Inpatient Procedures

Inpatient Procedures - Tapping Treasures

I. Thoracentesis (Pleural Tap)

• Indications: Dx (new effusion), Tx (dyspnea).
• Site: Mid-scapular/axillary line, 1-2 ICS below fluid, above rib. US guidance.
• Complications: Pneumothorax, hemothorax, re-expansion pulmonary edema (drain <1.5L), vasovagal.
• Light's Criteria (Exudate if any 1):
  • Pl.Pr/S.Pr >0.5 (Pleural Protein/Serum Protein)
  • Pl.LDH/S.LDH >0.6 (Pleural LDH/Serum LDH)
  • Pl.LDH >2/3 ULN serum (Pleural LDH > two-thirds Upper Limit of Normal for serum LDH). 📌 Mnemonic "PLE": Protein ratio, LDH ratio, Enz_LDH (absolute).

II. Paracentesis (Ascitic Tap)

• Indications: Dx (new ascites, SBP rule-out), Tx (tense ascites).
• Site: LLQ (2-3cm medial-superior to ASIS) or midline infraumbilical. Z-track.
• Complications: Leak, hematoma, bowel perf., infection.
• SAAG (Serum-Ascites Albumin Gradient):
  • SAAG = S.Alb - Asc.Alb (Serum Albumin - Ascites Albumin)
  • ≥1.1 g/dL: Portal HTN (cirrhosis, CHF).
  • <1.1 g/dL: Non-portal HTN (malignancy, TB).

⭐ SAAG ≥1.1 g/dL ~97% accurate for portal HTN ascites.

Inpatient Procedures - LP Lowdown

• Indications: Dx (meningitis, SAH, MS), Therapeutic (↑ICP, meds).
• Contraindications:
  • ↑ICP signs (papilledema, focal deficits) → CT head first!
  • Coagulopathy (INR > 1.5, Plt < 50k)
  • Local skin infection.
  • Spinal epidural abscess.
• Procedure Key Points:
  • Position: Lateral decubitus, knees to chest.
  • Landmark: L3-L4/L4-L5 (iliac crests).
  • Opening Pressure (OP): Normal 10-20 cm H₂O.
  • Collect 3-4 tubes (📌 Order: 1.Chem/Immuno, 2.Micro, 3.Cells, 4.Special).
• Complications: Post-LP headache, infection, bleeding, herniation.

⭐ Xanthochromia (yellow CSF) indicates SAH if >6-12 hrs post-bleed (bilirubin).

Inpatient Procedures - Vascular Ventures

• Central Venous Catheter (CVC):

  • Indications: CVP monitoring, TPN, vasopressors, poor peripheral access, rapid fluid resuscitation.
  • Sites: Internal Jugular (IJV) (preferred), Subclavian (↑ pneumothorax risk), Femoral (↑ infection risk).
  • Technique: Seldinger (needle → guidewire → dilator → catheter).
  • Complications: Pneumothorax (esp. subclavian), arterial puncture, hematoma, infection (CLABSI), thrombosis, air embolism.
  • 📌 Mnemonic (IJV anatomy): "Two Heads Are Better Than One" (Sternocleidomastoid heads for IJV triangle).

• Arterial Blood Gas (ABG) Sampling:

  • Indications: Assess oxygenation ($PaO_2$), ventilation ($PaCO_2$), acid-base status (pH, $HCO_3^-$).
  • Sites: Radial (preferred), brachial, femoral.
  • Pre-procedure: Modified Allen's Test (for radial artery patency).
  • Complications: Hematoma, arterial spasm, thrombosis, nerve injury, infection.

⭐ Most common non-infectious complication of CVC is catheter malposition.

Inpatient Procedures - Tube Trails & Tips

• Nasogastric (NG) Tube Essentials:

  • Uses: Gastric decompression (SBO), lavage, medication/feed delivery.
  • Sizing: Adults 12-18 Fr. Measurement: NEX (Nose-Earlobe-Xiphoid).
  • Insertion: Upright, lubricate tube, chin-to-chest, swallow sips of water.

• Placement Verification (CRUCIAL):

  • Bedside checks: Aspirate appearance & pH (gastric target < 5.5). Epigastric "whoosh" on air insufflation.

  ⭐ Chest X-ray (CXR) is the gold standard for confirming NG tube tip location, vital before initiating feeds or high-risk medications.

• Key Pearls & Pitfalls:

  • 📌 Mnemonic: NEXt, X-ray Confirms Position (NEX, X-ray Confirmation).
  • Risks: Malposition (tracheal, pulmonary, intracranial), sinusitis, epistaxis, aspiration pneumonia.
  • ⚠️ If cough, excessive gagging, or respiratory distress during insertion, withdraw tube immediately.

High‑Yield Points - ⚡ Biggest Takeaways

• Thoracentesis: Use Light's criteria for exudates; site: 8th-9th ICS, mid-axillary line.
• Paracentesis: SAAG > 1.1 g/dL implies portal hypertension; site: LLQ.
• Lumbar Puncture: Avoid if raised ICP; normal opening pressure <20 cm H2O.
• Central Lines: Seldinger technique used; IJV preferred; risk: pneumothorax.
• ABG: Allen's test pre-radial puncture; radial artery common.
• NG Tube: X-ray confirms placement (gold standard).
• Urinary Catheter: Aseptic technique prevents CAUTI.