1. TAPPING METHODOLOGY IN
MODERN AND aYURVEDIC
THERAPY
Arunitha .R
2nd Year PG Scholar
Dept of Kayachikitsa
Govt.Ayurveda College,
Thiruvananthapuram.

2. CONTENTs
PARACENTESIS
Thoracentesis
Pericardiocentesis
Arthrocentesis
Lumbar puncture
ventriculoperitoneal shunting
hydrocele aspiration

3. paracentesis
Peritoneocentesis
Laparocentesis
Abdominal paracentesis
The procedure used to remove fluid from
the peritoneal cavity.

5. Indications
✓ Identify etiology of ascites
✓To alleviate abdominal pressure or respiratory
distress in hemodynamically stable patients.
✓To diagnose spontaneous bacterial peritonitis.
✓Diagnose metastatic cancer.
✓To diagnose blood in peritoneal space in case
of trauma.

6. Absolute contraindication
• Acute abdomen
Relative contraindications
• Pregnancy
• Patients with organomegaly.
• Distended urinary bladder
• Abdominal wall cellulitis
• Obstructed bowel
• Intra-abdominal adhesions.

9. PRE-Procedure
Patient Evaluation: General appearance,
vital signs.
The patient does not need to restrict
food or fluids.
Check patient history for hypersensitivity
to the local anesthetic
Empty bladder.

10. Explain the purpose, risks, benefits and steps
of the procedure.
Obtain informed consent from the patient or
appropriate legal designee.
Check platelet count and/or presence of
coagulopathy.

12. • .

13. Anesthetize the skin over the insertion site
With the catheter mounted to the syringe,
puncture the anesthetized skin.
Needle is inserted at a 45 degree angle or
with z tracking technique.

15. After the procedure, gently remove the
catheter, and apply direct pressure to the
wound.
Observe the characteristics of the fluid, and
send it for the appropriate studies. If the
insertion site is still leaking after 5 minutes of
direct pressure, suture the site.
Apply a pressure dressing.

16. For a therapeutic tap, do not remove more
than 500 ml in ten minutes.
One liter is the maximum that should be
removed at one time.
Removal of 5L or more than 5 is considered as
Large volume paracentesis.

19. Post Procedure
Observe patient for 30 minutes for
signs/symptoms of hypotension, bleeding, or
abdominal distress.
Provide post-procedural analgesics as needed.

20. Complications
i. Persistent leakage of ascitic fluid at the needle
insertion site.
ii. Abdominal wall hematoma or bleeding
iii. Infection
iv. Perforation of surrounding vessels or viscera.
v. Hypotension after large volume fluid removal
(more than 5 L to 6 L).
vi. Electrolyte imbalance

22. Thoracentesis
Pleural fluid analysis, is a procedure in which a
needle is inserted through the back of the
chest wall into the pleural space to remove
fluid or air.

23. Purpose
❖ For diagnostic purpose
To differentiate transudate from exudate
Pleural biopsy
❖ As treatment procedure
To drain large amounts of pleural fluid
To equalize pressure on both sides of the thoracic cavity
Relieve shortness of breath and pain
Instillation of medication into the pleural space

24. ➢ INDICATION
➢Pleural effusion
➢Traumatic pneumothorax
➢Hemopneumothorax
➢Bronchopleural fistula
➢CONTRAINDICATION
➢An uncooperative patient
➢Coagulation disorder
➢Atelectasis
➢Emphysema
➢Severe cough or hiccups

25. Pre procedure
➢ Consent
➢Assess for known allergies, especially to local
anesthetic.
➢ If unable to sit, the patient should lie at the edge
of the bed on the affected side with the ipsilateral
arm over the head and the midaxillary line
accessible for the insertion of the needle.
Elevating the head of the bed to 30 degrees
➢Instruct the patient to refrain from coughing,
breathing deeply or moving during the procedure

27. The usual site for insertion of the
thoracentesis needle is the posterolateral
aspect of the back.
Mark the top of the dullness by washable ink
mark or indenting the skin.
Incision- below the fluid level.
Confirm site based on chest x-ray and
percussing out the fluid level.

28. Post procedure
• Sterile dressing is fixed in place.
• Obtain post-procedure chest x-ray results. The x-ray
verifies that there is no pneumothorax.
• Record total amount of fluid withdrawn, nature of fluid
its color and viscosity.
• A specimen container with formalin may be needed if
a pleural biopsy is to be obtained.
• Evaluate the patient at intervals for increased
respiration rate, asymmetric lung movement, vertigo,
tightness in the chest area, uncontrolled cough with
blood-tinged mucus, rapid pulse and signs of
hypoxemia.

32. COMPLICATIONs
▪ Pneumothorax
▪ Re expansion pulmonary edema(REPE)
▪ Bleeding
▪ Respiratory distress
▪ Infection
▪ Air embolism
▪ Dyspnea and cough
▪ Cardiac tamponade
▪ Atelectasis

34. Pericardiocentesis
Therapeutic and diagnostic procedure in
which fluid is removed from the pericardium,
the sac that surrounds the heart.
Removal of 5 – 10 ml may increase stroke
volume by 25 – 50%

35. Pericardial effusion v/s Tamponade.
The acute or chronic accumulation of fluid in
the pericardial space (between the parietal
and the visceral pericardium) is pericardial
effusion
Cardiac tamponade, also known as
pericardial tamponade, when fluid in the
pericardium builds up, resulting in
compression of the heart.

36. Causes
• Pericarditis
• Cytomegalovirus
• Coxsackieviruses
• Echoviruses
• HIV
• Cancer
• Injury to the sac or heart from a medical procedure
• Heart attack
• Severe kidney failure, also called uremia
• Autoimmune diseases
• Bacterial infections, including tuberculosis

38. Pre procedure
➢ Prior to procedure: Use echocardiogram or
ultrasound to identify the fluid.
➢ Patients who are receiving anticoagulants
should discontinue those medications prior to
the procedure.
➢ Raise the blood pressure throughout the
procedure.

39. ➢ Procedure is done under imaging guidance.
➢ Patient placed on supine position
➢ The skin is sterilized and local anesthetic given
➢ Use 3 inch, 16-20 gauge needle
➢ The most standard location is through
the infrasternal angle/subxiphoid approach.
➢ Another location is through the 5th or
6th intercostal space at the left sternal border at
the cardiac notch also called as parasternal
approach.

40. Leave the needle in the place, and secure

42. ➢ After the procedure
➢The tube is left connected to the drainage.
➢Echocardiogram will be performed to monitor
the clearance of fluid.
➢Monitor vitals
➢The fluid should be tested for identification of
the cause.

44. Lumbar puncture/ Spinal tap
Procedure in which a needle is inserted into
the spinal canal to collect cerebrospinal
fluid (CSF) for diagnostic testing.

45. Indications
❖ Diagnose bacterial, fungal and viral infections, including
meningitis, encephalitis.
❖ Inflammatory conditions of the nervous system, such as
multiple sclerosis(oligoclonal band) and Guillain-Barre
syndrome.
❖ Malignancies of the brain or spinal cord.
❖ Subarachnoid hemorrhage
❖ Inject anesthetic medications or chemotherapy drugs into
cerebrospinal fluid.
❖ Inject dye (myelography) or radioactive substances into
cerebrospinal fluid to make diagnostic images.

46. Contraindications
Idiopathic ICP
Precaution
CT brain, especially in the following situations
Age >65
Recent history of seizure
Focal neurological signs
Abnormal respiratory pattern
Bleeding diathesis (relative)
Coagulopathy
Decreased platelet count (<50 x 109/L)
Vertebral deformities

48. Procedure
Fetal position/ sit on a stool and bend their head and shoulders forward.

49. Lumbar Puncture needle pierces-
• Skin
• Subcutaneous tissue
• Supraspinous ligament
• Interspinous ligament
• ligamentum flavum
• Epidural space
• Subarachnoid space.

51. • Autoimmune conditions, such as multiple sclerosis and
Guillain-Barre syndrome, can lead to an inflammatory
response, which can be detected by the presence of
autoantibodies in the CSF.
• CSF analysis test to check for primary and metastatic
cancerous tumors in the CNS.
• Diagnose Alzheimer's disease, by measuring levels of
amyloid beta 1-42 (Aß1-42) and p- and t- tau proteins.
• In cases of infectious diseases meningitis and encephalitis,
CSF test can done to find out if the cause is viral, fungal,
bacterial, or due to a parasite, which will influence the
course of treatment.
• Intracranial bleeding

52. Complications
• Post LP headache
• Post LP back pain
• Infection
• Epidermoid tumor implantation
• Spinal hematoma

54. Arthrocentesis
Clinical procedure to collect synovial fluid
from a joint capsule.It is also known as joint
aspiration.

55. When is Arthrocentesis Performed?
❖ Identification of the etiology of Arthritis.
❖ Therapeutically for pain relief, drainage of
septic effusion
❖ For Relieving pressure in the joint
❖Injection of medications

57. In Gout
There is increased uric acid,monosodium urate
crystals,monocytes.
Calcium pyrophosphate is present in chondrocalcinosis
(pseudogout).
Cholesterol crystals is common in RA
Synovial glucose level
Lowest in septic arthritis.
Glucose is also low in rheumatoid arthritis.

59. ❖ In bacterial arthritis, there is an increased level of
protein and lactate.
❖ Rheumatoid arthritis shows more lymphocytes
(lymphocytosis).
❖Gram staining is done to distinguish gram
positive and negative bacteria
❖AFB stain is done to rule out tubercle bacilli.
❖Complement level is done which is low in:
Systemic lupus erythematosus.
Rheumatoid arthritis.

61. Contraindications
i. No absolute contraindications for diagnostic
arthrocentesis
ii. Do not inject steroids into a joint which is
already infected
Relative Contraindications:
– Overlying cellulitis
– Coagulopathy
– Joint prosthesis

62. Equipments
Betadine or Chlorhexadine
Sterile gloves/drape
Lidocaine
Syringes
– Small syringe (6-12cc) for injection of local anesthetic
– Large syringe (one 60cc or two 30cc) for aspiration
Needles
– 18 gauge: knee
– 20 gauge: most other joints
– 25 gauge: MTP joints
– 27 gauge for anesthetic injection
Collection tubes (red top and purple for crystal analysis)
Culture bottles

63. Shoulder

64. Elbow

65. Wrist

66. Knee

71. VENTRICULOPERITONEAL
SHUNTING
Ventriculoperitoneal (VP) shunt is a medical
device that relieves pressure on the brain
caused by fluid accumulation. VP shunting is a
surgical procedure that primarily treats a
condition called hydrocephalus. This condition
occurs when excess cerebrospinal fluid (CSF)
collects in the brain's ventricles.

72. Different Kinds of Shunts
1. The abdomen (ventriculo-peritoneal or
lumbo-peritoneal shunt)
2. The lung (ventriculo-pleural shunt)
3. The heart (ventriculo-atrial shunt)

73. Ventriculoperitoneal shunts consist of a valve
and two tubes, called catheters, which drain
the fluid.
One catheter drains fluid from the brain out of
a small hole . This is called the inflow catheter.
The other runs under the skin, taking the fluid
to a drainage site elsewhere in the body. This
is called the outflow catheter.

74. There are two types of ventriculoperitoneal shunt
Programmable
Nonprogrammable
With a nonprogrammable shunt, the doctor
programs the valve so that it activates whenever
the fluid reaches a certain volume. It is not
possible to adjust a nonprogrammable shunt
after insertion.
A programmable shunt, however, has an external,
adjustable valve that the doctor can re adjust at
any time according to the person's needs.

76. • Positioning
The patients are kept supine with the head
rotated to the opposite side.

77. Procedure
• The surgeon makes a skin incision behind the ear. Another small surgical
cut is made in the belly.
• A small hole is drilled in the skull. One end of the catheter is passed into
a ventricle of the brain.
• A second catheter is placed under the skin behind the ear. It is sent down
the neck and chest, and usually into the belly area.
• A valve is placed underneath the skin, usually behind the ear. The valve
is connected to both catheters. When extra pressure builds up around
the brain, the valve opens, and excess fluid drains through the catheter
into the belly or chest area. This helps lower intracranial pressure.

78. Risks and complications may
include
o Blockage
o Shunt malfunction
o Over-drainage
o Under-drainage
o Infection
o Disconnection

81. HYDROCELE ASPIRATION
Accumulation of serous fluid around testicle.
It is often caused by fluid secreted from a
remnant piece of peritoneum wrapped
around the testicle, called tunica vaginalis.

82. COMPLICATIONS
a. Infertility
b. Pyocele
c. Fournier's gangrene
d. Scrotal calculi
e. Testicular ischemia
f. Calcification of the sac wall
g. Rupture of hydrocele sac
h. Hernia of the hydrocele sac in long standing
cases when tension of the fluid within tubica
causes herniation through dartos muscle.

83. Procedure
Hydrocele is held tense by an assistant
Incision depending upon size is made over the most
prominent part of the swelling parallel to the median
raphe of the scrotum.
Layers opened :skin, dartos, external spermatic fascia ,
cremasteric fascia , internal spermatic fascia.
At this stage hydrocele sac is visible and is delivered
outside the incision
Hydrocele fluid is drained by using trocar and cannula

85. Post –operative management
Antibiotics and analgesics
Suture removal after 7-8 days

86. COMPLICATIONS

87. Ayurvedic view
The concept of Ashta Vidha Shastra Karma is a
unique contribution of Acharya Sushruta.
Chedana
Bhedana
Lekhana
Vyadhana
Visravana
Eshana
Aharana
Sivana

88. Sushruta described 106 Yantras and 20 Sastras

90. Kutharika, Vrihimukha, Ara, Vetasapatra and
the Suchi used in puncturing
Vrihimukha measures 6A
Top is like that of a vrihi seed,and the edge is
cut into small thorn 32 like projections.

91. Udara roga(su.u 14,ca.c 13,Ah.c 15)
तथा जातोदक
ं सर्वमुदरं व्यधयेद्भिषक्|
र्ामपार्श्र्े त्र्धो नािेनावड ं दत्त्र्ा ल ेा येत
वर्स्राव्य ल वर्मृद्यैतद्र्ेष्टयेद्र्ाससोदरम ्| तथा
बस्ततवर्रेकाद्यैर्म ावनं सर्ं ल र्ेष्टयेत्
ननिःस्रुते ङ्नितिः पेयामतनेह र्णां वपबेत्| अतिः
परं तु षण्मासान ् क्ष रर्ृवििवर्ेन्नरिः
त्र न् मासान् पयसा पेयां वपबेत्त्र ंर्श्लावप
िोजयेत्र्श्यामाक
ं कोरदूषं र्ा क्ष रेणा र्णं िु

92. Mootravridhi(AH.chikitsa 13)
❑ First fomented and then a piece of cloth should
be tightened.
❑ A puncture should then be made in the bottom
of the sac with a Vrihimukha instrument, on
either side of the Sevani.
❑ A tube open at both ends should be introduced
and the accumulated fluid should be let out. The
tube should then be taken off and the scrotum
should be tied up with a bandage(Sthagika) and
the incidental ulcer should be healed.