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ICU techniques & procedures

Chest procedures

Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid will help to confirm a diagnosis or if drainage of fluid will effect an improvement in ventilatory function. When possible, the patient sits with arms supported by a table (A). A skin wheal with local anesthetic is raised one to two levels below the percussed fluid level, followed by infiltration of deeper tissues with a 20-gauge needle over the middle of the underlying rib. The needle is advanced over the top of the rib with frequent aspirations until the pleural space is entered (inset in panel A). The depth is marked with a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3]. Following needle insertion, the catheter is advanced into the pleural space (B), and the needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a syringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be used for fluid collection, first clamping the connecting tubing, then opening the clamp once the tubing is attached to the bottle (E).

Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid will help to confirm a diagnosis or if drainage of fluid will effect an improvement in ventilatory function. When possible, the patient sits with arms supported by a table (A). A skin wheal with local anesthetic is raised one to two levels below the percussed fluid level, followed by infiltration of deeper tissues with a 20-gauge needle over the middle of the underlying rib. The needle is advanced over the top of the rib with frequent aspirations until the pleural space is entered (inset in panel A). The depth is marked with a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3]. Following needle insertion, the catheter is advanced into the pleural space (B), and the needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a syringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be used for fluid collection, first clamping the connecting tubing, then opening the clamp once the tubing is attached to the bottle (E).

Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid will help to confirm a diagnosis or if drainage of fluid will effect an improvement in ventilatory function. When possible, the patient sits with arms supported by a table (A). A skin wheal with local anesthetic is raised one to two levels below the percussed fluid level, followed by infiltration of deeper tissues with a 20-gauge needle over the middle of the underlying rib. The needle is advanced over the top of the rib with frequent aspirations until the pleural space is entered (inset in panel A). The depth is marked with a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3]. Following needle insertion, the catheter is advanced into the pleural space (B), and the needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a syringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be used for fluid collection, first clamping the connecting tubing, then opening the clamp once the tubing is attached to the bottle (E).

Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid will help to confirm a diagnosis or if drainage of fluid will effect an improvement in ventilatory function. When possible, the patient sits with arms supported by a table (A). A skin wheal with local anesthetic is raised one to two levels below the percussed fluid level, followed by infiltration of deeper tissues with a 20-gauge needle over the middle of the underlying rib. The needle is advanced over the top of the rib with frequent aspirations until the pleural space is entered (inset in panel A). The depth is marked with a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3]. Following needle insertion, the catheter is advanced into the pleural space (B), and the needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a syringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be used for fluid collection, first clamping the connecting tubing, then opening the clamp once the tubing is attached to the bottle (E).

Figure 7-1. Thoracentesis. This procedure is indicated if a sample of pleural fluid will help to confirm a diagnosis or if drainage of fluid will effect an improvement in ventilatory function. When possible, the patient sits with arms supported by a table (A). A skin wheal with local anesthetic is raised one to two levels below the percussed fluid level, followed by infiltration of deeper tissues with a 20-gauge needle over the middle of the underlying rib. The needle is advanced over the top of the rib with frequent aspirations until the pleural space is entered (inset in panel A). The depth is marked with a clamp.Drainage of an effusion can be performed with a through-the-needle catheter [3]. Following needle insertion, the catheter is advanced into the pleural space (B), and the needle withdrawn (C). A three-way stopcock is attached and fluid withdrawn into a syringe and injected into a sterile container (D). Alternatively, a vacuum bottle can be used for fluid collection, first clamping the connecting tubing, then opening the clamp once the tubing is attached to the bottle (E).

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-2. Tube thoracostomy. Tube thoracostomy is indicated to remove air or fluid (including blood) from the pleural space. Preferred sites are the fourth or fifth intercostal space in the anterior axillary line (A) or the second interspace in the midclavicular line (pneumothorax alone) (B). Local anesthetic is infiltrated into the skin, subcutaneous tissue, intercostal muscles, periosteum, and pleura (C). A 2-cm incision is made below the selected rib (D) and a subcutaneous tunnel formed with a Kelly clamp (E). The clamp is then inserted into the pleural space over the superior margin of the upper rib (F and G), followed by insertion of a gloved finger to confirm thoracic penetration (H). The tip of the thoracostomy tube is grasped by the Kelly clamp and inserted posteriorly and superiorly into the pleural space (I). The tube is then connected to a collection-suction apparatus with high-volume flow, adjustable suction, and underwater seal (See Fig. 12-4) and is sutured to the skin.

Figure 7-3. Heimlich catheter insertion. This procedure is an alternative to conventional tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and a J wire threaded through the needle (Seldinger technique), following which the needle is removed leaving the guidewire in place (B). A catheter is then advanced over the guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheter and connected to the pleural drainage system (D).

Figure 7-3. Heimlich catheter insertion. This procedure is an alternative to conventional tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and a J wire threaded through the needle (Seldinger technique), following which the needle is removed leaving the guidewire in place (B). A catheter is then advanced over the guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheter and connected to the pleural drainage system (D).

Figure 7-3. Heimlich catheter insertion. This procedure is an alternative to conventional tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and a J wire threaded through the needle (Seldinger technique), following which the needle is removed leaving the guidewire in place (B). A catheter is then advanced over the guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheter and connected to the pleural drainage system (D).

Figure 7-3. Heimlich catheter insertion. This procedure is an alternative to conventional tube thoracostomy. A 14-gauge needle attached to a 10-mL syringe is inserted into the pleural cavity (verified by aspiration of air/blood/fluid) (A). The syringe is removed and a J wire threaded through the needle (Seldinger technique), following which the needle is removed leaving the guidewire in place (B). A catheter is then advanced over the guidewire (C), and the wire is withdrawn. Connecting tubing is attached to the catheter and connected to the pleural drainage system (D).

Figure 7-4. Chest tube drainage system (bottles). These systems are variable in appearance but similar in principle. The chest tube external tip must be submerged beneath the level of water in a container, usually 1 to 2 cm below the surface (A) to effect an underwater seal. A three-bottle system is also shown (B). Fluid collected from the patient passes into the first bottle where it can be measured. The second bottle provides the underwater seal described in panel A, serving as a one-way valve allowing air to escape from the chest but preventing it from being sucked in with respiration. The third bottle controls the negative (subambient) pressure that the suction can generate. The inlet tube to this bottle is exposed to the outlet (suction) tube above a water level that is vented to ambient. Should the negative pressure above the water level exceed that generated by the water, air will enter the vent, bubble through the water, and offset the excess negative pressure above the water. Disposable, compact, portable collection chambers combine the three-bottle functions (C) and are used almost exclusively today.

Figure 7-4. Chest tube drainage system (bottles). These systems are variable in appearance but similar in principle. The chest tube external tip must be submerged beneath the level of water in a container, usually 1 to 2 cm below the surface (A) to effect an underwater seal. A three-bottle system is also shown (B). Fluid collected from the patient passes into the first bottle where it can be measured. The second bottle provides the underwater seal described in panel A, serving as a one-way valve allowing air to escape from the chest but preventing it from being sucked in with respiration. The third bottle controls the negative (subambient) pressure that the suction can generate. The inlet tube to this bottle is exposed to the outlet (suction) tube above a water level that is vented to ambient. Should the negative pressure above the water level exceed that generated by the water, air will enter the vent, bubble through the water, and offset the excess negative pressure above the water. Disposable, compact, portable collection chambers combine the three-bottle functions (C) and are used almost exclusively today.

Figure 7-4. Chest tube drainage system (bottles). These systems are variable in appearance but similar in principle. The chest tube external tip must be submerged beneath the level of water in a container, usually 1 to 2 cm below the surface (A) to effect an underwater seal. A three-bottle system is also shown (B). Fluid collected from the patient passes into the first bottle where it can be measured. The second bottle provides the underwater seal described in panel A, serving as a one-way valve allowing air to escape from the chest but preventing it from being sucked in with respiration. The third bottle controls the negative (subambient) pressure that the suction can generate. The inlet tube to this bottle is exposed to the outlet (suction) tube above a water level that is vented to ambient. Should the negative pressure above the water level exceed that generated by the water, air will enter the vent, bubble through the water, and offset the excess negative pressure above the water. Disposable, compact, portable collection chambers combine the three-bottle functions (C) and are used almost exclusively today.

Figure 7-5. Sites involved in paracentesis procedure (circled numbers). Diagnostic paracentesis is used for patients with ascites, unexplained fever, leukocytosis, or suspected bacterial peritonitis [3], [4]. Occasionally, therapeutic paracentesis is applied to patients with tense ascites that is thought to be causing respiratory compromise. After production of a skin wheal with lidocaine, the skin is stretched about 1.0 cm inferiorly and lidocaine is injected through the wheal, subcutaneous tissue, fascia, and peritoneum using a 21-gauge needle. Next, a 20-gauge over-the-needle catheter is advanced through the anesthetized tract and aspiration is performed continuously with a 10-mL syringe. When fluid is obtained, the catheter is advanced and a 50-mL syringe is attached to its hub to obtain the required sample.

Characteristic ascitic fluid findings in various disease states Cell Count Red Blood White Blood Cells Cells > 3 3 (per mm ) 10,000/mm ) <250(90&percnt;); predominantly endothelial Cytology, >1000(50&percnt;): cell block, variable cell types peritoneal biopsy Peritoneal biopsy, stain and culture for acid-fast bacilli Positive Predominantly Gram polymorphonuclear stain, leukocytes culture <1000(90&percnt;); usually mesothelial, mononuclar If chylous, ether <250: mesothelial, extraction, mononuclear Sudan staining Increased amylase in ascitic Variable fluid and serum >1000(70&percnt;); usually > 70&percnt; lymphocytes

Condition

Gross Specific Gravity Appearance

Protein, g/dL

Other Tests

Cirrhosis

Neoplasm

Strawcolored or <1.016(95&percnt;) <2.5(95&percnt;) bile stained Strawcolored, Variable, hemorrhagic, >2.5(75&percnt;) >1.016(45&percnt;) mucinous, or chylous

1&percnt;

20&percnt;

Clear, turbid, Tuberculous Variable, hemorrhagic, >2.5(50&percnt;) peritonitis >1.016(50&percnt;) chylous

7&percnt;

Pyogenic peritonitis

Turbid or purulent

If purulent, >1.016

If purulent, >2.5

Unusual

Congestive Strawheart failure colored Strawcolored or chylous

Variable, Variable, 1.55.3 10&percnt; <1.016(60&percnt;)

Nephrosis

<1.016

<2.5(100&percnt;) Unusual

Pancreatic Turbid, ascites Variable, often hemorrhagic, (pancreatitis, >1.016 or chylous pseudocyst)

Variable often >2.5

Variable, may be blood stained

Figure 7-6. Characteristic ascitic fluid findings in various disease states. The percentage figures should be taken as an indication of order of magnitude rather than as the precise incidence of any abnormal finding. (Adapted fromYeston and coworkers [4]; with permission.)

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-7. Diagnostic peritoneal lavage (DPL). DPL is commonly used to assess blunt abdominal trauma, penetrating trauma, lower thoracic and flank trauma, unexplained hypotension, and some nontraumatic intra-abdominal processes [5]. Only predetermined laparotomy is a true contraindication. The reported accuracy for determining the presence of intraperitoneal bleeding is 100% when a liter of lavage fluid is administered. The open technique employs a 3- to 4-cm infraumbilical incision (A), following which the fascial edges are grasped and elevated with towel clips (B). The underlying peritoneum is opened (C), and the lavage catheter (without trochar) is inserted (D) and directed toward the pelvis (E). A 3-0 chromic purse-string suture is placed around the catheter through the peritoneum (F). Aspirations are drawn through the catheter with a 10-mL syringe. If gross blood is not obtained, a 1-L bag of normal saline is attached to an infusion set and administered through the catheter, leaving a small amount of saline in the bag and tubing. The bag is lowered to the floor (G). At least 300 mL of fluid should be obtained, which is then submitted for erythrocyte and leukocyte counts, amylase determination, and the presence of particulate matter, bile, or bacteria. The catheter is removed and the pursestring suture closed.

Figure 7-8. Closed technique diagnostic peritoneal lavage. A prepackaged kit or a dialysis catheter trochar kit can be used. With the latter approach, a 2- to 3-cm infraumbilical incision is established to the linea alba. Following additional local anesthesia, the catheter-trochar is thrust in a controlled fashion with both hands toward the pelvis (A). When a pop is felt, all pressure is released. The catheter is advanced and the trochar removed (B). The irrigation tubing is attached, and then the open technique procedure is followed.

Figure 7-8. Closed technique diagnostic peritoneal lavage. A prepackaged kit or a dialysis catheter trochar kit can be used. With the latter approach, a 2- to 3-cm infraumbilical incision is established to the linea alba. Following additional local anesthesia, the catheter-trochar is thrust in a controlled fashion with both hands toward the pelvis (A). When a pop is felt, all pressure is released. The catheter is advanced and the trochar removed (B). The irrigation tubing is attached, and then the open technique procedure is followed.

Figure 7-9. Diagnostic peritoneal lavage with a prepackaged kit. A 3-mm skin incision is made, followed by introduction of an 18-gauge needle angled toward the center of the pelvis (A). A 15-cm J guidewire is passed through the needle (B). When half of the wire has been advanced, the needle is removed, the catheter is threaded over the guidewire and advanced with a twisting motion through the fascia. The wire is removed when the catheter is positioned. The infusion tubing is then attached, following which the procedure is continued as with the other methods.

Figure 7-9. Diagnostic peritoneal lavage with a prepackaged kit. A 3-mm skin incision is made, followed by introduction of an 18-gauge needle angled toward the center of the pelvis (A). A 15-cm J guidewire is passed through the needle (B). When half of the wire has been advanced, the needle is removed, the catheter is threaded over the guidewire and advanced with a twisting motion through the fascia. The wire is removed when the catheter is positioned. The infusion tubing is then attached, following which the procedure is continued as with the other methods.

Diagnostic peritoneal lavage interpretation Positive Aspiration of > 10 mL of blood Lavage fluid exits by means of Foley catheter or chest tube Grossly bloody lavage return 3 Erythrocyte > 100,000/mm 3 Leukocyte > 500/mm Amylase > 175 U/dL Presence of bile, bacteria, or particulate matter Negative (Nonpenetrating Trauma) 3 Erythrocyte < 50,000/mm 3 Leukocyte < 100/mm Amylase < 75 U/dL Indeterminant Dialysis catheter fills with blood 3 Erythrocyte > 50,000-< 100,000/mm 3 Leukocyte > 100- < 500/mm Amylase > 75- < 175 U/dL

Figure 7-10. Diagnostic peritoneal lavage interpretation. In blunt trauma, accuracy is 96% [4]. Retroperitoneal injuries can be missed, and false-negative results are reported for ruptured diaphragm, bladder, and spleen, lacerated liver. The false-negative rate is higher for penetrating injury. (Adapted from Yeston and coworkers [4].)

Figure 7-11. Distal saphenous venous supply. These veins are useful for venous cannulation or cutdown in cardiac arrest when resuscitative activity is centered on the upper body.

Figure 7-12. Proximal saphenous vein. In the groin, the 4- to 5-mm diameter proximal saphenous vein joins the femoral vein 7 to 8 cm inferior to the inguinal ligament along the anteromedial aspect of the thigh. Large-bore venous access cutdowns are easily accomplished.

Figure 7-13. Basilic vein. The basilic vein is consistently of large diameter and is advantageous when long-line central venous catheterization is desired. The brachial artery and median nerve can be damaged by deep dissection. The cephalic vein is more variable in size and does not lend itself well to central venous catheter placement because of the right angle turn at the clavipectoral fascia.

Figure 7-14. Percutaneous insertion of central venous and pulmonary artery catheters. Catheter placement at these sites is common in the intensive care unit. The relevant anatomy of the internal and external jugular veins, the subclavian veins, and their adjacent structures is shown [6]. These are by far the most popular access sites, and a wide variety of introducer kits are available for insertion.

PREFERABLE INSERTION SITES FOR CENTRAL VENOUS AND PULMONARY ARTERY CATHETERS Choices (Order of Preference) Clinical Situations 1st 2nd 3rd 4th Femoral Large peripheral vein IC 5th

Bleeding diathesis Obesity or generalized edema Decreased pulmonary reserve; ventilation with PEEP Parenteral nutrition Hypovolemia; shock Cardiopulmonary resuscitation Emergency airway management Temporary hemodialysis Multiple catheter insertions Pulmonary artery catheter insertion Temporary pacemaker Tracheostomy or sternal wounds Short diagnostic techniques Inability to lower the head

EJV IC EJV

IJ SC IJ

High SC IJ Femoral

SC

IC IJ SC IC or SC Femoral IJ IJ IC EJV Femoral Femoral

EJV Femoral Large peripheral vein IC High Large peripheral vein SC SC IJ Femoral Femoral IC SC EJV EJV

Large peripheral vein IC IJ Femoral IC SC Femoral IC or IJ SC or IJ EJV IJ IC SC EJV or IJ Femoral High SC Femoral IJ IC EJV Femoral SC

Figure 7-15. Preferable insertion sites for central venous and pulmonary artery catheters. The choice depends on the clinical setting, condition, or both [6].High supraclavicular (SC) refers to skin puncture 1 to 2 cm above the clavicle, thereby allowing easier tamponade for inadvertent arterial bleeding. The skin puncture site is close to the central internal jugular (IJ) technique. The femoral approach is suitable for bedridden patients. Short-term use in nonobese patients is possible. During resuscitation, the catheter should be long enough to reach the intrathoracic veins. Peripheral vein cannulation is useful for intravascular volume resuscitation and rarely for hemodynamic monitoring or temporary pacing. If the infraclavicular (IC) vein is used, left is preferred over right. If the SC vein or the IJ vein is used, the preferred site is the right. EJV external jugular vein; PEEPpositive end-expiratory pressure. (Adapted from Novak and Venus [6].)

Figure 7-16. Characteristic direct pressure tracings that identify the position of a balloontipped, flow-directed pulmonary artery catheter as it traverses the right atrium (RA), right ventricle (RV), and pulmonary artery (PA) during insertion, finally residing in a pulmonary capillary wedge (PCW) position (with the balloon inflated). With rare exceptions, the tracings are so easily recognized that ancillary techniques such as fluoroscopy are unnecessary.

Complications of central venous and pulmonary artery catheter insertion Immediate Late Multiple puncture Pulmonary artery rupture Pneumo- hemo- hydro* Pulmonary infarction chylothorax-mediastinum Arterial puncturehematoma or Catheter-related sepsis bleeding * Air embolism Balloon rupture * Cardiac arrhythmias Endocardial or valvular damage Catheter malposition Venous thrombosis Catheter knotting Infections (cellulitis, osteomyelitis, endocarditis, thrombophlebitis) Subcutaneous and mediastinal Nerve injury (brachial, phrenic, recurrent, laryngeal, vagus, cranial IXXII, emphysema Horner and Brown-Squard syndromes) Tracheal puncture-laceration Cerebrovascular compromise Cardiac perforation and tamponade Arteriovenous fistula Thrombocytopenia
*

Applies to pulmonary artery cannulation only.

Figure 7-17. Immediate and delayed complications associated with central venous and pulmonary artery catheter insertion [7]. (Adapted from Venus and Mallory [7].)

Figure 7-18. Pericardiocentesis procedure. Pericardiocentesis is used for relief of cardiac tamponade and for diagnosis of a pericardial effusion. A paraxiphoid approach most commonly is used (A) because it avoids the pleura and coronary vessels. A left parasternal approach through the fourth interspace can be employed. A 12- to 18-cm, 16to 18-gauge, short-bevel cardiac needle is attached to a 10-mL syringe. A sterile alligator clip is attached to the metal needle and an electrocardiographic V-lead (B). For the paraxiphoid approach, the skin is entered just below the costal margin lateral to the xiphoid and the needle is advanced at a 45 angle under the ribs toward the clavicular midpoint, while gentle traction is applied continuously on the syringe plunger. For the left parasternal approach, the needle is advanced through the fourth intercostal space at the sternal border and perpendicular to the chest wall. When deep to the costal arch, the hub is depressed and the needle directed toward the left shoulder with ongoing aspiration.With either approach, an ST-segment elevation (injury current) (C) must be monitored for when the needle tip touches the ventricular epicardium. (PR elevation results from atrial epicardial contact.) When fluid is obtained, the needle is stabilized with a hemostat at the skin surface. Removal of only 20 mL of fluid or blood may be life saving in cardiac tamponade. ECGelectrocardiography.

Figure 7-18. Pericardiocentesis procedure. Pericardiocentesis is used for relief of cardiac tamponade and for diagnosis of a pericardial effusion. A paraxiphoid approach most commonly is used (A) because it avoids the pleura and coronary vessels. A left parasternal approach through the fourth interspace can be employed. A 12- to 18-cm, 16to 18-gauge, short-bevel cardiac needle is attached to a 10-mL syringe. A sterile alligator clip is attached to the metal needle and an electrocardiographic V-lead (B). For the paraxiphoid approach, the skin is entered just below the costal margin lateral to the xiphoid and the needle is advanced at a 45 angle under the ribs toward the clavicular midpoint, while gentle traction is applied continuously on the syringe plunger. For the left parasternal approach, the needle is advanced through the fourth intercostal space at the sternal border and perpendicular to the chest wall. When deep to the costal arch, the hub is depressed and the needle directed toward the left shoulder with ongoing aspiration.With either approach, an ST-segment elevation (injury current) (C) must be monitored for when the needle tip touches the ventricular epicardium. (PR elevation results from atrial epicardial contact.) When fluid is obtained, the needle is stabilized with a hemostat at the skin surface. Removal of only 20 mL of fluid or blood may be life saving in cardiac tamponade. ECGelectrocardiography.

Figure 7-18. Pericardiocentesis procedure. Pericardiocentesis is used for relief of cardiac tamponade and for diagnosis of a pericardial effusion. A paraxiphoid approach most commonly is used (A) because it avoids the pleura and coronary vessels. A left parasternal approach through the fourth interspace can be employed. A 12- to 18-cm, 16to 18-gauge, short-bevel cardiac needle is attached to a 10-mL syringe. A sterile alligator clip is attached to the metal needle and an electrocardiographic V-lead (B). For the paraxiphoid approach, the skin is entered just below the costal margin lateral to the xiphoid and the needle is advanced at a 45 angle under the ribs toward the clavicular midpoint, while gentle traction is applied continuously on the syringe plunger. For the left parasternal approach, the needle is advanced through the fourth intercostal space at the sternal border and perpendicular to the chest wall. When deep to the costal arch, the hub is depressed and the needle directed toward the left shoulder with ongoing aspiration.With either approach, an ST-segment elevation (injury current) (C) must be monitored for when the needle tip touches the ventricular epicardium. (PR elevation results from atrial epicardial contact.) When fluid is obtained, the needle is stabilized with a hemostat at the skin surface. Removal of only 20 mL of fluid or blood may be life saving in cardiac tamponade. ECGelectrocardiography.

Method

A. Assessing tracheal vs esophageal tube position Comments Tube movement can occur before taping the tube and with changes in head position No CO2 may be detected with severe bron-chospasm or in the fully arrested patient with absent pulmonary blood flow. CO2 may be exhaled from the stomach from prior mask ventilation Unreliable Unreliable Unreliable Unreliable Unreliable Unreliable Unreliable Excessive cuff volume may indicate a tube above the cords or in the esophagus Unreliable Not fail-safe even when done Can be seen with esophageal tube Reliable, but expensive, prone to breakage A late sign; may get some alveolar gas exchange with esophageal ventilation and hence slow desaturation

Direct visualization of vocal cords End-tidal CO2 Breath sounds Chest rise Epigastric auscultation/observation Reservoir bag compliance and refilling Presence of tidal volumes with respiratory efforts Quality of air leak around tube Cuff palpation in trachea Cuff volume necessary to occlude leak Normal ventilator function Chest radiography Tube condensation Fiberoptic bronchoscopy Pulse oximetry

Figure 7-19. Methods for assessing tracheal versus esophageal tube position and preventing endobronchial intubation. Loss of the airway because of inability to intubate, placement of the endotracheal tube in the wrong place (esophagus or mainstem bronchus), inadvertent extubation, or failure of ventilation (eg, kinked or plugged tube, disconnect) is a leading cause of anesthesia and intensive care unit (ICU) morbidity and mortality [8]. Although correct tube placement and maintenance would seem, a priori, to be easily verifiable, such is not always the case. Traditional tests of assessing tracheal versus esophageal positioning can be misleading and are sometimes completely unreliable (A) [9]. Bronchial intubation, which frequently is deliberate and planned in thoracic surgery, can be lethal when unplanned and unrecognized in other operations or during mechanical ventilation in the ICU. Preventive measures and their drawbacks are summarized here (B). (Adapted from Birmingham and Cheney [9]; with permission.)

Method

B. Detection of endobronchial intubation Comments

Equal breath sounds/chest rise Unreliable Tube position at incisors Precut adult oral tubes to 2.5 cm Position tube 21 cm at incisors in normal-sized adult woman Position tube 23 cm at incisors in normal-sized adult man Chest radiography Tube tip at T2 to T4 with head in neutral position (mandible overlying C5-6) Fiberoptic bronchoscopy As reliable as radiography Pulse oximetry Desaturation does not necessarily occur Has led to detection of endobronchial intubation End-tidal CO2

Figure 7-19. Methods for assessing tracheal versus esophageal tube position and preventing endobronchial intubation. Loss of the airway because of inability to intubate, placement of the endotracheal tube in the wrong place (esophagus or mainstem bronchus), inadvertent extubation, or failure of ventilation (eg, kinked or plugged tube, disconnect) is a leading cause of anesthesia and intensive care unit (ICU) morbidity and mortality [8]. Although correct tube placement and maintenance would seem, a priori, to be easily verifiable, such is not always the case. Traditional tests of assessing tracheal versus esophageal positioning can be misleading and are sometimes completely unreliable (A) [9]. Bronchial intubation, which frequently is deliberate and planned in thoracic surgery, can be lethal when unplanned and unrecognized in other operations or during mechanical ventilation in the ICU. Preventive measures and their drawbacks are summarized here (B). (Adapted from Birmingham and Cheney [9]; with permission

Figure 7-20. The Difficult Airway Algorithm published by the American Society of Anesthesiologists in 1993 [10]. This algorithm was intended for operating room application but is useful in the ICU if unconscious or unresponsive is substituted for anesthetized. (Adapted from American Society of Anesthesiologists [10]; with permission.)

Figure 7-21. Tube movement. Even when an endotracheal tube is correctly placed initially, it may subsequently move to an endobronchial position or wind up outside the trachea. Conrardy et al. [11] showed that flexion or extension of the head on the neck can move the tube tip down or up an average of 1.9 cm (3.8 cm total range of motion) with no change in position at the teeth or lips. Failure to recognize this possibility by physical assessment, chest radiography, or fiberoptic bronchoscopy has led to fatal complications and malpractice litigation. Mainstem intubation, when inadvertent, usually involves the right bronchus because it bifurcates from the trachea at a considerably lesser angle than does the left. Because its origin is close to the carina, the right upper lobe bronchus may also be occluded, leaving only the right middle and lower lobes for ventilation. Significant shunting and hypoxemia result.Body position changes also can lead to endobronchial movement of the tube tip, particularly in conditions associated with increased abdominal pressure. When a patient with tense ascites, intrauterine pregnancy, or abdominal tumor is placed head down (Trendelenburgs position), the diaphragm is displaced cephalad as are the lungs and carina. An initially correctly placed endotracheal tube thus may end up in the mainstem brochus. (Adapted from Conrardy and coworkers [11].)

Figure 7-22. Inadvertent right mainstream intubation. In this case, intubation occurred 30 minutes before the chest radiograph was taken during the induction of anesthesia. Complete atelectasis of the left lung and right upper lobe is demonstrated (the endotracheal tube has been pulled back into the correct tracheal position). The rapidity with which atelectasis can occur in such situations is obvious.

Step Position Mouth opening Blade insertion Vocal cord exposure Tube introduction

Problems associated with tracheal intubation Error Axes not aligned

Correction

Tube position

Put patient in sniffing position Tilt back head or open mouth using Mouth not wide open crossed-finger technique Wrong size or wrong blade Blade not inserted Change blade Withdraw blade and reinsert on right side of tongue on right side Keep wrist rigid and pull handle upward Leverage rather than traction and apply traction Reinsert tube along right side of mouth Obscuring line of vision of tube lateral to path of blade Failure to maintain natural curve of tube Use a stylet Angulation of trachea due to excessive Release traction traction Endobronchial intubation/ esophageal Auscultate for breath sounds (unreliable); intubation check chest radiograph Inadvertent extubation Secure and tape tube in place

Figure 7-23. Problems associated with tracheal intubation. Problems can occur at any point during the procedure. Causes and corrective actions are outlined [12]. (Adapted from Salem and coworkers [12].)

Figure 7-24. Tube insertion in the case of a difficult-to-visualize anterior glottic opening. A, The endotracheal tube has been inserted without a stylet, making control of its tip difficult or impossible. B, The stylet has been placed and the tube tip angulated toward but, in this case, not into the glottic opening. C, The stylet is slowly withdrawn without changing the tube position. This maneuver automatically elevates the tube tip anteriorly as much as 1 to 2 cm, allowing it to be carefully advanced through the vocal cords.

Figure 7-25. Laryngeal mask airway (LMA). The LMA can be used in lieu of tracheal intubation in selected cases [13], [14], [15]. The LMA resembles a conventional endotracheal tube with a small mask at the tip that, when properly inserted, covers the glottic aperture and allows the patient to breathe spontaneously. Low-pressure positivepressure ventilation can be used, although leaks around the mask are common. The mask is deflated for insertion (A) and inflated for maintenance (B). The LMA does not prevent aspiration. It is placed blindly and can be life saving when the glottis cannot be visualized. However, insertion in some cases can be difficult [15]. Six sizes currently are available for pediatric through adult applications.

Figure 7-25. Laryngeal mask airway (LMA). The LMA can be used in lieu of tracheal intubation in selected cases [13], [14], [15]. The LMA resembles a conventional endotracheal tube with a small mask at the tip that, when properly inserted, covers the glottic aperture and allows the patient to breathe spontaneously. Low-pressure positivepressure ventilation can be used, although leaks around the mask are common. The mask is deflated for insertion (A) and inflated for maintenance (B). The LMA does not prevent aspiration. It is placed blindly and can be life saving when the glottis cannot be visualized. However, insertion in some cases can be difficult [15]. Six sizes currently are available for pediatric through adult applications.

Figure 7-26. 14-Gauge intravenous catheter for percutaneous needle cricothyroidotomy. In association with a high-pressure oxygen source, this procedure can be life saving when transoral or transnasal intubation fails. Shown here is the catheter with an attached tuberculin syringe, connecting oxygen tubing, and a 15-cm endotracheal tube adaptor that can be plugged into a common gas outlet of an anesthesia machine. Other adaptors can be fashioned, depending on the source of high-pressure oxygen used. When the anesthesia machine is used, the flush button is rapidly and sequentially depressed. Ventilation cannot be achieved by compressing a self-inflating bag, rebreathing bag in the anesthesia circuit, or any bag in a Mapleson D configuration. High-frequency jet ventilation can be employed if a suitable ventilator and attachments are available.

Time

Problems associated with endotracheal intubation, maintenance, and extubation Tissue Injury Mechanical Problems Other

Corneal abrasion; nasal polyp dislodgement; bruise/laceration of lips/tongue; tooth extraction; Tube retropharyngeal perforation; vocal cord placement tear; cervical spine subluxation or fracture; hemorrhage; turbinate bone avulsion; aspiration Tear/abrasion of larynx, trachea, Tube in bronchi; barotrauma, leaks, place disconnections; airway edema; nerve injury; webs

Esophageal/endobronchial intubation; delay in cardiopulmonary resuscitation

Arrhythmia; pulmonary aspiration; hypertension; hypotension

Airway obstruction; migration of Bacterial infection tube; ignition of tube during laser (secondary) surgery Gastric aspiration Paranasal sinusitis Problems related to mechanical ventilation (eg pulmonary barotrauma) Pulmonary Difficult extubation; airway aspiration; laryngeal obstruction from blood, foreign edema; bodies, dentures, or throat packs laryngospasm; tracheomalacia

Extubation

Damage to vocal cords if cuff not deflated

Figure 7-27. Complications associated with intubation, maintenance, and extubation. Complications are numerous and vary from minimal to severe [16]. (Adapted from Flemming and coworkers [16].)