How To Perform Fine Needle Aspiration of Thyroid

• Indications:
o Evaluation of palpable thyroid masses
o Differentiation of benign from malignant thyroid lesions.

• Contraindications:
None

• Anesthesia:
Anesthesia is not routinely used for FNA. However, if needed, a small amount of 1% lidocaine may be infiltrated locally, taking care not to distort the palpable lesion.

• Equipment:
o Alcohol prep
o 10-ml syringe
o 1/2-inch 25-gauge needle
o Syringe holder (optional)
o Glass microscope slides (two)
o Spray fixative, gauze
o In many situations, it may be preferable to have a cytopathologist present.

• Positioning:
The patient is placed in a supine position, and a roll is placed behind the shoulders to allow for neck extension and to bring the lesion closer to the surface.

• Technique:
o Prep the area for aspiration with an alcohol prep pad as if for phlebotomy.
o Palpate the lesion and immobilize the mass between the fingertips of the nondominant hand.
Using the dominant hand, advance a 25-gauge needle with an attached 10-ml syringe into the lesion. The needle should be directed medially, toward the trachea.
o Note the consistency of the mass upon entering it with the needle (firm, soft, rubbery, doughy, gritty).
o Once the lesion is entered, a full 10 ml of suction is applied to the syringe. In a variant of this procedure, the nonsuction technique, no negative pressure is applied to decrease local trauma and bleeding.
o While maintaining suction (if used), move the needle back and forth through the lesion several times in different directions.
o Release the syringe plunger and allow it to return to a neutral position prior to removing the needle from the lesion. In the nonsuction technique, the plunger will already be in neutral
position. At this point the specimen is within the needle and hub and should not be in the syringe.
o Remove the needle from the patient, and have the patient apply pressure to the puncture site with a gauze pad.
o Detach the needle from the syringe.
o Fill the syringe with air.
o Reattach the needle onto the syringe.
o Touch the needle tip to a glass microscope slide with the bevel at a 458–908 angle to the slide surface.
o Expel material within the needle onto the slide.
o Make a smear by using a second glass slide to gently press down and draw out the material to a feathered edge. If the material is more liquid, it is pulled in the same fashion as a blood smear, except that before the feathering process is completed, the spreading slide is raised, leaving a line of particles across the slide. The spreading slide is then turned and again pressed down against the line of particles and drawn out into a feathered edge.
o Air dry or apply cytological fixative to the slide per the protocol of the cytopathology laboratory that will be processing the specimen. (If a fixative is applied, it must be applied very quickly, usually within seconds of preparing the smear.)
o Most cytopathologists require 3–6 needle passes (samples) for an adequate pathological diagnosis.
o If a cyst is aspirated, the cyst fluid should be sent for cytology. The region of the cyst should then be re-examined; if a residual mass is felt, it should then undergo FNA.

• Complications and Management:
o Bleeding and hematomas
Thyroid punctures may produce significant hematomas and ecchymoses.
Apply firm direct pressure to puncture sites immediately following aspiration.
o Tracheal puncture
If the trachea is entered, the suction in the syringe will be lost, and the aspiration will need to be repeated.
Puncture is usually of no consequence due to the small gauge of the needle.
o Infection
Extremely rare in FNA but has been reported
Antibiotics as appropriate
Incision and drainage as necessary

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How to Perform Paracentesis

• Indications:
  • Diagnostic studies
  • Ascites
  • Spontaneous bacterial peritonitis
  • Therapeutic purposes
  • Relief of respiratory compromise
  • Relief of abdominal pain and discomfort
• Contraindications:
  • Coagulopathy (PT or PTT > 1.3)
  • Thrombocytopenia (plt < 60,000)
  • Bowel obstruction
  • Pregnancy
  • Infected skin or soft tissue at entry site
• Anesthesia:
  1% lidocaine
• Equipment:
  • Sterile prep solution
  • Sterile towels
  • Sterile gloves
  • 5-ml syringes, 20-ml syringes, 25-gauge and 22-gauge needles
  • 3-way stopcock, IV tubing
  • IV catheter (diagnostic: 20-gauge, therapeutic: 18-gauge) or long 16-gauge (CVP-type) catheter with 0.035-cm J wire
  • 500- to 1000-ml vacuum bottles and IV drip set (for therapeutic paracentesis)
• Positioning:
  Supine
  • Preferred sites of entry to prevent bleeding from epigastric vessels (see Figure 5.7)
  • Either lower quadrant (anterior iliac spine)
  • Lateral to the rectus muscle and at the level of or just below the umbilicus
  • Infraumbilically in the midline
  
  
• • The entry site should not be the site of a prior incision and should be free of gross contamination and infection.
  • The entry sites are percussed to confirm the presence of fluid and the absence of underlying bowel.
  • The patient should empty his or her bladder prior to the procedure, and/or a Foley catheter should be placed to decrease the possibility of puncturing the bladder.
• Technique Diagnostic Sampling:
  • Prepare site with sterile prep solution and drape with sterile towels.
  • Use 25-gauge needle to anesthetize skin and 22-gauge needle to anesthetize abdominal wall to peritoneum.
  • Introduce IV catheter into the abdominal cavity, aspirating as it is advanced. The needle should traverse the abdominal wall at an oblique angle to prevent persistent leak of ascites from the puncture site (see Figure 5.8).
  • When free flow of fluid occurs, the catheter should be advanced over the needle and the needle removed.
  • Draw 20–30 ml of fluid into a sterile syringe for diagnostic studies and culture.

• Technique Therapeutic Drainage:
  • Prepare site with sterile prep solution and drape with sterile towels.
  • Use 25-gauge needle to anesthetize skin and 22-gauge needle to anesthetize abdominal wall to peritoneum.
  • Introduce IV catheter into the abdominal cavity, aspirating as it is advanced. The needle should traverse the abdominal wall at an oblique angle to prevent persistent leak of ascites from the puncture site.
  • When free flow of fluid occurs, the catheter should be advanced over the needle and the needle removed. Alternatively, a CVP-type catheter with extra side holes may be placed over a guide wire using the Seldinger technique.
  • After insertion of the needle and aspiration of fluid, a J-tip guide wire is placed through the needle into the peritoneal space. The needle is removed, leaving the wire in place.
  • A stiff plastic dilator is used to dilate the tract by placing it over the wire and into the abdomen. A #11-blade scalpel can be used to make a tiny nick at the entry site as well.
  • The dilator is removed, the catheter is placed over the wire and into the abdomen, and the wire is removed.
  • Draw 20–30 ml of fluid into a sterile syringe for diagnostic studies and culture.
  • IV tubing is hooked to the catheter and to a vacuum bottle to remove a large volume of fluid.
  • Should the catheter become occluded, careful manipulation of the catheter to re-establish flow may be undertaken. Alternatively, asking the patient to turn on his or her side and again onto his or her back may also help re-establish flow. However, the needle or guide wire should not be reintroduced because of the risk of bowel injury. If less than an adequate volume is withdrawn, the catheter should be removed and replaced, possibly at another entry site.
• Complications and Management:
  • Hypotension
    • Can occur during or after procedure due to rapid mobilization of fluid from intravascular space or due to vasovagal response.
    • IV hydration can prevent and correct the hypotension in most cases.
    • 5% albumin solution or other colloid-based fluid is often used for this purpose.

• Bowel perforation
  • Rarely recognized at time of procedure
  • Can lead to infected ascites, peritonitis, and sepsis
• Hemorrhage
  • Rare, but can be caused by injury to mesentery or injury to inferior epigastric vessels.
  • Usually self-limited. Avoided by entering abdomen lateral to rectus and by correcting coagulopathy.
  • Hemodynamic instability requires laparotomy.
• Persistent ascites leak
  • Usually will seal in <2 weeks. Can result in peritonitis.
  • Skin entry site may be sutured to minimize leak.
• Bladder perforation
  • Avoided by inserting Foley catheter prior to procedure.
  • May require a period of bladder catheterization until sealed.
  • Obtain urology consult.

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How to Reduce Rectal Prolapse

• Indications:
  • Prolapse of rectum (full-thickness)
  • Mucosal prolapse of rectum (mucosa only)
• Contraindications:
  • Infarction or gangrene of prolapsed segment
  • Severe tenderness of prolapsed segment
  • Extreme edema of prolapsed segment
• Anesthesia:
  None

• Equipment:
  • Gloves
  • Water-soluble lubricant
• Positioning:
  Decubitus or dorsal lithotomy
• Technique:
  • Don gloves and apply a liberal amount of water-soluble lubricant to the prolapsed segment.
  • The concept is to apply steady, circumferential pressure on the prolapsed segment (to decrease edema) while simultaneously trying to reduce it. This is done by placing as many fingers of both hands as possible, oriented parallel to its longitudinal axis, around the segment and compressing it from all sides.
  • Apply pressure firmly and steadily, with more pressure applied at the tip than at the base.
  • Progress is typically slow and almost imperceptible. Be patient and squeeze for one to several minutes at a time, using plenty of lubricant.
  • To prevent recurrence, the patient should be placed on stool softeners and should be instructed in the technique of manual self-reduction of prolapsed hemorrhoids, which may occur at each bowel movement.
• Complications and Management:
  Unsuccessful reduction
  • May result in infarction of prolapsed segment
  • Requires surgical management with excision of prolapsed portion

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How to Perform Rigid Sigmoidoscopy

• Indications:
  • Rectal bleeding
  • Lower abdominal and pelvic trauma
  • Extraction of foreign bodies
  • Stool cultures
  • Evaluation and biopsy of ileoanal pouch
• Contraindications:
  • Anal stricture
  • Acute perirectal abscess
  • Acutely thrombosed hemorrhoids
• Anesthesia:
  None
• Equipment:
  • Rigid sigmoidoscope and obturator
  • Light source
  • Suction apparatus
  • Insufflating bulb
  • Water-soluble lubricant
  • Long cotton-tipped swabs
  • Biopsy forceps, if desired
• Positioning:
  Lateral decubitus, lithotomy, or prone jackknife
• Technique:
  • Administer tap water or saline enema before procedure to empty distal colon of feces.
  • Perform a digital rectal examination to assess for masses.
  • Assemble sigmoidoscope by placing the obturator through the scope. Check light source and suction. Lubricate the scope thoroughly with water-soluble lubricant.
  • Gently insert the sigmoidoscope through the anus to 5 cm, remove the obturator, and attach the light source.
  • Judiciously insufflate air to visualize the lumen, using the minimum amount of air necessary to see.
  • Slowly advance the sigmoidoscope as a unit to visualize the rectum. Air will leak during the procedure, and intermittent insufflation will be necessary.
  • The lumen of the sigmoid will be posterior toward the sacrum and then gently curving to the patient's left. To minimize the risk of perforation, advance the sigmoidoscope only when the lumen is clearly visualized.
  • If stool is obstructing the view, use the cotton-tipped swabs to clear the lumen.
  • Advance the sigmoidoscope under direct vision as far as tolerated by the patient (most rigid scopes are 20 cm long) (see Figure 5.4).
  • To biopsy a mass or polyp, advance the scope until part of the mass is within the barrel of the scope. Insert the biopsy forceps into the barrel, and grasp a specimen of tissue. If needed, silver nitrate sticks may be used to achieve hemostasis.
  • • Systematically inspect the mucosa while withdrawing the instrument slowly.
  • Complications and Management:
    • Bleeding
      • Usually self-limited, but may occur after biopsy.
      • Rarely will require treatment, but if bleeding is hemodynamically significant, then resuscitate and consider endoscopic treatment.
    • Perforation
      • Manifested by abdominal pain, distention, and loss of hepatic dullness to percussion.
      • Obtain upright chest radiograph; free air under the diaphragm confirms the diagnosis.
      • IV fluids, IV antibiotics, urgent operative management.

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How to Perform OroGastric Intubation

• Indications:
  The indications for orogastric (OG) tubes are generally the same as for NG tubes. However, because they are generally not

  • tolerated well by the awake patient, they are used in intubated patients and newborns. The OG tube is the preferred tube for decompressing the stomach in the head trauma patient with a potential basilar skull fracture.
    • Acute gastric dilatation
    • Gastric outlet obstruction
    • Upper gastrointestinal bleeding
    • Ileus
    • Small bowel obstruction
    • Enteral feeding
  • Contraindications:
    Recent esophageal or gastric surgery
  • Anesthesia:
    None
  • Equipment:
    • Levin or Salem sump tube
    • Water-soluble lubricant
    • Catheter-tip syringe (60 ml)
    • Stethoscope
  • Positioning:
    Supine
  • Technique:
    • Measure tube from mouth to earlobe and down to anterior abdomen so that last hole on tube is below the xiphoid process. This marks the distance the tube should be inserted.
    • Apply lubricant liberally to tube.
    • Because the patients in whom OG tubes are used are generally unable to cooperate, the tube should be placed into the mouth, directed posteriorly, until the tip begins to pass downward into the esophagus.
    • Advance the tube slowly and steadily. If any resistance is encountered, stop and withdraw the tube completely. Repeat step c.
    • If the tube advances easily, with little resistance, continue until the premeasured distance is reached. Resistance, gagging,

      • • fogging of the tube, or hypoxia suggests errant placement of the tube into the trachea.
        • Confirm correct placement into stomach by injecting 20 ml of air with the catheter-tip syringe while auscultating over the epigastric area. Correct placement is also confirmed by aspiration of a large volume of fluid.
        • Irrigate tube with 15–20 ml of saline every 4 hours. Salem sump tubes will require injection of 15–20 ml of air through the sump (blue) port every 4 hours to maintain proper functioning.
        • Constant low suction may be applied to Salem sump tubes, whereas Levin tubes should have only low intermittent suction.
        • Monitor gastric residuals if tube is used for enteral feeding. Obtain a chest radiograph to confirm placement before using for enteral feeding.
        • Monitor gastric pH every 4–6 hours and correct with antacids for pH < 4.5.
      • Complications and Management:
        • Pharyngeal discomfort and gagging are a problem with OG tubes when they are placed in awake and alert patients, and essentially eliminates their use in such patients except in conjunction with an oral endotracheal tube.
        • Tracheal intubation
          • Correct placement in the esophagus is usually evident by the ease of advancement of the tube. Any resistance suggests tracheal intubation or coiling within the posterior pharynx.
          • Obtain a chest radiograph to confirm placement prior to use for enteral feeding.
        • Gastritis
          • Usually manifests itself as mild, self-limited upper gastrointestinal bleeding.
          • Prophylaxis consists of maintaining gastric pH > 4.5 with antacids via the tube, IV histamine₂ receptor blockers, and removal of tube as soon as possible.

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How to Perform Nasogastric Intubation

• Indications:
  • Acute gastric dilatation
  • Gastric outlet obstruction
  • Upper gastrointestinal bleeding
  • Ileus
  • Small bowel obstruction
  • Enteral feeding

• Contraindications:
  • Recent esophageal or gastric surgery
  • Head trauma with possible basilar skull fracture
• Anesthesia:
  None or viscous lidocaine in the nose
• Equipment:
  • Levin or Salem sump tube
  • Water-soluble lubricant
  • Catheter-tip syringe (60 ml)
  • Cup of ice
  • Stethoscope
  • Cup of water with a straw
• Positioning:
  Sitting or supine
• Technique:
  • Measure tube from mouth to earlobe and down to anterior abdomen so that last hole on tube is below the xiphoid process. This marks the distance that the tube should be inserted.
  • Some surgeons will place tip of tube in cup of ice to stiffen it or bend the tip downward to facilitate the tube's passage into the proximal esophagus.
  • Apply lubricant liberally to tube.
  • Ask patient to flex neck, and gently insert tube into a patent naris.
    
  • Advance tube into nasopharynx aiming posteriorly, asking the patient to swallow if possible.
  • Once the tube has been swallowed, confirm that the patient can speak clearly and breathe without difficulty, and gently advance tube to estimated length. If the patient is able, instruct him or her to drink water through a straw; while the patient swallows, gently advance the tube.
  • Confirm correct placement into the stomach by injecting approximately 20 ml of air with catheter-tip syringe while auscultating epigastric area. Return of a large volume of fluid through tube also confirms placement into stomach.
  • Carefully tape tube to the patient's nose, ensuring that pressure is not applied by tube against naris. Tube should be kept well lubricated to prevent erosion at naris. With the use of tape and a safety pin, the tube can be secured to the patient's gown.
  • Irrigate tube with 30 ml of normal saline every 4 hours. Salem sump tubes will also require the injection of 30 ml of air through the sump (blue) port every 4 hours to maintain proper functioning.
  • Constant low suction may be applied to Salem sump tubes, whereas Levin tubes should have only low intermittent suction.
  • Monitor gastric pH every 4–6 hours and correct with antacids for pH < 4.5.
  • Monitor gastric residuals if tube is used for enteral feeding. Obtain a chest radiograph to confirm correct placement before using any tube for enteral feeding.
  • The tube ideally should not be clamped because it stents open the lower esophagus, increasing the risk of aspiration if the patient's stomach should distend.
  • Complications and Management:

    • Pharyngeal discomfort
      • Common due to the large caliber of these tubes.
      • Throat lozenges or sips of water may provide relief.
      • Avoid using aerosolized anesthetic for the pharynx because this may inhibit the gag reflex, interfering with the protective mechanism of the airway.
    • Erosion of the naris
      • Prevented by keeping tube well lubricated and ensuring that tube is taped so that pressure is not applied against naris. Tube should always be lower than the nose and never taped to the forehead of the patient.
      • Frequent checking of the tube position at the naris can help prevent this problem.
    • Sinusitis
      • Occurs with long-term use of nasogastric tubes.
      • Remove the tube and place in other naris.
      • Antibiotic therapy if needed.
    • Nasotracheal intubation
      • Results in airway obstruction that is fairly easy to diagnose in the awake patient (cough, inability to speak).
      • Obtain a chest radiograph to confirm placement prior to use for enteral feeding.
    • Gastritis
      • Usually manifests itself as mild, self-limited upper gastrointestinal bleeding.
      • Prophylaxis consists of maintaining gastric pH > 4.5 with antacids via the tube, intravenous (IV) histamine₂ receptor blockers, and removal of tube as soon as possible.
    • Epistaxis
      • Usually self-limited.
      • If persists, remove the tube and assess location of bleed.
      • Refer to Chapter 1 for treatment of anterior and posterior epistaxis.

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How to Perform Shunt Tap

Ventriculoperitoneal (VP), ventriculoatrial (VA) and ventriculopleural shunts are commonly encountered neurosurgical devices used for chronic CSF diversion. A shunt tap is often required to evaluate for shunt problems.

• Indications:
  • Obtain CSF for analysis
  • Evaluate shunt function
  • Measure intraventricular pressure
  • Temporizing measure to remove CSF in a distally occluded shunt
  • Injection of antibiotic or chemotherapeutic agents
  • Injection of contrast agents
• Contraindications:
  • Scalp infection around shunt site
  • Severe coagulopathy or platelets <25K
  • Collapsed or slit ventricles
• Anesthesia:
  None usually needed
• Equipment:
  • Sterile prep solution
  • Sterile gloves and towels
  • 25-gauge or 23-gauge butterfly needles
  • 10-ml syringe
  • Manometer with stopcock
• Positioning:
  Supine
• Technique:
  • Palpate scalp for shunt bulb, which is usually in the right frontal or right occipital regions within 2 cm of the scalp incision used to insert the shunt. Do not tamper with other shunt components because this may affect shunt function.
    
  • Shave and prep the area for 5 minutes.
  • Introduce the butterfly needle into bulb at a slight oblique angle and observe for spontaneous flow of CSF into tubing.
    
  • Attach stopcock with manometer to end of tubing, ensuring that the zero level on the manometer is level with the bulb. Alternately, if no manometer is available, the distance that CSF travels up the butterfly tubing when held vertically may be measured.
  • If no spontaneous CSF flow is observed, take 5-ml syringe and gently attempt to aspirate CSF. If CSF is aspirated easily, then the ventricular pressure is at or near zero. If CSF is difficult to aspirate or no CSF is obtained, then the proximal end of the shunt is occluded or the ventricles are collapsed, and aborting the procedure is necessary.
  • • Send CSF for laboratory analysis.
    • Inject chemotherapeutic or antimicrobial agent if desired.
    • Withdraw needle and hold gentle pressure over bulb.
  • Complications and Management:
    • Ventriculitis
      • Every time the shunt is manipulated, there is a chance of introducing infection into the system.
      • In patients with systemic infection with no obvious central nervous system source whose shunt was placed more than 2 months prior to the date of the intended tap, a lumbar puncture should be performed rather than a shunt tap to reduce the chance of seeding the shunt.
    • Occlusion
      • In patients with collapsed or slit-like ventricles, attempting to aspirate CSF can cause occlusion of the proximal shunt. A head CT should always be obtained prior to shunt tap to minimize the risk of this complication.

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How to Perform Anoscopy

• Indications:
  • Anal lesions (fistulas, tumors, etc.)
  • Rectal bleeding
  • Rectal pain
  • Banding or injection of hemorrhoids
• Contraindications:
  • Anal stricture
  • Acute perirectal abscess
  • Acutely thrombosed hemorrhoid
• Anesthesia:
  None
• Equipment:
  • Clear polyethylene anoscope
  • Water-soluble lubricant
  • Directed light source or head-light
• Positioning:
  Lateral decubitus position or lithotomy position
• Technique:
  • Examine anus by gently spreading anoderm and performing digital rectal examination.
  • Insert the anoscope slowly, using a liberal amount of lubricant and with the obturator in place, until the flange at the base rests on perianal skin.
  • Remove the obturator, and while withdrawing the anoscope, examine the anal mucosa in a systematic manner.
  • Repeat the procedure as needed to ensure full inspection of the anal canal.
• Complications and Management:
  • Fissure
    • Anal or perianal tears may occur and usually respond to conservative measures.
    • Bleeding
    • Unusual, but may occur especially in the setting of large internal hemorrhoids; usually self-limited.

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How to Perform Lumbar Puncture

• Indications:
  • Cerebrospinal fluid (CSF) evaluation
    • Meningitis
    • Subarachnoid hemorrhage
    • Neoplastic disease
  • CSF drainage
    • Communicating hydrocephalus
    • Pseudotumor cerebri
    • CSF leak
  • Intracranial pressure measurement
    • Communicating hydrocephalus
    • Pseudotumor cerebri
  • Intrathecal drug administration
    • Radiopaque contrast
    • Antibiotics
    • Antineoplastic chemotherapy
• Contraindications:
  All patients should receive intracranial imaging (computed tomography [CT] or magnetic resonance [MR]) to rule out an intracranial mass lesion prior to lumbar puncture.
  • Noncommunicating hydrocephalus
  • Intracranial mass (tumor, abscess, hematoma)
  • Coagulopathy or platelets <50K
  • Cellulitis at intended puncture site
  • Complete spinal block above tap site
  • Tethered cord syndrome
• Anesthesia:
  Lidocaine (0.5%, 1.0%, or 2.0%)
• Equipment:
  • Sterile prep solution
  • Sterile gloves and towels
  • 22-gauge and 25-gauge needles
  • 22-gauge, 20-gauge, or 18-gauge spinal needle with stylet
  • CSF collection vials
  • Manometer with stopcock
• Positioning:
  • Lateral: Patient is placed on his or her side with chin and knees tucked into the chest. This position is favored for accurate measurement of intracranial pressure.
    
  • Sitting: Patient sits on the side of a bed, flexed forward over a pillow for support. Intracranial pressure cannot be measured in this position. This position is superior for obese patients.
    
  
  
  Technique:
• Apply sterile prep solution to the lower back and cover region with sterile drapes.
• Identify the target interspace. The L4-5 interspace falls in the midline along the intercristal line connecting the superior iliac crests. Lumbar puncture may be attempted at the L3-4, L4-5, and L5-S1 interspaces.
• Inject 1 ml of lidocaine subcutaneously into the target interspace to raise a skin wheal. Anesthetize the deep tissues by injecting 3 ml of lidocaine through the skin wheal with a 22-gauge needle. Follow the intended track of the lumbar puncture needle, directed slightly cranially and parallel to the midline.
• Advance the needle deeper, aiming rostrally about 15°, taking care to maintain a midline trajectory. The needle will encounter slight resistance, then a pop will be felt, representing penetration through the ligamentum flavum (yellow ligament) into the thecal sac (the stylet should always be used with needle to prevent introduction of epidermal cells or subcutaneous tissue into thecal sac).
  
• If bone is encountered, pull the needle back to the subcutaneous tissues. The tip of the needle must be above the dorsal lumbar fascia to successfully redirect. Confirm that the trajectory is in the midline and that the patient is adequately flexed to open the interspace. If bone is encountered a second time, use the needle to “march” cranially to caudally until the thecal sac is entered. If this technique is unsuccessful, try another interspace or reposition the patient for the sitting approach.
• Once the needle is in the thecal sac, remove the stylet and observe for CSF. If blood appears, allow blood to drain and observe for clearance. If blood clears, then the tap was traumatic. If blood does not clear and blood clots, replace stylet, withdraw needle, and reattempt. If blood does not clear and does not clot, the patient may have had a subarachnoid hemorrhage and samples should be sent to the laboratory for cell counts and examined for xanthochromia.
• Once CSF flow is established, place stopcock on end of spinal needle with manometer. Rotate spinal needle so that bevel is pointed cranially. Open stopcock and measure CSF pressure in cm H2O (Normal <15 cm H₂O; borderline 15–20 cm H₂O; abnormal >20 cm H₂O).
• Collect CSF samples in tubes. The following tubes should be sent for analysis on every lumbar puncture performed:
• • • Cell count
    • Protein and glucose
    • Culture and sensitivity
    • Cell count (to compare with first cell count)
  • Replace stylet and withdraw needle.
  • Place sterile gauze over puncture site. Changes in mental status, vital signs, and pupil size and reactivity must be carefully monitored.
• Complications and Management:
  • Tonsillar herniation
    • Manifests initially as altered mental status, followed by cranial nerve abnormalities (third nerve palsy, respiratory difficulties) and Cushing response (hypertension, bradycardia, respiratory depression). May be rapidly fatal.
    • Immediately remove needle and raise the head of bed to improve venous return from the brain.
    • Administer 1 g/kg of mannitol intravenously.
    • Intubate patient and hyperventilate to a goal PCO₂ = 30 mm Hg.
    • Emergent neurosurgical consult.
  • Nerve root injury
    • Withdraw needle immediately.
    • If pain or motor weakness persists, start corticosteroids (Decadron 4 mg every 6 hours).
    • Electromyogram/nerve conduction velocity studies should be scheduled if pain persists.
  • Spinal headache
    • Keep the patient supine as tolerated.
    • Usually resolves within hours but can persist for days.
    • Hydration and caffeine may help ameliorate symptoms.
  • Aortic/arterial puncture
    • Withdraw needle immediately and keep the patient supine for 4–6 hours while monitoring hemodynamics.
    • Vascular surgery consult.

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How to Perform Percutaneous Suprapubic Cystotomy

Two main types of percutaneous suprapubic catheters are the Bonanno percutaneous suprapubic catheter set (Becton-Dickinson and Co., Franklin Lakes, NJ) and Stamey percutaneous suprapubic catheter set in 10F, 12F, or 14F (Cook Urological, Spencer, IA).

• Indications:
  • Urethral stricture
  • False passage
  • Inability to catheterize
  • Acute prostatitis
  • Traumatic urethral disruption
  • Periurethral abscess
• Contraindications:
  • Prior midline infraumbilical incision
  • Nondistended bladder
  • Coagulopathy
  • Pregnancy
  • Carcinoma of the bladder
  • Pelvic irradiation
• Anesthesia:
  1% lidocaine
• Equipment:
  • Bonanno percutaneous suprapubic catheter set or Stamey percutaneous suprapubic catheter set in 10F, 12F, or 14F
  • Urinary drainage bag
  • Sterile prep solution
  • Sterile gloves and towels
  • 20-gauge spinal needle
  • 10-ml syringe (two)
  • 1% lidocaine
  • 22- to 25-gauge needles
  • 3-0 nylon suture
  • Needle driver
  • Suture scissors
  • Scalpel
• Positioning:
  Supine
  
  
• Technique:
  • Administer appropriate antibiotics, especially if urinary tract infection is suspected.
  • Percuss the suprapubic area to confirm an adequately distended bladder.
  • Shave, prep, and drape the suprapubic area.
  • Assemble the catheter.
  For the Bonanno catheter: Place the disposable catheter sleeve adjacent to the suture disc. Insert the 18-gauge puncture needle into the catheter so that the needle tip is always directed along the inside of the curve. To prevent the needle tip from damaging the inside of the catheter during assembly, advance the needle and the catheter sleeve simultaneously (the catheter sleeve straightens the J of the distal catheter), always maintaining the needle tip within the center of the catheter sleeve. Once the bevel of the needle extends beyond the end of the catheter, remove the disposable catheter sleeve and rotate the pink needle hub clockwise to lock the needle to the catheter hub.

For the Stamey catheter: Guide the needle obturator into the catheter tip to stretch and straighten the self-retaining mechanism of the Malecot catheter. Secure its position with the Luer lock to close the Malecot wings.

• If catheter damage occurs during assembly, discard the catheter.
• Anesthetize the skin with 1% lidocaine at a point 4 cm above the symphysis pubis in the midline. If the patient has a previous midline incision scar, anesthetize 4 cm above the symphysis pubis and 2 cm lateral to the incision. Direct the angle of the needle inferomedially toward the symphysis. Real-time ultrasonography can be helpful.
• Insert the spinal needle into the anesthetized skin 4 cm above the pubic symphysis in the midline (also 2 cm lateral to the midline if an old midline incision scar is present). Direct the needle toward the symphysis, using a 60° angle to the skin. After the skin is punctured, two additional points of resistance (rectus fascia and bladder wall) are encountered as the needle is advanced. Stop needle advancement after penetrating through the second point of resistance.
• Remove the obturator of the spinal needle and attach a 10-ml syringe.
• If urine is not aspirated, the obturator of the spinal needle can be safely replaced and the needle can be advanced up to 1 cm at a time until urine is aspirated.
• If urine is aspirated, leave the needle in place as a guide.
  
  
• If the catheter is larger than 14F, consider making a small stab wound on the puncture site with a scalpel to aid catheter insertion. Next, take the previously assembled suprapubic catheter and puncture the skin adjacent to the spinal needle. Advance the suprapubic catheter in a similar manner as described above (step g), following the tract of the spinal needle. The catheter has a reference mark on the needle obturator indicating the distance at which the catheter should have penetrated the bladder in most patients.
• Remove the black vent plug (for Bonanno catheter), attach a 10-ml syringe to the catheter hub, and aspirate.
• Caution: Once the needle has been withdrawn from a suprapubic catheter, do not reinsert it! Remove the entire device from the patient and reassemble as in step d.
• Once urine is obtained, advance the catheter an additional 1–2 cm.
• Disengage the suprapubic catheter and the needle obturator, and advance the catheter.
  • For the Bonanno catheter: Stabilize the catheter and rotate the pink hub of the needle obturator counterclockwise. Stabilize the needle while advancing the catheter over it until the suture disc lies flush with the skin.
  • For the Stamey catheter: Stabilize the catheter and rotate the white hub of the needle obturator counterclockwise. This maneuver opens the Malecot wings.
• Aspirate again to confirm proper catheter placement. Insert the connecting tube between the catheter and the urinary drainage bag.
• For the Stamey catheter, slowly withdraw the catheter until the Malecot wings meet the resistance of the bladder wall. Advance the catheter approximately 2 cm back into the bladder to allow for movement.
• Secure the catheter to the skin with 3-0 nylon suture. Tape the catheter to the abdominal wall to avoid kinking the tubing.
• Complications and Management:
  • Bowel injury
    • Adequate bladder distention and ultrasonographic guidance are helpful in preventing injury to loops of small bowel.
    • If bowel is entered, one may exchange the needle and continue with the procedure. Peritonitis is rare.
  • Hematuria/clots
    • Transient hematuria is common, but usually clears quickly.
    • If obstruction of the catheter from clots is suspected, gently irrigate the suprapubic catheter with normal saline. These percutaneous cystostomy catheters are of small caliber (14-gauge lumen, Bonanno; 10F–14F, Stamey) and are often insufficient for treating gross hematuria with clot obstruction.
    • Leakage around the insertion site may indicate catheter damage, obstruction, or bladder spasm.
    • Urology consult.

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How to Perform Male Urethral Catherization

URETHRAL CATHETERIZATION

• Indications:
  • Therapeutic
    • Urinary retention
    • Urinary output monitoring
    • Evacuation of blood clots
    • Intravesical chemotherapy
    • Postoperative urethral stenting
  • Diagnostic
    • Collection of urine for culture
    • Measurement of the postvoid residual urine
    • Retrograde instillation of contrast agents (cystourethrography)
    • Urodynamic studies
    
    
• Contraindications:
  • Acute prostatitis
  • Suspected urethral disruption associated with blunt or penetrating trauma
    • Blood at urethral meatus
    • Hemiscrotum
    • Perineal ecchymoses
    • Nonpalpable prostate
    • Inability to void
  • Severe urethral stricture

• Anesthesia:
  Recommend 2% lidocaine jelly

• Equipment:
  • Urethral catheterization kit (includes Foley catheter, povidone-iodine solution, lubricating jelly, 10-ml syringe with sterile normal saline, gloves, sterile towels, and urinary drainage bag)
  • Recommend 18F Foley catheter for male and 16F for female patients
  • Recommend 22F–24F Foley catheter for blood clot irrigation
  
  
• Positioning:
  Supine (men)

• Technique:
• Place sterile towels around the penis.
  

• Test the balloon of the catheter, lubricate the catheter with lubricating jelly, and set it aside on the sterile field.
• Retract the foreskin (if present). Grasp the penis laterally with the nondominant hand and place it on maximum stretch perpendicular to the body to straighten the anterior urethra.
• Swab the glans with povidone-iodine with the dominant hand. Observe sterile technique at all times.
• Inject 10 ml of 2% lidocaine jelly into urethra. Place a sterile urethral clamp for 5 minutes to provide anesthesia as well as additional lubrication. If lidocaine jelly is not available, it is helpful to inject 10 ml of lubricating jelly into the urethra.
• Grasp the catheter with the dominant hand.
  
• Using steady, gentle pressure, advance the catheter into the urethra until both the hub of the catheter is reached and urine is returned. Inflate the balloon with 10 ml normal saline.
  

• If urine is not returned, irrigate the catheter to confirm correct placement prior to inflating the balloon.
• Replace the foreskin to prevent a paraphimosis. Connect the catheter to a urinary drainage bag.
• If the catheter cannot easily be passed, a strategy for successful catheterization must be planned.

• Strategies for Difficult Catheterization of Men
  If resistance is met during catheter advancement, manually palpate the catheter tip to define the point of obstruction along the urethra . Once the location and nature of the lesion is defined, the next step is to develop a strategy for bypassing the obstruction.

• Anterior urethral obstruction”urethral stricture, a concentric
  narrowing of the lumen by scar tissue. Can occur at the fossa navicularis, bulbous urethra, or along the penile urethra.
  • Etiology: sexually transmitted disease, prior urethral instrumentation including transurethral resection of prostate (TURP), trauma.
  • Signs/symptoms: splayed and/or slow stream, straining.
  • Strategy for penile urethral stricture:
    • Use 16F or smaller straight-tip Foley catheter.
    • If unsuccessful, consult urology department to attempt catheter placement.
  • Strategy for bulbous urethral stricture:
    • Same as above.
    • If unsuccessful, 16F coudé-tip catheter will better negotiate the natural angle of the bulbomembranous junction. A coudé catheter has a curved tip that enables one to better engage the normal S-shaped curve of the bulbomembranous junction or to bypass an enlarged, obstructing prostate in the male urethra. To insert a coudé catheter, always keep the angled tip pointing superiorly and follow steps 6a–6j.
• Posterior urethral obstructions
  • Spasm of the external urinary sphincter
    • Etiology: contraction of the voluntary sphincter secondary to anxiety or pain. Often the cause of unsuccessful catheterization of men < 50 years old.
    • Signs: As the catheter tip approaches the sphincter, the patient becomes tense and complains of pain.
    • Strategy: (a) Inject 10 ml of lubricant (water-soluble jelly works as well as 2% lidocaine jelly). (b) After reaching the sphincter, pull the catheter back a few centimeters. (c) Distract the patient with conversation and by having him breathe deeply. (d) Advance the Foley catheter steadily with a slow, gentle pressure when the patient is relaxed.
  • Benign prostatic hypertrophy (BPH)
    • Suspect with age >60 years, prior transurethral resection of the prostate (TURP), treatment with finasteride (Proscar), terazosin (Hytrin), doxazosin (Cardura), or tamsulosin (Flomax).
    • Symptoms: hesitancy, intermittent and/or slow stream, straining, sensation of incomplete emptying.
    • Strategy: (a) A large catheter (18F or 20F) provides the additional stiffness needed to overcome the obstruction. A coudé-tip catheter is often helpful for negotiating the angle between the bulbous and membranous urethra . (b) Use the two-person technique: While catheter placement is attempted in the usual fashion, the assistant places a lubricated index finger in the rectum and palpates the apex of the prostate. The tip of the catheter usually can be felt just distal to the apex . The index finger presses anteriorly, thus elevating the apex and straightening out the area of obstruction.
      

• Prostate cancer: typically is not the sole cause of difficult catheterization unless the cancer is locally advanced. Strategy is similar to that for BPH.
• Bladder neck contracture.
  • Etiology: prior open or radical retropubic prostatectomy, bladder neck incision, or TURP.
  • Symptoms: hesitancy, intermittent and/or slow stream, straining, sensation of incomplete emptying.
  • Strategy: (a) Attempt a 12F catheter placement, following steps 6a6. (b) Consult urology department.

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Breast, Lymphnode, and Soft Tissue Fine Needle Aspiration Biopsy

• Indications:
o Evaluation of palpable masses
o Aspiration of breast cysts
o Differentiation of benign from malignant lesions. In breast disease, stereotactic large-gauge needle biopsy by radiologists has become the technique of choice for evaluation of breast lesions. However, FNA continues to be a valid technique and is essential for centers lacking stereotactic facilities.

• Contraindications:
None

• Anesthesia:
Anesthesia is not routinely used for FNA. However, if needed, a small amount of 1% lidocaine may be infiltrated locally, taking care not to distort the palpable lesion.

• Equipment:
o Alcohol prep
o 10-ml syringe
o 1 1/2-inch 25-gauge needle
o Syringe holder (optional)
o Glass microscope slides (two)
o Spray fixative
o Gauze

• Positioning:
o Breast: For upper quadrant lesions, the patient is placed in an upright seated position. Lower quadrant lesions are better managed in a supine position.
o Lymph node and soft tissue: depends on location of lesion.

• Technique:
o Prep the area for aspiration with an alcohol prep pad as if for phlebotomy.
o Palpate the lesion and immobilize the mass between the fingertips of the nondominant hand.
o Using the dominant hand, advance a 25-gauge needle with an attached 10-ml syringe into the lesion.
o Note the consistency of the mass upon entering it with the needle (firm, soft, rubbery, doughy, gritty).
o Once the lesion is entered, a full 10 ml of suction is applied to the syringe.
o While maintaining suction, move the needle back and forth through the lesion several times in different directions.
o Release the syringe plunger and allow it to return to a neutral position prior to removing the needle from the lesion. At this point the specimen is within the needle and hub and should not be in the syringe.
o Remove the needle from the patient, and have the patient apply pressure to the puncture site with a gauze pad.
o Detach the needle from the syringe.
o Fill the syringe with air.
o Reattach the needle onto the syringe.
o Touch the needle tip to a glass microscope slide with the bevel at a 45 angle to the slide surface.
o Expel material within the needle onto the slide.
o Make a smear by using a second glass slide to gently press down and draw out the material to a feathered edge. If the material is more liquid, it is pulled in the same fashion as a blood smear, except that before the feathering process is completed, the spreading slide is raised, leaving a line of particles across the slide. The spreading slide is then turned and again pressed down against the line of particles and drawn out into a feathered edge.
o Air dry or apply cytological fixative to the slide per the protocol of the cytopathology laboratory that will be processing the specimen. (If a fixative is applied, it must be applied very quickly, usually within seconds of preparing the smear.)
o Most cytopathologists require 3 “6 needle passes (samples) for an adequate pathological diagnosis.
o If a cyst is aspirated, the cyst fluid should be sent for cytology. The region of the cyst should then be re-examined; if a residual mass is felt, it should then undergo FNA.

• Complications and Management:
o Bleeding and hematomas
Breast FNA can be associated with significant hematomas and ecchymoses.
Apply firm direct pressure to puncture sites immediately following aspiration.
o Pneumothorax
More likely in thin patients and deep lesions
If tension pneumothorax suspected, decompression with 16-gauge intravenous line (IV) into second intercostal space and then tube thoracostomy
If 10% to 20% pneumothorax, observation and serial chest radiographs.
If .20% pneumothorax, tube thoracostomy.
o Infection
Extremely rare in FNA but has been reported.
Antibiotics as appropriate.

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How to Excise Thrombosed External Hemorrhoid

• Indications:
  Painful thrombosed external hemorrhoid
• Contraindications:
  • Coagulopathy (PT or PTT >1.3× control)
  • Thrombocytopenia (platelet count < 50,000/mm³)
  • Nonthrombosed prolapsed hemorrhoid
• Anesthesia:
  1% lidocaine (mixing lidocaine with 1/100,000 epinephrine may reduce bleeding)
• Equipment:
  • Scalpel handle and #15 blade
  • Sterile prep solution
  • 25-gauge needle and syringe
  • Forceps
  • Small clamps
  • Vaseline or Xeroform gauze

• Positioning:
  Lateral decubitus or lithotomy
• Technique:
  • Prep and drape the anal area with sterile prep solution.
  • Identify the thrombosed external hemorrhoid. By definition, it lies exterior to the dentate line, and it is firm and tender.
    
  • Perform a field block of the hemorrhoid by infiltrating the surrounding skin and soft tissues with lidocaine using a 25-gauge needle.
  • Using a scalpel, make an elliptical incision over the thrombosed hemorrhoid.
    
  • Using the forceps to hold one side of the incision, enucleate the clot within the hemorrhoid with the aid of a clamp. Apply a Vaseline gauze or Xeroform dressing.
  • The patient should be instructed to do sitz baths three times a day and after each bowel movement.

• Complications and Management:
  • Bleeding
    • A small amount of dark bloody ooze is to be expected. Bright red bleeding indicates that the hemorrhoid is not thrombosed, and the incision should be stopped.
    • Direct pressure or packing may be required to control bleeding.
  • Fissure
    • Usually results from extending the incision beyond the hemorrhoid into anoderm.
    • Treat conservatively with sitz baths and Anusol suppositories.
    • Manage operatively if conservative treatment fails.

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