Fine-needle-aspiration-Operationscript

From Wiki Surgery
Jump to: navigation, search

Last edited Michael edwards 11:50, 11 January 2009 (EST)


FINE NEEDLE ASPIRATION (FNA)


A PANTOGEN OPERATION SCRIPT


MICHAEL EDWARDS


NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON


THIS SCRIPT COVERS:

SECTION 1.00 INTRODUCTION TO FINE NEEDLE ASPIRATION

AIM

The person performing the aspiration is aiming to provide the pathologist with cells from a lesion.
There should be sufficient cells for the pathologist to make an accurate diagnosis from the appearance of the cells (cytology).
The lesion is usually a swelling or thickened area.
It may be a suspicious area on an ultrasound scan.
The aspiration is done through a fine needle, which is usually well tolerated by patients.
Other methods, such as Trucut and drill biopsies, use larger bore needles.
These alternative procedures can be more painful.
They have the advantages of providing more cells, with the architecture preserved (histology).

METHOD

The success rate of fine needle aspiration is very user dependent.
However, with a correct technique and attention to detail, the clinician can provide satisfactory samples.
For instance, the pathologist should be able to give a confident cytological diagnosis (C5) in up to 80% of fine needle aspirations of breast carcinomas.
The method consists of 4 parts.
1 PASSING THE FINE NEEDLE INTO THE LESION
2 ASPIRATION
Aspirate repeatedly on the attached syringe, to draw tissue into the needle and syringe.
3 MAKING CLINICALLY PREPARED SPECIMENS (CPS)
Make 2 slide preparations of the tissue:
1 air dried.
1 fixed with a chemical fixative.
4 TAKING WASHINGS
Place remaining tissue in a preservative solution for later centrifuging and slide preparation in the laboratory.


The script below contains virtually all the information that an expert uses during a fine needle aspiration.
The information, broken into very small steps, is easy for you to learn and retain.
You should have no difficulty in handling all this information during the procedure, which usually lasts less than 2 minutes.


SECTION 2.00 CASE SELECTION

Fine needle aspiration is often a useful first step towards making a pathological diagnosis.
Unsuitable lesion
Making a diagnosis from a fine needle aspirate is not always possible, even if the pathologist is given excellent tissue.
The pathologist may not have sufficient expertise.
Eg Thyroid swellings.
The lesion sampled may not be suitable.
Eg Inflammatory v neoplastic lymph nodes.
The pathologist may not be able to give extra information.
Eg Tissue typing of lymphomas.
Tender tissue.
Eg breast fibroadenosis
A few minutes discussing the case with your pathologist will clarify the best method of making a diagnosis.
Unsuitable patients
Very nervous.
Low pain threshold.
Previous bad experience of needle biopsies.
Child.
Anticoagulated.
Bleeding disorder.
Dangerous site eg Near eye, major blood vessels or nerves.
Tender site. eg Nose, perianal, perineal, penis, female genitalia, digits


SECTION 3.00 SKILLS TO LEARN

There are 6 skills which the trainee needs to master before trying an FNA on a patient.
1 FINDING AND FIXING THE LESION WITH THE NON-DOMINANT HAND
2 FIXING THE NEEDLE
3 DISCONNECTING THE NEEDLE
4 CREATING A VACUUM AND ASPIRATING AT THE SAME TIME ONE HANDED
5 MAKING SLIDES
6 TAKING WASHINGS


1 FINDING AND FIXING THE LESION WITH THE NON-DOMINANT HAND
This is likely to be most unfamiliar.
Start by finding the lesion using the digits of both hands.
Make sure that you can feel the area of interest.
Localise and fix the area of interest with the digits of your non-dominant hand (left hand in this script).
Practice this on 20 patients with, for instance, breast swellings.
2 FIXING THE NEEDLE
It is essential that the needle is tightly fixed onto the syringe to:
Make an airtight seal to maintain a vacuum in the syringe during aspiration.
Prevent the needle blowing off the syringe during the procedure, with loss of tissue :::and possible injury to patient and staff.
Push the needle onto the collar of the syringe until you hear a creaking noise.
Continue increasing the pressure until the creaking noise stops.
The needle is now sufficiently tight for the FNA.
If the needle or the collar of the syringe are wet inside:
There will be no creaking and the needle will not fit tightly.
Replace the needle and syringe with dry ones.
Repeat the procedure 30 times to become proficient.
NB To remove the tightly fixed needle from the syringe efficiently and safely.:
Use artery forceps to grasp the hub of the needle and twist the needle free.
Using your fingers to do this risks a needle stick injury.
3 DISCONNECTING THE NEEDLE
You will need to disconnect the needle and syringe when making the slide smears and if the syringe needs replacing.
The connection is very firm.
Removing the tightly fixed needle from the syringe requires a surprising amount of strength.
If replacing the syringe while aspirating a cyst:
Disconnect the syringe very smoothly to avoid dislodging the needle from the lesion.
Grasp the collar of the needle very firmly between your left index and thumb.
Twist the syringe off the needle with your right hand.
If your digits are not strong enough:
Grasp the collar of the needle with an artery forcep.
Repeat the removal 20 times to become proficient.
4 CREATING A VACUUM AND ASPIRATING AT THE SAME TIME ONE HANDED
The aim is to produce a vacuum in the syringe.
The sharp end of the needle will free tissue from the area of clinical interest.
The vacuum will draw the semiliquid tissue up the needle and syringe.
To make the vacuum:
Withdraw the piston up the syringe to the 5ml. mark with the right hand.
Maintain this position of the piston until aspiration is complete.
It may last a minute or more.
It is a slightly unusual position to hold with your right hand, and quite tiring at first.
Hold the top of the plunger between your right little and ring fingers and the thenar eminence (Ed. Fleshy part of the base of your thumb).
Push against the wings on the top of the barrel of the syringe with your index and middle fingers until the piston reaches the 5ml. mark
Make 30 3mm. jabs into a pear or raw potato.
Practise this 20 times to become proficient.
5 MAKING SLIDES
The aim is to spread the aspirated tissue onto the clear parts of 2 slides.
The tissue should cover the whole of the clear parts without any spillage and loss
around the edges of the slides.
There should be a ground glass strip on the tissue side of the slide.
This will enable the patient’s details to be written, without rubbing off the tissue.
Place the first slide with a ground glass strip uppermost.
Place one drop of water on the first slide at the junction of the clear and ground glass.
Hold the second slide with a ground strip downwards.
Slide the second slide over the clear part of the first slide, to spread the specimen ::over the whole of the clear sections of each slide.
Separate the 2 slides and hold them specimen-side upwards.
Repeat the exercise 5 times to become proficient.
6 TAKING WASHINGS
Make sure the needle is firmly attached to the syringe before you start
Place the needle into the preservative solution.
Draw 1ml. of preservative into the syringe.
Squeeze the fluid and material back into the preservative bottle.
Repeat 3 times.

SECTION 4.00 PRELIMINARIES AND WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

STEP 4.01 CHECK EQUIPMENT, MATERIALS AND SPARES

REFER TO SECTION 9.00 EQUIPMENT, MATERIALS AND SPARES LIST

STEP 4.02 ASSEMBLING EQUIPMENT AND MATERIALS

STEP 4.03 LABEL THE SLIDES

Write the patient’s name, hospital number, date of birth and today’s date on one ::ground glass strip on both slides.
Use the pencil.
Place the slides on the tray with the labelled strips uppermost.

STEP 4.04 CHECK THE FIXATIVE

For the best results, the fixative must be applied to the tissue before there is any ::drying of the cells.
Ie within 2-3 seconds of making the smears.
The fixative must be ready for instant use.
If it is a spray:
Do a test spray.
If it is a liquid:
Check the bottle top is easy and quick to open.
To maintain sterility, avoid touching the skin at the site of aspiration and shaft of the :needle .
Wearing gloves may reduce the sensitivity of feel during the localisation and aspiration.

STEP 4.05 ASSEMBLE THE SYRINGE AND NEEDLE

The procedure should be performed in a sterile manner.
Take the syringe and needles out of their packets.
Avoid touching the shaft of the needle.
Pull the handle on the syringe to release any stiffness of the piston against the syringe ::tube.
Push the plunger fully in, to empty the syringe of air.
Hold the needle by its collar.
Push the needle onto the syringe until creaking stops.
Replace the cover on the needle.
Place the syringe and needle on the tray.

STEP 4.06 CHECK YOU HAVE DISCUSSED THE CASE WITH THE PATHOLOGIST

STEP 4.07 CHECK YOU HAVE THE CORRECT PATIENT

STEP 4.08 CHECK YOU HAVE THE CORRECT SIDE.

STEP 4.09 THE CONSENT FORM

STEP 4.10 CHECK THE LESION HAS NOT DISAPPEARED

STEP 4.12 CHECK THE PATIENT HAS NOT FOUND ANOTHER LESION

STEP 4.13 CHECK THE PATIENT IS NOT ANTICOAGULATED OR HAS A BLEEDING DISORDER

STEP 4.14 CHECK THERE IS NO OTHER PROCEDURE TO DO

WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT


SECTION 5.00 ASPIRATION PROCEDURE

STEP 5.01 POSITION THE PATIENT

Position the patient so that the lesion is accessible.
For breast, thyroid and most lymph node lesions: Supine (Ed face up).
Ideally, position the patient horizontal, to minimise the effects of a faint.

STEP 5.02 STANCE

Stand on the side of the patient that is most familiar to you and in reach of the lesion.
This will usually be on the patient’s right hand side.
EXPLAIN EACH CLINICAL STEP TO THE PATIENT BEFORE YOU DO IT

STEP 5.03 SWAB THE SKIN

Use a propanol swab (eg a Mediswab).
Sterilise a 10 cm. diameter area centred on the site of clinical interest.
Do not inject local anaesthesia because the lesion may be lost in the swelling of the ::anaesthetic.
Though EMLA cream can be used to reduce surface pricking sensation.

STEP 5.04 FIX THE LESION

Use the fingers of your left hand to surround the lesion.
Do not touch the skin over the centre of the lesion, so as to maintain sterility.

STEP 5.05 CHOOSE THE NEEDLING POINT

This will usually be in the centre of the site of the lesion.

STEP 5.06 HOLD THE SYRINGE

Use your right index finger and thumb on the barrel of the syringe with a dart grip.

STEP 5.07 WARN THE PATIENT

Tell the patient that there will be a slight sting as the needle goes through the skin.
Be prepared for the patient to jump or make a sudden movement as the needle is ::inserted.
Brace yourself against the patient’s skin with your right wrist to anticipate the patient ::moving.

STEP 5.08 INSERT THE NEEDLE

Pop the needle through the skin.
This is about a 3mm. penetration.
Push the needle through the subcutaneous fat and into the lesion.
This is a limited movement of about 10mm.
This will feel firmer than penetrating the skin.
If the lesion is a carcinoma:
The tissue grates slightly, like an unripe pear.
If the lesion is benign:
The tissue (eg Breast fibroadenosis) feels more rubbery.
If the lesion slips out of your grasp:
Reposition your fingers before inserting the needle again.
If the needling is too painful:
Stop the procedure.
Consider doing a Trucut or drill biopsy under sedation at a later date.

STEP 5.09 STEADY THE COLLAR OF THE NEEDLE

Use the left index and thumb.
Make sure the tip of the needle does not move in the lesion.

STEP 5.10 CHANGE TO AN ASPIRATION GRIP WITH YOUR RIGHT HAND

SEE SECTION 3.00 SKILLS TO LEARN

STEP 5.11 CREATE THE 5ML ASPIRATION VACUUM

SEE SECTION 3.00 SKILLS TO LEARN

STEP 5.12 ASPIRATE ANY CYST

If the lesion is a cyst containing thin liquid:
Aspirate it completely.
If the lesion contains more than 10 ml. liquid:
You will need to replace the syringe with an empty one.
Take care that you do not dislodge the needle from the lesion as you remove the full :::syringe and push on a new one.
If you dislodge the needle:
Reinsert the needle.
If the liquid looks like pus
Aspirate as much as possible.
Drop 0.1ml. of the liquid on a bacteriology culture swab.
Continue with aspirating procedure.
If there is any residual swelling after aspirating a cyst:
There may be a further cyst to aspirate or solid tissue suitable for a FNA.
Reaspirate with a fresh needle and syringe:
Measure the volume of fluid aspirated.
Place 1ml. of the aspirated fluid into the preservative fluid for centrifuging.
More than 1ml. may make the preservative clot and be unsuitable for making a slide.
If you aspirate pure blood:
It is likely to have come from a blood vessel and not from a blood - containing cyst.
Remove the needle from the patient.
Apply pressure on the area with a gauze swab for 3 minutes.
Make Clinically Prepared Specimens and a Preservative Specimen as below.
Consider reinserting a fresh needle into the lesion from a different skin site straight :::away.
The patient will probably develop a minor haematoma, which will infiltrate the tissues :::within a minute or two.
This will make a second Fine Needle Aspiration less successful than a primary :::aspiration.
If the lesion is solid:
You need to provide the pathologist with at least a whole needleful of material.
Maintain the vacuum position of the syringe piston.
Make repeated tiny (3mm.) stabs into the lesion.
If there is an air leak between the needle and syringe:
Squeeze the needle more tightly onto the syringe.
If there is still a leak:
Remove the needle from the patient.
Repeat the procedure with a new needle pushed correctly onto a new syringe (no :::creaks).
Continue the stabbing movement until you see a mush of material entering the collar of :::the needle and starting to flow into the syringe.
This may require 20 – 30 tiny stabbing movements.
If this is too painful for the patient:
Stop the procedure.
Consider doing a Trucut or drill biopsy under sedation at a later date.
If you do not see any material coming into the syringe after 30 stabs:
Stop stabbing, but continue with making clinically prepared specimens etc.

SECTION 6.00 MAKING CLINICALLY PREPARED SPECIMENS (CPS)

STEP 6.01 RELAX THE VACUUM GRIP

The piston will slide to the bottom of the syringe.

STEP 6.02 REMOVE THE NEEDLE FROM THE PATIENT

STEP 6.03 PLACE A GAUZE SWAB ON THE ASPIRATION SITE.

STEP 6.04 REMOVE THE NEEDLE FROM THE SYRINGE

This will require some strength of the fingers.

STEP 6.05 PULL THE PISTON OUT TO THE 10ML MARK

This will fill the syringe with 10ml. air.

STEP 6.06 REPLACE THE NEEDLE (NO MORE CREAKS)

STEP 6.07 HOLD THE SLIDE

Use your left hand with a ground glass strip uppermost.

STEP 6.08 EXPRESS THE SPECIMEN FROM THE NEEDLE

Place the point of the needle at the junction of the clear and ground glass on the slide.
Push in the piston until tissue appears at the end of the needle.
Limit the amount of tissue reaching the slide to a 5mm. blob.
Any more will spill over the edge of the slide when the smear is made and will be lost.
If no tissue appears:
Remove the syringe, refill with air and repeat the pumping procedure.
If tissue still does not appear:
Go To SECTION 7.00 MAKING WASHINGS
If sufficient or less than sufficient tissue appears:
Continue.

STEP 6.09 MAKE THE SMEARS

Hold the second slide with a ground strip downwards.
Slide the second slide over the clear part of the first slide to spread the specimen over
the whole of the clear sections of each slide.
Separate the 2 slides and hold them specimen-side upwards.

STEP 6.10 FIX THE FIRST SLIDE

Spray or drip fixative onto the first slide within 5 seconds.
This will prevent the specimen drying out before it is fixed.
Make sure the fixative covers the whole of the specimen.
Add more fixative as needed to cover the whole smear.

STEP 6.11 AIR DRY THE SECOND SLIDE

Wave the second specimen in the air to air dry it.
This will take a minute or more until the specimen looks completely dry.

STEP 6.12 PLACE THE 2 SLIDES IN THE SLIDE CONTAINER.

STEP 6.13 SEAL THE SLIDE CONTAINER.

Use a patient’s name label.

SECTION 7.00 MAKING WASHINGS

STEP 7.01 PLACE THE NEEDLE POINT INTO THE PRESERVATIVE.

STEP 7.02 DRAW 1ML. PRESERVATIVE INTO THE SYRINGE

This will wash any material into the syringe.

STEP 7.03 SQUEEZE THE FLUID AND MATERIAL INTO THE PRESERVATIVE BOTTLE

STEP 7.04 REPEAT 3 TIMES

STEP 7.05DISCARD THE NEEDLE AND SYRINGE.

Use a sharps container.


SECTION 8.00 FINAL TOUCHES AND WHO SAFE SURGERY SIGN OUT

STEP 8.01 COMPLETE THE DOCUMENTATION

Write the patient’s name, hospital number, date of birth and date of FNA on each slide ::on the ground glass strips.
Use the pencil.

STEP 8.02 LABEL THE SLIDE CONTAINER WITH:

The patient’s name, hospital number, date of birth, date of aspiration and site of ::aspiration.
Use the ball point pen.

STEP 8.03 LABEL THE WASHINGS BOTTLE

Use the ball point pen.
Write the patient’s name, hospital number, date of birth, date of aspiration and site of ::aspiration.

STEP 8.04 FILL IN THE BACTERIOLOGY SWAB CONTAINER LABEL

Write the patient’s name, hospital number, date of birth, date of aspiration and site of aspiration.

STEP 8.05 FILL IN THE CYTOLOGY REQUEST FORM

Write the patient’s name, hospital number, date of birth, date of aspiration, site of ::aspiration, referring consultant, address, referring hospital/clinic.

STEP 8.06 FILL IN THE BACTERIOLOGY REQUEST FORM

Include details of any antibiotics given.

STEP 8.07 CHECK THE PATIENT’S WOUND

Check that there is no bleeding.
Continue pressure with a swab for 3 minutes until the bleeding stops.
If the bleeding continues:
Close the needle site with a Steristrip.
If this does not work:
Insert a stitch.

STEP 8.08 CONGRATULATE THE PATIENT.

END OF PROCEDURE


WHO SAFE SURGERY CHECKLIST SIGN OUT


SECTION 9.00 EQUIPMENT, MATERIALS AND SPARES

1 X COPY OF THE EQUIPMENT, MATERIALS AND SPARES LIST
1 X F.N.A. FIXATIVE SPECIMEN POT ( FROM PATH. LAB. )
2 X MICRO SLIDES
Check the slides are clean and not broken.
If not:
Polish them with a dry tissue.
Check whether the slides have ground glass labelling strips on one or both surfaces.
1 X SLIDE FIXATIVE
1 X PENCIL
For writing on the microscope slide.
1 X BALL POINT PEN,
For writing on all other surfaces.
1 X SLIDE CARRIER.
1 X CYTOLOGY FORM
1X BACTERIOLOGY FORM
1 X 10 ml SYRINGE
1 X BLUE 19 SWG …mm diameter NEEDLE
1 X INSTRUMENT TRAY
1 X ETHANOL SKIN SWAB
(eg Mediswab)
1 X PACKET OF 5 GAUZE SWABS
1 X SKIN PLASTER
(eg Elastoplast spot dressing)
1 X ARTERY FORCEP
1 X WASTE BIN
1 X SHARPS BIN
1 X EXAMINATION COUCH WHICH CAN BE TILTED HEAD DOWN
(TRENDELENBURG MANOEUVRE)
SPARES
3 X F.N.A. FIXATIVE SPECIMEN POT ( FROM PATHOLOGY LABORATORY. )
1 X BOX OF MICRO SLIDES
1 X SPARE SLIDE FIXATIVE
1 X PENCIL
3 X SLIDE CARRIERS
3 X CYTOLOGY FORMS
3 X BACTERIOLGY FORMS
6 X 10 ml SYRINGE
6 X BLUE 19 SWG …mm diameter NEEDLES
3 X ETHANOL SKIN SWABS
2 X PACKETS OF 5 GAUZE SWABS
3 X SKIN PLASTER (eg Elastoplast spot dressing)
1 NON-STERILE ARTERY FORCEP

CLICK HERE FOR A PDF VERSION OF THE SCRIPT

(You will need Abobe Acrobat Reader which can be downloaded from here)


CLICK HERE TO SEE TRUCUT NEEDLE BIOPSY

WE WELCOME YOUR COMMENTS

Click on the Discussion tab at the top of the Wikisurgery screen.
Type in your comment.
Remember to sign your name and institution on the comment.
You can sign your name by clicking on the second icon on the right at the top of this
editing screen or just type in 4 tildes for an automatic signature. (A tilde looks like this ~)


Michael edwards 04:45, 29 October 2008 (EDT)