TOPIC 7. BASIC SURGICAL MANIPULATIONS – PUNCTURE AND INTUBATION
A. Puncture
Definition: Puncture is the introduction of a needle or trocar through tissue into a body cavity, vessel, organ or collection to obtain fluid/tissue, measure pressure, administer medication or relieve pressure.
Indications and examples
- Venepuncture for blood sampling and intravenous access.
- Arterial puncture for blood gas analysis.
- Joint aspiration (arthrocentesis) for diagnosis or relief of effusion.
- Pleural aspiration (thoracentesis) for diagnostic or therapeutic removal of pleural fluid.
- Ascitic tap (paracentesis) for diagnosis or symptomatic relief.
- Lumbar puncture for cerebrospinal fluid sampling or selected therapeutic purposes.
- Abscess aspiration in selected cases; many established abscesses require incision and drainage.
General principles and complications
- Confirm indication, patient identity, consent, relevant imaging and contraindications; assess bleeding risk and anatomy.
- Use hand hygiene, appropriate skin antisepsis, sterile gloves and equipment; use ultrasound guidance where it improves safety.
- Position the patient appropriately, identify landmarks, use local anaesthesia when indicated and maintain controlled needle advancement.
- Label and send specimens promptly in the correct containers; document the site, volume, appearance and complications.
Complications: bleeding/haematoma, infection, injury to adjacent structures, organ perforation, pneumothorax (thoracic procedures), vasovagal reaction and inadequate sampling.
B. Intubation
Definition: Endotracheal intubation is placement of a tube through the mouth or nose into the trachea to secure the airway and permit oxygenation, ventilation and airway protection.
Indications
- Failure to maintain or protect the airway (e.g. reduced consciousness with inability to protect airway).
- Respiratory failure or inadequate ventilation/oxygenation despite less invasive support.
- Anticipated deterioration, major trauma, severe shock or selected emergency procedures.
- General anaesthesia when airway control and controlled ventilation are required.
Preparation and principles
- Call for skilled help and assess airway difficulty; prepare suction, oxygen, bag-mask ventilation, laryngoscope/video-laryngoscope, endotracheal tubes, introducer, supraglottic rescue device and emergency front-of-neck access equipment.
- Preoxygenate, monitor ECG, oxygen saturation, blood pressure and capnography; establish IV access and haemodynamic support.
- Use an appropriate induction and neuromuscular-blocking strategy when indicated, considering aspiration risk and physiological instability.
- Visualise the glottis, pass the tube through the vocal cords, inflate cuff and confirm tracheal placement with sustained waveform end-tidal COn, alongside clinical assessment.
- Secure the tube, record depth, reassess ventilation and haemodynamics, and obtain imaging when clinically indicated (e.g. after stabilisation in many settings).
Complications
- Failed intubation, hypoxia, aspiration, oesophageal or endobronchial placement.
- Dental, oral, pharyngeal or laryngeal trauma; bleeding and swelling.
- Haemodynamic instability, arrhythmia and raised intracranial pressure in susceptible patients.
- Ventilator-associated complications and pressure injury with prolonged intubation.