Quick cards
Procedure Checklists
Assisting at the bedside: before, during and after
Central line insertion
Before
- Time-out: patient, site, procedure, consent
- Hand hygiene
- Ultrasound ready; avoid femoral if possible
- Chlorhexidine-alcohol skin prep, dried 30 seconds
During
- Cap, mask, sterile gown and gloves for the operator
- Full-body sterile drape
- Assistant masked; observer empowered to stop the procedure
- Guidewire removed and counted
After
- Chlorhexidine dressing, dated
- Tip position confirmed (x-ray or ultrasound) before use
- Document site, depth, ultrasound use
- Daily review of line need
Thoracentesis
Before
- Time-out: patient, side, site and consent; side confirmed on recent imaging
- Coagulation tests only if anticoagulated or known coagulopathy (BTS 2023)
- Elective (BTS 2023): warfarin to INR 1.5 or less, DOAC held 24–48 h; aspirin and prophylactic heparin continue
- Sitting up, leaning on a padded table; if ventilated, supine or rolled as the operator scans
- Ultrasound marks the site in that position; no moving the patient before the needle
- Baseline SpO₂, HR, BP and RR; oxygen, suction and atropine at hand
During
- SpO₂, HR and BP watched; vasovagal slowing, pallor or hypotension called out
- Drained slowly by syringe or gravity; no vacuum bottle or wall suction (BTS 2023)
- Stop at 1.5 L, or sooner for chest tightness, pain, persistent cough or breathlessness
- Samples: protein and LDH (serum sent at the same time), glucose, cell count, culture, cytology
- pH (suspected infection): capped heparinized syringe, no air, run on the blood gas analyzer
After
- Vital signs and SpO₂ soon after, then per policy; site dry; volume and color charted
- First hour: cough, frothy sputum or falling SpO₂ suggests re-expansion edema
- Chest film for symptoms, air aspirated or several passes; not routine after a simple tap (BTS 2023)
- Ventilated: watch peak pressure, SpO₂ and BP for a pneumothorax turning into tension
Paracentesis
Before
- Time-out and consent; bladder emptied (void or catheter)
- No routine plasma or platelets for a high INR or low platelets (AASLD 2021); flag DIC or oozing
- Ultrasound marks a pocket, usually left lower quadrant, lateral to the rectus (inferior epigastric artery)
- Baseline BP, HR, weight and girth; 25% albumin ready for a large-volume tap
- Supine, head slightly up, tilted toward the tap side
During
- BP and HR watched through a large-volume tap; slow or stop for hypotension
- Cell count with differential, albumin, total protein; culture bottles inoculated at the bedside
- Same-day serum albumin for the gradient (SAAG 1.1 g/dL or more: portal hypertension)
- Volume, color and clarity recorded; cloudy or bloody fluid reported
After
- Albumin 6–8 g per liter removed when over 5 L (AASLD 2021): 8 L calls for 48–64 g
- BP, HR and urine output for 2–4 h: hypotension or low output after a big tap is reported
- Site leak: ostomy bag over the site, patient on the opposite side, provider told
- Neutrophils 250/mm³ or more is SBP: antibiotics plus albumin 1.5 g/kg day 1 and 1 g/kg day 3
Lumbar puncture
Before
- Suspected meningitis: cultures, dexamethasone and antibiotics before CT, or before LP if the tap is delayed
- CT first for immunocompromise, CNS lesion, seizure within a week, papilledema, low GCS, focal deficit (IDSA)
- Platelets: transfuse under 20,000 (AABB 2025); UK 2016 defers LP under 40,000 or INR over 1.4
- Anticoagulants held: prophylactic LMWH 12 h, therapeutic 24 h (UK 2016); others per protocol
- Pencil-point (atraumatic) needle on the tray: headache 4% vs 11% (Nath 2018)
- Side-lying at the bed edge, knees to chest, chin down, shoulders and hips stacked vertically
- Sitting forward is easier in obesity, but opening pressure is valid only lying on the side
During
- Opening pressure lying on the side, legs relaxed, once the column settles; normal 10–25 cm H₂O (Whiteley 2006)
- Tubes numbered 1–4 in order; lab map often 1 chemistry, 2 Gram stain and culture, 3 cell count, 4 hold
- SAH question: cell count on tubes 1 and 4; last tube shielded from light for xanthochromia
- Serum glucose drawn now for the CSF-to-serum ratio
- Culture tube to the lab at room temperature, never refrigerated
After
- Site checked for CSF leak or bleeding; neuro checks per policy
- No routine flat bed rest: it does not prevent headache (Cochrane 2016)
- Back pain with leg weakness, numbness or new incontinence: possible spinal hematoma, call now
- Headache within 5 days, worse upright, eased lying flat: analgesia, caffeine; blood patch if severe
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For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.