C H A P T E R 3

PROCEDURES
Deanna Todd Tzanetos

INTRODUCTION
In the evaluation and management of patients, invasive procedures fre-
quently need to be performed. Certain basic principles should be followed
prior to every procedure. For all nonemergent procedures, informed consent
must be obtained from the patient or the patient’s next-of-kin or legal deci-
sion maker. The person providing consent (the performing physician) must
understand the reasons for performing the procedure, the potential benefits,
the possible risks, and any alternatives to the procedure. After this has been
explained, the patient should feel free to ask questions and must agree to the
procedure before it is performed. When the procedure is performed, sterile
technique must be used. Although this varies with the invasiveness and
risks of the procedure, handwashing should always occur before and after
the procedure. Always prep the patient with antimicrobial soap and wear
sterile gown, gloves, and mask as necessary. Drape the area with sterile tow-
els or sterile drapes so that nothing used in the procedure comes in contact
with a nonsterile area.

CENTRAL VENOUS LINE PLACEMENT

A central venous line is commonly placed when patients require fluids or
medications and peripheral administration is either impossible or inappropri-
ate. It also provides access for frequent blood draws and invasive monitoring.
Central venous lines are generally placed in three anatomic areas: the
internal jugular vein, the subclavian vein, or the femoral vein. The internal
jugular and the subclavian are the preferred sites, because they have lower
risks of infection; however, both sites are also technically more difficult. The
internal jugular vein lies below the anatomic triangle formed by the two
heads of the sternocleidomastoid muscle and the clavicle (Fig. 3-1). To enter
the vein, a needle should be inserted at the apex of the triangle (between the

17
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18 SECTION I / GENERAL

Internal jugular vein

Subclavian vein

Figure 3-1 Thoracic vein anatomy and insertion points for

internal jugular and subclavian central venous catheterization.
(Source: Reproduced with permission from DeCherney AH, et al.
Current Obstetric & Gynecologic Diagnosis & Treatment, 9th ed.
New York: McGraw-Hill, 2003, Figure 58-1.)

heads of the sternocleidomastoid) and aimed toward the ipsilateral nipple.

A common mistake is to puncture the carotid artery, so the carotid pulse
located medially to the triangle should be palpated to avoid this complica-
tion. The subclavian vein lies directly below the clavicle, but veers toward
the arm at the bend of the clavicle (midway between the suprasternal notch
and acromion; Fig. 3-1). To find the subclavian vein, a needle should be
inserted caudal to the distal third of the clavicle and directed toward the
suprasternal notch. Femoral vein catheters should only be placed in an
emergency or when all other options are exhausted. The femoral vein lies
medial to the femoral artery. The femoral artery should be palpated and a
needle inserted just medial to the artery.
Once the location is determined, the most common method for catheter
placement is the Seldinger technique (Fig. 3-2). Occasionally, one may be
unsure if the needle is in the vein or in an artery. In order to evaluate this,
one can look for dark, nonpulsatile venous blood versus bright red, pulsatile
arterial blood. Ultrasound guidance is being used more commonly to find
the exact location of the vein, because it reduces the number of punctures to
find the vein and complications. The most common complications of central
venous lines are mechanical complications, such as arterial puncture, pneu-
mothorax, or malposition. Thus, after any subclavian or internal jugular
CHAPTER 3 / PROCEDURES 19

C
D

E F

Figure 3-2 Seldinger technique for placement of a central venous catheter.

(A) Use a small needle to locate the vein; (B) once blood returns into the
syringe, remove the syringe and thread the wire into the vein (never let go of
the wire); (C) remove the needle, leaving the wire in the vein; (D) use a scalpel
to make a small incision at the location where the wire enters the skin; (E) insert
the dilator over the wire into the skin with a twisting motion; (F) remove the
dilator leaving the wire in place. Finally, the catheter is placed over the wire and
the wire can be removed. (Source: Reproduced with permission from Conahan TJ III,
Schwartz AJ, Geer RT. Percutaneous catheter introduction: the Seldinger technique.
JAMA 1977;237:446.)

catheterization, a chest x-ray (CXR) should be obtained to evaluate for

appropriate line placement and pneumothorax. Other complications include
deep venous thrombosis and catheter line infections, both of which are most
common with femoral vein catheters.
20 SECTION I / GENERAL

LUMBAR PUNCTURE
Lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for eval-
uation of meningitis (fever with meningeal signs or mental status changes)
and evaluation of central nervous system (CNS) disorders such as multiple
sclerosis. Some important contraindications exist: soft tissue infection over
the location of puncture, focal neurologic signs or papilledema, or bleeding
disorders (e.g., international normalized ratio [INR] >1.5 or platelets <50,000).
Focal neurologic signs or papilledema could reflect increased intracranial
pressure or brain tumor, and a computed tomography (CT) scan of the head
is necessary to guard against cerebral herniation.
Any location below the tip of the spinal cord is considered a safe location
for lumbar puncture. Most patients have a spinal cord which ends at L2, but
a small percentage have a spinal cord extending to L3. Because of this, the
L4-L5 intervertebral space is preferred area, but the L3-L4 interspace is also
acceptable. The L4-L5 space may be difficult to locate, but an imaginary line
connecting the top of both iliac crests should intersect with the L4 vertebral
body, so the space just caudal to this should be the site. A lumbar puncture
can be performed with the patient seated or in lateral decubitus position.
The decubitus position is generally preferred, because it allows the mea-
surement of CSF pressure. When inserting the needle, a few general princi-
ples should be remembered. First, the bevel of the needle should be parallel
to the spine to minimize injury to the longitudinal dural fibers. Second, in
children the vertebral processes are directed perpendicular to the long axis
of the body, so the needle should be inserted in a slight cephalad direction.
With aging, osteophytes form and the vertebral bodies become more angu-
lated, so the needle requires a greater cephalad angle, at times reaching
almost 45°. Third, the needle must pass through skin, subcutaneous fat,
dural fibers, and finally the ligamentum flavum to reach the subarachnoid
space. Experienced operators will feel a “pop” when passing through the lig-
amentum flavum and into the subarachnoid space.
The most common complication is a “posttap headache,” which occurs
in 10–30% of patients, often attributed to the decrease in CSF pressure, and
relieved by recumbency. As mentioned, cerebral herniation can occur if the
patient has elevated intracranial pressure. Although damage to nerve tissues
is often a concern, this is a very rare complication.

THORACENTESIS
The two most common indications for a thoracentesis are to evaluate a new
pleural effusion or to remove pleural fluid for symptomatic relief in a
patient with a chronic pleural effusion. No absolute contraindications exist;
however, special attention should be made to patients at risk for respiratory
CHAPTER 3 / PROCEDURES 21

complications (poor contralateral lung function) or patients with small or

loculated effusions. Ultrasound can be useful to evaluate for loculation and
to mark the exact location for thoracentesis if the effusion is small.
The general location for thoracentesis can be determined by percussing
the extent of dullness (effusion) on the chest wall and using a site one to two
interspaces below the top of the effusion. The usual site is either along the
posterior axillary line or the midscapular line one intercostal space below
the base of the scapula. The needle with syringe should be inserted into the
intercostal space by aiming just over the top of the rib. The needle should
always be inserted just superior to the rib to avoid the neurovascular bundle
located inferior to all ribs (Fig. 3-3). Once you are able to draw back pleural
fluid, stop advancing the needle to prevent parenchymal injury. For a diag-
nostic thoracentesis enough fluid should be obtained for all appropriate tests
(see Chap. 18). If a therapeutic thoracentesis is performed, fluid removed
should be limited to 1–1.5 L as exceeding this can lead to rebound pul-
monary edema.
The most common complication is pneumothorax which occurs in ~10%.
Many of these are minor, but approximately half will require chest tube tho-
racostomy. A CXR should always be obtained after the procedure to evalu-
ate for pneumothorax. Most other complications are minor such as cough
and pain at the puncture site.

Air
Fluid

Fluid

Diaphragm

Figure 3-3 Chest wall anatomy and proper technique for a thoracentesis.
(Source: Reproduced, with permission from Chesnutt MS, et al. Office &
Bedside Procedures. Originally published by Appleton & Lange. New York:
McGraw-Hill, 2002.)
22 SECTION I / GENERAL

PARACENTESIS
Paracentesis is performed to evaluate any patient with new-onset ascites, to
diagnose spontaneous bacterial peritonitis in patients with suggestive
symptoms and for symptomatic relief of patients with tense ascites. No
absolute contraindications exist and coagulopathy is not necessarily a reason
to delay paracentesis. Complications are not increased with an elevated INR
unless associated with disseminated intravascular coagulation (DIC).
Patients should always be evaluated for ascites on physical examination
first. With the patient lying supine, percuss the abdomen to determine the
location of fluid (areas of dullness). If ascites is poorly localized on examina-
tion, an ultrasound should be obtained to quantify the fluid and mark an
appropriate site for the procedure. The general location for paracentesis
should be midway between the umbilicus and the anterior superior iliac
spine. The midline is generally avoided because of large collateral veins
located in this area. An Angiocath needle attached to a syringe is inserted
while constantly aspirating until peritoneal fluid is returned. A “Z” track
technique should be used to prevent postprocedure leakage of peritoneal
fluid. Once the flow of peritoneal fluid is established, the needle should be
removed leaving the Angiocath in place. This will limit any potential damage
to bowel that may occur from the needle. If a diagnostic tap is being per-
formed, a syringe can be used to draw off the amount of fluid needed. If
removing a large volume, vacuum containers can be attached for faster
removal of fluid.
The most common complications of paracentesis are local mechanical
problems such as persistent leak of peritoneal fluid and abdominal wall
hematoma. Although bowel perforation is a feared complication, it is
uncommon and most heal without intervention. Patients with cirrhosis can
have dramatic fluid shifts with large volume paracentesis causing systemic
complications (see Chap. 27).

ARTERIAL PUNCTURE
Arterial blood is necessary for blood gas determination. Few contraindica-
tions to arterial puncture exist, but special consideration should be given to
patients receiving thrombolytic therapy, because bleeding from an arterial
site may be very difficult to stop. One important consideration for a radial
arterial puncture is to ensure that the patient has sufficient blood flow
through the ulnar artery (15–20% have inadequate collateral circulation). If
the radial artery becomes thrombosed, arterial insufficiency will occur if the
ulnar artery is nonviable. The Allen test is used to confirm patency—have
the patient make a tight fist, occlude both the radial and ulnar arteries with
your hand, have the patient open his or her fist, and release the ulnar artery.
CHAPTER 3 / PROCEDURES 23

Adequate blood supply is present if the palm returns pink and it is safe to
perform an arterial puncture of the radial artery.
The most essential step is palpation and localization of the radial artery.
This can be facilitated by having the patient hyperextend his or her wrist
which will bring the radial artery closer to the surface. The needle with a
syringe should be inserted bevel up at a 30–60° angle. After obtaining the
specimen, pressure should be held at the site for at least 5 minutes to prevent
postprocedure bleeding (the most common complication). Thrombosis
although uncommon is another potential complication, so the Allen test
should be repeated after the procedure to ensure patency of the radial artery.

NASOGASTRIC TUBE PLACEMENT

Gastrointestinal (GI) tubes are commonly used in medicine and have multiple
indications. The most common reasons for placement are for GI decompres-
sion (paralytic ileus, bowel obstruction), gastric lavage for GI bleeding, or for
administration of tube feeding or medicine in a patient unable to swallow. The
only contraindications are patients with facial or basilar skull fractures (may
cause additional trauma) or esophageal stricture (will be unable to pass).
When placing a nasogastric tube (NGT) it is important to know the
length of tube necessary which can be estimated by measuring the distance
from the corner of the mouth to the tragus to xiphoid process. This measure-
ment provides the length of tubing which must be inserted to place the NGT
into the stomach. The use of a water-soluble gel (K-Y Jelly or 2% lidocaine)
will allow the tube to gently pass through the nasopharynx. Having the
patient swallow while applying gentle but firm pressure once he or she feels
the tube touching the back of the throat will also facilitate esophageal intu-
bation (and not tracheal). The tube should be inserted to the previously mea-
sured depth. Prior to using the tube, proper placement is confirmed by either
aspirating stomach contents or auscultating gurgling over the stomach when
air is injecting into the NGT. The most serious complication is inadvertent
placement into the trachea, so placement must always be confirmed. (A CXR
is a reliable means to confirm proper placement.) Other complications
include local irritation of the nose, pharynx, or stomach and a predisposition
to sinusitis, because of sinus ostia blockage.

ENDOTRACHEAL INTUBATION
The main indications include cardiac arrest, hypoxemic respiratory failure,
ventilatory failure, and to protect the airway in patients with high risk of
aspiration. Endotracheal intubation should not be performed in patients
with severe facial trauma or cervical spinal cord injury. These patients most
frequently require either nasotracheal or fiberoptic intubation.
24 SECTION I / GENERAL

The most essential and often neglected step in intubation is proper posi-
tion of the patient. Patients should be placed in the “sniffing position,” flex-
ion of the neck and slight extension of the head (Fig. 3-4). This position aligns
the pharyngeal and laryngeal axes to allow optimum visualization of the
glottic opening and relieves any obstruction to airflow (thus it improves the
efficacy of bag-mask ventilation). A general rule is that a patient in proper
position will have the tragus and sternum in the same horizontal plane. If
the patient is not in proper position, the operator often must lift the head off
the bed in order to obtain adequate visualization of glottic structures. The
next step is to ensure the proper equipment is in place. Most adults require
a 7.0–8.5 cuffed endotracheal tube (ETT) with a stylet inserted into the tube,
because the tube itself is often too floppy to insert. A laryngoscope with a
functional light and a blade should also be obtained. Two blades are com-
monly used, the Miller (straight) and the MacIntosh (curved) blade. The
Miller blade retracts the epiglottis out of the way, whereas the MacIntosh is

10 cm

Figure 3-4 Proper tracheal intubation technique with a

Macintosh blade of a patient in the “sniffing position.”
(Source: Modified and reproduced with permission from
Dorsch JA, Dorsch SE. Understanding Anesthesia Equipment:
Construction, Care, and Complications. Philadelphia, PA:
Lippincott Williams & Wilkins, 1991.)
CHAPTER 3 / PROCEDURES 25

inserted into the vallecula (space anterior and superior to the epiglottis)
which will cause the epiglottis to open. Some clinicians sedate the patient to
aid in intubation. However, no patient should be paralyzed without expe-
rienced airway assistance available. When the laryngoscope is inserted, it
should always be pulled at a 45° angle toward the patient’s feet (Fig. 3-4), as
this will provide maximum visualization and prevent damage to the teeth.
Once the ETT is inserted between the vocal cords, several steps to confirm
placement must be performed. Auscultation of lung sounds with ventilation
through the ETT and placement of a carbon dioxide detector (proper place-
ment is indicated by a color change from purple to yellow) can be used
immediately to confirm proper placement. A CXR should be obtained imme-
diately to evaluate tube location and proper placement (end of the tube
should be ~2 cm above the carina).
Endotracheal intubation can be associated with several complications.
Improper tube placement is the most common problem, including intuba-
tion of the esophagus or of the right mainstem bronchus. Trauma to the
oropharynx, trachea, or epiglottis may occur, particularly with poor tech-
nique. Prolonged attempts at intubation commonly cause gastric distention
(from continued bag-mask ventilation), but may also result in ischemic dam-
age to the brain or cardiac arrest.