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Act as an Assistant to the Physician Performing Special Procedures

Georgianna Sergakis, PhD, RRT, RCP, CTTS

Learning Objectives

a.  moderate (conscious) sedation

b.  intubation

c.  bronchoscopy

d.  thoracentesis

e.  chest tube insertion

f.  tracheostomy

g.  insertion of venous or arterial catheters

h.  cardioversion

After viewing this module, the learner will understand how to assist the physician for special procedures including:

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Assisting the Physician

Prepare the patient

Prepare equipment

Monitor during

procedure Assure

ventilation

Monitor post-

procedure

Moderate (Conscious) Sedation Before and During Procedure: §  Administer IV sedation medications:

§  midazolam (Versed) or diazepam (Valium) §  fentanyl (Duragesic)

§  Prepare for overdose of sedation medications with reversal agents on hand

§  Monitor the patient during the procedure §  Prepare to bag-mask ventilate if necessary

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§  Administer IV medications for reversal of sedation: §  Flumazenil (Romazicon) if midazolam used §  Naloxone (Narcan) if fentanyl was used

§  Monitor the patient post-procedure

Moderate (Conscious) Sedation After Procedure:

Intubation Assisting - Before Set up and check function of equipment (laryngoscope, suction, ETT, oxygen)

Prepare the patient (positioning, hyperinflation & oxygenation)

Set up & prepare ventilator

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Intubation Assisting – During & After

Monitor patient and assure ventilation

Assist in ETT placement (hand over equipment, use manual resuscitator)

Inflate cuff, check tube placement (BS, ETCO2, order CXR)

Secure tube, connect to ventilator, post-procedure care of the patient

Bronchoscopy - Indications Diagnostic

•  Signs and symptoms of disease •  Cough, hemoptysis, atelectasis, obstructive pneumonia

•  Lung Cancer •  Tissue diagnosis, staging, early diagnosis

Removal of a foreign body

Assist with difficult intubation or tracheostomy procedure

Need to assess stent function

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Bronchoscopy Assisting - Before Prepare the patient (place adaptor if ventilated)

Set-up and check function of equipment

Prepare syringes: anesthetic, vasoconstrictor, mucolytic, or lavage solutions

Bronchoscopy Monitoring Level of consciousness

Vitals (BP, RR, HR & ECG rhythm)

Lavage volumes (delivered & retrieved)

Medications delivered

Sites of biopsies/washings and tests requested

SpO2, FIO2, ETCO2

Response to procedure

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Bronchoscopy Assisting – During & After

Monitor patient and assure ventilation

Document site of biopsies/washings and tests required for each sample

Prepare specimens for processing

Post-procedure care of the patient & monitoring for complications

Thoracentesis §  Definition: A sterile procedure to sample pleural fluid

collected percutaneously by needle insertion into the pleural space

§  Also a common cause of pneumothorax

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Thoracentesis: Specimen evaluation

• CHF, atelectasis, cirrhosis, lymphatic obstruction, nephrotic syndrome Transudate

•  Inflammation, infection or neoplasti disease of the lung Exudate

• Marked by pus or bacteria on Gram stain Empyema

Check CXR

Prepare patient

Assure oxygenation with 100% NRM

Assisting in Tube Thoracostomy Before tube placement

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Assisting in Tube Thoracostomy After tube placement

Prepare and connect to drainage system

Observe and monitor patient

Tracheotomy Traditional surgical procedure • Incision over second or third tracheal ring, surgical placement of tube

Percutaneous dilatational method • Needle insertion followed by guidewire placement, progressive dilation, then tube is placed

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Tracheotomy Assisting Monitor patient

Assure ventilation: volumes, oxygenation

Manipulate ETT, assist with bronchoscope

Inflate cuff, secure tube, verify placement

Monitor post-procedure

Example: Tracheotomy Assisting You are assisting with a bedside percutaneous tracheotomy. Shortly after the surgeon places the #6 Shiley tracheostomy tube you notice acute onset of subcutaneous emphysema of the neck and the patient is experiencing dyspnea. Your assessment should conclude that the tracheostomy tube is:

a. occluded

b. malpositioned

c. too small

d. too large

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Example: Tracheotomy Assisting You are assisting with a bedside percutaneous tracheotomy. Shortly after the surgeon places the #6 Shiley tracheostomy tube you notice acute onset of subcutaneous emphysema of the neck and the patient is experiencing dyspnea. Your assessment should conclude that the tracheostomy tube is:

a. occluded

b. malpositioned

c. too small

d. too large

Assisting in insertion of venous or arterial catheters

Prepare the patient

Prepare equipment

Monitor during

procedure Assure

ventilation

Monitor post-

procedure

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Example: You are assisting with right central venous line placement for a mechanically ventilated patient in the ICU. During the procedure, you note an acute drop in SPO2 and increased peak pressures on the ventilator. Auscultation reveals absent breath sounds on the right. What is the appropriate action at this time?

Prepare the patient

Prep area

Monitor during procedure

Decreased Sp02,

increased PIP

Chest tube prep

Physician  places  line  Pneumothorax  noted  

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Cardioversion Assisting

Confirm correct electrode placement

Select lead for optimal view of ECG

Charge defibrillator

Assure ventilation

References Wilkins, RL, Stoller J, Kacmarek RM editors: Egan’s Fundamentals of

Respiratory Care, ed 9, St. Louis, 2009, Mosby.

White, G. Basic Clinical Lab Competencies for Respiratory Care: An Integrated Approach, ed 4, 2003, Clifton Park, Delmar.

AARC Clinical Practice Guidelines;

Bronchoscopy Assisting