cmecde 2052

 

• Remove the protective cap from the other end of the giving set.

• Squeeze and release the collecting chamber of the giving set until it is about half full.

General skills

Station 4 Cannulation and setting up a drip 9

• Open the regulating clamp and run fluid through the giving set to expel any air/bubbles.

• Close the regulating clamp.

• If using an extension ‘octopus’ connector, open and flush with normal saline so that no air

remains.

• Wash your hands (see Station 1) and follow the cannulation procedure above.

• Rather than capping the cannula immediately after removing the needle, connect the giving

set directly and flush with fluid from the bag.

• Apply the adhesive plaster or transparent film dressing to secure the cannula.

• Adjust the drip-rate (1 drop per second is equivalent to about 1 litre per 6 hours).

• Check that there is no swelling of the subcutaneous tissue i.e. that the line has not ‘tissued’.

• Tape the tubing to the arm.

After the procedure

• Discard clinical waste appropriately.

• Ensure that the patient is comfortable and inform him of possible complications (e.g. pain,

erythema).

• Thank the patient.

• Sign the fluid chart and record the date and time.

Examiner’s questions: complications of cannula insertion

• Infiltration of the subcutaneous tissue. • Phlebitis.

• Nerve damage. • Thrombophlebitis.

• Haematoma. • Septic thrombophlebitis.

• Embolism. • Local infection.

Clinical Skills for OSCEs

10 Station 5

Blood cultures

Before starting

• Introduce yourself to the patient, and confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Ask him which arm he prefers to have blood taken from.

• Ask him to expose this arm.

• Wash your hands.

• Gather the equipment in a clean tray.

The equipment

In a clean tray, gather:

• Aerobic and anaerobic blood culture bottles

• Winged collection set (or 18g needle and 20ml syringe)

• Apron

• Non-sterile or sterile gloves

• Disposable tourniquet

• Alcohol sterets (x2)

• Chlorhexidine sponge

• Sterile gauze

• Sharps bin

• For the blood culture bottles, check types (aerobic and anaerobic) and expiry dates, and ensure

that the broth is clear. Do not remove the barcodes.

Every effort to use aseptic technique should be made. If blood is being collected for other

tests, the blood culture sample should be collected first. Do not use existing peripheral lines

to obtain blood cultures. The most common skin contaminants include Staphyloccus

epidermidis, Corynebacterium spp., Propionibacterium spp., and Bacillus spp.

The procedure

• Decontaminate your hands.

• Position the patient so that his arm is fully extended. Ensure that he is comfortable.

• Select a vein by palpation: the bigger and straighter the better. The vein selected is most commonly the median cubital vein in the antecubital fossa.

• Release the tourniquet.

• Decontaminate your hands.

• Clean the venepucture site with the chlorhexidine sponge.

• Decontaminate your hands.

• Remove the flip tops from the culture bottles and disinfect the rubber caps each with a fresh

alcohol steret.

• Decontaminate your hands and don the apron and gloves.

• Warn the patient to expect a ‘sharp scratch’.

• Retract the skin to stabilise the vein and insert the butterfly needle into the vein.

• Fill each bottle with at least 10ml of blood, as per the markings on the bottle (let the vacuum in

the bottles do the job for you). Fill the aerobic bottle first to minimise the amount of air in the

anaerobic sample. If using a needle and syringe, collect at least 20ml of blood into the syringe

General skills

Station 5 Blood cultures 11

so as to inject a minimum of 10ml of blood into each bottle. (It is advised not to change needles

between drawing blood and injecting into culture bottles since the risk of needlestick injury

outweighs that of contamination of the sample with skin flora.)

• Release the tourniquet.

• Withdraw the needle and apply pressure to the puncture site.

• Unscrew the adaptor and immediately dispose of the needle in the sharps bin.

After the procedure

• Ensure that the patient is comfortable.

• Thank him.

• Dispose of clinical waste in a clinical waste bin.

• Decontaminate your hands.

• Label the bottles, including clinically relevant information e.g. the puncture site and any

antibiotics that the patient has been taking (ideally, blood cultures should be taken before the

administration of antibiotics; if not, they should be taken immediately before the next dose,

with the exception of children).

• Fill in a blood request form.

• Convey the samples to the microbiology laboratory without delay (or else incubate the bottles).

• Document the procedure.

Clinical Skills for OSCEs

12 Station 6

Blood transfusion

Specifications: This station requires you either to cannulate an anatomical arm and set up a blood

transfusion, or, more likely, simply to set up a blood transfusion. You may be instructed to talk through

parts of the procedure.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the requirement for a blood transfusion, explain the risks, and obtain his consent.

• Ensure that baseline observations have been recorded (pulse rate, blood pressure, and

temperature).

Cannulation

See Station 4.

Blood transfusion

1. Sample collection

• Re-confirm the patient’s name and date of birth and check his identity bracelet.

• Extract 10 ml of blood into a pink tube (some hospitals may require two tubes for new patients).

• Immediately label the tube and request form with the patient’s identifying data: name, date of

birth, and hospital number.

• Fill out a blood transfusion form, specifying the total number of units required.

• Ensure that the tube reaches the laboratory promptly.

2. Blood transfusion prescription

• Prescribe the number of units of blood required in the intravenous infusion section of the

patient’s prescription chart. Each unit of blood should be prescribed separately and be administered over a period of 4 hours.

• If the patient is elderly or has a history of heart failure, consider prescribing furosemide (loop

diuretic) with the second and fourth units of blood.

• Arrange for the blood bag to be delivered. The blood transfusion must start within 30 minutes

of the blood leaving the blood refrigerator.

3. Checking procedures

Ask a registered nurse or another doctor to go through the following checking procedures with you:

A. Positively identify the patient by asking him for his name, date of birth, and address.

B. Confirm the patient’s identifying data and ensure that they match those on his identity bracelet,

case notes, prescription chart, and blood compatibility report.

C. Record the blood group and serial number on the unit of blood and make sure that they match

the blood group and serial number on the blood compatibility report and the blood compatibility label attached to the blood unit.

D. Check the expiry date on the unit of blood.

E. Inspect the blood bag for leaks or blood clots or discoloration.

General skills

Station 6 Blood transfusion 13

4. Blood administration

• Attach one end of the transfusion giving set to the blood bag and run it through to ensure that

any air in the tubing has been expelled. Note that a transfusion giving set has an integral filter

and is not the same as a standard fluid giving set.

• Attach the other end of the giving set to the IV cannula which should be a grey (16G), wide-bore

cannula (minimum pink/20G, or larger for resuscitation situations).

• Adjust the drip rate so that the unit of blood is administered over 4 hours. Because one unit of

blood is 300 ml, and because 15 drops are equivalent to about 1 ml, this amounts to about 19

drops per minute.

• Sign the prescription chart and the blood compatibility report recording the date and time the

transfusion was started. The prescription chart and blood compatibility report should also be

signed by your checking colleague.

5. Patient monitoring

• Record the patient’s pulse rate, blood pressure, and temperature at 0, 15, and 30 minutes, and

then hourly thereafter.

• Ensure that the nursing staff observe the patient for signs of adverse transfusion reactions such

as fever, tachycardia, hypotension, urticaria, nausea, chest pain, and breathlessness.

• Make an entry in the patient’s notes, specifying the reason for the transfusion, the rate of the

transfusion, the total number of units given, and any adverse transfusion reactions.

Examiner’s questions: complications of blood transfusion

Immune • Acute haemolytic reaction, (usually due to ABO incompatibility).

•  Delayed haemolytic reaction, (usually due to Rhesus, Kell, Duffy,

etc., incompatibility).

•  Non-haemolytic reactions such as febrile reactions, urticarial

reactions, and anaphylaxis.

Infectious • Hepatitis.

• HIV/AIDS.

• Other viral agents.

• Bacteria.

• Parasites.

Cardiovascular • Left ventricular failure from volume overload.

Complications of massive

transfusion (>10 U)

• Hypothermia.

• Coagulopathy (from dilution of platelets and clotting factors).

• Acid–base disturbances.

• Hyperkalaemia.

• Citrate toxicity (from additive in bag of packed red blood cells).

• Iron overload.

Other • Air embolism.

• Thrombophlebitis.