Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
20 Cards in this Set
- Front
- Back
|
Arterial line
Used for? Indications for? Where is it put? & where not put? Contraindications? Complications? |
USED FOR
-MAP (hypotension, ICP, hypertension) -ABGs -trace characteristics INDICATIONS -continuous pressure haemodynamic monitoring -repeated ABGs/bloods LOCATIONS -usually radial or dorsalis pedis -dont use endarteries eg brachial, but can use femoral even though endartery as large size makes occulsion unliekly Contraindications? -severe raynauds, inadequate circulation -Dialysis fistula -absent collaterals -full thickness burns/infection over site ?coagulopathy/meds Cx -thrombosis 10-20% (related to duration of use, wrist size/art diameter, sex, prolonged systemic hypotension) -haematoma (>50%), haemorrhage -Sepsis (4-5 days) -distal emboli -aneurysm -accidental arterial drug administration -compartment syndrome -air embolis -nerve injury ------------------------------------------------------------------------- D. Arterial Cannulation 1. Indications: a) Routine measurement of systemic blood pressure in ICU b) Multiple blood gas and laboratory analysis c) Measurement of BP during transport of patients in hostile environments 2. Management protocol: a) Remove and replace lines inserted in unsterile conditions as soon as possible. b) Brachial and femoral arterial lines should be changed as soon as radial or dorsalis pedis arteries are available. c) Aseptic technique: i) Handwash with AVAGARD® (chlorhexidine 2%) or MEDISPONGE® (chlorhexidine 4%) + sterile gloves ii) Skin prep. with SOLU-IV (chlorhexidine 2% / 70% alcohol) d) Local anaesthesia in awake patients. e) Cannulae: i) Arrow® radial or femoral kits (Seldinger technique). ii) 20G Insyte® . iii) Single lumen 20G CVC (paediatric) for femoral arterial lines. f) Insertion sites – in order of preference: radial > dorsalis pedis > femoral > brachial g) The femoral artery may be the sole option in the acutely shocked patient. h) Secure with a StatLock® device. i) There is no optimal time for an arterial line to be removed or changed. j) IA cannulae are changed/removed in the following settings: i) Invasive IA line is no longer necessary. ii) Distal ischaemia iii) Mechanical failure (overdamped waveform, inability to aspirate blood) iv) Evidence of local or unexplained systemic infection k) Measurement of pressure: i) Transducers should be ‘zeroed’ each nursing shift ii) Zero reference = the mid-axillary line, 5th intercostal space l) Maintenance of lumen patency i) Continuous pressurised (Intraflo® ) saline flush at 3ml/hr. 3. Complications a) Infection b) Thrombosis / digital ischaemia c) Vessel damage / aneurysm d) Haemorrhage / disconnection |
|
|
central venous line
Used for? INdications for? WHere is it put? Contraindications? Complications? Duration of use? |
USED FOR
-CVP measurement (usually 5-10mmHg) -INfusion of hypertonic or irritant fluids -facilitate other therapy eg pacemaker, PA catheter, dialysis, plasmapheresis (not useful for rapid volume replacement) Giving: -NUtritional support -administration of caustic medications eg vasopressors Monitoring: - CVP monitoring -Pulmonary artery catheterisation Doing -transvenous pacing wire introduction -Haemodialysis Sites Subclavian - lowest infection risk, more comfortable for awake patient BUT higher pneumothorax and arterial puncture risk Internal jugular -lower pneumothorax risk BUT higher infection risk, less comfortable for awake pt Femoral -no pneumothoraX risk, safer in emergency or coagulopathy BUT moderate risk of infection, less accurate CVP, uncomfotable. PICC -lowest infection risk, well tolerated, good for long term access (>2 weeks) BUT no CVP External Jugular - similar to IJ CONTRAINDICATIONS -infection at site ?distorted anatomy (?USS) -?coagulopathy -?uncooperative pt ?potential for future thrombolysis NOTE: direct pressure cannot be applied to subclavian COMPLICATIONS -Failure to site in SVC -Haematoma -arterial puncture -pneumothorax -rarely damage to other structures eg nerves, (vagus, recurrent laryngeal, cervical plexus, stellate ganglion), thoracic duct, trachea -line sepsis -rare: thromboembolism, AV fistula Duration -standard 3 days -antiseptic coated up to 14 days (unless evidence of infxn) ---------------------------------------------------------------------- E. Central Venous Catheters NB: Registrars should be familiar with the interpretation and limitations of haemodynamic variables derived from central catheters (CVC, PICCO and PAC) in critically ill patients. 1. Indications: a) Standard IV access in ICU patients: i) Vasoactive infusions ii) Fluid administration (including elective transfusion) iii) Hypertonic solutions (TPN, amiodarone, nimodipine, etc.) b) Monitoring of right atrial pressure (CVP) c) Venous access for: i) Pulmonary artery catheterisation (PAC) ii) Continuous renal replacement therapy (CVVHDF) iii) Plasmapheresis. iv) Transvenous pacing. v) Jugular bulb oximetry. d) Resuscitation i) Large bore peripheral IV line(s) are 1st line. ii) Standard lumen CVCs are not appropriate for acute volume resuscitation. iii) Consider using a PAC sheath or Vascath if central access is required and adequate peripheral access is unobtainable. 2. Management protocol: (applies to all types of CVC): a) Types: i) The default CVC for all ICU patients is a Cook antimicrobial impregnated (rifampicin/minocycline) 7F 15 or 20cm 3-lumen catheter. ii) Non-impregnated catheters inserted outside the ICU should be changed to an impregnated catheter according to clinical indication. iii) Dolphin Protect® catheters are used for CVVHDF and plasmapheresis iv) Pulmonary artery catheter sheath (part of the PAC kit) v) Dress non-impregnated catheters with a BioPatch® b) Sites: i) Preferred site for routine stable patients → SCV > IJV. ii) Femoral v. access is preferable where: Dolphin Protect® / CVVHDF Limited IV access (burns, multiple previous CVC’s), A thoracic approach is considered hazardous with: a. Severe respiratory failure from any cause (PaO2/FiO2 < 150) b. Hyper-expanded lung fields (severe asthma, bullous disease) c. Coagulopathy (see below) Inexperienced staff requiring urgent access, where supervision is not immediately available. |
|
|
chest drain
indications? Contraindications? Anatomical considerations? |
INDICATIONS
Large bore -haemothorax -empyema -Tension pneumothorax or traumatic simple pneumo -post cardiac and thoracic surgery Small bore -simple penumothorax -secondary pneumothorax win pt with lung dz -pneumothorax in any ventilated pt -malignant pleural effusion CONTRAINDICATIONS Lung adhered to chest wall on XR bullous lung dz - be wary of looking like PTX relative - coagulopathy ANATOMICAL CONSIDERATIONS - neurvascular bundle runs inferiorly hence approach via top of rib -layers include 3xmuscles then pleura -Long thoracic nerve runs down lateral border of thorax hence aim anterior to mid axillary -Boundaries of safe triangle = lat dorsi (or mid axillary line), pec major, nipple (6th rib) -outside of the safe triangle: long thoracic nerve, breast, muscle, axillary structures, liver, spleen If a loculated pleural collection is suspected, the insertion site should be identified using ultrasound Note: if inserting a chest tube outside the triangle of safety, you may need a longer needle (e.g. a spinal needle), to reach the parietal pleura. The following structures are particularly well innervated and should be anaesthetised before dissection: skin periosteum of the lower rib parietal pleura. Structures that could be injured during insertion of a chest tube, include: intercostal vessels and nerve lung (underlying or contralateral) pericardium/myocardium aorta/great vessels of mediastinum intra thoracic sympathetic nerves (causing Horner's syndrome) diaphragm liver spleen stomach kidney oesophagus long thoracic nerve (overlying serratus anterior). When the chest x-ray shows a unilateral 'white out', it is important to differentiate between the presence of lung collapse and a pleural effusion. Even small pleural effusions may mask underlying collapse of lung or lobes which can result in significant displacement of intrathoracic organs and/or the diaphragm and subdiaphragmatic organs from their normal anatomical position. Vulnerable anatomy Structures that could be injured during insertion of a chest tube, include: intercostal vessels and nerve lung (underlying or contralateral) pericardium/myocardium aorta/great vessels of mediastinum intra thoracic sympathetic nerves (causing Horner's syndrome) diaphragm liver spleen stomach kidney oesophagus long thoracic nerve (overlying serratus anterior). When the chest x-ray shows a unilateral 'white out', it is important to differentiate between the presence of lung collapse and a pleural effusion. Even small pleural effusions may mask underlying collapse of lung or lobes which can result in significant displacement of intrathoracic organs The position of the diaphragm varies significantly between full inspiration (as on a normal chest x-ray) and expiration There should be easy access to resuscitation equipment at the site of the procedure. An assistant should be available throughout the procedure to assist with patient care, and help with the procedure. (5) Ideally, monitor oxygen saturation continuously and the vital signs intermittently during the insertion of the tube. Reliable venous access is recommended throughout the procedure. Factors to consider for each patient prior to chest tube insertion include: -risk of haemorrhage eg coags -Risk due to unidentified pulmonary or pleural pathology: ptx vs bullous dz, unilateral whiteout If possible the tip of the tube should be aimed: apically to drain air, or basally to drain fluid. Insert the chest tube using artery forceps (Fig 17) or guided by a finger. Once the tube is in the pleural space, continue to insert cautiously until resistance is met, then withdraw slightly. Ensure that all side holes of the chest tube are inside the pleural cavity. The cm markings on the side of the chest tube indicate the distance from the most proximal side hole (eyelet), NOT the tip of the chest tube. These markings can be used as a guide to the distance between the skin and the nearest side hole. A maximum of 1.5 litres should be drained in the first hour after chest tube insertion. After an hour the rest of the fluid may be drained off slowly (1) at a suggested rate of up to 500 ml/hr. |
|
|
arterial line procedure
|
TO GET
KIt -sterile gloves -skin prep, chlorhex -local & needle (without adrenaline to avoid vessel constriction) -suture (3-0, 4-0) For radial 20gauge, for femoral 18gauge 1. Position radial - in dorsiflexion & tape femoral - hip in mild external rotation 2. feel pulsation +- USS 3. local 4. flash + 2mm advance, 5. insert wire, don't advance against resistance Pressure over site 5mins ... APply pressure 5mins |
|
|
what can cause increased art line systolic variation during respiration ?
|
-hypovolaemia
-tamponade -severe LV dysfunction -High intrathoracic pressure during MV -pneumothorax |
|
|
Central venous line procedure
|
TO GET
kit sterile gloves skin prep eg chlorhex local & Needle (without adrenaline) sutures sterile saline flush Aseptic technique - surgical scrub, hat, mask, gown etc ECG monitoring USS Consent Remove hair from site& Clean 1. position - supine, head down 15degrees, bed raised. Don;t turn head. (head down also reduces risk or air embolism -when line is secured, clean site of blood and clean with clhorhex, allow to dry and apply dressing POst CXR |
|
|
when a pt arrives with a CVL insitu - things to do/think about?
|
Does it need to be changed?
-time -infection -can it be removed completely? -if inserted under emergency conditions may need to be replace due to non aseptic concerns Assess Suture & dressing integrity Position Patency of lumens |
|
|
chest drain insertion procedure
triangle of safety borders? |
?coags
?able to lie flat CXR informed consent **confirm side on both XR and pt TO GET ensure resus equipment, suction and full monitoring O2, IVC Assistant POSITION -arm behind head, may need to be held -some head up (alternatively may sit upright leaning over table/pillow) -LOCAL 3MG/KG insertion trhough 4th-5th intercoastal space anterior to midaxillary line -2-3cm incision -blunt dissect -insert finger and sweep -estimate depth, and insert tube so that all holes within pleura, generally aim to wards apex -Don not let go of drain until sutured in place -connect and check for bubbling and swinging NOTE - no more than 1.5L removal at a time (re-expansion pulmonary oedema) -suture in using tough suture eg 1.0, horizontal mattress CXR Post educate pt to keep drain below hole -notify if disconnected or respiratory sx triangle of safety borders -5th intercostal space -lat dorsi -pec major -axilla |
|
|
Internal Jugular CVL anatomy & procedure
basic anatomy? R vs L? Procedure? |
IJ lies within the cartid sheath lateral to artery and vagus
-runs beneath the sternal and clavicular heads of the SCM muscle where it can be palpated -passes under the medial border of the clavicle to joint the subclavian right usually used if possible as straighter vessels and avoids thoracic duct Pleura higher on left Left is often smaller than right and more likely to overlap cartid artery Steeper angles to traverse, more change of vascular injury PROCEDURE Position - neutral (no large flexion/extension) - very slight head turn Identify anatomical landmarks prior to draping etc - sternal notch, clavicle, SCM muscle heads Patient should be - calm, sedated - oxygenated - monitored (ECG, BP, HR, Sats) FULL ASEPTIC - surgical hand wash - gown, mask, gloves - skin clean widely from earlobe to sternal notch (chlorhex) - large sterile drape Identify Anatomy again - particularly artery Head down - unless hypervolaemic dyspnoeic Local anaesthetic Insert needle between heads of SCM @30degrees -aim to ipsilateral nipple, gently aspirating |
|
|
Subclavian CVL
|
Preferred if long term due to decreased infection risk, Increased pt comfort
Can be preferred in trauma patients in collar POSITION -arms fully adducted, slight head turn -towel placed between shoulder blades to expose infraclavicular area Skin punctured 2-3cm caudad from midclavicular -far enough from inferior edge of clavicle to avoid down ward anglulation Insert just below the posterior surface of the clavicle -needle tip directed toward sternal notch Advance whilst drawing back NOTE Avoid bilateral attempts at subclavian due to the potential for bilateral PTX |
|
|
External Jugular CVL
|
PRO
Superficial therefore almost no risk of PTX or arterial puncture CON Tortuous course of vein (mainpulating shoulder >90degrees can help guide wire) So dont use large force. |
|
|
Lengths to aim for for different CVL approaches?
|
R internal jug 16cm
R Subclavian 18.4 L internal jug 19.1 L subclavian 21.2cm femoral ? external jug ? |
|
|
RSI
|
3. Techniques
a) Orotracheal intubation is the standard method of intubation in this unit. b) Nasotracheal intubation may be indicated where: i) Patients require short-term ventilation and are intolerant of oral ET tubes. ii) Nasal Fibreoptic intubation may be indicated for: Oro-maxillary surgery and pathology Inability to open the mouth: e.g. intermaxillary fixation, TMJ trauma, rheumatoid arthritis. Upper airway obstruction and nasal route preferred iii) Contraindicated in base of skull & LeForte facial fractures c) Methods: i) Direct laryngoscopy, C-MAC after rapid sequence induction ii) Fibreoptic bronchoscopic awake intubation (oral or nasal) iii) Intubating laryngeal mask –LMA – Fastrac®45 4. Endotracheal Tubes a) Standard tube: i) Low pressure, high volume cuff. ii) Males: 8-9 mm secure at 21-23cm to incisors iii) Females: 7-8 mm secure at 19-21cm to incisors iv) Do not cut tubes to less than 26 cm length c) Intubated patients from theatre may have the following tubes that are not recommended for prolonged intubation. These tubes must be changed if intubation is anticipated > 48 hrs and exchange is safe and feasible. i) Plain PVC tubes - no above cuff suction port ii) Armoured tubes - risk kinking & obstruction iii) RAE tubes - difficulty with suction & malposition 5. Protocol for endotracheal intubation in ICU a) Personnel: i) Intubation is a 3-4 person procedure - skilled assistance is mandatory ii) The “top end” intubator coordinates the procedure iii) One person to administer drugs iv) One person to apply cricoid pressure (CP) post-induction: This is routine for all emergency intubations CP is considered safe in the presence of suspected spinal injury. CP must be correctly applied - distortion of the larynx and difficulty in intubation may occur if poorly applied. v) One person to provide in-line cervical spine immobilisation (trauma and spinal patients only). b) Secure adequate IV access c) Equipment (kept in difficult airway & intubation trolleys in P4-A,B&C). Ensure the following equipment is available and functional: i) Adequate light ii) Oropharyngeal airways iii) Working suction with a rigid (Yankauer) sucker iv) Self-inflating hand ventilating assembly and mask v) 100% oxygen, i.e. working flowmeter at 15 l/min vi) 2 working laryngoscopes (standard & long blades) vii) Magill forceps viii) Malleable introducer and gum-elastic bougie46 ix) 2 Endotracheal tubes Normal size + 1 size smaller Check cuff competence x) Access to difficult intubation equipment and be aware of the difficult airway trolley location and its contents. Be aware of the Failed Intubation Drill. Airtrach, C-MAC, Heine Flex tip Intubating Fastrach LMA Cricothyroidotomy equipment a. Percutaneous kit or b. #15 scalpel & #6.0 cuffed ETT d) Monitoring (on all patients) : i) SpO2, ETCO2, ECG ii) Invasive BP *desirable but not essential and must not delay intubation if urgent e) Drugs i) Induction agent - propofol, fentanyl, ketamine, midazolam ii) Suxamethonium - 1-2mg/kg is the muscle relaxant of choice. Consider Rocuronium (1-2 mg/kg) if Sux. contraindicated iii) Atropine - 0.6-1.2mg available iv) Adrenaline - 10ml 1:10000 solution available f) Procedure: Rapid sequence induction and orotracheal intubation i) Pre-oxygenate with 100% oxygen for 3-4 minutes. ii) For patients on mask CPAP/NIV, pre-O2with the NIV mask iii) Preload with 250-500ml IV crystalloid iv) Inotropes may be necessary after induction/intubation v) Induction agent + suxamethonium Induction doses in the critically ill must be modified from routine doses used in general anaesthesia vi) Cricoid pressure applied (ensure correct positioning) vii) Direct visualisation of vocal cords and tracheal intubation viii) Inflation of cuff until airway sealed ix) Confirmation of ETCO2 x) Chest and gastric auscultation with manual ventilation xi) Cricoid pressure released xii) Secure tube at correct length xiii) Connect patient to ventilator (see default ventilator parameters) xiv) Ensure adequate sedation ± muscle relaxant47 xv) Consider insertion of a naso/oro-gastric tube. Required by the majority of ICU patients. Insertion will avoid repeating the CXR. xvi) Chest X-ray xvii)Confirm blood gas analysis and adjust FIO2 accordingly. g) Sedation post-intubation: i) None if comatose or haemodynamically unstable ii) Propofol ± fentanyl infusions as clinically indicated |
|
|
lumbar puncture
INDICATIONS CONTRAINDICATIONS ANATOMY - layers NORMAL PRESSURE? PRIOR TO PROCEDURE PROCEDURE (maxium needle size in adults?) WHAT IS EACH TUBE FOR? POST LP HEADACHE? Other complications? |
INDICATIONS
1. DIAGNOSTIC -CNS infection (especially in partially treated/immunosuppressed) -CNS bleeding (second line Ix) -Dx CNS malignancy, Guillian Barre, demyelinating dz -documentation of CSF pressure 2. THERAPEUTIC -injection of radiocontrast/radionuclide -Reduction of CSF pressure -Administration of spinal aneasthetics, antimicrobial agents, antitumour agents CONTRAINDICATIONS Without CT -focal CNS signs (pupils, III Vi palsy, hemiparesis -papilloedema -altered LOC -slowly preogressive headache With CT -lateral midline shift -Loss of suprachiasmic or basilar cisterns. -obliteration of fourth ventricles -Obliteration of superior cerebellar/quadrigeminal plate cisterns with sparing of ambient cisterns.??? AND -localised infection at puncture site -uncorrected coagulopathy -platelet count <50000 or <10000 absolute ANATOMY Layers -skin, subcut -suprspinous, -interspinous (90degrees) -ligamentum flavum -epidural space -dura mater NORMAL PRESSURE <6 10-100mm >6 60-200mm if >30 only take 2-3ml if high take <5ml Get assistant explain to pt SHould not usually need sedation Sterile procedure -monitoring -position - left lateral or sitting (sitting precludes -pressure measurment) -flex everything -mark out lumbar spines & spaces iliac crest = L4 -Aim L3/4, L4/5 and in kids L5S1 or L4/5 -maximum needle size 22G, -7cm, longer for obese -bevel parallel to fibre to reduce post LP leak -pop felt at dura mater ~ 4-6cm (1/2 to 3/4 needle) -If bone is encountered, withdraw to subcutaneous tissues and modify line of approach. -After the “give”, go about 0.5 cm into sac; remove stylet and measure pressure. - 5+ secs may elapse before fluid appears with 22G needle. Try rotating needle tip if flow is poor -. If pressure very high eg > 30cm, terminate procedure after taking 2-3 ml CSF Pull needle and stylet out together, clean, dress ?prone position for 2 hrs ? Tube1 - protein, glucose, EPP TUbe 2 - microbiology & cytology TUbe 3 - cell counts, serology and other special Tube 4 - spectrophotometry if SAH to be excluded POST LP HEADACHE -beings minutes to 2 days later -can last up to 2 weeks -treat with analgesia, hydration, caffiene -refractory headache sometimes mx with blood patch Radicular sciatic pain - needle displace laterally into nerve root, withdraw & reinsert, some pain may persist for weeks Bleeding - usually if too far anteriorly into venous plexus, severe bleeding usually only with coagulopathy Local trauma to structures infection - rare Dermoid tumour formation - epidermoid tissue implanted during LP, occurs years later, presents and back and leg pain |
|
|
epidural
|
Epidural Catheters
1. Indications a) Post-operative pain relief (usually placed in theatre) b) Analgesia in chest trauma. 2. Management protocol: a) Notify the Acute Pain Service of any epidural placed in ICU. b) Epidural cocktails should follow the Acute Pain Service protocols c) Strict aseptic technique at insertion. d) Daily inspection of the insertion site. The catheter should not be routinely redressed, except under the advice of the APS. e) Leave in for a maximum of 5 days and then remove. f) Remove if: i) Not in use for > 24 hours, or ii) Clinical evidence of unexplained sepsis, or iii) Positive blood culture by venipuncture with likely organisms (S. epidermidis, candida). iv) Heparin/Warfarin Protocol *also see ‘Acute Pain Service Guidelines for Anaesthetists’ 3. Complications a) Hypotension from sympathetic blockade / relative hypovolaemia i) This usually responds to adequate intravascular volume replacement ii) Occasionally, a low-dose vasopressor infusion is required iii) If this is considered, occult bleeding must be excluded. b) Pruritis, nausea & vomiting, or urinary retention (opioid effects) c) Post-dural puncture headache d) Infection: epidural abscess e) Pneumothorax (rarely) |
|
|
PLeural drainge/chest drain
|
Pleural Drainage
1. Indications: a) Pneumothorax b) Tension pneumothorax may require urgent needle thoracostomy c) Haemothorax d) Large symptomatic pleural effusion 2. Management protocol: a) Needle thoracostomy (tension pneumothorax): i) 14 or 16G cannula placed in mid-clavicular line, 2nd intercostal space ii) Always place an UWSD following this procedure b) Pleurocentesis: (pleural effusion) i) Prior to commencement, ultrasound the chest to confirm the presence of fluid and indentify/mark an appropriate insertion site. ii) Strict aseptic technique at insertion: Handwash with AVAGARD® (chlorhexidine 2%) or MEDISPONGE® (chlorhexidine 4%) Sterile barrier: gown, sterile gloves, mask, hat & drape(s) Skin prep. with SOLU-IV (chlorhexidine 2% / 70% alcohol) iii) Local anaesthesia in conscious patients. iv) Seldinger technique: Pigtail catheter or ThalQuick® 12F kit. Insert guidewire through needle into pleural space Insert catheter into pleural space over the wire Aspirate intermittently with closed system or attach to an UWSD. v) Record volume removed and send for MC&S, cytology & biochemistry. vi) Check CXR post-procedure. c) Underwater seal drainage: i) Local anaesthesia in awake patients. ii) Aseptic insertion technique - as above. iii) Site: Mid-axillary line, 3-5 th intercostal space Mid-clavicular line, 2nd intercostal space ( air only) Do not insert drains through old wounds iv) ICU patients need large drains: 28F catheter or larger v) Use soft Mallinkrodt tubes in preference to the stiffer Argyle tubes vi) Remove the trochar from catheter: do not use the trochar for insertion vii) For the usual lateral ICD, go for the anterior or mid-axillary lines, avoid the posterior sites as the chest wall is too thick, and there is a danger to neurovascular structures viii) Make a 2-3cm skin incision parallel to the ribs (#10 or #15 scalpel) ix) Instruments & technique: Blunt dissect using short artery forceps, avoid long forceps. Do not “plunge” into the chest with either instrument. Access to the intercostal space is by careful blunt dissection of the intercostal muscles above the rib below. The chest wall hole must be 2-3 cm wide in order that a finger can be inserted into the pleural space to identify possible adhesions. The soft tube should be guided by the intrapleural finger so that the tube goes in between the finger and chest wall x) Connect to an underwater seal drain apparatus xi) Insert 2 purse string sutures: 1 to fasten the tube 1 (‘Z’ or purse-string) to close the skin incision on drain removal. xii) Insert additional sutures as required to close the external wound. xiii) Dressing: occlusive dressing (Hypafix) xiv) Check CXR. xv) Maintenance Remove or replace drains inserted in unsterile conditions ASAP. Leave the drain in situ until: a. Radiological resolution of pleural collection (air/fluid) b. No ongoing air-leak (no drain bubbling) c. Minimal drainage (< 150 ml/24 hrs). In ventilated patients, consider clamping the drain for 4 hours prior to removal, providing the patient remains stable and/or post CXR. Surgically placed drains are the responsibility of the surgeon and should only be removed in consultation. 3. Complications a) NB: minimised using the blunt technique b) Incorrect placement - extrapleural, intrapulmonary, subdiaphragmatic c) Pulmonary laceration - haemorrhage, fistula d) Pneumothorax e) Bleeding i) local incision, intercostal vessels ii) lung iii) IMA (with anterior placement) iv) Great vessels (rare) f) Infection i) Soft tissue ii) Empyema g) Mechanical (kinking, luminal obstruction) |
|
|
abdominal paracentesis
Causes of ascites Symptoms consistent with ascites EXAMINATION TECHNIQUES INDICATIONS CONTRAINDICATIONS PREPROCEDURE OPTIMAL LOCATION? PROCEDURE HOW MUCH FLUID TO REMOVE? COMPLICATIONS |
CAUSES
-***chronic liver dz with portal HTN -*malignancy -heart failure -renal failure esp nephrotic -pancreatic dz -TB EXAMINATION TECHNIQUES -distend abdo, bulging flanks while supine (>500ml) -percussion dullness in flanks -shifting dullness (>500ml) -fluid thrill -?puddle sign INDICATION -new ascites/unknown origin/suspected malignant -known origin with anu of: fever Painful abdominal distension/resp compromise Peritonism hypotension encephalopathy sepsis RELATIVE CONTRAINDICATIONS -pregnancy -organomegaly -bowel obstruction -intraabdominal adhesions -bladder distension -DIC PREPROCEDURE coags, empty bladder, consent LOCATION unclear -Suggest insertion in obviously percussion-dull area, - L > R, lower quadrant, - lateral to rectus abdominis sheath (avoid inferior epigastric artery). -Generally 4-5cm medial to and above ASIS -USS improves PROCEDURE sterile pt semirecumbant 30-45 use Z technique to minimise post procedure leak HOW MUCH FLUID TO REMOVE? tap - >25ml therapeutic -if peripheral oedema >5L (over 4 hrs) & albumin replacement need for every 2 L (25ml of 25%) -without peripheral odema <=1.5L COMPLICATIONS -fail -persistant leak from puncture site (single skin suture can solve) -wound infection -haematoma -hollow viscous perforation(bowel, stomach, bladder) -post paracentesis hypotension (can occur >12 hrs post large volume -sponateous haemoperitonium -Catheter laceration and loss in abdominal cavity: NEVER reinsert needle into curled pigtail catheter! -Laceration of major blood vessel (aorta, mesenteric artery, iliac artery) |
|
|
SPECIALISED PROCEDURES
Fibreoptic bronchoscopy Percutaneous tracheostomy Cardiac (transvenous) pacing Pericardiocentesis Intra-aortic balloon counterpulsation Oesophageal tamponade tube insertion Extracorporeal Membrane Oxygenation |
-
|
|
|
Endotracheal tube change protocol
|
a) Ensure adequate skilled assistance, equipment, drugs and monitoring as for de
novo intubation. b) Procedure i) Set the FIO2 = 1.0 and change SV modes to SIMV. ii) Ensure sufficient anaesthesia and muscle relaxation (fentanyl / propofol + neuromuscular blockade) iii) Perform laryngoscopy and carefully identify: Patency of upper airway after suction Anatomy of larynx Degree of laryngeal exposure and swelling. iv) IF clear view of larynx and no or minimal laryngeal swelling: Application of cricoid pressure by assistant and careful, graded extubation under direct laryngoscopic vision. Maintain laryngoscopy and replace tube under direct vision. v) IF impaired visualisation of larynx: Re-evaluate the need to change ETT Use gum elastic or ventilating bougie Place bougie through tube under direct vision and insert to a length that would be just distal to the end of the ETT (approximately 30cm from end of tube) Have an assistant control the bougie so that it does not move during movement of the endotracheal tube Application of cricoid pressure by assistant and careful, graded extubation Maintain laryngoscopy and ensure bougie is through the cords on extubation Replace tube over bougie and guide through larynx under available vision. Inflate cuff, check ETCO2, auscultation and expired tidal volume Release cricoid pressure. Secure tube with tape. |
|
|
intubation2
INdications? Sux contraindications? maintenance of ETT |
2. Indications
a) Institution of mechanical ventilation b) To maintain an airway i) Upper airway obstruction Potential e.g. early burns Real e.g. epiglottitis, trauma ii) Patient transportation c) To protect an airway i) Patients at risk of aspiration ii) Altered conscious state iii) Loss of glottic reflexes d) Tracheal toilet Sux contraindications a. Burns > 3 days b. Chronic spinal injuries (i.e. spastic plegia) c. Chronic neuromuscular disease (e.g. GBS, motor neurone disease) d. Hyperkalaemic states. (K+ > 5.5) Maintenance of endotracheal tubes a) Securing to face i) Secure ETT with white tape after insertion. ii) Ensure that the loop of tape is snug around back of neck but not too tight to occlude venous drainage should allow 2 fingers under tape. iii) Re-secure with adhesive tape once CXR check done. b) Cuff checks i) Volumetric tests are done following insertion and whenever a leak is detected: sufficient air to obtain a seal + 1ml ii) Seal is assessed by auscultation over trachea during normal ventilation. iii) Manometric tests are inaccurate and do not correlate with mucosal pressure. These are an adjunct only if cuff malfunction is suspected. c) Persistent cuff leaks i) Tubes requiring more than 8ml of air to obtain a seal or if there is a persistent cuff leak must be examined by direct laryngoscopy as soon as possible: Even if taped at the correct distance at the teeth. Ensure that the cuff has not herniated above the cords Tube has not ballooned inside the oral cavity and “pulled’ the cuff above the cords. ii) Patients at high risk for cuff leaks: Nasal RAE’s - prone to outward migration Cut tubes - do not cut tubes < 26 cm Facial swelling - burns, facial trauma Patients requiring high airway pressures during ventilation |
