Bedside Procedures for the Intensivist (eBook)

Preface 8
Contents 10
Contributors 12
1: General Considerations 16
INTRODUCTION 16
WHY PERFORM BEDSIDE PROCEDURES 16
EQUIPMENT 18
Ultrasound 18
Procedure Kits 18
Generic Procedure Cart 19
Endoscopy Cart 21
Fluoroscopy 22
Centralized Procedure Areas 22
PERSONNEL AND CREDENTIALING 23
CONSIDERATIONS FOR THE ACTUAL PROCEDURE 24
INFECTION CONTROL ISSUES 27
FAMILY PRESENCE DURING PROCEDURES 29
References 29
2: Conscious Sedation and Deep Sedation, Including Neuromuscular Blockade 33
INTRODUCTION 33
EXISTING GUIDELINES 34
Depth of Sedation 34
Patient Monitoring 36
CLINICAL FACTORS INFLUENCING DRUG SELECTION 38
Type, Duration, and Noxiousness of the Bedside Procedure 38
Patient History 38
MEDICATION SELECTION 40
Sedatives 40
Benzodiazepines 42
Etomidate 42
Propofol 43
Dexmedetomidine 43
Analgesics 43
Opioids 44
Acetaminophen 45
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) 45
Neuromuscular Blocking Agents 46
Succinylcholine 48
Benzylisoquinoliniums 48
Aminosteroidals 49
SUMMARY 49
REFERENCES 49
3: Airway Management 51
INTRODUCTION 51
DEFINITION OF A DIFFICULT AIRWAY 52
AIRWAY ASSESSMENT, PREDICTION, AND PREPARATION 52
VENTILATION 54
INTUBATION 58
ETT CHANGES 67
EXTUBATION 68
CONCLUSION 69
REFERENCES 69
4: Ultrasound Physics and Equipment 70
INTRODUCTION 70
Physics 71
Sound Waves 71
Image Formation 72
Reflection 75
Attenuation 76
Modes of Ultrasound 77
2D Ultrasound 77
M-mode Ultrasound 77
Doppler Ultrasound 78
Types of Doppler Ultrasound 80
Aliasing 83
Artifacts 84
Acoustic Shadowing 84
Acoustic Enhancement 84
Reverberation 86
Comet Tail 86
Mirror Image Artifact 87
Harmonic Imaging 87
INSTRUMENTATION 88
Transducer Frequency 88
Control Panel 90
CONCLUSION 93
SUGGESTED READING 93
5: Ultrasound-Guided Vascular Access Procedures 94
INTRODUCTION 94
ULTRASOUND USE FOR ACCESS 96
REVIEW OF ULTRASOUND 97
Transducer Selection 97
Modes 97
TECHNIQUES OF ULTRASOUND GUIDANCE 100
Planes and Views 101
Methods of Orientation 103
HOW TO PERFORM ULTRASOUND-GUIDED CANNULATION 106
Internal Jugular Vein 106
Subclavian Vein 110
Axillary Vein 110
Femoral Vein 112
ARTERIAL CATHETER PLACEMENT WITH ULTRASOUND GUIDANCE 113
PICC LINES/MIDLINES 117
SUMMARY 122
REFERENCES 122
6: Ultrasound-Guided Drainage Procedures for the Intensivist 125
INTRODUCTION 125
ESSENTIAL ULTRASOUND PHYSICS AND IMAGING PRINCIPLES 126
ULTRASOUND-GUIDED BEDSIDE DRAINAGE PROCEDURES 131
Thoracentesis 131
Pericardiocentesis 139
Paracentesis 143
REFERENCES 148
7: Focused Echocardiography in the ICU 150
INTRODUCTION 150
ULTRASOUND PHYSICS 151
IMAGE ACQUISITION 157
Instrument Settings 157
Image Depth 157
Gain and Time-Gain Compensation 157
Tissue Harmonic Imaging 158
Dynamic Range 158
Scan Area 158
Doppler Controls 158
Signal Power Output 159
Imaging Artifacts and Pitfalls 159
THE ECHOCARDIOGRAPHIC EXAM 159
Transthoracic 160
Parasternal 160
Apical 160
Subcostal 164
Transesophageal 164
Esophageal 164
Transgastric 166
Transgastric Apical 167
FUNCTIONAL ASSESSMENT 167
Preload 167
Left Ventricular Chamber Dimensions 168
Right Ventricular Chamber Dimensions 168
Inferior Vena Caval Dimension 169
Doppler Assessment of Left Ventricular Inflow 172
Preload Responsiveness 174
Vena Caval Dynamics 174
Stroke Volume Variation 175
Ventricular Performance 177
Wall Motion Abnormalities 179
Fractional Shortening and Ejection Fraction 179
Stroke Volume and Cardiac Output 182
Right Ventricular Function 183
Afterload 183
Right Ventricular Afterload 183
Ventricular Interdependence 184
Cardiac Arrest and Resuscitation 186
STRUCTURAL ASSESSMENT 187
Pericardial Effusion and Tamponade 187
Valvular Regurgitation 188
Intracardiac Shunts 188
REFERENCES 191
8: Procedures in Critical Care: Dialysis and Apheresis 193
INTRODUCTION 193
WHEN TO INITIATE RENAL SUPPORT AND WHAT MODE OF THERAPY TO USE 194
PERITONEAL DIALYSIS 195
BLOOD SIDE THERAPIES 195
Hemodialysis 197
Hemofiltration 197
Hemodiafiltration 197
CONTINUOUS VERSUS INTERMITTENT THERAPIES 198
INTENSIVE VERSUS CONVENTIONAL THERAPIES 199
DIALYSIS ACCESS 200
Peritoneal Access 200
Venous Access 201
DIALYSIS PRESCRIPTION 201
Peritoneal Dialysis 201
Intermittent Hemodialysis 203
Continuous Renal Replacement Therapy 205
Slow Extended Dialysis 206
Slow Continuous Ultrafiltration 206
ANTICOAGULATION 206
Unfractionated Heparin 207
Anticoagulation Protocols 207
COMPLICATIONS OF RENAL SUPPORT 208
USE OF HEMODIALYSIS AND HEMOPERFUSION IN POISONING 208
Indications for Using Hemodialysis/Hemoperfusion for Drug/Toxin Removal 209
Hemodialysis 210
Hemoperfusion 210
PLASMAPHERESIS IN THE ICU 210
PLASMAPHERESIS PRESCRIPTION 211
REFERENCES 212
9: Pericardiocentesis 215
HISTORY 215
ETIOLOGY 216
DIAGNOSIS OF TAMPONADE 216
NONOPERATIVE MANAGEMENT 217
OPEN PERICARDIOTOMY 217
PERICARDIOCENTESIS 218
Indications 218
Contraindications 218
Procedure 219
Procedural Steps 220
COMPLICATIONS 224
REFERENCES 225
10: Bedside Insertion of Vena Cava Filters in the Intensive Care Unit 227
HISTORY 228
CONSIDERATIONS 228
INDICATIONS FOR VCFs 229
CONTRAINDICATIONS 230
ANATOMY 230
EQUIPMENT 231
SETUP, PREPARATION, AND POSITIONING 232
TECHNIQUE 234
COMPLICATIONS 239
SUMMARY 240
REFERENCES 241
11: Percutaneous Dilational Tracheostomy 243
HISTORY 243
INDICATIONS FOR PDT 244
PDT TECHNIQUE 245
Patient Selection 246
Monitoring 246
Sedation 246
Positioning 246
Anatomic Assessment 247
Airway Management 247
Skin Incision and Blunt Dissection 248
Video Bronchoscopy 249
SPECIAL SITUATIONS 251
PERI-PROCEDURAL COMPLICATIONS 252
POSTOPERATIVE CARE 253
CONCLUSIONS 253
REFERENCES 254
12: Open Tracheostomy 256
INTRODUCTION 256
INDICATIONS 256
TIMING 257
OPEN VS. PERCUTANEOUS 257
ANATOMY 257
ICU ROOM SETUP 258
EQUIPMENT 258
TYPES OF TRACHEOSTOMY TUBES 259
ANESTHESIA 259
TECHNIQUE 260
COMPLICATIONS 261
REFERENCES 262
13: Transbronchial Biopsy in the Intensive Care Unit 264
INTRODUCTION 264
INDICATIONS FOR FB 265
COAGULOPATHY 267
UNSTABLE CARDIOVASCULAR DISEASE 268
INCREASED INTRACRANIAL PRESSURE 269
REACTIVE AIRWAY DISEASE 269
NECESSARY EQUIPMENT 269
PREPROCEDURE 269
PROCEDURE 271
SUMMARY 278
REFERENCES 278
14: Percutaneous Endoscopic Gastrostomy 283
INTRODUCTION 283
INDICATIONS AND CONTRAINDICATIONS 284
PREOPERATIVE PREPARATION 285
DESCRIPTION OF PROCEDURES 285
Pull Method 285
PUSH METHOD 287
Introducer/Serial Dilating Method (Russell Technique) 289
SLiC METHOD 289
POSTPROCEDURE MANAGEMENT 289
COMPLICATIONS 291
CONCLUSION 292
REFERENCES 292
15: Chest Drainage 294
INTRODUCTION 294
HISTORY 294
THE PLEURAL SPACE 295
INDICATIONS FOR PLEURAL DRAINAGE 295
Pneumothorax 295
Fluid in the Pleural Space 296
CONTRAINDICATIONS 296
ANATOMY 296
EQUIPMENT 298
SETUP, PREPARATION, AND POSITIONING 299
ANESTHESIA 299
TECHNIQUES 300
Blunt Dissection 301
Seldinger Technique 302
Catheter-Over-Needle 304
Suture Technique 305
DRESSING THE CHEST TUBE 305
DRAINAGE DEVICE 306
COMPLICATIONS 308
ASSESSMENT OF FUNCTION AND TROUBLESHOOTING 309
REMOVAL 310
SUMMARY 311
References 311
16: Intracranial Monitoring 313
INTRODUCTION 313
INDICATIONS AND CONTRAINDICATIONS 314
MONITORING DEVICES 316
SETUP, PREPARATION, AND POSITIONING 317
ANESTHESIA 319
INSERTION TECHNIQUES 319
Ventriculostomy 320
ICP Bolt (CAMINO™, VENTRIX™) 322
LICOX 323
Codman ICP Monitor 325
Tunneling Insertion Technique 326
COMPLICATIONS 327
REMOVAL 327
CONCLUSIONS 328
REFERENCES 328
17: Billing for Bedside Procedures 329
INTRODUCTION 329
PATIENT CARE CODES 330
CRITICAL CARE CODES 330
MODIFIERS 332
MEDICAID AND MEDICARE 336
REFERENCES 336
Index 338