Bedside Procedures

• Obtain informed consent prior to any procedure
• Don’t forget to use appropriate antibiotic coverage
• Central Line
• All patients require CXR to confirm placement prior to use
• Hyperalimentation requires a virgin port, so plan ahead and save one port if need is anticipated
• Lines are changed if there is evidence of infection (fever, ↑WBC, erythema, +cultures)
• One line change over a wire is acceptable if skin entrance site appears normal
• Send catheter tip for culture for fever work-ups
• Prep skin exit site with betadine prior to removal
• Swan-Ganz Catheter
• Use a full bed sterile field for placement
• All patients require CXR to confirm placement prior to use
• Change catheter to a triple lumen if introducer is no longer needed, but central access is still needed
• Arterial Line
• Use 20 gauge angiocath and secure with tape (may suture if desired)
• Wire placement kits are available
• Lumbar Spinal Drains
• Drains fluid from lumbar theca into external bottle
• Frequently used with CSF leaks and intra-op to allow decompression to permit more brain retraction
• Soak catheter in NS solution while exposed on field
• Touhy needle should enter parasagitally (not between spinous processes)
• Use benzoin and tape to secure catheter in place
• May require suture at skin site after removal to prevent continued leakage of CSF
• Check CSF # daily
• Nafcillin 1 g q 6h for prophylaxis
• Halo Ring Placement
• Shave hair at projected pin sites to allow better pin site care
• Torque pins to 8 lbs.
• Order pin site care (1/2 strength H₂O₂ to sites tid)
• Gardner-Wells Tongs
• Shave hair above patient’s ears bilaterally
• Torque pins until recessed pin is flush with edge of outer pin
• Check daily and retorque as needed
• Order pin site care (1/2 strength H₂O₂ to sites tid)
• Ventriculostomy Placement
• Drains fluid from ventricle into external bottle
• Use a full bed sterile field for placement
• Shave hair generously at placement site
• Soak catheter is NS/gentamycin solution while exposed on field
• Catheters should be replaced every 7 days with a new placement site
• Require suture at skin site after removal
• Appropriate sedation is often essential for safe placement
• Typically inserted into the right lateral ventricle
• Typical entry sites:
• Kocher’s point (coronal) – 2-3 cm lateral to midline just anterior to the coronal suture
• Keene’s point (occipital) – 2.5-3 cm. posterior and 2.5-3 cm superior to the pinna
• Frazier’s point – 6 cm up, 4 cm lateral from inion
• Dandy’s point – 3 cm up, 2 cm lateral to inion
• Never put this drain to the floor since it may collapse the ventricles and cause acute SDH by tearing bridging veins
• CSF is sent daily for cell count, pro, glu and C/S
• DO NOT ignore reports of a drain without output, it is likely plugged and requires flushing
• Subdural catheter
• Drains subdural fluid (usually chronic SDH) to external bottle
• Placed to floor level to allow maximal drainage and collapse the potential subdural space
• Intracranial Pressure Monitor (intraparenchymal)
• Typically used in trauma patients to assist in treatment of cerebral edema
• Usually use Kocher’s point
• use smaller drill bit provided in kit so bolt can be screwed into skull
• Save the Camino ventriculostomy bolt wrench for later removal
• Camino fibroptic catheters
• Self-contained fibroptic system capable of transducing ICP
• Other types or pressure monitors:
• Subdural – typically used after craniotomy
• Intraventricular (ventriculostomy) – allows ventricular CSF drainage in addition to ICP monitoring