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Paracentesis

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Subido el 8 de marzo de 2018 por Mercedes C.

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This is a video in Clinical Medicine from the New England Journal of Medicine. 00:00:03
many patients undergoing paracentesis will have baseline coagulopathy or thrombocytopenia however the incidence of clinically significant bleeding during paracentesis is extremely low and routine use of fresh frozen plasma or platelet concentrates is not recommended 00:00:42
paracentesis should be avoided in patients with disseminated intravascular coagulation the paracentesis needle should not pass through sites of cutaneous infection 00:01:03
visibly engorged subcutaneous veins surgical scars or abdominal wall hematomas extra caution should be used in pregnant patients and those with organomegaly small bowel obstructions or probable adhesions 00:01:14
when available ultrasound guidance should be used to minimize the risk of intra-abdominal organ injury especially in patients who are overweight and those with multiple surgical scars 00:01:31
there are various devices which are frequently assembled in prepackaged kits that can be used to perform paracentesis you should be familiar with the specific devices available at your institution 00:01:46
For sterile preparation and administration of anesthesia, you will need a skin cleansing agent, sterile gauze, sterile gloves and drape, and a face shield. 00:01:59
You will also need a skin marking pen, 1 or 2% lidocaine, a 10 mL syringe, and a 22 or 25 gauge needle. 00:02:11
For a collection of acidic fluid, you will need an over-the-needle catheter device, a 60-milliliter syringe, and high-pressure drainage tubing. 00:02:21
You will also need specimen tubes, large evacuated containers, and a sterile occlusive dressing. 00:02:32
In this video, we will demonstrate the use of a paracentesis-specific needle and catheter assembly. 00:02:40
This device has a safety mechanism with a retractable blunt obturator. 00:02:47
When pressure is applied to the distal end of the device, 00:02:52
the obturator retracts and the bevel of the needle is exposed, allowing penetration of the tissues. 00:02:55
An indicator at the top of the device will turn red whenever the obturator is retracted. 00:03:02
Once the peritoneal cavity is entered, the obturator redeploys. 00:03:08
This safety mechanism theoretically reduces the risk of organ injury. 00:03:12
Additional advantages of paracentesis-specific devices include 00:03:17
multiple distal drainage holes, which facilitate rapid fluid removal, 00:03:23
and a pigtail mechanism that curves the distal end of the catheter 00:03:28
away from intra-abdominal structures during advancement. 00:03:33
If such devices are not available at your institution, 00:03:36
standard 18-gauge intravenous catheters may be used. 00:03:40
The technique described in the following section 00:03:44
is applicable to all over-the-needle catheters. 00:03:46
Explain the procedure to the patient and obtain informed consent. 00:03:54
Risks of bleeding, infection, intra-abdominal organ injury, 00:03:58
and post-procedure hypotension should be discussed. 00:04:02
Position the patient supine in the bed with the head slightly elevated. 00:04:06
Recommended sites of needle insertion are 2 cm below the umbilicus in the midline 00:04:11
and either the left or right lower quadrants. 00:04:16
If a lower quadrant approach is used, 00:04:20
confirm that the entry site is lateral to the rectus sheath 00:04:22
to avoid puncturing the inferior epigastric artery. 00:04:25
If the subumbilical approach is used, 00:04:29
the bladder should be emptied before the procedure. 00:04:32
If available, bedside ultrasound should be used 00:04:35
to find an appropriate location that contains acidic fluid 00:04:38
but is devoid of loops of bowel or solid organs. 00:04:42
Mark the site of needle insertion with a skin marking pen. 00:04:46
Paracentesis is a sterile procedure. 00:04:50
Sterile gloves and a face shield are required. 00:04:53
The use of a sterile gown is optional. 00:04:56
Prepare the site with an antiseptic solution and then apply a sterile drape. 00:04:58
Using a 22 or 25 gauge needle, 00:05:03
anesthetize the superficial skin with a wheel of local anesthetic such as lidocaine. 00:05:06
Continue to anesthetize the deeper tissues in the anticipated tract of the paracentesis catheter, 00:05:12
intermittently pulling back on the syringe every 2 to 3 millimeters. 00:05:18
Once peritoneal fluid begins to fill the syringe, 00:05:23
inject additional anesthetic to anesthetize the highly sensitive parietal peritoneum. 00:05:25
A total of 5 to 10 milliliters of lidocaine is generally used. 00:05:32
Begin by making a small puncture in the skin with either a scalpel or a large gauge needle 00:05:36
to facilitate advancement of the paracentesis catheter. 00:05:45
Next, advance the catheter through the epidermis. 00:05:49
In this video, we will demonstrate an angular entry technique 00:05:53
in which the cutaneous site of insertion does not directly overlie the site of penetration into the peritoneal cavity. 00:05:56
Alternatively, a Z-tract technique may be used. 00:06:04
In this method, the cutaneous tissues are pulled 2 cm caudad prior to needle insertion and advancement through the peritoneum. 00:06:07
When the catheter is withdrawn at the end of the procedure, the cutaneous entry site will retract to its original position. 00:06:17
Both techniques ensure that the cutaneous and peritoneal insertion sites do not directly overlie each other, 00:06:25
theoretically minimizing the risk of an acidic fluid leak following the procedure. 00:06:32
Intermittently pull back on the plunger as you continue to advance the needle through the subcutaneous tissue. 00:06:36
Bedside ultrasound may be used to confirm proper placement. 00:06:42
You may feel a sudden loss of resistance when the needle pierces the peritoneum. 00:06:46
Immediately stop advancement once the acidic fluid begins to fill the syringe. 00:06:51
Next, guide the plastic catheter over the needle and into the peritoneal cavity, and then remove the needle. 00:06:56
if a diagnostic sample is required attach a large syringe to the catheter and aspirate thirty to sixty milliliters of fluid for analysis for therapeutic large-volume paracentesis attach the high-pressure tubing to the end of the catheter and then to an evacuated container 00:07:03
further containers may be used for collection of fluid if necessary blood pressure and heart rate should be monitored during large volume paracentesis once the desired quantity of fluid has been removed withdraw the catheter and apply a bandage 00:07:23
aspirated fluid should be immediately placed into appropriate specimen tubes a tube without additives should be sent for chemical analysis of albumin and total protein concentrations 00:07:39
an edta tube should be sent for evaluation of cell count and differential blood culture bottles should be inoculated at the bedside using aseptic technique if spontaneous bacterial peritonitis or other infection is a diagnostic concern 00:07:55
specimens for other tests such as cytology or mycobacterial culture may be sent depending on the clinical scenario and are discussed in further detail in the accompanying written supplement 00:08:12
Analysis of the fluid begins with the determination of the serum ascites albumin gradient. 00:08:24
Gradients higher than 1.1 grams per deciliter indicate that the ascites is due to portal hypertension. 00:08:31
Gradients less than 1.1 grams per deciliter suggest other causes, such as cancer, infection, or pancreatitis. 00:08:39
Post-parasynthesis circulatory dysfunction may occur after large-volume parasynthesis 00:08:47
and may lead to hypotension, hyponatremia, renal failure, and shortened survival. 00:08:57
Although the use of albumin as a plasma expander is controversial, 00:09:04
its use is recommended if more than 5 liters of fluid have been removed. 00:09:08
Other complications of parasynthesis include localized infection, 00:09:13
abdominal wall hematomas, and persistent ascites fluid leak. More serious complications are rare 00:09:17
and include hemorrhage, intra-abdominal organ injury, and inferior epigastric artery puncture. 00:09:24
Subido por:
Mercedes C.
Licencia:
Dominio público
Visualizaciones:
103
Fecha:
8 de marzo de 2018 - 13:25
Visibilidad:
Público
Centro:
IES BENJAMIN RUA
Duración:
09′ 52″
Relación de aspecto:
4:3 Hasta 2009 fue el estándar utilizado en la televisión PAL; muchas pantallas de ordenador y televisores usan este estándar, erróneamente llamado cuadrado, cuando en la realidad es rectangular o wide.
Resolución:
320x240 píxeles
Tamaño:
29.39 MBytes

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