Common Procedures in the ICU

Common Procedures in the ICU

Fariha Sheikh, MD and Adam D. Fox, DO, DPM

Division of Trauma and Critical Care Surgery, Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA

  1. When preparing to intubate a patient with a difficult airway, which of the following is true?

    1. An assistant is unnecessary
    2. Having a variety of laryngoscopes is unnecessary
    3. You do not need videolaryngoscopy as back up
    4. Single person mask ventilation is ideal
    5. Preoxygenating the patient is recommended

    Per the American Society of Anesthesiology guidelines for difficult intubations, the initial assessment for identifying a potentially difficult airway begins with history and physical exam. Physical characteristics that might indicate a difficult airway include, but are not limited to, a short and thick neck, overbite, thyromental distance less than 3 fingerbreadths, inability to extend the neck, and stiff or non‐resilient mandible.

    If a difficult airway is suspected, recommendations include having an assistant to help with adequate bag mask ventilation and preparing alternate tools and methods of intubation. A portable airway equipment kit is recommended and should include various types and sizes of laryngoscopes, various sizes of endotracheal and supraglottic tubes, and a device to assess for end‐tidal CO2. If available, a videolaryngoscope is recommended to aid in visualization of the cords and safe intubation. A laryngeal mask airway or other supraglottic tube may also be useful in the event of a failed attempt at endotracheal intubation. Although data vary on the exact duration of preoxygenation, studies recommend at least one minute of preoxygenation prior to intubation. Additionally, attempts to oxygenate during intubation, such as through nasal cannula or a blow by mask, should be attempted.

    Answer: E

    American Society of Anesthesiologists (2013) Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology , 118 (2): 1–20.

    Higgs, A., McGrath, B. A., Goddard, C. (2018) Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anesthesia , 120 (2): 323–352.

  2. Which of the following is true regarding arterial line catheters for hemodynamic monitoring?

    1. The most common complication is permanent arterial occlusion.
    2. The most common artery catheterized is the femoral artery.
    3. A risk factor for line infection includes arterial catheters that have been in place for greater than 96 hours.
    4. Sepsis occurs in up to 5% of all arterial line infections.
    5. Axillary artery catheterization has a known risk of potential brain emboli.

    Arterial catheters are often placed for hemodynamic monitoring and frequent evaluation of arterial blood gas. The most common location for arterial line placement is the radial artery, though other commonly used sites include the femoral and axillary arteries. Potential complications from arterial catheterization include occlusion, line infection, sepsis, hemorrhage, pseudoaneurysm, and hematoma. The most common complication is temporary occlusion of the artery which has been reported at 1.5% to 35%, rather than permanent occlusion which occurs in <1% of cases. However, the risk of occlusion does increase when larger catheters are utilized.

    Although infections associated with arterial lines are relatively rare, risk factors include an indwelling catheter for >96 hours, pseudoaneurysm, and lack of aseptic technique. Additionally rare is the rate of sepsis which has been reported to be <1%; however, this again can be linked to pseudoaneurysm.

    Answer: C

    Bedford, R. F. (1977) Radial arterial function following percutaneous cannulation with 18‐ and 20‐gauge catheters. Anesthesiology , 47: 37–39.

    Brzezinski M, Luisetti T, London MJ . Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesthesia and Analgesia 2009 Dec; 109(6): 1763–1781.

    Scheer, B. V., Perel, A., Pfeiffer, U. J. (2002) Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and critical care medicine. Critical Care , 6 (3): 199–204.

    Wolf, S., Mangano, D. T. (1980) Pseudoaneurysm, a late complication of radial‐artery catheterization. Anesthesiology , 52 (1): 80–81.

  3. A 60‐year‐old woman underwent a pelvic exenteration with significant blood loss. She is noted to be hypotensive and oliguric. After some time trying to resuscitate the patient through 2 large‐bore peripheral intravenous lines without improvement, you have decided to place a central line. In terms of preventing central venous catheter line infections:

    1. Aseptic technique is only needed for immunocompromised patients.
    2. Maximum barrier precautions should be utilized.
    3. Antibiotic‐coated catheters do not offer any benefit in preventing infections.
    4. Catheter insertion sites should be checked every 3 days for signs of infection.
    5. Catheters can remain in place for any number of days as long as the insertion site does not demonstrate signs of erythema.

    Aseptic technique, including maximum barrier precautions, is recommended for all patients when placing central venous access. The possible exception is for when the line is placed in an emergent fashion for the patient in extremis; however, central lines not performed under sterile technique must be removed as soon as possible and new lines placed using sterile technique. Antibiotic‐coated catheters do decrease the risk of catheter‐related blood infections. All catheters should have the dressing and insertion site assessed at least once per day to ensure it remains protected and clean in order to minimize risk of infection. Catheters should be removed once the catheter is no longer needed and they should not stay in longer than a maximum of 7 days.

    Answer: B

    Apfelbaum, J. L. (2020) Anesthesiologists task force on central venous access. Anesthesiology , 132: 8–43.

    Ikusika, O., Waxman, M., Asher, S. (2013) Recommended site for central venous catheter placement: a review of current practice guidelines. Critical Care Medicine , 41 (12): A275.

  4. Which of the following are true when considering using ultrasound guidance for central line placement as opposed to landmark techniques?

    1. The landmark techniques allow for visualization of thrombus within the vein.
    2. Inadvertent puncture of the adjacent artery is always prevented when using ultrasound guidance.
    3. Ultrasound guidance for placing a central line in the subclavian vein has not shown any benefit in outcomes and less complications.
    4. There is a higher rate of success with the landmark technique.
    5. Ultrasound aids in identifying abnormal vascular anatomy prior to puncture.

    Use of ultrasound guidance for central line placement has increased due to numerous studies demonstrating decreased complication rates in terms of arterial puncture, hemothorax, pneumothorax, and hematoma formation. Furthermore, the number of puncture attempts is fewer when utilizing ultrasound guidance and overall success in line placement is higher with the use of ultrasound, including for access to the subclavian vein. Additional benefits to ultrasound use include visualization of thrombi or in identifying abnormal anatomy.

    Answer: E

    Fragou, M., Gravvanis, A., Dimitriou, V. (2011) Real‐time ultrasound‐guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Critical Care Medicine , 39 (7): 1607–1612.

    Saugel, B., Scheeren, T. W. L., Teboul, JL. (2017) Ultrasound‐guided central venous catheter placement: a structured review and recommendations for clinical practice. Critical Care , 21: 225.

  5. A 63‐year‐old woman is being cared for in the ICU and undergoes a chest x‐ray which demonstrates a large right pleural effusion. The decision was made to proceed with chest tube placement. Which of the following is true regarding tube thoracostomy?

    1. The trochar puncture technique is not associated with a higher risk of complications.
    2. Special consideration should be made when considering placing a drain in a patient with previous thoracic or cardiac surgery or previous tube placement.
    3. The chest tube should be placed along the inferior border of the rib.
    4. There is a risk of injuring the lung and cardiac ventricles when placing a chest tube, but the esophagus is far too medial to be at risk for injury.
    5. The borders of the triangle of safety for chest tube placement include the axillary fold of pectoralis major, serratus anterior, and the line along the 5th intercostal space or nipple.

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Dec 15, 2022 | Posted by in CRITICAL CARE | Comments Off on Common Procedures in the ICU

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