Bedside Procedures for the Intensivist

Preface

Contents

Contributors

1: General Considerations

INTRODUCTION

WHY PERFORM BEDSIDE PROCEDURES

EQUIPMENT

Ultrasound

Procedure Kits

Generic Procedure Cart

Endoscopy Cart

Fluoroscopy

Centralized Procedure Areas

PERSONNEL AND CREDENTIALING

CONSIDERATIONS FOR THE ACTUAL PROCEDURE

INFECTION CONTROL ISSUES

FAMILY PRESENCE DURING PROCEDURES

References

2: Conscious Sedation and Deep Sedation, Including Neuromuscular Blockade

INTRODUCTION

EXISTING GUIDELINES

Depth of Sedation

Patient Monitoring

CLINICAL FACTORS INFLUENCING DRUG SELECTION

Type, Duration, and Noxiousness of the Bedside Procedure

Patient History

MEDICATION SELECTION

Sedatives

Benzodiazepines

Etomidate

Propofol

Dexmedetomidine

Analgesics

Opioids

Acetaminophen

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Neuromuscular Blocking Agents

Succinylcholine

Benzylisoquinoliniums

Aminosteroidals

SUMMARY

REFERENCES

3: Airway Management

INTRODUCTION

DEFINITION OF A DIFFICULT AIRWAY

AIRWAY ASSESSMENT, PREDICTION, AND PREPARATION

VENTILATION

INTUBATION

ETT CHANGES

EXTUBATION

CONCLUSION

REFERENCES

4: Ultrasound Physics and Equipment

INTRODUCTION

Physics

Sound Waves

Image Formation

Reflection

Attenuation

Modes of Ultrasound

2D Ultrasound

M-mode Ultrasound

Doppler Ultrasound

Types of Doppler Ultrasound

Aliasing

Artifacts

Acoustic Shadowing

Acoustic Enhancement

Reverberation

Comet Tail

Mirror Image Artifact

Harmonic Imaging

INSTRUMENTATION

Transducer Frequency

Control Panel

CONCLUSION

SUGGESTED READING

5: Ultrasound-Guided Vascular Access Procedures

INTRODUCTION

ULTRASOUND USE FOR ACCESS

REVIEW OF ULTRASOUND

Transducer Selection

Modes

TECHNIQUES OF ULTRASOUND GUIDANCE

Planes and Views

Methods of Orientation

HOW TO PERFORM ULTRASOUND-GUIDED CANNULATION

Internal Jugular Vein

Subclavian Vein

Axillary Vein

Femoral Vein

ARTERIAL CATHETER PLACEMENT WITH ULTRASOUND GUIDANCE

PICC LINES/MIDLINES

SUMMARY

REFERENCES

6: Ultrasound-Guided Drainage Procedures for the Intensivist

INTRODUCTION

ESSENTIAL ULTRASOUND PHYSICS AND IMAGING PRINCIPLES

ULTRASOUND-GUIDED BEDSIDE DRAINAGE PROCEDURES

Thoracentesis

Pericardiocentesis

Paracentesis

REFERENCES

7: Focused Echocardiography in the ICU

INTRODUCTION

ULTRASOUND PHYSICS

IMAGE ACQUISITION

Instrument Settings

Image Depth

Gain and Time-Gain Compensation

Tissue Harmonic Imaging

Dynamic Range

Scan Area

Doppler Controls

Signal Power Output

Imaging Artifacts and Pitfalls

THE ECHOCARDIOGRAPHIC EXAM

Transthoracic

Parasternal

Apical

Subcostal

Transesophageal

Esophageal

Transgastric

Transgastric Apical

FUNCTIONAL ASSESSMENT

Preload

Left Ventricular Chamber Dimensions

Right Ventricular Chamber Dimensions

Inferior Vena Caval Dimension

Doppler Assessment of Left Ventricular Inflow

Preload Responsiveness

Vena Caval Dynamics

Stroke Volume Variation

Ventricular Performance

Wall Motion Abnormalities

Fractional Shortening and Ejection Fraction

Stroke Volume and Cardiac Output

Right Ventricular Function

Afterload

Right Ventricular Afterload

Ventricular Interdependence

Cardiac Arrest and Resuscitation

STRUCTURAL ASSESSMENT

Pericardial Effusion and Tamponade

Valvular Regurgitation

Intracardiac Shunts

REFERENCES

8: Procedures in Critical Care: Dialysis and Apheresis

INTRODUCTION

WHEN TO INITIATE RENAL SUPPORT AND WHAT MODE OF THERAPY TO USE

PERITONEAL DIALYSIS

BLOOD SIDE THERAPIES

Hemodialysis

Hemofiltration

Hemodiafiltration

CONTINUOUS VERSUS INTERMITTENT THERAPIES

INTENSIVE VERSUS CONVENTIONAL THERAPIES

DIALYSIS ACCESS

Peritoneal Access

Venous Access

DIALYSIS PRESCRIPTION

Peritoneal Dialysis

Intermittent Hemodialysis

Continuous Renal Replacement Therapy

Slow Extended Dialysis

Slow Continuous Ultrafiltration

ANTICOAGULATION

Unfractionated Heparin

Anticoagulation Protocols

COMPLICATIONS OF RENAL SUPPORT

USE OF HEMODIALYSIS AND HEMOPERFUSION IN POISONING

Indications for Using Hemodialysis/Hemoperfusion for Drug/Toxin Removal

Hemodialysis

Hemoperfusion

PLASMAPHERESIS IN THE ICU

PLASMAPHERESIS PRESCRIPTION

REFERENCES

9: Pericardiocentesis

HISTORY

ETIOLOGY

DIAGNOSIS OF TAMPONADE

NONOPERATIVE MANAGEMENT

OPEN PERICARDIOTOMY

PERICARDIOCENTESIS

Indications

Contraindications

Procedure

Procedural Steps

COMPLICATIONS

REFERENCES

10: Bedside Insertion of Vena Cava Filters in the Intensive Care Unit

HISTORY

CONSIDERATIONS

INDICATIONS FOR VCFs

CONTRAINDICATIONS

ANATOMY

EQUIPMENT

SETUP, PREPARATION, AND POSITIONING

TECHNIQUE

COMPLICATIONS

SUMMARY

REFERENCES

11: Percutaneous Dilational Tracheostomy

HISTORY

INDICATIONS FOR PDT

PDT TECHNIQUE

Patient Selection

Monitoring

Sedation

Positioning

Anatomic Assessment

Airway Management

Skin Incision and Blunt Dissection

Video Bronchoscopy

SPECIAL SITUATIONS

PERI-PROCEDURAL COMPLICATIONS

POSTOPERATIVE CARE

CONCLUSIONS

REFERENCES

12: Open Tracheostomy

INTRODUCTION

INDICATIONS

TIMING

OPEN VS. PERCUTANEOUS

ANATOMY

ICU ROOM SETUP

EQUIPMENT

TYPES OF TRACHEOSTOMY TUBES

ANESTHESIA

TECHNIQUE

COMPLICATIONS

REFERENCES

13: Transbronchial Biopsy in the Intensive Care Unit

INTRODUCTION

INDICATIONS FOR FB

COAGULOPATHY

UNSTABLE CARDIOVASCULAR DISEASE

INCREASED INTRACRANIAL PRESSURE

REACTIVE AIRWAY DISEASE

NECESSARY EQUIPMENT

PREPROCEDURE

PROCEDURE

SUMMARY

REFERENCES

14: Percutaneous Endoscopic Gastrostomy

INTRODUCTION

INDICATIONS AND CONTRAINDICATIONS

PREOPERATIVE PREPARATION

DESCRIPTION OF PROCEDURES

Pull Method

PUSH METHOD

Introducer/Serial Dilating Method (Russell Technique)

SLiC METHOD

POSTPROCEDURE MANAGEMENT

COMPLICATIONS

CONCLUSION

REFERENCES

15: Chest Drainage

INTRODUCTION

HISTORY

THE PLEURAL SPACE

INDICATIONS FOR PLEURAL DRAINAGE

Pneumothorax

Fluid in the Pleural Space

CONTRAINDICATIONS

ANATOMY

EQUIPMENT

SETUP, PREPARATION, AND POSITIONING

ANESTHESIA

TECHNIQUES

Blunt Dissection

Seldinger Technique

Catheter-Over-Needle

Suture Technique

DRESSING THE CHEST TUBE

DRAINAGE DEVICE

COMPLICATIONS

ASSESSMENT OF FUNCTION AND TROUBLESHOOTING

REMOVAL

SUMMARY

References

16: Intracranial Monitoring

INTRODUCTION

INDICATIONS AND CONTRAINDICATIONS

MONITORING DEVICES

SETUP, PREPARATION, AND POSITIONING

ANESTHESIA

INSERTION TECHNIQUES

Ventriculostomy

ICP Bolt (CAMINO™, VENTRIX™)

LICOX

Codman ICP Monitor

Tunneling Insertion Technique

COMPLICATIONS

REMOVAL

CONCLUSIONS

REFERENCES

17: Billing for Bedside Procedures

INTRODUCTION

PATIENT CARE CODES

CRITICAL CARE CODES

MODIFIERS

MEDICAID AND MEDICARE

REFERENCES

Index