เวชบำบัดวิกฤตพื้นฐาน Fundamental in Critical Care

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. nrlfi cardiac output flnn'tlfio\to1nn1'lY hypothermia n::{uhirfinnr:nad'rtol

xnonrfioadlu ala fr'lfifirr'tfiruflrutawtooot6on trol rfildu tutruvdqnfn::{u'lfifinr:riu
r-:fdlafl1?! 1nnur 0qru14q n1uner.t.t rir'trilfianms hypovolemia olnlofl:rr.torqdrli:vu fin[iuu

lofioriroruftorJn6

. narnfroudfiqljn6 tdo,:lrnnrlc diuresis drlfifilnfiauilurfioasirn'r Lfion11; hypo-

phosphatemia, hypokalemia, hypomagnesemia unt hypocalcemia

. nmyrtrlerdufin{.tnr: d,,revrfluldrYl ventricular librillation, ventricular tachycardia.

bradycardia v5o asystole uridnurjaulfi llri bradycardia

. Rlx:rilfflntutaoergt lnypergtycemia) tdo,rlrnfinl:fl9n15n4ljf,ua\trio insulin 10n

dr.:ntu uavaonr:nfl"{ll0{ insulin

. rfitnrrltfimron bleeding niomrnnT: plalelet dysfunction !!aY impaired coagulation
. nirnrrt.ttdrllanfl 'l:fioldo
. n1:fli!u'r sedative drug [[n; neuromuscular blockers firn.rrir'lfiqvrdlo.rululudu

nTrE rlerl\ns u:15!61'r1l

nrr:ur:ndauvr':rv)r!:h;fl'rflLflufl'rthEf1la.in1?[frfl6im'lurjr.r post-cardiac arrest 10u
ronr:'lu{rJ'luiirfio cardiac anest uanl:wtu'iuro uoncrndu-.:rflust'rdruunnruormrnlunti

drurnuro.rrotfi ru'lu::u: urr6ndra dun:rufr rfioduniu:;lurl::nr d?unnr.ltitJnv{ ueinr:

lrordorrljrdu.rorJo.rturir,:drfio cardiac arrest nnoortlfi'to'un:rudrfiqernnalnnr:drtruftnrlnfi
rrrrunrTl66rdrfior*rnn'rqrnnr:ldilrdao}ludu'roiarsiirfionr:rrnrfioer6nnit liunjr reperfusion
inlury drnm;drdlfiudun, ufin',:crnnr:fi Rosc lla:oT entoqj'ldlutrnrvnrEldrl iqufitvnruriu
luiolriunrrfnurfi6a'jT fiil::lsnilunr:nont:6'ntduto.r::tttttlt:drudtunR'NfiR".t cardiac arest

ldrrrinr:rir therapeutic hypothermia d'.ildndrrrrdrdr.'rfiu nr:inurdul m'r::;:-ruJl;ormfi,ir

tUUtJO\tU

I . nr:fl ot nluua ginnrar': sc"n (seizu re m ana ge mentt

;{rtr ufi ri.rhjfr u6u n6vfi'{e 1 n nr:fi Rosc fi lo nr air'nlfi fir5o u n 20 O,ililn'jrfun l?

n:rqndu-h'lflrauotour'rciorfjo,rlu{lrodrlilrlffind,rna.r tfin cardiac arrest rir'lfin:rqvrunrrr
fnuauuc,,r (non-convulsive seizure; '[drfirl*u uilu:loXriuti.,rlrifi'rio4onr:'lfiurriut'nrfroflo.rrfu
nm:"i'n'lu{rhu post-cardiac arrest rtsiuu:dr1finhnr:r-nurnrr:tnrntoorr.rr:n'lfinr:ifiedald

'lri'jrl;arduornr:mrn6finrioornnr:n:rcndull'hnra a\r nl Lru'rfl1{n1'lfnurntvf'ntiolutt:.t

(status epilepticus)

z. nr: rcriuf,nunrurood o,lfifltRl?v cardiac arrest

nr:rh:rfiudnunrunr#r.trutatalottu{rhu post-cardiac anest uonl1netfi 6'11N
drn"rplunr:rniurnl:ro{{gun{fiuriouiuftJruoonornfxuurrrnufil u-',rfinrT lal"rdEotirl0l

I'():tt-Cardiac Anesl (lurc aiai ttanti 97

lun:nifida,rlfrJ*no nliet-aAulqun^nlrfnBrd?un1r'ldqrJn:nidravrq.,,rd'cpq1ru6Tr0i1.,:"1 niu rnio,r
tirurrg'terionr:5nb1lo rrruln fl'nFto!fluaflo{T;u :yctrdfiarflu poor neurological outcome
'lduri nr:rfiufiin (dearh) n't:'lrirrorldrm:nfiuylrnuro.rldtufiinil:y<iriurn-.,: rrarairul 6 16ou
(inabilily to undertake independent activities after 6 months) flcq"ufr rfluorrynl0{n11i cardiac

arrest :Jeiufi lfialorvrirnr:!frffinr:fl6w r5o:10{urri',:nr:fi nosc n1Lflu 24 rirT ,rurn ern

nr:frn:grr,'ruir'lrlfiflqo-ufifi'rflq{fltac;arrr:nrirrrr'ldyisrn:ninr:frud'rra,l::rlt.lr.l::armo,rdtrflld

nr:n:rofildilnr:ua itl'irotlr:ntdllsrn:ninr:mauduo,:rta.tit:J!!:rfl.tyl1a,rrf!rEJ oost-lardiac

arrest ldrrri nr:gn're somalosensory evoked poteniial (SSEpsl ttavnr:ot:lodtrnluT.t{:ylllj

:l::orvrllrru:fi"hjfinrr;fifif,:nr:vir,:rulo,t::llrJ::fi.14 (contounding Jactors) lfiud nrx:
otrrd'uTnfi ot n't nr :gn nr:ldil sruouyo-U yio ut neurom uscular b tockers

nrtnttqit.lnru r{::l:J :cdrynrfllu zq dr1tJ.,:yn''.1 cardiac arrest lriaur:nl{lunrr

rurn:ninr:frud'rurt:yr.tlr.l:yoryt'ld nr:m:10'jrfirlruhjrlalauo,ro{a rrd,: un;n1lf, iJk (absence
of both papillary ljght and corneat reftexes) nn",rfi BOSC urun.jr 72 drlrur d'rr{ufnilnr:fi
poor neurological outcome 1aifi 'tu post-cardiac arrest uonelndnltrll absence oi veslibulo-
ocular reflexes u1unil 24 rirTl.,r uaynr:fi clasgow Coma Scale (GCS) score rioun,jr s rflu

t'rd1u1uni'r zz tr,lt,r dlnYuf,rir-rnr:diuri'rrat:rrr:J::arrfi'tri6 niuriu nr?er:.r?rL bitateral

absence of the N 20 cortical response to median nerve somatosensory evoked potential test

va't z+ t'fl1.: post-cardiac anest flt'uii'nilnr:fi poor neurological outcome 1u1'i',rhtfilil1d
ilnr:fnardrs therapeutic hypothermia

o'',r'ldnnirrurdr nr:n:tl :yrfitnr'r:sL! ::gr lfiolirtrrflnrt urn:niT:nar:rirhfunry

dlrjfinlr:fiarq?irlfinr:noloua.:rar::ur.rrJ::dryaoo,: (confounding factors) ldud R1t:a.t1rl

tlfr'u1nfinpir nr:lfiir uruouyn-ln?orLrlun njr neuromuscutar btocking agents tt{n1xt

qruuafinrtrdr 1rj'jiqr rfior1su ro.r (spontaneous hypothermia) nSoqrnnr:inur (therapeutic
hypothermia) fionr otriltu{rJruf,16finr::-nurdiunrtdl hypothermia d,r'triRurrn!:; rfiu

nr:frum-rrat:;lrrlrl:y arnrruyfi firJr urira qjtunlr: hypothermia u5o16ilur sedative LrRt

neuromuscular blockers orild :rrlvr".,:oredol:au tuntt tz drl ,:c.Jli'lnr:gl:rqn1:flaufluo{r1n

:s!! ::or rfi odrn t:ll sr n:rfiI: n rr n r d'n fiun r:in ur sia\

airyirlnr:n:lefi!fiurfiurfrra'u1 nju nr:n:raodu1 lflrdr.to,: letectroencephatogram. EEG)

nr:o:fenr i.)dft'] CT scan ttor MRl, transcranial Doppler ultrasound Ltnynl:sti'te biomarkers

fi'rqrn rdanun:f'r'hfruvn-,: ti,rhiorrlr:ndrur'lflunr:rlurn:ninr:fru6'rro.r:y!rirJ:sfl'ryryn-.Jnrry

cardiac arrest 16

3. n1:inn'tf,'l rfi niinhlfi rfi onm v ca rdiac a rrest
fiilrufrfi nosc l"rn.:finrrru rdu'lc.:fic: rfia cardiac arrest r?r lrr n ri,rLilfiil nr:inrr ufllt

98 lmdlfsinqnduglu

fl']rvq90\tn11v cardiac arrest ?1fln'l?frnEltl]tfi,JTsulnivst' n I'tt]it f,1r?lqfi6f1d'ru10{n1'lt cardiac
arresr fi rfinrl*unruuon1r.rl,rrJ'rrl'ro lfiurri nrrcndrrrrion-rhlror6ooernnr:qoo'uodro tdurvtti'u
talrrooor16aoun.,llnT:uri lacute myocardial infaraion) 6.,tfi:rurru'jrtfluer tficrlton out-hospital
cardiac arrest ldfi,rioun: 70 fi.r 90 or rrq6udnr:otnurrlfiud nr:l6urfionlrnqr!firrlq un;
n.rrn.rq",Yuoaeflr,r tfiufirulq rflufiu 6'.rriuPhu post-cardiac arrest o1fluofllt\tl/il'r1l1nn?l
16t!nr:arn'r}jfunr:inurriori.fl:rnur:lrafiar r:nd1nr::*nurTnunr:rsru noorfionv"r'h1nT:url

ruurqnrduld Touravrr:{ileuiinduldflrr{rlrrnn'.,rnr:fi nosc ufirn:mflrlir f,nr:snduro,r sr

segment fl5om?lalr:ldnurus Lefi bundle branch brand block (LBBB) tuflt1:iuuurriTlrnr:

d,r{rJrtrrfirirnr:n:rrTnErnr:fr0fin:rennanrfioerfirtq'ufifirirl6ufi{rJruo;tr".ilrifa6fioru rfio,rlrn
lurlqulurhkifii6nr::h;rfiu'lofiour:ouannurn:nil:ma.tnr:frusi'tlo.'n;lrtJ:lf,rvnrund,,:c1nfi

Rosc nru'lu za rirlmldodrrqndor finr:frnu, llu'jrnrrirnr:oneo aoqrdon un:rurufioon
rfioofrhorrur:ndrdrilr}finr:SnurTali6 iherapeutic hypothermia 'ldorir*rfirh:RrBnrvr ua;
ororirurfj lonro:aorfiinro,r{ilruInufinr:dr,iruro{r:rr:l:;arrturnruryifi6ld'""

drnir{rJrudrfion1?r cardiac arrest tuT:.luuuraurinl;ndrrrdafi'rhtrordao

rrduvrnuti,r rfluor rtqdrcrrpratnr:tfiqn'ny arrest udl,wtflun'rtrn nfiEi't:J:; vfi'J'luortJto.i

fi:Jruui'nfu'"'n {rjrufrag'tuI:.ruut:-troore tfinnrr: cardiac arrest e1nn1:aosiuto{Tr.1t6uvruh

ld ::Hrruiauay 30 un;ornnrufiorlnfivrrr rrnrua66r lourour:errufio nfiroonornfioud

nr:T rrfr Z ttfi9t{ post-cardiac anest care algorithm

Ventilator/ oxygenation

. rdn6u':n'nrir hyperventilation
. d,:rnSoodru rule RR 1o.t2 nicrurfi trilfirirrurufi PetCO 35-40 tJsJ.lro1l
r flFr Fior tfi'ld o"ygen saturation d 94%

lV bolus

. li normal saline }l5o Ringer's lactate solution 1-2 An:

. nrnidvh therapeutic hypothermia hi'lfiflr:rirqnlr4fi +"c

Medication

. Epinephrine 0.1-0.5 plkg/min (uf,.lncynrin zo filanil tdlurour 7-35 !g/min)

. Dopamine 5- 10 tq/kg/min
. Norepinephrine 0.1-0.5 r€/kg/min 11uffltrqifi{n zo filnnir'ldaurqer 7-35 Fgimin)

Reversible causes

. 5H : hypovolemia, hypoxia, hydrogen ion (acidosis), hypo-/hyperkalemia, hypothermia
. 5T : tension pneumothorax, tamponade (cardiac), toxins. thrombosis (pulmonary),

thrombosis (coronary)

Post-Cardiac Arre.lr Care qiai naoagi 99

3nr:r.1fi lrf,9t,t multisyslem approach 1u post-cardiac arrest care

Ventilation 1. Capnograph,

. rflq n : rfia6ulTus{rut .:rooyiori.: Urr ule un:6oql ventitarion
. lfliHrJ,tu : petcO, 35-40 l.]l.t. roy, l%CO, 40-45 sJrJ.jjla

2- Chest X-rav

. LMqr.ro : rfAioa6uu-ius'irrl?uasoaviatirunra'lq uny'1fr'lunr:nrarrrq/fl.rxyufl:n

d0utof cardiac arrest ni1l pneumonitis, pneumonia. pulmonary edema

3. Pulse oximetry/ ABG
. r144r{n : udoinur:yn"roan€rcu'lurfiorr uoynornr:td Fio, flllisf,,r
. l:rr'rrflrnarru : saor 2 94%, pao,
. nq FiO, rvirfiooild 100:JN. :oyr

r 6erqu PaOlFio, 'lunr:ifodunrrv acute tung injury

4. Mechanical ventilation

. tfi4hrn : rfioOonr:rfio acute lung iniury, nrr: rflUrirornoonfinu

pressure > 90 ,J- royt

2. inDl hypotension

. lt1lq o : uiainur perfusion d.raiUrvoir.tl

. nlrfnD'l

1) Fruid bolus fir{r-lruiilfi

2) Epinephrine 0.1-0.5 tr.g/kgi min
3) Dopamine 5-10 pg/kg/min

4) Norepinephrine 0.1 -0.5 prg/kglmin

Cardiovascular 1. Continuouscardiacmonitoring
system . tilqntn : rfiaif,qdanrryrirhr6'ufioq",rurydrflur3.r
. hifi n T rl'rir rijudoo'lfi prophytactic arrhyth m ias "Ifi nr:inlrfi-x'la rdtrfi n

o'rvryrdadrrflI t-flu't reversible causes

2. 121ead EKG Llflc troponin

. ruEt{a : rdoifio{i'u ACS, STEM|. r.J:rtfiu eT inrerval

3. iniJ't acute coronary syndrome

. lt{nr:Snurrirs aspirin d':rio{ilrilrJri,rdr.lJ acute coronary syndrome lfrnr:

inurd':u pcl fii0 fibrinotysis ufirurinrfi (rtnrflu acute coronary

syndrome fifi0'lnh cpn do,:vir pct rvirusu hjor r:nlii {ibrinotysis 16)

4- Echocardiogram

. tHqi.Jfl: ifiod'r myocardial slunning. wall motion abnormalities.

cardiomyopathies

100 rrtdrrioinqnrdrgru

qrmlii g tlflo,t multisystem approach lu post-cardiac arrest care (flb)

s. lfinrrfnsr myocardial stunning

. lfi ar:ritrlosdufiud'nsruvnr':n 6fi n

. Dobutamine 5-10 [g/kg/min
. Intraaortic balloon pump tdati]u mechanical augmentation

(q!unr^-*-r,12r.ou{t)

Neurological 1. Serial neurological examination
system
. [?qNn : rfioif,qdcj coma, brain injury ttfls rt ffi1]nt:l,llrn:ni1:n
. qilad't{n1u 53tfiunr:ga:jflla't. : tuqt, corneal reflex, nr:tedou'lnr

ao,:gnnrdre6ou'lnxton, gag reflex. nr:la, nr:r'tru'lctoe

EEG monitoring

. LfinflO: I nfll:tnoonlu

. 'hinr::"nrr dr s ur ri'ut"n rfiaflrlrudn

io core temperature tfia{:Jra coma
. LvnHfl : l1; {0flgn15U'lCcltlln' od 0{ttavL; l.ll.jllflqv- ltnlfl nll.lnlllnw B'l

1 ) inulqrufi {fi nlurjoan'jruiorvirnil gz.z"c

2) r+N?ir rher;peutic hypothermia firl fifi0#r loruli ernutrtfiu 6luid bolusl

ft30 n./nfl. fr{rji{oriral surface/ endovascular cooling lotuinur

qrun4finrrd 32-34"c Lflullnlu,u 24 fdrl.r tdoa:r 24 ri'rIrutufiri#

rewarm fithu 0.25"c/!tl.

Non-enhanced CT scan

. rl1qHn : uiauan:auT:nlualotoan}J

Sedation LtaY muscle relaxant

. LfiqbJfl : rfio:-nurarnr:f,u, agitation unrriralfifir-huwrular{rril rn*0,:tiru
?ru'le
1. Serial lactate
I
. tuq!.la : [lAl0allLlu-u pertusion']'llvlu{1'10
I
2. Serum potassiu. |
. !?qeJfl :niaifioii'unrrvhypokalemiadr'1r'1firfiqfi"?'lardufiqdo?'l:1d |

. inurrvol'! potassium hirrnnir 3.5 mEq/L I
I

Urine output. creatinine

. !fiqbJa: rfioifici:'u acute kidney injury
. itnteJu0ru-h-1i0fi1r--,l.ttrXful ag- lunrrt euvolemialrinr:fnurfrru renal replacement therapy

Serum glucose

. rt1Etia : rfioifioou hyperglycemia/ hypoglycemia
. lfinr:inrr hypoglycemia (BS < 80 trfl./oa.) innr::oilrirornhioplurir.r

'144-180 tJfr./9rfl.

5. lflani tRbs hypotonrc llurd

. Lfiqg{fl : rdo'rernf{fi1f,q cerebral edema

Post-Cardiac Aresr Care qind noro(i l0l

mvr'r?in?"l rfl mqdNro{!600 uriuarruqlo.,: cardiac anest ldilr:mruioun: 3o niuriu
drnil{r-hululafig nr:rfio cardiac arrest ll-nfif,trodrurrnnirud.rslror-u ddrd'qldud nrrv
nr:fiordadluu'r.rirlfiunr:rfioar.:vrvt.run1:urutofliolnrir,orufta:ln6 rfludu nr:inu.r{rhu

post-cardiac arrest ntrfintulr.rnurrrai{60{ ulirrJnlrduurorrrqntorrdo'ftirfinn.ny cardiac
arest llncythn't?lrfi1.Ucrl1rqdr.:1finuadLrrfi 'rcf,rJ

ronfird1{6{

1. FBberdy MA Callaway CW. Neumar RW. et al. Part 9: Post-Cardiac Arrest Care 2010 American Heart Association

Guidelines lor Cardiopulmonary Resuscitation and Emergency Cardiovascular Cars Circutation 2010;122 lsuppt 3l:
s768-86.

2. Neumar RW, Nolan JP, Adrie C. et al. Post-Cardiac Anesl Syndrom€. Epidemiology, pathophysiology. Treatment,

and Prognostication. A Consensus Statemeni From the Intemational Uaison Committe€ on Resuscitatiofl (American
Hearl Association. Australian and New Zealand Council on R€suscitation, European Resuscitation Council. Heart
and Stroke Foundation of Canada InterAmerican Hean Foundation. Resuscitation Council ol Asia and lhe Hesus-
citation Council of Southem Atrica): the American Heart Association Emergency Cardiovascular Care Committe€:
the Council on Cardiovascular Surgery and Anesthesia th€ Council on Cardiopulmonary, Ferioperalive, and Critical
Care: the Council on Clinic€l Cardiology and the Stroke C,ouncit. Circulation 20OgJ.l8:2rlS2-Bg.

3. Adde C. Adib-Conquy M, Laurent L et al. Successful cardiopulmonary rasuscitation after cardiac arest as a -sepsis-

like- syndrome. Circulation 2002:106:562-568.

4. Adrie C, Laurent l, Monchi M, Canou A. Dhainaou JF. Spaulding C. Fostresuscitation disease after cardiac arrest:

a sepsisiike syndrome? Curr Opin Crit Care 2004J 0:20812.

5. Hypoth€rmia After Cardiac Arrest Study Gmup. Mild therapeutic hypothemia to improve the neurologic outcome

after cardiac aresl hublished correciion appears in N Engt J Med 2002:346:549-56.

6. Bemard SA. Gray TW. Buist MD. Jones BM. Silvester W, Gutteridge G. Smith K. Treatmefll of comatose survi\ors

of out-ot-hospitai cadiac arFsl with induced hypothemia" N Engl J Med 2002:346:5OZ-63.

7. R€a TD, FahEnbruch C. Culley L. et al. CPR with Chest Compr€ssion Alone or with R€scue Breathing. N Engl J Med

201 0:363:423-33.

8. Anytuntakis ZA Baron G, Aubry P, et al. Acuts corcnary angiographic findings in survivors of oufof-hospital cardiac

anes{. Am Heart J 2009:157:312-8.

9. Spaulding CM, Joly LM. Rosenberg A et al. lmmediate coronary angiognphy in survivors ol out-olhospital cardiac

an€st. N Engl J Med 1997:3361629-33.

10. Reynolds JC. Callaway CW El Khoudary SR, et al. Comnary angiography predicls improved outcome fo owing
cardiac anest propensity-adjusted analysis. J Intensive Care Med 200€24179-86.

'11. Dumas F, Caiou A Manzo-Silbeman S, et al. lmmediate percutaneous coronary inten€ntion is associated v/ith
b€tter survival after out-ot-hospital cafdiac arest insighls lrom the PROCAT (Parisian Region Out of Hospital

Cardiac A/rest) Registry. Circ Cafdiovasc Interv 2010:3:200-7.

12. Knafelj R, Radsel P. Ploj T. Noc M. Primary percutaneous coronary intffvention and mib induced hypoth€rmia in
comatose survivors of ventricular fibrillation with Sl-elevation acute myoc€rdial infarction. Resuscitation 2OO7;74:

227-34.

102 r':trhrTnlnqnfrug'nr

19- Surassanlvongse S, Chavraru€chd T, Sasngsung P, l(omoltri C. Outcorn€ of cadiopulmonary €suscibtion in a
2300-bed hoepital in a dsyelofing counfy. RsstlsciHion 2006:71:188-193.

'14. tob3ldy MA , Kays W, Onato JP, ot al. Cardiopulmonary rBuscitatloo of adults in tho hospltal A r€porl of 14 720

cardiac arests from ths Natonsl Regbtry of cadlopulmonary R6us6itation R6uscitatlon 20G:58:297-308

€15.'Tian J, Kaufman DA, Zalch S, et al,outcorn€s of critically lll pati€nb who r€ceiwd cardiopulmonary scitatlon.

Am J ResDir Crit CaG M€d 2010J82:501-6.

Post-Cardiac Al:re$ Care qiaf nangi 103

RInHU?n

Adult Intermediate post-Cardiac Arrest Care

Return of Spontaneous Circulation {ROSC)

optimize ventilation and oxygenation

. inulsrdu oxygen saturation lfildodrr:riou gl%

o fixrtrur Advanced airway ua:finounrr{ngrdru

r capnography waveform

finds'lnr:flh hyperventilation

dolfin Hypotension lsystolic Bp < 90 u.rJ:on)

l*uSrraa"od

. ru/ IO fluid bolus (ridrifidorirl)
. Vasopressor infusion
r lfinr:fner Reversible causes
. EKG 12 leads

Th€rapeutic {rJ r o rh ertr ni *.'rr.rE olri
hypothermia

fin1rffi Coronary 39oau du'irrfl u Acute myocardial

reperfusion

tttugfifi t uf,nt post-cardiac aftest care atgorithm

104

Practical and usefi.rl Monitoring Parameters

for Critically Ill Patients

"lxefin$ fixfiqa

nttrflt:vt-.rua;6nnrrornr:{fi1 (monitoring) rfluairudrfi'rydrunfi.rtunr:q ttnfnur Tou
rarr:atjr.rE'r'lu{ilrafifinrr:inqn nr:rflr:vie'ii6q:rirhi{Snurarur:n6an1}Jn1ll-nul noafi?u
lfinr:fnrrrfirrfirrlSoulduuurlo.'rnr:inurlfi rrrTud{qrrn{rha6.':dotfinrufomrr{rte io"nr6on
'ldi6lilr::r'.,rfirvrr:nr.r qnda.'rnll{oritdrunrfiil:;latri{urir:rnr'lun:nifirflu invasive monitoring
ruum rio: do,rfi n rr rurirur o-"lun r:rirriorn n r: f unraur:n ttfi'ltnrrvttu:nfioufi lfioe1nn1:drfnnnr:
rtul 16 uonrrnduflflriq:dotidnnl:rr oo.rn{aqnrir'r'1 'jrrfludoqndrdafla'ldvio'lil rdrri'uldrir
ornr:rrln6f,nvialrl *o:firuqofio':50-nnr:rirdaryaoir.tl rvtdolonr,lnfifinrrn;{aryafi16crn
rniarfiarrira:r;rddtrriu rfio6omrr :;tfiunr::-nrr nnfiu1finr::-nurviarinnnllrirrl :run"',l
rrr ununr:fnursial:J

Clinical monitoring (clinical assessment)
nr:6rinrrornr: uoo.': ua;dory arrsn6fi n ii}irj afl ilon 6irrldci'td

Vital signs
lflufirduSruiidrn''ryun;r'rrflufio:fio,rdrlu{rhuvrn:rr rroi{agarftilh (sensitive) ttflt

'kje'rrilr: (specitic) rda':trndaqntun{rd tflurun:rrna.lnr:nJduu"*rJn.rduSrutitt compensatory

response ratirrnrr tta;fiil{unruuanrlnruorir'rfr:lnru{olof,

qrun4fi"
qruu4finrum.r{ilruvrinficrtrrorr'ufi'lnr:drrfiu}nutn:zunnrrinur qnrr4finrufiq'r:.nn

(hyperthermia) vian'tn'turn (hypothermia) rflunrr;antiufifiotnr:nr:fnurodr,: tiooiru m:r:

0'rQrlluounSluLLnfl 1a L0

Practical and useful x{onitorin€l Paramcters fof Criricall} Ill patienrs ltaiad $hftna 105

nfinqrufi1fr o'tflu thermometer d,rrr ooon'ldrnruull nju :J:ovriold (mercury in
glass thermometers), liquid crystal disptay (LCD) thermometers nia u0ul-naruynfi, riru digital
temperatures fild::uu thermisters tliu tympanic inlrared emission detection thermometers
ffiumitiinqannf orcldi6nr:r"ofrlfidu Snut yio rectum 6.tu mercury in gtass rhermometers
unvdrurrnTuTnfi digital nr?t"oq fl4fiorarir1fid tympanic membrane, esophagus, temporal

artery. urinary bladder nialu pulmonary artery il4lfia'itfiu lftig,tuta{ core temperature

nrrr6onn'rruti.rfiina*uo{nh dnuilc{oilofr6o,,rn'n nllrJficoxn un:nr1}irfiu,rernfiauu:ndou

fi oro rfi ndrcr n n r:'l-e 6 ndr fl

finet
da nfi'ldcrnn'r:n:ro6rcr ddrn'q 6oo"or:r6vrtr nrr r nrir rf, ra (regu tarity) rL ordutr

Rtturlr eiourorfinr: nnonlunr:rrliur rfioufi{o:lutldntrix ra{il,Jnru ufilufll1iuc:fi

lynTuln6tunr:o:rcndlldf,rridcodr.rsia rda,: r",r1d6nflrilo"firrrdufirtqua; anhvthmia ud

rrnTuTn6fil arrur?filrqRyr nlren??dr.rnrfldr,tfiurury olnuuo r:fi rudfiino:luuoin;uvi.:za,:

ir.,,rnrfllriryirdu niu 1u1:nto.lnoorrrfioorsir.:r n1:u flflnfiflal fiao:Ln66a 6yrc:dr (fiaunir oo

n:Y"t/urfra1.i fi':orrymarqrfiocrnur nr:rir'lv{fir1ul'rlcft9riln6 nionrr fiq n6ra{ electrotytes tl1,t

tfioinerrfr (r5rn'jr 100 nitturfi iuflrrl) dlymarcrfinqrnnlxx hypovotemia, ur rionru

fio:Jnfito.r etectrotytes niuniu ttdttvrnfc;do.r:ca'n ra o'jrdoilflfi]dlridl rvtlr un;lrihsianr:

tUfiu u R.,

n'trudulnfin'
nr:ioamro"ulnfinrirldunruiF urirriu z noiilnqjl 6a
1. Invasive methoc 6anr:td intravascular catheter luflaogr16oo rrot rrn yr"o lt:.roiu r.iru

pressure transducer ri'.rolldnniredal'luairuto.r invasiye monitoring

2. Noninvasive method 6.tufi..:tflu manual methods ltfly automated methods

. Manual methods rflunr:i'orTounr:'ldnr:r rnl (inflarion) rro: eioual (deftation)

r{rqi otooo pressure cuff cuu:oniudrfionEuqonyunr, rlnurfiooto,rfiilru udrld4rtr{ rdu,,i btood
llow thu stethoscope rdo::sriurl:oduriilaofl\: (auscultatory pressures) iirirfluiinor:r{urnu
riur'r}.t riilfituqnfi udfifloa'rn"n6o 60,:'lSu:o,lru:lerarnr finr:eroralna/auro,:doUnl6a'tn human

enor 'lufi:-hufifin'r?J vasoconstriction uia hypotension rlruriarofl.,rrdur blood flow ldu1n
xrn nr:ld manuat Doooter methods rfian??e btood flow orcd'ru16'1un:fid udeciolfirar'nc
systolic pressure Mttil

. Automated methods ardu:;udnlul6'lunr:r rnuua; eiaunl rrdrfl.rrfi utloru'ld

doppler flow, infrasound, oscillometry::llnr:ionrrlro''uTnfinrrur automate finr:idlrnn*l

tuna{rhrriTttua:fio{txuinqs rdo.rcrnfrlfiira hjfio.:1du:.:,rrur;nfl1nl fi .ru naen-u.fli.r:

106 ratdrdnlnqnfrug'ru

lrilfiilnr:tdnreroruunooufioatlnt rlnc6finl nr:tlduutt:la,motnrruo'uInfisrld'ilfl do tril:ndou
finofirir.r rtiu ulnar nerve palsy unvnt:trotfioozooulultd'lu nrlqrnnr:fnrjotl

f, o.ir n"ol a.r nr:iofi o uld non i nvasive methods 6o

. nr:r6onrutort0,0 cuff nxr'ldluloul? 2'tu g lotfiutttluviadutrfido,tnr:i'o
. {rhufifi arrhythmias

{lh ud fi nr:r tr"r rndau st-r rr n l vr"n rir'ldt r n
fi:Jruiifi nr:rildauu noso,rnrrrroulafi nodr'tr':ert5r

. f--lU?U)a n'l'ltjtl [n 6fl0]mon1 'ln

lu{drtr a ndrsn-.'rd flrrflul:Jldnrr1'fii6ioIoa%i intravascular catheter (arterial line)

nrrrt'rsle
nral:; rfiuvntn6fin:J::noldrunr:f.ttnn dot:rnr:firg'le dnuru;nr:tru'lo uflv!!tlu[[flu

roinr:vru'to

t. o'n:rnrlnrulo a'n:rfr 6rniodrlrno;ri,:ronfi',: vrur6cnrlT d.lrfindulfintolurra;uon

'::rrrr utr d.,: uvril riorqfi o.'r'hinr:rir uvrulo

2. d'nun::ro,tnrrvru1e ilnu vn'l:vru'ledrtrn (dyspnea) e;il,:drurianrlrtunr.:t6u

uru'lo miu

. firlruiifi nr:qnrYulaivr.:t6uvru'lqdruuu q;fi nrrvrulctdrtfi u,ro",,t, fi tduo svidor,

fi retractjon to.] suprastenal notch dlLvqol?rfrualn soft tissue (niu pharynx. du) secretion
rlflJ {oreign bodies nr:vruhlfiairllrnlufitleufin{qrnnr:lorianrubaan lpost extubation stridor)

. firlruiifi nrrqorYuto{rr{tdufiru'ledrurir{ e:fi ornr:vru'lqaonaht.trn finr:td

accessory expiratory muscle Tsuuoltlr: rectus abdominis rfi'ofl{rfiu.i on 1; u prolonged

expiratory phase io rhonchi
lufirteudldirnrrdrflvrulq firfiornr:urulo lflrn'rrrnvSofioroan u:rrrnrftdldiun.t

drufira'lq arrrqorerhnmnnr:qnfiuto,rviorT trle, trigger threshold frg.:rfiub, tidal volume fi
ri.rHhilra, dynamic hyperinflation, nr:fr.t inspiratory flow rate n'rrfiulil'lu volume control
mode r,riorflrBRn'rulu:Joofirflurrndu drunr:vrfl'lclritf,'rri!terio.:druvT u'lcororfiootn dynamic
hyperinf lation dr ur,rn6{g uoo :datlfi nr:inurln u rEr

3. rr!!ttr.r!na{nrvrulodft o:Jn6 arqtfi qlrnl:nr'.:'luun;uon:s:.runt:rrsll

. fl'r?fi1u'lcrru! agonal tia air hunger d,rri,rronfi'rnrrJlvn tiuutaogrfitJltlnrl|o:

fi r6ooll rdulfi rua a{fl n n{ l'r rfl udooldiunr:riru rateTouriru

. niiv'rs'letr u Cheyne-strokes airultr!rrfirovil.ruonfi.!011ilfioilnfifl'l.lttJfiluoA6tJ

d,rar:mrrqrrcrrrq uoiorohifia,rnr:ntdrunrulc crnrqfrvrr:-iou triu :oul:nlirrru diencephalon

{rlrug'lorqdrflu congestive heart tailure

PracticaL and useful .\,Ionitoring paramcters for Criticall_v Ill patient.s laainrt fiufiqa 107

. n'rrylu'hnu apneic, ataxic rto ctusrer c;ilutu*iltudfiFxrilftoljn6rfiurfi'u

respiratory center fiuirrrufirucra.,:unv,ilfludorldirnr:fnnrrY.,:alnq:rryrs,tnr:rmr:;irrnSurJ
lnivionralo uoyrirurru'le nr:ryrfiJraaroruorralold

. nt ns'loulu Kussmaul o:rfrunr:uru'laii'rfrfinunvnrfi Tnudil'rrorlunr:y1u'lq

rdrurrn'jrrlnfirFnriou ru'lu{ilr#finr'ri metabolic acidosis nr:ufi'lafio.rrufidnr rrqdrrrilnrr

bipir,: nril usinrr ilol rilu

nrts|:rc"h{ntunt :vuu

. Tnrr,r''rll{:huir'aqjtun'rr:inqn *ne;fiflurif,nrflua:nr.ufio:Jn6raryfirfrluunruoic'r:

n".11 fia'l-ar:6lriudurrntoterrr 16l rufirfialuvi,,,:r6m niu firhudfinrl: septic shock {.tn
acute pyelonephritis o'l{fi shock ARDS, Dtc !!nc acute kidney injury irrrYunio'lu{rhriifi
prolonged shock ?tn massive Gl bleeding A1efi acute kidney injury UAVnr:rir,:rulA{A1"ur:
du1 rfiul:.t ocliunl:er:rqdr,rnrumtr::u:Jorjr,:nv16uo6,r rfludrrfra'ryun: ulrrrifiounfiirainqn

l : dor fi ef, o r.Jfr :rG o u'r.l fl ll'r r or o

Urine output

nr:r"nl3lrnna':flcam;nnaofrh.lfinrudrn'rgtunr:l:;rfiu organ perfusion loru

rayrryadrodl'lunrrvf an uoiulrrnfcydatld,fio4ndodr.:::fiq::i.r u$r;fi raur,J:rudfin'rd.rcru
toilnftnilnfinialnlrulrnnrr;fian ryfiiact:aonriatfio*fi pretoad rlnfiniorfiu, ftJruiifi

::drrirnT nturfionq.rarefifloarr:oonrrn {:-hudldt'uurrr.rrfio nju flrd:Jianrr:yio contrast
media orrfiinor?roanrJln Tnafrrjirrru pretoad ri.rlro {rhafifinr:qo6'uts,,rdrBfiruflnfirry
arrgnrdrlrfi n'jrfinm: anuria 16

Arterial blood gasess 7
n'unl?3 blood gas arl"lfrnr:rcr: rdan rra,,:rfrueri.rn:1? (periodic sampling) yialun:di

fifioucr; ou oroldflruaruraaorfioouo,l (intra-arterial catheter n5o arterial line)

iori,rC rdorhyrfi oxygenation. ventitation !!flJ acid base status aot{rha

Timing of sampting tu{nrudfi:Janr.Jnfi unyrrinr:fi'.lrirlxdl 5-10 urfiua'tornnr:td
taia.rtirayra'loraior fitu setting ra,: rnio,:fiio rrJduuu:Jnonr:lfi oxygen rioulqt;r6oouo,:n:'re
druiu{r-hu coeo nr:y*.njr,:rror eo urfifia'{ernnr:r fiuuur.ln,riEnr:riruyru'loy?onr:'lfioon€reu

rfi o-rm ntun { ldfi d iff usion def ect d.: rfl un olnyn-nitnr: rfi n hypoxemia

IirrJn6 rir:lnfuornrai'le arteriat ulooa gaslduan.ililurnmad cirrsohdrflunirfili

rfialir-hayrulo room air lnullr1tl!{n?? nB{ pao, fiu paco, oyriounir 140 mmHg fi'u,o?x
ilrnn'jrdlfisnrlsou'ir{rJruldfuoonfirounialriuncfirlri arnnr:n:roriurilocr,r'o n1n

nlt]trja a $t-i{tflunrr:l:c tfiu oxygenation, ventilation trn; acid base status

108 rTtLirrinlnqndugru

flua;[6ug'lun']:[[ flfla 1fi6inH1e1nuro?1 rio{ arterial blood gas interpretation

Venous blood gases

nr:nlle venous blood gas firJ::lamilunrlhJlfiu oxygenation lu{ilrtrvrin rrn:rflu

airutdttunr:rJ:; tfiu tissue oxygenation tfio.:o1n venous blood gas 1ou tavlr:odrt0.l Pvo,

ufli svo, rflu.iruruoan8leutu plasma LLosa?l rdrufiutoo oxyhemoglobin frru6ana1lrfir{

rtrlc fi{oorrirdfi (irudrn-ry'lunr:rJ:; tfiu tissue oxygenation

Portable chest X-ray
'hlq:rao:16uor'lurCo{nrrairunriJrira:'.:6ivr:r.ranlu{ilruvrin

Electroca rdiographyl o

nr:ld exc monitoring tun a{:J'runrinfirJ::1umifi rfiulid'n tcu6a nr:tflr:ci.J cardiac
arrhythmia rioluu:,rrra:lfinr:inurdrr defibrillation ldriufi uonernr.ryul-.1fi:l:;Tug lunr:6FrFn
ri'nmlduli{q. arrhythmia gi'r''t'i, myocardial ischemia nr.tfifiornr: uio silent ischemia tuautasl
arofinr:q:?c6on1 QT interval tu{rJrufifinrlr rdu.,r niu {rhufildtniifiqnf proanhythymic

166ndru ndnel'rri'q6a uflrriqvda{rdr'le'l lead system, nt:rnirLlf,rhu, electrodes, ?c!:.t cable.
runcfl co"udfi orionr:dru

Lead system

Tofl fi"iil :vrlrdidriuurnfi qn6a nrrtd bipolar electrode 3 1o uitrrur:rtondrulu

dru r'r'r uo:Hri,lvnrronsiru*xt6ozuftvrirfioo :llr-rde:nflo1dto11l: lead l. lead ll, ttfl; lead
tll yia modified chest leads (McD'[d i6dl:6osrr nrrtdutra.lri'rlqld.irrill: heart rate ttflv
ventricular arrhghmia 1fi ttdlriaT]'r:nfionr n11: silenl ischemia, bundle branch block vio

arrhythmia u1ntfie'ld t :r;nr:n:rod,,rndrrdal'ld precordial leads nr:td:vu:t 5 electrodes d
rl:cnaridru 4limb leads !!n: I precordial leads q:drutfitJ :;filinrnd',':nrirr'ld

:;rudu1 d'lflurr,rnnrriulln;fi:rr.tru:}vlermf ldu t o electrodes system fi'tfinrrfio
electrodes ndral rilnr:dr ECG iln6 nio 8 electrodes vectorcardiographic lead system fi54
5 electrodes 12-lead ECG system 1n"1 ti.tfii6nr:6ofi{':urn llrdfiounr:finn1t]ll'ruurnr:riobl

nr:rniurfirnri.rfiilT u

oru:nrirtfindu'hiflriiaanrrqndo.r mrilv etectrical resistance nanr nr:t6ofirv .:dru

rronnaaod dt'hiufitua:gftruu-td'un::n'ruyrrluul{"i fi6arir electrode q:d'rtJ'r:nRn resistance

ld drum:ld conductive get o:1i1'hinr:d1'lv,lff16du

nfiuf,n6ufijnxu
arqrfincrn electromagnetic tieto {i':rfiolrnlndorfiooir,: 1 lulofig fiairn'rpfio power ljne
?o,i unit (soHz) dtovrir'hirfin voltage'h: electrode teads tta:oirur{r{{rhu ri'rzuotrifinr:luru

Practical and useful \{onitorinSl Parametcrs for Critjcally Ill Patients lxoiafi $ixftna 1rO9

frqryrnuar{rhuld nr:ufi'luororirldlnuld shietded etectrode teads. nr:6ofr.: cabte ad1.t
(fitJ'rcfl n15Ln;urfirru",loti, rnnfio\r rrn;ld filtering adaptation 'lud'r monitor

Pulse oximetryr' tt

tflunr:q:rc oxygen saturation lu tissue rot{:Jriloaldvn"nnltro,tn1:nad'1l rrfl{firrq,J

(red wavelength.660 nm) ?o'l oxyhemoglobin [[aJ[[6[.] infrared (infrared wavelength.940 nm)

ixflo{ deoxyhemoglobin njunl:a1drlqruaruifi pulsatile rla.xfinofirfionunr yirlfirnio,rf,'DJrrn

drueir oxygen saturation salrdordadrufifin'r'uJfiu1 ry 1ru 5-10 fiafirrtnr rtildrrd r?rrru

rJarudruia6.r1rro,rfilnr! rsorirrrudT fi otol 16nr6nld

Accuracy

l,ruir g5%o confidence limit ,!s{ pulse oximeters os'ludr,: g-syo rion:ro'tu{:J':aiifi
oxygen saturation > 85% n6i116o Fi'r Sat o, olnnlifl:lqd?uIn4o{do;fiIonrorfi'fl.Jr1.ru91nnrr
n:rodraifi lrn:X 1u 3 -5o/o

1-l,AtU{S
t. rfiofionu oxygen saturation lufilJrudli:bnr:rjruuru'lo niald oxygen rfia fir

fl'tlinH1fi5a weaning
2. tunr':tnaau exercise test

s. lufio'rqn rfiu 1unr:nnuun (triage) {:Jrarflun{rfil:fio,rldirnr::-nlrodroirdru vio
,lri rd.: oiT u yi o'lu lfl r: :r".:tru; drfim n nr: rtiu endotracheat i ntubarron

4. 'lu diagnostic procedures oir,r1

isi, rintot nr:'lfi putse oximetry

l.L>uflie{dl\1ru?ufiATfafi carboxyhemogtlobin nrT:n8nodtu'luuadt{frdluloo.tr (red wavelength, 660 nm,) ao3:aauutu
rjruln'urnT oxyhemogtobin lir'hlrrvutiur ana oxygen saturation 4tnirfinrro;rflu d?tt methe-

moglobin o:finr:qofitto.:6fi,rlurirt reo wavelength (660 nm) lrfl! infrared wavelength (940
nml ddrieirud, oxygen saturation r:rlrru 85% dtq,ln'jro'nrtflul?.,rrdudu lilr, :{tlxilfi.'l

2 nnirfi oxyhemogtobin sl"r uonelnd {ilrunturr6ruiofiT:nfirfu {rJrufifinrr:6oniifi vasocon-
striction cyli' fidrpelrud sensor aaa.l tta:{illufuriufial lrnaootrnrqv:unrunr:n:r dniuniu

Ir{suulnrrlo't pulse oximetry lould wavelength qa qcvrhbiuvwltid,]t.trtnttunnrr:

carboxyhemoglobin fiio methemoglobin ld n1:fi0uu1 sensors un;;rJd'nrnilirLi rniolfiod

fi1ilrrntdfi!fiilxufiitfu fi o\.tr.rrld 6nr".rrirvrinur rrnvr.rn10nR\t

isnrtrca{sannr{d pulse oximetry
n'r:s':rcflrioru'rrnynu1rufl1:n?xa otooo gasld'tuXnn:ri rfio,rrrnrato, riarrr:nin
pH Paco, du-nronfi.onrrrrilun:onirrufly ventitation ld uang'lndf,f,??e?:6a.rifl'rr r{r'le

oxygen-hemoglobin dissociation curve d.lfin"nuturtflu: sigmoid Toufi upper plateau portion

ll0 rTtrhrininqadu5'ru

rdratr
D.('sdB|np
D.ou..d 1-3 DPG

oc<rcrcd tL+l

O 4.t
,tr';*EE! .'t0
$ro
El /tt tndu..d dtity)
Iao l|tol. artEtp
h.r:.r.d l-! OFG

Elo

(1a-t t

t!

Pe {trrnHt}
pli t uaat oxygen-hemoglobin dissociation cuNe

d paor 60 mmHg lroi saturation 90% n1#n:1eld'j'r{ilxufi saor goyo J,,:uan6{ Pao, lcrJ'rru

60 mmHg nlrrfj nlrlioonir{uqc1i{fi eo, rdrtruuoio:lririrtri oxygen saturation rdrdurrn

uluflnfl?unvu\me

Gapnography''

n1rnflrli6 co,t ilT nlG^il111uledrhu'turirrtdr,,r 1 ra{n15mu'hliun'ir capnometry ua:

fir uoer.r lflun:rrioio rfio.re:riun'jr capnography nr:rirrrusa.,,:rnia.:d':uln{arduqruar:i6nr:

qo:i'r un.: infrared na\:ff'rfl co, tuudn:tir,mro,rnrrrruho:gntoorir,rsioriio.r (capnogram) lnu

""n"o. dAqdolu ventilator circuit (mainstream capnometer) io sensor n'luuonii.0f o}|flr c
oonoiru gas sample line (sidestream capnometer) Srrru carbon dioxide lun yrEjhoone;

ucn.tiru time based capnogram ra"'qrli z rir expiratory gas dr PCO, drJn'ruqnto\t alveotar

ptateau o;riun'jrtflu end tidal co, (Petco,) drrin rfllrir co, fig#qntunrffrahusinv?ir.l

1::r'fi,r phase d e ttn: q)

PetCO, Teu nfi?vttdqnfi{ PACO, drrir ventilation-perfusion, V/Q agltlnrudrJnfi [sid1

vlQ finr:r:Jduurrrin.oornvru'rionr rdrtl rirvrtoooro:lriMrrYun?ofi pAco,- pet co, gradient
rfindulfi un:tunr.:nn-riniunrtq:rq rL gradient 1u{rhua't?ri?ut.tonfi{ V/Q mismatcn ld o:rfu

n'nrrdarin Pei CO, uflyrriecfio,:finr1lrrcrTo:ci':tnurovrrcoEjr'tdrlufllr-havrin d'rrinfi vro

mismatch louilnfirir PaCO, aJd\rfli1 PetCO, rv:J1ru 5 mmHg

Practical and useful l.lonitoring Paramerers for Cliticall.v Ill padc.nts luaiai $iuftqa lll

zgli uan,t capnognm n6 uts,t phase rix1 lrann1lffiulq 4 d1n
Inr1\rii unn,rnr:r fiUulnlo,r petco,

PetCO, lrildufi Petco, oofl.'rti'ufi

. -inlltt{8J cardiac output 0u'}\tl'lFtLt') . finr:nootgo't cardiac output oriro:rottfr
. Pulmonary embolism
. 'itAe-:Lfl'l:yelflAlUt!dl.l carbondioxide . rqdo,rdrunrulquqo
. viatir u rr ula a oq'u
ohul:lrn . fi'lili1 hyperventilation aeirt:rot5r

PetCO, fiotl,ilfi Petco, riou.l aoa.t

. co, production tl4ut! . nrrzdfi 16oor-l:Jrdu,: annornoarir,rdrl
. HYPoventilation
. n1rd1 hyperventilate aeir,tdrl
. rrunlo6filaorn.:

'hjfinrrlizo,: end tidal co,

. Esophageal intubation

iarjtdtoo capnography

t - rdon:rlaornh !!fiil.Jn'rr'ldyiafi'rfltl'jr rirnoooarnr: (esophageat intubation) fiio'l

nil't:lun"rrLl1xi{n",rnGi'r? PetCO, ertl'fi'rsr"ul1n

2. nrtrHr:;{r::r'jr.:nrrrir cPn rvr:rrtr cardiac arrest rir Fbtco, qrryirn-!fl1ui rfiolrrn
lrifinr:lnarluutorrfian rfio{rhu'ldiln1rdlu CpR Fi1 petco, lyrfiridu:1un:tduo1o.,:nrttt
end tidal CO, 1u{:-Jrr cardiac arrest'lfrfinurlulunrurCo.r practical CPR atgorithm

S. nr:itn:r:f capnogram a1a!anf,\tnl?3 airway obstruction, bronchospasm. air trapping

tto; rebreathing 1d

112 retrjrr5ninqndug'ru C{! tilt*{g) R..|ltia
Cot (ilrritl
J,

C9?flltttlbl

CO' (rmtlgl R{l-Tln glor {rrr*10} R|.l-;lna

're,*mil aE.

^g

ali 3 uaaoatlxfrntJnflta,t capnogmph LLuudxT Iaafi cu*e utnta,tuoiatnu:ranttilu capnognph

fllnn

1. capnograph rioul nrilll udo{j1 artificial airway riuhiagjlu trachea ttnnttttflotfi.':

esophageal intubation

2. capnograph 'lutirl expiratory time dun'l udn{'j1fiflili'loonlil on arrificial airway
qtnnt rtdn{fi'l cuff leakage

3. capnograph riaulgtl*u tdotorn eetco, ortdu arrtfigtrn minute ventilation ootff{

rio co. production qmt*u

4. capnograph rioulnodu tdotorn PetCo, nod'u arctfiolrn minute ventilation {'tdu
rn3o Co, production aqn\t

5. capnograph rioulq,rdu Inutfifl.rtnn'it baseline eioul q.ldu lutru:firir e"tco, ntfi

ernnryruno,o'hirfiufit rebreathing 6.:orqtfioqrnnrr:Jfiotlnfifr exphatory valve. inspira-

tory flow rate fiourfiul l?o expiratory time lliu't? a

6, capnograph rrflo\rdnr c slope fifio:Jnfi 6o1il16gduri'ufi uoiriarl g.rdu uoo,:'Jr

fi nr:qofruto,,rounulcoon crnnr ucordnuruv bronchospasm r,riofi nT :qnn'uta.,r

expiratory valve

Invasive hemodynamic monitoring'a''

Ac a .J s t!| arterial catheterization LLn; central venous

fidrd'rp luna fi:-huurinrirlr}l::nold'til

catheterization

Practical and useful Monitoring Param€ters for Criricallv Ill Parienls "haini fiiuftqa ll3

Arterial catheterization

lflunr:n:rrfiyrhriarodT lndt'luuo{rhunfn iifl1tni1?1 rJ::nol6ru nr:'ldsrua'tuaurn

rFn ::rrru t8-20 c r{{il'lu}raoq16oorro,r rrn;iou:.:o"u16aoeiru transducer frhrrxil,rdldliou
dqo6o raoiat artery nr:lsioruc'luorrdrldlqurryr.,r sheathed needte sirufiryf.r ylo cut down

firlei cattreter i1u radial artery rrnmdl:do{nt?a Allen's test rdBylolflo:J collateral circulation

fl0\: ulnar artery lf,tJo

Transducer system
tu:.:o-ut6oerlo,ifirhuecci.,t'lilti.: pressure transducer njruyiadfior:rirrfludrrir transducer

er!ilAuuur.!o'utirflun:yucly'lfiT drul:J{rn3o.,r moniror uvrrti{rirnr:n:ror;fio,rrdrleriiurdu
rnnfin rtiu nrrns,r transducer nr:frrcir ,ero nlido tubing tr{gndo,r lilfivlorotn''tFtfiio A 1609
'lu:ylrr noanrunr:urJnaao'nuru;dqcu'l{ud'h1.1

!-aun':a

tfiouvtvtida,rnrm?lu btood pressures otl"r.ror'ardo.,r tu{rJrufifi hemodynamic instabtitity
Tou laflrcodr{Ei.r rlrur'ttlfllturufiaoqtfionr unyurfirtn0n t6o6 rdadxu synchronize intra-aortric
balloon counterpuslation uncrfrolflurr.rdrni;fiurfionuo',rlrm:rdun:ri!ddouer:16oououioul

ifautznfiau
ddrdEfia nr:n'ordo (0.6-4%) vascular injury !!n: thrombosis

Central venous pressure

rit centrat venous pressure r'r?a Gunlouda'jr cvp rfludrerrtro"uluynon 16ono"rdru

fln1.,triatrrd, d right atrium flqa'afifiilnriad'r cve fin"rn'qfia intravascular votume nrtyrhlrura.r

ri'rh lcardiac contractility) !!flt impedance t|B{ venous return dr nfi CVp ad ::urru 2-O

ru.:J:ar rio 3-8 tr. li'r nrruidsuu:Jn,riuri'r cvP !fie1lnfladud.r s {rrdu6a

. dr cvP annn fi1$!fitlfiumltJfiul6ooflqan d1[fiqri']?: rflue1n intravascular volume

nan,: nia resistance oio venous return tfirudu ttrdfi'rfirirufinrtrd'urfiaorfill*u fl''t!figrl.l're;tflu

l1nn15T'h":',tu1jO'J?t?-,, d2
t301JU

. eir cvp ldlrdu riru:.rdrln"rnxl oiurfioennn{ arruqrirl: riluornnr:dr,:rutorfirlo

noa.,,: uoifir{rJrufinrrud'u16onr$irlnsu nrrtqrirr:rfluorn intravascular votume 6du ria resistance

na venous return nnn{

rYrd rir systemic vascutar resistance rifio''rilnfi nian,,:fi1unr:intiliutLtfiuufi'uttdo;
n:s,l un''lunrd::tfiu preload ?rn CVP Lw,rilricvfio''6fifi,Jil?r t6ud1,i.i drtfiu :rr.rnv.oT:nrdrtT
lo.rrirle rdu tricuspid vatve disease. dryr;sooirh6ndru

114 rrti.irininqnfiugru

fariodtarnrtldalur,tu cvP
fi16fil nr:fi geriir fi :J:cTurlicio6o nr:tfi urvia Rr:arvr:fi fi n rr*r t{rdu4ovrtraoer tfi an
rirbqj airudorioddufrorefiil::Iutdfio nr?in cvP rfiarfluoruvddu hemodynamic monito-
rin g uo: niovti {lu id chal len ge 1rn"'ro rjrtlfi rron.fl uotr:r'rfi z1

znr, rtd uoq,:nr:vir fluid challenge testr6

Guided by

<8 < 10 200 mU10 min

>12 < 14 100 mU10 min

>12 > 14 50 mU10 min

During infusion A>s L>t Stop

After 10 min <2 <3 Continue

2 >a < 5 3> A<7 Wait 10 min

After waitin: 10 min A>5 L>7 Stop l
sri a>2 Stop
sri a>3

I L<2 A<3 Repeat

dou n,lilfl Weil MH. Henning RJ: Ne\ry concepts in the diagnosis and fluid treatment of circ!latory shock, Anesth Analg

1979: 58124
CVP, central venous pressure: PCWP, pulmonary capillary wedge pressure;

n'lr'ldfl1u 6nu cvP

rirl6'lounr:um'rvaaordaorrjruftrmit (percutaneous catheterization) tdroi internal jugular

vio subclavian vein r,tionr:rh cut down (venesection) 6.'r'lun:rfivri'trirfiu16aoo"rd'l{riou 6o

antecubitat vein srhuu {rla,r arunrudru'lur.toon lfioonr:ogluldurfiono"rlnr! (superior vena

cava via brachiocephalic veinl Inad,:tnm'irfi respiratory fluctualion nr:fir{rttvrjt artgru

o{duufiu1:J uo:oqj proximat oio venous valve q:drtfrnr:u:laFir cvP fioflala drunr:tdanrfir
'lrllu avium arcdrlfirfin perforation LLn: arrythmia 'ld

n1:dluri,l cVP

lnurionir:;rr tranducer n?oeirura.rTnsior:;ri'rlrirdnrTr-dun,:srr nr:vru"le[[r do:60.t

rirvun zero point 'lfigndo.: un: rufiauriutulnl ni.r rar.ra sl"runrj,r zero point filfiIoaWrh6o fr
da
LU1l'11-lOU:'l1J 11{ tlA11la{n1lA1UA3gO{ttlUtl{fi'lU [1OAnfl9tfi]JO
nnnA'l,ia'l'ltJ111.l'lflA{Yll'l,J0n

rir cvp fiielde: rdafiolfivia'lilr*uo{fi'r oir urrj.rlo,r cve fiqnda.: arsrurun--lzurir

xno0rnaa rfiolnir'firtion',raone;llifiur.'tfi1u alerlrnqorfioooonldlrifisrso un; rfioiautrSoor:rir

f,rhuo:lrjaruffinrfr.r rn uavfrrirfrry cve da:60'r tcrfioudua.rnrrnr:firutq fir$irufi 'r n'ru

ll5Practical and u,seftrl Monitoring Parameters for Crirically I1l patienrs 'hnia{ 6ttfr4a

fl1unnfiE,rrroirrtu6eniu6,ti,lyflon[6oae:ut!.it rfi0aoLfiaa rfioalcl s0nriooonhidra?n usirdao
orililfloanldfilil6iaurraoruU nrgiiodfiamiuurir0lev{!.fifid?m315u'tuni umirrlnruo.ru ua:
riiofi n nr:riryi o ur ?:lfl n'l dc n1nn?o l6:Lrr nnlu

lunr:leiorsoru cvp fi1rflul:.Id nr:'ldarsfiu*aruo;a.::n:rqflo:.lsir uyri.,rdrunr:riru
nrrilfirJoorrnro al'r uyri,rfinnda.:arro{or'rnir sternoclavicutar joint luilrin?rdnrfiufi,:nnrsro.r
r,:rrolfrhdrunrr

n,t:lfir:s?-{Tosflil

fi$'ldnrirrlr{r',rfiurilunr:r::ururfiuariunr:rfl'r::irfirhlluusio:sfin usirfiofior:rur
{ilrrtrrnfi.l16rfrnsrBont'rluailr; rdurySaynruatur:finrru urrtiaro r;a:Lflrywrlun.r:16on
tfieta,Jn'r:rn'tcu.o;nr:rflr::r-.r lun:fidnr:ardulrd'nnr:#dr6'rpEa nr:n:roriuc:do.:fidorj.id
iu{ilrr.r uoio,rfiou'unr:rflurnio.rfiafifiil::r'roqjudrturo{rhr 'lun:efldnr:sr:rqdo.rardunr:d.r
fmnnr:unrtiuo:fi1{inurnarurno:datfinruJ nrrrr{r'lo orllr:nu:Jnruoioqnldod.r,rgnfia.r
6nrf.rntn:nufihflryrrrfiorfinnt; ur:nfiou un;ddrd'ryiiqa,fioroornnr:rl:ro1o1 e;60-rfi

:l:;lurrilunr: ryrfiunr:n"T rfiuI:n rfiati':un"nRunrrinrr rionr:r duuurjolnrrfnuldra

lonfl:d1\:5{

'1. lnsler BS Perioperatjve Thermoregulation and Temperature lvlonitoring. Anesthesiology Clin 2006;24:823-37.

2. How€ll MD et al. Routine monitoring of critically ill patients ln: lrwin RS. (eds)lntensive Care Medicine. Pensilvania:

Lippincott Williarns & Wlkins 2008:235'55.

3. Dantzker DR. Pllmonary gas exchange In: Dantzker DR (eds) Cardiopulmonary Critical Car€. Pensilvania: wB

Saunders 1991:25-44.

4. Shapiro BA Peruzzi WT. Artedal blood gases. In: Parillo JE. Bone R.C. (eds). Critical Care Medicine. Principle of

diagnosis and management. Missouri : Mosby Year Book. Inc. 1995:171-90.

5. l\4enn. SJ. Evaluation of arterial blood gassed acid-base homeostasis. In: Bordow RA, Moser KM. [eds]. Manual of

Clinical Problems in Pulmonary Medicine 3'oed. i,,lassachusetts: Little. Brown and Company'1991:28 32.

6. Kellum JA. Disorders of acid-base balance Crit Care Med 2007:35:2630-6.
7. Palmer BF.. Approach to fluid and electrol),'te disordeE and acid-base problems. Prim Care Clin Ofiice Pract 2008:

35:195-213.

L Turner AF. Intelpretation of the con\entional chest X ray in the critically ill and jnjured. In: Shoemaker WC. Ayres S.

Grenvik A, et al (eds). Textbook of Critjcal Care 2'ed. Philadelphia: WB Saunders. Inc. 1989:230-41.

g. Umali CB, Balikian JP. Chest radiographic examination In: lrwin RS. (eds)lntensive Care Medicine Pensilvania:

Lippincott Williams & Wlkjos. 2008:724 54.
'10. Drew BJ. Practice siandards for electrocardiographic monitoing in hospital settings. Circulation 2004110:2721 46.

116 rrtrhrlnlnqafrgru

11, Jubran A, Tobin MJ. Noninvasiw raspimlory monitoring. In: Parillo JE, Bon6 R.C. (€&). Critical care Mgdicins.
Principl€ of diagno€i8 ard manag€.n€nt. Missouri : Mosby-Year Book' Inc. 1995157-70.

12. Callahan M J Pulss oximsty in Emorg€ncy M€dicine. Bn€rg M€d Clin N Am 2008:26:869-79.
13. Nagl* J Capnography A laluable bol for ainiEy rnanag€m€nt Emerg M€d Clln N Am 2008:26:8{t1-97.
14. Paticio M. Practical lssu€s of kmodynamic Monllodng at the Bsdslde. Surg Clin N Am 2006;861431-56.
'15. Atllio B. ArtErial ard central vgnous pr€8surs rnonitoring An€stlEiology Clin 20{Xi24717-35.
16. Wbit MH, Henning FJ: New conc€pts in the diagnosis and iuld tr€dn€||t of clrculatol)' shock An€6th Analg 1S79:

58r 24.

Shock Earlv Assessment
J

ronhttri ffiwg

{:jruda{'lunmvinqo {criticatty il patient) da,ildrilnrrfmnuoyn.mfinnrurflrrsr-l

odr.-rlnfifio urrvlti6rdolintulnrruorur:ndrfiuwolunr:quo{rJruurrird :lErrnnRron{nrr
lnoriuurfioolrin.rd (nemodynamic instabititg lnura rl{il'ruda{1unrr:Son riuflrgrnfinuld

riolun:fi nrrudrn-Edrnfunrrqun{rJ'runslld urn'rudeidndrrfituur6n (concepts) lray

:Jrrrfrudrf;'r1dldturm:Jfiil6 Fractica pointl'lunrrqun{rJrun{ld

Shock
nr?c6on nlrufit arr;drdonlilrda.rrdordasir.,:1lirfiulm (poor rissue perfusion) .tn

inur'lilfiurir'1fi cvdrornftioturcdrrl dr *rar (organ faiture] n1r "l

fl edairol dlirru4lmuf,u1efi n
gru:fl usn fiqrnnrtrdlrflufsiolild

Blood pressure = C.O. x SVR

= (SVx HR) x SVR
= (EDV - ESV) x HR) x SvR

rirrar eov/ eov drfiritrirriu t nrurfrl:Jlusr.rnr:

= EDV x (EDV - ESV) x HR) x SVR

EDV

= EDV x ((EDV - ESV) x HR) x SVR

EDV

118 rrtdtinrinqndug, u

eir leov- ESV) / EDV rflurliilrrulfioqfi rvfioo{un"trlr'loilfi'r r:Jiuu rfiulrfi:Jtrrnlfioo
daufilciirrtir dt6orir election lraction (EF)

=Blood pressure EDV x EF x HR x SVR

1ourirfiilolfi

C.O. Ylllufi{ cardiac output
SVB vmufil systemic vascular resistance
SV fitJ'lufi{ stroke volume

EDV 14tJ1ufi.1 end diastolic volume

ESV lru'lufr'l end systolic volume

lfi ofi lr:rurern or r rdrn'uf

=Blood oressure EDV x EF x HR x SVR

c:rfiulfiir flqdudnr:rqrJnrr o"ulnfin fi I:lo{u 6o

1. End diaslolic volume (EDV) rfiurliursurdaetilil''r1cdaufrleY'l 6ln'Jr preload
2. Ejection fraction (EF) liunruour:n'lufl1r:i!6'1to'Jli'il1 tiunir contractility
3. Heart rate rflu{,:ul:nr:rfiuzotfrtt tiunir rnytnm
4. Systemic vascular resistance tflunrrrld'rutrutroltdltfiaodru nru 6un'jr afterload

Blood pressure = preload x contractility x rhythm x afterload

ud,ru'u riionrurq'ulnfiqr duuuln.'t rido.ttier: rj'r rfinernrrniJo{ulo'lu a rl::nr:

d'.rndrr

fl1?u aHaa?lrJi'ulafin
drnlildulnfin (Blood pressure) tl::no!druFirnrrln'uaolraon lfiontru:rirtetlun-r

(syslolic blood pressure) un:rirnrrrouro.rvoaorfiootru:rir'lqnfl'tun"x (diastolic blood pressure)
1. Systolic blood pressure 1sae1 rfrurirnruri'utto,,,:nnan 6anlru:u"rtlfir-roTr ri.luanfi.:

systolic function firrir SBP g't uao.'r'jr systolic function 6 firnir Sep mrl uaot'ir systolic
function lri6

2. D iastol ic blood pressure 1oee1 lfl udr nru d'ulo.tv n o o t6 aolru;v"r'iqnnr ud'l ri.Mn

fi'r diastolic function vio afterload tN:r: trarnfiu tdarirlqnnrudr da,,r{riutl:ldrunruto.r

xn0Gt60ad'lu:1fl1u (systemic vascular reststance. SVR) firrir DBP fl,J ufl91\t'jl afterload fl{
firri'r oep nir uoqu'ir afterload sit

Shock: Earl;- Assessmenr nnFwlf nNfrLlIS LLg

mltJ[[nn9i't{1a{ systolic blood pressure ttfl: diaslolic blood pressure riun,jr oulse

pressure

lPulse pressure = systolic blood pressure - diastolic blood pressure
rnru?i1unrifi?dui'r putse pressure nittialri firr:rurlrnirn't putse pressure fid1

tfiun'jrn:a.rud,:ro,,r systotic btood pre""r," lurruvrfur.riolil rir pube pressure dnirs ,,rlanir

stroke volume tlff; cardiac output fl,J drurir pulse pressure filra:J ritlJon'ir stroke volume
uo; cardiac output el'r d'ruandudrsdr.toio}Jd

1. Bp 80/30 ul.rJ:or n'rurrudl pulse pressure ld so ut. :an d.l rflu wide pulse

pr"ssur" ldo.:otnrit pulse pressure 1nn'jlnittut,:la.:dr systolic blood pressure 6orutnn,1t
40 utJ. ?ayr rj.rlon'jrnt:6onlu:rsdlflunrry6ondfi cardiac output F,{ (high cardiac output

shock, hyperdynamic shock)

2- BP g0/60 ul.rj:ou r'irurrurdl putse pressure 1d zo xu.rj:ol fi{rflu narrow pulse
pre""rr" tdo,tetnrit pulse pressure fioun'jrni,:nut,:ta.:rir systolic blood pressure 6orjaun,jr

40 ,J, iol ri.rron'jrnm;6onlu:ruflriunrryfiondfi cardiac ourput Frrl (tow cardiac output

shock. hypodynamic shock)

n-r:tt nrunrir diastolic blood pressure !ra! pulse pressure arlr:nriruifirduntr:
6onldar'r.r:rn l5r Tnfl rqflr:6onlu:trJ:ri urn (earty shock)

Mean arterial pressure (MAP)

rdrnrrlnulafi nrafi u lmean arteriat pressure. tUne; cur:nriruxruldiln

'- __lL MAP = l/3 SBP + 2/3 DBP

?1n90?nrtniu?ru mean arterial pressure dr'rdu rfiu1fi'jr

1. Mean arterial pressure tsuadn-u diastolic blood pressure ulnnit systolic blood
pressure Toa diastolic blood pressure finttldrd'cglflu z rilfla.: systolic blood pressure
!do'ie1n diastotic time finrr Enrrflu 2 ryi'tlro,t systotic time ftrfu{rhudo{1un1x;6an?rui

ltiurr:ne;finr:r daurr:Jowa.r diastolic blood pressure dau systotic btood pressure oiit,

finrl aor:tun'r:niu? mean arteriat pressure firsrf,u ifi'trin:rifi heart rate lrir5?rnul ru:r:
fir heart rate l5rocdrlfi diastotic time #un.r ah:rdturo{ diastolic tme irlrihi 2 tillo.,t
systolic time lunlfififi tactrycaroia d.: systotic time rrlfiornleuilfiuro.J eRS comptex e!fi\t
laiiuqo sr segment ttfl; diastotic tme oldrrnooriufiusa.,l T wave tufi.roa 6rfiu.r,o{ eRS

complex

120 rrtrjniainqofiugru

z, lunm;6on tilruurmolnr:inura{finr:inur mean arterial pressure hlo{d as
r.nr.rJ:on'lu{rhufifinlln'ulafifliln6rrriou lrj'ldnlrunru'irtflrrrralo.:nr:inu'ro{fi systotic
blood oressure 90 tJ .!roy| t lll:nlXCfion lytRYl high cardiac output snocf lriOrln:nld

systotic blood pressure 90 rJrJ, ?0r lflurfl1y rEl'lunr:r-nurld rfio.rmn6onn{tdfiR1?3 afterload

m'r rirlfi diastotic btood pressure oirnulild, o uriir systolic blood pressure 43fi.J 90 tJ.:J5ovl
1firfinu rtsidt mean arteriat pressure ffq:ti',1'[jfi.] 65 u . :oYl dru{on :;tnn low cardiac
outpur shock o1alfid'1 systotic blood pressure gO ll.:J:ar rflurflrvlrulunrrinurld rfia'tlrn

6onrJ::rnvrdfi afterload q.: r'':d{:hufiotfinmldulafinoqjturnrud:Jnfitr'lriau

iofi nra'r#uulfirio u'lun1f, [lrjfl fl antnfiu1afi n'lunr:a-iirdt nretion
t. tu{rJrudfi nlln'ulnfi or gtlrriou lriauT :n'lfi rdr svstolic blood pressure n'r n'jr go

11. :an 'lunr:ificdBn1;6on1fi tu:l;rir syslolic blood pressure fig,:n'jr so :'tr':J:al filrl

fi o{tunrr ;6 o nli 6''rriu6.: datil:: rfi uduniu tissue perf usion dl u tfl la
z. lufirlrtriifinlud'ulafinrioudr.rq'rr.rrriou lrintn:n'lfirdr svstolic blood pressure lu

nr:ifiqounrrvdan'ld rdu {rJrufinaurn finfirnrdoriou systolic blood pressure fiosn'jr go
lU.rJ:olr UiotU{ilrUfifr tett ventricular ejection fraction n"tr.trnlt tflU::s: Lxdl1t1ll systolic

btood pressure fiq:riosnir 90 rJ. roroliufix uriflCOm:aon9r' ::d'lnruifinoYrrJnfi ttOn.:'j-t

{rtrulrio{tunm:6on rfio.tcrn tissue perf usion Ll nfi
3. nr:ldruroto,': cuff fi}jttr.rr;o*rrfuturorutuao':{ ru Tnurorr:1u{ilxufid?u Yln

'lfi:rtrrotlo,i cuit ii rfr n rfi uIil o;5o ntur rfi'ulafi n'ldo.l tfi un1r tfl uqi.l

t. nr:tdrniotionlr.rri'uTnfino'mTuffi (automated blood pressure measurement) lu{

d?uiififixlo rfiufinq-lfirr lnatar'n;'lu atrial fibrillation usu nrrrtur'otatfiuo:lurrrin;nito:-lrirvirrfu
air n n"hinrrl.l ri'ulnfi srdinl6qr n rnia{ionrr lrn''uIofi no''mlu116mi n'ir nrT il rfl ucE,t

n1,rnr?ed1{n1uilrsl$ilfi $rqlort shock
1, nr:n:rcitrnra :: tfi u preload higJuriraiururirdanral::duar:rirrirudr"r"l ta',r

ir,rnrEvl'r,inftfin

2, nr: ::tfi u contractility aT.rr:nr.l:;rfiuldTeru

. rds.'r 51 : firrfiu,r St rur udqeir contractilivbid f,,lrfiu': St tr".t u6[r].t'i1 contractility

o

. !r6u..: s3 : fitn:tq 53 gallop tlflo{'il contractility bi6 'lfirirnr:trunrio't:l'irrfil'r

53 gallop drlt'tdrflu LV 53 gallop n6o Rv sg gattop {i':J,r:lonfin LV dysfunction
ttn; RV dysfunction Fl1tJfl"'ld'!

. [du,J 34: flrntlclw 54 gallop ttf,a{-j'] contractility 6 LLgi diastolic function ftn

Shock: Errly Assessment Lon'iuni rfifirtn l2l

:Jn6 lqild1u restrictiv€/ hypertrophic cardiomyopathy niolun{:.r LV pressure

ovefloao

3. n1? ryrfiu rhythm f,.trJ1in ?:rfiu'ldqrn6tcr rrny EKG Torja"n:.r r5rta.l6viqrfifi!.ln
rionrr d'uIofiq 6o filre:frfioanir oo niroiaurfi yiorirn.ir rso ni,rsiourfi

4. nrr :lrfiu aftertoad fl1 1Tfl :yrfiu1dTot

. Diastotic btood pressure (DBp) : fi1 DBp ri.t lrilfl.j1 afterload nir d'r oee 4,:

r[flo\r'it afterload d.]

. Pulse pressure: tir pulse pressure n{1\t t!fla\:,jl afterload gl".t fir oulse oressure

rrFtu [[flo{,]'t afterload {{

r Capillary refitling time: fit capillary refilling time du rroo,r,jr afterload grh d',r

capillary refilling time U,t? rrfio,r.j1 afterload fl,0

n1:lnj{rhsmrla{f;on (Classification of shock}

2orm:o ur-i'rrl:: mrla,rdanld Ir rnfl flr vlutBoi:ivr ur n'.:ri

1. Low cardiac output shock (hypodynamic shock) rflunrt:fonfi cardiac output sir

ttflrlfrun]x:fionfirnaotdoodlr (vasoconstriction) d.,rruoli diastoric brood pressure fi{ lrfl;

q{pulse pressure unu ri'r'lfi systemic vascular resistance (SVR) ::naldrunrr:fian ::myr

sir,.rr sioltd

1) Hypovolemic shock
2) Cardiogenic shock
3) Obstructive shock ldrrri cardiac tamponade, massive pulmonary embolism,

tension pneumothorax, severe pulmonary artery hypertension

2. High cardiac output shock (distributive shock. hyperdynamic shock) rflunrrydanfi

cardiac output a'r llncrflunrr:6ondvngott6oorrluruFl"? (vasodilatation) d,rarnlfi diastotic btood

pressure O,l"l ![Oi pulse pressure nif.f fif'lfi systemic vascular resistance (SVR) Ot'1 rynoll
drsnrr:{on :: rnvrsir,tr Fialild

1) Septic shock
2) Anaphylactic shock
3) Endocrinologic shock ldlLri adrenal crisis. thyroid storm
4) Neurogenic shock

5) Drug and toxin lfiuriudfiqudrittri'ynon rfiaorflluot"'r (vasodilataiion effect)

O1 6u1 nju post-resuscitation syndrome detrltd-r: return or spontaneous circulation
(ROSC) e1n cardiac arrest

nrrfio;irildernrrv6anrrcin; :;lny dr.r&u do,rordsa-nuruvlrrnfifinro16on ::rnyrfur

::norfi'lu

122 ntrirdoinqnduS'tu

nrmrdstli:milla.rf,onlcugern iugular venous pressure {JVP)
.1. .tvp eir rrrlldlu hypovolemic shock rto:lu dislributive shock
We gr ruifr'lu cardiogenic shock !!nv obstructive shock llunalflrTuld1au

o JVP {r tlflvnflei1.':nluld lung crepitation tfludnuru:to'l cardiogenic shock
r JVP d,l uavnrleilnn1u1d16 lung crepitation tflud'npru:ta': obstructive shock

nroair.rn,rryf;sr#fidnnsu:na,l low cardiac output shock uas high cardiac output
shock delnlu

1. {rJru septic snocx fifi vascular ldakage oriro ln eyfidnuru:yr':nfifinlo.:ntttrn
rir (nypovotemia) irudrt {i,trflua'ns i1tf,tJ1Jo{ low cardiac output shock ttnt high cardiac
output shock rSaiu{:-ht septic shock tu::u;firudornrtluu:o c:fiAr:6ionar.r (mediator) fi

nqn1tf1,r1uflo.:nfiurtianrio (myocardial suppressant factor) 6tfif,nuru;to't cardiogenic shock
{itrflu low cardiac output shock rxtloiid?!

lil2. nrx hypocalcemia dlurr:.rriu o1o low cardiac output shock uia high cardiac

outout shock fi"ld rfio.lmn catcium rflurn6orrdddrn"qlunr:nndr1a.,,:rh1o'ludrl isovolemic
contraction R,t1y hypocalcemia rir}in1'1xit"ttJTn'l1n11fi:Ld'rtrO1u'rh (sysiolic function) xmrign

i?,,rc:fidnr ;ndr n-u cardiogenic snocf d,,r rflu low cardiac output shock ]urrwrdlenu

calcium rflurnfiauifidrdruJunr:nooY, lo,{nd1 [do[iu1t!g\: noo!fiandxutln1fl (vasoconstriction)
nr?; hypocatcemia fi1urr:oi'r}iun0n!6oodx n1wmu6'1 (vasodilatation) fittflu high cardiac
output shock lun.ny hypocatcemia iilurr:uiuordrio'ng6u;r1{nfifinfilflu low cardiac output
shock nia high cardiac output shock fi1d

fl'rn4nflon hypocalcemia fitarucrur,tq rroiormqfiiin,rrdrdrlrra:finrurfiurfiotrYu

{rJru fi o glunm:fi an'[r{rrri
1) Refractory shoct tdasorn tfra {:-Jruoqitunrr;6an tfluLxfl'lu'lu ?viiflTrt$ ATP

l(adenosisne triphosphate) q"ruru 'ln 6,1finr:1fi calcium rfio'lfilunlrfiofrx

la.rnfirl.t rdori"t'lo unYnfi 'ttJ tdoliu:Jrtotvnfl n tAog'hoiluxutJln

z1 {ilrud}ir6oo.iruMn (massive blood transfusionl rdotornnr:16ontunula'll

rfioero:finr:ld citrate a':'lrlrdolrilfirfionrr{osl''r 6.:lirhi calcium'hrfionfirirlnlfi

{rhuoira,r

3) Rhabdomyolysi" rfio''rlrnnrr:drir}l phosphate'tu16ooglrfiarorntfianr:dora
lo.lnd'l tdo i'tr"r}i:vni:.nro.r calcium oirn,:

4) nd',rrir plasmapheresis rio plasma exchange tdamrn blood component fild

l:finr:ld citrare n,rllnioll'hi16oorrfi.rn"r i.rr'rlfi catcium'lurfionfirirlrlfi{rJru

nhn.,,:

Shock: Early Assessmcnt nniuv{ nfrfi$S 123

3 n1r: metaboric acidosis d:utn{ dr,:nruq;nfl!flllo{lgufifloor6oorlEJrflsirr'rir,lnru
(vasodilatation) d,: rflun"nsru;rar high cardiac output shock iurYurr: metabolic acidosis d

?uttl{fu3:nanrrvri,rrura$ir'lovs'rrta.idruIacfio$r'r'r 6,rfin-nuru:ra.r cardiogenic shock d,r

lflra"nuru:ta': tow cardiac output shock 'lurr,:nfifin6.:ul cvp q,ltufirJrunajild d{qcnar

ot.to':sionr:inurdra uasopressor'[ri6

nr:r.tfi 1 [cqonr:trjiu-rtfiUtl low cardiac output shock lrflJ high cardiac output shock

Cardiac outpul Lorv caidiac output shock High cardiac output shock

Pulse pressure A"oeas" r".*"*

Diastolic blood pressure narrow wtde

Extremitjes increase decrease

cotd warm

Capillary refill slow fast

Heart sound decrease increase

Temperature Not change increase or decrease

:ioii$mnernnmrrGsrjlfiuu bw cardiac output shock lroc high cardiac output shock
1- n'trst:?? capillary refilling test 'ldrj::tfiu tissue perfusion ldrarrrr:lu tow cardiac

oulput shock 'irna ouarsionr::"nuryio'ki lnufirrflu tow cardiac outpui shock finauouoa
rionr:inur capittary refitting time o: r5rtiun.irnnilriounrrfnur fi5a'lrioo:tcuo.rsionr:inur

2, fl'nnt?a capi ary refi ing test lriotrr:ntdrJ:: rfiu ssue perfusion lun{il trign

cardiac output shock'ld rl:r:lufirjrldrflu high cardiac output shock ?:fi systemic vascular
resistance n;r rirlfi capittary refi ing rime rirn.jrrlnfi rrfiir{rlrua-.ro{1ufl.tx; shock odfin1

n'l:fl ?u?'lUlo\rf,T fli1'lud1{n1s

or:rirluir,rnrs fi nr:n::mtioanriu 2 dru

'1. Intracettutar compartment rflurl3lrruar:rirfraqjlurrnri' fiafiofl za 6qrflu 4eo/o att

rirrrinur-'r fi.,ror:rirrirudrfl urlirrruorlirn'fi lrndar,'ludr.:]nrs

2. Extracettular compartment lf urJilrnrcr:rirfiatiuonrrnd r1fia{ rfs 6orflu zox
to'rfryfnor"r n'ur:nurit'ldlflu z oru 6a

1) Interstitiat compartment rflu:J?lrruor:rirfioqilu interstitium d,rfiori gf+ 1a.t vS
d+virrir tr+ 6nrflu is% ro,rrirrrind'r

2) Intravascutar compartment rflul|?rrrunr:rirfiodlunaoordoo {irfiod v+ ro,r
t/g {i'rrirni! 1/12 Frrlflu solo ragjrrfnd'r d':nr:rjrsiru intravascurar compartment ulilrfi

124 rrtdrtTnlnqndunru

n1:Nflro 2 [lfl9\:l|u']1rl1.tlufl'l:lu9nun'l'l:ton

Low cardiac output shock
Hypovolemic shock

Cardiogenic shock 1

e Left side
r Right side

Obstructive shock

High cardiac output shock (distributive shock)

Septic shock I

Endocrinologic shock

Anaphylactic shock

Neurogenic shock

Drug and toxin

H 'tulflq : CVP : central venous pressure, PCWP : pulrnonary capillary wedge pressure SVR : systemic vascular

resistance

ilir.nruriaudqntuirsnru usifrrfluer:rirdfinlldr6'zu.l nrinu1d qano{}tofl1flqin'}l

ilrlarisu r6ao (hemodynamics) 6"lutuluvn,:n6fin6.rfinr:6ofiufirifid'r{'i de;lrttfitr 'tru

or:rirludrudlrnnirnrr ::tfiuor:rirtudrudu

n1fll:vt ud1Tltl1, 6l2 n1\tl n0ntl{fl'lllYl'l{9A n
1. Intracettutar compartment ltfi'j'rornirludrudc: rfluo'r:riidfirFuruu'rnfrqn'ludr.:nru

finrrudrirnr:::ffiuliurndqolnurfT}IIdi6nr:n:rc:voiunrtrffinn'r{furflun1: r:riu'jlrtad
:h;amororfinr:ur flsorfifl ?fi nrjnfivialri ad1,tbfi nu ::nirnru!6ins'"rdfi oiln6fu hjldrfi o
ornrJilrruor:rir'luir.rnrafi o:lnfi Mtiu r".,,:fi nlnq6ul 6no"rururrn

Inlerstitiat compartment 6['1 1rfi rytfi uldq'rnnnutu;vrr''rnfifintda1lJd
1) nllgE1?vilr edema Lj,:lon'jrdlrdltu interstitium tnu
2) n']lfrl'lev!! dry lip, dry tongue, sunken eyeball, poor skin turgor 1J{ flnx1ff'll

tir'lu interstitiu. tin
lntravascular compartment fll 1rn:hctfit-t'ldlnrLi6nr:niolilri

1) n,l:tnxefllnnnfin'idrrri nr:n:ro postural tachycardia. resting tachycardia postural

hypotension, iugular venous pressure

2) ntrdl "nnfl1r'ldttri nr:io central venous pressure (CVP) [la;n']?itl pulmonary

capillary wedge pressure (PCWP)

Slrock: Earll- Assc.ssment nniHni nfrftftg L25

tttlfi uso,JiEntits JVP (jugular venous pressure) [qunlruaufrt*za,t 45 onFn anFnufianFi.t CVp

(centra! venous pressure) difinetnntziarr JVp uxndn b mu LtJnlil

u0ne1nfAi :Lt u-llaefuriofinr:vrsruufroay1i6f-rrdaJnn1tnaLflu0..lsion1r-hifltrd1 (fluid respon-

nisiveness) fin1fli6 pulse pressure variation (PPV). stroke volume variarion (SW), peak

aortic llow velocity variation, aortic blood llow velocity variation

fflJ

n1?;{0n Lilunixrfifluldil0ulurio,ronriu un:turrt:Ji:t6vr'.:'l:J uvfftichrflufierda.:fin.r 5

rf.:lunr:ificdur[n:nrii-nrflfinnda\:[y't:flxril.lyix\rfi 6rc:flrrr:naonrl: Lr tndo!Fi.t.]"i leu
rovrr;or"flryd rfin'tyd1u::Llll (multiorgan failure) rracdl ltnnfia'n:1n1irfiufiinfl0.Jftil?ua\:ld

Isnd'trd'].i6\r
1. David C. Mccee, l\.4.D.. and Michael K. Gould. M.D. Preventing Complications of Centrai Venous Catheterization. N

Engl J [4ed. Volume 348i1123-1133, l/arch 20, 2003.

2. Vlncent Jl. Weil lVH. Fluid challenge revisited. Crit Care Med 2006:1333 7.
3. Collojd solutions lor lluid resuscitation. Cochrane Database Syst Rev 2008 Jan 23:{1):CD001319.
4. Ellender TJ. The Use ol Vasopresso6 and Inotropes in the Emergency Medical Treatment of Shock. Emerg Med Cln

North Am - 01-AUG 2008;26(3):759-86. ix.

5. Winlers ME. Monitoring the Critically lll Emergency Department Patient. Emerg Med Clin North Am - 01-AUG-2008:

26(3J:741 57. ix.

6. Famsay J. Noninvasive Technologies for Tissue Perfusion. Anesthesiol Clin 0 i -DEC-2006:24(4):76G 15.
7. Beinhart K Monitoring Ortransport and tissue oxygenatior ln critically ill patient. In: Fleinhart K. Eyrich K (eds).

Clinical aspects of O, transport and tissue oxygenation. Berlin: Springer: j999. pp. 195 211.

126 ntfrrintnqnCuSru

8. Cabnacci MH. SaErB Sopsis and Septic Shock lmplwlng outcoms in the EmsrgBncY DBparfistt - Emerg M€d

Clln Norfi Am - 01 -AUG-200826{3):603-23, vii.

g. Rivars E tmproving Outcorns icr So/€re Sepsis and S€ptlc Shock Toots lor Eariy ld€ntlficatlon of At-Risk |%rierts

ard Tr€atnent kotocol lmplarnfftation. Crit Car€ Clln - July 2008:24(3 SuppDl47.

al10- Riv€rs E. Ngulrff 8.. Hwslad S., et Early goEl-dlr€ct€d th€rapy in the tr€lmsnt of ssr€rB 8ep8i5 and septic

shock. N Engl J M€d 315. 1368-77.2001.

Vascular Access

qilafi nawgi

nr;rirrinnnr:rrl aoqrfionlqurovtrcnr:ldsru central venous catheter (CVC) riu

r'nnnrtdfinlrrrhrfulunrrgun{:Jrululoigriuarirdir rdomrn{lJrunt;inqnfinrrlirrflufior
ldfusr:uxr uT r.lfr6ru; fl'r:o1lr1i u.rilfiJnrililnrluuTnfi nmctuurr:ruamfi nmuirrflufio.ild

firnr:fnurmcrunuln (renal replacement therapy) lqun1flrh hemodialysis 5a continuous renal
replacement therapy rfludu 5,,:finrril l'r rflufiuyrnriuncnurlrod:Jg'rifi.nulula$g{:Jruinqorda.l

f,nruiunvnrrmrlr:n1unr:n'rr.r"nnnrrd'rndrr rnrufiriorj.odtunr:lei cvc un:nrrcllynnsou
domrfi odu rtrfrrbinr:guainurdafl orrTunmrurrndaurfi urn'! cvc ldrfl uadr.rd

lu:lq:.tiu alcuri.,r cvcldrflu 4 :hylnryn-n d.:d

1. Peripherally inserted central venous catheter (plCC) 60 catheterdfi 1-3 lumensld
rdr{naoordonniuinruusu Insfi:in1u catheter o{dunoo 16aacl'rdrunn.r.l

2. Temporary (non-tunneled) central venous catheter 6oflu catheter firi.rmnr"nqminfir.r

tdu silicone nia iaqdufuiu ldu potyurethane rlo tefton orrfi t-g tumens niour.nfiq

aonrrrLulirdah4armrnld putmonary aftery carneter ldlourfrlil cvc rfiodo;firyuvrsu,jr,,l
vrrrdrdftrnri.roqlnfirYunrordr$nooqr6ontnurfrb cvc tfindcc'l$drnfilfirJrudfiornrrld cvc
'lu:vug rmrlriuru

3. Long-term (tunneled) central venous catheter f,1u catheter tiindcurrnag"tun"r{
rhuldurulrnn'ir o flr.tor#u\t udnr{daru catherer !fioo,l?tdda.,:orffunr:nirn'nf,tsrudru
nfto{ldfiarftriourrrilnrir{nooorfiocr ils,rdldo!flunrnlooniunr:rfin coronizarion ro.ruunfiriu

fl'll'lu{ln1{ Iumen flA\t catheter

128 rrtdrriainqnCr5ru

4. Ports 6onr:fl.:q!n?ninfilunrl t ltvlhc. n plastic riofiicru catneter d,:il-roiitfi

firrfiw?nnrvflron lqu arucru catheter tfl otdr{fi nonl6oqq'ldxunn1.J tdoetuiv, ru'ltdld

rnoan rdanm'rldTou uvl,: r{ujruft rr,tri,,rrdr{n:: r:jr:d":nslrr

lulvrnrrr.rdqr'lonsirrfir cvc tfinfr z d,,rrflu catheter fi'ldlJou'luloig{rJruinqnrrol

otn:nvrinr:'ldlou unvr ri{g un{:J'runr alulofi groo

Indication for central venous catheter insertion
drnir{oil.rd'lunr:td cvc fi o'rd'

t. rfjaldtunr:rJ:: tfiunm;emlvlotfiu.ttotcr:rir'lurnoantfion (invasive hemodynamic

monitoring)

z. rdoldliunr'r1unr:lficraihadrs:roriruri{rJrudfin1?: hypovolemic shock x;a septic

snocK

s. rdoldtunr':tfif,1To'r?1"rlvl't{fi noot6oo (parenteral nutrition)
c. rdot'fitunrrtfifl rrnfidrfa (chemolherapy)
s. rfjoldtunr:fnsrtouruln (renal replacement therapy)

o. rfialdrfluvrr.rtunr:'lei pulmonary artery catheter tia temporary pacemaKer

Gontraindication of central venous catheter insertion
flo r$iq;'[ri fi absolute contraindication lunlrtd cvc uri fi donr:r ;r-t n',':d

i. Jilid cvc nirufi ruri,rliuT nrfr fi nr:60rdoo{rfi r

z. {:Jrrdfinrrvnr:16{sr"lra{ rfianfto:Jn6 (abnormal coagulopathy) nr:ldilnrrufill

nr':rdrndrrriauo;rirrinnnr:
s. {ll'rv"oronr;nr:rflu{iifinrrujun;nttuirurqlunrairu"nnnr:tfluod'xd uSor{rrinnnr:

nr aldnrrr g umalfirirurrp

nr:llfllfl fl 1x unrt rfi t drt a'r 160 fi fi oiln 6
tunrrrirrinnnr:rdatd cvc lourovr:rfu{rJrudo{tuladg{:-hur'rrinrYu nr::;rio:;i.otu

n:riii{ilrromfinrrrfto:Jnfiro.onr:u6.':nrrarrfioolfi tufidq;lfinnirrfi.onruftnrlnBfinuldilos

runviiufllnlnld.r nd''
L Thrombocytopenia {rhufifirn6n 16arrsirriourirrinnnr:#sli-rvaaorfionnr:'ld:iu

rnfi nrfi onfl qrmu rfr a'lfi::ri'rrn6nra'onrrnn'ir 50.000-80.000 /uL

2. Thrombocytopatny{rhilu1ofig{r-hufifnfilon"rflrnonr:rirtruftpr nfitotrn6srfioo'lfi
rufi'jro;fi:sd'!rn6ou6oooqjtulnruri:Jnfiufirfisrril orrtqfinlld:Jou lduri nm; uremia, nr:'lfiir

\ja\(ular Ac(css qiari na':agl 129

urdrumfinrfiae rdu aspirin niourlunsju thienopyridine (tictopidine and clopidogrel) [[aJU1

NSAIDs Touflt,lild1 1?fiti'ni'qnnrirl.xfifloo [6aorr'.lLLnEn1rld cvc ldlauilaonn-u urifi.]nrfiff
ntt;ur:ndau rriu urn'lrdrlrdldurianun.,,: r4iorfin pneumothorax fia.:'ldoru:;uruoriaancrn
oo (intercostal chest drain, tCD) unmf{q llno'rrflulr'qsdorfinrrlortr:nlunr:ufihnrr;nr:

rirmura,: m6n rfi on fi oiln61dd{ii

2.1 runurfiriuol q
z.z iu{:-Jrufrfin,'ry uremia nr:vri diatysis tfirfisrvto
2.3 'Ifi cryoprecipitate 10 units t1n"i tz drl.n
2.4 tii 1-diamino-8-D-argimine vasopressin (DDAVP) flu1fr 0.3 ug/kg yl,t\rlifl0g

r6on uoy'hifrrnn o-t z rirlr.r-:

2.5 tfi intravenous conjugated estrogen

2.6 'lfirn6qrfionflnuru
d'rvtJfilxufl6,iafor tdul glycoprotein (GP) llb/llla inhibitor (riiu abciximab. eptifibatide)
urnrfior1ryrnrrfioooonfin:Jnfinr:ufi'lslosnr:tfim6a 16aororlru un;rqourdlndm

3. Unfractionated heparin (UFHI laufi'dil UFH firir r,,, rJ:suruudrdrl \: r41nflt.uJ
'jrl:riru''nonr: R?rllunul urH riouoejr.rriau o r"'illonlu}l un;rnrlrdr activated partial
thromboplastin time (aPTf) 'jrnaiulr{:Jn6riolrj lunrdri.rrdrlnrrr:n ufillnm; rfi0froonlu
{rJrufifi aerr urrfio nficrnnr:ldiu urH ldTqunr:lfi proramine sutfate (1u.r0 .1 mg ra\:

protamine orrr:nthtu'.,,: UFH ldillJrJ'lfu 100 U] lrin?r6o Drotamine lrnnir 3s un. oion*,,,:

4. Low molecular weight heparin (LMwHl lfluurfrfi t,,, urrnir UFH ua:bjnrrr:o

n:tnrufio n6rolnr:uftn"elolr6ooolnnltnr?e aertld n.r:nqo LMWH rio flhfinnnr:adln

riou a+:irlr.r.r rnnrfinnrr: rfioooonfterilnn'fin"ddiu L[rwH drilrr0ufilsldlnunr:lfi fresn trozen

plasma (FFP)

5. warfarin rfluurdrunr:uu{.:n"rta.,:rfiooiitfrrjou'lurxml5n"6 Toarfr}lriourirrtnanr:

R?flluq warfarin rfluncrsdrtriau 5 iu uo:rnrr prothrombin time (pT) ouolilurnfu?iilnfi tu
n:drd,rpi'ru fl1 'rrnlfi vitamin K 1ula 1-5 rn. yrlrnoorfion riovrr.rnr:fiuld n1.trnx1 fio
nfito,':nr:u{rq'rta{ r6onevna!6u{rJnfildart'lunnr a-tz rir1lr nr::rfin:;i, rj'lfi viiamin

x lulJurniiosrJrnrfiu}J rdo.n, nororir'lfirfionn:nr:u{.rsYrlalrfiooarn-idnfiId uanorndu-.r

sT ur:n'lfi r rp rfr o urillnrr v rfi oer o o n fi oil n filu fl:Jr ufildil warf ari n Ifi

6. FibrinoMic tfrerapy {rhufrldiuUrlun4'ud r:iu streptokinase (SK, T1,, rj:vrJ.t l 10

'ttyurfi), recombinant tissue plasminogen activator (r'tPA, T-.? 10 urfi1 rrfirfi:)qtr16oo

aonfin:Jnd arm:nufiltlqan, :bl FFp 1,000 rJo. rln o-a drfu.r nrnfiflrgylria.r votume overtoad
orltln'lti cryoprecipitate uruld

130 rrrdrrioinqmfi'ugru

1u{rhun{lfili:1u fibrinotytic drugs lnuronr: sK err:vdntds.:nt:rhtinnnr:rrwtoon
rfiooynrfiorvd.rsrn.ldflrurriurrarotjr{riou s lvjrtoorir T,,, lotutttrinvtfier dr"irtiunr:tFan
dtinonr:iir?nnr {emoral vein tfiatornnrnrfin:!ry ttfionoonevflr r:nrtrrr rfiaolnunr:nold'
kjar:rfiondtisrnnrtrrirrru internal jugular vein ttio subclavian vein tdatornttrn rfinrlrynt

r6ooraano;drnr:fir 16anlfiurn

fioar:fier:anriould cvc

1. elrdan catheter uuuln

nr:fiqr:rurfi1xro-nuru;nr:lderurLo'rfllu cvc rdu lufitrudfinrrroi lfluda,:trinr:

inurlnui6 renal replacement therapy Frl:tfiondra catheter fifi lumen turo'ltld 2 lumens tfio
rfluvrr.rtfi16onlnooanua:lr.ronairrdrqin"r{druldaair.rovnrn airufi audfinm;6on.irrfludo,,rlni
cvc rriiorl::rfiu intravascular volume ua:'hidr:riruouruadrmror5rarer6onld catheter fifi
tumen tlroltqjtfiu't 1 lumen fl5oricrrml6itflu vascular sheath (cordis calheter) rfiorqiuil'ld
putmonary artery catneter oial rfrvilflilrufitirrflufio'r'ldiuurvionlrfl']fi.tilr1,Jr4Roa [6onHaru
tfiaorqrFan"ld cvc rfiB 2 vio 3 tumens lfirf.rdfimvfinliroro'jr singte lumen catheter rfu

fi o-n:rnr:fi orrdan'rn'ir multFlumen catheter3

2. nrufintoccru catheter

firi',rernnr:'l6i CVC frvnoarFao internal jugular vein rt6o subclavian vein tiu:Jaru

d'ru cvc nr:odlunhurri':drrnr;cr6o:J:;rrru 1-3 ttu6t sri riouiin:rdr{ right atrium (RA)
lnusl"rrLu .ra'"lnrirrar r:ncr:rq'ldernnr:rir chest x ray tn':"[ai catheter {rirtt"nnnr?Fr']?yri'ru

:::vri:?ir,r1nu rruernol'runrirfi'tnialu cvc lilfi.J superior vena cava (SVc) riourflrei Rn' n''.r

ruool'luarr:r.rfi t

nr:roi 1 uao'::v s velrfi nd ur vr:drl o,:n, :lei cvc luorh uurjtdr': 1

Internal jugular vein tc
Right 20
Left
10
Subclavian vein
Right 50
Left 55

Antecubital vein
Risht
Left

\jirsL lllar Ar'(e)s aiqfi nansd l3L

rfiyiln'r:lai cvc .r*t femorat vein F?r'ldfin ::rJ.tru 15-20 mu6rrJ6r niairfirlaru

fl1U CVC orjufif,o:ousioro*l itiac bifurcation 10,,: inferior vena cava (tVC) rfinfiafl

s. r;r6antd cvc iirhrmi,rln

tufloXlTu ni ulrri,rfildfunrrlfiuuld*ri intemal jugutar vein (tJV) rY.l anterior approach

!!fly posterior approach rdoternfi:1smua"n:rnr:n'otdodrn'jrsr"rufirj.r femoral vein rro:l.r'lonra

tfin pneumothorax oirn'jr un:our:nfilrr6ooldirun'jr subcravian veinn i.onr:rfionldlufi ru
fiorlfiflryrrur'odrunr:u{rd'rra.:16oo r.ria{lhrdldrn{0.:riruflrulc riryir suoctavian vei-n riu

rfluol'r rrvl,:fin'10n1filfiF] catheter related blood stream infection (cFBSr) n:.rfidrr"6 rrpial?fi

mechanicat compticarion '16'rjoun.jr t.lv i.rn.r:16anlflu{:jrlfililfiflqurnr:u{-:n-rlatr6oot

ltnvfirirv"qnnr:r'nruthurqrfia$ta:rrvr"rnr:ld uttrasound (u/s) rixurilfi n6iuyrj,:ro,r
tfiurfion'lu:;r'ir,rnr:lirn"nonrro:fl'trJ.trnfletnl.tcur:ndoura''tnr:1ai cvc iiel'.t uyil..r subctavian
vein'ld 0d'Nhfiq1 fi rflfrfinrr;nr:u{.rd'rro,:rdaofior.lnfiorir.r:uu:rrrnfiarrrLqhrfludo''fl6icvc
n'::lfinr:inurrfioufihnrrvnrrrfinrlnfio,:nairr uacrfionld cvc firirrru femorar vein rfio{qrn
riun"r uy,:fr nrrr:nnofi ril16oqldirsyrnrfi onlr:ur:n$ou

tuflrpTu nr:'lei cvc orfrflnr:rirfiunoirrrnirsalrdurfianloufl.trff anatomicat tand-
mark rflundn d{fi:rflo: rdufla-{d'"

Anterior internal jugular vein approach

tdurfion intemat jugular vein ltJV1 rr,:n'rodvrrl lateral dordurfioo carotid artery'l!n.l:

'loi cvc vr.runanrdao uv cur:nordu anatomicat tandmark dqlndrr:rJnrrrnfirLrii.rfigrurar
orl tydsladfrn::on ctavicte rirutnfiniln:lgn sternum (mediat portion of ctavicte) ttnrd.urY.:
2 toaau t14dglrl::naldrgnirurrsmra,lnfir rda sternocteidomastoid (two heads of sterno-
cleidomastoid musctel d',r: fi t n. lfirdurtrrgl.r.,ryiruriun middte approach)

nr:{orvirri:iT s nr:OortrifuJruogluvirta!fi\:1rJ (supine posirion) fl'uyrirbirr,rdrumr,rdlr

ntYuugst'rt"rrtrrluu''ii1ajo0..IIrLdiu{ul6rno0e9filfiiFor-arn'rrn:r1"5rfii1ofnonnrn: r: tdn'":q:qrrnnrTh"leenlrrt fA,caarroof6ilUlu antiseptic tto;tlfirrlr:
nnr,odnjrunr:eir rda ufir 1;:..td 1n.1 orol-nn"r rn'rrj,rro,: rfit..r}{:Jnrtrrrra.rfir-huunlsug.:n.ird:ul

16ndori niorfiililirrruGaoo"rlunaonr6on t,Lv lfilrntau fi,re:n"r}inr:riy-nnnr:o;nrnr'u

rijariuirrinnnrrnr:lfilnrldrm.:fioir.rdlrinu-n (fiodrudryilnr:r!r.rdu uv d?ufiarx.r)

ndrrfia :;rn'unh ufi .no.l carotid arterylirala 6nurtryr"linruuonro.rcrlrnfist (l: .j1{ two

heads of sternocreidomastoid muscte) Touriourdusrrrnr:uuto'irrJorur{uhilda{turdu16on
flounr:lrivw'irfi rfiooriounn"lrdrmlurnaadnurz :drtfirfio negative pressure) n-rcrndour

tr ud'rorl'ldr{rrurorFn 1te-zo gaugel 'lunr:rrol"ruvrj.:ra'r t..tv lorLriruvr,r rirfiroorjo,:
crrrrdurulurirrrud6oarsrli lnairhjnrs r{rft:Jlufiavrrrro.r nippre aa,rfirJrr6ru 16urnir.r

132 rrrnhrininqndugru
rdurfionfiqcfl'rtinnnli n'tiltll{lfi nxr1i11tJ 1:tl'lfu 60 a,:filniuttuxlru, urto"fi?ilf\:10'0{tl'lu
1d'.:;:Jd tl.1 uay!ur':ur{t6 d6n?tod lateral dortuuoo carotid artery dnd,ldlnufiod'ru fid'.:
ornn:rrnhunr,i.oro.r t.lv udri.rlfirflrurnh{drnluilieiafiu syringe tu1n 5-10 m. iifirir
rn6oo{ ::lrru 1 un. (nn:uli'lc'jirjfia'rnrna{lutJorurill urwnirufi'uril'lndriun'rrrnilrlo.rr{l

tl.lurorfnlilluuuriru1 UV riu riior1nrurfr.rrir|1|finrJr:mru 3-q rrdrbintr negative pressure

rfinriaun{o dlneur6 unc syringe dr1 nrn:Jaru r{loflutaasrtfiooo'r uv ttdrrvorlr:nqn

rfiaoldadr.:irfleru vn'tqrnfu:Jan syringe otn tdlttn:ffttnn'jrr6oodaonorn:Jorurirri,rdru
nrr*ru:,r nSor!,,rrfluo.':ur:mlnt:tfiulo.:rirlqnialil nrr;rY'rneirrrj,:lon'j't nrur{loqilunnoot6ao

lue.; carotid lfirlriruittaregorfiaoornr{ d'l:ndr':dtn??? blood gas analysis rdodutTulf, lrin'::
drnr:rmsvnao16oofirlrifulcjrau'lunnonrdano"rti.rrdooernorcrio'hitfiqt6onoan ilrrurrn
rurfioduo:rudo{rhuld; ro'.trrnriub'jrrJnrur{log1u t..tv rrdrhidrnr:ld cvc n'ltJ seldinger's

technique oiol:J

artr 0n.) udan anatomicat tandnn* tantid CVC,; anterior aryroach of UV insedion, Pnflt

Flmln{uanwutr,ln head of sternocleidomastoid muscle tdutht uf,f,Jtau7aa,t clavicle,
1tr.1 uan,tuuttiu ntzrhtpttlzzatu oo otat uuutztu'nmo$nffiin$1'tu, 1t a.1 uaa,tntzld
CVC ifr posteior apprcech of IJV insertion tdutllluga'lffiundwt\t sfernocleidomastoid
muscle, (1n.) ufiflt anatomical landmafu ntmz'ld CVC sf'tunit infaclaviculat subclavian

vein approach

Vxsculxr Access ain{ no,ta$ 133

Posterior internal jugular vein approach

rfio,:ernrdutfroFt t.tV n'r rruri,:fiaEl:;y,i'r.l two heads of sternocteidomastoid muscle
riu og'lndnilnaonar lu{rtrufildfinr:vrtr tracheostomy usuorefiro :yionr:n-nno'rlrlurfloufi

cvc lun:ruyrhrirnsirr rnyorerfi nlrrr6iurrionr:Fo ldara{ cvc ld rmour:nrfiontd cvc

fi uv lulinrudg'ldun'jrrdr'ld louorrlu anaromicar randmark fiotjvdooiaran-otowaurd.,:ra.r

sternocleidomastoid muscle [rn; external jugular vein d,:rirrnro"tnEjrr rfiut6oo uv o:rrtn''r

o{ldtorno'.rla..r sternocteidomastoid muscte (?rJii 1 n.)

cvc{ol,fifirhruouluri'nuru: rdsrrYlnr:td 1n anterior approach Tosc,t'r uyil,lfiqlin

artrun: uYl'l ffire;o{rn.roia1o6'nn"rnEirr:J:;rrru t sr. rfrflf!fisflr{lor arurf rn{erne.iru

fiTrftufi'l nt:ri.lrl'rmr'tdrunrir drtt sternat notch ursifio.lLLLitq'irkinr.trfl rir}Jlundurdo

sternocleidomastoid rrn:fis r.na.rr{rfimur:cr nr:ogldoiondurda stemocleidomastoid od

Infraclavicular subclavian vein approach

rdu16oo subctavian vein rfludtufido rqrnrdur6oo axillary vein Tnurr.16"ladlfioion::qrn
ctavicte rrsir fioFion:;qn61n:li,rtnr riaufiR;:rtn'l rffurfioot intern"tlugrtar. u"in 16or"flu or""r,il-
cephalic vein l?rrrulfisia sternoctavicular joint Tntfiudurfion subctavian arterv tr,:6"rtutub
n1.'tdtu superior ttni medial sio subclavian vein

lnrtriourrntdn:yFtn clavicle !fl! anatomicat landmark drniltd CvC rt\r subclavian
vein'[d Tordryildrut':luLi,rn::on ctavicte rflu 3 dru sirund,rvr'lyrrvr.r r{ls,irufiryfr 6o ::rrru

'l-2 rr. m'tn'ireiru0iola.t medial 2/3 Lr8: tateral 1/3 fla.inT;9n clavicte (: fi t,r.; drnfidrudru

tsrh r!fixi.rfr ry 'wouc;riJur:irr 1-z . ntrn'ireofirnfll.rnannt;nn clavicle

nr:{nvirfirJra or:Lir.ilhuuau ,nu ,"uurir}Jdrum:.,,:{uflurnoor6anficydr}innnr: 'lu
{:Jrufidrun5ofi sofl tissue Mulnt:'ldyraur:rty6ofiryiarirururn :;rrrutrnrrirrndarara6n
rulon5'r6sr: ':r'rnryrrdruyd',1'lurrtlrn'rn:tnnt,r::y,jttn:ynn scaputa Te,: z drr rfiobildurdae

subclavian lfiourrlr.: anterior rutntju rr,: utufiltrrurunrldrudrrra.lnlrfi'r lufirhrLiiuou

lrurul attfiflqn'ryn'{,:oi qyd{firdurdoor subctavian vein otitun'r uyt,rfinn.ir nfi nrr:o*r

rlauynru::n'jr.l scaputa rilntirrdrlrTlo',r umra.rftrJrtrn.:.hJsrtrdrudr.:ro,rrird'r e:dru'lfinr:

approac h udu rfi onvrhldir uriu

fin-.rQ'rnlirn1'trJflro1flfi?rf{ trni fi1n1rnn1{f,;ornrLfirlirnr:f,ouMfiait[[Til,:[[r{ttil
o'tndrrdrofiu fnaar: infittrate urrrdfittir un: rdorEia'lfifiryri,: finLlaufir periosteum ta.J

nrran clavicte firartlr:n:Jil rfiurtfitrffr-hua{nln.i:;a"1fi:n:ld e;drurfirJlurnlo.:rfi!r6oer
rq'rld nr:rtyrrfl 16ontd introducer needte number 16 gauge turnrEnrloufiqr..ltra,:r{ru ar:
tuturi1ruur:;urr.lrn:ri,r'tdyn,: stemat notch louhirf uirt'hj:ln.irin::en ctavicte t[n! first

134 rrtLirfninqmdlgru

riO rfia uvr,r r{lfinlt: 16u 4 11. udxd.ilrildtfion'lfina,t negative pressure ttncnaU t{xoonfi1"l

fllnrinlrjldrdoo6nnd'onaurf uaontr?utnff?;fiqooonernftrnri,,r udrftiun.,r16und'ur{rlillurjtu

fiffrr.r superior via inferior n'jr16ilrfinriofl'lu{rhulr.r:raloutolr:firhsfidrulrnoro'l{ii
rryr,lrfril lfi{ileu!fl1u1{ildile.r'f,n?cEn clavicle ttfiroottfirndl :vlrru 1fl , ng nlut{ n{o1n

:; n.r rdr rfi a'hifiu?o:l clavicle ufir6..rrrr.rr{rrd :-1fl1 sternal notch 'luttu?tu'lufiltttut:vurl
e;rir'hifiIanrruvrr rflt{rrfiur6oo'ldirsdunr::lrio:vi.rhiurnl rfirfinrfiuI rrtr:r:orountr{Tqi
rdu16oo uorfioqjvrr,r mediat n'a subclavian vien uo:hiar:ur.: r{ hJvrr.: posterior }150 inferior

t ot firJr ur.rr n r fiu}l tfla,:ernoretfifl pneumothorax ld

efruslrirJrufilsrniofiiru rulc riauriirnr: ur.,r 16l introducer nr:1fi{ri'luno iidal volume

1o{tnio.'rrirunrstc (fi,rld mode vcvl uioao inspired pressure (fir'ifi mode pcq rfioflotliu

nrtnfllma{uaa ootrruvnrutetfi ii.resnnTanrorfio pneumothorax ldld'{aln introducer needle
a1jtu subclavian vein rrfir}ivrhnr:'lsi cvc srrtJ Seldinger's technique oioltJ

Femoral vein approach

nr:tai cvc iimtr*nrit femoral vein ucuardunr:n6irfi$llTno\: femoral artery Tnl femoral

li tvein rtd'raqjrr,: medial eio femoral artery lru 1 . sl'rttvli'ifirfi r;tunr:td cvc nxr

odn'rnir inguinal ligament itll'lru z-s lu.lnud'rlil inguinal ligament e:rr.rd'ragldrrur itiac
skin crease uoilu{:-hu4,:arq ttnJd'lufl'j1 n6 skin crease olcodn;1n'i1 inguinal ligament ld
tun:firrjuii oroidlEn6[1fi1n::gn anterior superior iliac spine titL pubic bone rfiufiarn ldalr
1uflv{da'rq:tflu inguinal ligament ufir tnjttfiun".:nnjrlstr nlrlurltflu 3 dru femoral artery e:
rr.,:oirogluuur medial fifi{dxud'ltfla{ inguinal ligament fiiao'noldu fluoroscope rirutu

nt:nrm'runri':rao femorat vein ld lourdurfioo femoral artery 3:?r'toulutturlottutoluntrlrLo,l

lolritrto,: femoral head nlrrtyhrtfi trivil'ral n B{1ltfi *tna,] femoral artery ff.1nfi'l1tJ1Yl1*l medial

:J::rrru t-2 sr. lqufifl r*rtosrf c:#l fira:6orLot{r-hu

Seldinger's technique

6ai6nr:'ld intravascutar catheterTalorda guide wire"" itsdorm:nidldrt:nl?'ld catheler
'luroon16onn'rrro:vaoordaouo.t louvnnnr:6otd'rorndnurtrdfir f'Jn:ln'r umri,,:fidalnr:rir
rionnrlrfir lfirfiudficmilnir{so,t internal lumen tfiu'tnafiq:'lsi guide wire niruld oiorilnaoo

fiouraura 05-1 n. fi r:1fi1:rirnrutur-l:vlrru e-3 a. lajarnrqoonorn r{ilririu:-riott llvt.rtSl

ajtufiryri.r'bjnrilfi6yr,rrLo,runoordaoo.:najrrrrfirtfiu tu: uvn t6 r fin niruru'rtf.: udr'lthir negativ,e

pr"""ur.lir6nrioaurn nrur{ujrtrruftuaonGaoo;nrur:n rfiurfiaolnorfirqiuoaoiourldforeu

firarm:noo 16ooldodr.t:rotSros'::Jaortooo6ostsanmnt6r.r cr u'ir t6oouuoaonorntfrfrn:

rio! uoarjr nru16*roglunnoo16oorir uririrrfrond.raonornrflt lflutirul nrr:d,:tl:nr:tfiuto':

\':rslular Accers ain i nanfrFj 135

f?te uan.:'j'l orur{lo{iurnool6oo ue,r lfinou16r.,oonlviaunnfirirrnrnaoo r60oLro*1-lsui.!.rt,t

::lrru 5-1 0 urfi vSoeurfr anvfl o ufl :n?frrrT6:rr'rrfi arornorofi rfioqaonldfi rrf,,r {i,:c;

f.r rnnld'jrrirruuvr,,r rflfinrrurrdu{rirrionnr:rfrrfluda.:nnuirrruo-rnrirrlicunirr6one:ruo

[oclrifinr: rrta.lrdo rdaldfirnri.rr*udn uanerndti.ror r:nd.:rfiooqrn nrtrrfilrdas,:roilr
t:drnrrr rdrfiuracaanfilqu (oxygen salurationy uJiaurfiuurilta.ttnnoorfianuno nioriaoru
extension tuoe niu!nrs 16rnfior"oermrd'utatGan :':uvirflornrnr:r 6flurnja{so,,1nlrrniu rrn

ulirnmruoulrio.rurn uavr'nr:r!fluurrrjo'r:rdrRruoyusn nrrflrulardraan o;druariuouuir
:Jnrl 6lodtunaoo rfi aoohei.,:

riiauulo'irilnrurfiroriluvnon r6ono'r ud'r ri'rnr:'ldnrs guioe wrre lnrltsrJnrrfidoun'ir

uiarlorudruTd.r'jrur{r}lnulfirii6r,rag'turnaor6onn"r nrr'lni guioe wire'lrtfinnoarnr: :l::rrru
e0 ru. n'rntd cvc fisriunr.i..r tJV fiio femorat rein rra;hirfiu ts sr.r. urntd cvc ydel'1ttfl1-1,:

subclavian vein rfialritfi:Jnru guide wire r.irutou:augioto,l superior vena cava n'r.r right atrium

(mr:r*rfi tt

Hn"{crnliunout6tJfrrrvrurdu16oooon loEJu'a6nfirtfifitnoafnur guide wire'lfiorjlucl"rurri,r

r6u ilururr,lillfi guide wire rfiaur{ru5oaoncrnol"lru ordr ufirdrnr:rilounoifirnri,rdrufio

nruuunr d'nfirmri,rarr:l:vurrulrirfiu s finfitrtn: vlurflr n'ntfifinnoondufirralr{ rfiaa:ornlu

nrrrrruw'rufidrfl diralor rrndqa'rfif,r !!R! unrdurfiu}J c;drlfifidruf;flnrfu ro rnrruc

narururu'rsfiruri.:

funotrria}Jfionr:rurtifirfitiidru dirator lnuorfr, guide wire rflun-ruh'ro lai ortator

drliltufirvrirlarfiarjr,,rnrier rru:fi6nfiord.r{:.1:lnrucru guide wirelilnno ufroilo,'rn-ubfti oitator

fl'r guide wire finrdrl tunr{,:Jrr Hn"':ornturafi'l1fii dn'rrrurnfifio{nr:e',rnou dirator afln los
':vr-,r'irHorEj guide wire el",:n,:ad1ufiaoq rdaa 'ldfilu catheter ldr'l:jtuvnan rfioolnuarryu guide
wire quldnlr.Jfinmrrfio-rnr: vn'.:erndunou guide wire aan ltfirsiofiaaodnfl1ni! n1fl catheter

niufilfiofla,rriu air embolism ontfionaanqtn lumen flo{ catherer n lumen rfiaq:rqr6rt,it
currntd':rul66viaki liion:rqoa!riu:i5au udrfrnr:16ifi1u carheter drurirrndoqurille.ir
lilfi 16anrir,toqjiu tumen 10\r catheter R-\:?lnfuncio tumen ?,0{ carheter druor:n:oru
ltto'u naol:dela:t heparin 'luo-rnr t.oo0 ufisr?oo heparin eiafl.tiflyfl-lu 1 :Jn. (ildl heparin

15.000 ufiol/t.tn. rJirrru o. riuor:o:orultrdurJnoal:d + uo.; nr:or:rlrfn.jrnrutu tumen

ro{ catheter fi:li rn:rilrl,s 'lrin'nndoorro:o1u heparin lrn rfiurjilrn:ra.: lumen rfiollrn
orrn.rlfi fi ilrs'ldiu heparin n 1n 1nfi u}ld.,rorrdo'lfi rfi onrrv uyr:nf oudunrurld

liludrniunr:loi Cordis catheter u"u nto?r.t Cordis catheter ollator tm:m4u6on

'ufl'ru cordis ril oitator Li6urioariouvrinr':1urufi'rvrj.rlnsarflu guide wire rfio'':crner-r cordis

calheter rirqrnrinqiiiiaulrirvlr;do:rirnr:ldrirufirru-,ldrun-l?o,uluro',r dryrnruruurir rtiu

riuorcdrifi catheter rfi nn r:rinfii uio rfi o oiun:r u pia a oo rfr oerld

136 r':trirrininqnfruSru

ofi.r nr:srrrcgarltrirrritei{u lumen to{ catheter Ltn; dilator tiu 6?r16i-!n'lry6iod'1
rnfialirioiliierlsir{{il'ludr{:Jrtrfiafla.lriunl?r air embolism Lta:l axrtilo:JRlu catheter fiia

ditator oaRdu:tu.ln1flrfl fiuir1n 1 rii0no1nfi1flthhu{ofiluletdlTqull:na;qnn qlnR'luuon

ii'ruvr"hr lumen son cvc rirtrtrfin tir embolism ldtriufiu

A Catheter over nsedle bJ rem(

a) insect into vein

B.Catheter over guidewirc (Seldinger technique

a) insect wire through needle in vein b) remove needle

c) Dass catheter over wire d) remove wrre

E

ffi -/

Affercnt methods of inseftion

zEtli uto,r Se/drnger's technique lunzld cvc

u1ru1Yr1o.0 ultrasonograptry'lunT ttri CVC

nl?'ld cvc rfl un-n nnr:fi fi nrurdu.: ln u taur :fi r{ritln n nr:fi :.J: valnr:nilxi rfi u.0 a a1e

rfinnournnfisuo triu nt:ttfitlirrrnaarfionlto{ lnn hematoma nrt!!vl{$n pleura tfig pneumothorax

run:nr:fio rdolun:J rrdrfianld 1euil'r}lnr:'ldnra cvc oldu anatomical landmark tt'l fild

nri'nrrdrlduriluxn"n ldfi{Anu1n1:ld ultrasound lriofiuvrnhrrvrj,rtoouaaotdanohriounr:

cvc{[! central venous catheler louvit'irevd'lu'lfin1r'l6i rvolnrrldr tiqlrnduunvrfio

nlxi ur:ndoulioun,J

Vascular -{ccess qiai notaEi 137

!tuil n.Fr. ZOOS Hind D LLa:n c 'ld:ru.r1unr:6nurlr meta-analysist lrn i g nt:fintr

fiu.Jiwrfiulnr:'l$ utrrasound t|ulunr:tni CVc lourj::naudru o nr:6lnurfr1d doppter U/S,

itt nrrfrnurlfi externar z dimension urtrasound (2D u/s) un: nr:6nu'rtdn'.r z iBduriu fi

,r'ruru{rJrurYrrurr 1.646 au nvjr nT:ld u/s Iourofl1! zo uus rjrllunr:ld cvc frsirrfiill
internal jugular vein, subclavian vein rrflv femoral vein orrr:ntfr onra'ld cvc drr5olunr:

rrnrrfiroi,rrudnt|rr:n (relative risk of faiture rate in first attempt = 0.59.95%ct 0.39-0.88) rro:

nn failure rate (relative risk 0.14, O.OO-O.SS1 ld

rdolriuruudfi nr:fi ritdwon.r:iiurru! randomized controlted trial, ?rndligarffi nr loa

finur{lrudruru zot nu fifinrrilchrfludo,r'ld cvc ntr{''r uvrjr internar jugurar vein loufifir
fi o.ilrifi {ofiutunr:'loi cvc ri nr:urj{ fi rrruoan rfl u s n {r lorulisir uurdr onrn fi rfl e'ruru

os nu.ld:"unr:'l6i cvc loaards anatomicar randmark {:-hunrirdaa,,riru 1\ 72 n\ vri urtrasound

tfronrn"'r uru,l uv dou'ld cvc ufl;nci flgfiruirtlru oo nulfiilnr:vrh dynamic urtrasound
nrwwhr CVC ornaonr:f,nnrru.fi{rJrUfildiunr:ni dynamic ultrasound rrwld CvC fio'n:r
nr:ld cvc drriegtnir nairfrdr eo u/s l41Bl"1rrflli.,rHnoerrfiondould cvc untndrfiardr
anatomicaf landmark odrliriurl'rA'q (98o/o. B2%io Lta!, 64ok nrlrfrau uoncrnriu nr:lf UIS
rirfllunr:ld cvc f{o1anon1t: uvr:ndoua.r'ld (3yo,3% rn: 13%) 6ndru odr,t}frnril1unr:

6nurdrt:l'jtJ:catnr:nita.,:filirrinnnr:finrrlunndr.lriumn si,: uri:J:; o! n1:ni 30 nrs,! rufl.u rn

n'ir too nir d,rareiidriernro'rnrr'ld cvc lna'ld anatomicar randmark lddrriqiaunirn'nr:

Q v tllu

luilolriuuuyuh'jr 'lu:rsfi anatoricat tandmark Lj.i'orau louranrttlnufifi body mass
index fl\:.l uiafi mass lSrrn-rne'raofrarorir'hi anatomy ?a{ centrat vein r:Jdsuu:Jn,rlfi nt:ld
uttrasound dxu guide lunr:duvrul'runri{r0{ central vein rfrodrulfinr:'ld cvc drEoldlrn
?u"

nr:ld U ft raso un d dr sdrrun cl'r urnirr rfi urda n o'r

Tolrtrl internal jugular vein ly'n.oet-ratjmrtdrulfiruo:druuanria carotid artery tu
nr:td uls yrsrluu ,r t.tv rhldlnlrrt probe :L?nru talerat of neck lfi marker fhhr,rnnr.,r
rlrn"r nr firfiucv :J carotid artery g r,rnn:lotjn'nrrovriou'hlyrr,,:n'r uy .t::to.l marker'luluvfi

IJV eyfir r:,J rlnnoir.lfi'u uoncrndrdooonln{nn probe r6nriauo:vru.jr uv 6lrMlolnuu:.r
nn lurrulfi carotid arrery rJ-,:a.lfi: dr.xLLn;turn Mr16:.1 1:!fi sn,y

dtuilr subclavian vein u3u 'n,,:nraddtuttri.lrn: lateral oio artery niuniu tdaml probe

uls'ht marrer d^[ i,,t medial avrll subclavian vein ativiroqrn marker !!nr subclavian artery

odrrc'lfi marker 'lddorfiut6onfls'lao.ro;rflurdofirtrlaa (pteura) aT.nrnld U/s in.:vu;yirmrn
fi'lvu".rdqv uvrr r{rcrtfi.rvnoorfioqrdorirutunrrlrc rru:sucnrtJfinra,r r{r rfioflo.rfiunr: lfio

ri'un:ruoio rEio{l.rrJonrruvriru-nnnr:ld 1g# st.y

138 r.rttirrioinqeidugru

3 B.) right inhrnal iugular vein Tiwu'r1

UV nnrtTaliiunh carotid artery

uflz!fisf,sn|'j,nnntix probe UlS nn

du 6 onti'1,zfisutadna,t zutfi
tlu da no *itnnut o ua ry.|'!'rot6 u

3 !.) subclavian vein 'nnflan1t latenl

do artery et#,innit 'lfrsio vascu-
Iat structure dsf'tunl,uf,e z tfiudo

iutJf,fr (pteutal line)

3 ts.) femoral vein 1?fa n1n medial riq

artety unzafraiflnu1nffi lJlS probe

a,nunaantdaa nvit trtwfraarit

tJflul0nnfrn

sztlii uaotmz'lfr vascular LJ/S ilnuaghufii,t vascular structure

VascLrlar Acccss ft;nfi nanoti 139

dttitl femoral vein riurr.:oiro{11\r mediat 1o\: femoral artery Lfial'l{ probe'lurrur

lrr{tfisio inguinal ligament tJ:vrrru 3 tfll-lft[ mr Qvlr! vascular structure (d',]3ilfi 3n.) yn.,t
laterat o;fi::Jirtrfluvrtfln ua:kiuJdsuu:Joarurnrdooanu:rna probe rfindou tutru;fi femoral
vein tiu srructure fiadwt': mediar orofir:..Jtr:.:trnnrirrfi'u uo:61lll,hatrd',r aan ut,:nnfi probe

R12s]liltflfau?lnfn:td CVC

orrr:nur-i,l'lduflu 1nr:rofi zy

1. |mmediate comptications firfiodulrucdrfnonr:'lniaru cvc lriaorerflodunrufifl,,j
ldnru cvc lriuruu-n B*'lda.rnrrnr:o:rr6ornrrrflr:vi.ro ur.'rlndio :rlri'rdo,rldtrnr:r-nur
atirtfuyirlfr yrnrfi onr':yut:ndourndrddu

2. Delayed compltcations lflunrrt un:ndoufirflodun.rurii',:nr:ta CvC rrrfllurrnruru

znrm.:d uao,lRmsur:ndouiiarcrfioduornnr:ld cvc iiairunrlooir,rlau

I c",nrn""u* Frequency according to venous sites (o/o)

I

lmmediate complication 6.3 9.4 3.1 - 4,9 9.0 - 15.0
Arterial puncture 1.2 - 2.1 3.8 - 4.4
Hematoma o.1 - 2.2 0.4 - 0.6
Hemothorax NA
Pneumothorax NA 1.5 3.1 NA

0.1 - 0,2

Delay complication 0 - 11.9 0.45 - 3.3 1.44 - 12.5
Catheter related infection LI
Catheter thrombosis NA 21.5

lmmediate complications

Pneumothoraxl- ts

rflunrr: uynndoun'orofiri'un:rufirdin {i,rorcrfiorrru:rirnr:laiars cvc Iosfirruoru

irarur:nvruld::rn'jr.,riauar 1 o r&.:ddua{fi'unrrlrirurqro,ld}iors cvc un:nhurri,:dld cvc
Iorvru'irnr:lei cVC fi subcravian vein filonrarfio pneumothorax ldriasn'irfid'ru .{ rnternal
jugular vein Tosravlr;atjr',:6,r rfiorirnr:uur rflnir rr:nrlirrru subclavian vein rrdtlriartr:nyr

ol'r uvri'rrorrfiu16aootrldfia.r*vrrrfrairfi z vio e r:ti,rni anrRn.r:rfin pneumothoru* rrnl*u

o-tfuyn-rrirrtnnnT rlddlu CVc 1{ subclavian vein yioutjlrri internal jugular vein

finru nr:fl.rllonri,r z dr.rHJiflLrfiurriu tln:orirrirrruzuftr:r,ronirfi subcutaneous emohvsema
?t
lJ-s [{ rx CXR rfi'trirf'nnnr:rnnf,l
1{,]B:xq

t40 rrujrrYninqnfrugru

fl1n !i'rfi pneumothorax :Jimrur6nriautu{rjrufr'hjldl'firnia.rrjrEJvru'lo orc6norxl

rflrr:i.rarn.rmo..:{ ruld urifir{rhu.l'rrfludo.r:'ldrnCoodruyru'hnr:fic1:ful'ld intercostal chest
drainage (lCD) $ioialriunr:rfian1?t tension pneumotnorax d,,rnrnlrildiln1?inulodl,:nltJtdtl
aroai.,r nr ntrinru d'u1nfi qni'r n eutfi n card iac arre$ ldlufi qo

Inadvertont great vessel puncture / perloration
n'::ar{tiun:ddnftutttj.tto,tfitu cvc o{ftolJernlirrnrfinr:q:rflu fiiovlutt: hemo-
thorax, mediastinal hematoma t!o: cardiac tamponade unvorqrflucrtvg fitfiqntt; cardiac

arrest ld nr:ulu6lr{rraonr6oouo,il,rilld"lunr:vrhrisrnnr:filitrrurdu16on internal jugular vein

[[A; femoral vein LiOUn'irfilitrru subclavian veinr3 Orir'r't:finTrUrnrfioflq;Ur6anOanOrn internal

carotid puncture nio femoral artery puncture o:dur:nnrlq ddn'ir rfioqfioanorntdurfioo

uornru'lutir':rrr.:onlurru:ltvt.l subclavian vein d'trfulu{rhufifirlr1urnrlr6.:n'rtolt6onnr:
y6nrds,rnr:'l6i cvc rrn subclavian vein ttn:t,trnc'ttflufiootoi cvc nr:rdan'ldnrt femoral vein
c v rfl u rir uilli ofr il a aon-u tJrnfi no

uonernetriolfitfieflrptrdutfioolrnnrrtfiur6onrlirruurn florutarrvrrnrirnr:'ld guioe
wire udv dilate artery udrl nr:rrvr.trfi etu carotid artery ti':ororiotrirfinflryr'trdrol 6nlrn

ldffi airway obslruction, aortic dissection, arteriovenous fistula viotfin cerebrovascular event

to

lour'rlilrrnlriour:ntirr t6anfioonrrnro"tnr:rirfinnnr: nSoa{du'irfinr:ull t{lrfir

raaer16oouoe'ltqjud'r drrflufio.rfiqr:rur'ltinr:inurlounr:r.iror"adrl}Jriln'l?ttfi'hn1?tn1'l fie
fi61A{nlrtrfr,tfl')n0{tdaoo +Luqloctu nll00nttu!talo4{tJao;v' lt'lu nLunl:fi't']}Jtaana1nfifl0a Lfl0B ttn{

ynrasfio uri.itfludq;fia.xo1rl'tl interventionist dfinrrrrirurry

Air Embolism
lu:vrjr.rrirrinnnr:tai cvc uSorrn',rrirr{r'lunoan16onlnaiJdrdr rrn{r-hunruhrirfin
lrnirlflufinre:g, odr:rit 1int."u""cular volume deficit) a1?r".l.lli intrathoracic pressure tflu
nu6,rorntflotnnluuonr{rl:Jtutaan16aortfi otnrrc air emuotism duld

nr:4,:fu'jr{:Jrurfinn1lt air embolism durrn{rJrtrfinr'li hypoxemia, cyanosis. sudden
respiratory distress, sudden hypotension, sudden loss of consciousness yio sudden cardiac

flarrest rliln1{d tionou cvC tucl"r lrvrj'r subclavian llia internal jugular vein drrflnr:

sr:??i'r.,tn1uorer:J centralvenous pressure 4,'tduodro:ro6r tlavfi:rofl!tfiu't machinery murmur

m

dorfio air embolism t*u or:{n1fi{rlruuoduvir qleft laleral rrendelenourg,'lfi t oo%,

rirunrutrdru mechanical ventilator, tln:nrnfi pulmonary artery catheter vlultil eno'ln1rf

oon?"rfl right atrium ttflt right ventricle ! !o lnvdlqotvl,'lv.lilalJu\lu.\etfl

Vascrrlar Access dind nsoati 74L

rdo{qr nyr n rfi eln r ? y air em bot i sm du ufi rorerialfi rf, nd'u n:r s firrdinld 6,: crr:fl o,rriu
lnuvrurutJrfir irt'rrudl#{ finoorfiootar{ilrrdo.rff 'jrarqinrr: severe metaboric acidosis

1d,n;rrn'nuru;nr:flru'le rr:.lu force inspiration) ilrlu:;el161.0lfifi:acn'.tn.ir arurfiryrnc;'l6i

cvc iiei'luflil.t IJV m3o subclavian vein uoreri'r?flautriurito'irlfuirn1:fl6iafl111iltu catheter
iirira*ncdrnr:16ir{r'lufi'rf,rJrrrial{ourfir:r vrsirdnnruro,ror:fr un;{ooiooir,rl lfiil*utcir

ruilu6ufir

Cardiac arrhythmia

tuqru:dtd cvc lt'l.J IJV l4io subctavian vein los raur:ufio rfionld catheter dfiom urr
rrnn'ir 20 rrufi ll n:dul:J yrntde!finrfirJnr1 fl.rllro{ catheter d.tufl.tuorqadnru'lufirlq
|to:dolfirfia cardiac anhythmialourofll: atriat fibriltationld ri',fliulru:tri cvc Hlnrno anhythmia
dunr:noucru catherer fi50 guide wire aanotnrir uyrj,l 16 rfinfiou uonolndnr:'ld cvc qydo,l
fint: monitor erc rru:td cvc lflrJa rfiaiiodunm:y'rle lfiufioe'.:yry

Catheter malposition

na'.:ldaru cvc udrnr:nrtor6nol"lntirrar a.rilfl.rs cvc ro o drunr:d,rcr:re cxR
n:r uyri,rr.lnr u cvo fidnrroqjlu svc uoihin'n r{r'h.flu rignt atrium (grJfi +1 rfiaomnnrrriru
i':frrtr':on nrunru cvc lilnx:rnu right main bronchus rfia,:crn ntudrfl cvc olanr;fi1.t
iJu"{ RA'lfirfie atrial fibrilation fiialfionr:uyr.u;nnfr nnld rfryfunr:'lainlu CVC rr.] subctavian
vein {r*rdrEJ'l nr:lfiilaruarsadfiorir-[.ni,na,: svc rr,rfirurrr rfja.:qrnurnii',r cvc rfuliurul

orlrfioolun:rudoaru"rynoordan svc ua:da'lfirfin vascutar teakaqe ld c',lnr:ldoru cvc lli
finr.firIiltu svc 1n ofl n?t udhirourdr Rn

tttlii uso,sti'tuni,tfiMutzs$1a,, cvc 6a a!?unaaa6aodtlv4j uoililmad'iltJ'Iu right atium lfwa

itfrsoafnsat catheter dturttu fiwantioatitnainaufrlu cathetet aBn rfra,ti.tnfr1 CVC
atonnaNtinruzaa'#uldl

142 rrtrilioinqndugru

Delay complication

Central venous catheter related infectiono 6

lourfrlilnr:hordaddlr{uddlnr:tni cvc vuldrdaudrciau louranrrludtlruflldiunr:

"lai cvc riurrnruru fi:ra,'tru'irtfionr:6or4'od cvc r;tr1tu s-s",6 ildt'ld cvc tiiut?R't 3 iu

runcrfjildurfllioun: 5-10'ht?nl z tu Totrtu'irofr rttlti,tso,: cvc finlr*rdrd"qeiaTonrofio ldo
ro\: cvc fi:1u,nu'jrnr:'ld cvc duitxru {emoral vein fidn:tnt:fin ldaq,:nirlirrru subclavian
(19.g% lfiuuriu 4.so/o. p < 0.001) adl{t'o[eu" drnfiaru cvc duirrru uv vt 'jrfia"qnnr:

6nrda'lndrdwrird subclavian vein"

dtr{ulrsrBaS:iilurtsonr:6ordofi cvc usuarqrfi o'ldornnr mqtn-n 1 t-oti'"

t. nr:6nrdadqnnr crnftruf{uitrrun"ld cvc (invasion of the skin infection site)

2. nr::Jutfloulrnlitrnr:ouoiata.l catheter (contamination of catheter hub)
3. rfionr: cotonization tolrdoulnfi 6srl1e1 nrtudl 'lnfin qrnst'ru d,ma.lnr:finrdo

ttltit6u thematogenous spread)
4. nr: urflaulo,tcr:rlr urfitfir.iruvr1{ cvc (infusion of contaminated fluid)

Inudruh{udrnr:fiorrdoza.: cvc finfinrtnqudnornnr:qnn'rrto,:rdor.jrufirvfin'rtlvri,l

dla cvc un:nr: urf,aurit':ru:oan'aror cvc dtrdodru'in{frriuorrrnqrTnrflurdada{

orrlfirnri.:to.r{ilrura.: 16rrri coagulase-negative Staphylococci ttat St4pty/ococcus aureus
lurnrvdrdolrotfin niu Stenotrophomonas, Pseudomonas, Enterococci unt Candida o1a
rlurflaurrrrnfiaro.JUnnrnlv'r,rnl:truvrti lflr{ cvc flrt:otLsiogo\: catheter vioorur}rrnfiold'
ud.rornrdoqnau rfir{ tntemat tumen fla.ld1u cvc un:ev:r d'rfiuoqjnrulu biofilm d''t rcno!

firs n:rr fibrin ufl; fibronectin d.lrfluc, :rj:;nauernrdoodoun-orilfuot'rnrulu catheter fin-{
rrnruafiriunim'rururfirdu:trvt',rairtar: ::nou :vmr polysaccharide rir'hirfirnllm.trtroc

oiofitm rrnrru:vv'jr,rdnrnfirnnfirtutfindur{r{ Cvc rvlnu rd1nr.:n:vuotdaofi?ocrn direct

invasion fiq;f,rrur:n6ilno{nrutwfu niotitm fld qu'lufiqo cvc detnnlutfiu source of bacterial

infection riotrirfiofll1s bacteremia un:rialfirfianm: septicemia orrl.llrluii4o fr{dlonrniic:

rfionry septicemia nialrjriu duaqjniurJirrrula.:uuofi fiudaqjnrultr biolilm dxu

rioricr:rurlrn ur6oS'iiru'mo.,rnr:rfi q CVC intection rfi?eyuyirnr:'hiurrjfi6ruvfi'

n:oue,qlrdadorrl:nqr'r{1r:re'rfln1r1i'l hemoculture ldrfirLtor-ir,r rdarlrjtfirtvtofilv:"nrrnrr:

nr:o'ordoi cvc lfi lfio{ernur:Jidru;riulriorur:nrir{nrdofioqjnrutu biotitm'ld uonernd

r!nfiriuynrurfiodorjnra'iu biofitm arsdlnlluan r:Jduuor:r,Yuqn::rdlriur,ralniu (ptasmio

exchange) .nv^ lnqn1l[[V{l,nl:?lUnO'l ltunf4i a[:UYAlXnBn'DU']lrflfl?UJ !y

1'l'l lfl [n

drviunr:ifrsauunvinurnr:6Frtdosol cvc riu{au1cfllil'l:06nu1tfiilL6il16erntonnrt
dr.o6,:d t o unr 17 'luurcrx'r dcvn6i'rrn'{i6nr:flotriunr:lfio cvc infection dfinn"ngruori:.io4u

-anAUn'l'lt0 t?U9l\tU

\rascular Access qifld non*tj 143

1. n1'fioniltl}nirrro{ cVC4
nrr'ld cvc fin'ruuril iemorat vein rfiuni unri.,riiu.r}irfionr:6ordoddlriuf,n-u cvc

rrnfian ldorornrirrrun-rnairrrflurinrufia-rdu fiIanrofievflil bacteriar coronization ldr.rrn

n'iru uitrn: subclavian vein rln; t.rv ii.rl:Jn'itfunrrfi cvc tu temorar vein u-,r nii nrr rdu.rsio

fltttfiq venous thrombosis lrrnn'jTd subclavian vein" !Lo; t,lv," d,rcydrtfifi central venous

catheter related blood stream infection ,irudu

dry:":l cvc fi subctavian vein tiufi:ru{ruo'n:rnr:Enrdon'rnir cvc d uv odr,il:
fiorutil'lrifin, :finur'lun"nuru; randomized controlled rdar iuurfifluan:rnr:6nrdaro,t cvc
lun'runriluv.rooo nrnr:n-ndu1c'lei cvc finhunri'l subctavian vein rfiaaodn:rnr:finrdo nrr

o;:;finliro o'irnrr'ld CvC fi subctavian vein filonrarfio mechanicat comptication [r1-l

pneumothorax nia hemothorax ld t"'tt*uri'lnrrlrirurq;tatfirirn-nnnr:rraynnrr;to.tfi rudrl

2. nrrf,r{fiouac aseptic technique6

firrumu'irnr:fir.rfio ua;rdr,rrortur,rfi:nrrn'nlyl-.:nr:dordo nr:ldn,:fiafrnirunr:sir

rdo *fir nuurrnun:rfirnrn:rryrs,r'tairdonqrrlnoordo:rrlfrrnr: fir ror:nnriidrun.r*j.d'o
rlfir or r:naoost:rnr:rfin CVC infection n. d

s. nr:li skin antiseptic6

6'trri povidone iodine ?Jlflu antiseptic fi1firiuorirlulriynru'lunr:rirnrrlg;aro

fir ri.: riourirnrrriqnnr:riou'laiaru cvc uoiqrnnr:ilnt.tu.lrr meta-anatysis lufl n.a. z0oz,. d,l

:tl:rrrunnt:dnutlrt randomized controlled tiruru I nr:finr+r loufit'ru,lu{ilran'ririrr.t

nr:fingrl]":du 4.143 ?'tu nl'jrnt:'ldar:n:n1u chlorhexidine gluconate out,:nnno-n:tnr:fin
ldo'lln':yunl6onrfidr.rr-udnil CVC (catheter-related btoodstream iniection, CneSq nt16

:u 1ru5oun; +9 rfrorfrsun"lnT:td povidone iodine tirnx.t flsornfitru"r (957o Cl, 0.27-0.92)
r5a :vlrueroirrl'jrnr:1fr chlorhexidine gluconate drnrue ;arofitrri,rriounr:1d cvc fi

llaq:rnr:fioidoro,,r CvC riaunirnr:ld povidone iodine ni.r rianr:lai cvc In1 1.000 nio

+. nr:r6an1fi catheter iinrtrslrt
rfio.:ornqruclriGtandlu catheter fiNooianrlfiq cRBSt o-0r", ilfinruo'rrflufil:

d'a.,:r6on1d catheter'lfi mrryolsrrunrrr.l'r rfl u o'ld

n.t. xfiaw$aqfrIiit catheter'
fifioqnririi'ir catherer frd1?1n Tefton yio potyurethane q;fiIonrordu.teionr:rfio

CFBSI doun'j1 catheter dd1e1n polyvinyt chloride r?a potyethylene

4.2 iluzu lumen aa\, catheter
ctnnr:iinutuu meta-anatysis d.nrmru'lufl R.fl. 20043 fiui1a1nnr::,lu:ltdatnqrn

s nr:6nnr tudnr r randomized triat fil r:J3ul rfiuldenrnr:norrdaro.,r cvc fi:hu?on 2ss mu

144 retrirtiolnqndugru

fi'td cvc rru! single-lumen rfiurLriu {rhu zzo :rufi'ld multilumen cvc vuljl o'qmnr:tfin

cnasr tu{rhudtei single- lumen CVC rvirri!5ouo; 3.t rfiu:-rriu5ouo: a.a'lu{rJrunlld mutti-
tumen CVC o'',rriui.rnr:16antri multi-lumen catneter tu{rhufifrf,orj,rddiiorlurviliu

I4.3. Catheter iimiiau'nefrlru?airn (Antimicrobial Antiseptic impregnated

catheters)

iu:Io1lTu antiseptic impregnated catheter fi z tfiellfi*ri antimicrobial impregnated
catheter 6lm6oud?u chlorhexidine/ silver sulfadiazine [[n: antiseptic impregnated catheters

*',,rrnfiordrtr minocycline / rifampin crnnr:ilnur !'ir catheter fitndald?u chlorhexidine /

sitver sutfadiazine rf.,.:iuu:n dltnfiolurratr:dufi'ldruuonlat catheter ua;iudca'rdlrnfiol

chlorhexidine / silver sulfadiazin" fr.'rdru'lurrnvdruuon dl ttnnnosl:rnr:tfi91 colonization fi

CVc ld'o'' 'lurrurfi catheter fi ta6oldru antibiotic (minocycline/rifampin) 6l'ltJ11n09n-ll

colonization lo.ttt!nfiriuuacfilon1fl tna cRBSI oirn'j't catheter firsrFaldru chlorhexidine /

sitver sulfadiazine iuu:n1dadr.:ir'olru" 1q:i6nr':ninrrtfio cRast rvirn':i5oun: o.g rfiulffi
5oao: s,5 mtrrirnirl orjr.:'l:finT r flolrjfidoXnuJiuufral:vu'jro antiseptic impregnated catheter

fl-u antimicrobial impregnated catheter jufioo.l

s. {rderen{unrrld cvc

fida4o:-il4'ird'n:rnr:rfio cRBSt rfilduonur'rurur-ufi1* cvc'li ri'rriuuurri{guo

{rhunr:'lfinlr.rou'h'lunrrficr:rurnoudlu cvc ri'ufifinr.ronrtr"irtflufia'l'lfi udornio4nfrfi

afluiluiu1ilorirdl{tln1Tru'ru'r n'r:uldflunhuvlJ,Jviotrifiau catheter loulfiol"runilo rfiu16on

16 qr rirfiugrrrnr" rfio,,:lrnnuirlriorrr:naora:i6nr:ni:rot cRest unramtfio mechanical
comptications dr.r1fii{q'r:rilfiEru cvc rfrofimqnirrflu rdu n,tdu'jrfinr?; CFBSI rfiodu firlrynr
nr:oosriuro,r lumen tiafi skin infection tfiodu.

6. nr:'lfiurfirr.rnr:ui.r#rtorr6onnir r')g catheter

rdoro, nnr:fiaurdoouia librin lu lumen 1o.J catheter d.rraSlnr:tfio colonization
qa,,,:uunfir?u'lu catheter rro;ri{ d cRBSI i.tinrurlurul.rtfiurdrunr:u{rn"rto.uiaodruvr.t
catheter rdori.nyonlanrarfie thrombosis 'lu cvc mnnr:6ntr'ludnuru: meta-analysis 6.t
6fim{1ui n.6. 1998 rnruirn'r:trt anticoagutants ldud nr:lfi heparin eldriufl'l'invnrun*tfiiru
tumen 1B.r catheter n1i ftush ff'ru cvc dxu heparin flura 5,000 U yln o-tz rirT*ro vionr:6o
low molecular weight heparin ldfirtfttunv z,soo U o'ttr:nnonr:tfio central venous thrombosis

nr16"o odr,:I:fr srunr:fnu'rd',rnairr .[rjnur:nnnql"fi nr:nila.: cRest l6'

drvfinr:nnrur:Jfr6ru; rdu vancomycin drurYl neparin tun'r: dooru cvc riu

-1d'?5

fi:ruuu'irour:nnnqrifinr:niro.r cRBSt uriorqrial#rfionr:undn:;qtuto.: tt:.rnfrriuni:.r

urnddodam vancomycin d.m;rialfirfinflrynr'luauroold 6.,rlriuuai{rTlfiffidtunr:flo.cfi'u cRBSt6

Vascular Access ain{ no'lati l4t

Gatheter dysfunction
y'r:ri1n1rld cvc rflurxnr!'tuorcdr'htfinr:aneYuna{ cvc d,idxulfidrfioornfi fibrin uny

thrombus nrulu tum"n .t o{ cvc thrombus d rfi nduo:rirn-rrfl urefi auduijo rfl onrudur (one-

way vatuel vr:llfifi,r|rric;ri.,tcr r:o'hiorflirvrr.r cvclduoiorle:lriour:nqn!6flooflne1n calheter

Ifi nr:rfin thrombus n'nunr:iil,u1d:ioulu cvc iiM't,i subctavian vein' uonelndarclfiqnrr:
catheter dysfunction lficrnnr:fi CVC qnnaytilTaflntyofl ctavicte un: first rio lTou rourdu
{ilrufflfiirnr:td cvc fio ctavicte lrnrfiu}J1 r?annrtyd.jr pinch-otf syndrome

Catheter associated central vein thrombosis
nr:tri cvo orurrnrfrrntrrrdu.matnr:fi or cenrrat vein thrombosisld filfl.Jru.irnr:'ld

CVC d femoral vein olriuf,fiinr:lfig venous thrombosis lrnn'irnt,:'lni CvC fiol"'runri'.: subctavian
vein (21.5vo VS 1.9%; 3 luaruciinr:tri CVc #gi1rr4li,r t.lv filanrarfin thrombosis orn'jrfi
pit utrir: subclavian vein 4 tyit"

orir. :finlrnr:rfio venous thrombosis n',:neimrinLilrlornrtrroo..:tr'':nifin lroyrirlrifi
r.rnngrudlriufr.rnm;u :nfiauiiarcrfinnrtrr nhl acute putmonary embotism i.trJntlrhLifidaqln
crirorlu'Jrnr:tfiarfirunrru6,:orlo,r rFan uri{:Jrutulofigfifia.:1d cvc ?:d.rrJ.nnflno*m:rnr:rfin
venous thrombosis ld tuflolriut-lti,rlrjuu;rjrtfi'ldsrdl,rndrr'lun'nflorn'u venous thrombosis
n1r u1s'r nou6r'ru cvc rfrahifinrrile'rrflufio,r'td{,rrflui6fr6finoiunrrflo,rfliuvenous rhrombosis

tuflrutu

dflJ

rfjo,:qrnnr:'ld cvc rfluu"nnnr:fifinrrilq1rflulu'lafia rfluadr.rE,r uur6unlvrurrrn{

:l4l-fi.,:rutula6g6.:nr:fiorfiarr:rarrrrntunr:drrinnnr:uo:'hinr:ouainur cvc tutyfi.jl{n1i
.llf-trulfl!idr.fluati,rtd1a.fio"rvnqaFai doarfinrrurdfrfiur-rilr-do,rit$iun:{onr:::irlunr:td cvc 'hinr:ouo
fla.trfuunsinarnrryu:ndoufiorqrfioduldatir,:rnr:rvau uaclfi{::n'nllrnra'ir rfiolrifinru

l'tiudottfr cvc udxnxtlilnlrno 6['ru cvc oanriufi

loflfitd1rt6\t

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