Placing and managing various tubes is an important part of a veterinary technician’s role in patient care, and knowing the proper procedures and most effective methods will ensure that you are offering the best possible treatment. With so many critical steps involved, it is important to regularly review the protocol to ensure that you continue to use the most effective methods. You may also choose to keep these simple instructions in an easily accessible area in your hospital for quick reference.
- Dilute chlorhexidine solution
- Exam gloves and sterile gloves
- Sterile catheter (size and type dependent on patient size and intended use)
- Sterile lubricant
- Suture (3-0 nylon monofilament)
- Needle drivers and Adson-Brown forceps
- Sterile saline for Foley balloon inflation (see individual Foley catheter for specific amount)
- Christmas tree adapter (or other adapter of choice to attach closed collection system to catheter)
- Closed collection system
- Tape for tape butterfly
Step 1: While wearing exam gloves, clip excess hair as needed around vulva or prepuce to maintain cleanliness during placement and while indwelling. Long hair can contaminate the catheter or closed collection system. However, be careful not to trim too closely, which can cause clipper burn or irritation.
Step 2: Using the dilute chlorhexidine solution (which is one ounce of chlorhexidine solution per gallon of distilled water), flush the prepuce or vulva, and clean around the area with gauze squares covered in the solution.
Step 3: While wearing sterile gloves, use sterile lubricant to place the urinary catheter through the urethra into the urinary bladder. Attach the Christmas tree adaptor and closed collection system to the urinary catheter.
Step 4: If using a Foley catheter, fill the balloon with sterile saline and gently pull catheter back until you feel resistance (the balloon will stay in the bladder and keep the catheter in place).
Step 5: Attach the line of the closed collection system to the patient by suturing a “tape butterfly” to their hip. Make sure the loop is not pulling on the catheter itself but that the patient cannot get their leg between the line and the urinary catheter.
This is a long piece of tape folded back onto itself and over the extension set/fluid line of the closed collection system. The extension set that is attached to the patients urinary catheter and closed collection bag.
Step 6: Place an E-collar on every patient.
Although we use urinary catheters most commonly for urinary obstructed felines, these catheters are placed for multiple reasons. Urinary catheters can be placed for temporary use, such as placement for sample collection or to empty a patient’s bladder if they are immobile. They can also be placed for longer term use with a closed collection system for quantifying urinary output.
Laterally recumbent patients or post-operative patients (and their technicians) will benefit from having a urinary catheter placed with a closed collection system to help keep the patient clean, dry and more comfortable. Nonambulatory patients can dribble urine, which puts them at risk of urine scald and possible complications. A closed collection system is also a very useful in patients with leptospirosis to help contain contaminated urine. Leptospirosis is a contagious disease and strict barrier precautions should be observed in addition to a closed collection system. An indwelling urinary catheter will allow for close monitoring of a patient’s ins and outs and protect the staff and other patients from this zoonotic disease.
Basic care for urinary catheters starts with an E-collar, as patients frequently attempt to chew at or bite off their catheter. The next step is checking suture integrity (while wearing gloves) every four hours at the tension loop on their hip and their prepuce. Clean their prepuce or vulva as needed with dilute chlorhexidine solution and wipe down the entire line starting from the patient down to the collection system. Quantify urinary output every four hours, or more frequently if needed. Keeping the closed collection system off of the floor, on a potty pad or attached to an empty kennel below the patient will help keep the bag clean and free of tears and will keep staff from accidentally stepping on the bag.
Urinary catheters unfortunately bypass the patient’s natural defenses to bacterial invasion, so they can be associated with hospital-acquired infections. Observing these precautions will help to minimize this risk.
NASOGASTRIC AND NASOESOPHAGEAL TUBES
- Mild sedative +/- analgesic
- Anti-nausea medication
- Exam gloves
- Feeding tube in appropriate diameter and length for patient
- New 3-6 mL empty syringe
- 3-6 mL syringe with sterile saline
- 3-0 Dermalon
- Olsen-Hegar cutting needle drivers
Step 1: Start by giving a balanced sedation to help make the patient relaxed and comfortable. This will make it easier for to place and secure the tube.
Step 2: Place a few drops of proparacaine from a small syringe into the patient’s nares and eyes.
Step 3: With the patient’s head in a relaxed but slightly extended position, premeasure the tube placement and make a note of the measurement or use a permanent marker to mark the appropriate insertion length. Nasoesophageal (NE) tubes should be measured to the tenth rib. Nasogastric (NG) tubes should be measured to the last rib.
Step 4: With sterile lubrication, insert the feeding tube into the nares directing it ventrally and medially. Advance the tube slowly until reaching the noted measurement – all while watching for the patient to swallow, which helps to indicates that the tube is in the esophagus. If you feel resistance or crunching, you will need to redirect and try again. In dogs, trying to “pig nose” the patient can help set up the direction of the tube. Coughing or gagging also indicates that you will need to remove the tube and try again.
Step 5: Confirm the correct placement. When placing an NG tube, there are a few ways to tell if it has reached the stomach. First, try to aspirate gastric fluid by puffing air into their stomach with an empty syringe and listening with a stethoscope. For both NG and NE tubes, you can also add a small amount of sterile saline into the tube. If they cough in response, the tube is most likely in the trachea or bronchi. The final and most accurate technique is a lateral radiograph confirming the correct placement. No tube should be used for feeding without a radiograph confirming proper placement.
Step 6: If needed, adjust the tube’s placement and make a new note of the placement measurement to reference later.
Step 7: To loosen the stylet in the tube, flush a few milliliters of sterile saline into the tube and slowly pull the stylet straight out. Once the stylet is removed, it is time to suture the tube into place (Figure 2). The suture placement will depend on how the tube naturally curves and how it can be positioned on the face without kinking. It may need more of a loop, or it may need to be tacked inside the nares fold. The most common way to secure NG or NE tubes is to tack the tube at the base of the nares and then work up the tube in a Chinese finger trap pattern. The remainder of the tube will need to be tacked with a suture and another tape butterfly along the side the patient’s face. This will keep it from flopping in their face or putting pressure on their nares. It is important to be mindful of their whiskers, as it can be irritating.
Figure 2: Suture placement depends on how the tube naturally curves and how it can be positioned on the patient's face without kinking.
Step 8: Place E-collar on the patient.
NG or NE tubes are a great option for short-term use, such as continuous trickle feedings, bolus feeding, and emptying gastrointestinal fluid or air in patients with low GI motility. Since the tube is inserted though the patient’s nose, the tube is smaller in diameter and can easily become clogged. Therefore, the use time is limited to three to seven days.
Care of NG and NE tubes starts with the placement of an E-collar, so patients are restricted from rubbing their face or pawing at their nose. A thin, liquid diet for trickle or bolus feedings can prolong the life of the tube. After bolus feedings, flush with warm water. After trickle feedings, disconnect the feeding or administer medication so the liquid doesn’t harden or clog the tube.
The tube or sutures may need to be adjusted if it is irritating the patient or causing the patient to sneeze (which can forcefully dislodge the tube). And finally, watch for signs of nausea. Patients with an NG or NE tube can easily vomit up their tube and chew through it, causing a gastric foreign body. This is a great reason to include anti-nausea medications in your protocol.
PERIPHERALLY INSERTED CENTRAL CATHETER
A peripherally inserted central catheter, or a PICC line, is a long line catheter that starts peripherally and ends centrally. It is placed using a sterile technique, most commonly in the lateral or medial saphenous veins.
- Chlorhexidine scrub and alcohol for prep
- Exam gloves and sterile gloves
- Bandage material
- PICC line (Cavafix MT)
- 18 g IV catheter (the Cavafix comes with an 18 g IVC for placement, but the majority of our staff are more comfortable placing a normal 18 g catheter)
- Sterile saline
- Luer lock T-port
- Male adaptor plug
Step 1: Start by giving balanced sedation and analgesia for patient comfort and ease of placement. Placing a large bore catheter in smaller patients (and feeding the long stylet) can be uncomfortable and stressful.
Step 2: Decide where to place the PICC line, clip generously, and prep using a sterile technique and wearing exam gloves.
Step 3: Open all of your materials prior to placement. This makes them easier to grab off a clean surface when needed.
Step 4: Place the 18 g IV catheter, remove stylet from the 18 g catheter, and insert PICC line into the IVC. Make sure the yellow hub is seated in the catheter.
Step 5: Slowly and carefully feed the line and stylet (they are moving together) through the IV catheter using the protective plastic sleeve to guide them. If you feel resistance, move the patient’s limb more cranial or caudal and try again. Sometimes the stylet can be tricky to ease though the iliac bifurcation. Never force the catheter and stylet.
Step 6: When you have reached the end, slide the red protective piece over the end of the stylet and cap. The red cap is also attached to the plastic sleeve; set both of them aside.
Step 7: Carefully pull the yellow adapter out of the IV catheter hub and pull the wings apart to separate and remove the yellow piece from the PICC line. Twist the lure lock adaptor that is connected to the IVC hub.
Step 8: Carefully pull the cap (at the end of the PICC line), which is attached to the stylet, out of the PICC line and IVC. Do this slowly. Attach the luer lock T-port to the PICC line or, if you choose, just attach a male luer lock adaptor.
Step 9: Flush a small amount of saline through the PICC line to clear it, and tape the IVC hub. Use bandage materials to make a soft, padded bandage for the limb (toes and all), leaving the adaptor exposed for future blood draws.
Step 10: Make a note in the medical records on placement location, time and type of bandage placed.
PICC lines are a great option for patients who will need frequent blood sampling (for example, frequent blood glucose readings), as you can easily draw samples from the PICC line. This decreases patient stress and the amount of times their veins are accessed. They are also great for central distribution of hyperosmolar fluids (7.5% dextrose solution, calcium or bicarbonate infusions), since the central distribution greatly reduces the risk of phlebitis.
Care of a PICC line starts with monitoring the bandage and PICC line adaptor or T-port for cleanliness. Every 24 hours, the bandage should be changed (or more frequently if soiled), the insertion site should be checked, and the patient’s toes should be monitored for swelling.
When collecting a sample for testing, the PICC line should be cleared of the fluid in the line. Use a 3 mL syringe with 0.5 mL of heparinized saline and pull back 3 mLs of blood into the syringe. Invert the syringe and set aside (you will give this back to the patient at the end). Use another syringe to pull your sample; then run the sample or put into the necessary tubes. Now, give the 3 mLs of blood set aside back to the patient and flush with 0.5 mLs of heparinized saline to clear the line. The PICC line only holds a small amount of fluid, so keep the flushing amount to a minimum to avoid giving excessive heparin or fluids to small patients. If the patient is not receiving fluids through their PICC line, then flush the unused line every four hours with 0.5 mL of heparinized saline.
Liss, D. Protocol-Driven Medicine. Clinician's Brief, 2012.
Norkus, CL. Veterinary Technician's Manual for Small Animal Emergency and Critical Care. Wiley-Blackwell, 2012.