Dr. Mazzaferro is a critical care specialist who is the co-author of the textbook Veterinary Emergency and Critical Care Procedures.
Introduction and indications: Abdominal paracentesis (abdominocentesis) is a useful and inexpensive technique to identify abdominal effusion, particularly in patients with clinical signs of acute abdominal pain or unexplained fever. Evaluation of any fluid obtained often aids in the diagnosis and helps guide treatment. Limitations of this technique are if small (< 6 ml/kg) amounts of abdominal effusion are present, a false-negative abdominocentesis may occur.
Equipment needed: 20- to 22-gauge 1–1½ inch needles, latex gloves, sterile EDTA and red top tubes for sample collection, clippers and fresh blades, antimicrobial scrub and 70% ethyl alcohol
Preparation: The patient should be placed in lateral recumbency, and the ventral abdomen clipped on midline at the level of the umbilicus, laterally, and cranially and caudally to obtain approximately 10 cm x 10 cm clipped area.
Procedure: Following aseptic scrub of the clipped area, needles should be placed in four quadrants: cranial and left, cranial and right, caudal and left, and caudal and right of the umbilicus. Each needle should gently but quickly be inserted into each site, twisting slightly as the needle is pushed in, to push any intestines away from the tip of the needle. Any fluid that flows freely should be collected and saved for cytological, biochemical, and microbial analysis/susceptibility, as indicated. If no fluid flows freely, a 3-ml syringe can gently be attached to each needle and gently suctioned with negative pressure, repeating for all four quadrants, as necessary.
Diagnostic Peritoneal Lavage
Introduction and indications: Diagnostic peritoneal lavage (DPL) can be performed in patients with acute abdominal pain and unexplained fever when 4-quadrant abdominocentesis is negative. DPL is more sensitive when small amounts of abdominal effusion are present, and when there is rupture of a hollow viscus, particularly after blunt or penetrating trauma. A limitation of this technique is that any fluid collected must be interpreted carefully, as dilution of total cell count and chemical analysis always occurs.
Equipment needed: 20- to 22-gauge 1–1½ inch needles or over-the-needle catheters, sterile glass red and purple topped tubes for sample collection, clippers, blades, antimicrobial scrub, 70% ethyl alcohol, 16- to 20-gauge 1½ inch over-the-needle catheter, warm (37°C) isotonic crystalloid fluid (Normosol-R, lactated Ringer's, 0.9% saline), intravenous fluid administration set, rapid infusion IV pressure bag, sterile gloves
Preparation and procedure: The patient is placed in lateral recumbency and the abdomen clipped and aseptically prepared as with performing a 4-quadrant abdominocentesis. Wearing sterile gloves, insert the over-the-needle catheter into the abdominal cavity caudal and to the right of the umbilicus at the level of the nipples. The catheter should be advanced slowly and with gentle twisting to prevent iatrogenic puncture of any abdominal organs. Withdraw the stylette and examine the catheter hub for any fluid. If any fluid is present, withdraw the fluid using a 3-ml syringe. If no fluid is present, rapidly instill 10–20 ml/kg of warmed crystalloid fluid into the abdominal cavity over a period of 3–5 minutes. Remove the catheter, and roll the animal from side to side, or allow the animal to stand and walk while you massage the abdomen to distribute the fluid. Lay the patient in lateral recumbency, and aseptically prepare the abdomen as previously described. Perform a 4-quadrant abdominocentesis and remove at least 0.5–1 ml of the lavage fluid to analyze for culture, susceptibility, cytology, and biochemistry analyses.
Enteral Feeding Supplementation
Nasogastric and Nasoesophageal Tube Placement
Introduction and indications: Placement of nasogastric (NG) and nasoesophageal feeding tubes should be considered in any inappetant patient for short-term nutritional support, particularly in patients that are not going to undergo pharyngeal, esophageal, or abdominal exploratory surgery. Placement of a small-bore polyvinyl flexible feeding tube is well tolerated by most patients and allows administration of a variety of commercially available, nutritionally complete polymeric enteral diet formulations. Whenever possible, enteral nutrition is preferred over parenteral nutrition in critically ill patients. An added benefit and indication for placement of nasogastric tubes is to perform gastric decompression in patients with gastric atony, including parvoviral enteritis, severe pancreatitis, and severe trauma with diaphragmatic hernia and stomach entrapment in the thorax. In such cases, passing the tube past the lower esophageal sphincter is indicated to allow gastric decompression. If gastric decompression is not indicated, the tube should ideally not be passed past the level of the lower esophageal sphincter, to prevent reflux of gastric hydrochloric acid into the esophagus that can cause irritating esophagitis.
Equipment: 0.5–2 ml 0.5% proparacaine hydrochloride or 2% lidocaine, 5% lidocaine viscous or 2% lidocaine mixed with sterile lubricant, 3-0 nylon suture, needle holders, permanent marker, Argyle feeding tube (5–8 French x 91 cm)
Preparation and procedure: Place a small amount of topical anesthetic in the nasal cavity, tilting the head up to allow the nasal mucosa to be coated and anesthetized. The tube should be placed from the level of the tip of the nose to the 7th-8th intercostal space (for nasoesophageal placement) or to the level of the last rib (for nasogastric placement). A tape or water impermeable permanent marker should be placed in the tube to note placement after the appropriate measurement is taken. Lubricate the tip of the tube with lidocaine viscous, and insert the tube into the ventral portion of the nares, holding the head in normal position. Hold the tube as close to the nose as possible, to prevent the patient from sneezing the tube out as you attempt to pass it. Pass the tube ventrally and caudally, directing the tube in a medial direction. In dogs, once the tube is passed 2–3 cm inside the nostril, push the nostril dorsally to open the ventral nasal meatus. Once the tube is in the caudal portion of the pharynx, the patient will swallow and then continue to pass the tube caudally. Confirmation of tube placement can be performed by instilling 3–5 ml of sterile saline into the tube and causing a cough, or by listening for borborygmi at the level of the xiphoid as 6–12 ml of air is instilled. Alternatively, a lateral thoracic radiograph that includes the cranial portion of the abdomen can be performed to check placement. Following confirmation that the tube is in the correct place, the tube should be secured with a stay suture attached to a finger-trap suture. We often secure the tube on the dorsal nasal midline to avoid contact with the whiskers, causing irritation. The tube is secured with staples, sutures or surgical glue on nasal midline and to the top of the head. A firm Elizabethan collar should be placed immediately to avoid patient dislodging the tube by paws or facial rubbing. A column of water should be placed in the tube after each use, and capped to avoid intake of air, esophageal reflux, and tube occlusion by the liquid diet.
No moistened diet (even blenderized) or crushed tablets of any form should be placed through the tube, even after blenderizing, as tube occlusion can occur. Should tube occlusion occur, a column of Coca-Cola can be instilled into the tube for 20–60 minutes to help dislodge or dissolve the clot.
Esophagostomy Tube Placement
Introduction and indications: Esophagostomy tubes are easy to place, require minimal equipment, and are well tolerated in the anorexic patient, or patients with orofacial trauma, or neoplasia that cannot properly prehend food. E-tubes are indicated in any patient with anorexia or oropharyngeal problems that have a functioning lower gastrointestinal tract. E-tubes are contraindicated in vomiting patients, patients with esophageal strictures, esophagitis, esophageal surgery, or megaesophagus). Advantages of E-tubes are numerous, and are well tolerated by patient and caretaker alike. Complications of E-tubes are few, and are usually associated with early removal or displacement of the tube from patient vomiting. Very few long-term or life-threatening complications have been reported.
Equipment: clippers, antimicrobial scrub and 70% ethyl alcohol, sterile gloves, curved Carmalt or other curved blunt-tipped forceps, Mayo scissors, scalpel handle and No. 10 blade, thumb forceps, sterile field towels and towel clamps, 20- to 24-French Argyle catheter or red rubber feeding tube, 3-ml syringe, sterile gauze 4 x 4s, bandaging material, permanent marker, 2-0 to 0 nonabsorbable suture material on curved cutting needle
Preparation and procedure: The patient's neck should be clipped in the left side from the ramus of the mandible caudally to the thoracic inlet and laterally to the dorsum of the spine and ventrally to midline. The patient should then be placed under general anesthesia and intubated with a cuffed endotracheal tube. The patient is then placed in right lateral recumbency and the clipped area aseptically scrubbed and draped with sterile field towels secured with towel clamps. The neck and head should be extended slightly and the mouth can be held open with a speculum, if necessary. The tube should be premeasured to the level of the 7th-8th intercostal space and marked with a permanent marker at the point of exit in the area of the midcervical region. The tip of the tube to be inserted into the esophagus should be cut on an angle to maximize outflow and minimize occlusion. The curved forceps should be placed in the mouth and directed caudally with the curved tips directed laterally to the level of the skin in the mid cervical area. The tips of the forceps should be visualized, then a blunt small stab incision made through the skin into the open tips of the forceps in the esophagus. The tips of the forceps are then pushed through the stab incision in the skin, and the distal tip of the catheter placed in between and over the tip of the forceps. The tips of the forceps are then closed and locked, and the distal tip of the catheter pulled cranially into the oral cavity and out the front of the mouth until the catheter is visualized. At this point, the distal tip of the catheter is directed cranially (orad) and the proximal tip of the catheter is directed caudally. The distal tip of the catheter is turned around and pushed with the operator's fingers or a forceps into the esophagus, taking care to avoid any tie gauze, mouth gag, or endotracheal tube. The tip of the catheter is pushed caudally until the proximal tip "flips" cranially toward the patient's head. At this point, the tube is in the esophagus and can gently be twisted to dislodge any facial attachments at the level of the skin. The proximal tip of the tube is secures with stay sutures and a finger-trap suture to the wing of the atlas (C2) and with a loose purse-string/finger-trap suture at the point of entry into the esophagus. The area is bandaged using gauze 4 x 4s, antimicrobial ointment, and a loose bandage or stockinet. The tube placement can be verified using a lateral thoracic radiograph. The tube can be used for feeding immediately upon anesthetic recovery. Like the NG and NE tubes, the E-tube should be flushed with water and have a column of water placed and capped with a 3-ml syringe after each use to prevent tube occlusion and air intake. Once the patient is eating normally, the tube can be removed by clipping the sutures and simply pulling on the tube for removal. The exit wound is loosely bandaged for 2–3 days, and the sound left to heal by 2nd intention.
Oxygen Supplementation Techniques
Nasal and Nasopharyngeal Oxygen Catheter Placement
Introduction and indications: Placement of a nasal oxygen insufflation catheter is a quick and simple means to provide supplemental oxygen to the hypoxic patient. Nasal oxygen insufflation catheters are well tolerated, require minimal equipment, and are easy to maintain. Their use should not be considered in patients with laryngeal obstruction, nasal or facial trauma, nasal obstruction (foreign bodies or mass lesions including fungal infections or neoplasia), or bleeding disorders. Additionally, since sneezing sometimes occurs during placement, their use is relatively contraindicated in patients with risk of increased intracranial pressure including intracranial neoplasia.
Equipment: Argyle feeding tube or red rubber catheter, surgical staples or 3-0 nylon suture, 2% lidocaine or 0.5% proparacaine hydrochloride, sterile lubricant, permanent marker, 1-ml syringe case, flexible extension tubing, oxygen source, bubble for humidification, rigid Elizabethan collar
Preparation and procedure: The patient's nostril should be anesthetized with 0.5–1 ml of dilute 2% lidocaine or several drops of 0.5% proparacaine, tilting the head back to assure coating of the nasal mucosa with the topical anesthetic. In the case of nasal oxygen catheter placement, the tip of the tube is placed at the lateral canthus of the eye, and the portion adjacent to the tip of the nose marked with a permanent marker. In the case of nasopharyngeal oxygen catheter placement, the tip of the tube is measured from the ramus of the mandible to the tip of the nose, and marked accordingly. The tip of the tube is lubricated, and the tube held just adjacent and in front of the nostril, as close to the nostril as possible. The patient's muzzle is held with the other hand, for ease of placement. The tube is directed ventrally and medially to the level of the mark on the tube. In the case of nasopharyngeal catheter placement, the nostril is pushed dorsally and the lateral portion of the nostril pushed medially at the same time, directing the catheter into the ventral nasal meatus. Once the tube is in place, it is secured using surgical staples or nylon suture material, avoiding the whiskers. We usually secure it over the top of the nasal planum in between the eyes, to the top of the head, and immediately place a rigid Elizabethan collar. Oxygen flow rates of 50–100 ml/kg/min are usually well tolerated, as long as the oxygen source is humidified to prevent drying of the nasal and airway mucosa. Topical anesthetic (0.5% proparacaine) can be instilled as necessary for patient comfort.
Intratracheal Oxygen Supplementation Catheter
Introduction and indications: The placement of an intratracheal catheter for oxygen supplementation is an effective and well-tolerated means of providing supplemental oxygen to the patient with head trauma, nasopharyngeal obstruction, pulmonary parenchymal disease, and hypoventilation. In some patients, placement may require sedation or general anesthesia.
Equipment: Cook catheter, red rubber or Argyle catheter, trocar, No. 10 and No. 11 scalpel blade with scalpel handle, sterile gloves, groove director (from spay pack), small Gelpi retractors, Metzenbaum scissors, 3-0 nylon suture
Preparation and placement: The patient's ventral cervical region should be clipped from the ramus of the mandible caudally to the thoracic inlet on ventral midline. The patient should be placed in dorsal recumbency and the ventral neck aseptically scrubbed and draped with sterile field towels. A 1-cm skin incision should be made just caudal to the larynx, dissecting through the underlying fascia to the level of the trachea with a curved hemostats. Once the trachea is visualized, a small stab incision can be made horizontally in between tracheal rings. The groove director can be inserted into the horizontal hole and the catheter directed into and through the groove, directing the catheter caudally into the trachea. Once the catheter is secured in the trachea, the trocar/stylette and the V-shaped device is removed, then the tracheal oxygen insufflation catheter secured with nylon suture at the level of the skin. The catheter can also be secured with a piece of 1-inch tape around the neck.
Tracheostomy Tube Placement
Introduction and indications: A temporary tracheostomy tube should be placed in cases of severe upper airway obstruction, trauma, laryngeal or pharyngeal collapse, or if long-term positive pressure ventilation is going to be performed.
Equipment: Sterile surgical pack including sterile field towels, towel clamps, No. 10 scalpel blade, scalpel handle, small Gelpi retractors, sterile Metzenbaum scissors, curved hemostats, gauze 4 x 4s, nylon suture, No. 11 scalpel blade, various sized Shiley tracheostomy tubes, umbilical tape
Preparation and procedure: The procedure is performed with the patient under general anesthesia. The patient's ventral neck is clipped from the ramus of the mandible caudally to the thoracic inlet and laterally to the dorsal cervical region. The patient is positioned in dorsal recumbency, making sure that the head and neck are perfectly straight. The ventral cervical region is aseptically scrubbed and draped with sterile field towels secured with towel clamps. The larynx is palpated carefully, and a skin incision made with a No. 10 scalpel blade caudally on ventral cervical midline for several centimeters. The subcutaneous tissue, underlying fascia and sternohyoideus muscles are visualized and bluntly dissected using curved hemostats and Metzenbaum scissors, using care to dissect through tissue/muscle planes and not cause any damage or hemorrhage. Hemorrhage should carefully be controlled to allow best visualization. The lateral edges of the skin incision and the underlying tissue should be carefully retracted using Gelpi retractors to allow best visualization. A horizontal incision should be made with No. 11 scalpel blade in between the 4th and 5th or 5th and 6th tracheal rings, using care to not cut more than 50% of the circumference of the trachea. A suture should be placed around the tracheal ring at the cranial and caudal edges of the incision to allow retraction of the incision to hold the incision open and place the tracheostomy tube. The suture should not penetrate into the lumen of the trachea, but should be placed carefully through the cartilage of the tracheal rings, wherever possible. The sutures should be left long and tied as stay sutures. The stay sutures are retracted to pull the incision in the trachea open, and the appropriate sized Shiley catheter placed into the trachea. The tracheostomy tube can be secured with umbilical tape and a light wrap. Once no longer needed, the tracheostomy tube cane be removed. The stay sutures should be left in place until you are sure that the patient no longer requires tracheostomy tube. Once the stay sutures are removed, the sutures can be cut and simply removed. The wound is left to heal by second intention.
Thoracic Evacuation Techniques
Introduction and indications: Thoracocentesis should be considered in any patient with respiratory distress and a short, choppy restrictive respiratory pattern caused by various causes of pleural effusion or pneumothorax. Thoracic auscultation will reveal dull muffled heart and lung sounds. Other causes of a restrictive respiratory pattern such as pain from fractured ribs, flail chest, pulmonary contusions, pulmonary edema, and lower airway disease should be considered prior to thoracocentesis, or if thoracocentesis is unrewarding.
Equipment: 20- to 22-gauge 1-inch needles, 3-way stopcock, IV extension tubing, 60-ml syringe, clippers and blades, nonsterile gloves, aseptic scrub, collection basin for fluid, EDTA and red-topped tubes, sterile culturettes, and Port-A-Cul for bacterial culture
Preparation and procedure: The patient should be restrained in sternal recumbency or in a standing position. The entire thorax should be visualized as a box, and a 10 cm x 10 cm area clipped in the center of the box on both sides of the chest. The clipped areas should be aseptically scrubbed. Wearing gloves, assemble the needle, IV extension tubing, 3-way stopcock, and 60-ml syringe. In the center of the box 6th-9th intercostal space), palpate the intercostal area and carefully insert the needle into the pleural space. Avoid the arterial blood supply and the nerves at the caudal portion of each rib. The bevel of the needle should be directed internally. Once the needle has entered the pleural space, the entire needle should be placed parallel to the body wall, to avoid iatrogenic lung laceration/puncture. The bevel of the needle can be directed dorsally if air is present, and ventrally if fluid is present. Often, it is necessary to sweep the needle in a circular motion (always making sure that the length of the needle is parallel with the thoracic wall), to aspirate air or fluid that is in pockets within the thorax. In some cases, multiple areas will need to be tapped. Any fluid collected should be saved in EDTA and red-topped tubes for cytological and bacterial analyses. Always aspirate both sides of the thorax. Once the thorax has been evaluated and a more normal respiratory pattern has resumed, remove the needle. If negative pressure cannot be obtained, or if air re-accumulates rapidly due to an ongoing leak, a thoracostomy tube should be placed.
Thoracostomy Tube Placement
Introduction and indications: A thoracostomy tube (or tubes) should be placed when ongoing accumulation of air or fluid causes continued respiratory distress, or if thoracic lavage is indicated (i.e., in cases of pyothorax). Whenever the thorax is entered during surgery, a chest tube is placed in order to evaluate the pleural space of air postoperatively. Once a chest tube is placed, continuous suction can be used to control ongoing accumulation of air (pneumothorax), or fluid such as in cases of chylothorax.
Equipment: Clippers and blades, antimicrobial scrub, 2% lidocaine, 3-ml syringe, 22-gauge needle, sterile surgical pack including field towels, towel clamps, scalpel handle and No. 20 scalpel blade, needle holders, thumb forceps, hemostats, Mayo scissors, gauze 4 x 4s, trocar-type chest tube (Argyle), 2-0 nylon suture, bandage material, sterile gloves, 3-way stopcock, Christmas Tree adapter, wire, wire cutters, antimicrobial ointment
Preparation and procedure: The animal should be placed and restrained in lateral recumbency and the entire lateral portion of the thorax shaved. Sedation may be necessary in some patients. The clipped area should be scrubbed aseptically, and draped with sterile field towels secured with towel clamps. Infuse lidocaine at the level of the 10th intercostal space and tunnel the needle cranially and insert at approximately the 7th intercostal space where the trochar will enter the thorax. While the lidocaine is taking effect, cut the widened end of the thoracic drain with a scissors, and assemble the IV extension tubing, 3-way stopcock, Christmas Tree adapter, and 60-ml syringe. Make a very small (1 cm) stab incision (just large enough to accommodate the size of the thoracic drain but no larger) at the level of the 10th intercostal space dorsally. Have an assistant pull the thoracic skin cranially and ventrally. This technique will help make a larger skin tunnel. Tunnel the trochar cranially and once over the 7th intercostal space, direct the trochar perpendicular to the thoracic wall. Grasp the trochar at the level of the skin firmly, and using the palm of your hand, push the trochar through the intercostal space into the thorax. Once the trochar has entered the thorax, push the tube off of the trochar cranially and ventrally, and have the assistant release the skin. Immediately secure the Christmas Tree adapter set-up, and have an assistant evaluate the thorax while you are securing the tube in place. Place a purse-string suture around the point of entry at the level of the skin, leaving the ends of the suture long in order to make a finger-trap suture. Place a horizontal mattress suture cranially to the purse-string suture, around the tube. Use care to not puncture the tube, and don't make the suture so tight to occlude blood flow and cause skin damage. Secure the finger-trap suture against the tube, puckering the tube with each knot. Place a piece of 1-inch tape around the tube, and suture the piece of tape to the skin to prevent movement as the skin moves. Secure the 3-way stopcock, Christmas Tree adapter to the tube with wire. Place a piece of gauze 4 x 4 with antimicrobial ointment over the chest tube point of entry into the skin, and secure to the thorax with.
Vascular and Intraosseous Access Techniques
Introduction and indications: A central venous catheter can be useful for large and small volume intravenous fluid, blood product, or drug administration, central venous pressure measurement, and frequent collection of blood samples. A jugular catheter often well tolerated by the patient, and can be maintained for many days. Additionally, jugular catheters tend to stay cleaner and dryer than catheters placed in other areas of the body. Jugular catheters are contraindicated in patients with various forms of coagulopathies, and in hypercoagulable patients (i.e., hyperadrenocorticism, DIC, IMHA). Sedation may be necessary in some patients.
Equipment needed: Clippers and blade, antimicrobial scrub, nonsterile gloves, 1-inch white tape, cling, and other bandaging material, antimicrobial ointment, 14-, 16-, or 18-gauge Venocath catheter, 3-ml syringe with heparinized saline to use as flush, T-port, gauze 4 x 4s
Preparation and procedure: Restrain the patient in lateral recumbency. Clip the lateral cervical area from the ventral ramus of the mandible caudally to the thoracic inlet and dorsally and ventrally to midline. Extend the head and neck and have the restrainer pull the front legs caudally. Occlude the jugular vein and visualize. Aseptically prepare clipped area. Wearing gloves, tent the skin over the jugular vein. Insert the needle carefully and briskly though the skin. Do not try to immediately enter the vein. Once the needle is inserted under the skin, occlude the vein and "strum" the vein with the needle. Isolate the vein under the needle and insert the needle in a smooth motion. Once the needle is inserted into the vein, a flash of blood should appear in the catheter. Insert the needle a small amount into the vein, and then push the catheter into the vein, not letting go of the needle. Once the catheter is secured in the hub of the needle/catheter assembly, remove the needle from the vein and push down the wings over the needle and place clean 4 x 4s over the point of entry at the level of the skin to decrease bleeding from the venipuncture site. Make a small loop in the catheter approximately the size of a quarter, and tape the shaft of the needle assembly with a piece of white tape, securing the white catheter hub to the blue piece. Continue the wrap around the neck. Attach one of two more pieces of white tape around the neck and gauze 4 x 4s in the direction opposite than the first piece of white tape. Secure the bandage with 2-inch Kling, going in the same direction as the last two pieces of white tape. Secure the Kling with Elasticon or white tape, and label the bandage with the date of catheter placement, catheter type and gauge, and person who placed the catheter.
Introduction and indications: It is sometimes necessary to perform a surgical cutdown to isolate and catheterize a vein. The following procedure describes jugular venous cutdown, but the same method applies to catheterization of any peripheral vein, as well. Vascular cutdown can be performed to obtain venous access for intravenous fluid, colloid, blood product, and medication administration, and to obtain venous blood samples. In most cases, alternatives such as intraosseous catheterization can be performed until vascular access is possible.
Equipment: Sterile surgical pack including hemostats, scalpel blade and handle, aseptic antimicrobial scrub, sterile gloves, field towels, towel clamps, tissue/thumb forceps, Mayo or Metzenbaum scissors, curved mosquito forceps, 3-0 absorbable suture, 3-0 Nylon suture, sterile gauze 4 x 4s, 14- to 18-gauge Venocath, heparinized saline flush solution, T-port connector, antimicrobial ointment, 2-inch Kling, 1-inch white tape or Elasticon
Preparation and procedure: Restrain the patient in lateral recumbency and clip the neck over the jugular vein from the level of the thoracic inlet to the larynx and 4 cm on either side. Aseptically scrub clipped area and drape with field towels secured with towel clamps. Occlude the jugular vein in the jugular furrow and visualize the vein. If the patient is not anesthetized, placed a small bleb (0.5–1.0 ml) of 2% lidocaine over the jugular vein. Use care to not lacerate the vein during insertion of the local anesthesia. Make a small stab incision through the anesthetized area, tenting the skin and using care to not lacerate the underlying vein. Bluntly dissect the subcutaneous fat and fascia with the tips of a scissors or the tips of a hemostat, and isolate the vein. Place a curved mosquito hemostats under the vein. Place a 15–20 cm piece of absorbable suture around the vein and leave in place, securing with a mosquito hemostats as a stay suture. Repeat the process so that there are two sutures loosely encircling the vein. Using a through the needle catheter, insert the needle into the vein, directing the needle and catheter caudally towards the heart. Loosely tie the proximal and distal suture in place, and secure the catheter in the vein. Pull the phalanges over the needle and secure with the plastic cuff. Remove the stylette from the catheter and flush with a 3-ml syringe of heparinized saline. Attach a T-port. Close the skin over the catheter in 2 layers with absorbable then nonabsorbable skin sutures in an interrupted pattern. Make a quarter-sized loop with the catheter and place a gauze 4 x 4 with antimicrobial ointment over the point of entry into the skin. Secure with 1-inch white tape. Place two more pieces of white tape around the neck in the direction opposite to the first. Secure with Kling, and then additional layers of white tape or Elasticon. Sign and date the bandage as previously described.
Introduction and indications: Intraosseous catheters are an excellent means of infusing large volumes of crystalloid and colloid fluids, blood products, and drugs to a patient in which intravenous access is difficult or impossible due to extreme hypovolemia, hypotension, or small patient size or exotic species. Uptake of fluids and other products from the intraosseous space is as rapid as intravenous infusion. Placement of an intraosseous catheter is simple and well tolerated in most patients, and can be lifesaving when valuable time is sometimes wasted in procuring vascular access.
Equipment: Clippers and blades, antimicrobial scrub, 16- to 18-gauge bone marrow needle or spinal needle with stylette, 16- to 18-gauge needle, 2% lidocaine, 22- to 25-gauge needle, heparinized saline flush, antimicrobial ointment, T-port connector, ½–1 inch white tape, 3-0 nylon suture
Preparation and procedure: Position the patient in lateral or sternal recumbency. Palpate the greater trochanteric fossa of the femur and intertrochanteric fossa. Clip a 2–4 cm area over the intertrochanteric fossa and aseptically scrub. Infuse 0.5–1.0 ml 2% lidocaine over the greater trochanter and infuse to the level of the periosteum. Adduct the distal limb to prevent damage to the sciatic nerve. Introduce the needle and stylette through the skin to the level of the intertrochanteric fossa. Grasp the needle and stylette (or just the needle in very small patients) and turn the needle back and forth while firmly pushing the tip of the needle into the shaft of the femur. Once the needle is into the medullary cavity, it will become much easier to push the needle. Let go of the distal limb and push the top portion of the needle/stylette. If the needle is in the correct place, the femur will move with it. Remove the stylette and flush with heparinized saline. The flush solution should flow with little resistance. If a needle was used (no stylette), in some cases a bone plug will be present. In such cases, it may be necessary to remove the first needle and re-insert an identical needle in its place through the same hole created by the first needle. If any of the fluid accumulates under the skin, there is leakage or the needle has been placed incorrectly. Placement can be confirmed with a lateral and VD radiograph. Once correct placement is confirmed, a T-port connector should be attached to the needle. ½ to 1 inch tape should be placed around the shaft of the needle protruding from the femur and sutured in place. The catheter is now ready for use.
Open-Chest Cardiopulmonary Cerebral Resuscitation
Introduction and indications: Cardiopulmonary cerebral resuscitation is indicated whenever there is inadequate or ineffective spontaneous respiration and cardiac output or circulation to sustain vital organ perfusion. Internal cardiac massage and open-chest CPCR causes more effective circulation than external thoracic and cardiac compressions. Internal cardiac massage and internal or open-chest CPCR is indicated in large or obese patients, patients with pleural effusion or pneumothorax, pericardial tamponade, penetrating thoracic injuries, rib fractures including flail chest, and diaphragmatic hernia. In all of the above cases, it is impossible to generate enough of a change in intrathoracic pressure with closed-chest compressions to generate adequate circulation. The decision to open the thorax must be immediate if any of the above injuries are present, and not delayed if closed-chest CPCR is unsuccessful.
Equipment: Clippers and blades, antimicrobial scrub, sterile gloves, scalpel handle and blade, blunt-tipped scissors, hemostats, red rubber catheter, Rommel tourniquet
Preparation and procedure: Place the patient in right lateral recumbency. Clip a wide patch of fur just caudal to the elbow on the lateral thoracic wall dorsally to the level of the spine and ventrally to the level of the sternum. Quickly aseptically scrub the clipped area. Make a skin incision at the left fifth intercostal space with the scalpel blade through to the level of the intercostals muscles. With the blunt-tipped scissors, make a stab incision through the intercostal muscles. Make sure that the person performing artificial respiration does not inflate the lungs at this point, to avoid lung puncture. With the tips of the scissors, quickly extend the stab incision dorsally and ventrally. Insert your hand into the thorax and grasp the heart. Visualize the phrenic nerve and incise the pericardium just ventral to the nerve. Remove the heart from the pericardial sac and grasp it and squeeze from the apex to base. Make sure that you don't twist the heart, to avoid lacerating the vena cava and aorta. To provide more effective coronary and cerebral blood flow, the descending aorta can be occluded with a Rummel tourniquet or a red rubber catheter secured with a Hemostats. Intravenous drugs, such as atropine (0.04 mg/kg IV), epinephrine (0.02 mg/kg IV), naloxone (0.03 mg/kg IV), magnesium chloride, and sodium bicarbonate (1 mEq/kg IV after 10 minutes of cardiac arrest) can be administered as indicated by cardiac rhythm, time interval since cardiac arrest, and the presence of anesthetic or analgesic drugs that depress cardiovascular function. Intravenous fluids can be titrated accordingly.
References are available upon request.