Procedures Guide

Consent, time-out, cap/mask/gown/gloves, full sterile drape. Position: Trendelenburg 15–20° (distends IJ). Head turned slightly contralateral. US with sterile probe cover.

IJ = lateral, round, compressible. Carotid = medial, pulsatile, non-compressible. Confirm with Doppler if unsure. Use short-axis (transverse) view for access.

Lidocaine to skin. 18G finder needle at 45° angle into IJ under US. Aspirate dark non-pulsatile blood. Thread guidewire through needle (should pass easily -if resistance, reposition). Remove needle over wire.

Nick skin with scalpel. Thread dilator over wire with twisting motion -only insert 2–3 cm (just enough to dilate the tract). Remove dilator.

Thread catheter over wire. Right IJ: 15–17 cm depth (tip at cavoatrial junction). Left IJ: 17–19 cm. ALWAYS confirm wire out the back of the catheter before securing.

Aspirate and flush all ports. Suture + sterile dressing. Post-procedure CXR to confirm tip position (at carina or slightly above) and rule out PTX.

Supine or slight lateral decubitus (fluid pools to dependent side). Empty bladder first (or confirm with US).

Left lower quadrant, 2 fingerbreadths medial and 2 cephalad to ASIS. Avoids the inferior epigastric artery (runs in the rectus sheath). US-guided preferred -mark the pocket with the deepest fluid and no underlying bowel.

Sterile prep. Lidocaine track down to peritoneum (you'll feel a "pop"). 18G needle or 15–18G catheter-over-needle (preferred for large volume). Z-track technique: pull skin 2 cm caudally before inserting → prevents persistent leak after removal.

Diagnostic: 60–100 mL (send cell count, albumin, protein, culture in blood bottles). Therapeutic: drain to dryness (up to 8–10 L). If > 5 L → give albumin 6–8 g per liter removed.

Sitting upright, leaning forward over bedside table (arms resting on pillow). Maximizes dependent pooling and intercostal space width.

US-guided mandatory (reduces PTX from ~10% to < 1%). Mark site with largest fluid pocket, ≥ 10 mm depth, no lung sliding. Insert 1–2 intercostal spaces below the fluid meniscus. Go OVER the top of the rib (neurovascular bundle runs under each rib -intercostal artery, vein, nerve).

Sterile prep + drape. Lidocaine to skin → deeper → walk over the top of the rib → into the pleural space (you'll aspirate fluid). Insert 16–18G catheter-over-needle or thoracentesis kit (safe-T-centesis). Attach tubing to vacuum bottles.

Diagnostic: 50–60 mL. Therapeutic: up to 1.5 L maximum per session (risk of re-expansion pulmonary edema if > 1.5 L). Stop if: cough, chest tightness, or pleuritic pain (lung against chest wall).

Lateral decubitus (fetal position -knees to chest, chin tucked) or seated upright leaning forward. Lateral decubitus is required for accurate opening pressure measurement.

L3–L4 or L4–L5 interspace. Find the iliac crests (a line between them = Tuffier's line = approximately L4 vertebral body). Palpate the spinous processes. Spinal cord ends at L1–L2 in adults -always go below L2.

Sterile prep + drape. Lidocaine skin to deeper tissues. 22G spinal needle with stylet, bevel up (parallel to the longitudinal dural fibers). Aim slightly cephalad (toward the umbilicus). Advance slowly -feel a "pop" through the ligamentum flavum and dura. Remove stylet to check for CSF flow.

Opening pressure first (attach manometer -patient must be in lateral decubitus with legs slightly extended for accurate reading). Normal: 6–20 cmH₂O. Collect 4 tubes (~1–2 mL each): Tube 1 = cell count, Tube 2 = glucose + protein, Tube 3 = Gram stain + culture, Tube 4 = cell count (to distinguish traumatic tap from SAH -RBC should decrease from tube 1 to 4 in traumatic tap).