep any adhesion within pleural space

• Guide drain down track with forceps and finger to pleural cavity

• Advance drain gently into cavity over your finger using Spencer Wells forceps to grasp the tip on the drain (DO NOT USE THE TROCAR THAT COMES WITH THE DRAIN), then attach underwater drainage apparatus

• Close incision and tie to chest drain (Fig. 24.5)

• Insert purse string suture

• Check drain is working

• Secure connection between drain and underwater drainage apparatus

• Dress and tape drain to chest wall

• Check CXR.

Figure 24.4 The position of a patient during pleural drainage/chest drain.

Figure 24.5 (a) Technique for securing of a chest drain. (b) Chest drain in position with underwater drainage.

Removal

• Undo dressing, release suture from drain

• Ask patient to take two large breaths and hold (Valsalva)

• Remove drain quickly and tie purse string

• Dress with occlusive dressing

• Concern? Check CXR.

Venous access

Choosing the site

Common sites for cannulation in the body are shown in Figure 24.6. Avoid arteriovenous fistulas, poor venous or lymphatic drainage (see Box 24.1). Avoid the foot if possible. Types of venous cannula are shown in Table 24.1.

Figure 24.6 Sites used for venous access.

Box 24.1 Aids to location of a vein

Use a sphygmomanometer and inflate it to below diastolic pressure to allow arterial inflow but not venous escape of blood

Hang the patient’s arm over the edge of the bed or couch and tap (not slap) the back of the hand to cause venodilatation

Immerse the forearm in a bowl of warm water for 2 minutes and place the tourniquet before removing the hand from the bowl

Additional hint

In paediatrics or for anxious adults, EMLA cream can be helpful; apply over selected veins and cover with an occlusive dressing; wipe off after 45–60 minutes. After EMLA cream has been applied, veins do not distend as easily

Table 24.1 Types of intravenous cannula

Size	Colour	Use
22G	Blue	Children, small fragile veins
20G	Pink	Low-flow intravenous infusions such as analgesia, sedation
18G	Green	Intravenous fluids and drugs
16G	Yellow	Blood transfusions
14G	Grey	Rapid fluid administration – shock, major trauma and GI bleeding
12G	Brown	Rapid fluid administration – shock, major trauma and GI bleeding

You will need:

• clean gloves

• tourniquet

• appropriate needle

• adhesive tape

• 5 mL syringe

• saline flush

• appropriate infusion

• bandage, cotton wool and tape.

Venous cut-down

This method should only be used if it is not possible to obtain venous access elsewhere (Fig. 24.7).

Figure 24.7 Technique for venous cut-down.

Blood gas sampling

The vessels of choice are the radial, femoral and brachial in that order. The sites for puncture of the femoral and brachial arteries are shown in Figures 24.8 and 24.9. For radial artery cannulation always check the patency of the ulnar artery first (Allen test).

Figure 24.8 The position of the femoral artery in the groin.

Figure 24.9 The site for puncture of the brachial artery.

You will need:

Insertion of a nasogastric tube

You will need: