icu techniques and procedures

7/29/2019 ICU Techniques and Procedures

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ICU techniques &

procedures


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Chest procedures


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Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid will

help to confirm a diagnosis or if drainage of fluid will effect an improvement inventilatory function. When possible, the patient sits with arms supported by a table (A).

A skin wheal with local anesthetic is raised one to two levels below the percussed fluidlevel, followed by infiltration of deeper tissues with a 20-gauge needle over the middle ofthe underlying rib. The needle is advanced over the top of the rib with frequent

aspirations until the pleural space is entered (inset in panel A). The depth is marked with

a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3].Following needle insertion, the catheter is advanced into the pleural space (B), and the

needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a

syringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be

used for fluid collection, first clamping the connecting tubing, then opening the clamponce the tubing is attached to the bottle (E).


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help to confirm a diagnosis or if drainage of fluid will effect an improvement in

ventilatory function. When possible, the patient sits with arms supported by a table (A).A skin wheal with local anesthetic is raised one to two levels below the percussed fluid

level, followed by infiltration of deeper tissues with a 20-gauge needle over the middle of

the underlying rib. The needle is advanced over the top of the rib with frequentaspirations until the pleural space is entered (inset in panel A). The depth is marked with

a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3].

Following needle insertion, the catheter is advanced into the pleural space (B), and theneedle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a


used for fluid collection, first clamping the connecting tubing, then opening the clamp

once the tubing is attached to the bottle (E).


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help to confirm a diagnosis or if drainage of fluid will effect an improvement inventilatory function. When possible, the patient sits with arms supported by a table (A).

A skin wheal with local anesthetic is raised one to two levels below the percussed fluid



a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3].Following needle insertion, the catheter is advanced into the pleural space (B), and the

needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a




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Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid willhelp to confirm a diagnosis or if drainage of fluid will effect an improvement in





Following needle insertion, the catheter is advanced into the pleural space (B), and theneedle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a




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help to confirm a diagnosis or if drainage of fluid will effect an improvement in





Following needle insertion, the catheter is advanced into the pleural space (B), and the

needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into asyringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be

used for fluid collection, first clamping the connecting tubing, then opening the clamp

once the tubing is attached to the bottle (E).


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Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid

(including blood) from the pleural space. Preferred sites are the fourth or fifth intercostalspace in the anterior axillary line (A) or the second interspace in the midclavicular line(pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous

tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below

the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp

is then inserted into the pleural space over the superior margin of the upper rib (F and G),followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of

the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and

superiorly into the pleural space (I). The tube is then connected to a collection-suctionapparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4)

and is sutured to the skin.


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Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid(including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal

space in the anterior axillary line (A) or the second interspace in the midclavicular line

(pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneoustissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below


is then inserted into the pleural space over the superior margin of the upper rib (F and G),

followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip ofthe thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and

superiorly into the pleural space (I). The tube is then connected to a collection-suction

apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4)



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(including blood) from the pleural space. Preferred sites are the fourth or fifth intercostalspace in the anterior axillary line (A) or the second interspace in the midclavicular line








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space in the anterior axillary line (A) or the second interspace in the midclavicular line(pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous

tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below







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(pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous

tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made belowthe selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp


followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of

the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly andsuperiorly into the pleural space (I). The tube is then connected to a collection-suction




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apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4)and is sutured to the skin.


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space in the anterior axillary line (A) or the second interspace in the midclavicular line




followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip ofthe thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and


apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4)and is sutured to the skin.


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(including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal

space in the anterior axillary line (A) or the second interspace in the midclavicular line(pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneoustissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below







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(including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal

space in the anterior axillary line (A) or the second interspace in the midclavicular line(pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous

tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made belowthe selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp


followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of

the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly andsuperiorly into the pleural space (I). The tube is then connected to a collection-suction




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Figure 7-3. Heimlich catheter insertion. This procedure is an alternative to conventional

tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the

pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and aJ wire threaded through the needle (Seldinger technique), following which the needle is

removed leaving the guidewire in place (B). A catheter is then advanced over the

guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheterand connected to the pleural drainage system (D).


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Figure 7-3. Heimlich catheter insertion. This procedure is an alternative to conventionaltube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the

pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and a

J wire threaded through the needle (Seldinger technique), following which the needle is

removed leaving the guidewire in place (B). A catheter is then advanced over theguidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheter

and connected to the pleural drainage system (D).


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tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the

pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and aJ wire threaded through the needle (Seldinger technique), following which the needle is


guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheter

and connected to the pleural drainage system (D).


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tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into thepleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and a

J wire threaded through the needle (Seldinger technique), following which the needle is


guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheterand connected to the pleural drainage system (D).


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Figure 7-4. Chest tube drainage system (bottles). These systems are variable inappearance but similar in principle. The chest tube external tip must be submerged

beneath the level of water in a container, usually 1 to 2 cm below the surface (A) to effectan underwater seal. A three-bottle system is also shown (B). Fluid collected from thepatient passes into the first bottle where it can be measured. The second bottle provides

the underwater seal described in panel A, serving as a one-way valve allowing air to

escape from the chest but preventing it from being sucked in with respiration. The third

bottle controls the negative (subambient) pressure that the suction can generate. Theinlet tube to this bottle is exposed to the outlet (suction) tube above a water level that is

vented to ambient. Should the negative pressure above the water level exceed that

generated by the water, air will enter the vent, bubble through the water, and offset theexcess negative pressure above the water. Disposable, compact, portable collection

chambers combine the three-bottle functions (C) and are used almost exclusively today.


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Figure 7-4. Chest tube drainage system (bottles). These systems are variable in

appearance but similar in principle. The chest tube external tip must be submerged

beneath the level of water in a container, usually 1 to 2 cm below the surface (A) to effectan underwater seal. A three-bottle system is also shown (B). Fluid collected from the

patient passes into the first bottle where it can be measured. The second bottle providesthe underwater seal described in panel A, serving as a one-way valve allowing air to

escape from the chest but preventing it from being sucked in with respiration. The third

bottle controls the negative (subambient) pressure that the suction can generate. The

inlet tube to this bottle is exposed to the outlet (suction) tube above a water level that isvented to ambient. Should the negative pressure above the water level exceed that

generated by the water, air will enter the vent, bubble through the water, and offset the

excess negative pressure above the water. Disposable, compact, portable collectionchambers combine the three-bottle functions (C) and are used almost exclusively today.


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Figure 7-4. Chest tube drainage system (bottles). These systems are variable inappearance but similar in principle. The chest tube external tip must be submerged

beneath the level of water in a container, usually 1 to 2 cm below the surface (A) to effect

an underwater seal. A three-bottle system is also shown (B). Fluid collected from thepatient passes into the first bottle where it can be measured. The second bottle provides

the underwater seal described in panel A, serving as a one-way valve allowing air to

escape from the chest but preventing it from being sucked in with respiration. The thirdbottle controls the negative (subambient) pressure that the suction can generate. The

inlet tube to this bottle is exposed to the outlet (suction) tube above a water level that is

vented to ambient. Should the negative pressure above the water level exceed that

generated by the water, air will enter the vent, bubble through the water, and offset the

excess negative pressure above the water. Disposable, compact, portable collectionchambers combine the three-bottle functions (C) and are used almost exclusively today.


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Figure 7-5. Sites involved in paracentesis procedure (circled numbers). Diagnostic

paracentesis is used for patients with ascites, unexplained fever, leukocytosis, orsuspected bacterial peritonitis [3], [4]. Occasionally, therapeutic paracentesis is applied topatients with tense ascites that is thought to be causing respiratory compromise. After

production of a skin wheal with lidocaine, the skin is stretched about 1.0 cm inferiorlyand lidocaine is injected through the wheal, subcutaneous tissue, fascia, and peritoneum

using a 21-gauge needle. Next, a 20-gauge over-the-needle catheter is advanced through

the anesthetized tract and aspiration is performed continuously with a 10-mL syringe.When fluid is obtained, the catheter is advanced and a 50-mL syringe is attached to its

hub to obtain the required sample.


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Figure 7-6. Characteristic ascitic fluid findings in various disease states.

The percentage figures should be taken as an indication of order of magnitude rather thanas the precise incidence of any abnormal finding. (Adapted fromYeston and coworkers

[4]; with permission.)

Characteristic ascitic fluid findings in various disease states

Cell Count

ConditionGrossAppearance

Specific Gravity Protein, g/dLRed BloodCells >10,000/mm

3)

White Blood Cells(per mm

3)

OtherTests

CirrhosisStraw-colored orbile stained

1000(50&percnt;):variable cell types

Cytology,cell block,peritonealbiopsy

Tuberculousperitonitis

Clear, turbid,hemorrhagic,chylous

Variable,>1.016(50&percnt;)

>2.5(50&percnt;) 7&percnt;>1000(70&percnt;);usually >70&percnt;lymphocytes

Peritoneal

biopsy,stain andculture foracid-fastbacilli

Pyogenicperitonitis

Turbid orpurulent

If purulent, >1.016 If purulent, >2.5 UnusualPredominantlypolymorphonuclearleukocytes

PositiveGramstain,culture

Congestiveheart failure

Straw-colored

Variable,


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Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt

abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplainedhypotension, and some nontraumatic intra-abdominal processes [5]. Only predeterminedlaparotomy is a true contraindication. The reported accuracy for determining the presence

of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open

technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascialedges are grasped and elevated with towel clips (B). The underlying peritoneum is

opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward

the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through theperitoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If

gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and

administered through the catheter, leaving a small amount of saline in the bag and tubing.

The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which isthen submitted for erythrocyte and leukocyte counts, amylase determination, and the

presence of particulate matter, bile, or bacteria. The catheter is removed and the purse-

string suture closed.


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abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplainedhypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined

laparotomy is a true contraindication. The reported accuracy for determining the presence

of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The opentechnique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial

edges are grasped and elevated with towel clips (B). The underlying peritoneum is

opened (C), and the lavage catheter (without trochar) is inserted (D) and directed towardthe pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the

peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If

gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set andadministered through the catheter, leaving a small amount of saline in the bag and tubing.

The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is

then submitted for erythrocyte and leukocyte counts, amylase determination, and the

presence of particulate matter, bile, or bacteria. The catheter is removed and the purse-string suture closed.


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abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplainedhypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined

laparotomy is a true contraindication. The reported accuracy for determining the presenceof intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open

technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial

edges are grasped and elevated with towel clips (B). The underlying peritoneum isopened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward

the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the

peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. Ifgross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and

administered through the catheter, leaving a small amount of saline in the bag and tubing.

The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which isthen submitted for erythrocyte and leukocyte counts, amylase determination, and thepresence of particulate matter, bile, or bacteria. The catheter is removed and the purse-



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Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess bluntabdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained

hypotension, and some nontraumatic intra-abdominal processes [5]. Only predeterminedlaparotomy is a true contraindication. The reported accuracy for determining the presence

of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open

technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascialedges are grasped and elevated with towel clips (B). The underlying peritoneum is

opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward

the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through theperitoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If

gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and

administered through the catheter, leaving a small amount of saline in the bag and tubing.The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is

then submitted for erythrocyte and leukocyte counts, amylase determination, and the

presence of particulate matter, bile, or bacteria. The catheter is removed and the purse-



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Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess bluntabdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained

hypotension, and some nontraumatic intra-abdominal processes [5]. Only predeterminedlaparotomy is a true contraindication. The reported accuracy for determining the presenceof intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open

technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial

edges are grasped and elevated with towel clips (B). The underlying peritoneum is

opened (C), and the lavage catheter (without trochar) is inserted (D) and directed towardthe pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the

peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If

gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set andadministered through the catheter, leaving a small amount of saline in the bag and tubing.

The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is

then submitted for erythrocyte and leukocyte counts, amylase determination, and thepresence of particulate matter, bile, or bacteria. The catheter is removed and the purse-



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Figure 7-8. Closed technique diagnostic peritoneal lavage. A prepackaged kit or a dialysis

catheter trochar kit can be used. With the latter approach, a 2- to 3-cm infraumbilicalincision is established to the linea alba. Following additional local anesthesia, the

catheter-trochar is thrust in a controlled fashion with both hands toward the pelvis (A).

When a pop is felt, all pressure is released. The catheter is advanced and the trocharremoved (B). The irrigation tubing is attached, and then the open technique procedure is

followed.


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Figure 7-8. Closed technique diagnostic peritoneal lavage. A prepackaged kit or a dialysis

catheter trochar kit can be used. With the latter approach, a 2- to 3-cm infraumbilicalincision is established to the linea alba. Following additional local anesthesia, the

catheter-trochar is thrust in a controlled fashion with both hands toward the pelvis (A).

When a pop is felt, all pressure is released. The catheter is advanced and the trocharremoved (B). The irrigation tubing is attached, and then the open technique procedure is

followed.


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Figure 7-9. Diagnostic peritoneal lavage with a prepackaged kit. A 3-mm skin incision is

made, followed by introduction of an 18-gauge needle angled toward the center of thepelvis (A). A 15-cm J guidewire is passed through the needle (B). When half of the wire

has been advanced, the needle is removed, the catheter is threaded over the guidewire and

advanced with a twisting motion through the fascia. The wire is removed when the

catheter is positioned. The infusion tubing is then attached, following which theprocedure is continued as with the other methods.


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Figure 7-10. Diagnostic peritoneal lavage interpretation. In blunt trauma, accuracy is

96% [4]. Retroperitoneal injuries can be missed, and false-negative results are reportedfor ruptured diaphragm, bladder, and spleen, lacerated liver. The false-negative rate is

higher for penetrating injury. (Adapted from Yeston and coworkers [4].)

Diagnostic peritoneal lavage interpretation

Positive

Aspiration of > 10 mL of blood

Lavage fluid exits by means of Foley catheter or chest tube

Grossly bloody lavage return

Erythrocyte > 100,000/mm3

Leukocyte > 500/mm3

Amylase > 175 U/dL

Presence of bile, bacteria, or particulate matter

Negative (Nonpenetrating Trauma)

Erythrocyte < 50,000/mm3

Leukocyte < 100/mm3

Amylase < 75 U/dL

Indeterminant

Dialysis catheter fills with blood

Erythrocyte > 50,000-< 100,000/mm3

Leukocyte > 100- < 500/mm3

Amylase > 75- < 175 U/dL


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Figure 7-11. Distal saphenous venous supply. These veins are useful for venouscannulation or cutdown in cardiac arrest when resuscitative activity is centered on theupper body.


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Figure 7-12. Proximal saphenous vein. In the groin, the 4- to 5-mm diameter proximalsaphenous vein joins the femoral vein 7 to 8 cm inferior to the inguinal ligament along

the anteromedial aspect of the thigh. Large-bore venous access cutdowns are easily

accomplished.


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Figure 7-13. Basilic vein. The basilic vein is consistently of large diameter and isadvantageous when long-line central venous catheterization is desired. The brachial

artery and median nerve can be damaged by deep dissection. The cephalic vein is more

variable in size and does not lend itself well to central venous catheter placement becauseof the right angle turn at the clavipectoral fascia.


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Figure 7-14. Percutaneous insertion of central venous and pulmonary artery catheters.

Catheter placement at these sites is common in the intensive care unit. The relevant

anatomy of the internal and external jugular veins, the subclavian veins, and theiradjacent structures is shown [6]. These are by far the most popular access sites, and a

wide variety of introducer kits are available for insertion.


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Figure 7-15. Preferable insertion sites for central venous and pulmonary artery

catheters. The choice depends on the clinical setting, condition, or both [6].High

supraclavicular (SC) refers to skin puncture 1 to 2 cm above the clavicle, therebyallowing easier tamponade for inadvertent arterial bleeding. The skin puncture site is

close to the central internal jugular (IJ) technique. The femoral approach is suitable for

bedridden patients. Short-term use in nonobese patients is possible. During resuscitation,the catheter should be long enough to reach the intrathoracic veins. Peripheral vein

cannulation is useful for intravascular volume resuscitation and rarely for hemodynamic

monitoring or temporary pacing. If the infraclavicular (IC) vein is used, left is preferred

over right. If the SC vein or the IJ vein is used, the preferred site is the right. EJVexternal jugular vein; PEEPpositive end-expiratory pressure. (Adapted from Novak

and Venus [6].)

PREFERABLE INSERTION SITES FOR CENTRAL VENOUS AND PULMONARY ARTERY CATHETERS

Choices (Order of Preference)

Clinical Situations 1st 2nd 3rd 4th 5th

Bleeding diathesis EJV IJ High SCFemoral Largeperipheral vein

Obesity or generalized edema IC SC IJ

Decreased pulmonary reserve;ventilation with PEEP

EJV IJ Femoral IC SC

Parenteral nutrition IC IJ SC EJV Femoral

Hypovolemia; shock IC or SC Femoral IJ Large peripheral vein

Cardiopulmonary resuscitation IJ EJV Femoral Large peripheral veinIC HighSC

Emergency airway management IC FemoralLarge peripheral

vein

Temporary hemodialysis IC IJ Femoral SC

Multiple catheter insertions IC SC Femoral IJ EJV

Pulmonary artery catheter insertion IC or IJ SC or IJ EJV Femoral

Temporary pacemaker IJ IC SC Femoral EJV

Tracheostomy or sternal wounds EJV or IJ Femoral High SC IC

Short diagnostic techniques Femoral IJ IC SC

Inability to lower the head EJV Femoral SC


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Figure 7-16. Characteristic direct pressure tracings that identify the position of a balloon-tipped, flow-directed pulmonary artery catheter as it traverses the right atrium (RA), right

ventricle (RV), and pulmonary artery (PA) during insertion, finally residing in a

pulmonary capillary wedge (PCW) position (with the balloon inflated). With rareexceptions, the tracings are so easily recognized that ancillary techniques such as

fluoroscopy are unnecessary.


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Figure 7-17. Immediate and delayed complications associated with central

venous and pulmonary artery catheter insertion [7]. (Adapted from Venus and Mallory

[7].)

Complications of central venous and pulmonary artery catheter insertion

Immediate Late

Multiple puncture Pulmonary artery rupture*

Pneumo- hemo- hydro-chylothorax-mediastinum Pulmonary infarction*

Arterial puncturehematoma orbleeding

Catheter-related sepsis

Air embolism Balloon rupture*

Cardiac arrhythmias Endocardial or valvular damage*

Catheter malposition Venous thrombosis

Catheter knotting Infections (cellulitis, osteomyelitis, endocarditis, thrombophlebitis)

Subcutaneous and mediastinalemphysema

Nerve injury (brachial, phrenic, recurrent, laryngeal, vagus, cranial IXXII,Horner and Brown-Squard syndromes)

Tracheal puncture-laceration Cerebrovascular compromise

Cardiac perforation and tamponade

Arteriovenous fistula

Thrombocytopenia

*Applies to pulmonary artery cannulation only.


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Figure 7-18. Pericardiocentesis procedure. Pericardiocentesis is used for relief of cardiactamponade and for diagnosis of a pericardial effusion. A paraxiphoid approach most

commonly is used (A) because it avoids the pleura and coronary vessels. A left

parasternal approach through the fourth interspace can be employed. A 12- to 18-cm, 16-to 18-gauge, short-bevel cardiac needle is attached to a 10-mL syringe. A sterile alligator

clip is attached to the metal needle and an electrocardiographic V-lead (B). For the

paraxiphoid approach, the skin is entered just below the costal margin lateral to thexiphoid and the needle is advanced at a 45 angle under the ribs toward the clavicular

midpoint, while gentle traction is applied continuously on the syringe plunger. For the

left parasternal approach, the needle is advanced through the fourth intercostal space at

the sternal border and perpendicular to the chest wall. When deep to the costal arch, thehub is depressed and the needle directed toward the left shoulder with ongoing

aspiration.With either approach, an ST-segment elevation (injury current) (C) must be

monitored for when the needle tip touches the ventricular epicardium. (PR elevation

results from atrial epicardial contact.) When fluid is obtained, the needle is stabilizedwith a hemostat at the skin surface. Removal of only 20 mL of fluid or blood may be life

saving in cardiac tamponade. ECGelectrocardiography.


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Figure 7-18. Pericardiocentesis procedure. Pericardiocentesis is used for relief of cardiactamponade and for diagnosis of a pericardial effusion. A paraxiphoid approach most

commonly is used (A) because it avoids the pleura and coronary vessels. A leftparasternal approach through the fourth interspace can be employed. A 12- to 18-cm, 16-

to 18-gauge, short-bevel cardiac needle is attached to a 10-mL syringe. A sterile alligatorclip is attached to the metal needle and an electrocardiographic V-lead (B). For the

paraxiphoid approach, the skin is entered just below the costal margin lateral to the

xiphoid and the needle is advanced at a 45 angle under the ribs toward the clavicularmidpoint, while gentle traction is applied continuously on the syringe plunger. For the

left parasternal approach, the needle is advanced through the fourth intercostal space at

the sternal border and perpendicular to the chest wall. When deep to the costal arch, thehub is depressed and the needle directed toward the left shoulder with ongoing

aspiration.With either approach, an ST-segment elevation (injury current) (C) must be

monitored for when the needle tip touches the ventricular epicardium. (PR elevationresults from atrial epicardial contact.) When fluid is obtained, the needle is stabilized

with a hemostat at the skin surface. Removal of only 20 mL of fluid or blood may be life



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Figure 7-18. Pericardiocentesis procedure. Pericardiocentesis is used for relief of cardiac

tamponade and for diagnosis of a pericardial effusion. A paraxiphoid approach mostcommonly is used (A) because it avoids the pleura and coronary vessels. A left

parasternal approach through the fourth interspace can be employed. A 12- to 18-cm, 16-

to 18-gauge, short-bevel cardiac needle is attached to a 10-mL syringe. A sterile alligatorclip is attached to the metal needle and an electrocardiographic V-lead (B). For the

paraxiphoid approach, the skin is entered just below the costal margin lateral to the

xiphoid and the needle is advanced at a 45 angle under the ribs toward the clavicular

midpoint, while gentle traction is applied continuously on the syringe plunger. For theleft parasternal approach, the needle is advanced through the fourth intercostal space at

the sternal border and perpendicular to the chest wall. When deep to the costal arch, the

hub is depressed and the needle directed toward the left shoulder with ongoingaspiration.With either approach, an ST-segment elevation (injury current) (C) must be

monitored for when the needle tip touches the ventricular epicardium. (PR elevation

results from atrial epicardial contact.) When fluid is obtained, the needle is stabilizedwith a hemostat at the skin surface. Removal of only 20 mL of fluid or blood may be life



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Figure 7-19. Methods for assessing tracheal versus esophageal tube position and

preventing endobronchial intubation. Loss of the airway because of inability to intubate,

placement of the endotracheal tube in the wrong place (esophagus or mainstembronchus), inadvertent extubation, or failure of ventilation (eg, kinked or plugged tube,

disconnect) is a leading cause of anesthesia and intensive care unit (ICU) morbidity and

mortality [8]. Although correct tube placement and maintenance would seem, a priori, to

be easily verifiable, such is not always the case. Traditional tests of assessing trachealversus esophageal positioning can be misleading and are sometimes completely

unreliable (A) [9]. Bronchial intubation, which frequently is deliberate and planned in

thoracic surgery, can be lethal when unplanned and unrecognized in other operations orduring mechanical ventilation in the ICU. Preventive measures and their drawbacks are

summarized here (B). (Adapted from Birmingham and Cheney [9]; with permission.)

A. Assessing tracheal vs esophageal tube position

Method Comments

Direct visualization of vocal cordsTube movement can occur before taping the tube and with changes inhead position

End-tidal CO2No CO2 may be detected with severe bron-chospasm or in the fullyarrested patient with absent pulmonary blood flow. CO2 may be exhaledfrom the stomach from prior mask ventilation

Breath sounds Unreliable

Chest rise Unreliable

Epigastricauscultation/observation

Unreliable

Reservoir bag compliance andrefilling

Unreliable

Presence of tidal volumes withrespiratory efforts

Unreliable

Quality of air leak around tube Unreliable

Cuff palpation in trachea UnreliableCuff volume necessary toocclude leak

Excessive cuff volume may indicate a tube above the cords or in theesophagus

Normal ventilator function Unreliable

Chest radiography Not fail-safe even when done

Tube condensation Can be seen with esophageal tube

Fiberoptic bronchoscopy Reliable, but expensive, prone to breakage

Pulse oximetryA late sign; may get some alveolar gas exchange with esophagealventilation and hence slow desaturation


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Figure 7-19. Methods for assessing tracheal versus esophageal tube position and

preventing endobronchial intubation. Loss of the airway because of inability to intubate,placement of the endotracheal tube in the wrong place (esophagus or mainstem

bronchus), inadvertent extubation, or failure of ventilation (eg, kinked or plugged tube,disconnect) is a leading cause of anesthesia and intensive care unit (ICU) morbidity and

mortality [8]. Although correct tube placement and maintenance would seem, a priori, to

be easily verifiable, such is not always the case. Traditional tests of assessing trachealversus esophageal positioning can be misleading and are sometimes completely

unreliable (A) [9]. Bronchial intubation, which frequently is deliberate and planned in

thoracic surgery, can be lethal when unplanned and unrecognized in other operations orduring mechanical ventilation in the ICU. Preventive measures and their drawbacks are

summarized here (B). (Adapted from Birmingham and Cheney [9]; with permission

B. Detection of endobronchial intubation

Method Comments

Equal breath sounds/chest rise Unreliable

Tube position at incisors Precut adult oral tubes to 2.5 cm

Position tube 21 cm at incisors in normal-sized adult woman

Position tube 23 cm at incisors in normal-sized adult man

Chest radiography Tube tip at T2 to T4 with head in neutral position (mandible overlying C5-6)

Fiberoptic bronchoscopy As reliable as radiography

Pulse oximetry Desaturation does not necessarily occur

End-tidal CO2 Has led to detection of endobronchial intubation


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Figure 7-20. The Difficult Airway Algorithm published by the American Society ofAnesthesiologists in 1993 [10]. This algorithm was intended for operating room

application but is useful in the ICU if unconscious or unresponsive is substituted for

anesthetized. (Adapted from American Society of Anesthesiologists [10]; withpermission.)


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Figure 7-21. Tube movement. Even when an endotracheal tube is correctly placed

initially, it may subsequently move to an endobronchial position or wind up outside thetrachea. Conrardy et al. [11] showed that flexion or extension of the head on the neck can

move the tube tip down or up an average of 1.9 cm (3.8 cm total range of motion) with nochange in position at the teeth or lips. Failure to recognize this possibility by physicalassessment, chest radiography, or fiberoptic bronchoscopy has led to fatal complications

and malpractice litigation. Mainstem intubation, when inadvertent, usually involves the

right bronchus because it bifurcates from the trachea at a considerably lesser angle than

does the left. Because its origin is close to the carina, the right upper lobe bronchus mayalso be occluded, leaving only the right middle and lower lobes for ventilation.

Significant shunting and hypoxemia result.Body position changes also can lead to

endobronchial movement of the tube tip, particularly in conditions associated withincreased abdominal pressure. When a patient with tense ascites, intrauterine pregnancy,

or abdominal tumor is placed head down (Trendelenburgs position), the diaphragm is

displaced cephalad as are the lungs and carina. An initially correctly placed endotrachealtube thus may end up in the mainstem brochus. (Adapted from Conrardy and coworkers

[11].)


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Figure 7-22. Inadvertent right mainstream intubation. In this case, intubation occurred 30minutes before the chest radiograph was taken during the induction of anesthesia.

Complete atelectasis of the left lung and right upper lobe is demonstrated (the

endotracheal tube has been pulled back into the correct tracheal position). The rapiditywith which atelectasis can occur in such situations is obvious.


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Figure 7-24. Tube insertion in the case of a difficult-to-visualize anterior glottic

opening. A, The endotracheal tube has been inserted without a stylet, making control of

its tip difficult or impossible. B, The stylet has been placed and the tube tip angulatedtoward but, in this case, not into the glottic opening. C, The stylet is slowly withdrawn

without changing the tube position. This maneuver automatically elevates the tube tip

anteriorly as much as 1 to 2 cm, allowing it to be carefully advanced through the vocal

cords.


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Figure 7-25. Laryngeal mask airway (LMA). The LMA can be used in lieu of tracheal

intubation in selected cases [13], [14], [15]. The LMA resembles a conventionalendotracheal tube with a small mask at the tip that, when properly inserted, covers the

glottic aperture and allows the patient to breathe spontaneously. Low-pressure positive-

pressure ventilation can be used, although leaks around the mask are common. The mask

is deflated for insertion (A) and inflated for maintenance (B). The LMA does not preventaspiration. It is placed blindly and can be life saving when the glottis cannot be

visualized. However, insertion in some cases can be difficult [15]. Six sizes currently are

available for pediatric through adult applications.


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Figure 7-25. Laryngeal mask airway (LMA). The LMA can be used in lieu of trachealintubation in selected cases [13], [14], [15]. The LMA resembles a conventional

endotracheal tube with a small mask at the tip that, when properly inserted, covers the

glottic aperture and allows the patient to breathe spontaneously. Low-pressure positive-

pressure ventilation can be used, although leaks around the mask are common. The maskis deflated for insertion (A) and inflated for maintenance (B). The LMA does not prevent

aspiration. It is placed blindly and can be life saving when the glottis cannot be

visualized. However, insertion in some cases can be difficult [15]. Six sizes currently areavailable for pediatric through adult applications.


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Figure 7-26. 14-Gauge intravenous catheter for percutaneous needle cricothyroidotomy.

In association with a high-pressure oxygen source, this procedure can be life saving whentransoral or transnasal intubation fails. Shown here is the catheter with an attached

tuberculin syringe, connecting oxygen tubing, and a 15-cm endotracheal tube adaptor that

can be plugged into a common gas outlet of an anesthesia machine. Other adaptors can be

fashioned, depending on the source of high-pressure oxygen used. When the anesthesiamachine is used, the flush button is rapidly and sequentially depressed. Ventilationcannot be achieved by compressing a self-inflating bag, rebreathing bag in the anesthesia

circuit, or any bag in a Mapleson D configuration. High-frequency jet ventilation can be

employed if a suitable ventilator and attachments are available.


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Figure 7-27.

Complications associated with intubation, maintenance, and extubation. Complications

are numerous and vary from minimal to severe [16]. (Adapted from Flemming and

coworkers [16].)

Problems associated with endotracheal intubation, maintenance, and extubation

Time Tissue Injury Mechanical Problems Other

Tubeplacement

Corneal abrasion; nasal polypdislodgement; bruise/laceration oflips/tongue; tooth extraction;retropharyngeal perforation; vocal cordtear; cervical spine subluxation orfracture; hemorrhage; turbinate boneavulsion; aspiration

Esophageal/endobronchialintubation; delay incardiopulmonary resuscitation

Arrhythmia;pulmonary aspiration;hypertension;hypotension

Tube inplace

Tear/abrasion of larynx, trachea,bronchi; barotrauma, leaks,disconnections; airway edema; nerveinjury; webs

Airway obstruction; migration oftube; ignition of tube during lasersurgery

Bacterial infection(secondary)

Gastric aspiration

Paranasal sinusitis

Problems related tomechanicalventilation (egpulmonarybarotrauma)

ExtubationDamage to vocal cords if cuff notdeflated

Difficult extubation; airwayobstruction from blood, foreign

bodies, dentures, or throat packs

Pulmonaryaspiration; laryngealedema;

laryngospasm;tracheomalacia

icu techniques and procedures

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