Medications contraindicated in Myasthenia gravis | Mnemonic | Step 2 CK

The moderator band of the right ventricle

The moderator band is an intra-cavitary structure in the right ventricle (RV) spanning from the lower limit of the inflow tract of the RV anterior septum to the base of the anterior papillary muscle of the RV free wall.

It carries a fascicle of the right bundle that allows for rapid activation of the RV free wall.

That's all!

-IkaN

Why von Willebrand disease has normal aPTT sometimes ?

VWF acts as a carrier protein for factor VIII.  Factor VIII is more rapidly degraded when unbound, and VWF deficiency can therefore lead to impairment of the intrinsic coagulation pathway leading to a prolonged activated PTT.  

Etiology of Fetal hydrops Mnemonic

Mnemonic for pregnancy complications with short inter pregnancy interval

Definition : <6-18 months from delivery to next pregnancy

During pregnancy, maternal folate and iron are depleted for fetal development, and the resulting maternal anemia is exacerbated by normal blood loss during delivery (eg, up to 10%-20% of blood volume).  In breastfeeding women, continued nutritional demands from the newborn prevent repletion of normal folate and iron stores, resulting in prolonged anemia!

Anti-epileptics in pregnancy mnemonic

 The choice of antiepileptic drugs for women with epilepsy of childbearing age who are planning a pregnancy are

High Yield mnemonics | Pulmonary System | Uworld | Step 2 CK

Tricyclic antidepressants (TCA) mnemonic

Medications that can cause depression

Did you know that the medications we prescribe can be associated with depression?

Beta-blockers and reserpine should also be considered as the cause of depression in those newly started on the medication.

Other such medications include:

Tripod position mnemonic

Hi everyone!

Short mnemonic is here..

“Tripod TONE is forwarding air into the Lungs” 

Mnemonic | Major risk factors for Ventilator associated pneumonia | Step2 CK

 

Mnemonic for an opioid intoxication | Step 2 CK

Mnemonic for LAB evaluations for SSRI overdose

Hii! 

Short mnemonic!

Isolated SSRI overdose = Asx / mild CNS Depression 

If symptomatic SSRI overdose with altered mental status & abnormal physical findings. 

Then Check for “ECG” 

Mnemonic = ECG! 

E  = ECG ( As Citalopram & Escitalopram can cause QT prolongation ) 

MOST IMPORTANT 

C = Coingestants (Ethanol , Benzodiazepines, Acetaminophen )& biCarbonate Levels ( assess for Metabolic acidosis ) 

G = Glucose levels ( rule out hypoglycemia as a cause of altered mental status) 

Mnemonic for Caustic Esophageal injury

Hi everyone! 

Here is a short mnemonic! 

ACidic Substance = Coagulation Necrosis ( Protein denaturation) - 

results in Eschar - prevents further acid penetration & thereby severe injury.

ALakaline Substance = Liquefactive Necrosis (Cell membrane dissolution) - deeper penetration results in more severe injuries. 

1st step = Serial CXR & abdominal x-ray to identify perforation

If no perforation or respiratory distress then Upper GI endoscopy within 24 hours to assess severity for esophageal damage. 

Thank you! 

The Moderna Vaccine: End of Pandemic?

 

The Moderna (mRNA-1273) SARS-CoV-2 vaccine is the second vaccine to receive emergency use authorisation (EUA) by the FDA. Like the Pfizer vaccine, it is also a lipid nanoparticle encapsulated mRNA vaccine, and therefore has the same mechanism of action. Please read about the brief mechanism from the Pfizer vaccine article: https://www.medicowesome.com/2020/12/the-bnt162b2-covid-19-vaccine-pfizer.html I will try to avoid big numbers and statistics in this article. 

Both Moderna and Pfizer vaccines start protecting their recipients 10 days after the first dose, with maximum protection two weeks after the second dose. They both have efficacy ranging from 94-95% in protecting against symptomatic Covid-19. However, studies haven't yet evaluated their role in preventing asymptomatic Covid-19, a substantial missing link. 

Can Covid-19 vaccines mitigate the pandemic? 

People picture vaccines as a way back to normalcy, as before the pandemic; unless these mRNA vaccines' role in controlling asymptomatic SARS-CoV-2 infection is studied, normalcy is out of our reach. The other issues concerning the above question are -

1. Since the phase 3 studies of these vaccines are relatively 'young', we don't have sufficient knowledge about the nature and duration of immunological protection. Animal studies have shown that neutralizing antibodies confer protection and CD4 and CD8 T cells also amplify the immunological response. We don't know how long will the neutralizing antibodies last in our plasma after receiving the vaccine. 

2. With both these vaccines, there is an inevitable study flaw. Vaccine recipients faced more systemic adverse events, such as fever, fatigue, headache, myalgia than the placebo group. These symptoms can also occur with Covid-19. Therefore, it is not unlikely that vaccine recipients could have designated their symptoms to the 'shot', and hesitated to refer themselves to be tested for Covid-19.

3. The third issue is quite popular in the daily news. What if the virus mutates and renders itself 'immune' to the vaccine? Some new strains have come up worldwide, and expectedly, the diaspora has started panicking. People need answers quickly while science takes time. So we cannot rule out the possibility that the virus devises a way to escape from the vaccine-induced immunological response. 

4. Vaccine-associated enhanced disease (VAED). Earlier preclinical studies with SARS and MERS have demonstrated that low-level neutralizing antibodies in the plasma can trigger a severe form of the disease. Both the Moderna and Pfizer vaccines are 100% effective in protecting against severe Covid-19, notwithstanding this fact, the regulatory authorities should monitor these and other vaccine candidates for this adverse event. 

5. Anti-Vaxxers! The anti-vaccine sentiment is appalling, and there have been 'anti-vaccine' protests in many parts of the world, including the US, Germany, Poland, and others. There are numerous fake news and misinformation in social media platforms that misguide people and tarnish their perspective about the vaccines. And this phenomenon has even affected the medical professionals. The healthcare authorities have an onerous task to incite confidence in the general public and safeguard them from misinformation. 

Safety

The adverse effect profile of both the vaccines is similar, with the most common being local injection-site reactions. Systemic side effects are more common in the vaccine group and comprise mainly of fatigue and headache. Bell's palsy occurred in three (out of 15,210) vaccine recipients within 28 days of administration. This anecdotal risk would be studied in the planned two-year follow-up. 

Being a physician in the Indian subcontinent, there are various reasons to mistrust this vaccine. Both the mRNA vaccines have been studied primarily in the US population (mainly whites), and we don't have any data on its long-term effects. Recently, I have come across various tweets and posts in my social media feed with the headline - " Doctors and nurses are declining the vaccine." I am unaware of these posts' credibility; however, this isn't false in my experience. Well for what it's worth, we haven't seen a whole lot of polio, diphtheria or smallpox recently. 

Thanks for reading!

-VM

 

 

Perspective: My ideology and philosophy about medicine

 

 

The three O's of GI bleeding : Overt, obscure, and occult

GI bleeding can be classified into three O's: Overt, obscure, and occult! Can you define these terms?

If not, I'll help you out

Pediatrics | Pulmonary & Critical Care | CK Uworld

The BNT162b2 Covid-19 Vaccine: Pfizer-BioNTech Vaccine

 

The BNT162b2 mRNA Covid-19 vaccine, popularly known as the Pfizer vaccine is the first Covid-19 vaccine to receive authorization for use in the general public. The first jab was given to a 90-year old lady in the UK on December 8, 2020; a monumental event that brought hope to billions of people all across the globe. In this article, I will discuss this vaccine’s clinical trial and potential future implications.

 

How does it act?

The BNT162B2 is a lipid nanoparticle-formulated, nucleoside-modified mRNA that encodes the SARS-CoV-2 full-length spike protein, modified by two proline mutations to lock it in the prefusion conformation. This means that this is an mRNA that has been modified to resist disintegration by nucleases and that translates into the SARS-CoV-2 spike protein. However, this spike protein has also been modified to lock it into its pre-fusion conformation; so that it doesn’t fuse with the target cell’s plasma membrane and remain exposed to immunogenic stimulation.

 

Who is it for?

This primarily depends on the characteristics of the population included in the vaccine’s clinical trial. This trial randomised 43,458 persons from six countries: USA, Argentina, Brazil, South Africa, Germany, and Turkey. More than three-fourth of the study population (76.7%) belonged to the USA. Moving on to the representation of race or ethnicity in the study population - 82.9% were white, 27.9% were Hispanic, while African Americans, Asians, and Native Americans comprised 9.2%, 4.2%, and 0.5% of the study group. Males and females were almost equally included. The age range is from 16 years to 89 years in the intervention group. This trial did not evaluate the efficacy of the vaccine in children, adolescents, and pregnant women.  

 

Is it effective?

Define effective; it depends on the trial’s efficacy end points. The primary endpoint was the efficacy of the vaccine to prevent Covid-19 infection 7 days after the second dose in participants who had no serologic (antigen and antibodies) or virologic (RT-PCR) evidence of SARS-CoV-2 infection up to 7 days after the second dose; the second primary endpoint was to prevent infection in those with and without evidence of prior infection. Confirmed Covid-19 was defined as – the presence of at least one symptom (fever, new or worsened cough, new or worsened dyspnoea, chills, new or worsened muscle pain, new loss of taste or smell, sore throat, diarrhoea or vomiting combined with a positive RT-PCR test within 4 days).    

Efficacy End Point	BNT162b2 Group		Placebo Group		Vaccine efficacy, % (95% credible interval)
	Covid-19 Cases	N	Covid-19 Cases	N
1st Primary	8	18,198	162	18,325	95(90.3-97.6)
2nd Primary	9	19,965	169	20,172	94.6(89.9-97.3

 This trial showed that a two-dose regimen of BNT162b2 (30 micrograms per dose, given 21 days apart) was 95% effective in preventing symptomatic Covid-19 infection 7 days after its course. The efficacy was 52% after the first dose, and 91% in the first 7 days after the second dose.

However, the trial results did not show the efficacy in preventing asymptomatic infection. We don’t know if this vaccine can safeguard against transmissible asymptomatic infection; therefore, people who have taken the vaccine should not stop wearing masks for the sake of the people around them.

 

Is it safe?

The vaccine group reported more local reactions, such as pain, redness, and swelling at the injection site than the placebo group. In general, these were mild-to-moderate in severity and resolved within 1-2 days. The systemic adverse effects were also reported more in the intervention group, especially in the younger population (16 to 55 years of age), and more after the second dose. These included – fever (11%), fatigue (51%), headache (39%), chills (23%), muscle pain (29%), joint pain (19%), and 38% of the vaccine group needed to use antipyretic medication. These were generally mild and resolved within 1-2 days. Two deaths happened in the vaccine group, one from arteriosclerosis, and one from cardiac arrest. These deaths weren’t related to the vaccine or Covid-19. The investigators plan to continue the surveillance for adverse events for further 2 years.  

 

This study has importance beyond the efficacy of the BNT162b2 vaccine candidate. It demonstrates the utility of RNA-based vaccines, its speed of development, and its promising efficacy in preventing infectious diseases. The success of this clinical trial immensely improves our preparedness for a future pandemic.

Reference:

Polack, FP, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. New England Journal of Medicine. Dec 10, 2020. 10.1056/NEJMoa2034577. C4591001 Clinical Trial group

-Vinayak

All mnemonics for how to determine axis deviation of EKG

Hello Everybody! 

Before reading this post I would like to suggest please see both the videos of How to determine axis deviation in real scenarios... Then come back here for summary & some extra mnemonics. 

Hope it’ll definitely helps you! 

https://youtu.be/306jxLzyyag

https://youtu.be/7FHNmM-V2c0

How to remember numbers...? 

“Isoelectric Method” 

You are in front of me ... as arrows in the image..... 

I is perpendicular to avF ..

II  to avL 

III to  avR .....

So finally I & you are the leads 😂. 

Thank you..!! 

-Dr. Drashtant!

Tips on creating a Rank Order List (point system) for residency and fellowship

Types of Left Ventricular Hypertrophy (LVH)

 Types of Left Ventricular Hypertrophy (LVH)

LVH = increase in the mass of the left ventricle (LV)

Caused due to:

1. enlargement of the muscle cells

2. extracellular fibrosis

Concentric LVH 

- occurs in response to pressure overload

- examples: aortic stenosis or hypertension

- associated with: reduced cavity size

Eccentric hypertrophy

- occurs in response to volume overload

 -examples: aortic or mitral regurgitation

- associated with: dilation

LVH is also classified based on the cause

Due to primary condition (hypertrophic cardiomyopathy)

Secondary to pathology (hypertension, myocardial infarction, and valvular heart disease)

That's all!

-IkaN

Pediatrics | Male Reproductive System | CK Uworld

J-1 visa: Statement of Need and surety bond for Indian International Medical Graduates (IMGs)

Histoplasmosis mnemonic

Histoplasmosis mnemonic

Bubonic plague mnemonic

Bubonic plague mnemonic 

COVID-19 Vaccine Development

The worldwide magnitude of the COVID-19 pandemic is ineffable; it is unsurprisingly compared to the Spanish flu pandemic, which ravaged the world during the First World War (adding fuel to the fire!). One of the pandemic's various positive impacts has been the unprecedented research collaboration and data sharing across the world. Such singular efforts made it possible to cut down the usual time to achieve an approved vaccine from 10⁺ years to less than a year.

To put things into perspective, it took 60 years from the time of the first polio outbreak to developing its vaccine; in the case of Ebola, it took 15 years. Vaccine candidates for SARS-CoV-1 and MERS did not receive the necessary impetus to advance into fruition. However, with SARS-CoV-2, the situation is very different. Global initiatives such as ACTIV (Accelerating COVID-19 Therapeutic Interventions and Vaccines), a public-private partnership comprising of bigwigs like CDC, FDA, EMA (European Medicines Agency), and numerous leading biopharmaceutical enterprises. Another project on a similar scale is Operation Warp Speed, which has invited comparison to the infamous Manhattan Project.

What is an "ideal" COVID-19 vaccine? There are three criteria from the immunological perspective: 1) It induces a robust humoral immune response that produces long-lasting neutralizing antibodies against SARS-CoV-2 antigens, 2) It generates a strong cell-mediated immunity that includes the production of memory T cells, 3) It should be free of any serious local or systemic adverse effects. Considering the logistics of vaccinating the entire world, there are three more criteria: 1) It should be easy to administer, preferably in one or two doses, 2) It should be easy to produce on a large-scale, 3) Its storage should be uncomplicated, ideally possible at room temperature.

 Source: Front. Pharmacol., 19 June 2020 | https://doi.org/10.3389/fphar.2020.00937

Let us discuss the vaccines that are currently in development. We all have heard about a few of them in the news and social media, namely, Pfizer, Moderna, Covaxin, Astra Zeneca, and so on. There are, impressively, 125⁺ SARS-CoV-2 vaccines in development globally. Broadly, there are six platforms currently being utilized for vaccine development –

1.   DNA

2.   mRNA (examples – Moderna, Pfizer)

3.   Protein (Subunit vaccines)

4.   Viral vector – replicating/non-replicating (examples - Oxford/Astra Zeneca, Johnson & Johnson)

5.   Live attenuated virus

6.   Inactivated virus

Almost all of the above models have targeted the spike glycoprotein, which is present on the surface of SARS-CoV-2, to interfere with the viral entry into a cell.

This article is an oversimplified summary of the vaccine development process. I haven't covered the vaccine platforms, molecular targets, and vaccine candidates in detail. With the advent of vaccine administration, whether it's Pfizer's or any other, there will be a massive surge in vaccine-related information. There will be challenges at every step, from distribution to underdeveloped areas of the world to alleviate the concerns of the skeptical anti-vaxxers. Let us hope that these vaccines start the end of the pandemic.

-Vinayak

J-1 visa: Statement of need (SON) attestation from Indian Consulate

PDA dependent Congenital Heart Diseases mnemonic for step 2 CK

 

 

About the Pfizer BioNTech COVID-19 Vaccine trial

Important things we know about the Pfizer BioNTech COVID-19 Vaccine

• From roughly 44000 participants, vaccine and placebo were administered 1:1 ratio, the vaccine participants demonstrated 95% efficacy in preventing COVID-19 in those without prior infection 7 days or more after the second dose.

• Partial protection from the vaccine candidate appeared as early as 12 days after the first dose.

• The vaccine has shown consistent results in people of different ages, races, BMI, and with various co-morbid conditions.

Emoticon game: Acute Liver Failure answers

If you haven't tried the emoticon game, check it out here: https://www.medicowesome.com/2020/12/emoticon-game-causes-of-acute-liver.html

The answers are posted below.

Emoticon game: Causes of Acute Liver Failure

 

Pediatrics Allergy & Immunology UWorld Step 2 CK

 

COVID-19 and the increased risk of Parkinson's disease

Hi!

Currently posted in psychiatry, I was reading articles on Parkinson's disease and came through this important finding in context with the coronavirus disease.

Cosmetic surgery and Nontuberculous Mycobacterial infections

There has been an increase in plastic surgery tourism because some countries offer cheap cosmetic surgery. Common surgical procedures sought are breast augmentation surgery, liposuction, eyelid surgery, facelift, labiaplasties, and gluteal lift procedures. [1]

Conus medullaris syndrome vs. Cauda equina syndrome

Both of these are orthopedic/neurosurgical emergencies! But in general, CM syndrome is more severe than CE syndrome.

Here's a comparison between the two...

Guidelines for management of gout by ACR 2020

 Hi!

Long time..

Urate-lowering therapy indications and important guidelines for management of gout, as updated by ACR in 2020:

TORCH syndrome + mnemonic

 TORCH syndrome is caused by congenital infection by a group of infectious agents. 

Respiratory fluoroquinolones

Why are moxifloxacin, gemifloxacin, and levofloxacin also known as respiratory fluoroquinolones?

Determining axis of EKG (isoelectric method) practice tracings

How to determine axis of EKG (number, isoelectric method) with mnemonic

Mechanical ventilation

Terms you need to know

1.       PaO2: Oxygen saturation in arterial blood  (N = 80-100)

2.       PaCO2: Carbon Dioxide saturation in arterial blood (N = 35 – 45)

3.       FiO2: Fraction of inhaled O2 (N = 21% i.e. the fraction of O2 in atmosphere air which we inhale)

4.       PEEP: Positive End Expiratory Pressure – The pressure needed at the end of expiration to keep the alveoli open.

5.       RR: Respiratory rate (N = 12-16)

6.       TV: Tidal Volume (N = 6-8 ml/kg = approx. 500 ml)

Shunt fraction and its importance

 Hello Awesomites! :D

When should you start sodium bicarbonate in CKD patients? Mnemonic

When should you start sodium bicarbonate in CKD patients?

Data Collection Methods

DATA COLLECTION METHODS

Neurology examination template

Hi everyone!

Here is my template for documenting the basic bare minimum neurology examination.

It's a Carny Problem

 Carney's Triad - ENCHONDROMA + PARAADRENAL GANGLIOMA + GIST

Carney's Syndrome - multiple benign tumors, mainly of heart and skin

Carney Stratakis Syndrome - Pediatric GIST (Gastrointestinal Stromal Tumor)

Shock by Dr. Ganti (Pulm/Crit)

 

Blood Donation

BLOOD DONATION

PRE-DONATION

HISTORY:

• Men can donate safely once every three months while women can donate every four months
• Age between 18 and 60 years
• The donor should be in a healthy state of mind and body
• Past one year - not been treated for Rabies or received Hepatitis B immune globulin
• Past six months - not had a tattoo, ear or skin piercing or acupuncture, not received blood or blood products, no serious illness or major surgery, no contact with a person with hepatitis or yellow jaundice.
• Past three months - not donated blood or been treated for Malaria
• Past one month - had any immunizations
• Past 72 hours - had dental work or taken Aspirin
• Past 48 hours - taken any antibiotics or any other medications (Allopathic or Ayurveda or Siddha or Homeopathy)
• Past 24 hours - taken alcoholic beverages
• Presently - not suffering from cough, influenza or sore throat, the common cold
• Women should not be pregnant or breastfeeding her child or menstruating.
• No diabetes, chest pain, heart disease or high BP, cancer, blood clotting problem or blood disease, unexplained fever weight loss, fatigue, night sweats, enlarged lymph nodes in armpits, neck or groin, white patches in the mouth, etc.
• No history of TB, bronchial asthma or allergic disorder, liver disease, kidney disease, fits or fainting, blue or purple spots on the skin or mucous membranes, received human pituitary - growth hormones, etc.

EXAMINATION:

• Temperature - Normal (oral temperature not exceeding 37.50 C)
• Pulse - between 50 and 100/minute with no irregularities
• Blood Pressure -Systolic 100-180 mm Hg and Diastolic 50 - 100 mm Hg
• Bodyweight - not less than 45 Kg
• Hemoglobin - not less than 12.5 g/dL-

Procedure to measure Hb using CuSO4:

i) Massage the finger to be pricked (preferably ring finger)

ii) Disinfect it

iii) Prick using disposable needle/ lancet

iv) Put the drop of blood in CuSO4 containing beaker

v) If the blood drop sinks, Hb is more than 12.5, hence the person can donate blood (provided no other contraindication).

PROCEDURE:

• Identify donor and label blood collection bag and test tubes
• Ask the donor to state their full name
• Ensure that:

1. the blood collection bag is of the correct type;
2. the labels on the blood collection bag and all its satellite bags, sample tubes and donor records have the correct patient name and number;
3. the information on the labels matches with the donor's information

• Select a large, firm vein, preferably in the antecubital fossa, from an area free from skin lesions or scars
• Clean the site of venepuncture by alcohol and let it dry
• Perform phlebotomy using a 16-gauge needle, which is usually attached to the blood collection bag. Use of a retractable needle or safety needle with a needle cover is preferred if available, but all should be cut off at the end of the procedure.
• Ask the donor to open and close the fist slowly every 10–12 seconds during collection
• Remove the tourniquet when the blood flow is established or after 2 minutes, whichever comes first
• Ask the patient to squeeze a ball intermittently during the procedure
• Monitor the donor and the donated unit
• Remove the needle and collect samples
• Cut off the needle using a sterile pair of scissors
• Collect blood samples for laboratory testing

POST-PROCEDURE:

DONOR CARE:

• ask the donor to remain in the chair and relax for a few minutes
• inspect the venepuncture site; if it is not bleeding, apply a bandage to the site; if it is bleeding, apply further pressure
• ask the donor to sit up slowly and ask how the person is feeling
• before the donor leaves the donation room, ensure that the person can stand up without dizziness and without a drop in blood pressure
• offer the donor some refreshments

BLOOD UNIT AND SAMPLES:

• Transfer the blood unit to a proper storage container according to the blood center requirements and the product
• Ensure that collected blood samples are stored and delivered to the laboratory with completed documentation, at the recommended temperature, and in a leakproof, closed container

REFERENCES:

http://naco.gov.in/blood-transfusion-services-publications

Written by our guest authors HARSH JOGI and AYUSHI GUPTA

Ascitic Tap

Requirements

Written informed consent, Betadine, Spirit, Sterile gloves, Sterile drapes, a 1.5-3.5 cm 20-22 G needle, a 5-20mL syringe is used, 18-20 G needle attached to a non-collapsible tube (can be made by breaking drip chamber of an IV set and putting one end of it in an empty water bottle for therapeutic tap tubing to a sterile collection bag)

Procedure:

1. Follow universal precautions. 

2. Skin around the site of puncture to be disinfected with betadine or Chlorhexidine and spirit and draped with sterile drapes.

3. Position: The patient should be in supine position( can be asked to roll slightly to left)

4. Site: a) At the junction of medial two-third and lateral one-third of the line join umbilicus and left Anterior superior iliac spine (left side is preferred over right to avoid damage to caecum)

OR 

b) 4 inches above iliac crest, whichever is more dependent

Site has to be lateral to rectus muscle. Avoid areas of scar.

5. Local Anaesthesia:

a) Skin, subcutaneous tissue, abdominal wall layers up to parietal peritoneum to be anesthetized with 2% lidocaine filled syringe using a 22-25 G needle.The needle is advanced into the subcutaneous tissue aspirating every 2-3 mm prior to injecting. 

b) Once a loss of resistance is felt and peritoneal fluid is drawn into the syringe, it indicates that we have entered the peritoneal cavity. Additional lidocaine is then injected to anesthetize the pain-sensitive parietal 

peritoneum. 

(A total of approx. 4-5 ml lidocaine is adequate.) 

c) The needle is then withdrawn. 

6. Puncture: 

For diagnostic tap – a 1.5-3.5 cm 20-22 G needle attached to a 5-20mL syringe 

is used. 

Technique – The aim is to prevent leak by ensuring the skin puncture site is 

not directly over the puncture site into the peritoneal cavity. 

 Z track technique – Pull skin about 2 cm downward before puncturing 

skin→ then leave the skin after entering few mm so as to form a Z

OR 

prick the skin, go for some distance in the subcutaneous plane and then change the angle to vertically downwards to enter the peritoneal cavity.  

For therapeutic tap - A large bore 1.5-2 cm 16-18 G needle is used instead.The syringe is detached and the needle is attached to a non-collapsible rubber tubing.The ascites fluid is drained slowly through the rubber tubing connected to the needle into a sterile collection bag. 

7. Seal : After the puncture, the punctured skin is sealed with a tincture benzoin 

seal. 

8. Post procedures: T.P.R, B.P to be recorded half hourly and the 

patient should not be given feeds for the next 4 hours. If there is pain, analgesics may be given.

- Mitali shroff