A. Introduction. Bedside procedures are often indicated during the course of care for hospitalized inpatients. This chapter provides both general principles relevant to all procedures and more detailed information on the most commonly indicated bedside procedures for hospitalized medical patients.
B. Procedure Preparation. Before performing any procedure, informed consent must be obtained from the patient. This consists of explaining the indications for the procedure, a brief description of the process, potential complications, alternatives, and the risk(s) for deferring the procedure. If a patient is cognitively impaired, a surrogate decision maker must give consent. If the procedure is a medical emergency such that a delay in treatment may lead to significant harm or death, informed consent may be implied, and the physician should act in what the physician believes is the best interest of the patient. Informed consent should be documented in the medical record in compliance with institutional practice.
☐ Review procedure technique and pertinent anatomy.
☐ Obtain informed consent from the patient.
☐ Inform the patient’s nurse of the procedure and enlist the nurse’s assistance if necessary.
☐ Gather all equipment and supplies. Having an extra set of supplies available is often helpful.
☐ Remove your pager, stethoscope, and lab coat; sign out pager if necessary.
☐ Comfortably position yourself and the patient and ensure adequate lighting.
☐ Always wash hands and observe universal precautions.
C. Point-of-Care Ultrasound. The advent of smaller, affordable, high-resolution portable ultrasound machines has facilitated the safety of bedside procedures. While specific instruction on use is beyond the scope of this text, the role of point-of-care ultrasound related to the following procedures will be outlined where appropriate. Whenever possible, use of ultrasound is highly encouraged over physical examination and landmark techniques.
When performing any of the procedures below, any needle (regardless of bore) inserted through skin should be done so with the beveled surface facing upward.
During skin preparation for any of the following procedures, use of an alcohol-containing chlorhexidine solution and applicator sponge with 30 seconds of continuous gentle scrubbing over the procedure site is recommended.
If povidone-iodine is used for skin antisepsis (e.g., patient is allergic to chlorhexidine), this should be “painted” in a circular motion extending outward from the procedure site.
Both preparations should be allowed to air-dry for one to two minutes before procedure performance.
a. Definition: removal of fluid from the intrapleural space.
i. Diagnostic: to determine the etiology of a pleural effusion.
ii. Therapeutic: to relieve dyspnea due to a pleural effusion.
c. Contraindications: None absolute, but coagulopathies with an international normalized ratio (INR) >2 or platelets <50,000/µL may increase risk for bleeding. Areas of skin infection, anatomic defects, the presence of a small (<1 cm depth) or complex effusion, and an uncooperative patient should be considered relative contraindications.
d. Potential complications: pneumothorax, hemothorax, chest pain, cough, reexpansion pulmonary edema (rare), infection (rare).
e. Before the procedure
i. If bedside ultrasound is available, confirm the presence of a free-flowing fluid pocket, measure its point of maximal depth, and identify surrounding structures.
ii. If bedside ultrasound is unavailable, obtain a decubitus chest radiograph to confirm that fluid is free flowing (i.e., forms a layer along the lateral chest wall). Alternatively, ask for the spot and depth of the fluid pocket to be marked on the skin by a radiologist who has access to advanced ultrasound-based imaging.
f. Patient positioning
i. Posterior approach: patient seated at the edge of the bed, with arms resting on a bedside table.
ii. Lateral approach: lying in bed at about a 30° angle, with arm extended over the head (often preferred in mechanically ventilated patients).
g. Locating the point of entry
i. If ultrasound is available, identify the rib interspace where the fluid pocket is deepest and unobstructed. If unavailable, identify the highest point of the effusion by percussion and move one or two interspaces below.
ii. Mark the skin at the superior aspect of the inferior rib of the chosen interspace using a marking pen.
i. Clean the entry point with a chlorhexidine-isopropyl alcohol solution, don sterile gloves, and apply a sterile drape to cover the procedural area.
ii. Palpate the superior aspect of the inferior rib of the previously marked interspace.
iii. Anesthetize the superficial skin at the mark with 1% lidocaine and a 22-gauge needle by first making a wheal, then advancing the needle to anesthetize the subcutaneous tissue and periosteum of the superior aspect of the inferior rib. Note that the planned trajectory is above the rib, avoiding the neurovascular bundle that courses just below the rib.
iv. Advance the needle over the rib while applying gentle negative pressure to the syringe. Inject small amounts of anesthetic every 0.5 cm if there is no return of fluid or blood. Appearance of pleural fluid in the syringe signifies entry into the pleural space.
vi. Insert a 14- or 16-gauge catheter-over-needle apparatus along the previously anesthetized path, carefully advancing over the rib.
vii. Use your nondominant hand to stabilize the needle, which can also be rested on the patient’s back for more support. Use the dominant hand to apply negative pressure to the syringe as you slowly advance.
viii. With the return of pleural fluid into the syringe, stop advancing and withdraw 30–60 mL of fluid (for diagnostic studies) (see Figure A.1A).
ix. If therapeutic drainage is anticipated, advance the catheter-over-needle apparatus slightly further inward (~0.5–1 cm).
x. While maintaining the position of the syringe and needle with the dominant hand, use the nondominant hand to advance the flexible catheter into the pleural space. Remove the needle.
xi. Attach the end of the catheter apparatus (which should have a stopcock or other one-way mechanism present as part of the kit) to the extension tubing. Please note, the catheter should never be left open to the environment, as this can cause a pneumothorax by entrancing atmospheric air into the pleural space. The extension tubing should be connected to vacuum drainage bottles and then the stopcock opened to allow for fluid removal (see Figure A.1b.). Alternatively, the catheter-over-needle apparatus can be attached to a special one-way valve and 60cc syringe, allowing fluid to be manually pumped out into a collection bag for removal.
xii. After the desired amount of fluid is removed, briskly remove the catheter while having the patient generate positive intrathoracic pressure (ask the patient to hum continuously) to prevent possible air entry into the pleural space during removal. For patients on mechanical ventilation, remove the catheter during the expiratory phase. Quickly apply an occlusive dressing after removal.
xiii. If the procedure is successful and completed without incident, routine postprocedure imaging is not indicated. However, a chest radiograph should be obtained if the procedure is unsuccessful, multiple punctures are performed, air is aspirated, or the patient develops concerning symptoms (e.g., chest pain, dyspnea, syncope) to evaluate for pneumothorax, hemothorax, or reexpansion pulmonary edema.
xiv. Fluid analysis (see Table 24.2)
a. Definition: removal of fluid from the peritoneal space.
i. Diagnostic: to determine the etiology of ascites, to diagnose or exclude peritonitis.
ii. Therapeutic: to relieve abdominal pain or dyspnea due to ascites.
c. Contraindications: bowel obstruction, ileus, or extensive intraabdominal adhesions are relative contraindications. Areas with surgical scar, hematoma, skin infection, or hernia should be avoided at the site of puncture. Note that paracentesis is usually well-tolerated in the setting of coagulopathy or thrombocytopenia.
d. Potential complications: bowel perforation, persistent leakage of peritoneal fluid, abdominal wall hematoma, hypotension (after large-volume paracentesis), infection (rare unless bowel perforated), bladder perforation (rare).
e. Before the procedure: have the patient empty the bladder.
f. Patient positioning: semirecumbent or supine.
g. Locating the point of entry
i. Choose one of the following entry sites (the preferred site is not universally agreed on):
1. In the midline, 2–3 cm below the umbilicus. Please note, if this site is chosen, the patient must empty their bladder completely immediately prior to the procedure.
ii. Confirm the presence of free-flowing intraabdominal fluid and the depth of the fluid pocket using portable ultrasound. If unavailable, use percussion to localize fluid. Alternatively, ask for the spot and depth of the fluid to be marked on the skin by a radiologist who has access to advanced ultrasound-based imaging.
iii. Mark the skin over the planned puncture site with a marking pen.
i. Clean the entry site with a chlorhexidine/isopropyl alcohol solution, don sterile gloves, and apply a sterile drape to cover the procedural area.
ii. Anesthetize the superficial skin at the mark with 1% lidocaine and a 22-gauge needle by first making a wheal, then advance the needle perpendicular to the skin while anesthetizing the subcutaneous tissue and anterior abdominal wall.
iii. Keep the needle perpendicular to the skin and apply negative pressure to the syringe while advancing. If blood is aspirated, withdraw the needle and hold pressure for at least 1–2 minutes. A new procedure site should be chosen.
iv. With the easy return of peritoneal fluid (typically clear, straw-colored), withdraw the needle, noting the site of insertion and trajectory.
v. Choose the needle for the next puncture based on the intent of the procedure as follows:
1. For diagnostic paracentesis: 22-gauge, 1.5-inch needle attached to a -60-mL syringe
2. For therapeutic paracentesis: 16-gauge catheter-over-needle apparatus
vi. If performing a therapeutic paracentesis, a Z-technique is recommended. Before insertion, pull the skin about ½ inch to the side before needle insertion. When the procedure is completed and the needle is withdrawn, the intact skin will slide back over the hole created in the abdominal wall, preventing fluid leakage.
vii. Slowly advance the needle along the anesthetized tract. Apply gentle negative pressure to the syringe during advancement until easy return of peritoneal fluid is achieved (see Figure A.2).
viii. Withdraw 30–60 mL of peritoneal fluid into the syringe (for diagnostic studies).
ix. After diagnostic paracentesis, withdraw the needle and apply a bandage.
x. For therapeutic paracentesis, while holding the syringe and needle stationary with the dominant hand, use the nondominant hand to advance only the catheter forward until the hub is near the patient’s skin. Then use the dominant hand to slowly pull back and remove the syringe and attached needle.
xi. Attach extension tubing to the end of the catheter.
xii. Connect tubing into vacuum drainage bottles. Fluid may also be drained by manual pumping or gravity.
xiii. Drain peritoneal fluid as clinically indicated, with consideration for albumin replacement beyond 4 L of removal, also considering the risks and benefits of very large-volume drainage (greater than 6 L).
xiv. If fluid return decreases unexpectedly, gently manipulate the position of the catheter, turn the patient towards the side of the catheter, or both.
xv. After the desired amount of fluid is drained, remove the catheter and apply a bandage.
xvi. Fluid analysis (see Table 32.1)
a. Definition: removal of cerebrospinal fluid (CSF) from the intrathecal space.
i. Diagnostic: to analyze CSF for various neurologic diseases (e.g., meningitis, subarachnoid hemorrhage) and to measure CSF pressure (e.g., normal pressure hydrocephalus).
ii. Therapeutic: to inject chemotherapy, anesthetics, or contrast dye (myelogram).
i. Infection at the site of lumbar puncture.
ii. Increased intracranial pressure secondary to a mass lesion.
iii. Coagulopathy or platelet count <50,000/µL (relative contraindication, need to weigh risks and benefits of potential bleeding vs. delaying procedure).
iv. Current use of anticoagulants other than aspirin (relative contraindication, weigh risks and benefits of holding medications or delaying procedure).
v. Uncooperative patient or unable to maintain positioning.
d. Potential complications: postprocedure headache, local hematoma (rare), infection (rare), tonsillar herniation (rare).
e. Before the procedure
i. Rule out elevated intracranial pressure with funduscopic and neurologic examination.
ii. If papilledema or a focal neurologic deficit is present or concern for the same exists, obtain brain imaging to rule out the presence of a mass lesion.
f. Patient positioning
g. Locating the point of entry
i. Find the intersection of the line formed by the spinous processes (in a cephalad to caudad direction) and the line formed connecting the left and right superior iliac crests; this marks the L3–4 interspace (see Figure A.3A.)
ii. Feel between the upper and lower spinous processes in the midline for a small, soft depression; this is the site of entry. Mark this location on the skin with a pen.
h. Technique (lateral decubitus position)
i. Clean the area with chlorhexidine/isopropyl alcohol solution, don sterile gloves, and apply a sterile drape.
ii. Anesthetize the superficial skin at the mark with 1% lidocaine and a 22-gauge needle by first making a wheal, then advancing the needle while anesthetizing, and then injecting in the intended tract of the lumbar puncture (e.g., slightly toward the head or aimed at the umbilicus, parallel to the midline).
iii. Introduce the spinal needle (with the bevel facing the ceiling) in the interspace along the same tract.
iv. Slowly advance the needle, frequently stopping to remove the stylet, and check for return of CSF.
v. If there is no CSF, replace the stylet and advance the needle slightly, then check again. Note, do not advance the spinal needle without the stylet in place. A “pop” or giving-way sensation is often felt as the needle penetrates the dura (see Figure A.3b).
vi. With the return of fluid, attach the pressure manometer and measure the opening pressure. The patient must be relaxed and in the lateral decubitus position in order to obtain an accurate measurement.
vii. Collect 2–3 mL in each of the four collecting tubes. Ensure that the tubes are numbered consecutively to ensure accurate fluid analysis.
viii. Replace the stylet in the needle and withdraw the needle.
ix. Apply a bandage over the entry site.
x. Fluid analysis (see Chapter 87)
a. Definition: removal of synovial fluid from a joint.
i. Infection, skin redness, irritation, or breakdown overlying the arthrocentesis site.
ii. Prosthetic joint (procedure should be performed by an orthopedic surgeon or a skilled operator given the risk for infection and joint loss).
d. Potential complications: septic joint (very rare), bleeding at injection site or into joint (rare).
e. Patient positioning (knee): supine with the knee slightly flexed; place a roll under the knee.
f. Locating the point of entry (knee)
i. Confirm the presence of an effusion (ballottable patella, lateral or medial fluid bulge around the patella).
ii. The needle will be injected midway between the top (rostral) and bottom (caudal) of the medial patella, about 1 cm medial to the edge of the patella (see Figure A.4).
g. Technique (knee)
i. Clean the entry site with a chlorhexidine gluconate/isopropyl alcohol solution, don sterile gloves, and apply a sterile drape to cover the procedural area.
ii. Anesthetize the superficial skin over the planned puncture site with 1% lidocaine and a 22-gauge needle by first making a wheal, then advancing the needle and injecting approximately 1 mL of lidocaine to anesthetize the subcutaneous tissue.
iii. Attach a 60 mL syringe to a 1.5-inch, 18-gauge needle. Advance the needle through the entry point, directed at the center of the joint (slightly posterior).
iv. Apply negative pressure on the syringe as you advance the needle. When synovial fluid enters the syringe, do not advance the needle further.
vi. To attach another syringe (to either withdraw more fluid or inject a medication), secure the position of the needle with a sterile hemostat. Remove the first syringe and carefully attach a second syringe to the needle. Inject or withdraw as necessary.
vii. Withdraw the needle and apply a bandage.
h. Fluid analysis (see Table 74.1)
H. Femoral Central Venous Catheter Placement. Femoral vein cannulation is most often performed during medical emergencies when rapid central venous access is required. However, with the advent of intraosseous needles and techniques, it is becoming less frequently indicated, even in this setting. Although the internal jugular and subclavian vein sites are much preferred for central access because of their lower risk for infection and thrombosis, performance of these procedures is beyond the scope of this text.
a. Definition: catheterization of the central venous circulation through the femoral vein.
i. Administration of multiple intravenous medications or medications that require central venous delivery.
ii. Frequent blood draws.
iii. Inability to place a peripheral intravenous catheter/difficult venous access.
iv. Critical illness/medical emergencies in which central venous access is necessary and cannulation of the internal jugular or subclavian sites is unfeasible.
i. Overlying skin infection.
ii. Inability to leave leg in the extended position.
iii. Severe coagulopathy or anticoagulant use (relative contraindication, must weigh risk versus benefit based on clinical scenario).
d. Potential complications
i. Arterial puncture with or without local hematoma.
ii. Retroperitoneal hemorrhage.
iii. Local site infection or central line–associated bloodstream infection (CLABSI).
iv. Femoral vein thrombosis.
e. Patient positioning: recumbent.
f. Locating the point of entry
i. Use portable ultrasound if available to positively identify the location of the femoral artery and vein, 2–3 cm below the inguinal ligament. Color Doppler can be helpful for confirming the presence and direction of blood flow.
ii. If ultrasound is unavailable, begin by palpating the femoral arterial pulse.
iii. Locate the point of entry into the femoral vein, which should be 2–3 cm below the inguinal ligament and 1 cm medial to the femoral arterial pulsation. The mnemonic NAVEL (Femoral Nerve, Artery, Vein, Empty, Lymphatics) can be helpful for remembering the position of vessels in the femoral triangle (see Figure A.5).
i. Clean the planned entry site and a wide surrounding field with a chlorhexidine gluconate/isopropyl alcohol solution, don sterile gloves, and apply a sterile drape to cover the procedural area.
ii. Anesthetize the superficial skin over the planned puncture site with 1% lidocaine and a 22-gauge needle by first making a wheal, then advancing the needle to anesthetize the subcutaneous tissue. Note that in an emergency with an unresponsive patient, this step may be skipped.
iii. With the nondominant hand palpating the femoral artery, use the dominant hand to insert an 18-gauge needle on a syringe at a 45º angle to the skin, aiming cephalad and slightly medially.
iv. While applying negative pressure to the syringe, slowly advance the needle forward until blood flashes into the syringe.
v. If there is no blood return, slowly withdraw the needle while maintaining negative pressure, watching for a flash of blood that may occur if the vein was punctured “through and through” on the first pass.
vi. When positive blood flow is achieved, maintain the position of the needle with the nondominant hand, which is braced on the patient’s skin.
vii. Lower the angle of the needle and aspirate to confirm easy return of blood (i.e., to ensure that the needle remains in the vessel).
viii. With the position of the needle secured with the nondominant hand, remove the syringe from the needle with the dominant hand.
ix. Assess the flow of blood exiting through the needle hub, which should be dark and steady but not bright red, pulsatile, or forceful (which would suggest arterial puncture).
x. Feed the guidewire through the needle, which should advance easily. Be sure to maintain control of the guidewire at all times. Note, if significant resistance is encountered, do NOT attempt to further advance the guidewire. Remove the guidewire, reconnect the needle, and recheck the position of the needle in the vein by looking for blood aspiration in this setting.
xi. While holding the guidewire with one hand, remove the needle over the guidewire. Never stop holding the guidewire during the procedure.
xii. Make a small stab incision in the skin with a scalpel at the entry of the guidewire. The scalpel blade should face away from the guidewire during the incision, and penetrate both the skin and subcutaneous tissue.
xiii. Holding the guidewire with one hand, pass a dilator over the guidewire and dilate through the subcutaneous tissue. Remove the dilator.
xiv. With the dominant hand, insert the distal end of the catheter over the guidewire. Please note, catheters can have either one or multiple lumens. Ensure that the distal port is uncapped for only the main lumen, where the guidewire will exit.
xv. Continue to thread the guidewire through the tip of the catheter until it exits the distal port.
xvi. Holding the end of the guidewire past the distal port, advance the catheter over the guidewire into the vein.
xvii. Remove the guidewire.
xviii. Aspirate blood from each port, flush with saline, and place caps on each port.
xix. Secure the catheter through an advanced dressing; apply a transparent sterile dressing. Avoid suturing the catheter if possible, to prevent risk for needlestick injury.
a. Definition: introduction of a catheter into the (radial) artery.
i. Continuous monitoring of heart rate and blood pressure.
ii. Frequent arterial blood gas measurement.
iii. Critical illness/invasive hemodynamic monitoring.
c. Contraindication: infection/burn over site, digital ischemia, severe coagulopathy (relative contraindication).
d. Potential complications
i. Hematoma at the insertion site.
ii. Arterial pseudoaneurysm.
iii. Thrombosis or infection of the arterial line.
iv. Distal ischemia of extremity.
e. Technique (radial)
Before starting this procedure, it is helpful to have the arterial line flush system and sensors available and set up so that the line can be attached quickly when arterial access is achieved.
i. Place a roll under the dorsal surface of the wrist, leaving it in dorsiflexion (see Figure A.6).
ii. Secure the fingers and forearm to an arm board.
iii. Localize the radial artery pulsation proximal to the wrist crease. If there is difficulty in identifying a pulse, ultrasound can be used to identify the presence and course of the artery along with confirming the presence of blood flow.
v. Anesthetize the superficial skin at the entry site with 1% lidocaine if skin anesthesia is desired.
vi. Advance a 20-gauge integral-guidewire arterial catheter apparatus at a 45º angle, while gently palpating the radial artery proximal to the site of insertion to guide needle direction (note that too much pressure will occlude the pulse).
vii. Stop advancing when bright-red blood appears in the clear tubing connected to the needle; this signifies entry of the needle into the artery. If difficulty with arterial cannulation is encountered, consider real-time ultrasound (using a sterile probe cover) to watch the needle tip enter the artery.
viii. While stabilizing the apparatus with the dominant hand, use the nondominant hand to advance the guidewire through the needle. Blood flow will stop.
ix. If resistance to guidewire insertion is met before fully inserted, retract the guidewire and lower the apparatus, making a more acute angle with the skin. If blood continues to enter the clear tubing, guidewire insertion can be reattempted.
x. When the guidewire is fully inserted, hold the needle apparatus stationary using the dominant hand. Using the nondominant hand, advance the catheter forward until the hub is at the skin.
xi. With arterial compression applied proximally, remove the needle with the dominant hand.
xii. Release compression; return of pulsatile, bright blood signifies the presence of successful arterial cannulation.
xiii. If there is no blood return, then the catheter is not within the artery lumen or the catheter is pinched/obstructed.
1. Remove the catheter and apply pressure for 5 minutes.
2. Repeat the process at a more proximal entry site.
xiv. Attach the catheter to the flush system and sensors and check for an adequate arterial waveform on the monitor.
xv. Secure the catheter with an advanced stabilization device, apply a sterile transparent dressing, and remove the arm board.
J. Arterial Blood Gas Sampling
a. Definition: sampling of arterial blood.
i. Measurement of pH, partial pressures of oxygen and carbon dioxide (Po2, Pco2), and lactic acid.
ii. Assessment of methemoglobinemia and carboxyhemoglobinemia.
c. Contraindications: same as for arterial line placement.
d. Potential complications: insertion point hematoma, arterial thrombosis.
e. Patient positioning: Patient seated or recumbent with the wrist in a slightly hyperextended position.
f. Locating the point of entry: Palpate the radial artery at the proximal wrist crease. Ultrasound can be used to confirm target vessel location and can also confirm the presence and direction of blood flow using color Doppler.
g. Technique (radial)
i. Clean the overlying skin with an alcohol swab.
ii. Anesthetize the skin with 1% lidocaine using a 25-gauge needle if skin anesthesia is desired.
iii. Attach the 25-gauge needle to the 3 mL blood gas syringe (contains a dry disk of heparin to prevent coagulation). Withdraw the plunger to leave approximately 1 mL of air in the syringe.
iv. With your nondominant hand, palpate the artery approximately 2–3 cm proximal to the palmar crease and enter the artery at a 45º angle. Brisk return of bright-red blood signifies arterial puncture (see Figure A.7).
v. Keep the needle stationary in this position, collecting 2–3 mL of blood.
vi. Remove the needle and apply pressure to the puncture site for at least 1–2 minutes to ensure hemostasis.
vii. Cover the puncture site with a bandage.
viii. Carefully remove the needle from the syringe.
ix. Place a filter cap on the syringe.
x. Evacuate the excess air present by advancing the blood in the syringe until it reaches the filter cap.
xi. Transport the sample immediately to the laboratory for testing, on ice if possible.
a. Definition: introduction of a catheter into a peripheral vein.
b. Indication: administration of intravenous medications or fluids.
c. Contraindication: infection overlying the insertion site, presence of venous thrombus.
d. Potential complications: infection, bleeding, hematoma, or superficial thrombophlebitis.
i. Locate the vein with inspection and palpation, preferably in the upper extremity at a point of vein bifurcation.
ii. Apply a tourniquet proximal to the insertion point to engorge the vein and increase the odds of successful cannulation.
iii. Clean the overlying skin at the planned puncture site with a chlorhexidine/isopropyl alcohol solution.
iv. Apply slight pressure distal to the insertion site, securing the vein position.
v. Insert a 20-gauge catheter-over-needle apparatus into the vein at an acute angle (as flat as possible to the skin), with the bevel facing upward.
vi. Stop when blood enters the flashback chamber.
vii. Advance the apparatus 1 mm further into the vessel.
viii. Maintain the position of the needle with the dominant hand.
ix. Slowly advance the catheter into the lumen of the vessel with the nondominant hand.
x. Remove the tourniquet.
xi. Withdraw the needle.
xii. Quickly apply pressure to the vein proximal to the catheter, interrupting the return of blood.
xiii. Attach tubing and fluids to the catheter.
xiv. Apply a sterile transparent dressing.
Suggested Further Readings
Havelock T, Teoh R, Laws D, Gleeson F. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:i61.Find this resource:
Irwin RS, Rippe JM. Irwin and Rippe’s intensive care medicine. Philadelphia: Lippincott Williams & Wilkins; 2003.Find this resource:
Runyon BA. Management of adult patients with ascites due to cirrhosis: an update. Hepatology 2009;49:2087–107.Find this resource:
Smith RN, Nolan JP. Central venous catheters. BMJ 2013;347:f6570.Find this resource:
Straus SE, Thorpe KE, Holroyd-Leduc J. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA 2006;296:2012–22.Find this resource:
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