CHAPTER 47
Male Urinary
Drainage Catheter
Introduction catheter is inserted and removed periodically to
decompress bladder.
Urinary catheter insertion is performed to drain urine ■ Prostatic hypertrophy: A common cause of difficulty
from the bladder (Figure 47-1) in patients who are with spontaneous urinary drainage as well as
incontinent or have urinary obstruction or to frequently catheter insertion.
monitor urine output as a proxy for renal function.
Long-term catheterization is associated with increased Techniques
risk of urinary tract infection.
■ Indications:
Definitions and Terms —Perioperative urinary drainage
—Urinary tract outflow obstruction
■ French (Fr): The unit of measurement used in sizing —Urinary volume measurement in the intensive care
urinary catheters—where 1 French equals 1/3 of a unit (ICU)
millimeter.
■ Contraindications:
■ Intermittent straight catheterization: A technique —Urethral disruption
used for intermittent bladder drainage wherein the
Bladder Prostate
Pubic
bone
Penis Anus
Figure 47-1. Male urinary anatomy. Urinary
catheter
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Male Urinary Drainage Catheter 139
Figure 47-2. Urinary drainage catheter and tested
balloon.
■ Method: Figure 47-3. Penile preparation.
Figure 47-4. Hand positioning for catheter insertion.
—Prior to urinary catheterization, patient consent Figure 47-5. Catheter insertion.
should be obtained, the urethra and surrounding
areas prepped and draped (Figure 47-2), and the
universal protocol performed as described in
Section I.
—Prior to catheterization, the operator should wash
hands and wear sterile gloves.
—According to Centers for Disease Control guidelines,
Catheters should only be inserted by trained
personnel.
• Catheters should only be inserted when neces-
sary, rather than for the convenience of patient-
care personnel, and should only be left in place
as long as necessary.
• Alternative methods of urinary drainage should
be entertained (ie, condom catheter, suprapubic
drain).
—The smallest appropriate catheter should be
selected for insertion, and the balloon checked for
patency (Figure 47-3):
• Smaller catheters (12-14 Fr) are appropriate for
use in patients with strictures.
• Medium catheters (16-18 Fr) are typically used in
adult males.
• Larger catheters (20-24 Fr) may be used in
patients with prostatic hypertrophy or hematuria.
—If the patient is uncircumcised, the foreskin should
be retracted prior to skin preparation.
—The catheter should be lubricated and inserted
into the urethra and advance to its full length,
while the penis is held vertically with the nondom-
inant hand (Figures 47-4 and 47-5).
140 Procedures in Critical Care
Figure 47-6. Urinary catheter in place attached to Figure 47-7. Lubricant injected into urethra.
closed urinary drainage system.
—After urine has drained from the catheter, the ■ Stenoses or strictures may be managed by passage of
balloon should be inflated. a smaller catheter.
—If the foreskin has been retracted, it should be ■ Patients with prostatic hypertrophy may be success-
reduced to anatomical position following success- fully catheterized with a larger catheter or a Coude
ful catheterization. tipped catheter (which has a stiffer, asymmetric tip).
—The catheter is attached to a closed drainage ■ The urethra can be distended and lubricated with a
system (Figure 47-6) and the drainage bag is posi- lubricant when passage is difficult (Figure 47-7).
tioned below the level of the bladder to prevent
urinary reflux into the bladder. ■ If no urine drains from the catheter after insertion to
an appropriate length, the catheter may be irrigated
■ Complications: with sterile saline—free saline return suggests that
—Urethral trauma the tip is in the right location.
—Infection
Suggested Reading
Clinical Pearls and Pitfalls
Thomsen TW, Setnik GS. Male urethral catheterization.
■ When catheter passage is difficult, this may be due to N Engl J Med. 2006;354:e22.
one of several problems, including: Wong ES, Hooton TM. Guideline for prevention of
—Meatal stenosis catheter-associated urinary tract infections. Center
—Urethral stricture for Disease Control and Prevention Web site.
—Prostatic hypertrophy http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.
html. (Accessed in May 2008.)
CHAPTER 48
Female Urinary
Drainage Catheter
Introduction Techniques
Urinary catheter insertion is performed to drain urine ■ Indications:
from the bladder (Figure 48-1) in patients who are
incontinent or have urinary obstruction or to fre- —Perioperative urinary drainage
quently monitor urine output as a proxy for renal func-
tion. Long-term catheterization is associated with —Urinary tract outflow obstruction
increased risk of urinary tract infection.
—Urinary volume measurement in the intensive care
Definitions and Terms unit (ICU)
■ French (Fr): The unit of measurement used in sizing ■ Contraindications:
urinary catheters—where 1 French equals 1/3 of a
millimeter. —Urethral disruption
■ Intermittent straight catheterization: A technique ■ Method:
used for intermittent bladder drainage wherein the
catheter is inserted and removed periodically to —Prior to urinary catheterization, patient consent
decompress bladder. should be obtained, the urethra and surrounding
areas prepped and draped (Figure 48-2), and the
universal protocol should be performed as
described in Section I.
—Prior to catheterization, the operator should wash
hands and wear sterile gloves.
Bladder
Pubic
bone
Anus
Urinary Vagina
catheter
Figure 48-1. Female urinary anatomy. Figure 48-2. Patient preparation.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
142 Procedures in Critical Care Figure 48-3. Catheter insertion.
—According to Centers for Disease Control guidelines: ■ If no urine drains from the catheter after insertion to
• Catheters should only be inserted by trained an appropriate length, the catheter may be irrigated
personnel. with sterile saline—free saline return suggests that
• Catheters should only be inserted when neces- the tip is in the right location.
sary, rather than for the convenience of patient-
care personnel, and should only be left in place Suggested Reading
as long as necessary.
• Alternative methods of urinary drainage should be Leone M. Garnier F. Avidan M. Martin C. Catheter-
entertained (ie, condom catheter, suprapubic drain). associated urinary tract infections in intensive care
units. Microbes Infect. 2004;6:1026–1032.
—The smallest appropriate catheter should be Wong ES, Hooton TM. Guideline for prevention of
selected for insertion, and the balloon checked for catheter-associated urinary tract infections. Center for
patency. Disease Control and Prevention Web site. http://www.
• Medium catheters (16-18 Fr) are typically used in cdc.gov/ncidod/dhqp/gl_catheter_assoc.html.
adult females. (Accessed in May 2008.)
• Larger catheters (20-24 Fr) may be used in
patients with hematuria.
—The labia should be spread, the urethra identified,
and the catheter should be lubricated and
inserted into the urethra (Figure 48-3).
—After urine has drained from the catheter, the
balloon should be inflated.
—The catheter is attached to a closed drainage sys-
tem and the drainage bag is positioned below the
level of the bladder to prevent urinary reflux into
the bladder.
■ Complications:
—Urethral trauma
—Infection
Clinical Pearls and Pitfalls
■ Urethral identification may be difficult in obese
patients, patients with prior surgery, following child-
birth or with prolapsed of vagina and/or urethra.
CHAPTER 49
Suprapubic Catheterization
Introduction Techniques
Suprapubic catheterization is performed as an alterna- ■ Indications:
tive approach to urinary drainage in patients for whom —Phimosis
standard urinary drainage catheters are contra- —Urethral stricture
indicated. —Chronic urethral infection
Definitions and Terms ■ Contraindications:
—Coagulopathy
■ Suprapubic catheter: A catheter inserted into the —Infected skin over proposed cannulation site
bladder through the anterior abdominal wall —Intra-abdominal pathology (ie, peritonitis, scarring,
(Figure 49-1). wound)
—Bladder tumor
■ Phimosis: Constriction of the foreskin of the penis.
■ Prior to urinary catheterization, patient consent
Pubic bone should be obtained, the urethra and surrounding
areas prepped and draped, and the universal protocol
performed as described in Section I.
■ Ultrasound and/or physical examination should be
used to identify the location of the bladder.
■ Local anesthetic should be infiltrated into the skin
over the proposed insertion site.
■ A small bore needle or Angiocath is inserted into the
bladder and aspirated.
■ Aspiration of urine indication successful bladder can-
nulation and a urinary drainage catheter can be
inserted using Seldinger technique or a peel-away
introducer sheath.
■ Complications:
—Bowel perforation
—Bladder injury
—Hematuria
—Infection
Bladder Clinical Pearls and Pitfalls
Figure 49-1. Anatomic placement of a suprapubic ■ Failure to aspirate urine following several attempts
catheter. suggests aberrant anatomy and the procedure should
be abandoned in favor of alternative approaches.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
144 Procedures in Critical Care prospective randomized trial of suprapubic versus
urethral catheterization. Br J Surg. 1995;82:
■ Suprapubic catheters, while more invasive, may be 1367–1368.
associated with lower rates of infections. Sethia KK, Selkon JB, Berry AR, Turner CM, Kettlewell
MG, Gough MH. Prospective randomized controlled
Suggested Reading trial of urethral versus suprapubic catheterization. Br
J Surg. 1987;74:624–625.
O’Kelly TJ, Mathew A, Ross S, Munro A. Optimum method
for urinary drainage in major abdominal surgery: a
CHAPTER 50
Continuous Renal
Replacement Therapies
CVVHD
Introduction IN OUT
Continuous renal replacement therapies have come Dialysis
into increasing use in intensive care units (ICUs), and membrane
a variety of alternatives are available, ranging from
fluid-removal approaches to continuous dialysis.
Definition and Terms Effluent Dialysate
■ Dialysis: Removal of waste products and fluid from Figure 50-2. CVVHD circuit showing countercurrent
the blood. dialysis fluid flow relative to blood flow.
■ Ultrafiltration: Removal of excess fluid from the ■ Continuous venovenous hemodialysis (CVVHD):
blood. Diffusive dialysis where the dialysate runs “counter-
current” to the blood (Figure 50-2).
■ Convection: Movement of solutes and fluid across a
semipermeable membrane across which there is a ■ Continuous venovenous hemodiafiltration (CVVHDF):
pressure gradient—effective for removal of fluid and Combination of convective and diffusive dialysis
certain molecules. which is common in the ICU and very effective at fluid
and solute removal (Figure 50-3).
■ Diffusion: Movement of (typically small) solutes (like
urea) along a concentration gradient from an area of
high concentration (the blood) into an area of low
concentration (the dialysate).
■ Continuous venovenous hemofiltration (CVVH):
Convective dialysis which is very efficient at fluid
and cytokine removal (Figure 50-1).
CVVH CVVHDF
IN OUT IN OUT
Resistor
Resistor Dialysis
membrane
Dialysis
membrane Dialysate
Ultrafiltrate Dialysate +
Ultrafiltrate
Figure 50-1. CVVH circuit showing the use of an out-
flow resistor to modify the pressure gradient across Figure 50-3. CVVHDF circuit showing the combined
the membrane. use of a resistor and countercurrent dialysis to
remove fluid and soluted.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
146 Procedures in Critical Care
■ Continuous arteriovenous hemodialysis: A largely
archaic method of continuous dialysis in which arterial
blood is processed prior to being reinfused into a vein.
Techniques Figure 50-6. Catheter threaded into internal jugular
vein.
■ Prior to initiation of continuous venous dialysis, a spe-
cial double lumen catheter is placed in a central vein.
■ Vascular cannulation is performed as per the chapter
on central line placement (Chapter 34) with the
exception that a larger specialty catheter is placed in
the vein (Figures 50-4 to 50-7).
■ One lumen of the dialysis catheter is treated as the
arterial lumen, for flow proceeding from patient into
dialysis machine, whereas the second “venous” lumen
is used to return blood to the patient (Figure 50-8).
Figure 50-7. Venous lumen injected with heparin
flush solution.
Figure 50-4. Insertion of a large bore dilator over a
wire in a Seldinger exchange.
Figure 50-5. Insertion of a double lumen dialysis Figure 50-8. Arterial (red) and venous (blue) lumens.
catheter and dilator over wire.
■ Blood is routed through a dialysis machine and the
selected dialytic method applied (Figure 50-9).
■ The effluent (equivalent of urine) is measured in the
medical record (Figure 50-10).
Continuous Renal Replacement Therapies 147
Dialysis Outflow
membrane
Dialysate
Dialysate + Inflow
Ultrafiltrate
Figure 50-9. Dialysis machine labeled with circuit Figure 50-11. Dialysis heater.
elements.
■ Blood running through the system is often heated to
Figure 50-10. Dialysis effluent. prevent (Figure 50-11) patient cooling.
Clinical Pearls and Pitfalls
■ Because critically ill patients are often hemodynami-
cally unstable, a fluid management strategy is essen-
tial to prevent excess or insufficient fluid removal.
■ Continuous fluid removal may permit full protein
nutrition in patients who would otherwise not toler-
ate the volume load.
■ Continuous renal replacement therapies may have an
effect as an adjuvant in the treatment of sepsis
through cytokine removal.
■ Systemic or local anticoagulation is required in con-
tinuous renal replacement therapies.
Suggested Reading
Hall, NA, Fox, AJ. Renal replacement therapies in
critical care. Contin Educ Anaesth Crit Care Pain.
2006;6:197–202.
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SECTION VII
Extremity
Procedures
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CCHHAAPPTTEERR 5X1
Deep Venous
Thrombosis Prophylaxis
Introduction Clinical Pearls and Pitfalls
Deep venous thrombosis (DVT) is a common problem ■ There is some evidence suggesting that sequential
in the ICU. Preventative measures include pharmaceu- compression devices have antithrombotic effects by
tical and physical measures, the latter of which will be acting to inhibit the clotting cascade, so that a single
covered in this chapter. sticking may be worn if there is a contraindication to
placement on one leg (ie, vascular surgery).
Definitions and Terms
Suggested Reading
■ DVT: Thrombosis in the deep veins of the legs
Ramos J, Perrotta C, Badariotti G, Berenstein G.
Techniques Interventions for preventing venous thromboem-
bolism in adults undergoing knee arthroscopy.
■ Sequential compression devices are applied to the Cochrane Database of Syst Rev. 2007;(2):CD005259.
calf or calves in bed-bound critically ill patients Brady D, Raingruber B, Peterson J, et al. The use of
(Figure 51-1). knee-length versus thigh-length compression stock-
ings and sequential compression devices. Crit Care
Nurs Q. 2007;30:255–262.
Figure 51-1. Sequential compression devices applied to both ankles.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
CHAPTER 52
Diagnosis of
Compartment Syndrome
Transducer
Introduction Needle
Compartment syndrome is an acute process wherein
increased pressure in a muscle compartment with a
confining fascial compartment leads to ischemia,
muscle and nerve damage.
Definitions and Terms Needle in muscle
compartment
■ Interstitial pressure: The pressure in the tissue
(typically muscle) in a compartment Figure 52-1. Graphic showing compartment
measurement using an ad hoc setup.
Techniques
Figure 52-2. Compartment pressure measurement
■ Indications for testing: with a commercial tonometer.
—Crush injury
—Bone fracture
—Vascular injury
—Hemorrhage
—Burns
—Extravasation of drug or intravenous fluid infusion
into compartment
—Envenomation
—Excess exercise (ie, running, marching)
—Casting (ie, after fracture)
■ Method:
—Insert needle attached to transducer into com-
partment(s) of interest using ad hoc (Figure 52-1)
or commercial (Figure 52-2) monitor.
—Ultrasound may be used to evaluate arterial inflow
into a compartment as an adjunct test.
■ Tissue pressure greater than 45 mm Hg or within
30 mm Hg of diastolic blood pressure, when accompa-
nied by signs or symptoms of compartment syndrome
(ie, pain, paresthesia, weakness, palpable compart-
ment rigidity), is consistent with compartment syn-
drome and warrants consideration of fasciotomy.
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152 Procedures in Critical Care
Clinical Pearls and Pitfalls Suggested Reading
■ A high index of suspicion should be maintained in Kostler W, Strohm PC, Sudkamp NP. Acute com-
unconscious patients in correct setting and compart- partment syndrome of the limb. Injury. 2005;36:
ment pressure monitored particularly in at-risk com- 992–998.
partments in the limbs.
CHAPTER 53
Doppler Evaluation
of Pulses
Introduction
Certain patients in the intensive care unit (ICU) are at
risk for arterial insufficiency due to arterial injury (ie,
aortic or other vascular dissection) or vascular surgery.
Portable Doppler evaluation may also be used as an
adjunct to standard blood pressure measurement or
pulse detection.
Definitions and Terms
Doppler ultrasound: The use of an ultrasound probe and
speaker to applied over a vessel to detect flow beneath
the probe
Techniques Figure 53-2. Doppler examination of posterior tibial
pulse.
The tip of the ultrasound probe is lubricated with
ultrasonic gel and applied to the skin over vessels in
the extremity to detect flow in arteries of interest,
such as the dorsalis pedis (Figure 53-1) and posterior
tibial (Figure 53-2) arteries.
Clinical Pearls and Pitfalls
If arterial sounds are absent over suspect arteries, the
probe should be applied to arteries with pulsatile flow
elsewhere on the patient, or the operator may apply
the probe to one of his own arteries to verify correct
functioning of the device.
Figure 53-1. Doppler examination of dorsalis pedis pulse. Suggested Reading
Campbell WB, Fletcher EL, Hands LJ. Assessment of
the distal lower limb arteries: a comparison of arteri-
ography and Doppler ultrasound. Ann R Coll Surg Engl.
1986;68:37–39.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
CHAPTER 54
Extremity Splinting
Introduction
Intensive care patients who suffer prolonged immobi-
lization are at risk for development of contractures,
and at-risk extremities should be splinted to retain
function.
Definitions and Terms
■ Contracture: Muscle and tendon shortening following
prolonged disuse
Techniques Figure 54-2. Wrist splint applied.
■ Resting splints are applied to the hands, wrists, and
ankles (Figures 54-1 to 54-5) of intensive care unit (ICU)
patients who are unconscious or unable to move for
prolonged periods.
Clinical Pearls and Pitfalls
■ Despite the fact that there are little published data
showing evidence for the efficacy of splints, many
physical therapists advocate their use.
Figure 54-3. Wrist and hand splint with straps.
Figure 54-1. Wrist splint. Figure 54-4. Ankle splint.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Extremity Splinting 155
Suggested Reading
Stiller K. Physiotherapy in intensive care: towards an
evidence-based practice. Chest. 2000;118:1801–1823.
Figure 54-5. Ankle splint showing heel clearance.
CHAPTER 55
Blood Culturing
Introduction ■ The operator should wear sterile gloves if a skin-
touch technique is to be used, nonsterile gloves may
Fever and sepsis work-ups are a routine part of intensive be used with a no-touch technique (Figure 55-3).
care unit (ICU) care and particularly challenging due to
indwelling catheters, and the lack of veins in chronically ■ At least 20 cc of blood should be withdrawn from the
critically ill patients. site if feasible, and 10 cc injected into both the aero-
bic and anaerobic media (Figure 55-4).
Definitions and Terms
■ Aerobic media: Culture media specifically designed
to support the growth of aerobic media (Figure 55-1)
■ Anaerobic media: Culture media specifically designed to
support the growth of anaerobic organisms (Figure 55-1)
Techniques
■ A peripheral vein is identified and the skin prepped
with a topical disinfectant such as chlorhexidine or
povidine-iodine (Figure 55-2).
Figure 55-2. Skin preparation.
Figure 55-1. Aerobic and anaerobic culture media. Figure 55-3. Blood sampling using no-touch technique.
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Figure 55-4. Blood sample injected into culture Blood Culturing 157
media.
Clinical Pearls and Pitfalls
Many experts recommend against the practice of draw-
ing blood cultures through existing, indwelling catheters,
believing that catheter contamination without true
patient infection may lead to false-positive results.
Suggested Reading
Bates DW, Sands K, Miller E, et al. Predicting bacteremia
in patients with sepsis syndrome. J Infect Dis. 1997;176:
1538–1551.
Shafazand S, Weinacker AB. Blood cultures in the crit-
ical care unit: improving utilization and yield. Chest.
2002;122:1727–1736.
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Index
A sites, 99, 100
Abdomen transfixion, 100–101
Arterial vasospasm, 101
in bag-mask ventilation, 62, 63 Arterial velocities, changes in, 56
Abdominal compartment syndrome, 134–135 Artifacts
on ECG, 96
chronic, 134 on EEG, 46
diagnosis, 134–135 Artifical airway
differential diagnosis, 135 chemical paralysis and, 33
primary, 134 Ascites fluid
secondary, 134 aspiration and drainage of, 131, 133
Acoustic window, 55 Aseptic technique, 15
Admission orders Auscultation, of stomach, 75
pain medication prescription on, 27 auto-PEEP risk, 81
Advance directives, 22 Automated rhythm detection, ICU, 6, 7, 96
Agitation scale, 28–29 AVDL (arteriovenous difference of lactate), 51
Air supply, ICU, 4 AVjDO2 (arteriovenous jugular oxygen content), 51
Airway(s), 22
anatomic evaluation, 61 B
anatomy, 82, 83 Bag-mask ventilation, 62–63
Bariatric bed, 8, 9
endotracheal intubation and, 71–72 Basilic vein, 107
artificial Benzodiazepines, 28
Beta waves, 45
chemical paralysis and, 33 BIPAP mode
bifurcations, 82, 83
difficult, 60, 61 ventilatory, 64, 65
Bispectral index (BIS)
algorithm for, 61
emergency, 66–67 EEG analysis, 45
emergency cart for, 60–61 Blood culturing, 156–157
percutaneous, 76–79
secretions occluding, 83, 84 blood drawing through indwelling
surgical, 60, 61 catheters and, 157
Alcohol based hand rub
ICU, 13, 14 blood sampling in, 156
Allen’s test media for, 156
arterial catheterization and, 102 Blood flow velocity, 55
Alpha waves, 45 Blood pressure, in ICU, 5, 6
Analgesia Blood tests, CPR and, 22
paralytic therapy, 33 Brachial vein, 107
Aneurysm formation, 101 Brain death
Angiography, cerebral, 40 causes of, 39
Ankle restraint, 29 clinical tests, 39–40
Ankle splint, 154, 155 conditions mimicking, 41
Antimicrobial activity, persistent, 13 confirmatory tests, 39, 40, 41
Antimicrobial soap, 13 criteria for, 40
Antipsychotic agents, in delirium, 28 EEG in, 46
Antisepsis, skin, 15 Brain death examination, 39–41
Antiseptic agents, application, 16 Brainstem examination, 39
Anxiety, 28 Breath sounds
Anxiolytics, 28 in laryngoscopy, 74, 75
Apnea test, 40 Breathing, 22
COPD and, 41 Bronchoscope(s)
Arrhythmia fiberoptic, 82
automatic, continuous detection of, 6, 7 flexible, 83
Arterial catheterization rigid, 82
arterial wave trace in, 101 Bronchoscopy, 82–84
complications of, 101 awake-sedated, 82
contraindications, 99 diagnostic, 82
direct cannulation, 100 endotracheal, 82, 83
equipment for, 100 secretions in, 84
indications, 99
Copyright © 2009 by The McGraw-Hill Companies, Inc. Click here for terms of use.
160 Index Cerebral spinal fluid (CSF) pressure
measurement of, 37
Bronchoscopy (Cont.):
therapeutic, 82 Cerebral technetium scan, 40, 41
video-assisted, 82 Chest compressions, 22, 23
Chest tube placement. See Tube thoracostomy
Bundle branch block Chest x-ray
pulmonary artery catheterization, 114
IABP placement, 120
Burst suppression, in coma, 45 nasoduodenal feeding tube placement, 128
PICC placement, 109–110
C tube placement, thoracostomy, 90
Cannulation. See also Arterial catheterization Chlorhexidine, 13
Chromophores, 47
arterial line, 99–102 Circulation, 22
catheter over needle, 97 Cirrhosis
needle through catheter, 97 paracentesis in, 133
site, 98 CMRL (cerebral metabolic rate of lactate), 51
ultrasound guidance, 97 CMRO2 (cerebral metabolic rate of oxygen), 51
CaO2 (arterial oxygen content saturation), 51 Color flow Doppler, 55
Cardiac arrest, 22 Coma, 39
Cardiac output irreversible, 39
analysis, confounders of, 116 Comatose patient
determination of, 7, 115–117 EEG in, 46
Fick method, 115 Compartment syndrome
ICU, 7 abdominal, 134–135
manual thermodilution bolus method, 115–116 diagnosis of, 151–152
measurement of, 111 IABP, 120
Cardiopulmonary resuscitation, 22–23 indications for testing, 151
ACLS algorithm for, 23 tonometer pressure measurement in, 151
contraindications, 23 Compression devices, 150
indications, 22 Computerized axial tomography (CT)
Catheter insertion. See also Intravascular cannulation with contrast enhancement, 57
vessel identification, 97, 98 noncontrast, 57
Catheter(s) portable, 57
central venous, 103 Consent
in cerebral microdialysis, 53 arterial line cannulation, 99
insertion, 97–98 (see also Intravascular ICP monitoring, 42
ICU procedure, 11
cannulation) implied, 17
intraventricular, 42, 43–44 jugular venous oximetry, 51
pulmonary artery, 111 percutaneous airway, 76
in thoracentesis, 85–86 Consent form, universal, 17, 18
urinary, 138–142 Continuous arteriovenous hemodialysis, 146
Catheterization Continuous renal replacement therapies (CRRT),
arterial, 99–102
central venous, 103–106 145–147
pulmonary artery, 111–114 anticoagulation, 147
urinary (see Urinary catheterization) in sepsis, 147
Cauda equina, 35 techniques, 146–147
CBF (cerebral blood flow), 42 Continuous venovenous hemodiafiltration
Central venous catheter (CVC), 103
multilumen, 103 (CVVHDF), 145
peripherally inserted, 107–110 Continuous venovenous hemodialysis (CVVHD), 145
Central venous catheterization, 103–106 Continuous venovenous hemofiltration (CVVH), 145
changing preexisting, 105, 106 Continuous wave Doppler, 55
complications, 105 Contracture, splinting for, 154
contraindications, 103 Contrast
direct, 103
indications, 103 contraindications, 57
Seldinger technique, 105, 106 CT enhancement, 57
sites, 103, 104, 105 Control mode, ventilation, 80
transfixion, 103 Convection, 145
ultrasound guided, 105, 106 Corneal reflex, 39, 40
venous anatomy, 103, 104 Cough reflex, 39, 40
Central venous pressure, 103 Counterpulsation, 118
CeO2 (cerebral extraction of oxygen), 51 CPAP (continuous positive airway pressure), 64
Cephalic vein, 107 CPP (cerebral perfusion pressure), 42
Cerebral angiography, 40 Craniotomy
Cerebral arterial velocities, age and, 56 for ICP monitoring, 43
Cerebral blood flow (CBF), 42 Cricothyroid membrane, 76
Cerebral microdialysis, 53–54 Cricothyroidotomy, 76, 78, 79
Cerebral oximetry, 47–48 Critical care transport, 20–21
interference with, 48 checklist for, 21
Cerebral perfusion pressure (CPP), 42
Index 161
Culture media Electroencephalography, 40, 45–46
aerobic and anaerobic, 156 lead placement, 45, 46
uses, 45–46
D
DAI (diffuse axonal injury), 49 Embolization, 101
Decontamination IABP, 120
alcohol-based hand rub, 13, 14 Emergency airway cart, 60–61
Decubitus ulcer, 8, 10 laryngeal mask airway on, 69
ICU bed for, 8 Emergency airway management
Deep venous thrombosis, 150 laryngeal mask airway for, 66–67
sequential compression devices for, 150 Emergency call button, 4, 5
Defibrillation, 22, 23 Emergency power system, ICU, 4, 5
Delirious patient, EEG in, 45, 46 Emphysema
Delirium, 28
subcutaneous, percutaneous airway
characterization of, 29 and, 78
consequences of, 29
differential diagnosis of, 28–29 Endotracheal intubation
Delta waves, 45 indications for, 71
Dementia, 28 nasal, 71, 72, 74–75
Dialysis, 145 oral, 71–74
Dialysis effluent, 147 rapid sequence, 72
Dialysis heater, 147
Dialysis machine, 147 Endotracheal tube(s) (ETTs), 60
Diastole, 118 bronchoscopy through, 82, 83
Difficult airway cuffed, 70–71
algorithm for, 61 position, confirmation of, 23
Diffusion, 145 standard, 70
Disorientation, 28
causes of, 28–29 Enteral feeding, 126
Dissection, 101 Epidural monitor, 42
Documentation Epidural space, 26
discontinuation of device, 17 Epileptiform discharges, 45
ICU procedure, 17, 18 Esophageal/tracheal tube, 60
Doll’s eyes, 39, 41 ETTs. See Endotracheal tube(s) (ETTs)
Doppler ultrasound Extremity splinting, 154
continuous wave, 55 Exudate, pleural, 85
in pulse evaluation, 153 Eye response, 30
Drainage system
for tube thoracostomy, 90 F
in urinary catheterization Face mask, 62, 64, 65
female, 142 selection of, 62
male, 140 transport, 20
Drapes, sterile, 16 Fall prevention bed, 8, 9
Draping, ICU, 15–16 Fiberoptic bronchoscope, 82
Duplex Doppler, 55 Fick method, cardiac output, 115
Dura, 35 FiO2 (inspired oxygen concentration),
E 80, 81
Echocardiography Fluid pressure, ICU, 6, 7
Fluid waveform, ICU, 6, 7
transthoracic, 122 Fowler position, 8, 10
Einthoven triangle, 94 Fractures, ICU bed for, 8
Electrocardiographic events
G
pulmonary arterial pressure events Gag reflex, 39, 41
and, 112 Glasgow Coma Score, 30–31
Electrocardiographic waves, 94 alternatives for children, 31
Electrocardiography, 94–96 confounders of, 31
modifiers of, 30
continuous, 94, 96 Glasses, ICU, 16
in ICU, 2, 3 Glutamate, 53, 54
interpretation, 96 Glycerol, 53, 54
lead vector, 94–95 Guillain-Barré syndrome, 41
leads in
H
augmented limb, 95 Hair removal, 16
ground, 96 Hand washing
limb, 95–96
modified chest, 96 ICU, 13–14
in pericardiocentesis, 121 routine, 13, 14
precordial, 95 Head of bed
twelve lead, 94, 95, 96 during transport, 20
waves in, 94 elevated, 8, 10
Headache, lumbar puncture, 37
Headwall, 2
162 Index Laryngeal mask airway (LMA), 60, 66–67
contraindications, 69
Health care proxy, 17 on emergency airway carts, 69
Hematoma, 101 insertion of, 67–68
High frequency ventilation, 80 intubating LMA, 66
placement and position, 68
I preparation for, 67
ICP selection, 67
uses, 66
normal range, 44
treatments for, 44 Laryngoscope, 60, 71
ICP monitoring Laryngoscopy, 73–74
contraindications, 44
craniotomy for, 43 direct, 23, 71
indications, 44 Larynx, 76
preparation for, 42 LMA. See Laryngeal mask airway (LMA)
ventriculostomy for, 43–44 Local anesthesia
ICU bed, 8–10
ICU equipment, 2–7 for arterial cannulation, 100, 101
ICU room, 2–7 for central venous catheterization,
Impedance pneumography, 2, 6
Informed consent, 17 103, 106
elements, 17 for IABP insertion, 118
form for, 17 for pain, 27
Infusion medications for paracentesis, 131, 132
transport and, 20 for tube thoracostomy, 88
Infusion pump, ICU, 5, 6 Locked-in syndrome, 41
Inspiratory pressure, 80 LOI (lactate index), 51
Intermittent mandatory ventilation, 80 Lumbar puncture, 35–38
Interspace approaches to, 37, 38
L4-5, 35, 36 headache from, 37
lumbar spine, 35 paramedian approach, 37, 38
Interstitial pressure
in compartment syndrome, 151 M
Intra-aortic balloon pump (IABP) insertion, 118–120 Macintosh curved laryngoscope blade, 75
complications, 120 Malignant stroke
confirmatory chest x-ray, 120
contraindications, 118 brain tissue oxygen measurement, 49
indications, 118 Manometer
inflation and pumping ratio, 119
methods, 119 for cerebral spinal fluid pressure, 37
triggering, 120 Manual ventilation, pitfall, 23
ultrasound guidance, 119 Mask(s)
Intracranial pressure (ICP) monitoring, 42–44
approaches to, 42 face, 62, 64, 65
Intraparenchymal monitor, 42 fitting, 65
Intravascular cannulation ICU, 16
direct, 97, 98 laryngeal, 66
Seldinger variants, 97, 98 nasal, 64
transfixion, 97, 98 Mechanical ventilation, 80–81
Intraventricular monitor, 42 contraindications, 80–81
Introducer needle, 35, 36 indications, 80
Intubation modes, 80
bronchoscopic, 61 weaning from, 81
endotracheal, 61 Mechanical ventilator, 7
laryngeal mask airway, 66 postintubation, 72
oral endotracheal, 70–74 Mental status
Iodophors, 13 endotracheal intubation and, 71
Microdialysis, 53. See also Cerebral microdialysis
J Minute ventilation (Vg), 80
Jugular venous oximetry, 51–52 Mode
mechanical ventilation, 80
contraindications, 52 Motor activity assessment scale, 28
Motor response, 30
K Murphy eye, 73
Kinetic therapy bed, 8, 9 Myopathy, NMB-induced, 34
L N
Lactate, 51, 53, 54 Narcotic agents, 27
Lactate-pyruvate ratio Nasal endotracheal intubation
in cerebral microdialysis, 53 contraindications, 75
Laminae, 35 vs. oral intubation, 74–75
Laryngeal anatomy, 76, 77 Nasoduodenal feeding tube
chest x-ray of, 128
feeds through, 128
insertion of, 126–128
Nasoduodenal feeding tube insertion Index 163
complications, 127
fluoroscopic assistance, 126–127 Partial pressure of oxygen in brain tissue (pBtO2), 49
postpyloric position, 127 decreased delivery, 50
high, 49–50
Nasogastric tube (NG), 124 low, 49, 50
complications, 125
contraindications, 124 Patent airway, 22
graphics, 124–125 Patient identification, 11
indications, 124 Patient-controlled analgesia (PCA), 26, 27
in unconscious patient, 125 Patient-controlled epidural analgesia (PCEA), 26
pBtO2, 49, 50
Near infrared spectroscopy, 47 PCA (patient-controlled analgesia, 26, 27
Nephropathy, contrast-induced, 57 Percussion therapy, 8, 10
Neurological emergency, 57 Percutaneous airways
Neuromuscular blockade, 32–34
Neuromuscular blocking agent(s) complications, 78–79
contraindications, 76
administration of, 33 cricothyroidotomy, 78–79
clearance in critically ill patients, 34 indications, 76
depolarizing, 32 tracheostomy, 76–78
indications for, 33 Percutaneous endoscopic gastrostomy (PEG) tube
nondepolarizing, 32 complications, 129–30
titration of, 33 contraindications, 129
train-of-four monitoring of, 32, 33, 34 indications, 129
twitch monitor for, 33, 34 pull technique, 129
No-touch procedure, 15, 16 push technique, 129
Noninvasive positive pressure ventilation (NPPV), Percutaneous tracheostomy, 76–78
Pericardial effusion, 121
64–65, 81 Pericardial tamponade, 121
contraindications, 64 Pericardiocentesis, 121–122
cycled, 65 anatomic approach to, 121
indications for, 64 blind, 122
patient preparation, 64–65 complications, 122
Nonsterile gloves and no-touch procedure, 16 contraindications, 121
Nonsteroidal anti-inflammatory agents, 27 drainage catheter for, 122
echocardiographic-guided, 122
O EEG in, 121
O2ER (global cerebral oxygen extraction indications, 121
Peripherally inserted central catheter (PICC), 107–110
ratio), 51 complications, 110
Obese patient, ICU bed for, 8 contraindications, 107
Obturator needle, 35 indications, 107
Oculocephalic examination procedure, 107–109
ultrasound vein identification, 108
confounder of, 41 uses of, 110
Oculovestibular response, 39, 40 veins for, 107
Opioids, chronic, 123 x-ray confirmation of placement, 109–110
Organ donation, brain death and, 39 Peritoneal lavage, 131
Oximetry Phimosis, 143
Physiologic monitor, 2, 7
cerebral, 47–48 Pleural effusion, 88
jugular venous, 51–52 Pleural tap, 85
pulse, 2, 3, 48 Pleurodesis, 88
transcranial, 47–48 Pneumography, impedance, 2, 6
Oxygen saturation, tissue and blood, 7 Pneumothorax, 88
Oxygen supply percutaneous airway and, 78
during transport, 20 risks, 81
ICU, 3 in thoracentesis, 87
Positive end-expiratory pressure (PEEP), 80, 81
P Postpyloric tube, 126, 127
Pain, 26 Preoxygenation, for intubation, 67, 72–73
Prepping, ICU, 15–16
consequences of, 27 Pressure relief beds, 8, 9
evaluation of, 26, 27 Pressure relief therapy, 8, 10
preemptive treatment, 27 Pressure support, 80
Pain management, ICU, 26–27 Pressure(s)
Pain scale, visual analog, 26 cerebral perfusion, 42
Paracentesis, 131–133 cerebral spinal fluid, 37
aspiration of ascites fluid, 131, 132 fluid, ICU, 6, 7
complications, 131, 133 mechanical ventilation, 80, 81
diagnostic, 131 pulmonary arterial, 111
Seldinger technique in, 131, 132 Procedure note, 17
therapeutic, 131
Paralysis
chemical, 32–34
therapeutic, 33–34
164 Index Spinous process, 35
Splinting, of extremity, 154–155
Procedure verification, 11 Sterile barrier precautions, 15
Prostatic hypertrophy, 138 Subarachnoid hemorrhage (SAH), 49
Pulmonary arterial pressures Subarachnoid monitor, 42
Suction, wall, 4
measurement of, 111 Suprapubic catheterization, 143–144
Pulmonary artery catheter(s)
aberrant anatomy and, 143
continuous cardiac output, 111 anatomic catheter placement, 143
mixed venous, 111 complications, 143
volumetric, 111 contraindications, 143
Pulmonary artery catheterization indications, 143
complications, 114 infection and, 143
contraindications, 111, 113 Surgical airway, 60, 61
difficulties in, 114 Synaptic transmission, 32
indications, 111 Syringe, in cannulation, 98
procedure, 111–114 Systole, 118
techniques, 111–113
Pulmonary edema risk, 87 T
Pulse oximetry, 48 TBI (total brain injury), 49
alarm in, 22 Telemetry, in ICU, 2, 3
in ICU, 2, 3, 5 Temperature, measurement devices for, 6
Pulses Thermistor, 115
Doppler evaluation of, 153 Thermodilution bolus method
monitoring, IABP, 120
cardiac output, 115–116
R Theta waves, 45
Radial artery Thoracentesis, 85–87
in arterial cannulation, 101, 102 contraindications, 85
Ramsey Scale, 28 indications, 85
Regurgitation pitfalls, 87
Thrombosis, 101
endotracheal intubation and, 72 Tidal volume (TV), 80
Report, pretransfer, 20 Time out
Respiratory arrest, 22 for procedure team, 11, 12
Respiratory rate, 80 Tissue pressure
Restraints, 29 in compartment syndrome, 151
Resuscitation bag, 62 Tracheal tube guides, 60
Resuscitation medications Tracheostomy
percutaneous, 76–78
transport and, 20 Tracheostomy tube, 79
Retrograde intubation, tracheal, 60 Train-of-four monitoring, 32, 33, 34
Reverse Trendelenburg position, 8, 10 Transcranial Doppler (TCD) examination, 55–56
Review of data, pretransport, 20 Transcranial Doppler ultrasound, 40
Richmond agitation sedation scale, 28 Transcranial oximetry, 47
Rigid bronchoscope, 82 Transducer, 99
Riker sedation agitation scale, 28 ICU, 5, 6
Rotation therapy, 8, 10 Transducer needle, 35, 36
Transection, 101
S Transport, 20
SAH (subarachnoid hemorrhage), 49 Transthoracic echocardiography
Secretions for pericardiocentesis, 122
Transtracheal jet ventilation, 60
airway, 82, 84 Transudate, pleural, 85
in bronchoscopy, 83, 84 Trendelenburg position, 8, 10
Sedation, paralytic therapy, 33 Trigger pressure, 80
Seldinger exchange, 85, 86 TTJV (transtracheal jet ventilation), 60
Seldinger technique Tube thoracostomy, 88–91
cannulation, 97 chest x-ray and, 90
central venous catheterization, 105, 106 complications, 91
modified, 97 contraindications, 88
in paracentesis, 131, 132 indications, 88
tube thoracostomy, 89 tube removal, 91
variants, in cannulation, 97, 98 Tube(s)
Sellick maneuver, 63, 72 nasoduodenal feeding, 126–128
Semi-Fowler position, 8, 10 nasoenteric, 126
Site marking, in ICU, 11, 12 nasogastric, 124–125
Site preparation, ICU, 16 percutaneous endoscopic gastroscopy, 129–130
SjvO2 (jugular venous oxygen saturation), 51–52 percutaneous gastric, 129–130
brain pathology and, 51–52 Twitch monitor, 34
Sleep medications, 28
Sniffing position, 72
Spinal needle, 35, 36, 37
Spinal tap. See Lumbar puncture
Spine, cross-section, 26
U Index 165
Ultrafiltration, 145
Universal protocol V
Ventilation
ICU, 11–12
indications, 11 bag-mask, 62–63
Urinary catheter(s) mask, 61
female, 141–142 mechanical, 80–81
male, 138–140 noninvasive, 62–63, 64–65
sizing, 138, 139, 141 in respiratory arrest, 22
Urinary catheterization transition from mechanical to manual, 20
Centers for disease control guidelines, 139, 142 transtracheal jet, 60
female, 141–142 Ventilator, portable, during transport, 20
Ventilatory status, pretransport, 20
closed drainage system in, 142 Ventricular ectopy
complications, 142 pulmonary artery catheterization, 114
contraindications, 141, 142 Ventriculostomy, 42
indications, 141 Verbal response, 30
intermittent straight, 141 Video monitor, for bronchoscopy, 84
urethral identification in, 142 Visual analog scale, 26
male Vital signs, in ICU, 5–6
anatomy and, 138 Vocal cords, 73
closed drainage system in, 140
complications, 139 W
contraindications, 138 Wave frequencies, brain, 45
difficult catheter passage in, 140 Waveforms
indications, 138
intermittent straight, 138 in pulmonary artery catheterization, 111, 112, 113, 114
method, 139–40 Weaning
urinary anatomy and, 138
suprapubic, 143–144 from mechanical ventilation, 81
Wrist and hand splint, 154
Wrist restraint, 29
Wrist splint, 154