tahir99-VRG & vip.persianss.ir tahir99-VRG & vip.persianss.ir SE V E N T H E D I T I O N VO LUM E 1 Irw in and R ippe’s IN TEN SIVE CARE M EDICIN E R G - V i r i r99 & ns s . h a Editors ta r s i Richard S. Irwin, MD, . pe James M. Rippe, MD Master FCCP vi p Professor of Biomedical Sciences, University of Central Florida Professor of M edicine and N ursing University of M assachusetts O rlando, Florida Worcester, M assachusetts Associate Professor of M edicine (Cardiology), Chair, Critical Care O perations Tufts University School of M edicine UM ass M emorial M edical Center Boston, M assachusetts Worcester, M assachusetts Founder and Director, Rippe Lifestyle Institute Shrewsbury, M assachusetts Founder and Director, Rippe H ealth Evaluation O rlando, Florida tahir99-VRG & vip.persianss.ir A cquisitions Editor: Brian Brown M anaging Editor: N icole T. Dernoski M ark eting M anager: Angela Panetta Production M anager: Alicia Jackson Senior M anufacturing M anager: Benjamin Rivera D esign Coordinator: Teresa M allon Com positor: Aptara, Inc. 7th Edition © 2012 by Richard S. Irwin, M.D. and James M. Rippe, M.D. 530 Walnut Street Philadelphia, PA 19106 LWW.com 6th Edition © 2008 by Richard S. Irwin, M .D. and James M . Rippe, M .D., 5th Edition © 2003 by Richard S. Irwin, M .D. and James M . Rippe, M .D., 4th Edition © 1999 by Richard S. Irwin, M .D., Frank B. Cerra, M .D., and James M . Rippe, M .D., 3rd Edition © 1996 by James M . Rippe, M .D., Richard S. Irwin, M .D., M itchell P. Fink, M .D., and Frank B. Cerra, M .D., 2nd Edition © 1991 by James M . Rippe, M .D., Richard S. Irwin, M .D., Joseph S. Alpert, M .D., and M itchell P. Fink, M .D., 1st Edition © 1985 by James M . Rippe, M .D., Richard S. Irwin, M .D., Joseph S. Alpert, M .D., and James E. Dalen, M .D. All rights reserved. This book is protected by copyright. N o part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the publisher, except for brief quotations embodied in critical Philadelphia, PA 19106-3780. R G articles and reviews. For information write Lippincott Williams & Wilkins, 530 Walnut Street, - V M aterials appearing in this book prepared by individuals as part of their of cial duties as U.S. i r 99 . government employees are not covered by the above-mentioned copyright. i r & ns s Printed in the China h a Library of Congress Cataloging-in-Publication Data ta r s i Irwin and Rippe’s intensive care medicine / editors, Richard S. Irwin, . pe James M . Rippe. — 7th ed. p. ; cm. vi p Intensive care medicine Includes bibliographical references and index. ISBN 978-1-60831-183-5 (alk. paper) 1. Critical care medicine. I. Irwin, Richard S. II. Rippe, James M . III. Title: Intensive care medicine. [DN LM : 1. Intensive Care—methods. 2. Intensive Care Units. WX 218] RC86.7.I555 2011 616.02 8—dc23 2011021282 Care has been taken to con rm the accuracy of the information presented and to describe generally accepted practices. H owever, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. H owever, in view of ongoing research, changes in government regulations, and the constant ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 tahir99-VRG & vip.persianss.ir D ED IC AT IO N To O ur Families Diane, Rachel, Sara, Catherine, Rebecca, John, Andrew K. Andrew M . and Adam; Stephanie, H art, Jaelin, Devon, and Jamie R G - V i r i r99 & ns s . h a ta r s i . pe vi p tahir99-VRG & vip.persianss.ir tahir99-VRG & vip.persianss.ir ■ C O N T R I BU T O R S Cynthia K. Aaron, MD, FACMT, FACEP Satya Allaparthi, MD Professor of Emergency M edicine and Pediatrics Fellow in Robotic and Laparoscopic Urology Program Director, M edical Toxicology Department of Urology/Surgery Department of Emergency M edicine UM ass M emorial M edical Center Wayne State University School of M edicine Worcester, M A Detroit M edical Center Regional Poison Center at Children’s H ospital of M ichigan Gilman B. Allen, MD Detroit, M I Assistant Professor Director, M edical Intensive Care Unit Wissam Abouzgheib, MD, FCCP Department of M edicine Attending Physician Division of Pulmonary and Critical Care M edicine Department of Pulmonary and Critical Care University of Vermont Sparks H ealth System Fletcher Allen H ealth Care Fort Smith, AR Burlington, VT Gregory A. Abrahamian, MD Luis F. Angel, MD Associate Professor of Surgery Associate Professor of M edicine Department of Surgery Department of M edicine University of Texas H ealth Science Center at San Antonio University of Texas H ealth Sciences Center at San Antonio San Antonio, TX San Antonio, TX Konstantin Abramov, MD Kevin E. Anger, PharmD, BCPS Assistant Professor of M edicine Clinical Pharmacy Specialist in Critical Care Division of Renal M edicine Department of Pharmacy Services UM ass M emorial M edical Center Brigham and Women’s H ospital Worcester, M A Boston, M A Christopher D. Adams, PharmD, BCPS Derek C. Angus, MD, MPH Clinical Pharmacist Professor and Vice Chair for Research Department of Pharmacy Services Department of Critical Care M edicine Brigham and Women’s H ospital University of Pittsburgh M edical Center Boston, M A Pittsburgh, PA Suresh Agarwal, MD, FACS, FCCM N eil Aronin, MD Chief, Surgical Critical Care Professor of M edicine and Cell Biology Associate Professor of Surgery Chief of Endocrinology and M etabolism Boston M edical Center Department of M edicine Boston, M A University of M assachusetts M edical School Worcester, M A Lauren Alberta-Wszolek, MD Assistant Professor of M edicine Samuel J. Asirvatham, MD, FACC, FHRS Division of Dermatology Professor of M edicine and Pediatrics University of M assachusetts M edical School Division of Cardiovascular Diseases Worcester, M A M ayo Clinic College of M edicine Rochester, M N Alfred Aleguas Jr, PharmD, DABAT M anaging Director Seth M. Arum, MD, FACE N orthern O hio Poison Center Assistant Professor of M edicine Rainbow Babies & Children’s H ospital Department of Endocrinology Cleveland, O H UM ass M emorial M edical Center Worcester, M A v tahir99-VRG & vip.persianss.ir vi Contributors Philip J. Ayvazian, MD Stephen L. Barnes, MD, FACS Assistant Professor Associate Professor and Chief, Division of Acute Department of Urology Care Surgery UM ass M emorial M edical Center Department of Surgery Worcester, M A University of M issouri Columbia, M O Riad Azar, MD Associate Professor of M edicine Suzanne J. Baron, MD Department of Internal M edicine Cardiology Fellow Division of Gastroenterology Department of Cardiology Washington University School of M edicine M assachusetts General H ospital Barnes Jewish H ospital Boston, M A St. Louis, M O Thaddeus C. Bartter, MD, FCCP Ruben J. Azocar, MD Professor of M edicine Associate Professor and Residency Program Director Department of M edicine Department of Anesthesiology Division of Pulmonary and Critical Care Boston University M edical Center University of Arkansas for the M edical Sciences Boston, M A Little Rock, AR Ednan K. Bajwa, MD, MPH Amit Basu, MD Associate Director, M edical ICU Assistant Professor of Surgery and Attending Physician Department of Pulmonary and Critical Care Department of Surgery M assachusetts General H ospital University of Pittsburgh M edical Center Boston, M A Thomas E Starzl Transplantation Institute Pittsburgh, PA K.C. Balaji, MD Professor, Department of Surgery Kenneth L. Baughman, MD (DECEASED) Division of Urology UM ass M emorial M edical Center Worcester, M A Richard C. Becker, MD Professor of M edicine Jerry P. Balikian, MD, FACR Department of M edicine Professor and Vice Chair of Radiology Duke University School of M edicine Department of Radiology Durham, N C University of M assachusetts M edical School Worcester, M A Robert W. Belknap, MD Assistant Professor of M edicine Ian M. Ball, MD, DABEM, FRCPC Division of Infectious Diseases Assistant Professor Denver H ealth and H ospital Authority Program in Critical Care M edicine and University of Colorado Departments of Clinical Pharmacology/Toxicology Denver, CO and Emergency M edicine Q ueen’s University Kingston Isabelita R. Bella, MD O ntario, Canada Associate Professor of Clinical N eurology Department of N eurology Meyer S. Balter, MD, FRCPC University of M assachusetts M edical School UM ass M emorial M edical Center Professor Worcester, M A Department of M edicine University of Toronto Director, Asthma Education Clinic Andrew C. Bernard, MD M ount Sinai H ospital Associate Professor of Surgery Toronto, O ntario, Canada Department of Surgery University of Kentucky H ealthcare Lexington, KY Gisela I. Banauch, MD, MS Assistant Professor of M edicine Division of Pulmonary, Megan Bernstein, MD Allergy, Critical Care and Sleep M edicine Resident University of M assachusetts M edical School Department of Dermatology UM ass M emorial M edical Center University of M assachusetts M edical School Worcester, M A Worcester, M A Daniel T. Baran, MD Mary T. Bessesen, MD Region M edical Director Associate Professor of M edicine M erck Department of M edicine Adjunct Professor of M edicine, Cell Biology, and O rthopedics University of Colorado at Denver UM ass M emorial M edical Center Department of Veterans Affairs M edical Center—Denver Worcester, M A Denver, CO tahir99-VRG & vip.persianss.ir Contributors vii Michael C. Beuhler, MD Veronica Brito, MD M edical Director Pulmonary and Critical Care M edicine Fellow Department of Emergency M edicine Department of M edicine Carolinas Poison Center Winthrop-University H ospital Charlotte, N C M ineola, N Y Bonnie J. Bidinger, MD Traci L. Buescher, RN Assistant Professor of M edicine Department of H eart Rhythm Services Department of Internal M edicine M ayo Clinic Division of Rheumatology Rochester, M N University of M assachusetts M edical School UM ass M emorial M edical Center Keith K. Burkhart, MD, FACMT, FAACT, FACEP Worcester, M A Senior Advisor for M edical Toxicology FDA Center for Drug Evaluation and Research Steven B. Bird, MD O f ce of N ew Drugs Associate Professor Silver Spring, M D Department of Emergency M edicine Division of M edical Toxicology Michael J. Burns, MD, FACEP, FACMT University of M assachusetts M edical School Worcester, M A Chief of Emergency M edicine Saint Vincent H ospital Bruce R. Bistrian, MD, PhD Worcester, M A Division of M edical Toxicology Professor of M edicine Department of Emergency M edicine H arvard M edical School Beth Israel Deaconess M edical Center Department of M edicine Boston, M A Beth Israel Deaconess M edical Center Boston, M A Tuesday E. Burns, MD Robert M. Black, MD Assistant Professor of Psychiatry Professor of Clinical M edicine Department of Psychiatry UM ass M edical School Eastern Virginia M edical School Chief, N ephrology N orfolk, VA Division of Renal M edicine St. Vincent H ospital Scott W. Byram, MD Worcester, M A Assistant Professor of Anesthesiology Department of Anesthesiology Ernest F.J. Block, MD, MBA, FACS, FCCM Loyola University M edical Center Professor of Surgery, University of Central Florida M aywood, IL Department of Acute Care Surgery H olmes Regional M edical Center Brian T. Callahan, MD M elbourne, FL Interventional Radiology Fellow Department of Radiology Jeremiah Boles, MD H arvard M edical School H ematology/O ncology Fellow Beth Israel Deaconess M edical Center Department of M edicine Boston, M A Division of H ematology/O ncology University of N orth Carolina at Chapel H ill Christine Campbell-Reardon, MD Chapel H ill, N C Associate Professor of M edicine Department of Pulmonary and Critical Care N aomi F. Botkin, MD M edicine Assistant Professor of M edicine Boston University School of M edicine Division of Cardiovascular M edicine Boston M edical Center UM ass M emorial M edical Center Boston, M A Worcester, M A Christopher P. Cannon, MD Suzanne F. Bradley, MD TIM I Study Group Professor Cardiovascular Division Department of Internal M edicine Brigham and Women’s H ospital Division of Infectious Diseases and Geriatric M edicine Associate Professor of M edicine, H arvard Veterans Affairs Ann Arbor M edical School University of M ichigan H ealthcare Systems Boston, M A Ann Arbor, M I Jason P. Caplan, MD William F. Bria, MD Chief of Psychiatry Chief M edical Information O f cer Department of Psychiatry Department of M edical Affairs Creighton University School of M edicine at St. Joseph’s Shriners H ospital for Children H ospital and M edical Center Tampa, FL Phoenix, AZ tahir99-VRG & vip.persianss.ir viii Contributors Raphael A. Carandang, MD Victor G. Cimino, MD, FACS Assistant Professor Associate Professor University of M assachusetts M edical School Department of Surgery Department of N eurology and Surgical Intensive Care Loyola University M edical Center UM ass M emorial M edical Center M aywood, IL Worcester, M A Mary Dawn T. Co, MD Paul A. Carpenter, MD Assistant Professor of M edicine Associate Professor University of M assachusetts M edical School Clinical Research Division UM ass M emorial M edical Center Fred H utchinson Cancer Research Center Worcester, M A Seattle, WA Shawn Cody, MSN , MBA, RN Karen C. Carroll, MD Associate Chief N ursing O f cer for Critical Care Professor Pathology and M edicine UM ass M emorial M edical Center Department of Pathology Worcester, M A Division of M edical M icrobiology Johns H opkins H ospital Felipe B. Collares, MD, MSc Baltimore, M D Interventional Radiologist Department of Radiology David A. Chad, MD Beth Israel Deaconess M edical Center Associate Professor of N eurology Instructor in Radiology H arvard M edical School H arvard M edical School Department of N eurology Boston, M A M assachusetts General H ospital N euromuscular Diagnostic Center Bryan R. Collier, MD Boston, M A Assistant Professor of Surgery Division of Trauma & Surgical Critical Care Eugene Chang, MD Vanderbilt University M edical Center M artin Boyer Professor of M edicine N ashville, TN Department of M edicine, Section of Gastroenterology University of Chicago N ancy A. Collop, MD Chicago, IL Professor of M edicine Steven Y. Chang, MD, PhD Department of M edicine Emory University Assistant Professor of M edicine Atlanta, GA Division of Pulmonary & Critical Care M edicine Director of the M edical Intensive Care Unit John B. Cone, MD, FACS, FCCM University of M edicine & Dentistry of N ew Jersey— N ew Jersey M edical School Professor of Surgery N ewark, N J N orma & N olie M umey Chair in General Surgery Department of Surgery Michael L. Cheatham, MD, FACS, FCCM University of H ospital of Arkansas Director, Surgical Intensive Care Units Little Rock, AR Department of Surgical Education O rlando Regional M edical Center Sara E. Cosgrove, MD O rlando, FL Associate Professor of M edicine Division of Infectious Disease Sarah H. Cheeseman, MD Johns H opkins M edical Institutions Professor of M edicine, Pediatrics, M icrobiology and Baltimore, M D M olecular Genetics University of M assachusetts M edical School Filippo Cremonini, MD, PhD Division of Infectious Diseases Attending Physician UM ass M emorial M edical Center Department of Gastroenterology Worcester, M A Beth Israel Deaconess M edical Center H arvard M edical School Annabel A. Chen-Tournoux, MD Boston, M A Cardiology Fellow Department of M edicine Jonathan F. Critchlow, MD Division of Cardiology Assistant Professor of Surgery M assachusetts General H ospital H arvard University Boston, M A Beth Israel Deaconess M edical Center Boston, M A William K. Chiang, MD Chief of Service and Associate Professor of Emergency Ruy J. Cruz Jr, MD, PhD M edicine Assistant Professor of Surgery Department of Emergency Department of Surgery Bellevue H ospital Center University of Pittsburgh M edical Center N ew York, N Y Pittsburgh, PA tahir99-VRG & vip.persianss.ir Contributors ix Frederick J. Curley, MD Gregory J. Della Rocca, MD, PhD, FACS Associate Professor of M edicine Assistant Professor University of M assachusetts M edical School Co-Director, O rthopaedic Trauma Service Lung, Allergy & Sleep Specialists Department of O rthopaedic Surgery H opedale, M A University of M issouri Columbia, M O Armagan Dagal, MD, FRCA Assistant Professor Thomas G. DeLoughery, MD, FACP Department of Anesthesiology and Pain M edicine Professor of M edicine, Pathology and Pediatrics University of Washington, H arborview M edical Center Department of H ematology Seattle, WA O regon H ealth and Science University Portland, O R Seth T. Dahlberg, MD Associate Professor of M edicine and Radiology Mario De Pinto, MD Department of M edicine and Radiology Assistant Professor University of M assachusetts M edical School Department of Anesthesiology Division of Cardiology University of Washington UM ass M emorial M edical Center H arborview M edical Center Worcester, M A Seattle, WA Frank F. Daly, MBBS Mark Dershwitz, MD, PhD Clinical Toxicologist and Emergency Physician Professor and Vice Chair of Anesthesiology Department of Emergency M edicine Professor of Biochemistry & M olecular Pharmacology Royal Perth H ospital UM ass M emorial M edical Center Western Australia, Australia Worcester, M A Jennifer S. Daly, MD Akshay S. Desai, MD Professor of M edicine Instructor in M edicine Clinical Chief, Infectious Diseases and Immunology H arvard M edical School Department of M edicine Associate Physician University of M assachusetts M edical School Cardiovascular Division Worcester, M A Department of M edicine Brigham and Women’s H ospital Lloyd E. Damon, MD Boston, M A Professor of Clinical M edicine Department of M edicine Asha Devereaux, MD, MPH University of California, San Francisco Pulmonary Physician San Francisco, CA Sharp Coronado H ospital Coronado, CA Raul E. Davaro, MD Associate Professor, Clinical M edicine Christopher R. DeWitt, MD Department of M edicine M edical Toxicologist and Emergency Physician University of M assachusetts M edical School Department of Emergency and British Columbia Worcester, M A Poison Center Saint Paul’s H ospital Wellington J. Davis III, MD University of British Columbia Assistant Professor of Surgery and Pediatrics Vancouver, BC Section of Plastic and Reconstructive Surgery St. Christopher’s H ospital for Children Peter Doelken, MD Philadelphia, PA Associate Professor Ronald J. DeBellis, PharmD, FCCP Department of M edicine Division of Pulmonary, Critical Care, Allergy & Professor and Chair Sleep M edicine Department of Pharmacy Practice Albany College of Pharmacy and H ealth Sciences—Vermont M edical University of South Carolina Charleston, SC Colchester, VT G. William Dec, MD Robert P. Dowsett, FACEM Chief, Cardiology Division Senior Staff Specialist M assachusetts General H ospital Department of Emergency M edicine Department of Cardiology Westmead H ospital Boston, M A Wentworthville, N SW, Australia Paul F. Dellaripa, MD David A. Drachman, MD Assistant Professor of M edicine Professor of N eurology H arvard M edical School Chairman Emeritus Division of Rheumatology Department of N eurology Brigham and Women’s H ospital University of M assachusetts M edical School Boston, M A Worcester, M A tahir99-VRG & vip.persianss.ir x Contributors David F. Driscoll, PhD Timothy A. Emhoff, MD Vice President Chief, Trauma, Surgical Critical Care Stable Solutions LLC Department of Surgery Easton Industrial Park UM ass M emorial M edical Center Easton, M A Worcester, M A Cathy Dudick, MD, FACS Jennifer L. Englund, MD M edical Director, Surgical Intensive Care Unit M edical Toxicology Fellow Department of Surgery Department of Emergency M edicine Jersey Shore University M edical Center Division of M edical Toxicology N eptune, N J University of M assachusetts M edical School Worcester, M A David L. Dunn, MD, PhD Vice President for H ealth Sciences Robert M. Esterl Jr, MD Professor of Surgery, M icrobiology and Immunology Professor of Surgery University at Buffalo, School of M edicine Biomedical Sciences Department of Surgery Buffalo, N Y University of Texas H ealth Science Center at San Antonio Cheryl H. Dunnington, RN , MS, CCRN San Antonio, TX O perations Director, eICU Support Center Program Critical Care O perations Salomao Faintuch, MD, MSc UM ass M emorial M edical Center Instructor in Radiology Worcester, M A H arvard M edical School Department of Interventional Radiology Kevin Dwyer, MD, FACS Beth Israel Deaconess M edical Center Director of Trauma Boston, M A Vice-Chair of Surgery Stamford H ospital Pang-Yen Fan, MD Stamford, CT Associate Professor of M edicine Division of Renal M edicine Steven B. Edelstein, MD University of M assachusetts M edical School Professor of Anesthesiology M edical Director, Renal Transplant Program Vice-Chairman Education & Compliance UM ass M emorial M edical Center Department of Anesthesiology Worcester, M A Loyola University M edical Center Loyola University Stritch School of M edicine James C. Fang, MD M aywood, IL Professor of M edicine Cardiovascular Division W. Thomas Edwards, PhD, MD Case Western Reserve University Director, Fellowship in Pain M edicine Cleveland, O H Associate Professor of Anesthesiology Department of Anesthesiology John Fanikos, RPh, MBA University of Washington Assistant Director of Pharmacy H arborview M edical Center Department of Pharmacy Seattle, WA Brigham and Women’s H ospital Boston, M A Richard T. Ellison III, MD Professor of M edicine, M olecular Genetics and Harrison W. Farber, MD M icrobiology Professor of M edicine University of M assachusetts M edical School Department of Pulmonary Center Department of M edicine Boston University School of M edicine Division of Infectious Diseases and Immunology Boston, M A UM ass M emorial M edical Center Worcester, M A Khaldoun Faris, MD Associate Director of Surgical Intensive Care Unit Ashkan Emadi, MD, PhD Department of Anesthesiology Adjunct Faculty University of M assachusetts M edical School Division of Adult H ematology UM ass M emorial M edical Center Department of Internal M edicine Worcester, M A Johns H opkins H ospital Johns H opkins University Alan P. Farwell, MD Baltimore, M D Associate Professor of M edicine Director, Endocrine Clinics Charles H. Emerson, MD Department of Endocrinology, Diabetes and Professor Emeritus of M edicine N utrition Department of M edicine Boston University School of M edicine UM ass M emorial M edical Center Boston M edical Center Worcester, M A Boston, M A tahir99-VRG & vip.persianss.ir Contributors xi Alan M. Fein, MD, FACP, FCCP, FCCM Joseph J. Frassica, MD Clinical Professor of M edicine VP and Chief M edical Information O f cer Chief of Pulmonary, Sleep and Critical Care M edicine Philips H ealthcare H ofstra N orth Shore—LIJ School of M edicine Senior Consultant M assachusetts General H ospital ProH EALTH Care Associates, LLP Research Af liate M assachusetts Institute of Technology Lake Success, N Y Cambridge, M A Philip Fidler, MD, FACS R. Brent Furbee, MD Associate Director, Burn Center M edical Director Department of Surgery Indiana Poison Center Washington H ospital Center Indiana University H ealth M ethodist H ospital Washington, DC Indianapolis, IN Michael A. Fifer, MD Shrawan G. Gaitonde, MD Director, Cardiac Catheterization Laboratory Surgery Resident Division of Cardiology Department of Surgery Department of M edicine University H ospital/University of Cincinnati M assachusetts General H ospital Cincinnati, O H Boston, M A Richard L. Gamelli, MD, FACS Robert W. Finberg, MD Dean, Stritch School of M edicine Professor and Chair, Department of M edicine Loyola University Chicago University of M assachusetts M edical School Senior Vice President Department of M edicine Loyola University M edical Center UM ass M emorial M edical Center M aywood, IL Worcester, M A Michael Ganetsky, MD Kimberly A. Fisher, MD Clinical Instructor, H arvard M edical School Assistant Professor of M edicine Clinical Director, Division of M edical Toxicology University of M assachusetts M edical School Department of Emergency M edicine UM ass M emorial M edical Center Beth Israel Deaconess M edical Center Worcester, M A Boston, M A Marc Fisher, MD Joseph J. Gard, MD Professor of N eurology Cardiology Fellow University of M assachusetts M edical School Department of Internal M edicine UM ass M emorial M edical Center Division of Cardiovascular Diseases Worcester, M A M ayo Clinic Rochester, M N Patrick F. Fogarty, MD Director, Penn Comprehensive H emophilia and James Geiling, MD, FACP, FCCP, FCCM Thrombosis Program Professor of M edicine Department of M edicine Dartmouth M edical School University of Pennsylvania H anover, N H ; Philadelphia, PA Chief, M edical Service VA M edical Center Dorrie K. Fontaine, PhD, RN , FAAN White River Junction, VT Dean and Professor School of N ursing Debra Gerardi, RN , MPH, JD University of Virginia CEO Charlottesville, VA EH CCO , LLC Principal, Debra Gerardi and Associates N ancy M. Fontneau, MD H alf M oon Bay, CA Associate Professor of Clinical N eurology University of M assachusetts M edical School Edith S. Geringer, MD UM ass M emorial M edical Center Psychiatrist Worcester, M A Department of Psychiatry M assachusetts General H ospital Marsha D. Ford, MD Boston, M A Director, Carolinas Poison Center Department of Emergency M edicine Terry Gernsheimer, MD Carolinas M edical Center M edical Director of Transfusion Charlotte, N C Seattle Cancer Care Alliance and University of Washington M edical Center Keith J. Foster, PharmD, BCPS Professor of M edicine Clinical Pharmacist Surgical Intensive Care Unit Division of H ematology Department of Pharmacy Puget Sound Blood Center UM ass M emorial M edical Center Department of M edical Education Worcester, M A Seattle, WA tahir99-VRG & vip.persianss.ir xii Contributors John G. Gianopoulos, MD Damian J. Green, MD System Chair of M aternal/Fetal M edicine Research Associate Department of O B/GYN Clinical Research Division Cook County H ealth and H ospital System Fred H utchinson Cancer Research Center Chicago, IL Seattle, WA Michael M. Givertz, MD Bruce Greenberg, MD Associate Professor of M edicine Assistant Professor H arvard M edical School Department of M edicine M edical Director, H eart Transplant and Circulatory University of M assachusetts M edical School Assist Program Worcester, M A Cardiovascular Division Brigham and Women’s H ospital Bonnie C. Greenwood, PharmD, BCPS Boston, M A Staff Development and Perioperative Services M anager Department of Pharmacy Richard H. Glew, MD Brigham and Women’s H ospital Professor of M edicine, M olecular Genetics and Boston, M A M icrobiology Vice Chair, M edicine—Undergraduate M edical Ronald F. Grossman, MD Education and Faculty Affairs Professor of M edicine Department of M edicine University of Toronto UM ass M emorial M edical Center Credit Valley H ospital Worcester, M A M ississauga, O ntario, Canada Dori Goldberg, MD Rainer W.G. Gruessner, MD Assistant Professor of M edicine Professor of Surgery Division of Dermatology Department of Surgery Department of M edicine University of Arizona University of M assachusetts M edical School Tucson, AZ UM ass M emorial M edical Center Worcester, M A Chandra Prakash Gyawali, MD, MRCP Associate Professor of M edicine Andrew J. Goodwin, MD Division of Gastroenterology Clinical and Research Fellow Department of M edicine Department of Pulmonary and Critical Care Washington University School of M edicine Brigham and Women’s H ospital Barnes-Jewish H ospital Boston, M A St. Louis, M O Ammar Habib, MD Kim L. Goring, MMBS Internal M edicine Resident Assistant Professor of M edicine Department of Internal M edicine Department of Internal M edicine M ayo Clinic Division of Pulmonary, Critical Care and Sleep M edicine Rochester, M N H oward University H ospital Washington, DC Shirin Haddady, MD Assistant Professor of M edicine and N eurology Robert M. Gougelet, MD Department of M edicine Assistant Professor of M edicine (Emergency M edicine) University of M assachusetts M edical School Director, N ew England Center of Emergency Preparedness UM ass M emorial M edical Center Department of Emergency M edicine Worcester, M A Dartmouth H itchcock M edical Center Lebanon, N H Pegge M. Halandras, MD Assistant Professor Andis Graudins, MBBS, PhD, FACEM, FACMT Department of Surgery Professor of Emergency M edicine Research and Division of Vascular Surgery and Endovascular Clinical Toxicology Therapy Faculty of M edicine N ursing and H ealth Sciences Loyola University Chicago Stritch School of M edicine M onash University M aywood, IL Department of Emergency M edicine M onash M edical Centre Wiley R. Hall, MD Clayton, Victoria, Australia Assistant Professor in N eurology and Surgery Director of N euroscience Critical Care Barth A. Green, MD University of M assachusetts M edical School Professor and Chairman M edical Director of the N euro/Trauma ICU Department of N eurological Surgery N eurology Department Jackson M emorial/University of M iami UM ass M emorial M edical Center M iami, FL Worcester, M A tahir99-VRG & vip.persianss.ir Contributors xiii Stephen B. Hanauer, MD Thomas L. Higgins, MD, MBA, FACP, FCCM Professor of M edicine and Clinical Pharmacology Professor of M edicine Department of Gastroenterology Department of Anesthesia and Surgery University of Chicago Interim Chair Chicago, IL Department of M edicine Baystate M edical Center Charles William Hargett, III, MD Spring eld, M A Associate in M edicine Division of Pulmonary & Critical Care N icholas Hill, MD Duke University M edical Center Chief Durham, N C Department of Pulmonary, Critical Care and Sleep Division Tufts M edical Center Boston, M A David M. Harlan, MD Chief, Diabetes Division John B. Holcomb, MD, FACS Co-Director, Diabetes Center of Excellence Vice Chair and Professor Department of M edicine Department of Surgery UM ass M emorial M edical Center M emorial H ermann H ospital University of M assachusetts School of M edicine H ouston, TX Worcester, M A Judd E. Hollander, MD Laura Harrell, MD, MS Professor, Clinical Research Director Assistant Professor of M edicine Department of Emergency M edicine Department of Gastroenterology H ospital of the University of Pennsylvania University of Chicago M edical Center Philadelphia, PA Chicago, IL Helen M. Hollingsworth, MD Lawrence J. Hayward, MD, PhD Associate Professor of M edicine Professor of N eurology Department of Pulmonary Allergy and Critical Department of N eurology Care M edicine University of M assachusetts M edical School Boston M edical Center Worcester, M A Boston, M A Kennon Heard, MD Shelley A. Holmer, MD Associate Professor Clinical Associate Rocky M ountain Poison and Drug Center, Department of Psychiatry Denver H ealth Duke University M edical Center Department of Emergency M edicine Durham, N C University of Colorado School of M edicine Denver, CO Donough Howard, MD Consultant Rheumatologist Stephen O. Heard, MD H ermitage M edical Clinic Dublin, Ireland Professor and Chair University of M assachusetts M edical School Department of Anesthesiology Michael D. Howell, MD, MPH UM ass M emorial M edical Center Director, Critical Care Q uality Worcester, M A Beth Israel Deaconess M edical Center Boston, M A John E. Heffner, MD Rolf D. Hubmayr, MD Garnjobst Chair and Professor of M edicine Professor Department of M edicine Department of M edicine and Physiology Providence Portland M edical Center M ayo Clinic Portland, O R Rochester, M N Jeremy S. Helphenstine, DO Abhinav Humar, MD Clinical Instructor Professor of Surgery Toxicology Fellow Division Chief, Transplant Surgery Department of Emergency M edicine Department of Surgery Emory School of M edicine University of Pittsburgh Atlanta, GA Pittsburgh, PA Robert J. Heyka, MD Thomas L. Husted, MD Director, O utpatient H emodialysis Assistant Professor of Surgery Department of N ephrology & H ypertension Department of Surgery Cleveland Clinic Foundation University of Cincinnati Cleveland, O H Cincinnati, O H tahir99-VRG & vip.persianss.ir xiv Contributors Richard S. Irwin, MD, Master FCCP Thanjira Jiranantakan, MD Professor of M edicine and N ursing Preventive and Social M edicine Department University of M assachusetts Siriraj H ospital Faculty of M edicine Chair, Critical Care M ahidol University, Thailand UM ass M emorial M edical Center M edical Toxicology Fellow Worcester, M A Department of Clinical Pharmacology and M edical Toxicology San Francisco General H ospital, University of John M. Iskander California Fellow in Gastroenterology The California Poison Control System—San Francisco Division of Gastroenterology Division St. Louis, M O San Francisco, CA Paul G. Jodka, MD Eric M. Isselbacher, MD Assistant Professor of M edicine and Professor of M edicine Anesthesiology H arvard M edical School Tufts University School of M edicine Co-Director, Thoracic Aortic Center Adult Critical Care Division M assachusetts General H ospital Baystate M edical Center Boston, M A Spring eld, M A Rao R. Ivatury, MD Scott B. Johnson, MD, FACS, FCCP Chair Associate Professor Department of Surgery Chief of General Thoracic Surgery Division of Trauma, Critical Care, Emergency Department of Cardiothoracic Surgery Surgery University of Texas H ealth Science Center, Virginia Commonwealth University San Antonio Richmond, VA San Antonio, TX Sreenivasa S. Jonnalagadda, MD, FASGE William L. Jackson Jr, MD, MBA Professor of M edicine M edical Director, Adult Critical Care Director of Pancreatic and Biliary Endoscopy Inova H ealth System Washington University School of M edicine Falls Church, VA Division of Gastroenterology St. Louis, M O Eric W. Jacobson, MD Bryan S. Judge, MD Associate Professor of M edicine University of M assachusetts M edical School Associate Program Director Senior Vice President, Clinical Research and Assistant Professor Regulatory Affairs Spectrum H ealth Chief M edical O f cer Grand Rapids M ERC/M ichigan State University Synta Pharmaceuticals Corp. Program in Emergency M edicine Lexington, M A Grand Rapids, M I Eias E. Jweied, MD, PhD Donald H. Jenkins, MD, FACS Cardiovascular/Thoracic Surgeon Trauma Director Department of Cardiothoracic and Vascular Surgical Associate Professor of Surgery Associates, S.C. Division of Trauma, Critical Care and Emergency Advocate Christ M edical Center General Surgery O ak Lawn, IL M ayo Clinic Rochester, M N Marc J. Kahn, MD Professor of M edicine Jing Ji, MD SR. Associate Dean Department of M edicine N eurology Resident Tulane University School of M edicine Department of N eurology N ew O rleans, LA University of M assachusetts M edical School Worcester, M A Raja Kandaswamy, MD Axline Professor of Surgery Tun Jie, MD, MS Director of the University of Florida Institute of Assistant Professor of Surgery Transplantation Department of Surgery Department of Surgery University of Arizona, College of M edicine Shands H ospital—University of Florida Gainesville Tucson, AZ Gainesville, FL tahir99-VRG & vip.persianss.ir Contributors xv Abhishek Katiyar, MD Stephen J. Krinzman, MD M edical and Toxicology and Emergency M edicine Assistant Professor of M edicine Department of Emergency M edicine Division of Pulmonary, Allergy, and Critical UIC/Advocate Christ H ospital Care M edicine O ak Lawn, IL University of M assachusetts M edical School UM ass M emorial M edical Center Carol A. Kauffman, MD Worcester, M A Professor Internal M edicine University of M ichigan M edical School Gowri Kularatna, MD Chief, Infectious Diseases Fellow in Gastroenterology Veterans Affairs Ann Arbor H ealthcare Washington University School of M edicine/Barnes Jewish System H ospital Ann Arbor, M I Division of Gastroenterology St. Louis, M O Christoph R. Kaufmann, MD, MPH Professor of Surgery, East Tennessee State University Sonal Kumar, MD Department of Trauma and Emergency Surgery Internal M edicine Resident Johnson City M edical Center Department of Internal M edicine Johnson City, TN Barnes Jewish H ospital St. Louis, M O Shubjeet Kaur, MD Clinical Professor and Vice Chair Margaret Laccetti, PhD, RN , AOCN , ACHPN Department of Anesthesiology Director, N ursing Professional Development University of M assachusetts M edical School UM ass M emorial M edical Center UM ass M emorial M edical Center Worcester M A Worcester, M A Hoa Thi Lam, BS Glenn Kershaw, MD Research Assistant Associate Professor of Clinical M edicine Department of Child Psychiatry Division of Renal M edicine M assachusetts General H ospital University of M assachusetts M edical School Boston, M A UM ass M emorial M edical Center Worcester, M A Robert A. Lancy, MD, MBA Chief of Cardiac Surgery Mark A. Kirk, MD Department of Cardiac Surgery M edical Toxicology Fellowship Director Bassett M edical Center Department of Emergency M edicine Cooperstown, N Y University of Virginia Charlottesville, VA Angeline A. Lazarus, MD Professor of M edicine Meghan S. Kolodziej, MD Department of Pulmonary M edicine Instructor in Psychiatry Division of Pulmonary Department of Psychiatry N ational N aval M edical Center Brigham and Women’s H ospital Bethesda, M D Boston, M A Jason Lee-Llacer, MD Scott E. Kopec, MD Fellow Assistant Professor of M edicine Department of Critical Care M edicine and Anesthesia Division of Pulmonary, Allergy and Critical George Washington University Care M edicine Washington, DC UM ass M emorial M edical Center University of M assachusetts M edical School Anthony J. Lembo, MD Worcester, M A Associate Professor of M edicine Department of M edicine Bruce A. Koplan, MD Beth Israel Deaconess M ed Center Assistant Professor of M edicine Boston, M A H arvard M edical School Cardiac Arrhythmia Service James A. de Lemos, MD Department of Cardiac Arrhythmia CCU and Cardiology Fellowship Director Brigham and Women’s H ospital Department of Cardiology/M edicine Boston, M A The University of Texas Southwestern M edical Center Dallas, TX Richard Kremsdorf, MD Clinical Professor of M edicine, Voluntary Adam B. Lerner, MD University of California, San Diego School of M edicine Director, Cardiac Anesthesia President Department of Anesthesia and Critical Care Five Rights Consulting, Inc. Beth Israel Deaconess M edical Center San Diego, CA Boston, M A tahir99-VRG & vip.persianss.ir xvi Contributors Phillip A. Letourneau, MD Mark S. Link, MD Research Fellow/General Surgery Resident Professor of M edicine Department of Surgery Department of Cardiac Electrophysiology University of Texas M edical School at H ouston Tufts M edical Center H ouston, TX Boston, M A Howard B. Levene, MD, PhD Carol F. Lippa, MD Assistant Professor of N eurological Surgery Professor of N eurology Department of N eurosurgery Department of N eurology University of M iami H ospital Drexel University College of M edicine M iami, FL Philadelphia, PA N ikki A. Levin, MD, PhD Associate Professor of M edicine Alan Lisbon, MD Division of Dermatology Associate Professor, Anaesthesia, H arvard University of M assachusetts M edical School M edical School Worcester, M A Department of Anaesthesia, Critical Care and Pain M edicine Stephanie M. Levine, MD Beth Israel Deaconess M edical Center Professor of M edicine Boston, M A Department of M edicine University of Texas H ealth Science Center at San Antonio Mauricio Lisker-Melman, MD San Antonio, TX Professor of M edicine Director, H epatology Program William J. Lewander, MD Department of Internal M edicine Professor and Associate Vice Chair of Pediatric Emergency Division of Gastroenterology M edicine Washington University School of M edicine The Warren Alpert M edical School of Brown University Barnes-Jewish H ospital Department of Emergency M edicine St. Louis, M O Rhode Island H ospital Providence, RI N . Scott Litofsky, MD, FACS Daniel H. Libraty, MD Professor and Chief Associate Professor Director of N euro-O ncology and Radiosurgery Department of M edicine/Infectious Diseases Division of N eurological Surgery University of M assachusetts M edical School University of M issouri School of M edicine Worcester, M A Columbia, M O Craig M. Lilly, MD Afroza Liton, MD Professor of M edicine, Anesthesiology and Fellow Surgery Department of Infectious Disease Department of M edicine University of M assachusetts University of M assachusetts M edical School UM ass M emorial M edical Center UM ass M emorial M edical Center Worcester, M A Worcester, M A Sonia Lin, PharmD, BCPS Frederic F. Little, MD Clinical Pharmacy Specialist Assistant Professor of M edicine Department of Pharmacy Pulmonary Center and Department of Pulmonary, University of Colorado H ospital Allergy, and Critical Care M edicine Aurora, CO Boston University School of M edicine Attending Physician Christopher H. Linden, MD Boston M edical Center Professor, Department of Emergency M edicine Boston, M A Division of M edical Toxicology University of M assachusetts M edical School N ancy Y.N . Liu, MD UM ass M emorial M edical Center Associate Professor of Clinical M edicine Worcester, M A Department of M edicine Division of Rheumatology Michael Linenberger, MD, FACP University of M assachusetts M edical School Professor, Division of H ematology Worcester, M A Department of M edicine University of Washington Associate M ember, Clinical Research Division Randall R. Long, MD, PhD Fred H utchinson Cancer Research Center Cheshire M edical Center/Dartmouth Seattle Cancer Care Alliance H itchcock Keene Seattle, WA Keene, N H tahir99-VRG & vip.persianss.ir Contributors xvii Robert B. Love, MD, FACS Avinash V. Mantravadi, MD Professor and Vice Chairman Resident Physician Department of Thoracic and Cardiothoracic Department of O tolaryngology—H ead and N eck Surgery Loyola University M edical Center Loyola University M edical Center M aywood, IL M aywood, IL Matthew W. Lube, MD Paul E. Marik, MD, FCCM, FCCP Assistant Professor of Surgery and Surgical Clerkship Professor of M edicine Director Department of Pulmonary and Critical Care M edicine University of Central Florida College of M edicine Eastern Virginia M edical School and N orfolk General Associate Director of M edical Education H ospital Department of Surgical Education Eastern Virginia M edical School Internal M edicine O rlando Regional M edical Center N orfolk, VA O rlando, FL William L. Marshall, MD Fred A. Luchette, MD, MSc Associate Professor of M edicine The Ambrose and Gladys Bowyer Professor of Surgery Department of M edicine Stritch School of M edicine UM ass M emorial M edical Center M edical Director, General Surgery III Service Worcester, M A Department of Surgery M aywood, IL Arthur J. Matas, MD Professor of Surgery Department of Surgery Alice D. Ma, MD University of M innesota Associate Professor of M edicine M inneapolis, M N Department of M edicine Division H ematology/O ncology Paul H. Mayo, MD University of N orth Carolina Professor of Clinical M edicine Chapel H ill, N C H ofstra N orthshore—LIJ School of M edicine Long Island Jewish M edical Center Theresa R. (Roxie) Macfarlan, RN , MSN , CCRN , N ew H yde Park, N Y ACN P-BC Advanced Practice N urse 2 Guy Maytal, MD Department of Thoracic-Cardiovascular Postoperative Director of Urgent Care and Primary Care Psychiatry Intensive Care Unit Department of Psychiatry University of Virginia H ealth System M assachusetts General H ospital Charlottesville, VA Boston, M A J. Mark Madison, MD Melanie Maytin, MD Professor of M edicine and Physiology Instructor in M edicine Chief, Division of Pulmonary, Allergy and Critical Care Department of Cardiovascular M edicine M edicine Brigham and Women’s H ospital UM ass M emorial M edical Center Boston, M A University of M assachusetts M edical School Worcester, M A Kathleen M. McCauley, PhD, RN , ACN S-BC, FAAN , FAHA Ajai K. Malhotra, MBBS, MD, MS, DN B, FRCS Associate Dean for Academic Programs Associate Professor and Vice Chair Class of 1965 25th Reunion Term Professor of Associate M edical Director, Level 1 Trauma Center Cardiovascular N ursing Department of Surgery Cardiovascular Clinical Specialist Division of Trauma, Critical Care and Emergency General University of Pennsylvania School of N ursing Surgery H ospital of the University of Pennsylvania Virginia Commonwealth University M edical Center Philadelphia, PA Richmond, VA Sara L. Merwin, MPH Assistant Professor of M edicine Atul Malhotra, MD Department of M edicine Associate Professor of M edicine H ofstra N orth Shore—LIJ School of M edicine Department of M edicine N orth Shore University H ospital Brigham and Women’s H ospital M anhasset, N Y Boston, M A Marco Mielcarek, MD Samir Malkani, MD Assistant Professor Clinical Associate Professor of M edicine University of Washington Division of Diabetes Assistant M ember Department of M edicine Department of M edical O ncology UM ass M emorial M edical Center Fred H utchinson Cancer Research Center Worcester, M A Seattle, WA tahir99-VRG & vip.persianss.ir xviii Contributors Ross Milner, MD James B. Mowry, PharmD, DABAT, FAACT Associate Professor of Surgery Director, Indiana Poison Center Chief, Division of Vascular Surgery and Endovascular Department of Emergency M edicine and Therapy Trauma Center Department of Vascular Surgery M ethodist H ospital, Indiana University H ealth Loyola University M edical Center Indianapolis, IN M aywood, IL Saori A. Murakami, MD Ann L. Mitchell, MD Psychiatrist Associate Professor of Clinical N eurology M assachusetts General H ospital, M cLean H ospital Department of N eurology Boston, M A University of M assachusetts M edical School UM ass M emorial M edical Center Michael C. Muzinich, MD Worcester, M A N eurosurgical Resident Department of N eurological Surgery University H ospital and Clinics Lawrence C. Mohr Jr, MD, ScD, FACP, FCCP Columbia, M O Professor of M edicine, Biometry and Epidemiology Director, Environmental Biosciences Program John G. Myers, MD M edical University of South Carolina Charleston, SC Associate Professor Department of Surgery University of Texas H ealth Science Center, San Antonio Takki Momin, MD San Antonio, TX Vascular Surgery Fellow Department of Vascular Surgery Shashidhara N anjundaswamy, MD, MBBS, Georgetown University/Washington MRCP, DM H ospital Center Assistant Professor Washington, DC Department of N eurology University of M assachusetts M edical School Jahan Montague, MD Worcester, M A Assistant Professor of M edicine Department of N ephrology Lena M. N apolitano, MD, FACS, FCCP, FCCM UM ass M emorial M edical Center Professor of Surgery Worcester, M A Department of Surgery University of M ichigan Ann Arbor, M I Bruce Montgomery, MD Associate Professor Jaishree N arayanan, MD, PhD Department of M edicine, O ncology Associate Professor Clinical N eurology University of Washington Department of N eurology VA Puget Sound H CS UM ass M emorial M edical Center Seattle, WA Worcester, M A Majaz Moonis, MD, MRCP(1), DM, Theresa A. N ester, MD FRCP (Edin) Associate M edical Director Professor of N eurology Puget Sound Blood Center Director, Stroke Services Department of Laboratory M edicine Director, Vascular Fellowship Program University of Washington M edical Center UM ass M emorial M edical Center Puget Sound Blood Center Worcester, M A Seattle, WA Michael S. N iederman, MD John P. Mordes, MD Professor of M edicine Professor of M edicine SUN Y at Stony Brook Department of M edicine/Endocrinology Chairman, Department of M edicine UM ass M emorial M edical Center Winthrop-University H ospital University of M assachusetts M edical School M ineola, N Y Worcester, M A Dominic J. N ompleggi, MD, PhD David A. Morrow, MD, MPH Associate Professor of M edicine and Surgery Director, Samuel A. Levine Cardiac Unit University of M assachusetts M edical School Department of Cardiovascular M edicine Chief, Division of Gastroenterology Brigham and Women’s H ospital Director, Adult N utrition Support Service H arvard M edical School UM ass M emorial M edical Center Boston, M A Worcester, M A tahir99-VRG & vip.persianss.ir Contributors xix Sean E. N ork, MD Mickey M. Ott, MD Associate Professor Assistant Professor in Surgery Department of O rthopaedics & Sports M edicine Division of Trauma & Surgical Critical Care H arborview M edical Center, University of Vanderbilt University M edical Center Washington N ashville, TN Seattle, WA John A. Paraskos, MD Robert L. N orris, MD, FACEP Professor of M edicine Associate Professor Department of M edicine Department of Surgery University of M assachusetts M edical School Chief, Division of Emergency M edicine UM ass M emorial M edical Center Stanford University M edical Center Worcester, M A Palo Alto, CA Richard A. Oeckler, MD, PhD Polly E. Parsons, MD Assistant Professor of M edicine and Physiology Professor and Chair of M edicine Department of Pulmonary and Critical Care M edicine Department of M edicine M ayo Clinic University of Vermont College of M edicine Rochester, M N Fletcher Allen H ealth Care Burlington, VT Patrick T. O’Gara, MD Executive M edical Director of the Carl J. and Laura Santos Pavia, MD Ruth Shapiro Cardiovascular Center Resident in Anesthesiology Associate Professor Boston M edical Center H arvard M edical School Boston University School of M edicine Director, Clinical Cardiology Boston, M A Brigham and Women’s H ospital Boston, M A Marie T. Pavini, MD, FCCP Intensivist Paulo J. Oliveira, MD, FCCP Department of Intensive Care Unit Director, Advanced Bronchoscopic and Rutland Regional M edical Center Pleural Procedures Rutland, VT Assistant Professor of M edicine Division of Pulmonary, Allergy and Critical David Paydarfar, MD Care M edicine Professor of N eurology and Physiology UM ass M emorial M edical Center Department of N eurology Worcester, M A University of M assachusetts M edical School Worcester, M A Kent R. Olson, MD, FACEP, FAACT, FACMT M edical Director, San Francisco Division William D. Payne, MD California Poison Control System Clinical Professor of M edicine and Pharmacy Professor of Surgery University of California, San Francisco Director, Liver Transplant San Francisco, CA Department of Surgery University of M innesota M inneapolis, M N Steven M. Opal, MD Professor of M edicine Warren Alpert M edical School of Brown University Randall S. Pellish, MD M emorial H ospital of Rhode Island Assistant Professor of M edicine Division of Infectious Disease Division of Gastroenterology Pawtucket, RI University of M assachusetts M edical School Worcester, M A Achikam Oren-Grinberg, MD, MS Director of Critical Care Echocardiography Alexis C. Perkins, MD Department of Anesthesia, Critical Care & Chief Resident Pain M edicine Department of Dermatology Beth Israel Deaconess M edical Center University of M assachusetts M edical School Boston, M A Worcester, M A David Ost, MD, MPH Catherine A. Phillips, MD Associate Professor Associate Professor of Clinical N eurology Department of Pulmonary M edicine University of M assachusetts M edical School The University of Texas M .D. Anderson Cancer Department of N eurology Center UM ass M emorial M edical Center H ouston, TX Worcester, M A tahir99-VRG & vip.persianss.ir xx Contributors Ryan F. Porter, MD John Querques, MD Resident Physician Assistant Professor of Psychiatry Department of Internal M edicine H arvard M edical School Washington University School of M edicine Associate Director, Psychosomatic M edicine—Consultation Barnes-Jewish H ospital Psychiatry Fellowship Program St. Louis, M O Department of Psychiatry M assachusetts General H ospital Louis G. Portugal, MD, FACS Boston, M A Associate Professor of Surgery Department of Surgery Sunil Rajan, MD, FCCP The University of Chicago Department of M edicine Chicago, IL Pulmonary M edicine and Critical Care Pulmonary Associates of Richmond, Inc. Joseph A. Posluszny Jr, MD M idlothian, VA Research Fellow Department of Burn and Shock Trauma Institute Paula D. Ravin, MD Loyola University M edical Center Associate Professor of Clinical N eurology M aywood, IL Department of N eurology UM ass M emorial M edical Center Melvin R. Pratter, MD Worcester, M A H ead, Division of Pulmonary and Critical Care M edicine Department of M edicine Cooper University H ospital Justin L. Regner, MD Camden, N J Assistant Professor of Surgery Division of Trauma and Critical Care David J. Prezant, MD University of Arkansas M edical School Little Rock, AR Chief M edical O f cer Special Advisor to the Fire Commissioner for H ealth Policy Co-Director WTC M edical M onitoring & Treatment Harvey S. Reich, MD, FACP, FCCP Programs Director, Critical Care M edicine N ew York City Fire Department Department of Critical Care M edicine Professor of M edicine Rutland Regional M edical Center Albert Einstein College of M edicine Rutland, VT Pulmonary Division Brooklyn, N Y Randall R. Reves, MD, MSc M edical Director of the Denver M etro Tuberculosis Timothy A. Pritts, MD, PhD Control Program Associate Professor of Surgery Department of M edicine and Public H ealth Department of Surgery Denver Public H ealth Department Division of Trauma and Critical Care Denver, CO University of Cincinnati Cincinnati, O H John Ricotta, MD, FACS John T. Promes, MD Professor of Surgery, Georgetown University Director, Trauma Services H arold H . H aw eld Chair of Surgery Department of M edical Center Department of Surgery O rlando Regional M edical Center Washington H ospital Center O rlando, FL Washington, DC Donald S. Prough, MD Teresa A. Rincon, BSN , RN , CCRN -E Professor and Chair N urse Director Anesthesiology Sutter H ealth System UTM B Anesthesiology Sacramento-Sierra Region eICU Galveston, TX Sacramento, CA Leon M. Ptaszek, MD, PhD Clinical Fellow Ray Ritz, BA, RRT, FAARC Department of M edicine Director of Respiratory Care Cardiology Division Department of Respiratory Care M assachusetts General H ospital Beth Israel Deaconess M edical Center Boston, M A Boston, M A Juan Carlos Puyana, MD Kimberly A. Robinson, MD, MPH Associate Professor of Surgery Assistant Professor of M edicine Department of Surgery Division of Pulmonary, Critical Care University of Pittsburgh M edical Center M arlborough H ospital Pittsburgh, PA M arlborough, M A tahir99-VRG & vip.persianss.ir Contributors xxi Mark J. Rosen, MD Michael G. Seneff, MD Division of Pulmonary, Critical Care and Sleep M edicine Associate Professor N orth Shore University and Long Island Jewish H ealth Department of Anesthesiology and Critical System Care M edicine Professor of M edicine The George Washington University H ospital H ofstra N orth Shore—Long Island Jewish School of Washington, DC M edicine N ew H yde Park, N Y M. Michael Shabot, MD System Chief M edical O f cer Aldo A. Rossini, MD Department of Executive O f cers Professor of M edicine M emorial H ermann H ealthcare System Emeritus H ouston, TX Department of M edicine University of M assachusetts M edical School Violet L. Shaffer, MA, BA Worcester, M A Research Vice President and Global Industry Service Director Alan L. Rothman, MD Department of Research Professor Gartner, Inc. Department of M edicine Stamford, CT UM ass M emorial M edical Center Worcester, M A Samir R. Shah, MD Plastic Surgery Fellow Marc S. Sabatine, MD, MPH Department of Plastic Surgery Vice Chair TIM I Study Group Loyola University M edical Center Associate Professor of M edicine M aywood, IL H arvard M edical School Associate Cardiologist Sajid Shahul, MD Division of Cardiovascular M edicine Brigham and Women’s H ospital Assistant Program Director Boston, M A Associate Director Cardiac Surgical Intensive Care Unit Beth Israel Deaconess M edical Center Marjorie S. Safran, MD H arvard M edical School Professor of Clinical M edicine Boston, M A Department of Endocrinology University of M assachusetts M edical School UM ass M emorial M edical Center Michael W. Shannon, MD, MPH, FAAP, Worcester M A FACEP (DECEASED) Chief and Chair, Division of Emergency Steven A. Sahn, MD M edicine Professor of M edicine and Division Director Director, Center for Biopreparedness Division of Pulmonary, Critical Care, Allergy and Co-Director, Pediatric Environmental Sleep M edicine H ealth Center The M edical University of South Carolina Professor of Pediatrics, H arvard M edical School Charleston, SC Children’s H ospital Boston Division of Emergency M edicine Todd W. Sarge, MD Boston, M A Instructor in Anaesthesia H arvard M edical School Richard D. Shih, MD Department of Anesthesia, Critical Care and Emergency M edicine Program Director Pain M edicine Department of Emergency M edicine Beth Israel Deaconess M edical Center M orristown M emorial H ospital Boston, M A M orristown, N J Benjamin M. Scirica, MD, MPH Andrew F. Shorr, MD, MPH Associate Physician and Investigator Associate Director, Pulmonary and Critical Care Department of M edicine Department of M edicine Cardiovascular Division Washington H ospital Center TIM I Study Group Washington, DC Brigham and Women’s H ospital Boston, M A Sara J. Shumway, MD Professor of Cardiothoracic Surgery Douglas Seidner, MD Vice-Chief Associate Professor of M edicine Division of Cardiothoracic Surgery Division of Gastroenterology, H epatology and N utrition Surgical Director, Lung Transplantation Director, Vanderbilt Center for H uman N utrition Department of Surgery Vanderbilt University M edical Center University of M innesota M edical Center, Fairview N ashville, TN M inneapolis, M N tahir99-VRG & vip.persianss.ir xxii Contributors Samy S. Sidhom, MD, MPH Howard G. Smith, MD, FACS Clinical Associate Director of Burn Services Tufts University School of M edicine O rlando Regional M edical Center Clinical Fellow Associate Professor of Surgery Division of Pulmonary, Critical Care and Sleep University of Central Florida College of M edicine M edicine O rlando, FL Tufts M edical Center Boston, M A Jason W. Smith, MD Fellow, Cardiothoracic Surgery Department of Cardiovascular and Thoracic Anupam Singh, MD Surgery Assistant Professor of M edicine, GI H ospitalist Loyola University M edical Center Department of M edicine M aywood, IL Division of Gastroenterology UM ass M emorial M edical Center Jennifer Smith, MD Worcester, M A Banner Good Samaritan M edical Center Phoenix, AZ Inder M. Singh, MD Fellow Dustin L. Smoot, MD Division of Digestive Diseases Associate Consultant University of California, Los Angeles Department of Trauma, Critical Care and Los Angeles, CA General Surgery M ayo Clinic Rochester, M N Jagmeet P. Singh, MD, PhD Associate Professor of M edicine N icholas A. Smyrnios, MD Department of Cardiac Arrhythmia Service Professor of M edicine M assachusetts General H ospital Director, M edical Intensive Care Units Boston, M A Division of Pulmonary, Allergy, and Critical Care M edicine Marco L.A. Sivilotti, MD, MSc, FRCPC, FACEP, University of M assachusetts M edical School Worcester, M A FACMT Associate Professor, Department of Emergency Patrick D. Solan, MD M edicine and of Pharmacology & Toxicology Surgery Resident Q ueen’s University Department of Surgery Kingston, O ntario, Canada University H ospital/University of Cincinnati Cincinnati, O H Brian S. Smith, PharmD, BCPS Director, Education and Clinical Services Dennis I. Sonnier, MD Department of Pharmacy Surgery Resident UM ass M emorial M edical Center Department of Surgery Worcester, M A University H ospital/University of Cincinnati Cincinnati, O H Craig S. Smith, MD Brennan M.R. Spiegel, MD, MSHS Assistant Professor of M edicine Assistant Professor of M edicine University of M assachusetts M edical School VA Greater Los Angeles H ealthcare System Director of Cardiac Critical Care Unit David Geffen School of M edicine at UCLA UM ass M emorial M edical Center Co-Director, Center for the Study of Digestive H ealthcare Worcester, M A Q uality and O utcomes Los Angeles, CA Dorsett D. Smith, MD, FCCP, FACP, FACOEM Clinical Professor of M edicine Amy E. Spooner, MD Department of Respiratory Diseases and Critical Care Instructor in M edicine M edicine H arvard M edical School University of Washington Department of M edicine Seattle, WA Division of Cardiology M assachusetts General H ospital Boston, M A Heidi L. Smith, MD Instructor of M edicine Judith A. Stebulis, MD University of M assachusetts M edical School Assistant Professor of M edicine Worcester, M A Department of M edicine Director, Clinical Affairs Division of Rheumatology M ass Biologics University of M assachusetts M edical School Boston, M A Worcester, M A tahir99-VRG & vip.persianss.ir Contributors xxiii Michael L. Steer, MD Joan M. Swearer, PhD, ABPP Professor, Department of Surgery Clinical Professor of N eurology and Psychiatry Tufts University School of M edicine Department of N eurology Boston, M A University of M assachusetts M edical School Worcester, M A M. Kathryn Steiner, MD Assistant Professor Daniel Talmor, MD, MPH Department of M edicine Associate Professor of Anaesthesia University of M assachusetts M edical School Department of Anesthesia, Critical Care and UM ass M emorial M edical Center Pain M edicine Worcester, M A Beth Israel Deaconess M edical Center Boston, M A Jay S. Steingrub, MD, FACP, FCCP Professor of M edicine Victor F. Tapson, MD Tufts University School of M edicine Professor of Pulmonary and Critical Care Boston, M A M edicine Director of M edical Intensive Care Unit Director, Pulmonary Vascular Disease Center Baystate M edical Center Department of M edicine Department of M edicine Duke University M edical Center Spring eld, M A Durham, N C Theodore A. Stern, MD Usha B. Tedrow, MD, MSc Professor of Psychiatry in the eld of Psychosomatic Director, Clinical Cardiac Electrophysiology Program M edicine Cardiovascular Division Consultation Brigham and Women’s H ospital H arvard M edical School Boston, M A Chief, Psychiatric Consultation Service Director, O f ce for Clinical Careers Milton Tenenbein, MD, FRCPC, FAAP, FAACT, Department of Psychiatry FACMT M assachusetts General H ospital Professor of Pediatrics and Pharmacology Boston, M A Director of Emergency Services University of M anitoba Garrick C. Stewart, MD Children’s H ospital Cardiovascular M edicine Fellow Winnipeg, M anitoba, Canada Department of Cardiovascular M edicine Brigham and Women’s H ospital Jeffrey J. Teuteberg, MD Boston, M A Associate Director, Cardiac Transplantation Department of Cardiovascular Institute Michael B. Streiff, MD, FACP University of Pittsburgh Associate Professor of M edicine Pittsburgh, PA Division of H ematology M edical Director, Johns H opkins Anticoagulation M anagement Service and O utpatient Clinics John A. Thompson, MD Johns H opkins M edical Institutions Professor of M edicine Baltimore, M D University of Washington Seattle Cancer Care Alliance Mark L. Sturdevant, MD Seattle, WA Assistant Professor of Surgery Recanati/M iller Transplant Institute Michael J. Thompson, MD M ount Sinai M edical Center Associate Professor of M edicine M ount Sinai College of M edicine Division of Endocrinology N ew York, N Y Department of M edicine The George Washington University David E.R. Sutherland, MD, PhD Washington, DC Professor and H ead, Division of Transplantation Director, Diabetes Institute for Immunology and Mark Tidswell, MD Transplantation Assistant Professor of M edicine and Surgery Golf Classic “ fore” Diabetes Research Chair Tufts University School of M edicine Department of Surgery Department of Adult Critical Care University of M innesota Baystate M edical Center M inneapolis, M N Spring eld, M A Colin T. Swales, MD Robert M. Tighe, MD Associate M edical Director M edical Instructor Transplant Division Department of M edicine H artford H ospital Duke University H artford, CT Durham, N C tahir99-VRG & vip.persianss.ir xxiv Contributors Mira So a Torres, MD Javier C. Waksman, MD Assistant Professor Associate Professor of M edicine Fellowship Program Director Department of M edicine Division of Endocrinology University of Colorado—Denver University of M assachusetts M edical School Aurora, CO UM ass M emorial M edical Center Worcester, M A J. Matthias Walz, MD, FCCP Assistant Professor of Anesthesiology and Surgery Ulises Torres, MD Department of Anesthesiology Assistant Professor of Surgery Division of Critical Care M edicine Director of Trauma Education and O utreach University of M assachusetts M edical School Division of Trauma and Surgical Critical Care UM ass M emorial M edical Center Department of Surgery Worcester, M A University of M assachusetts M edical School UM ass M emorial M edical Center Michael Y. Wang, MD Worcester, M A Associate Professor Matthew J. Trainor, MD Department of N eurosurgery University of M iami H ospital Assistant Professor of M edicine Jackson M emorial H ospital Department of M edicine M iami, FL University of M assachusetts M edical School UM ass M emorial M edical Center Worcester, M A Richard Y. Wang, DO Senior M edical O f cer Arthur L. Trask, MD, FACS Division Laboratory Sciences Adjunct Professor of Surgery N ational Center for Environmental H ealth Department of Surgery Centers for Disease Control and Prevention Uniformed Services University for H ealth Sciences Atlanta, GA Spring eld, M O Wahid Y. Wassef, MD, MPH Todd W. Trask, MD Director of Endoscopy Director, N eurosurgery Intensive Care Unit UM ass M emorial M edical Center Department of N eurosurgery Associate Professor of Clinical M edicine M ethodist N eurological Institute University of M assachusetts M edical School H ouston, TX Department of M edicine Division of Gastroenterology Christoph Troppmann, MD, FACS UM ass M emorial M edical Center Professor of Surgery Worcester, M A Department of Surgery University of California Paul M. Wax, MD, FACMT Davis M edical Center Clinical Professor of Surgery (Emergency M edicine) Sacramento, CA University of Texas, Southwestern Paradise Valley, AZ Patrick Troy, MD Toxicology Fellow University of Texas Department of Pulmonary, Critical Care and Dallas, TX Sleep M edicine Beth Israel Deaconess M edical Center John P. Weaver, MD Boston, M A Associate Professor University of M assachusetts M edical School Cynthia B. Umali, MD (DECEASED) Department of Surgery Department of Radiology Division of N eurosurgery UM ass M emorial M edical Center UM ass M emorial M edical Center Worcester, M A Worcester, M A Gaurav A. Upadhyay, MD Cardiac Fellow Mireya Wessolossky, MD Division of Cardiology Assistant Professor M assachusetts General H ospital Department of M edicine/Infectious Diseases Boston, M A UM ass M emorial M edical Center Worcester, M A Craigan T. Usher, MD Clinical Fellow in Psychiatry Matthew J. Wieduwilt, MD, PhD H arvard M edical School Clinical Fellow M assachusetts General H ospital/M cLean H ospital Division of H ematology and O ncology Child & Adolescent University of California, San Francisco M edical Psychiatry Fellow Center Boston, M A San Francisco, CA tahir99-VRG & vip.persianss.ir Contributors xxv Christopher H. Wig eld, MD, FRCS Rebecca J. Zapatochny Rufo, DN Sc, RN , CCRN Assistant Professor, Cardiothoracic Surgery Resurrection eICU r Program O perations Director Department of Thoracic and Cardiovascular Surgery Department of eICU Loyola University M edical Center Resurrection H ealthcare M aywood, IL H oly Family M edical Des Plaines, IL Mark M. Wilson, MD Associate Director of M edical ICU John K. Zawacki, MD Associate Professor Professor of M edicine Department of M edicine Department of M edicine Division of Pulmonary, Allergy and Critical Care Division of Gastroenterology M edicine University of M assachusetts M edical School University of M assachusetts M edical School UM ass M emorial M edical Center UM ass M emorial M edical Center Worcester, M A Worcester, M A Chad A. Zender, MD, FACS Ann E. Woolfrey, MD Assistant Professor Associate Professor Department of O tolaryngology Department of Clinical Research University H ospitals Case Western Reserve Fred H utchinson Cancer Research Center Cleveland, O H Seattle, WA Iva Zivna, MD Shan Yin, MD, MPH Assistant Professor Fellow, M edical Toxicology Department of Infectious Disease Rocky M ountain Poison and Drug Center University of M assachusetts M edical School Denver H ealth UM ass M emorial M edical Center Denver, CO Worcester, M A Luke Yip, MD Gary R. Zuckerman, DO US Food and Drug Administration, CDER Associate Professor of M edicine Division of Anesthesia, Analgesia, and Addiction Products Division of Gastroenterology Silver Spring, M D Department of Internal M edicine Denver H ealth and H ospital Authority Barnes-Jewish H ospital Department of M edicine, M edical Toxicology Washington University School of M edicine Rocky M ountain Poison & Drug Center St. Louis, M O Denver, CO Marc S. Zumberg, MD, FACS Firas E. Zahr, MD Associate Professor of M edicine Cardiovascular Fellow Department of M edicine Department of Cardiovascular M edicine Division of H ematology/O ncology University of Pittsburgh M edical Center Slands H ospital/University of Florida Pittsburgh, PA Gainesville, FL tahir99-VRG & vip.persianss.ir tahir99-VRG & vip.persianss.ir ■ P R E FA C E It is with great pleasure that we present the seventh edition (ii) decreasing variability by following clinical practice guide- of Irw in and R ippe’s Intensive Care M edicine. As with pre- lines based upon the best available evidence to ensure better vious editions, the editorial challenge that we faced with the outcomes for our patients; and (iii) doing more with less to seventh edition was to continue to ensure that the textbook decrease the cost of caring for our patients. While these prin- evolved as the eld has evolved and improved to meet the var- ciples have always been espoused, it has become clear that we ied and rigorous demands placed on it by the diverse group of must more consistently follow them. With respect to speci c specialty physicians and nonphysicians practicing in the adult issues, the day-to-day use of ultrasonography by critical care intensive care environment without losing strengths that have specialists is a very recent change and this is re ected in the made previous editions so useful and popular. We hope and liberal use of ultrasonographic images throughout the book believe that the seventh edition of Irw in and R ippe’s Intensive and a new chapter entitled Interventional Ultrasound; these are Care M edicine has risen to meet these challenges. prominently featured in the procedure and monitoring chap- O ver the past 27 years since the publication of the rst ters. M oreover, there is an imperative to increasingly utilize edition of our textbook, dramatic changes have occurred in information technology in the everyday practice of intensive virtually every area of critical care, and these are re ected in care medicine. This not only includes using electronic medical the evolution of our textbook. While our textbook initially records, computer physician order entry, and clinical decision focused primarily on medical intensive care, it now provides support tools but also tele-ICU. All of these issues are covered an interdisciplinary emphasis on anesthesia, surgery, trauma, in the section entitled “ Contemporary Challenges in the Inten- and neurointensive care as well as medical intensive care with sive Care Unit” edited by Craig Lilly. strong collaboration across all these disciplines. With this edi- In coronary care, rapid advances in techniques and inter- tion, a critical care nursing-centric section has been added. This ventions continue to occur. These changes are re ected in the re ects the reality that intensive care medicine has inevitably “ Cardiovascular Problems and Coronary Care” section of the become more interdisciplinary and collaborative. seventh edition. It is interesting to see how cardiovascular in- The seventh edition is approximately the same length as the tensive care has dramatically changed since the publication of previous edition. To make this happen, we challenged every our rst few editions, as the advances in cardiology and cardiac section editor and author to carefully balance edited materi- surgery became known from the large, multicenter, randomized als emphasizing new evidence-based as well as state-of-the-art controlled clinical trials. We welcome Akshay Desai who has information by discarding outdated information. All of our joined Patrick O ’Gara as co-section editor for this section. section editors and chapter authors have done a superb job Equally important advances have occurred in surgical criti- meeting this challenge. All chapters in every section have been cal care, including new therapies and techniques in a variety of updated with recent references and other materials that re ect conditions treated in this environment. O ur “ Surgical Problems current information, techniques, and principles. N ew chapters in the Intensive Care Unit” section remains a great strength have been added to re ect emerging areas of interest. As stated of this book. Fred Luchette did his usual magni cent job on earlier, an entirely new section has been added on “ N ursing this edition. We recognize Arthur Trask and Stephen Barnes Issues in the ICU” that was ably coedited by Dorrie Fontaine who have done an admirable job of updating the “ Shock and and Shawn Cody. This section was meant to focus on issues Trauma” section of the textbook as well. related to collaboration, healthy work environments, and the While our textbook has been updated and broadened to expanding roles of nurses not the speci cs of nursing care that include new understandings, information and techniques, our have been brilliantly covered in textbooks of ICU nursing; and goal has been to maintain the practical, clinically oriented ap- Dorrie and Shawn have admirably succeeded in this regard. An- proach that readers have come to expect from previous edi- other new section on “ Critical Care Consequences of Weapons tions. O ur editorial focus remains on clinically relevant studies (or Agents) of M ass Destruction” re ects the changing realities and information that readers have found so useful in the pre- of our world and has been ably edited by Larry M ohr. vious six editions. Evidenced-based medicine continues to play an ever more As in the past, our textbook opens with a detailed section prominent role in all branches of medicine including critical on commonly performed “ Procedures and Techniques in the care. With this in mind, we have asked every chapter author Intensive Care Unit.” This section, along with the “ M ini- to make recommendations that speci cally re ect recent trials mally Invasive M onitoring” section, has also been simultane- with a particular emphasis on randomized prospective con- ously published as a smaller book entitled “ Procedures, Tech- trolled trials. Authors have summarized such evidence, when niques, and M inimally Invasive M onitoring in Intensive Care the data have allowed, with helpful tables. M edicine. All chapters in these sections have been updated with In medical intensive care, important changes and advances new gures and descriptions of techniques which have been have occurred since the publication of the sixth edition. These added to re ect changes since the sixth edition of the textbook. include managing our ICUs according to the following guid- We are indebted that section editors Stephen H eard and Alan ing principles: (i) making our ICUs safer for our patients; Lisbon who have done a superb job on these sections. xxvii tahir99-VRG & vip.persianss.ir xxviii Preface The “ Pharmacology, O verdoses, and Poisoning” section, Some new section editors have joined us for the seventh consisting of 29 chapters, remains a great strength of this book edition and done great work. In addition to the individuals and essentially represents a textbook on these topics embedded that we have already mentioned, we would like to speci cally into our larger book. In this edition, we welcome new section acknowledge the excellent efforts by the following new sec- editors Luke Yip and Kennon H eard who have joined Steven tion editors or co-section editors: Pang-Yen Fan (Renal), Do- Bird as section editors for this outstanding and comprehensive minic N ompleggi (Gastrointestinal Problems), Patrick Fogarty section. (H ematologic Problems), David Paydarfar (N eurologic Prob- Because intensive care cannot be divorced from public pol- lems), David H arlan (Endocrine Problems), and N ancy Liu icy, we continue to emphasize this with a major section of our (Rheumatologic, Immunologic and Dermatologic Problems). textbook entitled “ Contemporary Challenges in the Intensive As with previous editions, our emphasis remains on clinical Care Unit.” This section includes not only more ethical and management. Discussions of basic pathophysiology are also in- legal issues but also issues related to ICU organization and cluded and guided and supplemented by extensive references management, economics, safety, and information technology. to help clinicians and researchers who wish to pursue more With this edition, we welcome Craig Lilly, who has done an in-depth knowledge of these important areas. When therapies outstanding job on this section. re ect institutional or individual bias or are considered contro- O ur team of section editors continue to do a wonderful versial, we have attempted to indicate this. job coordinating large bodies of information that comprise We hope and believe that the outstanding efforts of many the core of modern intensive care. M any of our section editors people over the past 4 years have continued to result in an have been with us for one or more editions. Richard Ellison III evidence-based and state-of-the-art and comprehensive text- (Infectious Disease), N eil Aronin (Endocrinology), Stephanie book that will elucidate the important principles in intensive Levine (Transplantation), Dominic N ompleggi (M etabolism/ care and will continue to guide and support the best efforts of N utrition), M ark M adison (Pulmonary), John Q uerques practitioners in this challenging environment in their ongoing (Psychiatry), and Joseph Frassica (Appendix, Calculations efforts to diagnosis and treat complicated diseases and relieve Commonly used in Critical Care) all fall into this category and human suffering. have done their usual, excellent job. A new table on Antidotes has been added to the Appendix based on the efforts of Luke R ichard S. Irw in, M D , M aster FCCP Yip, Jeremy H elphenstine, Jerry Thomas, and Ian Ball. Jam es M . R ippe, M D tahir99-VRG & vip.persianss.ir ■ ACKN O WLEDGM EN TS N umerous outstanding individuals have made signi cant con- this textbook. We have very much appreciated their deep com- tributions to all phases of writing and production of this text- mitment to this book and to advancing the eld of intensive book and deserve special recognition and thanks. First and care medicine. foremost is our managing editor, Elizabeth Grady. Beth lit- O ur editors at Lippincott Williams & Wilkins including erally lives and breathes this textbook as it works its way Brian Brown, executive editor, have been a source of great help through the production cycle every 4 years. She is the guid- and encouragement. As with the last edition, N icole Dernoski ing and organizing force behind this textbook. It would sim- continues to be extremely helpful and accommodating in su- ply not be possible without Beth’s incredible organizational pervising and coordinating all phases of production in an out- skills, good humor, and enormous energy. She has guided this standing way. book through six editions—this book is as much hers as it is Lastly, we are grateful to Indu Jawwad and her staff for the ours. outstanding job they have done copyediting the manuscript for O ur administrative assistants, of ce assistant, and clinical this edition. coordinators, Carol M oreau, Debra Adamonis, Karen Barrell, O ur families support our efforts with unfailing encourage- M ary Garabedian, and Cynthia French have helped us con- ment and love. To them, and the many others who have helped tinue to coordinate and manage our complex professional and in ways too numerous to count, we are deeply grateful. personal lives and create room for the substantial amount of time required to write and edit. O ur section editors have de- R ichard S. Irw in, M D , M aster FCCP voted enormous skill, time, and resources to every edition of Jam es M . R ippe, M D xxix tahir99-VRG & vip.persianss.ir tahir99-VRG & vip.persianss.ir ■ CO N TEN TS Contributors v Preface x x vii A ck now ledgm ents x x ix S E C T I O N I ■ P R O C E D U R E S, T E C H N I Q U E S, AN D M I N I M A L LY I N V A S I V E M O N I T O R I N G Chapter 1 Airway Management and Endotracheal Intubation 1 J. M atthias W alz, Shubjeet Kaur and Stephen O . H eard Chapter 2 Central Venous Catheters 16 Jason L ee-L lacer and M ichael G . Seneff Chapter 3 Arterial Line Placement and Care 36 Jason L ee-L lacer and M ichael G . Seneff Chapter 4 Pulmonary Artery Catheters 45 H arvey S. R eich Chapter 5 Temporary Cardiac Pacing 64 Seth T. D ahlberg Chapter 6 Cardioversion and De brillation 71 M ark S. L ink and N aom i F. Botk in Chapter 7 Pericardiocentesis 77 Craig S. Sm ith and R ichard C. Beck er Chapter 8 Chest Tube Insertion and Care 83 Ulises Torres and R obert A . L ancy Chapter 9 Bronchoscopy 89 Stephen J. Krinzm an, Paulo J. O liveira and R ichard S. Irw in Chapter 10 Thoracentesis 95 M ark M . W ilson and R ichard S. Irw in Chapter 11 Arterial Puncture for Blood Gas Analysis 102 Kim berly A . R obinson and R ichard S. Irw in Chapter 12 Tracheostomy 105 Scott E. Kopec and Tim othy A . Em hoff Chapter 13 Gastrointestinal Endoscopy 116 A nupam Singh, R andall S. Pellish and Wahid Y. Wassef Chapter 14 Paracentesis and Diagnostic Peritoneal Lavage 122 L ena M . N apolitano Chapter 15 Gastroesophageal Balloon Tamponade for Acute Variceal Hemorrhage 130 M arie T. Pavini and Juan Carlos Puyana xxxi tahir99-VRG & vip.persianss.ir xxxii Contents Chapter 16 Endoscopic Placement of Feeding Tubes 136 L ena M . N apolitano Chapter 17 Cerebrospinal Fluid Aspiration 143 John P. W eaver Chapter 18 Percutaneous Suprapubic Cystostomy 150 Satya A llaparthi, K.C. Balaji and Philip J. Ayvazian Chapter 19 Aspiration of the Knee and Synovial Fluid Analysis 155 Bonnie J. Bidinger and Eric W. Jacobson Chapter 20 Anesthesia for Bedside Procedures 160 M ark D ershw itz Chapter 21 Interventional Ultrasound 168 G isela I. Banauch and Paul H . M ayo Chapter 22 Interventional Radiology: Percutaneous Drainage Techniques 175 Brian T. Callahan, Salom ao Faintuch and Felipe B. Collares Chapter 23 Cardiopulmonary Resuscitation 181 Bruce G reenberg and John A . Parask os Chapter 24 Management of Pain in the Critically Ill Patient 206 A rm agan D agal, M ario D e Pinto and W. T hom as Edw ards Chapter 25 Therapeutic Paralysis 219 Khaldoun Faris SECT IO N I I ■ M I N I M A L LY I N V A S I V E M O N I T O R I N G Chapter 26 Routine Monitoring of Critically Ill Patients 227 Patrick Troy, N icholas A . Sm yrnios and M ichael D . H ow ell Chapter 27 Minimally Invasive Hemodynamic Monitoring 245 A ndrew J. G oodw in, Ednan K. Bajw a and A tul M alhotra Chapter 28 N eurologic Multimodal Monitoring 258 R aphael A . Carandang, W iley R . H all and D onald S. Prough Chapter 29 Echocardiography in the Intensive Care Unit 271 A chik am O ren-G rinberg, Sajid Shahul and A dam B. L erner Chapter 30 Monitoring Gastrointestinal Tract Function 286 R uben J. A zocar, L aura Santos Pavia and Suresh A garw al Chapter 31 Respiratory Monitoring during Mechanical Ventilation 294 Todd W. Sarge, R ay R itz and D aniel Talm or SEC T IO N III ■ C A R D IO VA SC U LA R PRO BLEM S AN D CO RO N ARY CARE Chapter 32 Approach to the Patient with Hypotension and Hemodynamic Instability 307 M ichael M . G ivertz and Jam es C. Fang Chapter 33 Management of Advanced Heart Failure 318 G . W illiam D ec tahir99-VRG & vip.persianss.ir Contents xxxiii Chapter 34 Valvular Heart Disease 328 G arrick C. Stew art and Patrick T. O ’G ara Chapter 35 Critical Care of Pericardial Disease 347 A k shay S. D esai and Kenneth L . Baughm an Chapter 36 Acute Aortic Syndromes 358 L eon M . Ptaszek , Eric M . Isselbacher and A m y E. Spooner Chapter 37 Evaluation and Management of Hypertension in the Intensive Care Unit 373 Benjam in M . Scirica and R obert J. H eyk a Chapter 38 Unstable Angina/ N on–ST-Segment Elevation Myocardial Infarction 382 Suzanne J. Baron, Christopher P. Cannon and M arc S. Sabatine Chapter 39 ST-Segment Elevation Myocardial Infarction 402 Jam es A . de L em os and D avid A . M orrow Chapter 40 Mechanical Complications of Myocardial Infarction 419 A nnabel A . Chen-Tournoux and M ichael A . Fifer Chapter 41 Ventricular Tachycardia 428 M elanie M aytin and Bruce A . Koplan Chapter 42 Supraventricular Tachycardias: Recognition and Management in the Intensive Care Setting 441 A m m ar H abib, Joseph J. G ard, Traci L . Buescher and Sam uel J. A sirvatham Chapter 43 Bradyarrhythmias and Temporary Pacing 455 G aurav A . Upadhyay and Jagm eet P. Singh Chapter 44 How to Manage Cardiac Pacemakers and Implantable De brillators in the Intensive Care Unit 466 M elanie M aytin and Usha B. Tedrow Chapter 45 Mechanical Support for Heart Failure 477 Jeffrey J. Teuteberg and Firas E. Z ahr SECT IO N IV ■ PU LM O N ARY PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 46 Respiratory Failure Part I: A Physiologic Approach to Respiratory Failure 488 T haddeus C. Bartter, M elvin R . Pratter, W issam A bouzgheib and R ichard S. Irw in Chapter 47 Respiratory Failure Part II: Acute Respiratory Distress Syndrome 493 G ilm an B. A llen and Polly E. Parsons Chapter 48 Respiratory Failure Part III: Asthma 512 J. M ark M adison and R ichard S. Irw in Chapter 49 Respiratory Failure Part IV: Chronic Obstructive Pulmonary Disease 525 M eyer S. Balter and R onald F. G rossm an tahir99-VRG & vip.persianss.ir xxxiv Contents Chapter 50 Respiratory Failure Part V: Extrapulmonary Causes of Respiratory Failure 534 H elen M . H ollingsw orth, M elvin R . Pratter and R ichard S. Irw in Chapter 51 Respiratory Failure Part VI: Acute Respiratory Failure in Pregnancy 548 Christine Cam pbell-R eardon and H elen M . H ollingsw orth Chapter 52 Venous Thromboembolism: Pulmonary Embolism and Deep Venous Thrombosis 565 Charles W illiam H argett, III and Victor F. Tapson Chapter 53 Managing Hemoptysis 578 R ichard S. Irw in and Kim berly A . R obinson Chapter 54 Aspiration 587 Kim berly A . R obinson and R ichard S. Irw in Chapter 55 Drowning 594 N icholas A . Sm yrnios and R ichard S. Irw in Chapter 56 Pulmonary Hypertension in the Intensive Care Unit 601 Kim berly A . Fisher and H arrison W. Farber Chapter 57 Pleural Disease in the Critically Ill Patient 608 Peter D oelk en and Steven A . Sahn Chapter 58 Mechanical Ventilation Part I: Invasive 624 R ichard A . O eck ler, R olf D . H ubm ayr and R ichard S. Irw in Chapter 59 Mechanical Ventilation Part II: N on-invasive Mechanical Ventilation for the Adult Hospitalized Patient 641 Sam y S. Sidhom and N icholas H ill Chapter 60 Mechanical Ventilation Part III: Discontinuation 658 R ichard S. Irw in, N icholas A . Sm yrnios and R olf D . H ubm ayr Chapter 61 Gas Embolism Syndromes: Venous Gas Emboli, Arterial Gas Emboli, and Decompression Sickness 669 M ark M . W ilson Chapter 62 Respiratory Adjunct Therapy 684 Scott E. Kopec and R ichard S. Irw in Chapter 63 Chest Radiographic Examination 700 Cynthia B. Um ali and Jerry P. Balik ian Chapter 64 Acute Inhalation Injury 731 D avid J. Prezant, D orsett D . Sm ith and L aw rence C. M ohr Jr Chapter 65 Disorders of Temperature Control Part I: Hypothermia 745 M . Kathryn Steiner, Frederick J. Curley and R ichard S. Irw in Chapter 66 Disorders of Temperature Control Part II: Hyperthermia 761 M . Kathryn Steiner, Frederick J. Curley and R ichard S. Irw in Chapter 67 Severe Upper Airway Infections 776 Stephen J. Krinzm an, Sunil R ajan and R ichard S. Irw in Chapter 68 Acute Infectious Pneumonia 791 Veronica Brito and M ichael S. N iederm an Chapter 69 Lung Biopsy 815 Scott E. Kopec and R ichard S. Irw in Chapter 70 Sleep Issues in the Intensive Care Unit Setting 823 Kim L . G oring and N ancy A . Collop tahir99-VRG & vip.persianss.ir Contents xxxv SECT IO N V ■ REN AL PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 71 Metabolic Acidosis and Metabolic Alkalosis 831 R obert M . Black Chapter 72 Disorders of Plasma Sodium and Plasma Potassium 843 R obert M . Black Chapter 73 Acute Kidney Injury in the Intensive Care Unit 867 Jahan M ontague and Konstantin A bram ov Chapter 74 Drug Dosing in Renal and Hepatic Failure: A Pharmacokinetic Approach to the Critically Ill Patient 893 Sonia L in, Keith J. Foster, R onald J. D eBellis and Brian S. Sm ith Chapter 75 Renal Replacement Therapy in the Intensive Care Unit 917 G lenn Kershaw, M atthew J. T rainor and Pang-Y en Fan SECT IO N VI ■ IN FECT IO U S D ISEASE PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 76 Approach to Fever in the ICU Patient 932 R aul E. D avaro and R ichard H . G lew Chapter 77 Use of Antimicrobials in the Treatment of Infection in the Critically Ill Patient 939 Iva Z ivna, R ichard H . G lew and Jennifer S. D aly Chapter 78 Prevention and Control of Healthcare-Acquired Infections in the Intensive Care Unit 952 M ireya W essolossk y and R ichard T. Ellison, III Chapter 79 Central N ervous System Infections 959 H eidi L . Sm ith and A lan L . R othm an Chapter 80 Infective Endocarditis and Infections of Intracardiac Prosthetic Devices 969 Karen C. Carroll, Sarah H . Cheesem an and Sara E. Cosgrove Chapter 81 Infections Associated with Vascular Catheters 986 Suzanne F. Bradley and Carol A . Kauffm an Chapter 82 Urinary Tract Infections 994 Steven M . O pal Chapter 83 Life-Threatening Community-Acquired Infections: Toxic Shock Syndrome, Overwhelming Postsplenectomy Infection, Meningococcemia, Malaria, Rocky Mountain Spotted Fever, and Others 1004 M ary T. Bessesen Chapter 84 Acute Infection in the Immunocompromised Host 1014 Jennifer S. D aly and R obert W. Finberg Chapter 85 Intensive Care of Patients with HIV Infection 1023 Sarah H . Cheesem an and M ark J. R osen Chapter 86 Infectious Complications of Drug Abuse 1030 A froza L iton and W illiam L . M arshall tahir99-VRG & vip.persianss.ir xxxvi Contents Chapter 87 Tuberculosis 1036 R obert W. Belk nap and R andall R . R eves Chapter 88 Botulism 1044 M ary D aw n T. Co and R ichard T. Ellison, III Chapter 89 Tetanus 1046 M ary D aw n T. Co and R ichard T. Ellison, III Chapter 90 Serious Epidemic Viral Pneumonias 1049 D aniel H . L ibraty SECT IO N VII ■ GAST RO IN T EST IN AL D ISEASE PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 91 Upper and Lower Gastrointestinal Bleeding 1059 Ryan F. Porter, G ary R . Z uck erm an and Chandra Prak ash G yaw ali Chapter 92 Stress Ulcer Syndrome 1067 Sonal Kum ar, Chandra Prak ash G yaw ali and G ary R . Z uck erm an Chapter 93 Gastrointestinal Motility in the Critically Ill Patient 1072 Filippo Crem onini, A nthony J. L em bo, Brennan M .R . Spiegel and Inder M . Singh Chapter 94 Fulminant Colitis and Toxic Megacolon 1079 Stephen B. H anauer Chapter 95 Evaluation and Management of Liver Failure 1083 G ow ri Kularatna and M auricio L isk er-M elm an Chapter 96 Diarrhea 1095 Colin T. Sw ales, L aura H arrell, Eugene Chang and John K. Z aw ack i Chapter 97 Severe and Complicated Biliary Tract Disease 1103 John M . Isk ander, Sreenivasa S. Jonnalagadda and R iad A zar Chapter 98 Hepatic Dysfunction 1108 M auricio L isk er-M elm an and G ow ri Kularatna Chapter 99 Acute Pancreatitis 1115 M ichael L . Steer SECT IO N VIII ■ EN D O CRIN E PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 100 Management of Hyperglycemia in Critically Ill Patients 1130 M ichael J. T hom pson, D avid M . H arlan, Sam ir M alk ani and John P. M ordes Chapter 101 Hyperglycemic Diabetic Coma 1139 Sam ir M alk ani, A ldo A . R ossini, D avid M . H arlan, M ichael J. T hom pson and John P. M ordes Chapter 102 Severe Hyperthyroidism 1151 M arjorie S. Safran Chapter 103 Myxedema Coma 1155 M ira So a Torres and Charles H . Em erson tahir99-VRG & vip.persianss.ir Contents xxxvii Chapter 104 Hypoadrenal Crisis and the Stress Management of the Patient on Chronic Steroid Therapy 1159 N eil A ronin Chapter 105 Disorders of Mineral Metabolism 1162 Seth M . A rum and D aniel T. Baran Chapter 106 Hypoglycemia 1168 John P. M ordes, M ichael J. T hom pson, D avid M . H arlan and Sam ir M alk ani Chapter 107 N onthyroidal Illness Syndrome (Sick Euthyroid Syndrome) in the Intensive Care Unit 1182 Shirin H addady and A lan P. Farw ell SECT IO N IX ■ H EM AT O LO GIC AN D O N CO LO GIC PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 108 Disorders of Hemostasis in Critically Ill Patients 1195 Jerem iah Boles and A lice D . M a Chapter 109 Thrombocytopenia 1211 T hom as G . D eL oughery Chapter 110 Antithrombotic Pharmacotherapy 1224 Christopher D . A dam s, Kevin E. A nger, Bonnie C. G reenw ood and John Fanik os Chapter 111 Diagnosis and Management of Prothrombotic Disorders in the Intensive Care Unit 1243 A shk an Em adi and M ichael B. Streiff Chapter 112 Anemia in the Critical Care Setting 1253 M arc S. Z um berg, M arc J. Kahn and A lice D . M a Chapter 113 Therapeutic Apheresis: Technical Considerations and Indications in Critical Care 1267 T heresa A . N ester and M ichael L inenberger Chapter 114 Transfusion Therapy: Blood Components and Transfusion Complications 1276 Terry G ernsheim er Chapter 115 Critical Care of Patients with Hematologic Malignancies 1284 M atthew J. W ieduw ilt and L loyd E. D am on Chapter 116 Oncologic Emergencies 1296 D am ian J. G reen, John A . T hom pson and Bruce M ontgom ery S E C T I O N X ■ P H A R M A C O L O G Y, O V E R D O S E S, AN D PO ISO N IN GS Chapter 117 General Considerations in the Evaluation and Treatment of Poisoning 1309 Ian M . Ball and Christopher H . L inden Chapter 118 Acetaminophen Poisoning 1329 Steven B. Bird tahir99-VRG & vip.persianss.ir xxxviii Contents Chapter 119 Alcohols and Glycol Poisoning 1337 Jennifer L . Englund, M arco L .A . Sivilotti and M arsha D . Ford Chapter 120 Antiarrhythmic Agents 1353 M ichael G anetsk y Chapter 121 Anticholinergic Poisoning 1363 Keith K. Burk hart Chapter 122 Anticonvulsant Poisoning 1366 Steven B. Bird Chapter 123 Antidepressant Poisoning 1376 Cynthia K. A aron and A bhishek Katiyar Chapter 124 Antipsychotic Poisoning 1386 M ichael J. Burns and Christopher H . L inden Chapter 125 Beta-Blocker Poisoning 1397 Shan Yin and Javier C. W ak sm an Chapter 126 Calcium Channel Antagonist Poisoning 1403 Christopher R . D eW itt Chapter 127 Cardiac Glycoside Poisoning 1409 M ark A . Kirk and Bryan S. Judge Chapter 128 Cholinergic Poisoning 1413 Cynthia K. A aron Chapter 129 Cocaine Poisoning 1418 R ichard D . Shih and Judd E. H ollander Chapter 130 Corrosive Poisoning 1423 R obert P. D ow sett and Christopher H . L inden Chapter 131 Salicylate and Other N onsteroidal Anti-In ammatory Drug Poisoning 1430 M arco L .A . Sivilotti and Christopher H . L inden Chapter 132 Envenomations 1439 R obert L . N orris Chapter 133 Heavy Metal Poisoning 1449 L uk e Yip Chapter 134 Hydrocarbon Poisoning 1464 W illiam J. L ew ander and A lfred A leguas Jr Chapter 135 Hydro uoric Acid Poisoning 1471 Kennon H eard Chapter 136 Iron Poisoning 1473 M ilton Tenenbein Chapter 137 Isoniazid Poisoning 1478 Jam es B. M ow ry and R . Brent Furbee Chapter 138 Lithium Poisoning 1481 Kent R . O lson and T hanjira Jiranantak an Chapter 139 Methylxanthine Poisoning 1486 M ichael W. Shannon Chapter 140 Opioid Poisoning 1492 R obert P. D ow sett and L uk e Yip Chapter 141 Pesticide Poisoning 1499 W illiam K. Chiang and R ichard Y. W ang tahir99-VRG & vip.persianss.ir Contents xxxix Chapter 142 Phencyclidine and Hallucinogen Poisoning 1516 Frank F. D aly and L uk e Yip Chapter 143 Sedative–Hypnotic Agent Poisoning 1521 A ndis G raudins Chapter 144 Amphetamines 1529 M ichael C. Beuhler Chapter 145 Withdrawal Syndromes 1536 Paul M . Wax and Jennifer Sm ith SECT IO N X I ■ SU RGICAL PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 146 Epistaxis 1548 Avinash V. M antravadi, Chad A . Z ender and L ouis G . Portugal Chapter 147 Esophageal Perforation and Acute Mediastinitis 1555 Jason W. Sm ith, Christopher H . W ig eld and R obert B. L ove Chapter 148 Management of the Postoperative Cardiac Surgical Patient 1562 Sajid Shahul, Cathy D udick and A lan L isbon Chapter 149 N oncardiac Surgery in the Cardiac Patient 1575 Steven B. Edelstein and Scott W. Byram Chapter 150 Diagnosis and Management of Intra-abdominal Sepsis 1591 D ennis I. Sonnier, Shraw an G . G aitonde, Patrick D . Solan and T hom as L . H usted Chapter 151 Mesenteric Ischemia 1605 Tak k i M om in and John R icotta Chapter 152 Compartment Syndrome of the Abdominal Cavity 1612 A jai K. M alhotra and R ao R . Ivatury Chapter 153 N ecrotizing Soft Tissue Infections 1619 R ichard L . G am elli and Joseph A . Posluszny Jr Chapter 154 Acute Limb Ischemia: Etiology, Diagnosis, and Treatment Strategies 1626 Pegge M . H alandras and R oss M ilner Chapter 155 Pressure Sores: Prevention and Treatment 1630 Victor G . Cim ino, W ellington J. D avis III and Sam ir R . Shah Chapter 156 Management of the Obstetrical Patient in the Intensive Care Setting 1636 John G . G ianopoulos and Jonathan F. Critchlow SECT IO N X II ■ SH O CK AN D T RAU M A Chapter 157 Shock: An Overview 1644 M ichael L . Cheatham , Ernest F.J. Block , H ow ard G . Sm ith, M atthew W. L ube and John T. Prom es Chapter 158 Resuscitation from Shock Following Injury 1656 D onald H . Jenk ins, John B. H olcom b, Phillip A . L etourneau, D ustin L . Sm oot and Stephen L . Barnes tahir99-VRG & vip.persianss.ir xl Contents Chapter 159 The Management of Sepsis 1669 Paul E. M arik Chapter 160 Multiple Organ Dysfunction Syndrome 1679 A ndrew C. Bernard and Tim othy A . Pritts Chapter 161 Trauma Systems 1684 Christoph R . Kaufm ann and Kevin D w yer Chapter 162 Traumatic Brain Injury 1687 Todd W. Trask and A rthur L . Trask Chapter 163 Spinal Cord Trauma 1691 H ow ard B. L evene, M ichael Y. W ang and Barth A . G reen Chapter 164 Thoracic and Cardiac Trauma 1704 Scott B. Johnson and John G . M yers Chapter 165 Critical Care of the Patient with Abdominal Trauma 1717 Justin L . R egner and John B. Cone Chapter 166 Burn Management 1727 Philip Fidler Chapter 167 Orthopedic Injury 1733 G regory J. D ella R occa and Sean E. N ork SECT IO N X III ■ N EU RO LO GIC PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 168 An Approach to N eurologic Problems in the Intensive Care Unit 1747 D avid A . D rachm an Chapter 169 Evaluating the Patient with Altered Consciousness in the Intensive Care Unit 1750 R aphael A . Carandang, L aw rence J. H ayw ard and D avid A . D rachm an Chapter 170 Metabolic Encephalopathy 1760 Paula D . R avin Chapter 171 Generalized Anoxia/ Ischemia of the N ervous System 1768 Carol F. L ippa and M ajaz M oonis Chapter 172 Status Epilepticus 1772 Jaishree N arayanan and Catherine A . Phillips Chapter 173 Cerebrovascular Disease 1778 M ajaz M oonis, John P. W eaver and M arc Fisher Chapter 174 N euro-Oncological Problems in the Intensive Care Unit 1787 N . Scott L itofsk y and M ichael C. M uzinich Chapter 175 Guillain–Barr´e Syndrome 1797 Isabelita R . Bella and D avid A . Chad Chapter 176 Myasthenia Gravis in the Intensive Care Unit 1805 Isabelita R . Bella and R andall R . L ong Chapter 177 Miscellaneous N eurologic Problems in the Intensive Care Unit 1811 Jing Ji, A nn L . M itchell and N ancy M . Fontneau tahir99-VRG & vip.persianss.ir Contents xli Chapter 178 Subarachnoid Hemorrhage 1819 W iley R . H all, M ajaz M oonis and John P. W eaver Chapter 179 Mental Status Dysfunction in the Intensive Care Unit: Postoperative Cognitive Impairment 1826 Joan M . Sw earer and Shashidhara N anjundasw am y Chapter 180 N ewly Acquired Weakness in the Intensive Care Unit: Critical Illness Myopathy and N europathy 1829 D avid A . Chad SECT IO N X IV ■ T RAN SPLAN TAT IO N Chapter 181 Immunosuppression in Solid-Organ Transplantation 1833 A m it Basu, A rthur J. M atas and A bhinav H um ar Chapter 182 Critical Care Problems in Kidney Transplant Recipients 1846 M ark L . Sturdevant and R ainer W.G . G ruessner Chapter 183 Speci c Critical Care Problems in Heart and Heart-Lung Transplant Recipients 1857 Sara J. Shum w ay and Eias E. Jw eied Chapter 184 Care of the Pancreas Transplant Recipient 1866 R obert M . Esterl Jr, G regory A . A braham ian, D avid E.R . Sutherland and R aja Kandasw am y Chapter 185 Management of the Organ Donor 1879 Christoph Troppm ann Chapter 186 Diagnosis and Management of Rejection, Infection, and Malignancy in Transplant Recipients 1903 Tun Jie, D avid L . D unn and R ainer W.G . G ruessner Chapter 187 Critical Care of the Liver and Intestinal Transplant Recipients 1920 R uy J. Cruz Jr, W illiam D . Payne and A bhinav H um ar Chapter 188 Hematopoietic Cell Transplantation 1938 Paul A . Carpenter, M arco M ielcarek and A nn E. Woolfrey Chapter 189 Critical Care of the Lung Transplant Recipient 1957 L uis F. A ngel and Stephanie M . L evine SECT IO N X V ■ M ETABO LISM / N U T RIT IO N Chapter 190 N utritional Therapy in the Critically Ill Patient 1969 D om inic J. N om pleggi Chapter 191 Parenteral and Enteral N utrition in the Intensive Care Unit 1974 D avid F. D riscoll and Bruce R . Bistrian Chapter 192 Disease-Speci c N utrition 1990 M ick ey M . O tt, Bryan R . Collier and D ouglas Seidner tahir99-VRG & vip.persianss.ir xlii Contents SECT IO N X VI ■ RH EU M AT O LO GIC, IM M U N O LO GIC, AN D D ERM AT O LO GIC PRO BLEM S IN T H E IN T EN SIVE CARE U N IT Chapter 193 Rheumatologic Diseases in the Intensive Care Unit 2004 N ancy Y.N . L iu and Judith A . Stebulis Chapter 194 Anaphylaxis 2031 Frederic F. L ittle and H elen M . H ollingsw orth Chapter 195 Dermatology in the Intensive Care Unit 2043 N ik k i A . L evin, D ori G oldberg, L auren A lberta-W szolek , M egan Bernstein and A lex is C. Perk ins Chapter 196 Vasculitis in the Intensive Care Unit 2064 Paul F. D ellaripa and D onough H ow ard SECT IO N X VII ■ PSYCH IAT RIC ISSU ES IN IN T EN SIVE CARE Chapter 197 Diagnosis and Treatment of Agitation and Delirium in the Intensive Care Unit Patient 2073 Jason P. Caplan Chapter 198 Diagnosis and Treatment of Anxiety in the Intensive Care Unit Patient 2080 Shelley A . H olm er and R obert M . Tighe Chapter 199 Diagnosis and Treatment of Depression in the Intensive Care Unit Patient 2087 Edith S. G eringer, John Q uerques, M eghan S. Kolodziej, Tuesday E. Burns and T heodore A . Stern Chapter 200 Managing the Suicidal Patient in the Intensive Care Unit 2099 Saori A . M urak am i and H oa T hi L am Chapter 201 Problematic Behaviors of Patients, Family, and Staff in the Intensive Care Unit 2103 Craigan T. Usher Chapter 202 Recognition and Management of Staff Stress in the Intensive Care Unit 2108 G uy M aytal SECT IO N X VIII ■ N U RSIN G Chapter 203 Use of N ursing-Sensitive Quality Indicators 2114 M argaret L accetti and Cheryl H . D unnington Chapter 204 Role of the Advanced Practice N urse in Critical Care 2120 T heresa R . M acfarlan Chapter 205 Interprofessional Collaboration Among Critical Care Team Members 2123 D ebra G erardi and D orrie K. Fontaine tahir99-VRG & vip.persianss.ir Contents xliii Chapter 206 Healthy Work Environments: N ecessary for Providers and Patients 2131 Kathleen M . M cCauley Chapter 207 ICU N ursing in the Telemedicine Age 2137 R ebecca J. Z apatochny R ufo, Teresa A . R incon and Shaw n Cody SECT IO N X IX ■ CO N T EM PO RARY CH ALLEN GES IN T H E IN T EN SIVE CARE U N IT Chapter 208 ICU Organization and Management 2143 T hom as L . H iggins and Jay S. Steingrub Chapter 209 Critical Care Information Systems: Structure, Function, and Future 2152 W illiam F. Bria, Joseph J. Frassica, R ichard Krem sdorf, M . M ichael Shabot and Violet L . Shaffer Chapter 210 De ning and Measuring Patient Safety in the Critical Care Unit 2160 A lan M . Fein, Steven Y. Chang, Sara L . M erw in, D avid O st and John E. H effner Chapter 211 Medical Ethics, End of Life Care, and Clinical Research in the Intensive Care Unit 2170 M ark Tidsw ell, Paul G . Jodk a and Jay S. Steingrub Chapter 212 Assessing the Value and Impact of Critical Care in an Era of Limited Resources: Outcomes Research in the Intensive Care Unit 2180 A ndrew F. Shorr, W illiam L . Jack son Jr and D erek C. A ngus SECT IO N X X ■ CRIT ICAL CARE CO N SEQ U EN CES O F WEAPO N S (O R AGEN T S) O F M ASS D EST RU CT IO N Chapter 213 Biological Agents of Mass Destruction 2189 A ngeline A . L azarus, A sha D evereaux and L aw rence C. M ohr Jr Chapter 214 Chemical Agents of Mass Destruction 2208 Jam es G eiling and L aw rence C. M ohr Jr Chapter 215 The Management of Acute Radiation Casualties 2217 L aw rence C. M ohr Jr Chapter 216 Planning and Organization for Emergency Mass Critical Care 2225 Jam es G eiling, R obert M . G ougelet and L aw rence C. M ohr Jr APPEN D IX Calculations Commonly Used in Critical Care 2232 Joseph J. Frassica Index 2255 tahir99-VRG & vip.persianss.ir tahir99-VRG & vip.persianss.ir SECTIO N I ■ PRO CEDURES, TECH N IQ UES, AN D M IN IM ALLY IN VASIVE M O N ITO RIN G STEPHEN O. HEARD CH APTER 1 ■ AIRWAY M AN AGEM EN T AN D EN DO TRACH EAL IN TUBATIO N J. MATTHIAS WALZ, SHUBJEET KAUR AN D STEPHEN O. HEARD In the emergency room and critical care environment, manage- has a dif cult airway and when learning how to insert airway ment of the airway to ensure optimal ventilation and oxygena- devices such as the laryngeal mask airway (LM A; discussed in tion is of prime importance. Although initial efforts should be M anagement of the Dif cult Airway section). directed toward improving oxygenation and ventilation with- out intubating the patient (see Chapter 59) [1], these interven- tions may fail and the placement of an endotracheal tube may N asopharynx be required. Although endotracheal intubation is best left to the trained specialist, emergencies often require that the procedure The base of the skull forms the roof of the nasopharynx, and be performed before a specialist arrives. Because intubated pa- the soft palate forms the oor. The roof and the posterior walls tients are commonly seen in the intensive care unit (ICU) and of the nasopharynx contain lymphoid tissue (adenoids), which coronary care unit, all physicians who work in these environ- may become enlarged and compromise nasal air ow or become ments should be skilled in the techniques of airway manage- injured during nasal intubation, particularly in children. The ment, endotracheal intubation, and management of intubated Eustachian tubes enter the nasopharynx on the lateral walls and patients. may become blocked secondary to swelling during prolonged nasotracheal intubation. AN ATOMY Oropharynx An understanding of the techniques of endotracheal intuba- tion and potential complications is based on knowledge of the The soft palate de nes the beginning of the oropharynx, which anatomy of the respiratory passages [2]. Although a detailed extends inferiorly to the epiglottis. The palatine tonsils pro- anatomic description is beyond the scope of this book, an un- trude from the lateral walls and in children occasionally be- derstanding of some features and relationships is essential to come so enlarged that exposure of the larynx for intubation performing intubation. becomes dif cult. A large tongue can also cause oropharyn- geal obstruction. Contraction of the genioglossus muscle nor- mally moves the tongue forward to open the oropharyngeal N ose passage during inspiration. Decreased tone of this muscle (e.g., in the anesthetized state) can cause obstruction. The orophar- The roof of the nose is partially formed by the cribriform plate. ynx connects the posterior portion of the oral cavity to the The anatomic proximity of the roof to intracranial structures hypopharynx. dictates that special caution be exercised during nasotracheal intubations. This is particularly true in patients with signi cant maxillofacial injuries. Hypopharynx The mucosa of the nose is provided with a rich blood sup- ply from branches of the ophthalmic and maxillary arteries, The epiglottis de nes the superior border of the hypopharynx, which allow air to be warmed and humidi ed. Because the and the beginning of the esophagus forms the inferior bound- conchae provide an irregular, highly vascularized surface, they ary. The larynx is anterior to the hypopharynx. The pyriform are particularly susceptible to trauma and subsequent hem- sinuses that extend around both sides of the larynx are part of orrhage. The ori ces from the paranasal sinuses and naso- the hypopharynx. lacrimal duct open onto the lateral wall. Blockage of these ori ces by prolonged nasotracheal intubation may result in sinusitis. Larynx The larynx (Fig. 1.1) is bounded by the hypopharynx superi- Mouth and Jaw orly and is continuous with the trachea inferiorly. The thyroid, cricoid, epiglottic, cuneiform, corniculate, and arytenoid carti- The mouth is formed inferiorly by the tongue, alveolar ridge, lages compose the laryngeal skeleton. The thyroid and cricoid and mandible. The hard and soft palates compose the supe- cartilages are readily palpated in the anterior neck. The cricoid rior surface, and the oropharynx forms the posterior surface. cartilage articulates with the thyroid cartilage and is joined to Assessment of the anatomic features of the mouth and jaw is es- it by the cricothyroid ligament. When the patient’s head is sential before orotracheal intubation. A clear understanding of extended, the cricothyroid ligament can be pierced with a the anatomy is also essential when dealing with a patient who scalpel or large needle to provide an emergency airway (see 1 tahir99-VRG & vip.persianss.ir 2 Section I: Procedures, Techniques, and Minimally Invasive Monitoring Epiglottis Trachea Hyoid The adult trachea averages 15 cm long. Its external skeleton Thyrohyoid is composed of a series of C-shaped cartilages. It is bounded me mbra ne posteriorly by the esophagus and anteriorly for the rst few S upe rior horn cartilage rings by the thyroid gland. The trachea is lined with Thyroid notch ciliated cells that secrete mucus; through the beating action of Body of thyroid the cilia, foreign substances are propelled toward the larynx. ca rtila ge The carina is located at the fourth thoracic vertebral level (of Cricothyroid relevance when judging proper endotracheal tube positioning me mbra ne on chest radiograph). The right main bronchus takes off at Cricoid a less acute angle than the left, making right main bronchial intubation more common if the endotracheal tube is in too far. Cricotra che a l me mbra ne EMERGEN CY AIRWAY FIGURE 1.1. Anatomy of the larynx, anterior, and lateral aspects. MAN AGEMEN T [From Ellis H : A natom y for A naesthetists. O xford, Blackwell Scien- ti c, 1963, with permission.] In an emergency situation, establishing adequate ventilation and oxygenation assumes primary importance [3]. Too fre- quently, inexperienced personnel believe that this requires im- mediate intubation; however, attempts at intubation may delay Chapter 12). The cricoid cartilage completely encircles the air- establishment of an adequate airway. Such efforts are time con- way. It is attached to the rst cartilage ring of the trachea by suming, can produce hypoxemia and arrhythmias, and may in- the cricotracheal ligament. The anterior wall of the larynx is duce bleeding and regurgitation, making subsequent attempts formed by the epiglottic cartilage, to which the arytenoid carti- to intubate signi cantly more dif cult and contributing to sig- lages are attached. Fine muscles span the arytenoid and thyroid ni cant patient morbidity and even mortality [4,5]. Some sim- cartilages, as do the vocal cords. The true vocal cords and space ple techniques and principles of emergency airway management between them are collectively termed the glottis (Fig. 1.2). The can play an important role until the arrival of an individual who glottis is the narrowest space in the adult upper airway. In is skilled at intubation. children, the cricoid cartilage de nes the narrowest portion of the airway. Because normal phonation relies on the pre- cise apposition of the true vocal cords, even a small lesion can Airway Obstruction cause hoarseness. Lymphatic drainage to the true vocal cords is sparse. In ammation or swelling caused by tube irritation Compromised ventilation often results from upper airway ob- or trauma may take considerable time to resolve. The supe- struction by the tongue, by substances retained in the mouth, rior and recurrent laryngeal nerve branches of the vagus nerve or by laryngospasm. Relaxation of the tongue and jaw lead- innervate the structures of the larynx. The superior laryngeal ing to a reduction in the space between the base of the tongue nerve supplies sensory innervation from the inferior surface and the posterior pharyngeal wall is the most common cause of of the epiglottis to the superior surface of the vocal cords. upper airway obstruction. O bstruction may be partial or com- From its takeoff from the vagus nerve, it passes deep to both plete. The latter is characterized by total lack of air exchange. branches of the carotid artery. A large internal branch pierces The former is recognized by inspiratory stridor and retraction the thyrohyoid membrane just inferior to the greater cornu of of neck and intercostal muscles. If respiration is inadequate, the hyoid. This branch can be blocked with local anesthetics the head-tilt–chin-lift or jaw-thrust maneuver should be per- for oral or nasal intubations in awake patients. The recurrent formed. In patients with suspected cervical spine injuries, the laryngeal branch of the vagus nerve provides sensory inner- jaw-thrust maneuver (without the head tilt) may result in the vation below the cords. It also supplies all the muscles of the least movement of the cervical spine. To perform the head-tilt larynx except the cricothyroid, which is innervated by the ex- maneuver, place a palm on the patient’s forehead and apply ternal branch of the superior laryngeal nerve. pressure to extend the head about the atlanto-occipital joint. To perform the chin lift, place several ngers of the other hand in the submental area and lift the mandible. Care must be taken to avoid airway obstruction by pressing too rmly on the soft tissues in the submental area. To perform the jaw thrust, lift up Epiglottis on the angles of the mandible [3] (Fig. 1.3). Both of these ma- neuvers open the oropharyngeal passage. Laryngospasm can be treated by maintaining positive airway pressure using a face Glottic mask and bag valve device (see the following section). If the Ope ning patient resumes spontaneous breathing, establishing this head position may constitute suf cient treatment. If obstruction per- sists, a check for foreign bodies, emesis, or secretions should Voca l be performed [6]. Cords Use of Face Mask and Bag Valve Device FIGURE 1.2. Superior view of the larynx (inspiration). [From Stoelt- If an adequate airway has been established and the patient is ing RH , M iller RD: Basics of A nesthesia. 2nd ed. N ew York, Churchill not breathing spontaneously, oxygen can be delivered via face Livingstone, 1989, with permission.] mask and a bag valve device. It is important to establish a tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 3 FIGURE 1.3. In an obtunded or comatose patient, the soft tissues of the oropharynx become relaxed and may obstruct the upper airway. O bstruction can be alleviated by placing the thumbs on the maxilla with the index ngers under the ramus of the mandible and rotating the mandible forward with pressure from the index ngers (arrow ). This maneuver brings the soft tissues forward and therefore frequently reduces the airway obstruction. tight t with the face mask, covering the patient’s mouth and FIGURE 1.5. The mechanism of upper airway obstruction and the nose. To perform this procedure apply the mask initially to the proper position of the oropharyngeal airway. [From Tex tbook of ad- bridge of the nose and draw it downward toward the mouth, vanced cardiac life support. Dallas, TX, American H eart Association, using both hands. The operator stands at the patient’s head and 1997, with permission.] presses the mask onto the patient’s face with the left hand. The thumb should be on the nasal portion of the mask, the index nger near the oral portion, and the rest of the ngers spread to establish an adequate airway when proper head positioning on the left side of the patient’s mandible so as to pull it slightly alone is insuf cient (Figs. 1.4 and 1.5). The oropharyngeal air- forward. The bag is then alternately compressed and released way is semicircular and made of plastic or hard rubber. The with the right hand. A good airway is indicated by the rise and two types are the Guedel airway, with a hollow tubular design, fall of the chest; moreover, lung–chest wall compliance can be and the Berman airway, with airway channels along the sides. estimated from the amount of pressure required to compress Both types are most easily inserted by turning the curved por- the bag. The minimum effective insuf ation pressure should be tion toward the palate as it enters the mouth. It is then advanced used to decrease the risk of insuf ating the stomach with gas beyond the posterior portion of the tongue and rotated down- and subsequently increase the risk of aspiration. ward into the proper position (Fig. 1.5). O ften, depressing the tongue or moving it laterally with a tongue blade helps to po- sition the oropharyngeal airway. Care must be exercised not to Airway Adjuncts push the tongue into the posterior pharynx, causing or exac- erbating obstruction. Because insertion of the oropharyngeal If proper positioning of the head and neck or clearance of for- airway can cause gagging or vomiting, or both, it should be eign bodies and secretions fails to establish an adequate air- used only in unconscious patients. way, several airway adjuncts may be helpful if an individual The nasopharyngeal airway is a soft tube approximately who is skilled in intubation is not immediately available. An 15 cm long, which is made of rubber or plastic (Figs. 1.4 oropharyngeal or nasopharyngeal airway occasionally helps and 1.6). It is inserted through the nostril into the posterior FIGURE 1.4. N asopharyngeal (A) or oropharyngeal (B) airways can be used to relieve soft tissue obstruction if ele- vating the mandible proves ineffective. tahir99-VRG & vip.persianss.ir 4 Section I: Procedures, Techniques, and Minimally Invasive Monitoring T A B LE 1 . 1 IN DICATION S FOR EN DOTRACHEAL IN TUBATION Acute airway obstruction Trauma M andible Larynx (direct or indirect injury) Inhalation Smoke N oxious chemicals Foreign bodies Infection Acute epiglottitis Croup FIGURE 1.6. The proper position of the nasopharyngeal airway. Retropharyngeal abscess [From Tex tbook of advanced cardiac life support. Dallas, TX, Ameri- H ematoma can H eart Association, 1997, with permission.] Tumor Congenital anomalies Laryngeal web pharynx. Before insertion, the airway should be lubricated with Supraglottic fusion an anesthetic gel, and, preferably, a vasoconstrictor should Laryngeal edema be administered into the nostril. The nasopharyngeal airway Laryngeal spasm (anaphylactic response) should not be used in patients with extensive facial trauma or Access for suctioning cerebrospinal rhinorrhea, as it could be inserted through the Debilitated patients cribriform plate into the brain. Copious Secretions Loss of protective re exes H ead injury IN DICATION S FOR IN TUBATION Drug overdose The indications for endotracheal intubation can be divided into Cerebrovascular accident four broad categories: (a) acute airway obstruction, (b) exces- Respiratory failure sive pulmonary secretions or inability to clear secretions ade- H ypoxemia quately, (c) loss of protective re exes, and (d) respiratory failure Acute respiratory distress syndrome (Table 1.1). H ypoventilation Atelectasis Secretions Preintubation Evaluation Pulmonary edema H ypercapnia Even in the most urgent situation, a rapid assessment of the H ypoventilation patient’s airway anatomy can expedite the choice of the proper N euromuscular failure route for intubation, the appropriate equipment, and the most Drug overdose useful precautions to be taken. In the less emergent situation, several minutes of preintubation evaluation can decrease the likelihood of complications and increase the probability of suc- cessful intubation with minimal trauma. based on the size of the posterior aspect of the tongue relative to Anatomic structures of the upper airway, head, and neck the size of the oral pharynx. The patient should be sitting, with must be examined, with particular attention to abnormalities the head fully extended, protruding the tongue and phonating that might preclude a particular route of intubation. Evalua- [8]. When the faucial pillars, the uvula, the soft palate, and tion of cervical spine mobility, temporomandibular joint func- the posterior pharyngeal wall are well visualized, the airway tion, and dentition is important. Any abnormalities that might is classi ed as class I, and a relatively easy intubation can be prohibit alignment of the oral, pharyngeal, and laryngeal axes anticipated. When the faucial pillars and soft palate (class II) or should be noted. soft palate only (class III) are visible, there is a greater chance of Cervical spine mobility is assessed by exion and exten- problems visualizing the glottis during direct laryngoscopy. Dif- sion of the neck (performed only after ascertaining that no culties in orotracheal intubation may also be anticipated if (a) cervical spine injury exists). The normal range of neck exion– the patient is an adult and cannot open his or her mouth more extension varies from 165 to 90 degrees, with the range de- than 40 mm (two- nger breadths), (b) the distance from the creasing approximately 20% by age 75 years. Conditions thyroid notch to the mandible is less than three- nger breadths associated with decreased range of motion include any cause (less than or equal to 7 cm), (c) the patient has a high arched of degenerative disk disease (e.g., rheumatoid arthritis, os- palate, or (d) the normal range of exion–extension of the neck teoarthritis, ankylosing spondylitis), previous trauma, or age is decreased (less than or equal to 80 degrees) [9]. The positive older than 70 years. Temporomandibular joint dysfunction predictive values of these tests alone or in combination are not can occur in any form of degenerative arthritis (particularly particularly high; however, a straightforward intubation can rheumatoid arthritis), in any condition that causes a receding be anticipated if the test results are negative [10]. In the emer- mandible, and in rare conditions such as acromegaly. gency setting, only about 30% of airways can be assessed in Examination of the oral cavity is mandatory. Loose, miss- this fashion [11]. A different evaluation method (LEM O N ) has ing, or chipped teeth and permanent bridgework are noted, been devised by M urphy and Walls [12]. LEM O N stands for and removable bridgework and dentures should be taken out. look, evaluate, Mallampati class, obstruction, and neck mobil- M allampati et al. [7] (Fig. 1.7) developed a clinical indicator ity (Fig. 1.7). In the emergency setting, there are still limitations tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 5 L Look exte rna lly Look a t the pa tie nt exte rna lly for cha ra cte ris tics tha t a re known to ca us e difficult la ryngos copy, intuba tion or ve ntila tion. E Eva lua te the 3-3-2 rule In orde r to a llow a lignme nt of the pha rynge a l, la rynge a l, a nd ora l a xe s a nd the re fore s imple intuba tion, the following re la tions hips s hould be obs e rve d. The dis ta nce be twe e n the pa tie nt's incis or te e th s hould be a t le a s t 3 finge r bre a dths (3), the dis ta nce be twe e n the hyoid bone a nd the chin s hould be a t le a s t 3 finge r bre a dths (3), a nd the dis ta nce be twe e n the thyroid notch a nd the floor of the mouth s hould be a t le a s t 2 finge r bre a dths (2). 1 2 1 – Inte r-incis or dis ta nce in finge rs 3 2 – Hyoid me nta l dis ta nce in finge rs 3 – Thyroid to floor of mouth in finge rs M Ma lla mpa ti The hypopha rynx s hould be vis ua lize d a de qua te ly. This ha s be e n done tra ditiona lly by a s s e s s ing the Ma lla mpa ti cla s s ifica tion. The pa tie nt is s a t upright, told to ope n the mouth fully a nd protrude the tongue a s fa r a s pos s ible. The exa mine r the n looks into the mouth with a light torch to a s s e s s the de gre e of hypopha rynx vis ible . In the ca s e of a s upine pa tie nt, Ma lla mpa ti s core ca n be e s tima te d by ge tting the pa tie nt to ope n the mouth fully a nd protrude the tongue a nd a la ryngos copy light ca n be s hone into the hypopha rynx from a bove . Cla s s I: s oft pa la te, Cla s s II: s oft pa la te, Cla s s III: s oft pa la te, Cla s s IV: ha rd pa la te uvula , fa uce s, pilla rs uvula , fa uce s vis ible ba s e of uvula vis ible only vis ible vis ible O Obs truction? Any condition tha t ca n ca us e obs truction of the a irway will ma ke la ryngos copy a nd ve ntila tion difficult. S uch conditions a re e piglottis, pe ritons illa r a bs ce s s e s, a nd tra uma . N Ne ck mobility This is a vita l re quire me nt for s ucce s s ful intuba tion. It ca n be a s s e s s e d e a s ily by ge tting the pa tie nt to pla ce his or he r chin down onto the che s t a nd the n to exte nd the ne ck s o the pa tie nt is looking towa rds the ce iling. Pa tie nts in ha rd colla r ne ck immobiliza tion obvious ly have no ne ck move me nt a nd a re the re fore ha rde r to intuba te . FIGURE 1.7. The LEM O N airway assessment method. [From Reed M J, Dunn M J, M cKeown DW: Can an airway assessment score predict dif culty at intubation in the emergency department? Em erg M ed J 22(2):99–102, 2005, with permission.] with the use of LEM O N since it is dif cult to ascertain the M al- these include neck radiation changes, male sex, a diagnosis lampati class. N onetheless, using elements of LEM O N that of sleep apnea, M allampati class III or IV airway, and the could be incorporated into the emergency evaluation of pa- presence of a beard [14]. Among these factors, neck radiation tients, Reed et al. [13] found that large incisors, a reduced changes were the most signi cant predictor of impossible mask interincisor distance, and a reduced distance between the thy- ventilation. roid and oor of the mouth were associated with a limited laryngoscopic view in emergency department patients. When- ever possible, patients in need of elective and emergent air- Education and Intubation Management way management should be assessed for indicators of dif cult mask ventilation as this may signi cantly in uence the deci- Emergent intubation in the acute care setting is associated with sion on the primary approach to airway management. In the a high complication rate. It is therefore important to provide largest analysis published to date, ve independent predictors adequate training to practitioners working in this environment, of impossible mask ventilation were identi ed by the authors; and have an adequate number of trained personnel be available tahir99-VRG & vip.persianss.ir 6 Section I: Procedures, Techniques, and Minimally Invasive Monitoring to assist the operator. Furthermore, a standardized approach to emergency airway management can improve patient outcomes. Laryngoscopes Although training on a mannequin is an important rst step in acquiring competency in performing endotracheal intubation, The two-piece laryngoscope has a handle containing batter- an investigation including nonanesthesia trainees has shown ies that power the bulb in the blade. The blade snaps securely that approximately 50 supervised endotracheal intubations in into the top of the handle, making the electrical connection. the clinical setting are needed to achieve a 90% probability of Failure of the bulb to illuminate suggests improper blade posi- competent performance [15]. Whenever possible, residents and tioning, bulb failure, a loose bulb, or dead batteries. M odern licensed independent practitioners should be supervised by an laryngoscope blades with beroptic lights obviate the prob- attending physician trained in emergency airway management lem of bulb failure. M any blade shapes and sizes are avail- during the procedure. This approach has led to a signi cant able. The two most commonly used blades are the curved reduction in immediate complications from 21.7% to 6.1% in (M acIntosh) and straight (M iller) blades (Fig. 1.8). Although one pre- and postintervention analysis [16]. pediatric blades are available for use with the adult-sized han- In addition, the use of a management bundle consisting of dle, most anesthesiologists prefer a smaller handle for bet- interventions that, in isolation have been shown to decrease ter control in the pediatric population. The choice of blade complications during emergency airway management can fur- shape is a matter of personal preference and experience; how- ther improve patient outcomes. Elements that should be in- ever, one study has suggested that less force and head exten- cluded in this approach are preoxygenation with noninvasive sion are required when performing direct laryngoscopy with positive pressure ventilation (N IPPV) if feasible, presence of a straight blade [18]. Recently, video assisted laryngoscopes two operators, rapid sequence intubation (RSI) with cricoid have become widely available in many perioperative and acute pressure, capnography, lung protective ventilation strategies care specialties. These have been shown to improve the suc- (LPVS), uid loading prior to intubation unless contraindi- cess rate for dif cult endotracheal intubation performed by cated, and preparation and early administration of sedation experienced physicians [19], as well as the rate of successful and vasopressor use if needed [17]. intubation by untrained individuals when performing normal intubations [20]. Several online tutorials are available demon- strating the use of video laryngoscopes. Two of them can be found here: Turk M , Gravenstein D (2007): Storz DCI Video EQUIPMEN T FOR IN TUBATION Laryngoscope. Retrieved M arch 15, 2010, from University of Florida Department of Anesthesiology, Center for Simula- Assembly of all appropriate equipment before attempted intu- tion, Advanced Learning and Technology Web site: http://vam. bation can prevent potentially serious delays in the event of anest.u .edu/airwaydevice/storz/index.html and http://www. an unforeseen complication. M ost equipment and supplies are youtube.com/watch?v=WdooBCJ79Xc& N R=1. H agberg has readily available in the ICU but must be gathered so they are compiled an extensive list of commercially available video- immediately at hand. A supply of 100% oxygen and a well- laryngoscopes [21]. tting mask with attached bag valve device are mandatory, as is suctioning equipment, including a large-bore tonsil suction at- tachment (Yankauer) and suction catheters. Adequate lighting facilitates airway visualization. The bed should be at the proper Endotracheal Tubes height, with the headboard removed and the wheels locked. O ther necessary supplies include gloves, M agill forceps, oral The internal diameter of the endotracheal tube is measured us- and nasal airways, laryngoscope handle and blades (straight ing both millimeters and French units. This number is stamped and curved), endotracheal tubes of various sizes, stylet, tongue on the tube. Tubes are available in 0.5-mm increments, starting depressors, a syringe for cuff in ation, and tape for securing at 2.5 mm. Lengthwise dimensions are also marked on the tube the endotracheal tube in position. Table 1.2 is a checklist of in centimeters, beginning at the distal tracheal end. supplies needed. Selection of the proper tube diameter is of utmost impor- tance and is a frequently underemphasized consideration. The TA B LE 1 . 2 resistance to air ow varies with the fourth power of the radius of the endotracheal tube. Thus, selection of an inappropriately EQUIPMEN T N EEDED FOR IN TUBATION small tube can signi cantly increase the work of breathing. M oreover, certain diagnostic procedures (e.g., bronchoscopy) Supply of 100% oxygen done through endotracheal tubes require appropriately large Face mask tubes (see Chapter 9). In general, the larger the patient, the Bag valve device larger the endotracheal tube that should be used. Approximate Suction equipment guidelines for tube sizes and lengths by age are summarized Suction catheters in Table 1.3. M ost adults should be intubated with an endo- Large-bore tonsil suction apparatus (Yankauer) tracheal tube that has an inner diameter of at least 8.0 mm, Stylet although occasionally nasal intubation in a small adult requires M agill forceps a 7.0-mm tube. O ral airways N asal airways Laryngoscope handle and blades (curved, straight; various sizes) Endotracheal Tube Cuff Endotracheal tubes (various sizes) Tongue depressors Endotracheal tubes have low-pressure, high-volume cuffs to re- Syringe for cuff in ation duce the incidence of ischemia-related complications. Tracheal H eadrest ischemia can occur any time cuff pressure exceeds capillary Supplies for vasoconstriction and local anesthesia pressure (approximately 32 mm H g), thereby causing in am- Tape mation, ulceration, infection, and dissolution of cartilaginous Tincture of benzoin rings. Failure to recognize this progressive degeneration some- times results in erosion through the tracheal wall (into the tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 7 A B FIGURE 1.8. The two basic types of laryngoscope blades, M acIntosh (A) and M iller (B). The M acIntosh blade is curved. The blade tip is placed in the vallecula and the handle of the laryngoscope pulled forward at a 45-degree angle. This allows visualization of the epiglottis. The M iller blade is straight. The tip is placed posterior to the epiglottis, pinning the epiglottis between the base of the tongue and the straight laryngoscope blade. The motion on the laryngoscope handle is the same as that used with the M acIntosh blade. innominate artery if the erosion was anterior or the esoph- agus if the erosion was posterior) or long-term sequelae of AN ESTHESIA BEFORE tracheomalacia or tracheal stenosis. With cuff pressures of 15 IN TUBATION to 30 mm H g, the low-pressure, high-volume cuffs conform well to the tracheal wall and provide an adequate seal during Because patients who require intubation often have a depressed positive-pressure ventilation. Although low cuff pressures can level of consciousness, anesthesia is usually not required. If in- cause some damage (primarily ciliary denudation), major com- tubation must be performed on the alert, responsive patient, plications are rare. N evertheless, it is important to realize that sedation or general anesthesia exposes the individual to po- a low-pressure, high-volume cuff can be converted to a high- tential pulmonary aspiration of gastric contents because pro- pressure cuff if suf cient quantities of air are injected into the tective re exes are lost. This risk is a particularly important cuff. consideration if the patient has recently eaten and must be T A B LE 1 . 3 DIMEN SION S OF EN DOTRACHEAL TUBES BASED ON PATIEN T AGE Distance between lips and location in midtrachea of Age Internal diameter (mm) French unit distal end (cm)a Premature 2.5 10–12 10 Full term 3.0 12–14 11 1–6 mo 3.5 16 11 6–12 mo 4.0 18 12 2y 4.5 20 13 4y 5.0 22 14 6y 5.5 24 15–16 8y 6.5 26 16–17 10 y 7.0 28 17–18 12 y 7.5 30 18–20 ≥ 14 y 8.0–9.0 32–36 20–24 a Add 2 to 3 cm for nasal tubes. From Stoelting RK: Endotracheal intubation, in M iller RD (ed): A nesthesia. 2nd ed. N ew York, Churchill Livingstone, 1986, p. 531, with permission. tahir99-VRG & vip.persianss.ir 8 Section I: Procedures, Techniques, and Minimally Invasive Monitoring TA B LE 1 . 4 DRUGS USED TO FACILITATE IN TUBATION Drug IV dose (mg/ kg) Onset of action (sec) Side effects Induction drugs Thiopental 2.5–4.5 20–50 H ypotension Propofol 1.0–2.5 < 60 Pain on injection H ypotension M idazolam 0.02–0.20 30–60 H ypotension Ketamine 0.5–2.0 30–60 Increases in intracranial pressure Increase in secretions Emergence reactions Etomidate 0.2–0.3 20–50 Adrenal insuf ciency Pain on injection M uscle relaxants Succinylcholine 1–2 45–60 H yperkalemia Increased intragastric pressure Increased intracranial pressure Rocuronium 0.6–1.0 60–90 — weighed against the risk of various hemodynamic derange- bone. The rate of absorption of lidocaine differs by method, ments that might occur secondary to tracheal intubation and being greater with the aerosol and transtracheal techniques. initiation of positive-pressure ventilation. Laryngoscopy in an The patient should be observed for signs of lidocaine toxicity inadequately anesthetized patient can result in tachycardia and (circumoral paresthesia, agitation, and seizures). an increase in blood pressure. This may be well tolerated in If adequate topical anesthesia cannot be achieved or if the younger patients but may be detrimental in a patient with patient is not cooperative, general anesthesia may be required coronary artery disease or raised intracranial pressure. Some- for intubation. Table 1.4 lists common drugs and doses that times laryngoscopy and intubation may result in a vasovagal are used to facilitate intubation. Ketamine and etomidate are response, leading to bradycardia and hypotension. Initiation of two drugs that are used commonly because cardiovascular sta- positive-pressure ventilation in a hypovolemic patient can lead bility is maintained. Caution should be exercised when using to hypotension from diminished venous return. etomidate in patients with signs and symptoms consistent with Some of these responses can be attenuated by providing severe sepsis or septic shock. In an analysis of risk factors of rel- local anesthesia to the nares, mouth, and/or posterior phar- ative adrenocortical de ciency in intensive care patients need- ynx before intubation. Topical lidocaine (1% to 4% ) with ing mechanical ventilation, single bolus etomidate administra- phenylephrine (0.25% ) or cocaine (4% , 200 mg total dose) tion was independently associated with relative adrenocortical can be used to anesthetize the nasal passages and provide local de ciency [24]. Similarly, when studied for rapid sequence in- vasoconstriction. This allows the passage of a larger endotra- tubation in acutely ill patients both ketamine and etomidate cheal tube with less likelihood of bleeding. Aqueous lidocaine– provided adequate intubating conditions but the percentage of phenylephrine or cocaine can be administered via atomizer, patients with adrenal insuf ciency was signi cantly higher in nose dropper, or long cotton-tipped swabs inserted into the the etomidate group [25]. Lastly, post hoc analysis of the cor- nares. Alternatively, viscous 2% lidocaine can be applied via ticosteroid therapy of septic shock study revealed an increased a 3.5-mm endotracheal tube or small nasopharyngeal airway rate of death at 28 days among patients who received etomidate inserted into the nose. Anesthesia of the tongue and poste- before randomization in both groups (hydrocortisone group rior pharynx can be accomplished with lidocaine spray (4% and in the placebo group), as compared with patients who did to 10% ) administered via an atomizer or an eutectic mixture not receive etomidate [26]. Taken together these ndings war- of local anesthetics cream applied on a tongue blade and oral rant a careful analysis of risks and bene ts before etomidate is airway [22]. Alternatively, the glossopharyngeal nerve can be used to facilitate endotracheal intubation in acutely ill patients blocked bilaterally with an injection of a local anesthetic, but with, or at risk for, severe sepsis. this should be performed by experienced personnel. Use of opioids such as morphine, fentanyl, sufentanil, alfen- Anesthetizing the larynx below the vocal cords before intu- tanil, or remifentanil allow the dose of the induction drugs to bation is controversial. The cough re ex can be compromised, be reduced and may attenuate the hemodynamic response increasing the risk of aspiration. H owever, tracheal anesthesia to laryngoscopy and intubation. M uscle relaxants can be used may decrease the incidence of arrhythmias or untoward circu- to facilitate intubation, but unless the practitioner has extensive latory responses to intubation and improve patient tolerance experience with these drugs and airway management, alterna- of the endotracheal tube. Clinical judgment in this situation tive means of airway control and oxygenation should be used is necessary. Several methods can be used to anesthetize these until an anesthesiologist arrives to administer the anesthetic structures. Transtracheal lidocaine (4% , 160 mg) is adminis- and perform the intubation. Although the use of muscle relax- tered by cricothyroid membrane puncture with a small needle ants is associated with improved laryngoscopy grade during to anesthetize the trachea and larynx below the vocal cords. Al- intubation, their use may not be associated with a decrease in ternatively, after exposure of the vocal cords with the laryngo- overall airway related complications, hypotension or hypox- scope, the cords can be sprayed with lidocaine via an atomizer. emia. Aerosolized lidocaine (4% , 6 mL) provides excellent anesthesia Recent reviews have extolled the virtue of rapid sequence to the mouth, pharynx, larynx, and trachea [23]. The superior intubation (RSI) [27,28]: The process by which a drug such laryngeal nerve can be blocked with 2 mL of 1.0% to 1.5% as etomidate, thiopental, ketamine, or propofol (Table 1.4) is lidocaine injected just inferior to the greater cornu of the hyoid administered to the patient to induce anesthesia and is followed tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 9 immediately by a muscle relaxant to facilitate intubation. Al- though numerous studies exist in the emergency medicine lit- Speci c Techniques and Routes of erature attesting to the safety and ef cacy of this approach, Endotracheal Intubation the practitioner who embarks on this route to intubation in the ICU must be knowledgeable about the pharmacology and Orotracheal Intubation side effects of the agents used and the use of rescue meth- ods should attempt(s) at intubation fail. Again, experience and O rotracheal intubation is the technique most easily learned and an approached based on a validated algorithm will increase most often used for emergency intubations in the ICU. Tra- patient safety. In a recent analysis of 6,088 trauma patients ditional teaching dictates that successful orotracheal intuba- undergoing emergency airway management in a single center tion requires alignment of the oral, pharyngeal, and laryngeal over 10 years, intubation by anesthesiologists experienced in axes by putting the patient in the “ snif ng position” in which the management of trauma patients utilizing a modi cation the neck is exed and the head is slightly extended about the of the American Society of Anesthesiologists dif cult airway atlanto-occipital joint. H owever, a magnetic resonance imag- algorithm was very effective, resulting in a rate of surgical ing (M RI) study has called this concept into question, as the airway management in only 0.3% of patients included in the alignment of these three axes could not be achieved in any of analysis [29]. the three positions tested: neutral, simple extension, and the “ snif ng position” [35]. In addition, a randomized study in elective surgery patients examining the utility of the snif ng position as a means to facilitate orotracheal intubation failed TECHN IQUES OF IN TUBATION to demonstrate that such positioning was superior to simple head extension [36]. In a true emergency, some of the preintubation evaluation is In a patient with a full stomach, compressing the cricoid necessarily neglected in favor of rapid control of the airway. cartilage posteriorly against the vertebral body can reduce Attempts at tracheal intubation should not cause or exacer- the diameter of the postcricoid hypopharynx. This technique, bate hypoxia. Whenever possible, an oxygen saturation mon- known as Sellick ’s m aneuver, may prevent passive regurgita- itor should be used. Preoxygenation (denitrogenation), which tion of stomach contents into the trachea during intubation replaces the nitrogen in the patient’s functional residual capac- [37]. H owever, an M RI study of awake volunteers demon- ity with oxygen, can maximize the time available for intuba- strated that the esophagus was lateral to the larynx in more tion. During laryngoscopy, apneic oxygenation can occur from than 50% of the subjects. M oreover, cricoid pressure increased this reservoir. Preoxygenation is achieved by providing 100% the incidence of an unopposed esophagus by 50% and caused oxygen at a high ow rate via a tight- tting face mask for 3.5 to airway compression of greater than 1 mm in 81% of the vol- 4.0 minutes. Extending the time of preoxygenation from 4 to unteers [38]. These ndings are in contrast to a more recent 8 minutes does not seem to increase the PaO 2 to a clinically rel- M RI study demonstrating that the location and movement of evant extent and may actually reduce the PaO 2 in the interval the esophagus is irrelevant to the ef cacy of Sellick’s maneu- from 6 to 8 minutes in some patients [30]. In patients who are ver to prevent gastric regurgitation into the pharynx. O f note, being intubated for airway control, preoxygenation is usually compression of the alimentary tract was demonstrated with ef cacious; whereas, the value of preoxygenation in patients midline and lateral displacement of the cricoid cartilage rela- with acute lung injury is less certain [31]. Whenever possi- tive to the underlying vertebral body [39]. In addition, cadaver ble, N IPPV should be utilized as the mode of preoxygenation studies have demonstrated the ef cacy of cricoid pressure [40] prior to intubation of hypoxemic patients. This approach has and clinical studies have shown that gastric insuf ation with been shown to be more effective than the standard approach gas during mask ventilation is reduced when cricoid pressure is in maintaining SpO 2 values before, during and even after the applied [41]. In aggregate, these data suggest that it is prudent intubation procedure resulting [32]. In obese patients, use of to continue to use cricoid pressure in patients suspected of hav- the 25-degree head-up position improves the effectiveness of ing full stomachs. In addition, placing the patient in the partial preoxygenation [33]. recumbent or reverse Trendelenburg position may reduce the Just before intubation, the physician should assess the like- risk of regurgitation and aspiration. lihood of success for each route of intubation, the urgency of The laryngoscope handle is grasped in the left hand while the clinical situation, the likelihood that intubation will be the patient’s mouth is opened with the gloved right hand. O f- prolonged, and the prospect of whether diagnostic or ther- ten, when the head is extended in the unconscious patient, the apeutic procedures such as bronchoscopy will eventually be mouth opens; if not, the thumb and index nger of the right required. Factors that can affect patient comfort should also hand are placed on the lower and upper incisors, respectively, be weighed. In the unconscious patient in whom a secure air- and moved past each other in a scissor-like motion. The laryn- way must be established immediately, orotracheal intubation goscope blade is inserted on the right side of the mouth and with direct visualization of the vocal cords is generally the pre- advanced to the base of the tongue, pushing it toward the left. ferred technique. In the conscious patient, direct laryngoscopy If the straight blade is used, it should be extended below the or awake beroptic intubation may be performed after ade- epiglottis. If the curved blade is used, it is inserted in the val- quate topicalization of the airway. Alternatively, blind naso- lecula. tracheal intubation is an option but requires signi cant skill With the blade in place, the operator should lift forward in a by the clinician. N asotracheal intubation should be avoided plane 45 degrees from the horizontal to expose the vocal cords in patients with coagulopathies or those who are anticoagu- (Figs. 1.2 and 1.8). This motion decreases the risk of the blade lated for medical indications. In trauma victims with exten- striking the upper incisors and either chipping or dislodging sive maxillary and mandibular fractures and inadequate ven- teeth. Both lips should be swept away from between the teeth tilation or oxygenation, cricothyrotomy may be mandatory and blade to avoid soft tissue damage. The endotracheal tube is (see Chapter 12). In patients with cervical spine injury or de- then held in the right hand and inserted at the right corner of the creased neck mobility, intubation using the exible broncho- patient’s mouth in a plane that intersects with the laryngoscope scope or specialized laryngoscope (Bullard) may be necessary. blade at the level of the glottis. This prevents the endotracheal M any of these techniques require considerable skill and should tube from obscuring the view of the vocal cords. The endotra- be performed only by those who are experienced in airway cheal tube is advanced through the vocal cords until the cuff management [34]. just disappears from sight. The cuff is in ated with enough air tahir99-VRG & vip.persianss.ir 10 Section I: Procedures, Techniques, and Minimally Invasive Monitoring Gra de I Gra de II Gra de III Gra de IV FIGURE 1.9. The four grades of laryngeal view during direct laryngoscopy. Grade I: the entire glottis is seen. Grade II: only the posterior aspect of the glottis is seen. Grade III: only the epiglottis is seen. Grade IV: the epiglottis is not visualized. [From Cormack RS, Lehane J: Dif cult tracheal intubation in obstetrics. A naesthesia 39:1105–1111, 1984, with permission.] to prevent a leak during positive-pressure ventilation with a of the endotracheal tube and changes color on exposure to bag valve device. carbon dioxide. An additional method to detect esophageal in- A classi cation grading the view of the laryngeal aper- tubation uses a bulb that attaches to the proximal end of the ture during direct laryngoscopy has been described [42] and endotracheal tube [47]. The bulb is squeezed. If the tube is in is depicted in Figure 1.9. O ccasionally, the vocal cords can- the trachea, the bulb reexpands, and if the tube is in the esoph- not be seen entirely; only the corniculate and cuneiform tuber- agus, the bulb remains collapsed. It must be remembered that cles, interarytenoid incisure, and posterior portion of the vocal none of these techniques is foolproof. Bronchoscopy is the only cords or only the epiglottis is visualized (grades II to IV view; method to be absolutely sure the tube is in the trachea. After Fig. 1.9). In this situation, it is helpful to insert the soft metal estimating proper tube placement clinically, it should be con- stylet into the endotracheal tube and bend it into a hockey- rmed by chest radiograph or bronchoscopy because the tube stick con guration. The stylet should be bent or coiled at the may be malpositioned. The tip of the endotracheal tube should proximal end to prevent the distal end from extending beyond be several centimeters above the carina (T-4 level). It must be the endotracheal tube and causing tissue damage. The stylet remembered that exion or extension of the head can advance should be lubricated to ensure easy removal. The BURP ma- or withdraw the tube 2 to 5 cm, respectively. neuver (backward–upward–r ightward pressure on the larynx) improves the view of the laryngeal aperture [43]. Alternatively, a control-tip endotracheal tube can be used. This tube has a N asotracheal Intubation nylon cord running the length of the tube attached to a ring M any of the considerations concerning patient preparation and at the proximal end, which allows the operator to direct the positioning outlined for orotracheal intubation apply to nasal tip of the tube anteriorly. Another aid is a stylet with a light intubation as well. Blind nasal intubation is more dif cult to (light wand). With the room lights dimmed, the endotracheal perform than oral intubation, because the tube cannot be ob- tube containing the lighted stylet is inserted into the orophar- served directly as it passes between the vocal cords. H owever, ynx and advanced in the midline. When it is just superior to nasal intubation is usually more comfortable for the patient and the larynx, a glow is seen over the anterior neck. The stylet is is generally preferable in the awake, conscious patient. N asal advanced into the trachea, and the tube is threaded over it. The intubation should not be attempted in patients with abnor- light intensity is diminished if the wand enters the esophagus mal bleeding parameters, nasal polyps, extensive facial trauma, [44]. The gum elastic bougie ( exible stylet) is another alterna- cerebrospinal rhinorrhea, sinusitis, or any anatomic abnormal- tive device that can be passed into the larynx; once in place, the ity that would inhibit atraumatic passage of the tube. endotracheal tube is advance over it and the stylet is removed. As previously discussed in Airway Adjuncts section, after Endotracheal tubes and stylets are now available that have a the operator has alternately occluded each nostril to ascertain beroptic bundle intrinsic to the tube or the stylet that can be that both are patent, a topical vasoconstrictor and anesthetic attached to a video monitor. If the attempt to intubate is still un- are applied to the nostril that will be intubated. The nostril successful, the algorithm that is described in the M anagement may be dilated with lubricated nasal airways of increasing size of the Dif cult Airway section should be followed. to facilitate atraumatic passage of the endotracheal tube. The Proper depth of tube placement is clinically ascertained by patient should be monitored with a pulse oximeter, and sup- observing symmetric expansion of both sides of the chest and plemental oxygen should be given as necessary. The patient auscultating equal breath sounds in both lungs. The stomach may be either supine or sitting with the head extended in the should also be auscultated to ensure that the esophagus has snif ng position. The tube is guided slowly but rmly through not been entered. If the tube has been advanced too far, it the nostril to the posterior pharynx. H ere the tube operator will lodge in one of the main bronchi (particularly the right must continually monitor for the presence of air movement bronchus), and only one lung will be ventilated. If this error through the tube by listening for breath sounds with the ear goes unnoticed, the nonventilated lung may collapse. A use- near the open end of the tube. The tube must never be forced ful rule of thumb for tube placement in adults of average size or pushed forward if breath sounds are lost, because damage is that the incisors should be at the 23-cm mark in men and to the retropharyngeal mucosa can result. If resistance is met, the 21-cm mark in women [45]. Alternatively, proper depth the tube should be withdrawn 1 to 2 cm and the patient’s head (5 cm above the carina) can be estimated using the following repositioned (extended further or turned to either side). If the formula: (height in cm/5) minus 13 [46]. Palpation of the an- turn still cannot be negotiated, the other nostril or a smaller terior trachea in the neck may detect cuff in ation as air is tube should be tried. Attempts at nasal intubation should be injected into the pilot tube and can serve as a means to ascer- abandoned and oral intubation performed if these methods fail. tain correct tube position. M easurement of end-tidal carbon O nce positioned in the oropharynx, the tube should be ad- dioxide by standard capnography if available or by means of vanced to the glottis while listening for breath sounds through a calorimetric chemical detector of end-tidal carbon dioxide the tube. If breath sounds cease, the tube is withdrawn several (e.g., Easy Cap II, N ellcor, Inc., Pleasanton, CA) can be used to centimeters until breath sounds resume, and the plane of en- verify correct endotracheal tube placement or detect esophageal try is adjusted slightly. Passage through the vocal cords should intubation. The latter device is attached to the proximal end be timed to coincide with inspiration. Entry of the tube into tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 11 the larynx is signaled by an inability to speak. The cuff should be in ated and proper positioning of the tube ascertained as previously outlined. O ccasionally, blind nasal intubation cannot be accom- plished. In this case, after adequate topical anesthesia, laryn- goscopy can be used to visualize the vocal cords directly and M agill forceps used to grasp the distal end of the tube and guide it through the vocal cords (Fig. 1.10). Assistance in pushing the tube forward is essential during this maneuver, so that the op- erator merely guides the tube. The balloon on the tube should not be grasped with the M agill forceps. O ccasionally, one may not be able to successfully place the endotracheal tube in the trachea. The technique of managing a dif cult airway is detailed later. Management of the Dif cult Airway A dif cult airway may be recognized (anticipated) or unrecog- nized at the time of the initial preintubation airway evaluation. Dif culty managing the airway may be the result of abnormali- ties such as congenital hypoplasia, hyperplasia of the mandible or maxilla, or prominent incisors; injuries to the face or neck; FIGURE 1.10. M agill forceps may be required to guide the endo- acromegaly; tumors; and previous head and neck surgery. Dif- tracheal tube into the larynx during nasotracheal intubation. [From culties ventilating the patient with a mask can be anticipated Barash PG, Cullen BF, Stoelting RK: Clinical A nesthesia. 2nd ed. if two of the following factors are present: age older than 55 Philadelphia, PA, JB Lippincott Co, 1992, with permission.] years, body mass index greater than 26 kg per m 2 , beard, lack of teeth, and a history of snoring [48]. When a dif cult air- way is encountered, the algorithm as detailed in Figure 1.11 Alg o rithm fo r airway manag e me nt in the ICU Airwa y ma na ge me nt ne ce s s a ry Ca ll s e nior phys icia n for a s s is ta nce Inva s ive a irwa y Noninva s ive a irwa y ma na ge me nt ma na ge me nt Fa ils NIP P V P ote ntia l for DMV Ye s , a de qua te P rima ry a wa ke te chnique a nd/or DI phys iologic re s e rve (FOI, na s otra che a l) Ye s , pt in S upra la rynge a l ve ntila tion No re s pira tory a rre s t a s conduit for intuba tion Dire c t Laryng o s c o py Abla tion vs . pre s e rva tion of No Ye s S B, with or without NMBA FIGURE 1.11. M odi cation of the dif cult air- Intuba ting-, vide o- way algorithm. ASA DAA, American Society Fa ils , ma s k of Anesthesiologists dif cult airway algorithm; Fa ils , ma s k a s s is te d-, or cla s s ic LMA ve ntila tion DM V, dif cult mask ventilation; FO I, beroptic ve ntila tion a s bridge for de finitive a de qua te intubation; LM A, laryngeal mask airway; N IPPV, ina de qua te a irwa y mgt noninvasive positive pressure ventilation; N M BA, neuromuscular blocking agents; SB, spontaneous breathing. [From Walz JM , Z ayaruzny M , H eard AS A DAA e me rge ncy pa thwa y(s ) SO , et al. Chest 131(2):608–620, 2007, with per- mission.] tahir99-VRG & vip.persianss.ir 12 Section I: Procedures, Techniques, and Minimally Invasive Monitoring should be followed [49]. When a dif cult airway is recognized If the operator is able to maintain mask ventilation in a before the patient is anesthetized, an awake tracheal intuba- patient with an unrecognized dif cult airway, a call for expe- tion is usually the best option. M ultiple techniques can be used rienced help should be initiated (Fig. 1.11). If mask ventilation and include (after adequate topical or local anesthesia) direct cannot be maintained, a cannot ventilate–cannot intubate sit- laryngoscopy, LM A (or variants), blind or bronchoscopic oral uation exists and immediate lifesaving rescue maneuvers are or nasal intubation, retrograde technique, rigid bronchoscopy, required. O ptions include an emergency cricothyrotomy or in- lighted stylet, or a surgical airway. sertion of a supraglottic ventilatory device, such as an LM A or a Combitube. (Puritan Bennett, Pleasanton, CA.) Flexible Bronchoscopic Intubation Other Airway Adjuncts Flexible bronchoscopy is an ef cacious method of intubat- The LM A is composed of a plastic tube attached to a shal- ing the trachea in dif cult cases. It may be particularly useful low mask with an in atable rim (Fig. 1.12). When properly when the upper airway anatomy has been distorted by tumors, inserted, it ts over the laryngeal inlet and allows positive- trauma, endocrinopathies, or congenital anomalies. This tech- pressure ventilation of the lungs. Although aspiration can oc- nique is sometimes valuable in accident victims in whom a ques- cur around the mask, the LM A can be lifesaving in a can- tion of cervical spine injury exists and the patient’s neck can- not ventilate–cannot intubate situation. An intubating LM A not be manipulated. An analogous situation exists in patients (LM A-Fastrach, LM A N orth America, Inc., San Diego, CA) with severe degenerative disk disease of the neck or rheuma- has a shorter plastic tube and can be used to provide ventila- toid arthritis with markedly impaired neck mobility. After ad- tion as well as to intubate the trachea with or without the aid equate topical anesthesia is obtained as described in the sec- of a exible bronchoscope (Fig. 1.13). The Combitube (Puritan tion Anesthesia before Intubation, the bronchoscope can be Bennett, Pleasanton, CA) combines the features of an endotra- used to intubate the trachea via either the nasal or oral route. cheal tube and an esophageal obturator airway and reduces An appropriately sized warmed and lubricated endotracheal the risk of aspiration. Personnel who are unskilled in airway tube that has been preloaded onto the bronchoscope is ad- management can easily learn how to use the LM A and the vanced through the vocal cords into the trachea and positioned Combitube together [50]. above the carina under direct vision. The exible bronchoscope has also been used as a stent over which endotracheal tubes are Cricothyrotomy exchanged and as a means to assess tracheal damage period- ically during prolonged intubations. (A detailed discussion of In a truly emergent situation, when intubation is unsuccess- bronchoscopy is found in Chapter 9.) Intubation by this tech- ful, a cricothyrotomy may be required. The technique is de- nique requires skill and experience and is best performed by a scribed in detail in Chapter 12. The quickest method, needle fully trained operator. cricothyrotomy, is accomplished by introducing a large-bore A B FIGURE 1.12. Technique for insertion of the laryngeal mask airway. [From Civetta JM , Taylor RW, Kirby RR: Crit- ical Care. 3rd ed. Philadelphia, PA, Lippincott–Raven Publishers, 1997, C D with permission.] tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 13 extubation, (b) to prevent advancement into one of the main D bronchi, and (c) to minimize damage to the upper airway, lar- ynx, and trachea caused by patient motion. The endotracheal tube is usually secured in place with adhesive tape wrapped C around the tube and applied to the patient’s cheeks. Tincture of benzoin sprayed on the skin provides greater xation. Alter- natively, tape, intravenous (IV) tubing, or umbilical tape can be tied to the endotracheal tube and brought around the pa- tient’s neck to secure the tube. Care must be taken to prevent B occlusion of neck veins. O ther products (e.g., Velcro straps) to secure the tube are available. A bite block can be positioned in patients who are orally intubated to prevent them from biting down on the tube and occluding it. O nce the tube has been secured and its proper position veri ed, it should be plainly marked on the portion protruding from the patient’s mouth or A nose so that advancement can be noted. Cuff Management Although low-pressure cuffs have markedly reduced the inci- dence of complications related to tracheal ischemia, monitoring FIGURE 1.13. The laryngeal mask airway (LM A)-Fastrach (A) has a cuff pressures remains important. The cuff should be in ated shorter tube than a conventional LM A. A special endotracheal tube just beyond the point where an audible air leak occurs. M ainte- (B) [without the adapter (C)] is advanced through the LM A-Fastrach nance of intracuff pressures between 17 and 23 mm H g should into the trachea. The extender (D) is attached to the endotracheal tube, allow an adequate seal to permit mechanical ventilation under and the LM A-Fastrach is removed. After the extender is removed, the most circumstances while not compromising blood ow to the adapter is placed back on the tube. tracheal mucosa. The intracuff pressure should be checked pe- riodically by attaching a pressure gauge and syringe to the cuff port via a three-way stopcock. The need to add air continually (i.e., 14-gauge) catheter into the airway through the cricothy- to the cuff to maintain its seal with the tracheal wall indicates roid membrane while aspirating with a syringe attached to the that (a) the cuff or pilot tube has a hole in it, (b) the pilot needle of the catheter. When air is aspirated, the needle is in tube valve is broken or cracked, or (c) the tube is positioned the airway and the catheter is passed over the needle into the incorrectly, and the cuff is between the vocal cords. The tube trachea. The needle is attached to a high-frequency jet venti- position should be reevaluated to exclude the latter possibility. lation apparatus. Alternatively, a 3-mL syringe barrel can be If the valve is broken, attaching a three-way stopcock to it will connected to the catheter. Following this, a 7-mm inside diam- solve the problem. If the valve housing is cracked, cutting the eter endotracheal tube adapter is tted into the syringe and is pilot tube and inserting a blunt needle with a stopcock into the connected to a high-pressure gas source or a high-frequency jet lumen of the pilot tube can maintain a competent system. A ventilator. An algorithm with suggestions for the management hole in the cuff necessitates a change of tube. of the dif cult airway is provided in Figure 1.11. Tube Suctioning Management of the Airway in Patients with Suspected A complete discussion of tube suctioning can be found in Chap- Cervical Spine Injury ter 62. Routine suctioning should not be performed in patients Any patient with multiple trauma who requires intubation in whom secretions are not a problem. Suctioning can produce should be treated as if cervical spine injury were present. In a variety of complications, including hypoxemia, elevations the absence of severe maxillofacial trauma or cerebrospinal in intracranial pressure, and serious ventricular arrhythmias. rhinorrhea, nasal intubation can be considered. H owever, in Preoxygenation should reduce the likelihood of arrhythmias. the profoundly hypoxemic or apneic patient, the orotracheal Closed ventilation suction systems (Stericath) may reduce the approach should be used. If oral intubation is required, an risk of hypoxemia but have not been shown to reduce the rate assistant should maintain the neck in the neutral position by of ventilator-associated pneumonia (VAP) compared to open ensuring axial stabilization of the head and neck as the patient suction systems [52]. is intubated [51]. A cervical collar also assists in immobiliz- ing the cervical spine. In a patient with maxillofacial trauma Humidi cation and suspected cervical spine injury, retrograde intubation can Intubation of the trachea bypasses the normal upper airway be performed by puncturing the cricothyroid membrane with structures responsible for heating and humidifying inspired air. an 18-gauge catheter and threading a 125-cm Te on-coated It is thus essential that inspired air be heated and humidi ed (0.025-cm diameter) guidewire through the catheter. The wire (see Chapter 62). is advanced into the oral cavity, and the endotracheal tube is then advanced over the wire into the trachea. Alternatively, the Tube Replacement wire can be threaded through the suction port of a 3.9-mm bronchoscope. At times, endotracheal tubes may need to be replaced because of an air leak, obstruction, or other problems. Before attempting to change an endotracheal tube, one should assess how dif cult Airway Management in the Intubated Patient it will be. After obtaining appropriate topical anesthesia or IV sedation and achieving muscle relaxation, direct laryngoscopy can be performed to ascertain whether there will be dif culties Securing the Tube in visualizing the vocal cords. If the cords can be seen, the defec- Properly securing the endotracheal tube in the desired posi- tive tube is removed under direct visualization and reintubation tion is important for three reasons: (a) to prevent accidental performed using the new tube. If the cords cannot be seen on tahir99-VRG & vip.persianss.ir 14 Section I: Procedures, Techniques, and Minimally Invasive Monitoring direct laryngoscopy, the tube can be changed over an airway the pharynx, larynx, or trachea; dislocation of an arytenoid exchange catheter (e.g., Cook Critical Care, Bloomington, IN ) cartilage; retropharyngeal perforation; epistaxis; hypoxemia; which allows insuf ation of oxygen via either standard oxygen myocardial ischemia; laryngospasm with noncardiogenic pul- tubing or a bag valve device [53]. monary edema; and death [5,54]. M any of these complications can be avoided by paying careful attention to technique and ensuring that personnel with the greatest skill and experience COMPLICATION S OF perform the intubation. Complications during endotracheal in- tubation vary according to the location of the patient in need EN DOTRACHEAL IN TUBATION of emergency airway management. Although the complication rates on the regular hospital oor and in the ICU appear to Table 1.5 is a partial listing of the complications associated be high at around 28% for both locations, they can be mod- with endotracheal intubation. Factors implicated in the etiol- i ed with standardized algorithms as outlined previously. The ogy of complications include tube size, characteristics of the most frequent complications encountered in these two settings tube and cuff, trauma during intubation, duration and route are multiple intubation attempts and esophageal intubation in of intubation, metabolic or nutritional status of the patient, the general hospital units, and severe hypoxemia and hemody- tube motion, and laryngeal motor activity. namic collapse in the ICU. Presence of acute respiratory failure During endotracheal intubation, traumatic injury can occur and presence of shock appear to be an independent risk factor to any anatomic structure from the lips to the trachea. Pos- for the occurrence of complications in the latter setting [55,56]. sible complications include aspiration; damage to teeth and dental work; corneal abrasions; perforation or laceration of Complications During Intubation TA B LE 1 . 5 A variety of cardiovascular complications can accompany in- COMPLICATION S OF EN DOTRACHEAL IN TUBATION tubation. Ventricular arrhythmias have been reported in 5% to 10% of intubations. Ventricular tachycardia and ventric- Complications during intubation ular brillation are uncommon but have been reported. Pa- Spinal cord injury tients with myocardial ischemia are susceptible to ventricular Excessive delay of cardiopulmonary resuscitation arrhythmias, and lidocaine prophylaxis (100 mg IV bolus) be- Aspiration fore intubation may be warranted in such individuals. Brad- Damage to teeth and dental work yarrhythmias can also be observed and are probably caused Corneal abrasions by stimulation of the laryngeal branches of the vagus nerve. Perforation or laceration of They may not require therapy but usually respond to IV at- Pharynx ropine (1 mg IV bolus). H ypotension or hypertension can oc- Larynx cur during intubation. In the patient with myocardial ischemia, Trachea short-acting agents to control blood pressure (nitroprusside, Dislocation of an arytenoid cartilage nicardipine) and heart rate (esmolol) during intubation may be Passage of endotracheal tube into cranial vault needed. Epistaxis Cardiovascular problems Ventricular premature contractions Complications While the Tube is in Place Ventricular tachycardia Bradyarrhythmias Despite adherence to guidelines designed to minimize damage H ypotension from endotracheal intubation, the tube can damage local struc- H ypertension tures. M icroscopic alterations to the surface of the vocal cords H ypoxemia can occur within 2 hours after intubation. Evidence of macro- Complications while tube is in place scopic damage can occur within 6 hours. As might be expected, Blockage or kinking of tube clinically signi cant damage typically occurs when intubation Dislodgment of tube is prolonged. The sudden appearance of blood in tracheal se- Advancement of tube into a bronchus cretions suggests anterior erosion into overlying vascular struc- M echanical damage to any upper airway structure tures, and the appearance of gastric contents suggests poste- Problems related to mechanical ventilation rior erosion into the esophagus. Both situations require urgent (see Chapter 58) bronchoscopy, and it is imperative that the mucosa underlying Complications following extubation the cuff be examined. O ther complications include tracheoma- Immediate complications lacia and stenosis and damage to the larynx. Failure to secure Laryngospasm the endotracheal tube properly or patient agitation can con- Aspiration tribute to mechanical damage. Intermediate and long-term complications Another complication is blockage or kinking of the tube, Sore throat resulting in compromised ventilation. Placing a bite block in Ulcerations of lips, mouth, pharynx, or vocal cords the patient’s mouth can minimize occlusion of the tube caused Tongue numbness (hypoglossal nerve compression) by the patient biting down on it. Suctioning can usually solve Laryngitis blockage from secretions, although changing the tube may be Vocal cord paralysis (unilateral or bilateral) necessary. Laryngeal edema Unplanned extubation and endobronchial intubation are Laryngeal ulcerations potentially life threatening. Judicious use of sedatives and Laryngeal granuloma analgesics and appropriately securing and marking the tube Vocal cord synechiae should minimize these problems. Daily chest radiographs with Tracheal stenosis the head always in the same position can be used to assess the position of the tube. O ther complications that occur while the tahir99-VRG & vip.persianss.ir Chapter 1: Airway Management and Endotracheal Intubation 15 tube is in position relate to mechanical ventilation (e.g., pneu- consciousness following anesthesia, or (c) suf cient resolution mothorax) and are discussed in detail in Chapter 58. of the initial indications for intubation. Complications After Extubation Technique of Extubation Sore throat occurs after 40% to 100% of intubations. Using a The patient should be alert, lying with the head of the bed smaller endotracheal tube may decrease the incidence of pos- elevated to at least a 45-degree angle. The posterior pharynx textubation sore throat and hoarseness. Ulcerations of the lips, must be thoroughly suctioned. The procedure is explained to mouth, or pharynx can occur and are more common if the ini- the patient. The cuff is de ated, and positive pressure is applied tial intubation was traumatic. Pressure from the endotracheal to expel any foreign material that has collected above the cuff as tube can traumatize the hypoglossal nerve, resulting in numb- the tube is withdrawn. Supplemental oxygen is then provided. ness of the tongue that can persist for 1 to 2 weeks. Irritation In situations in which postextubation dif culties are antici- of the larynx appears to be due to local mucosal damage and pated, equipment for emergency reintubation should be assem- occurs in as many as 45% of individuals after extubation. Uni- bled at the bedside. Some clinicians have advocated the “ leak lateral or bilateral vocal cord paralysis is an uncommon but test” as a means to predict the risk of stridor after extuba- serious complication following extubation. tion. The utility of this procedure is limited in routine prac- Some degree of laryngeal edema accompanies almost all en- tice, but for patients with certain risk factors (e.g., traumatic dotracheal intubations. In adults, this is usually clinically in- intubation, prolonged intubation, and previous accidental ex- signi cant. In children, however, even a small amount of edema tubation), a leak volume of greater than 130 mL or 12% of can compromise the already small subglottic opening. In a new- the tidal volume has a sensitivity and speci city of 85% and born, 1 mm of laryngeal edema results in a 65% narrowing of 95% , respectively, for the development of postextubation stri- the airway. Laryngeal ulcerations are commonly observed after dor [57]. Probably the safest means to extubate the patient if extubation. They are more commonly located at the posterior there are concerns about airway edema or the potential need to portion of the vocal cords, where the endotracheal tube tends reintubate a patient with a dif cult airway is to use an airway to rub. Ulcerations become increasingly common the longer the exchange catheter. This device is inserted through the endo- tube is left in place. The incidence of ulceration is decreased by tracheal tube, and then the tube is removed over the catheter. the use of endotracheal tubes that conform to the anatomic Supplemental oxygen can be provided via the catheter to the shape of the larynx. Laryngeal granulomas and synechiae of patient, and the catheter can be used as a stent for reintubation the vocal cords are extremely rare, but these complications can if necessary. seriously compromise airway patency. Surgical treatment is of- O ne of the most serious complications of extubation is ten required to treat these problems. laryngospasm, and it is more likely to occur if the patient is not A feared late complication of endotracheal intubation is tra- fully conscious. The application of positive pressure can some- cheal stenosis. This occurs much less frequently now that high- times relieve laryngospasm. If this maneuver is not successful, volume, low-pressure cuffs are routinely used. Symptoms can a small dose of succinylcholine (by the IV or intramuscular occur weeks to months after extubation. In mild cases, the pa- route) can be administered. Succinylcholine can cause severe tient may experience dyspnea or ineffective cough. If the airway hyperkalemia in a variety of clinical settings; therefore, only is narrowed to less than 5 mm, the patient presents with stridor. clinicians who are experienced with its use should administer Dilation may provide effective treatment, but in some instances it. Ventilation with a mask and bag unit is needed until the surgical intervention is necessary. patient has recovered from the succinylcholine. EXTUBATION Tracheostomy The decision to extubate a patient is based on (a) a favorable The optimal time of conversion from an endotracheal tube to a clinical response to a carefully planned regimen of weaning tracheostomy remains controversial. The reader is referred to from mechanical ventilation (see Chapter 60), (b) recovery of Chapter 12 for details on tracheostomy. References 1. Caples SM , Gay PC: N oninvasive positive pressure ventilation in the inten- 10. Tse JC, Rimm EB, H ussain A: Predicting dif cult endotracheal intubation in sive care unit: a concise review. Crit Care M ed 33:2651–2658, 2005. surgical patients scheduled for general anesthesia: a prospective blind study. 2. Snell RS, Katz J: Clinical A natom y for A nesthesiologists. N orwalk, CT, Ap- A nesth A nalg 81:254–258, 1995. pleton and Lange, 1988. 11. Levitan RM , Everett WW, O chroch EA: Limitations of dif cult airway pre- 3. Fowler RA, Pearl RG: The airway: emergent management for nonanesthesi- diction in patients intubated in the emergency department. A nn Em erg M ed ologists. W est J M ed 176:45–50, 2002. 44:307–313, 2004. 4. M ort TC: The incidence and risk factors for cardiac arrest during emergency 12. M urphy M F, Walls RM : M anual of em ergency airw ay m anagem ent. Chicago, tracheal intubation: a justi cation for incorporating the ASA Guidelines in IL, Lippincott, Williams and Wilkins, 2000. the remote location. J Clin A nesth 16:508–516, 2004. 13. Reed M J, Dunn M J, M cKeown DW: Can an airway assessment score predict 5. M ort TC: Emergency tracheal intubation: complications associated with re- dif culty at intubation in the emergency department? Em erg M ed J 22:99– peated laryngoscopic attempts. A nesth A nalg 99:607–613, 2004, table of 102, 2005. contents. 14. Kheterpal S, M artin L, Shanks AM , et al: Prediction and outcomes of im- 6. 2005 American H eart Association Guidelines for cardiopulmonary resusci- possible mask ventilation: a review of 50,000 anesthetics. A nesthesiology tation and emergency cardiovascular care. Circulation 112:IV-1–IV-5, 2005. 110:891–897, 2009. 7. M allampati SR, Gatt SP, Gugino LD, et al: A clinical sign to predict dif cult 15. M ulcaster JT, M ills J, H ung O R, et al: Laryngoscopic intubation: learning tracheal intubation: a prospective study. Can A naesth Soc J 32:429–434, and performance. A nesthesiology 98:23–27, 2003. 1985. 16. Schmidt UH , Kumwilaisak K, Bittner E, et al: Effects of supervision by at- 8. Lewis M , Keramati S, Benumof JL, et al: What is the best way to determine tending anesthesiologists on complications of emergency tracheal intubation. oropharyngeal classi cation and mandibular space length to predict dif cult A nesthesiology 109:973–977, 2008. laryngoscopy? A nesthesiology 81:69–75, 1994. 17. Jaber S, Jung B, Corne P, et al: An intervention to decrease complications 9. Gal TJ: Airway management, in M iller RD (ed): A nesthesia. 6th ed. Philadel- related to endotracheal intubation in the intensive care unit: a prospective, phia, PA, Churchill Livingstone, 2005, pp 1617–1652. multiple-center study. Intensive Care M ed 36:248–255, 2010. tahir99-VRG & vip.persianss.ir 16 Section I: Procedures, Techniques, and Minimally Invasive Monitoring 18. H astings RH , H on ED, N ghiem C, et al: Force, torque, and stress relaxation 38. Smith KJ, Dobranowski J, Yip G, et al: Cricoid pressure displaces the esoph- with direct laryngoscopy. A nesth A nalg 82:456–461, 1996. agus: an observational study using magnetic resonance imaging. A nesthesi- 19. Lim TJ, Lim Y, Liu EH : Evaluation of ease of intubation with the GlideScope ology 99:60–64, 2003. or M acintosh laryngoscope by anaesthetists in simulated easy and dif cult 39. Rice M J, M ancuso AA, Gibbs C, et al: Cricoid pressure results in compres- laryngoscopy. A naesthesia 60:180–183, 2005. sion of the postcricoid hypopharynx: the esophageal position is irrelevant. 20. N ouruzi-Sedeh P, Schumann M , Groeben H : Laryngoscopy via M acin- A nesth A nalg 109:1546–1552, 2009. tosh blade versus GlideScope: success rate and time for endotracheal 40. Salem M R, Joseph N J, H eyman H J, et al: Cricoid compression is effective intubation in untrained medical personnel. A nesthesiology 110:32–37, in obliterating the esophageal lumen in the presence of a nasogastric tube. 2009. A nesthesiology 63:443–446, 1985. 21. H agberg CA: Current concepts in the management of the dif cult airway. in 41. Lawes EG, Campbell I, M ercer D: In ation pressure, gastric insuf ation and A nesthesiology new s. N ew York, M cM ahon Publishing, 2010. rapid sequence induction. Br J A naesth 59:315–318, 1987. 22. Larijani GE, Cypel D, Gratz I, et al: The ef cacy and safety of EM LA cream 42. Cormack RS, Lehane J: Dif cult tracheal intubation in obstetrics. A naesthe- for awake beroptic endotracheal intubation. A nesth A nalg 91:1024–1026, sia 39:1105–1111, 1984. 2000. 43. Ulrich B, Listyo R, Gerig H J, et al: The dif cult intubation. The value of 23. Venus B, Polassani V, Pham CG: Effects of aerosolized lidocaine on circu- BURP and 3 predictive tests of dif cult intubation. A naesthesist 47:45–50, latory responses to laryngoscopy and tracheal intubation. Crit Care M ed 1998. 12:391–394, 1984. 44. Agro F, H ung O R, Cataldo R, et al: Lightwand intubation using the Tra- 24. M alerba G, Romano-Girard F, Cravoisy A, et al: Risk factors of relative chlight: a brief review of current knowledge. Can J A naesth 48:592–599, adrenocortical de ciency in intensive care patients needing mechanical ven- 2001. tilation. Intensive Care M ed 31:388–392, 2005. 45. O wen RL, Cheney FW: Endobronchial intubation: a preventable complica- 25. Jabre P, Combes X, Lapostolle F, et al: Etomidate versus ketamine for rapid tion. A nesthesiology 67:255–257, 1987. sequence intubation in acutely ill patients: a multicentre randomised con- 46. Cherng CH , Wong CS, H su CH , et al: Airway length in adults: estimation trolled trial. L ancet 374:293–300, 2009. of the optimal endotracheal tube length for orotracheal intubation. J Clin 26. Sprung CL, Annane D, Keh D, et al: H ydrocortisone therapy for patients A nesth 14:271–274, 2002. with septic shock. N Engl J M ed 358:111–124, 2008. 47. Kasper CL, Deem S: The self-in ating bulb to detect esophageal intubation 27. Reynolds SF, H effner J: Airway management of the critically ill patient: rapid- during emergency airway management. A nesthesiology 88:898–902, 1998. sequence intubation. Chest 127:1397–1412, 2005. 48. Langeron O , M asso E, H uraux C, et al: Prediction of dif cult mask ventila- 28. M ace SE: Challenges and advances in intubation: rapid sequence intubation. tion. A nesthesiology 92:1229–1236, 2000. Em erg M ed Clin N orth A m 26:1043–1068, x, 2008. 49. Benumof JL: Laryngeal mask airway and the ASA dif cult airway algorithm. 29. Stephens CT, Kahntroff S, Dutton RP: The success of emergency endotra- A nesthesiology 84:686–699, 1996. cheal intubation in trauma patients: a 10-year experience at a major adult 50. Yardy N , H ancox D, Strang T: A comparison of two airway aids for emer- trauma referral center. A nesth A nalg 109:866–872, 2009. gency use by unskilled personnel. The Combitube and laryngeal mask. A naes- 30. M ort TC, Waberski BH , Clive J: Extending the preoxygenation period thesia 54:181–183, 1999. from 4 to 8 mins in critically ill patients undergoing emergency intubation. 51. Criswell JC, Parr M J, N olan JP: Emergency airway management in patients Crit Care M ed 37:68–71, 2009. with cervical spine injuries. A naesthesia 49:900–903, 1994. 31. M ort TC: Preoxygenation in critically ill patients requiring emergency tra- 52. Subirana M , Sola I, Benito S: Closed tracheal suction systems versus open cheal intubation. Crit Care M ed 33:2672–2675, 2005. tracheal suction systems for mechanically ventilated adult patients. Cochrane 32. Baillard C, Fosse JP, Sebbane M , et al: N oninvasive ventilation improves pre- D atabase Syst R ev (4):CD004581, 2007. oxygenation before intubation of hypoxic patients. A m J R espir Crit Care 53. Loudermilk EP, H artmannsgruber M , Stoltzfus DP, et al: A prospective M ed 174:171–177, 2006. study of the safety of tracheal extubation using a pediatric airway exchange 33. Dixon BJ, Dixon JB, Carden JR, et al: Preoxygenation is more effective in catheter for patients with a known dif cult airway. Chest 111:1660–1665, the 25 degrees head-up position than in the supine position in severely obese 1997. patients: a randomized controlled study. A nesthesiology 102:1110–1115, 54. Schwartz DE, M atthay M A, Cohen N H : Death and other complications of 2005; discussion 5A. emergency airway management in critically ill adults. A prospective investi- 34. H astings RH , M arks JD: Airway management for trauma patients with po- gation of 297 tracheal intubations. A nesthesiology 82:367–376, 1995. tential cervical spine injuries. A nesth A nalg 73:471–482, 1991. 55. Benedetto WJ, H ess DR, Gettings E, et al: Urgent tracheal intubation in gen- 35. Adnet F, Borron SW, Dumas JL, et al: Study of the “ snif ng position” by eral hospital units: an observational study. J Clin A nesth 19:20–24, 2007. magnetic resonance imaging. A nesthesiology 94:83–86, 2001. 56. Jaber S, Amraoui J, Lefrant JY, et al: Clinical practice and risk factors for im- 36. Adnet F, Baillard C, Borron SW, et al: Randomized study comparing the mediate complications of endotracheal intubation in the intensive care unit: “ snif ng position” with simple head extension for laryngoscopic view in a prospective, multiple-center study. Crit Care M ed 34:2355–2361, 2006. elective surgery patients. A nesthesiology 95:836–841, 2001. 57. Jaber S, Chanques G, M atecki S, et al: Post-extubation stridor in intensive 37. Sellick BA: Cricoid pressure to control regurgitation of stomach contents care unit patients. Risk factors evaluation and importance of the cuff-leak during induction of anesthesia. L ancet 2:404, 1961. test. Intensive Care M ed 29:69–74, 2003. CH APTER 2 ■ CEN TRAL VEN O US CATH ETERS JASON LEE-LLACER AN D MICHAEL G. SEN EFF The art and science of central venous catheter (CVC) insertion, and it is simply inexcusable for institutions not to fully adapt maintenance, and management continues to evolve. Increased proven protocols and procedures that have been shown to emphasis on patient safety and prevention of nosocomial signi cantly reduce CRI and other catheter complications [1]. complications has focused attention on the impact of CVCs on Patient safety is also the main impetus for increased availability patient health. Catheter-related infection (CRI), often with a of simulation laboratories [2,3] for operator training in the resistant organism such as methicillin-resistant Staphylococcal use of portable ultrasound [4,5] to facilitate catheter insertion. aureus or vancomycin-resistant enterococci (VRE) remains an Insertion of CVCs is a procedure at the crossroads of the important cause of increased patient morbidity and mortality, controversy of the need for training versus patient safety. tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 17 Training of physicians in the United States has been guided [6,10]. Ultrasound has been less useful in cannulating the sub- for years by the mantra “ see one, do one, teach one,” but this clavian vein [11]. The subclavian vein is more dif cult to ac- approach can no longer be defended as the best practice. Dif- cess using ultrasound due to its deeper and posterior location ferent institutions have developed different solutions, ranging to the clavicle which prevents the transmission of ultrasound from specially designated “ catheter teams” responsible for waves. The subclavian vein may be accessed at the midpoint of all hospital-wide catheter insertions, to well equipped simu- the clavicle using a long-axis view or by a supraclavicular ap- lation laboratories that provide certi cation of competence proach. Similarly, the infraclavicular axillary vein, which lies a and which have been shown to reduce subsequent clinical few centimeters lateral to the subclavian vein, can be accessed complications [2]. with the short-axis ultrasound view [12]. Because of the availability and relatively low cost of portable Because of the success of ultrasound, some experts have ar- ultrasound units, many nonradiologists have been performing gued for the complete elimination of all nonultrasound-guided bedside image-guided central venous cannulation. Ultrasound CVC insertions. Although we recognize that even very experi- guidance allows visualization of the vessel showing its precise enced operators will bene t from ultrasound (if nothing else, location and patency in real time. It is especially useful for pa- by detection of anatomic variations and thrombosed vessels), tients with suboptimal body habitus, volume depletion, shock, it is not yet feasible to insist on 100% ultrasound availability. anatomic deformity, previous cannulation, underlying coagu- We also feel that there are still circumstances where standard lopathy, and intravenous drug use. The use of ultrasound guid- subclavian catheterization is warranted and that this access site ance has signi cantly decreased the failure rate, complication should not be abandoned. Therefore, it is important that one rate, and the number of attempts in obtaining central venous learns to obtain CVC via landmark techniques. access and, as a result, has become routine in many centers In this chapter, we review the techniques and complications [4,6]. Experts all over the world argue that ultrasound guidance of the various routes available for central venous catheteri- should be viewed as standard of care for all CVC insertions, a zation, and present a strategy for catheter management that recommendation met with resistance by many clinicians [6,7]. incorporates all of the recent advances. In 2001, the Agency for H ealthcare Research and Q uality Report listed bedside ultrasonography during central venous access as one of the “ Top 11 H ighly Proven” patient safety practices that are not routinely used in patient care, and it rec- IN DICATION S AN D SITE ommended all CVC insertions be guided by real-time, dynamic SELECTION ultrasound [8]. The Third Sonography O utcomes Assessment Program (SO AP-3) trial, a concealed, randomized, controlled Like any medical procedure, CVC has speci c indications and multicenter study, had an odds ratio 53.5 times higher for suc- should be reserved for the patient who has potential to bene t cess with ultrasound guidance compared with the landmark from it. After determining that CVC is necessary, physicians technique. It also demonstrated a signi cantly lower average often proceed with catheterization at the site they are most ex- number of attempts and average time of catheter placement [9]. perienced with, which might not be the most appropriate route Given the existing data and recommendations, it appears no in that particular patient. Table 2.1 lists general priorities in longer defensible to lack an active ultrasound training and uti- site selection for different indications of CVC; the nal choice lization program in the intensive care unit (ICU). Ultrasound of site in a particular patient should vary based on individual can be used in obtaining central venous access from multi- institutional and operator experiences. In general, we recom- ple sites, especially the internal jugular and femoral veins (FV) mend that all internal jugular and femoral vein cannulations T A B LE 2 . 1 IN DICATION S FOR CEN TRAL VEN OUS CATHETERIZATION (CVC) Site selection Indication First Second Third 1. Pulmonary artery catheterization RIJV LSCV LIJV With coagulopathy IJV FV With pulmonary compromise or high-level positive end-expiratory pressure (PEEP) RIJV LIJV EJV 2. Total parenteral nutrition (TPN ) SCV IJV (tunneled) Long term (surgically implanted) SCV PICC 3. Acute hemodialysis/plasmapheresis IJV FV 4. Cardiopulmonary arrest FV SCV IJV 5. Emergency transvenous pacemaker RIJV SCV 6. H ypovolemia, inability to perform peripheral IV IJV SCV FV 7. Preoperative preparation IJV SCV AV/PICC 8. General purpose venous access, vasoactive agents, caustic medications, radiologic IJV SCV FV procedures With coagulopathy IJV EJV FV 9. Emergency airway management FV SCV IJV 10. Inability to lie supine FV EJV AV/PICC 11. Central venous oxygen saturation monitoring IJV SCV 12. Fluid management of ARDS (CVP monitoring) IJV EJV SCV AV, antecubital vein; EJV, external jugular vein; FV, femoral vein; IJV, internal jugular vein; L, left; PICC, peripherally inserted central venous catheter; R, right; SCV, subclavian vein. IJV and FV assume ultrasound guidance. see text for details. tahir99-VRG & vip.persianss.ir 18 Section I: Procedures, Techniques, and Minimally Invasive Monitoring be performed under ultrasound guidance. As noted earlier, we drugs and de brillation, central access should be obtained by feel the traditional subclavian route offers many advantages for the most experienced operator available with a minimum inter- central access and should not be abandoned. H owever, only ex- ruption of CPR. Emergency ultrasound-guided femoral CVC perienced operators should use the traditional infraclavicular placement has been shown to be slightly faster with fewer com- approach; others should use ultrasound guidance with a mod- plications than the landmark technique [20]. i ed approach that is described later. The placement of CVC is now common in patients with se- Volume resuscitation alone is not an indication for CVC. vere sepsis, septic shock, or acute respiratory distress syndrome A 2.5-inch, 16-gauge catheter used to cannulate a peripheral (ARDS), to monitor central venous pressure (CVP) and central vein can infuse twice the amount of uid as an 8-inch, 16- venous oxygen saturation (ScvO 2 ). Rivers showed a 16% abso- gauge CVC [13]. H owever, peripheral vein cannulation can be lute reduction of in-hospital mortality with early goal-directed impossible in the hypovolemic, shocked individual. Previously, therapy for patients with severe sepsis, which included keeping we recommended the subclavian vein (SCV) as the most reliable the ScvO 2 greater than 70% [21]. Early goal-directed therapy central site because it remains patent due to its brous attach- was subsequently shown to be achievable in “ real-world” set- ments to the clavicle. But recently, use of real-time ultrasound- tings [22]. For these patients, the relationship between superior guided CVC placement by direct visualization of the internal vena caval and inferior vena caval oxygen saturations has not jugular vein (IJV) has increased success rate and decreased com- been de nitively elucidated [23]. Likewise, the ARDS network plications in the shocked or hypovolemic patient [5,6]. reported that CVP monitoring using a CVC is as effective as Long-term total parenteral nutrition is best administered a pulmonary artery catheter in managing patients with acute through SCV catheters, which should be inserted by interven- lung injury and ARDS [24]. Because many of these patients tional radiology or surgically implanted if appropriate. The are on high levels of positive end expiratory pressure (PEEP) IJV is the preferred site for acute hemodialysis, and the SCV and at high risk for complications from pneumothorax, IJV should be avoided because of the relatively high incidence of catheterization under ultrasound guidance represents the safest subclavian stenosis following temporary dialysis, which then approach. limits options for an AV stula should long-term dialysis be- come necessary [14,15]. The FV is also suitable for acute short- term hemodialysis or plasmapheresis in nonambulatory pa- tients [16]. GEN ERAL CON SIDERATION S AN D Emergency trans-venous pacemakers and ow-directed pul- COMPLICATION S monary artery catheters are best inserted through the right IJV because of the direct path to the right ventricle. This route is General considerations for CVC independent of the site of associated with the fewest catheter tip malpositions. The SCV insertion are the need for signed informed consent, insuring is an alternative second choice for pulmonary artery catheter- patient comfort and safety, ultrasound preparation, catheter ization even in many patients with coagulopathy [17]. The tip location, vascular erosions, catheter-associated thrombosis, left SCV is preferred to the right SV due to a less torturous air and catheter embolism, and the presence of coagulopathy. route to the heart. The reader is referred to Chapter 4 for ad- Catheter-associated infection is reviewed separately. ditional information on the insertion and care of pulmonary artery catheters. Preoperative CVC is desirable in a wide variety of clinical Informed Consent situations. O ne speci c indication for preoperative right ven- tricular catheterization is the patient undergoing a posterior It seems intuitively obvious that a signed informed consent is craniotomy or cervical laminectomy in the sitting position. mandatory before CVC insertion, but in clinical practice, it is These patients are at risk for air embolism, and the catheter not that straightforward. CVC insertions in the ICU are ex- can be used to aspirate air from the right ventricle [18]. N eu- tremely common, occur at all hours of the day, and may be rosurgery is the only common indication for (but used only crucial for early and appropriate resuscitation and commence- rarely) antecubital approach, as IJV catheters are in the op- ment of care. M any critically ill patients, especially in urban erative eld and theoretically can obstruct blood return from settings, have no available family members or legal net of kin. the cranial vault and increase intracranial pressure. Subclavian O btaining informed consent for these patients may inappro- catheters are an excellent alternative for preoperative neurosur- priately delay completion of the procedure and impact quality gical patients if pneumothorax is ruled out prior to induction of care. Because of these considerations, there is no uniform of general anesthesia. clinical or legal opinion regarding the necessity of individual Venous access during cardiopulmonary resuscitation war- informed consent prior to all CVC insertions or other ICU pro- rants special comment. Peripheral vein cannulation in circula- cedures [25]. Some institutions have dealt with this matter by tory arrest may prove impossible, and circulation times of drugs developing a single general “ consent form for critical care” administered peripherally are prolonged when compared with that is signed one time for each individual ICU admission and central injection [19]. Drugs injected through femoral catheters covers all commonly performed bedside procedures. A recent also have a prolonged circulation time unless the catheter tip review reported that 14% of all surveyed ICUs used such a is advanced beyond the diaphragm, although the clinical sig- consent form, and overall consent practice varied widely. In ni cance of this is debated. Effective drug administration is general, providers in medical ICUs sought consent for CVC in- an extremely important element of successful cardiopulmonary sertion more often than providers in surgical ICUs [25]. Given resuscitation, and all physicians should understand the appro- the lack of agreement on this topic, it seems prudent to make priate techniques for establishing venous access. It is logical to a few recommendations: (1) Written informed consent should establish venous access as quickly as possible, either peripher- be obtained prior to all truly elective CVC insertion or other ally or centrally if quali ed personnel are present. Prolonged procedures (2). Whenever possible, competent patients or le- attempts at arm vein cannulation are not warranted, and un- gal next of kin of incompetent/incapacitated patients should der these circumstances, the FV is a good alternative. Despite be thoroughly informed of the indications, risks, and bene ts the potential of longer drug circulation times, the FV is rec- of emergency CVC insertion prior to the performance of the ommended for access in a code situation as cardiopulmonary procedure. If informed consent is not possible prior to CVC resuscitation (CPR) is interrupted the least with its placement. insertion, then consent should be obtained as soon as possi- If circulation is not restored after administration of appropriate ble after completion of the procedure. A signed consent form tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 19 is always preferable, but sometimes not feasible. O ral consent ultrasound plane and appears as single bright echogenic foci on should be documented in the procedure note by the person ultrasound image. N eedle position may be better ascertained obtaining assent. (3) Emergent CVC placement should not be by slightly moving the needle back and forth displacing the delayed inappropriately by efforts to obtain consent—oral or surrounding soft tissue and possible tenting of vessel wall. It is written. Patients and family should be told as soon as possible important to note the depth of the vessel on the ultrasound im- after insertion why the CVC was required. (4) A general con- age to be mindful of how far to penetrate safely with the needle. sent form that is signed one time as close as possible to ICU The return of blood ow con rms intravascular placement of admission is a reasonable way to try and inform patients of the the needle tip, and CVC placement may proceed in the usual bene ts/risks of procedures without incurring unnecessary de- fashion. It is good practice to con rm guidewire placement lays or consumption of clinical time. This form can also serve within the vein as well. The longitudinal approach gives more as a useful reference for patients and families of all the various information but is more dif cult. When using the longitudinal common procedures that are performed in the ICU. (5) Finally, approach, the plane of the ultrasound and of the needle must it is good practice to document the practice that is used in the be perfectly aligned and is best for one operator to be holding ICU “ Policies and Procedures” book and the rationale for it. both probe and needle. First, the vein artery must be visualized using the transverse view. The probe should then be turned 90 degrees to image just the vein in the long-axis view. Enter the Patient Comfort and Safety skin just adjacent to the probe at a 45-degree angle. The needle and needle tip can be directly viewed as it is advanced through M any patients requiring CVC have an unstable airway or are the vessel. O nce in place, advance the guidewire under direct hemodynamically unstable. These considerations should im- visualization. pact preparation and choice of site. For example, many pa- tients are claustrophobic and will not tolerate their face being covered; others who are dyspneic will not tolerate lying at. Mobile Catheter Cart In our experience, signi cant physiologic decompensation or even “ code blues” may occur during CVC placement because Availability of a mobile catheter cart that contains all neces- the operator is focused on establishing access and/or interprets sary supplies and that can be wheeled to the patient’s bedside the silent patient as one who is having no problems. Every is good practice and likely reduces overall catheter infection patient should be speci cally assessed prior to CVC regarding rate by decreasing breaks in sterile technique [26]. In our expe- their positioning, airway, and hemodynamic stability. O n more rience, the mobile cart is also an excellent way to standardize than one occasion, we have placed a femoral catheter because all catheter insertions, facilitate communication of procedural a patient could not lie at or needed emergency venous access tasks (such as use of a time-out), and allow for staff to timely for endotracheal intubation. O nce the patient is stabilized, the complete mandatory forms. appropriate site/catheter can then be inserted under less unsta- ble/rigorous conditions. Catheter Tip Location Ultrasound Preparation Catheter tip location is a very important consideration in CVC placement. The ideal location for the catheter tip is the dis- Ultrasound enables immediate identi cation of anatomic varia- tal innominate or proximal superior vena cava (SVC), 3 to tion, con rmation of vessel patency, and direct visualization of 5 cm proximal to the caval–atrial junction. Positioning of the the needle entering the vessel. The difference between vein and catheter tip within the right atrium or right ventricle should artery can be determined by compressibility, shape, Doppler be avoided. Cardiac tamponade secondary to catheter tip per- ow, and increasing size with the Valsalva or other maneuvers. foration of the cardiac wall is uncommon, but two thirds of Veins are usually ovoid in shape, completely compressible, and patients suffering this complication die [27]. Perforation likely have thin walls; in contrast, arteries are circular, dif cult to results from vessel wall damage from infused solutions com- compress, and have thick walls. bined with catheter tip migration that occurs from the motion When performing ultrasound, the same general technique is of the beating heart as well as patient arm and neck movements. followed regardless of the site of puncture [6]. A quick, nonster- M igration of catheter tips can be impressive: 5 to 10 cm with ile survey should be made with the vascular probe to quickly antecubital catheters and 1 to 5 cm with IJV or SCV catheters identify the presence of a suitable vein for catheterization. After [28,29]. O ther complications from intracardiac catheter tip po- sterile preparation of the patient and site, the vascular probe sition include provocation of arrhythmias from mechanical irri- should be used with a sterile probe cover kit. This kit contains tation and infusion of caustic medications or unwarmed blood a sterile sleeve, sterile jelly, and rubber bands. To apply the [30]. sterile sleeve, have an assistant place nonsterile jelly inside the Correct placement of the catheter tip is relatively simple, sleeve and then place probe in the sleeve. Extend the sleeve beginning with an appreciation of anatomy. The caval–atrial over the cord and fasten the sleeve with rubber bands. O ne junction is approximately 16 to 18 cm from right-sided skin band should be fastened toward the head of the probe to en- punctures and 19 to 21 cm from left-sided insertions and is rel- sure the jelly remains in place for optimal imaging. Sterile jelly atively independent of patient gender and body habitus [31,32]. is then applied to the tip of probe on the outside of sleeve. Insertion of a standard 20-cm triple-lumen catheter to its full The target vessels may be visualized using a transverse or length frequently places the tip within the heart, especially fol- longitudinal view. The transverse approach is technically eas- lowing right-sided insertions. A chest radiograph should be ier than the longitudinal approach and is the best approach for obtained following every initial CVC insertion to ascertain beginners. The transverse view allows identi cation of the tar- catheter tip location and to detect complications. The right get vein in relation to the artery, which helps decrease risk of tracheobronchial angle is the most reliable landmark on plain unintentional puncture of the artery. O nce identi ed, the vein lm chest X-ray for the upper margin of the SVC, and is always should be centered underneath the probe. An 18-gauge needle at least 2.9 cm above the caval–atrial junction. The catheter tip should slowly be advanced with the skin puncture site proxi- should lie about 1 cm below this landmark, and above the mal to the probe, so that vessel puncture is directly visualized. right upper cardiac silhouette to ensure placement outside of With this approach, the needle traverses diagonally across the the pericardium [33]. tahir99-VRG & vip.persianss.ir 20 Section I: Procedures, Techniques, and Minimally Invasive Monitoring cannulation under ultrasound guidance has proven to be very Vascular Erosions safe, while the FV offers a viable alternative for general-purpose venous access. In nonemergent patients, peripherally inserted Large-vessel perforations secondary to CVCs are uncommon central venous catheters (PICC) can be used. and often not immediately recognized. Vessel perforation typ- ically occurs 1 to 7 days after catheter insertion. Patients usu- ally present with sudden onset of dyspnea and often with new pleural effusions on chest radiograph [34]. Catheter stiffness, Thrombosis position of the tip within the vessel, and the site of insertion are important factors causing vessel perforation. The relative Catheter-related thrombosis is very common but usually of importance of these variables is unknown. Repeated irritation little clinical signi cance. The spectrum of thrombotic compli- of the vessel wall by a stiff catheter tip or infusion of hyperos- cations includes a brin sleeve surrounding the catheter from molar solutions may be the initiating event. Vascular erosions its point of entry into the vein distal to the tip, mural thrombus, are more common with left IJV and EJV catheters, because for a clot that forms on the wall of the vein secondary to mechani- anatomical reasons the catheter tip is more likely to be posi- cal or chemical irritation, or occlusive thrombus, which blocks tioned laterally under tension against the SVC wall [35]. Posi- ow and may result in collateral formation. All of these lesions tioning of the catheter tip within the vein parallel to the vessel are usually clinically silent; therefore, studies that do not use wall must be con rmed on chest radiograph. Free aspiration venography or color ow Doppler imaging to con rm the di- of blood from one of the catheter ports is not always suf cient agnosis underestimate its incidence. Using venography, brin to rule out a vascular perforation. sleeve formation can be documented in a majority of catheters, mural thrombi in 10% to 30% , and occlusive thrombi in 0% to 10% [40–45]. In contrast, clinical symptoms of thrombosis occur in only 0% to 3% of patients. The incidence of thrombo- Air and Catheter Embolism sis probably increases with duration of catheterization but does not appear reliably related to the site of insertion. H owever, the Signi cant air and catheter embolism are rare and preventable clinical importance of femoral vein catheter-associated throm- complications of CVC. Catheter embolism can occur at the bosis compared to upper extremity thrombosis caused by IJ time of insertion when a catheter-through- or over-needle tech- and SCV catheters is unknown [46]. The presence of catheter- nique is used and the operator withdraws the catheter without associated thrombosis is also associated with a higher incidence simultaneously retracting the needle. It more commonly occurs of infection [47]. with antecubital or femoral catheters after insertion, because they are prone to breakage when the agitated patient vigorously bends an arm or leg. Prevention, recognition, and management of catheter embolism are covered in detail elsewhere [36]. ROUTES OF CEN TRAL VEN OUS Air embolism is of greater clinical importance, often goes CAN N ULATION undiagnosed, and may prove fatal. This complication is totally preventable with compulsive attention to proper catheter inser- tion and maintenance. Factors resulting in air embolism dur- Antecubital Approach ing insertion are well known, and methods to increase venous The antecubital veins are used in the ICU for CVC with PICC pressure, such as use of the Trendelenburg position, should and midline catheters. Use of PICCs in critically ill adults is be- not be forgotten. Catheter disconnection and passage of air coming increasingly important. Specialized nursing teams are through a patent tract after catheter removal are more com- now able to insert PICCs at beside with use of real-time ultra- mon causes of catheter-associated air embolism. An air embo- sonography and sterile technique thereby increasing safety and lus should be suspected in any patient with an indwelling or reducing the potential for infection. There are now triple lu- recently discontinued CVC who develops sudden unexplained men catheters that may be inserted with this approach. PICCs hypoxemia or cardiovascular collapse, often after being moved may be useful in ICU patients undergoing neurosurgery, with or transferred out of bed. A characteristic mill wheel sound may coagulopathy, or in the rehabilitative phase of critical illness be auscultated over the precordium. Treatment involves plac- for which general purpose central venous access is required for ing the patient in the left lateral decubitus position and using parenteral nutrition or long-term medication access (Table 2.1) the catheter to aspirate air from the right ventricle. H yper- [48,49]. Although many hospitals have a designated “ PICC” baric oxygen therapy to reduce bubble size has a controversial insertion team, they may have signi cant work hour limitations role in treatment [37]. The best treatment is prevention which that delay insertion of catheters and result in signi cant delays can be effectively achieved through comprehensive nursing and in delivery of care or throughput. For that reason, we believe physician-in-training educational modules and proper supervi- intensivists should be familiar with the antecubital route, and sion of inexperienced operators [38]. as a result, the technique of percutaneous insertion of catheters using the basilic vein is described later. Coagulopathy Anatomy Central venous access in the patient with a bleeding diathesis The basilic vein is preferred for CVC because it is almost always can be problematic. The SCV and IJV routes have increased of substantial size and the anatomy is predictable. The basilic risks in the presence of coagulopathy, but the true risk is fre- vein provides an unimpeded path to the central venous circula- quently overestimated and it is not known at what degree of tion via the axillary vein [50,51]. The basilic vein is formed at abnormality it becomes unacceptable. A coagulopathy is gener- the ulnar aspect of the dorsal venous network of the hand. It ally de ned as an international normalized ratio (IN R) greater may be found in the medial part of the antecubital fossa, where than 1.5 or platelet count less than 50,000. Although it is it is usually joined by the median basilic vein. It then ascends clear that safe venipuncture is possible (even with the subcla- in the groove between the biceps brachii and pronator teres on vian approach) with greater degrees of coagulopathy [39], the the medial aspect of the arm to perforate the deep fascia distal literature is also fraught with case reports of serious hemor- to the midportion of the arm, where it joins the brachial vein rhagic complications. In patients with severe coagulopathy, IJV to become the axillary vein. tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 21 Technique of Cannulation the catheter cannot be advanced easily, another site should be chosen. Several kits are available for antecubital CVC. The PICC and midline catheters are made of silicone or polyurethane and, depending on catheter stiffness and size, are usually placed Success Rate and Complications through an introducer. The method described below is for a Using the above-mentioned technique, PICC catheters have a PICC inserted through a tear-away introducer. 75% to 95% successful placement rate. O verall, PICCs ap- The success rates from either arm are comparable, though pear to be at least as safe as CVCs, but important compli- the catheter must traverse a greater distance from the left. With cations include sterile phlebitis, thrombosis (especially of the the patient’s arm at his or her side, the antecubital fossa is SCV and IJV), infection, limb edema, and pericardial tampon- prepared with chlorhexidine and draped using maximum bar- ade. Phlebitis may be more common with antecubital CVCs, rier precautions (mask, cap and sterile gown, gloves and large probably due to less blood ow in these veins as well as the drape covering the patient). A tourniquet is placed proximally proximity of the venipuncture site to the skin [52,53]. The risk by an assistant and a portable ultrasound device used to iden- of pericardial tamponade may also be increased if the catheter tify the basilic or its main branches. A vein can be distinguished tip is inserted too deep because of greater catheter tip migra- from an artery by visualizing compressibility, color ow, and tion occurring with arm movements [54]. Complications are Doppler ow (Fig. 2.1). After a time-out and administration minimized by strict adherence to recommended techniques for of local anesthesia subcutaneously, venipuncture is performed catheter placement and care. with the thin wall entry needle a few centimeters proximal to the antecubital crease to avoid catheter breakage and em- bolism. When free back ow of venous blood is con rmed, the tourniquet is released and the guidewire carefully threaded into Internal Jugular Approach the vein for a distance of 15 to 20 cm. Leaving the guidewire in place, the thin-wall needle is withdrawn and the puncture site The IJV has been used for venous access in pediatric and adult enlarged with a scalpel blade. The sheath-introducer assem- patients for many years but its use in some circumstances has bly is threaded over the guidewire with a twisting motion, and been limited by a relatively lower rate of success due to its com- the guidewire removed. N ext, leaving the sheath in place, the pressibility and propensity to collapse in hypovolemic condi- dilator is removed, and the introducer is now ready for PICC tions. In our opinion, ultrasound has had its greatest impact by insertion. The length of insertion is estimated by measuring improving the ef ciency of IJV cannulation, since real-time di- the distance along the predicted vein path from the venipunc- rect visualization of the vein is easily obtained. This minimizes ture site to the manubriosternal junction, using the measuring the impact of hypovolemia or anatomical variations on overall tape provided in the kit. The PICC is typically supplied with success, and has rendered the need for EJV catheterization al- an inner obturator that provides stiffness for insertion. The most extinct. Furthermore, under ultrasound guidance, the cen- PICC is trimmed to the desired length and ushed with saline tral approach is almost always used, and as a result, we will no and the obturator is inserted into the PICC up to the tip. The longer review the anterior or posterior approaches. In general, PICC/obturator assembly is inserted through the introducer to these techniques will differ only in the point of skin puncture the appropriate distance, the introducer peeled away, and the (Fig. 2.2), and readers are referred to previous editions of this obturator removed. The PICC is secured in place and a chest text for a thorough description of these approaches. X-ray obtained to determine tip position. If resistance to advancing the PICC is met, options are lim- Anatomy ited. Techniques such as abducting the arm are of limited value. The IJV emerges from the base of the skull through the jugular If a catheter-through- or over-needle device has been used, the foramen and enters the carotid sheath dorsally with the inter- catheter must never be withdrawn without simultaneously re- nal carotid artery (ICA). It then courses posterolaterally to the tracting the needle to avoid catheter shearing and embolism. If artery and runs beneath the sternocleidomastoid (SCM ) mus- cle. The vein lies medial to the anterior portion of the SCM muscle superiorly and then runs beneath the triangle formed by the two heads of the muscle in its medial portion before entering the SCV near the medial border of the anterior sca- lene muscle at the sternal border of the clavicle. The junction of the right IJV (which averages 2 to 3 cm in diameter) with the right SCV forming the innominate vein follows a straight path to the SVC. As a result, catheter malposition and looping of the catheter inserted through the right IJV are unusual. In contrast, a catheter passed through the left IJV must negotiate a sharp turn at the left jugulosubclavian junction, which re- sults in a greater percentage of catheter malpositions [55]. This sharp turn may also produce tension and torque at the catheter tip, resulting in a higher incidence of vessel erosion. Knowledge of the structures neighboring the IJV is essential as they may be compromised by a misdirected needle. The ICA runs medial to the IJV but, rarely, may lie directly posterior or, rarely, anterior. Behind the ICA, just outside the sheath, lie the stellate ganglion and the cervical sympathetic trunk. The dome of the pleura, which is higher on the left, lies caudal to the junction of the IJV and SCV. Posteriorly, at the root of the neck, course the phrenic and vagus nerves. The thoracic duct lies posterior to the left IJV and enters the superior margin of the FIGURE 2.1. Ultrasound view of the basilica vein at the antecubital SCV near the jugulosubclavian junction. The right lymphatic fossa. duct has the same anatomical relationship but is much smaller, tahir99-VRG & vip.persianss.ir 22 Section I: Procedures, Techniques, and Minimally Invasive Monitoring A B C D FIGURE 2.2. Surface anatomy and various approaches to cannulation of the internal jugular vein. A: Surface anatomy. B: Anterior approach. C: Central approach. D: Posterior approach. The external jugular vein is also shown. and chylous effusions typically occur only with left-sided IJV The IJV is usually readily identi ed by ultrasound (Fig. 2.3), cannulations. and if the anatomy is normal and the IJV of substantial size, use of a nder needle is not required. The operator can directly visualize the needle entering the vein, and then proceed with Technique of Cannulation insertion of the guidewire and catheter as described later. It With careful preparation of equipment and attention to patient is important not to be “ mesmerized” or to have a false sense comfort and safety as described earlier, the patient is placed in a of con dence because ultrasound is being used. Always follow 15-degree Trendelenburg position to distend the vein and min- standard catheterization technique and always con rm (using imize the risk of air embolism. The head is turned gently to multiple techniques) venous puncture. For example, it is good the contralateral side. The surface anatomy is identi ed, espe- practice to document that the needle or short cannula is in the cially the angle of the mandible, the two heads of the SCM , the IJV through the use of manometry or to visualize the guidewire clavicle, the EJV, and the trachea (Fig. 2.2). We recommend pre- within the vein by using ultrasound before proceeding with liminary ultrasound examination of the IJV before skin prepa- catheter insertion. ration to quickly identify anatomical variations and suitability If ultrasound is unavailable, skin puncture is at the apex for catheterization. The probe should initially be placed in the of the triangle formed by the two muscle bellies of the SCM center of the triangle formed by the clavicle and two heads of and the clavicle. The ICA pulsation is usually felt 1 to 2 cm the SCM . If on the ultrasound the IJV is very small, throm- medial to this point, beneath or just medial to the sternal head bosed, or there is a signi cant anatomical variant, it is best to of the SCM . The skin at the apex of the triangle is in ltrated choose another site since successful cannulation is directly de- with 1% lidocaine using the smallest needle available. Use of a pendent on cross-sectional luminal size of the vessel. The neck small-bore nder needle to locate the IJV should prevent unin- is then prepared with chlorhexidine and fully draped, using tentional ICA puncture and unnecessary probing with a larger maximum barrier precautions. Before the procedure is begun, bore needle. To avoid collapsing the IJV, the operator should a time-out is performed. maintain minimal to no pressure on the ICA with the left hand tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 23 perforation. Furthermore, if the patient has an IVC lter in place, the guidewire can become entangled in the lter. O cca- sionally, the guidewire does not pass easily beyond the tip of the thin-wall needle. The guidewire should then be withdrawn, the syringe attached, and free back ow of blood reestablished and maintained while the syringe and needle are brought to a more parallel plane with the vein. The guidewire should then pass easily. If resistance is still encountered, rotation of the guidewire during insertion often allows passage, but extensive manipulation and force lead only to complications. With the guidewire in place, a scalpel is used to make two 90-degree stab incisions at the skin entry site to facilitate pas- sage of the 7-Fr vessel dilator. The dilator is inserted down the wire to the hub, ensuring that control and sterility of the guidewire is not compromised. The dilator is then withdrawn and pressure used at the puncture site to control oozing and prevent air embolism down the needle tract. The proximal and middle lumens of a triple-lumen catheter are ushed with saline and capped. The catheter is then inserted over the guidewire, ensuring that the operator has control of the guidewire, either proximal or distal to the catheter, at all times to avoid intravas- cular loss of the wire. The catheter is then advanced 15 to 17 cm (17 to 19 cm for left IJV) into the vein, the guidewire withdrawn, and the distal lumen capped. The catheter is su- tured securely to limit tip migration and bandaged in a stan- FIGURE 2.3. Ultrasound appearance of the right internal jugular vein dard manner. A chest radiograph should be obtained to detect and normal relationship with the internal carotid artery. complications and tip location. and insert the nder needle with the right hand at the apex Success Rates and Complications of the triangle at a 45-degree angle with the frontal plane, di- N on–ultrasound-guided IJV catheterization is associated with rected at the ipsilateral nipple. The needle is advanced steadily a high rate of successful catheter placement. Elective proce- with constant negative pressure in the syringe, and venipunc- dures are successful more than 90% of the time, generally ture occurs within 1 to 5 cm. If venipuncture does not occur within the rst three attempts, and catheter malposition is rare. on the initial attempt, negative pressure should be maintained Use of ultrasound clearly improves the success rate, decreases and the needle slowly withdrawn, as often, the needle will the number of attempts and complications, avoids unnecessary compress the vein on advancement and penetrate the back procedures by identifying unsuitable anatomy, and minimally wall without blood return. O nce the needle is pulled back past impacts insertion time. Emergent IJV catheterization is less suc- the posterior wall of the vessel, it achieves free ow of blood cessful and is not the preferred technique during airway emer- from the vessel. If the rst attempt is unsuccessful, the operator gencies or other situations that may make it dif cult to identify should reassess patient position, landmarks, and techniques to landmarks in the neck. ensure that he or she is not doing anything to decrease IJV The incidence and types of complications are similar regard- lumen size (see later). Subsequent attempts may be directed less of the approach. O perator inexperience appears to increase slightly laterally or medially to the initial direction, as long the number of complications, but to an unde ned extent, and as the ICA is not entered. If venipuncture does not occur af- probably does not have as great an impact as it does on the ter three to ve attempts, further attempts are unlikely to be incidence of pneumothorax in subclavian venipuncture [60]. successful and only increase complications [56–58]. The overall incidence of complications in IJV catheteriza- When venipuncture has occurred with the nder needle, the tion (without ultrasound guidance) is 0.1% to 4.2% . Impor- operator can either withdraw the nder needle and introduce tant complications include ICA puncture, pneumothorax, ves- the large-bore needle in the identical plane or leave the nder sel erosion, thrombosis, and infection. Although the impact of needle in place and introduce the larger needle directly superior ultrasound use on other complications has not been conclu- to it. Leaving the nder needle in place has been shown to facil- sively demonstrated, it has been shown to signi cantly reduce itate successful puncture with the introducer needle [59]. M any the number of attempts and the incidence of arterial puncture, kits provide both an 18-gauge thin-wall needle through which a which is by far the most common complication [6]. In the ab- guidewire can be directly introduced and a 16-gauge catheter- sence of a bleeding diathesis, arterial punctures are usually be- over-needle device. With the latter apparatus, the catheter is nign and are managed conservatively by applying local pressure threaded over the needle into the vein, the needle withdrawn, for 10 minutes. Even in the absence of clotting abnormalities, and the guidewire inserted through the catheter. Both tech- a sizable hematoma may form, frequently preventing further niques are effective; the choice is strictly a matter of operator catheterization attempts or, rarely, exerting pressure on vital preference. Regardless of which large-bore needle is used, once neck structures [61,62]. Unrecognized arterial puncture can venipuncture has occurred the syringe is removed after ensur- lead to catheterization of the ICA with a large-bore catheter ing that the back ow of blood is not pulsatile and the hub is or introducer and can have disastrous consequences, especially then occluded with a nger to prevent air embolism or excessive if heparin is subsequently administered [63]. M anagement of bleeding. The guidewire, with the J-tip oriented appropriately, carotid cannulation with a large-bore catheter, such as a 7-Fr in- is then inserted and should pass freely up to 20 cm, at which troducer, is controversial. O ptions include pulling the catheter point the thin-wall needle or catheter is withdrawn. The ten- and applying pressure, percutaneous closure devices, internal dency to insert the guidewire deeper than 15 to 20 cm should stent grafting, or surgical repair [64,65]. Some experts ad- be avoided, as it is the most common cause of ventricular ar- vise administration of anticoagulants to prevent thromboem- rhythmias during insertion and also poses a risk for cardiac bolic complications, whereas others advise the opposite. O ur tahir99-VRG & vip.persianss.ir 24 Section I: Procedures, Techniques, and Minimally Invasive Monitoring approach is to remove small bore catheters and avoid hep- vanced in the axis of the vein at 20 degrees to the frontal plane. arinization if possible, as hemorrhage appears to be a greater The EJV may be more dif cult to cannulate than expected be- risk than thromboembolism. For larger bore catheters and cause of its propensity to roll and displace rather than puncture complicated cases, we involve interventional radiology and vas- in response to the advancing needle. A rm, quick thrust is often cular surgery before removal, and individualize the manage- required to effect venipuncture. When free back ow of blood ment based on the circumstances. is established, the needle tip is advanced a few millimeters fur- Pneumothorax, which may be complicated by blood, in- ther into the vein and the catheter is threaded over the needle. fusion of intravenous uid, or tension, is considered an un- The catheter may not thread its entire length because of valves, usual adverse consequence of IJV cannulation; however, it has tortuosity, or the SCV junction, but should be advanced at least an incidence of 1.3% in a large meta-analysis, statistically the 3 to 5 cm to secure venous access. The syringe and needle can same as 1.5% found for subclavian puncture [66]. It usually then be removed and the guidewire, J-tip rst, threaded up to results from a skin puncture too close to the clavicle or, rarely, 20 cm and the catheter removed. M anipulation and rotation from other causes. Logically, ultrasound should decrease or of the guidewire, especially when it reaches the SCV junction, even eliminate pneumothorax as a complication during IJV may be necessary but should not be excessive. Various arm and catheterization. head movements are advocated to facilitate guidewire passage; An extraordinary number of case reports indicate that any abduction of the ipsilateral arm and anterior–posterior pressure complication from IJV catheterization is possible, even the in- exerted on the clavicle may be helpful. O nce the guidewire has trathecal insertion of a pulmonary artery catheter [67]. In real- advanced 20 cm, two 90-degree skin stabs are made with a ity, the IJ route is reliable, with a low incidence of major compli- scalpel, and the vein dilator inserted to its hub, maintaining cations. O perator experience is not as important a factor as in control of the guidewire. The triple-lumen catheter is then in- SCV catheterization; the incidence of catheter tip malposition serted an appropriate length (16 to 17 cm on the right, 18 to is low, and patient acceptance is high. It is best suited for acute, 20 cm on the left). The guidewire is withdrawn, the catheter short-term hemodialysis and for elective or urgent catheteriza- bandaged, and a chest radiograph obtained to screen for com- tions in volume-replete patients, especially pulmonary artery plications and tip placement. catheterizations and insertion of temporary transvenous pace- makers. It is not the preferred site during airway emergencies, Success Rates and Complications for parenteral nutrition, or for long-term catheterization be- Central venous catheterization via the EJV is successful in 80% cause infectious complications are higher with IJV compared of patients (range 75% to 95% ) [68,69]. Inability to perform with SCV catheterizations. venipuncture accounts for up to 10% of failures [70,71] and the remainders are a result of catheter tip malpositioning. Failure to position the catheter tip is usually due to inability to ne- External Jugular Vein Approach gotiate the EJV–SCV junction, loop formation, or retrograde passage down the ipsilateral arm. Serious complications aris- The EJV is now rarely used for CVC, but in selected cases, it ing from the EJV approach are rare and almost always asso- remains an excellent alternative. The main advantages to the ciated with catheter maintenance rather than venipuncture. A EJV route for CVC are that it is part of the surface anatomy, the local hematoma forms in 1% to 5% of patients at the time of risk of hemorrhage is low even in the presence of coagulopathy, venipuncture [72] but has little consequence unless it distorts and the risk of pneumothorax is all but eliminated. The main the anatomy leading to catheterization failure. External jugular disadvantage is the unpredictability of passage of the catheter venipuncture is safe in the presence of coagulopathy. Infectious, to the central compartment. thrombotic, and other mechanical complications are no more frequent than with other central routes. Anatomy The EJV is formed anterior and caudal to the ear at the angle of the mandible by the union of the posterior auricular and Femoral Vein Approach retromandibular veins (Fig. 2.2). It courses obliquely across the anterior surface of the SCM , then pierces the deep fascia The FV has many practical advantages for CVC; it is directly just posterior to the SCM and joins the SCV behind the medial compressible, it is remote from the airway and pleura, the tech- third of the clavicle. In 5% to 15% of patients, the EJV is nique is relatively simple, and the Trendelenburg position is not not a distinct structure but a venous plexus, in which case it required during insertion. During the mid-1950s, percutaneous may receive the ipsilateral cephalic vein. The EJV varies in size catheterization of the IVC via a femoral vein approach became and contains valves throughout its course. Its junction with the popular until 1959 when M oncrief [73] and Bansmer et al. SCV may be at a severe, narrow angle that can be dif cult for [74] reported a high incidence of complications, especially in- a catheter to traverse [50,51]. fection and thrombosis, after which, it was largely abandoned. In the subsequent two decades, FV cannulation was restricted Technique to specialized clinical situations. Interest in short-term (< 48 hour) FV catheterization was renewed by positive experiences The EJV should be cannulated using the 16-gauge catheter- during the Vietnam con ict and with patients in the emergency over-needle, since guidewire manipulations are often necessary, department [75]. Some reports on long-term FV catheteriza- and secure venous access with a catheter is preferable. The pa- tion [76] suggest an overall complication rate no higher than tient is placed in a comfortable supine position with arms to the that with other routes, although deep vein thrombosis remains side and head turned slightly to the contralateral side. The right a legitimate concern. Furthermore, Centers for Disease Control EJV should be chosen for the initial attempt and can be identi- and Prevention (CDC) guidelines for the prevention of catheter- ed where it courses over the anterior portion of the clavicular related bloodstream infection recommend against the use of the belly of the SCM . After skin preparation with chlorhexidine, femoral site for catheterization if possible [77]. use of maximum barrier precautions, administration of local anesthesia subcutaneously and a time-out, venipuncture is per- formed with the 16-gauge catheter-over-needle using the left Anatomy index nger and thumb to distend and anchor the vein. Skin The FV (Fig. 2.4A) is a direct continuation of the popliteal vein puncture should be well above the clavicle and the needle ad- and becomes the external iliac vein at the inguinal ligament. At tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 25 B A FIGURE 2.4. A: Anatomy of the femoral vein. B: Ultrasound appearance of femoral vein and artery. the inguinal ligament, the FV lies within the femoral sheath a pubic tubercle is divided into three equal segments. The femoral few centimeters from the skin surface. The FV lies medial to the artery is usually found where the medial segment meets the femoral artery, which in turn lies medial to the femoral branch two lateral ones, and the FV lies 1 to 1.5 cm medial. Follow- of the genitofemoral nerve. The medial compartment contains ing a time-out, an 18-gauge thin-wall needle is inserted at this lymphatic channels and Cloquet’s node. The external iliac vein point, 2 to 3 cm inferior to the inguinal ligament, ensuring that courses cephalad from the inguinal ligament along the anterior venipuncture occurs caudal to the inguinal ligament, which surface of the iliopsoas muscle to join its counterpart from the minimizes the risk of retroperitoneal hematoma in the event of other leg and form the (IVC) anterior to and to the right of arterial puncture. While maintaining constant back pressure the fth lumbar vertebra. Using ultrasound, the femoral vein on the syringe, the needle, tip pointed cephalad, is advanced can be readily identi ed by placing the probe a few centime- at a 45-degree angle to the frontal plane. Insertion of the nee- ters caudal to the inguinal ligament, just medial to the arterial dle to its hub is sometimes required in obese patients. Blood pulsation (Fig. 2.4B). return may not occur until slow withdrawal. If the initial at- tempt is unsuccessful, landmarks should be reevaluated and subsequent attempts oriented slightly more medial or lateral. Technique A common error is to direct the needle tip too medially, toward Femoral vein cannulation is the easiest of all central venous the umbilicus. The femoral vessels lie in the sagittal plane at the procedures to learn and perform. Either side is suitable, and inguinal ligament (Fig. 2.4), and the needle should be directed the side chosen is based on operator convenience. Ultrasound accordingly. If unintentional arterial puncture occurs, pressure guidance is not usually required but for elective situations, we is applied for 5 to 10 minutes. believe it is optimal practice. Ultrasound con rms the anatomy, When venous blood return is established, the syringe angle identi es the depth needed for venipuncture, rules out preexist- is depressed slightly and free aspiration of blood recon rmed. ing thrombosis, and should not unduly delay time to catheter- The syringe is removed, ensuring that blood return is not pul- ization. It may be particularly useful in the obese [21]. The pa- satile. The guidewire should pass easily and never forced, al- tient is placed in the supine position (if tolerated) with the leg though rotation and minor manipulation are sometimes re- extended and slightly abducted at the hip. Excessive hair should quired. The needle is then withdrawn, two scalpel blade stab be clipped with scissors and the skin prepped with chlorhex- incisions made at 90 degrees at the guidewire insertion site, idine. M aximum barrier precautions should be used. The FV and the vein dilator inserted over the wire to the hub. The dila- lies 1 to 1.5 cm medial to the arterial pulsation, and the over- tor is then withdrawn and a catheter appropriate to clinical lying skin is in ltrated with 1% lidocaine. In a patient without requirements inserted, taking care never to lose control of the femoral artery pulsations, the FV can be located by dividing guidewire. The catheter is secured with a suture and bandage the distance between the anterior superior iliac spine and the applied. tahir99-VRG & vip.persianss.ir 26 Section I: Procedures, Techniques, and Minimally Invasive Monitoring Success Rate and Complications thrombosis occurs with similar frequency as with IJ and SV catheters, but it may be more clinically relevant. FV catheterization is successful in 90% to 95% of patients, including those in shock or cardiopulmonary arrest [77,78]. Unsuccessful catheterizations are usually a result of venipunc- ture failure, hematoma formation, or inability to advance the guidewire into the vein. O perator inexperience may increase Subclavian Vein Approach the number of attempts and complication rate but does not This route has been used for central venous access for many appear to signi cantly decrease the overall success rate. years and is associated with the most controversy, largely be- Three complications occur regularly with FV catheteriza- cause of the relatively high incidence of pneumothorax and the tion: arterial puncture with or without local bleeding, infection, occasional mortality associated with it. With the added safety and thromboembolic events. O ther reported complications are of ultrasound-guided IJV catheterization, there has been some rare and include scrotal hemorrhage, right lower quadrant debate about abandonment of landmark guided SCV catheter- bowel perforation, retroperitoneal hemorrhage, puncture of ization. Ultrasound guidance is possible with the SCV, but it the kidney, and perforation of IVC tributaries. These com- is more technically demanding and may require a different site plications occur when skin puncture sites are cephalad to the for venipuncture [12]. Given these factors, we still believe the inguinal ligament or when long catheters are threaded into the SCV is a valuable alternative in certain situations for experi- FV. enced operators, who should have a pneumothorax rate well Femoral artery puncture occurs in 5% to 10% of under 1% . Inexperienced operators have a far greater rate of adults. M ost arterial punctures are uncomplicated, but major pneumothorax; therefore, in settings where relatively inexperi- hematomas may form in 1% of patients, especially in the pres- enced physicians perform the majority of CVC, the SCV should ence of anticoagulants, brinolytics, or antithrombotic agents. be used more selectively or perhaps, not at all. The advantages As is the case with other routes, ultrasound should essentially of this route include consistent identi able landmarks, easier eliminate this complication. Even in the presence of coagu- long-term catheter maintenance with a comparably lower rate lopathy, arterial puncture with the 18-gauge thin-wall needle of infection, and relatively high patient comfort. Assuming an is usually of minor consequence, but there is a potential for experienced operator is available, the SCV is the preferred site life-threatening thigh or retroperitoneal hemorrhage [79]. Ar- for CVC in patients with hypovolemia, for long-term total par- teriovenous stula and pseudoaneurysm are rare chronic com- enteral nutrition (TPN ), and in patients with elevated intracra- plications of arterial puncture; the former is more likely to oc- nial pressure who require hemodynamic monitoring. It should cur when both femoral vessels on the same side are cannulated not be considered the primary choice in the presence of throm- concurrently [80]. bocytopenia (platelets < 50,000), for acute hemodialysis, or in Infectious complications with FV catheters are probably patients with high PEEP (i.e., > 12 cm H 2 O ). more frequent than SCV catheters but comparable to IJV catheters [81–83]. M odern series involving both short- and long-term FV catheterization in adults and children have re- ported signi cant CRI rates of about 5% or less [77,84]. Fur- Anatomy ther evidence that the inguinal site is not inherently “ dirty” is The SCV is a direct continuation of the axillary vein, begin- provided by experience with femoral artery catheters, which ning at the lateral border of the rst rib, extending 3 to 4 cm have an infection rate comparable to that with radial artery along the undersurface of the clavicle and becoming the bra- catheters [85]. Although more recent reports suggest that a chiocephalic vein where it joins the ipsilateral IJV at Pirogoff’s catheter properly placed and cared for has a similar rate of in- con uence behind the sternoclavicular articulation (Fig. 2.5). fection regardless of venipuncture site, CDC guidelines recom- The vein is 1 to 2 cm in diameter, contains a single set of mend avoidance of the femoral site unless absolutely necessary valves just distal to the EJV junction, and is xed in position [77,86]. directly beneath the clavicle by its brous attachments. These Two reports in 1958 highlighted the high incidence of FV attachments prevent collapse of the vein, even with severe vol- catheter-associated deep venous thrombosis, but these studies ume depletion. Anterior to the vein throughout its course lie were primarily autopsy based and prior to modern techno- the subclavius muscle, clavicle, costoclavicular ligament, pec- logical advances. Catheter-associated thrombosis is a risk of toralis muscles, and epidermis. Posteriorly, the SCV is separated all CVCs, regardless of the site of insertion, and comparative from the subclavian artery and brachial plexus by the anterior studies using contrast venography, impedance plethysmogra- scalenus muscle, which is 10 to 15 mm thick in the adult. Poste- phy, or Doppler ultrasound suggest that FV catheters are no rior to the medial portion of the SCV are the phrenic nerve and more prone to thrombosis than upper extremity catheters. Pul- internal mammary artery as they pass into the thorax. Supe- monary emboli have been reported following CVC-associated riorly, the relationships are the skin, platysma, and super cial upper extremity thrombosis [46] and the relative risk of aponeurosis. Inferiorly, the vein rests on the rst rib, Sibson’s femoral catheter-related thrombosis is unknown. Clearly, the fascia, the cupola of the pleura (0.5 cm behind the vein), and potential thromboembolic complications of FV catheters can- pulmonary apex [88]. The thoracic duct on the left and right not be discounted [87], but they do not warrant total aban- lymphatic duct cross the anterior scalene muscle to join the donment of this approach. superior aspect of the SV near its union with the IJV. In summary, available evidence supports the view that the The clavicle presents a signi cant barrier for ultrasound vi- FV may be cannulated safely in critically ill adults. It is partic- sualization of the SCV, which mandates using a different ap- ularly useful for inexperienced operators because of the high proach [12]. Typically, we identify the axillary/subclavian vein rate of success and lower incidence of major complications. FV junction by placing the probe inferior to the clavicle in the del- catheterizations may be performed during airway emergencies topectoral groove. We usually initially produce an axial view and cardiopulmonary arrest, in patients with coagulopathy, in of the vein by placing the probe in the cranial–caudal direction. patients who are unable to lie at, and for access during re- The probe is then rotated 90 degrees to produce a longitudinal nal replacement therapy. The most common major complica- view of the vein, which is maintained during venipuncture and tion during FV catheterization is arterial puncture, which can guidewire insertion (Fig. 2.6). Although this method is usu- be lessened or eliminated by ultrasound guidance. Infection is ally successful it tends to be more time consuming and in our no more common than with IJV catheters. Catheter-associated experience, not as useful. tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 27 FIGURE 2.5. Anatomy of the subclavian vein and adjacent structures. Technique the manubriosternal junction. For the infraclavicular approach Although there are many variations, the SCV may be can- (Fig. 2.7), the operator is positioned next to the patient’s shoul- nulated using surface landmarks by two basic techniques: der on the side to be cannulated. For reasons cited earlier, the the infraclavicular [89] or supraclavicular [90,91] approach left SCV should be chosen for pulmonary artery catheteriza- (Fig. 2.7). The differences in success rate, catheter tip malposi- tion; otherwise, the success rate appears to be equivalent re- tion, and complications between the two approaches are neg- gardless of the side chosen. Skin puncture is 2 to 3 cm cau- ligible, although catheter tip malposition and pneumothorax dal to the clavicle at the deltopectoral groove, corresponding may be less likely with supraclavicular cannulation [92,93]. In to the area where the clavicle turns from the shoulder to the general, when discussing the success rate and incidence of com- manubrium. Skin puncture should be distant enough from the plications of SV catheterization, there is no need to specify the clavicle to avoid a downward angle of the needle in clearing approach used. the inferior surface of the clavicle, which also obviates any The 18-gauge thin-wall needle is preferable for SCV can- need to bend the needle. The path of the needle is toward the nulation. The patient is placed in a 15- to 30-degree Trende- suprasternal notch. Using maximum barrier precautions, the lenburg position, and in our experience, use of a small bedroll skin is prepped with chlorhexidine. After skin in ltration and between the scapulae tends move the humeral head out of the liberal injection of the clavicular periosteum with 1% lidocaine plane of needle insertion. The head is turned slightly to the and a time-out, the 18-gauge thin-wall needle is mounted on contralateral side and the arms are kept to the side. The perti- a 10-mL syringe. Skin puncture is accomplished with the nee- nent landmarks are the clavicle, the two muscle bellies of the dle bevel up, and the needle is advanced in the plane already SCM , the suprasternal notch, the deltopectoral groove, and described until the tip abuts the clavicle. The needle is then A B FIGURE 2.6. Ultrasound view of the subclavian vein. A: Axial view; B: longitudinal view. See text for details. tahir99-VRG & vip.persianss.ir 28 Section I: Procedures, Techniques, and Minimally Invasive Monitoring A B FIGURE 2.7. A: Patient positioning for subclavian cannulation. B: Cannulation technique for supraclav- icular approach. “ walked” down the clavicle until the inferior edge is cleared. puncture is the claviculosternocleidomastoid angle, just above To avoid pneumothorax, it is imperative the needle stay parallel the clavicle and lateral to the insertion of the clavicular head of to the oor and not angle down toward the chest. This is accom- the SCM . The needle is advanced toward or just caudal to the plished by using the operator’s left thumb to provide downward contralateral nipple just under the clavicle. This corresponds to displacement in the vertical plane after each attempt, until the a 45-degree angle to the sagittal plane, bisecting a line between needle advances under the clavicle. the sternoclavicular joint and clavicular insertion of the SCM . As the needle is advanced further, the inferior surface of the The depth of insertion is from just beneath the SCM clavicular clavicle should be felt hugging the needle. This ensures that the head at a 10- to 15-degree angle below the coronal plane. The needle tip is as superior as possible to the pleura. The needle needle should enter the jugulosubclavian venous bulb after 1 to is advanced toward the suprasternal notch during breath hold- 4 cm, and the operator may then proceed with catheterization. ing or expiration, and venipuncture occurs when the needle tip lies beneath the medial end of the clavicle. This may require insertion of the needle to its hub. Blood return may not oc- Success and Complication Rates cur until slow withdrawal of the needle. If venipuncture is not Subclavian vein catheterization is successful in 90% to 95% accomplished on the initial thrust, the next attempt should be of cases, generally on the rst attempt [96]. The presence of directed slightly more cephalad. If venipuncture does not occur shock does not alter the success rate as signi cantly as it does by the third or fourth attempt, another site should be chosen, during IJV catheterization [97]. Unsuccessful catheterizations as additional attempts are unlikely to be successful and may are a result of venipuncture failure or inability to advance the result in complications. guidewire or catheter. Catheter tip malposition occurs in 5% to When blood return is established, the bevel of the needle is 20% of cases and tends to be more frequent with the infraclav- rotated 90 degrees toward the heart. The needle is anchored icular approach. M alposition occurs most commonly to the rmly with the left hand while the syringe is detached with ipsilateral IJV and contralateral SCV and is usually correctable the right. Blood return should not be pulsatile, and air em- without repeat venipuncture. bolism prophylaxis is necessary at all times. The guidewire is The overall incidence of noninfectious complications varies then advanced through the needle to 15 cm and the needle depending on the operator’s experience and the circumstances withdrawn. To increase the success rate of proper placement under which the catheter is inserted. Large series involving sev- of the catheter, the J-wire tip should point inferiorly [94]. The eral thousand SCV catheters have reported an incidence of ma- remainder of the procedure is as previously described. Triple- jor complications of 1% to 3% , with an overall rate of 5% . lumen catheters should be sutured at 15 to 16 cm on the right In smaller, probably more clinically relevant studies, the ma- and 17 to 18 cm on the left to avoid intracardiac tip placement jor complication rate has ranged from 1% to 10% [98–100]. [31,32,95]. Factors resulting in a higher complication rate are operator in- For the supraclavicular approach (Fig. 2.7), the important experience, multiple attempts at venipuncture, emergency con- landmarks are the clavicular insertion of the SCM muscle and ditions, variance from standardized technique, and body mass the sternoclavicular joint. The operator is positioned at the index. M ajor noninfectious complications include pneumotho- head of the patient on the side to be cannulated. The site of skin rax, arterial puncture, and thromboembolism. There are many tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 29 case reports of isolated major complications involving neck IJV catheterization, its use should be limited to those opera- structures or the brachial plexus; the reader is referred else- tors skilled in the technique. Inexperienced operators should where for a complete listing of reported complications [11]. use an alternative site. Experienced operators should continue Pneumothorax accounts for one fourth to one half of re- to use this route for certain indications (Table 2.1) but should ported complications, with an incidence of about 1.5% . The scrupulously avoid it in patients who cannot tolerate a pneu- incidence varies inversely with the operator’s experience and mothorax (severe lung disease, one lung), or in patients with the number of “ breaks” in technique. There is no magic gure severe coagulopathy, especially platelets < 50,000. Ultrasound whereby an operator matures from inexperienced to experi- guidance may be helpful, but requires a higher skill level and a enced. Fifty catheterizations are cited frequently as a cutoff different approach to catheterization. number [101], but it is reasonable to expect an operator to be satisfactorily experienced after having performed fewer. For the experienced operator, a pneumothorax incidence of less IN FECTIOUS COMPLICATION S than 1% is expected. M ost pneumothoraces are a result of lung puncture at the time of the procedure, but late-appearing Tremendous advances in the understanding of the pathophys- pneumothoraces have been reported. iology, causes, and prevention of CRI have occurred in re- M ost pneumothoraces will require thoracostomy tube cent years and have led to corresponding dramatic improve- drainage with a small chest tube and a H eimlich valve but some ments in catheter technology, insertion, and management. can be managed conservatively with 100% oxygen and serial Table 2.2 summarizes current recommendations or interven- radiographs or needle aspiration only [1]. Rarely, a pneumoth- tions that have been shown to reduce the risk of CRI. This orax is complicated by tension, blood, infusion of intravenous section reviews these recommendations, focusing on the epi- uid (immediately or days to weeks after catheter placement), demiology, pathogenesis, diagnosis, management, and preven- chyle, or massive subcutaneous emphysema. Bilateral pneu- tion of central CRI. mothoraces can occur from unilateral attempts at venipunc- ture. Pneumothorax can result in death, especially when it goes unrecognized [102]. De nitions and Epidemiology Subclavian artery puncture occurs in 0.5% to 1.0% of cases, constituting one fourth to one third of all complications. Ar- Consensus regarding the de nition and diagnosis of CRI is a terial puncture is usually managed easily by applying pressure necessary initial step in discussing catheter-related infectious above and below the clavicle. Bleeding can be catastrophic in complications. The semiquantitative culture method described patients with coagulopathy, especially thrombocytopenia. As by M aki et al. [103] for culturing catheter segments is the most with other routes, arterial puncture may result in arteriovenous accepted technique for diagnosing CRI. Which catheter seg- stula or pseudoaneurysm. ment to culture (the tip or intradermal segment) is still con- Clinical evidence of central venous thrombosis, including troversial; out of convenience, most centers routinely culture SVC syndrome, development of collaterals around the shoul- the catheter tip. If semiquantitative methods are used, catheter der girdle, and pulmonary embolism, occurs in 0% to 3% of contamination (probably occurring at time of withdrawal) is SCV catheterizations, but routine phlebography performed at de ned as less than 15 colony-forming units (CFUs) per culture catheter removal reveals a much higher incidence of thrombotic plate. CRI is a spectrum: growth of greater than or equal to 15 phenomena. The importance of the discrepancy between clin- CFUs is identi ed as signi cant colonization (all other cultures ical symptoms and radiologic ndings is unknown, but upper negative and no clinical symptoms); local or exit-site infec- extremity thrombosis, even if asymptomatic, is not a totally tion (skin site with erythema, cellulitis, or purulence); catheter- benign condition [46]. Duration of catheterization, catheter related bacteremia (systemic blood cultures positive for iden- material, and patient condition probably impact the frequency tical organism on catheter segment and no other source); of thrombosis, but to an uncertain degree. and catheter-related sepsis or septic shock. Alternative meth- In summary, the SCV is an extremely reliable and useful ods to diagnose CRI include differential time to positivity route for CVC, but because of the relatively high rate of pneu- [104] and direct Gram [105] or acridine-orange staining [106] mothorax and the increased success rate of ultrasound-guided of catheters. Using the differential time to positivity, blood T A B LE 2 . 2 STEPS TO MIN IMIZE CEN TRAL VEN OUS CATHETERIZATION (CVC)-RELATED IN FECTION 1. Institution-supported standardized education, with knowledge assessment, of all physicians involved in CVC insertion and care 2. Site preparation with approved chlorhexidine-based preparation 3. M aximal barrier precautions during catheter insertion 4. Use of mobile procedure carts, safety checklist, empowerment of staff 5. Strict protocols for catheter maintenance (including bandage and tubing changes), preferably by dedicated IV catheter team 6. Appropriate site selection, avoiding heavily colonized or anatomically abnormal areas; use of SCV for anticipated CVC of > 4 d 7. For anticipated duration of catheterization exceeding 96 hr, use of silver-impregnated cuff, sustained release chlorhexidine gluconate patch, and/or antibiotic/antiseptic-impregnated catheters 8. Prompt removal of any catheter which is no longer required 9. Remove pulmonary artery catheters and introducers after 5 d 10. Replace any catheter not placed with sterile precautions within 48 hr (i.e., catheter placed in emergency) 11. Use multilumen catheters only when indicated; remove when no longer needed 12. Avoid “ routine” guidewire exchanges 13. Use surgically implanted catheters or PICCs for long term (i.e., > 3 wk) or permanent CVC CVC, central venous catheterization; PICC, peripherally inserted central catheter; SCV, subclavian vein. tahir99-VRG & vip.persianss.ir 30 Section I: Procedures, Techniques, and Minimally Invasive Monitoring T A B LE 2 . 3 IN FECTION RATES FOR VARIOUS IN TRAVASCULAR CATHETERS IVD-related BSIs Device per 1,000 days (95% CI) Peripheral IV catheters 0.6 (0.2–0.9) M idline catheters 0.2 (0.0–0.5) Arterial catheters 1.4 (0.8–2.0) PICCs 0.8 (0.4–1.2) N ontunneled CVCs N onmedicated 2.9 (2.6–3.2) M edicated; Chlorhexadine–silver sulfadiazine 1.3 (1.0–1.7) M edicated; minocycline–rifampin 1.2 (0.3–2.1) Tunneled CVCs 2.1 (1.0–3.2) Pulmonary artery catheters 3.3 (1.9–4.6) N ontunneled hemodialysis catheters 6.1 (4.9–7.4) Adapted from M aki DG, Kluger DM , Crnich CJ: The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. M ayo Clin Proc 81:1159–1171, 2006. BSI, bloodstream infection; CI, con dence interval; CVC, central venous catheter; IVD, intravascular device; PICC, peripherally inserted central venous catheter. cultures are drawn from the catheter and a peripheral vein. If shown that catheters are most commonly infected by bacteria the time to positive culture is greater than 120 minutes longer colonizing the skin site, followed by invasion of the intrader- for the peripheral cultures, a diagnosis of CRI is made. This mal catheter tract. O nce the external surface of the intrader- method has good sensitivity, speci city, and the advantage of mal catheter is infected, bacteria can quickly traverse the en- faster diagnosis. tire length and infect the catheter tip, sometimes encasing the The morbidity and economic costs associated with CRI are catheter in a slime layer known as a bio lm (coagulase-negative truly impressive. Estimates vary because the overall incidence staph). From the catheter tip, bacteria may shed into the blood- of CRI is impacted by so many independent variables, includ- stream, potentially creating metastatic foci of infection [113]. ing type of ICU, catheter type and composition, duration of The pathophysiology of most catheter infections explains why catheterization, and site of insertion. Furthermore, critical care guidewire exchanges are not effective in preventing or treating practice is extremely dynamic, and the frequency and type of in- CRI: the colonized tract and, in many cases, bio lm, remain travascular catheters used changes over time, rendering much intact and quickly reinfect the new catheter [114]. of the data, somewhat out of date. Intravascular devices are The catheter hub(s) also becomes colonized but contributes now the single most important cause of health-care associated to catheter-related infectious complications less frequently than bloodstream infection in the United States and Europe, with an the insertion site [115,116]. H ub contamination may be rela- estimated incidence of 250,000 to 500,000 cases annually in tively more important as a source of infection for certain types the United States alone [107]. M ore than 5 million CVCs are in- of catheters (hemodialysis) and the longer the catheter remains serted annually in the United States, accounting for 15 million in place [117]. H ematogenous seeding of catheters from bac- CVC-days. Approximately 3% to 9% of all CVCs will become teremia is an infrequent cause of CRI. infected during clinical use, and the N ational H ealthcare Safety N etwork reports rates of CVC-associated bloodstream infec- tions varying from 1.2 to 5.5 per 1,000 catheter-days depend- Site Preparation and Catheter Maintenance ing on the location of the patient [108]. A recently completed systematic review of the literature reported BSI rates for all in- That the majority of CRIs are caused by skin ora highlights travascular devices [108] (Table 2.3); noncuffed, nontunneled the importance of site sterility during insertion and catheter CVCs had an average BSI rate of 2.9 per 1,000 catheter-days. maintenance. O rganisms that colonize the insertion site orig- When BSI does occur, often with a resistant organism such as inate from the patient’s own skin ora or the hands of op- methicillin-resistant Staphylococcus aureus (M RSA) and VRE, erators. Thorough hand washing and scrupulous attention to it increases healthcare costs by as much as $20,000 to 40,000, aseptic technique is mandatory during catheter insertion. A prolongs ICU and hospital stay by several days, and may in- prospective study proved that a nonsterile cap and mask, sterile crease attributable mortality [109–111]. Importantly, it has gown, and a large drape covering the patient’s head and body been estimated that as many as 50% of CRIs are preventable (maximal (triple) sterile barriers, compared to sterile gloves [112], which should serve as a powerful impetus and render it and small drape) reduced the catheter-related bloodstream in- indefensible for critical care physicians not to implement ev- fection rate sixfold and were highly cost-effective [118]. If a erything possible to minimize CRI. break in sterile technique occurs during insertion, termination of the procedure and replacement of contaminated equipment is mandatory. Use of a mobile catheter cart that can be wheeled Pathophysiology of Catheter Infection to the patient bedside facilitates maintenance of the sterile environment. Assuming that they are not contaminated during insertion, Chlorhexidine is a superior disinfectant and should be used catheters can become infected from four potential sources: the instead of iodine-based solutions [119,120]. Proper application skin insertion site, the catheter hub(s), hematogenous seeding, includes liberally scrubbing the site using expanding concentric and infusate contamination. Animal and human studies have circles. Excessive hair should be clipped with scissors prior to tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 31 application of the antiseptic, as shaving can cause minor skin placed single-lumen catheters for many indications for central lacerations and disruption of the epidermal barrier to infection. venous access. Because catheter hubs are a potential source Care of the catheter after insertion is extremely important of infection and triple-lumen catheters can require three times in minimizing infection, and all medical personnel should fol- the number of tubing changes, it was widely believed that they low standardized protocols [121]. The number of piggyback would have a higher infection rate. Studies have presented con- infusions and medical personnel handling tubing changes and icting results, but overall the data support the view that triple- manipulation of the catheter site should be minimized. Re- lumen catheters have a modestly higher rate of infection [134– placement of administration sets every 72 to 96 hours is safe 136]. If used ef ciently, however, they provide greater intravas- and cost-ef cient [122], unless there are speci c recommenda- cular access per device and can decrease the total number of tions for the infusate (e.g., propofol). Transparent polyurethane catheter days and exposure to central venipuncture. A slight dressings have become more popular than gauze and tape, but increase in infection rate per catheter is therefore justi able have not been found to be superior. It is recommended that from an overall risk–bene t analysis, if multilumen catheters the transparent dressing be changed every 7 days or sooner are used only when multiple infusion ports are truly indicated. if damp or soiled. Addition of a silver-impregnated cuff or Finally, it was hoped that routine subcutaneous tunneling chlorhexidine sponge has been shown to reduce the rate of of short-term CVCs, similar to long-term catheters, might be CRI and is cost-effective [123,124]. Application of iodophor an effective way to minimize CRI. This approach is rational or polymicrobial ointments to the skin site at the time of inser- since the long subcutaneous tract acts to stabilize the catheter tion or during dressing changes does not convincingly reduce and perhaps act as a barrier to bacterial invasion, and great the overall incidence of catheter infection, and certain polymi- technical skill is not required. A meta-analysis did not support crobial ointments may increase the proportion of Candida the routine practice of tunneling all percutaneously inserted infections [125]. CVCs [137], and it is not a common practice. H owever, further studies of the tunneling of short-term IJV and FV catheters are warranted, especially hemodialysis catheters, since these sites Frequency of Catheter-Related Infection have a higher infection rate and past studies have generally favored this approach [108,138]. O bserving the above-mentioned recommendations for catheter insertion and maintenance will minimize catheter-associated infection. Colonization of the insertion site can begin within 24 hours and increases with duration of catheterization; Duration of Catheterization 10% to 40% of catheters may eventually become colonized The length of catheterization should be based solely on the need [126]. Catheter-associated bacteremia occurs in 3% to 8% of for continued catheterization of the patient. N o catheter should catheters [101,127–129], although some studies incorporat- be left in longer than absolutely necessary. M ost data suggest ing newer catheter technologies and procedures have demon- that the daily risk of infection remains relatively constant and strated rates of catheter-associated bacteremia of 2% or less routine replacement of CVCs without a clinical indication does [130–132]. O verall, catheter-infection rates are best expressed not reduce the rate of CRI [137,139]. M ultiple clinical and as number of episodes per 1,000 days, and although each ICU experimental studies have also demonstrated that guidewire should strive for perfection (it is possible to attain and maintain exchanges neither decrease nor increase infectious risk [140]. the “ holy grail” of zero CRIs over an extended period of time The above-mentioned recommendations do not necessar- [1]), each ICU should de nitely reach or exceed an appropri- ily apply to other special-use catheters, which can be ex- ate benchmark. The N H SN publishes average rates of CRIs for posed to different clinical situations and risk. Pulmonary artery different types of ICUs [109]. Table 2.3 provides national ref- catheters (PACs) and the introducer should be removed after erences from published literature that has the added advantage 96 to 120 hours because of the increased risk of infection after of unique data for each speci c catheter type [108]. this time [141]. These catheters are at greater risk for infection because patients are sicker, the introducer used for insertion is shorter, and catheter manipulations are frequent. Type of Catheter Catheters inserted for acute temporary hemodialysis histor- ically have had a higher rate of infection than other percuta- The data presented earlier are derived from large studies and neously placed catheters. Factors contributing to the increased are not necessarily applicable to any given catheter in any spe- rate have not been completely elucidated, but logically patient ci c ICU because of variations in de nitions, types of catheters, factors probably in uence the incidence of infection more than site of insertion, duration of catheterization, types of uid in- the type of catheter or site of insertion [84]. For acutely ill, fused, and policies regarding routine guidewire changes, all of hospitalized patients, temporary dialysis catheters should be which have been implicated at some point as important fac- managed similarly to other multilumen catheters, recognizing tors in the incidence of CRI. The duration of catheterization that the underlying propensity for infection is distinctly higher in combination with the type of catheter are major factors; the [108]. As mentioned earlier, perhaps this is the area that tun- site of insertion is less important. Guidewire changes have an neling of catheters should be more thoroughly investigated. important role in evaluation of the febrile catheterized patient, For ambulatory outpatients, long-term experience with double- but routine guidewire changes do not prevent infection. Under lumen, Dacron-cuffed, silicone CVCs inserted in the IJV has ideal conditions, all of these factors are less important. Long- been positive [142]. term TPN catheters can be maintained for months with low rates of infection, and there is no cutoff time at which coloniza- tion and clinical infection accelerate. Today, when the need for long-term catheterization is anticipated, surgically implanted Site of Insertion catheters should be used. These catheters have low infection rates and are never changed routinely [133]. PICCs are also an The condition of the site is more important than the location. acceptable option for patients requiring long-term CVC. Whenever possible, sites involved by infection, burns, or other Catheters inserted percutaneously in the critical care unit, dermatologic processes, or in close proximity to a heavily col- however, are not subject to ideal conditions and have a nite onized area (e.g., tracheostomy) should not be used as primary lifespan. For practical purposes, multilumen catheters have re- access. Data tends to support that PICC and SCV catheters tahir99-VRG & vip.persianss.ir 32 Section I: Procedures, Techniques, and Minimally Invasive Monitoring are associated with the lowest rate of CRI, and IJV and FV 0 per 1,000 catheter days. These simple interventions were: catheters the highest [101]. education of physicians and nurses of evidence-based infection control practices, creation of a central catheter insertion cart which contained every item needed for insertion of a catheter, Guidewire Exchanges daily questioning of whether catheters could be removed, a bed- side checklist for insertion of catheters, and empowering nurses Guidewire exchanges have always been theoretically awed as to stop procedures where the infection control guidelines were a form of infection control, because although a new catheter is not being followed [146]. Similar interventions in Pennsylvania placed, the site, speci cally the intradermal tract, remains the reduced their CRI rate from 4.31 to 1.36 per 1,000 catheter same. Studies have shown that when the tract and old catheter days [147]. A statewide initiative in M ichigan, the Keystone are colonized, the new catheter invariably also becomes in- Project, implemented these strategies on a large scale over the fected. Alternatively, if the initial catheter is not colonized, entire state with equally impressive results [1]. Despite the fact there is no reason the new catheter will be more resistant to that these and other simple systems interventions and imple- subsequent infection than the original one. In neither situation mentation require very little capital outlay, many ICUs have will a guidewire change prevent infection. H owever, guidewire yet to adopt them [148,149]. changes continue to have a valuable role for replacing defec- tive catheters, exchanging one type of catheter for another, and in the evaluation of a febrile patient with an existing central catheter. In the latter situation, the physician can assess the MAN AGEMEN T OF THE FEBRILE sterility of the catheter tract without subjecting the patient to PATIEN T a new venipuncture. H owever one decides to use guidewire exchanges, they must be performed properly. Using maximal Patients with a CVC frequently develop fever. Removal of the barriers, the catheter should be withdrawn until an intravascu- catheter in every febrile patient is neither feasible nor clini- lar segment is exposed, transected sterilely, and the guidewire cally indicated, as the fever is often unrelated to the catheter. inserted through the distal lumen. The catheter fragment can M anagement must be individualized (Fig. 2.7) and depends on then be removed (always culture the tip) and a new catheter type of catheter, duration of catheterization, anticipated need threaded over the guidewire. To ensure sterility, most operators for continued central venous access, risk of establishing new should re-prep the site and change gloves before inserting the central venous access, and underlying medical condition and new catheter or introducer over the guidewire. Insertion of the prognosis. All critical care units must have protocols for man- guidewire through the distal hub of the existing catheter is not aging the febrile, catheterized patient [150]. Decisions to re- appropriate. move, change over a guidewire, or leave catheters in place must be based on a fundamental knowledge of risks and bene ts for catheters inserted at each site. N EW CATHETER TECHN OLOGIES Catheter sites in the febrile patient should always be ex- amined. Clinical infection of the site mandates removal of Improvements in catheter technology continue to play an im- the catheter and institution of antibiotics. Surgically implanted portant role in minimizing catheter complications. Catheter catheters are not easily removed or replaced and can often be material is an important factor in promoting thrombogenesis left in place while the infection is cleared with antibiotics, unless and adherence of organisms. M ost catheters used for CVC are tunnel infection is present. Percutaneously inserted CVCs are composed of exible silicone (for surgical implantation) and relatively easily removed, and the risks of leaving a catheter in polyurethane (for percutaneous insertion), because research place through an infected site outweigh the risk of replacement has shown these materials are less thrombogenic. Knowledge at a new site, except in very unusual circumstances. of the pathogenesis of most CRI has stimulated improvements In patients with severe sepsis or septic shock, CVCs should designed to interrupt bacterial colonization of the skin site, be considered a possible source. If all catheter sites appear catheter, and intradermal tract, and migration to the catheter normal and a noncatheter source of infection is implicated, tip. Antibiotic and antiseptic impregnated catheters represent a appropriate antibiotics are initiated and the catheters left in major advance in catheter management. Catheters differ from place. The usual guidelines for subsequent catheter manage- one another by the type of antibiotic or antiseptic with which ment should be followed, and this rarely results in treatment they are impregnated. Clinical results with these commercially failure. In contrast, if a noncatheter source cannot be identi- available catheters have been variable [143,144], likely due to ed, then central catheters in place more than 3 days should be varying practices and the baseline infection rate. Good ran- managed individually, with attention to duration of catheter- domized controlled trials comparing the various types of anti- ization (Table 2.3). O nly for patients with excessive risks for septic catheters with each other are lacking, but we believe that new catheter placement (i.e., severe coagulopathy), guidewire current evidence supports using one of the above catheters if exchange of the catheter is justi able after obtaining blood the baseline CRI rate remains high after instituting infection cultures through the catheter and a peripheral site and semi- control practices [101,132,133]. The preponderance of data quantitative culture of a catheter segment. If within the next 24 indicates that in real-life practice, these catheters decrease the hours an alternative source for sepsis is found, or if the catheter rate of CRI and improve patient safety, likely at a neutral or fa- segment culture is negative and the patient improves and stabi- vorable cost [129,145]. The emergence of resistant organisms lizes, the guidewire catheter can be left in place and the risk of and allergic reactions has not yet been a problem, but ongoing catheter insertion avoided. Alternatively, if the catheter culture surveillance is needed. becomes positive, especially if the same organism is identi ed on peripheral blood cultures, the cutaneous tract is also infected and the guidewire catheter should be removed and alternative SYSTEMS-BASED MEASURES access achieved. The most common situation is the stable febrile patient N ot surprisingly, evidence is pointing to systems-based fac- with a CVC in place (Table 2.4). As mentioned earlier, if a tors as being more important in reducing the incidence of CRI noncatheter source for fever is identi ed, appropriate antibi- than any new technology. At Johns H opkins, the addition of otics are given and the catheter is left in place, assuming it is ve systems-based changes reduced the CRI rate from 11.3 to still needed and the site is clinically uninvolved. In the patient tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 33 T A B LE 2 . 4 APPROACH TO THE FEBRILE PATIEN T WITH A CEN TRAL VEN OUS CATHETER 1. Catheter no longer needed—remove and culture tip 2. Patient with severe sepsis or septic shock (catheter > 72 hr)—promptly remove catheter and culture tip 3. Patient with severe sepsis or septic shock (catheter < 72 h)—initiate antibiotics, remove catheter if no improvement in 12–24 h 4. Stable patient (catheter > 72 h)—guidewire exchange with tip culture if culture with ≥ 15 CFU—remove catheter with no obvious source of fever [1], indications for the CVCs cultures without subjecting the patient to repeat venipuncture. should be reviewed and the catheter withdrawn if it is no longer If within the next 24 hours an alternative source for fever is required. O therwise, the physician must decide between ob- identi ed, and/or the initial catheter segment culture is nega- servation, potential premature withdrawal, and a guidewire tive, then the guidewire catheter can be left in place. change of the catheter. If the catheter is less than 72 hours When catheter-related bacteremia does develop, antibiotic old, observation is reasonable, as it is very unlikely that the therapy is necessary for a period of 7 to 14 days. Even in pa- catheter is already infected unless breaks in sterile technique oc- tients treated for 14 days, metastatic infection can develop. curred during insertion. For catheters that are at least 72 hours Catheter-related fever, infection, and septicemia is a compli- old, guidewire exchanges are rational but, in our opinion, not cated disease, and the expertise of an infectious disease consul- mandatory. An appropriately performed guidewire change al- tant may be required to assist with the decision on how long lows comparison of catheter segment cultures to other clinical to continue antibiotic therapy. References 1. Pronovost P, N eedham D, Berenholtz S, et al: An intervention to de- 21. Rivers E, N guyen B, H avstad S, et al: Early goal-directed therapy in the crease catheter-related bloodstream infections in the ICU. N Engl J M ed treatment of severe sepsis and septic shock. N Engl J M ed 345:1368, 2001. 356:2725–2731, 2007. 22. Trzeciak S, Dellinger RP, Abate N L, et al: Translating research to clinical 2. Barsuk JH , M cGaghie WC, Cohen ER, et al: Simulation-based mastery practice: a 1-year experience with implementing early goal-directed therapy learning reduces complications during central venous catheter insertion in for septic shock in the emergency department. Chest 129:225, 2006. a medical intensive care unit. Crit Care M ed 37:2697–2701, 2009. 23. Davison D, Chawla L, Selassie L, et al: Femoral based central Venous 3. Blitt RC, Reed SF, Britt LD: Central line simulation: a new training algo- oxygen saturation is not a reliable substitute for subclavian/internal jugu- rithm. A m Surg 73:680–682, 2007. lar based central venous oxygen saturation in critically ill patients. Chest 4. Abboud PA, Kendall JL: Ultrasound guidance for vascular access. Em erg 138:76–83, 2010. M ed Clin N orth A m 22(3):749–773, 2004. 24. The N ational H eart, Lung, and Blood Institute Acute Respiratory Distress 5. Denys BG, Uretsky BF, Reddy PS: Ultrasound-assisted cannulation of the Syndrome (ARDS) Clinical Trials N etwork: Comparison of two uid man- internal jugular vein. A prospective comparison to the external landmark- agement strategies in acute lung injury. N Engl J M ed 354:1–12, 2006. guided technique. Circulation 87(5):1557–1562, 1993. 25. Stuke L, Jennings A, Gunst M , et al: Universal consent practices in academic 6. Feller-Kopman D: Ultrasound-guided internal jugular access: a proposed intensive care units (ICUs). J Intensive Care M ed 25:46–52, 2010. standardized approach and implications for training and practice. Chest 26. H arting BP, Talbot TR, Dellit TH , et al: University health system consor- 132(1):302–309, 2007. tium quality performance study of the insertion and care of central venous 7. Calvert N , H ind D, M cWilliams RG, et al: The effectiveness and cost- catheters. Infect Control H osp Epidem iol 29:440–442, 2008. effectiveness of ultrasound locating devices for central venous access: a 27. Long R, Kassum D, Donen N , et al: Cardiac tamponade complicating cen- systematic review and economic evaluation. H ealth Technol A ssess 7:1–84, tral venous catheterization for total parenteral nutrition: a review. J Crit 2003. Care 2:39, 1987. 8. Rothschild JM : Ultrasound guidance of central vein catheterization. In: 28. Curelaru I, Linder LE, Gustavsson B: Displacement of catheters inserted M aking health care safer: A critical analysis of patient safety practices. through internal jugular veins with neck exion and extension. A prelimi- Agency for H ealthcare Research and Q uality. Available at http://www.ahrq. nary study. Intensive Care M ed 6:179, 1980. gov/clinic/ptsafety/chap21.htm . 29. Wojciechowski J, Curelaru I, Gustavsson B, et al: “ H alf-way” venous 9. M illing TJ Jr., Rose J, Briggs WM , et al: Randomized, controlled clinical catheters. III. Tip displacements with movements of the upper extremity. trial of point-of-care limited ultrasonography assistance of central venous A cta A naesthesiol Scand 81:36–39, 1985. cannulation: the Third Sonography O utcomes Assessment Program (SO AP- 30. M arx GF: H azards associated with central venous pressure monitoring. N 3) Trial. Crit Care M ed 33(8):1764–1769, 2005. Y State J M ed 69:955, 1969. 10. M aecken T, Grau T: Ultrasound imaging in vascular access. Crit Care M ed 31. Andrews RT, Bova DA, Venbrux AC: H ow much guidewire is too much? 35[5, Suppl]:S178–S185, 2007. Direct measurement of the distance from subclavian and internal jugular 11. M ans eld PF, H ohn DC, Fornage BD, et al: Complications and failures of vein access sites to the superior vena cava-atrial junction during central subclavian-vein catheterization. N ew Engl J M ed 331:1735–1738, 1994. venous catheter placement. Crit Care M ed 28:138, 2000. 12. Sandhu N S: Transpectoral ultrasound-guided catheterization of the axil- 32. Czepizak CA, O ’Callaghan JM , Venus B: Evaluation of formulas for opti- lary vein: an alternative to standard catheterization of the subclavian vein. mal positioning of central venous catheters. Chest 107:1662, 1995. A nesth A nalg 99:183–187, 2004. 33. Aslamy Z , Dewald CL, H effner JE: M RI of central venous anatomy: impli- 13. Graber D, Dailey RH : Catheter ow rates updated. J A m Coll Em erg Physi- cations for central venous catheter insertion. Chest 114:820, 1998. cians 6:518, 1977. 34. Robinson JF, Robinson WA, Cohn A, et al: Perforation of the great vessels 14. Schwab SJ, Q uarles D, M iddleton JP, et al: H emodialysis-associated sub- during central venous line placement. A rch Intern M ed 155:1225, 1995. clavian vein stenosis. Kidney Int 38:1156, 1988. 35. Duntley P, Siever J, Korwes M L, et al: Vascular erosion by central ve- 15. Cimochowski G, Sartain J, Worley E, et al: Clear superiority of inter- nous catheters. Clinical features and outcome. [Review] [44 refs]. Chest nal jugular access over subclavian vein for temporary dialysis. Kidney Int 101:1633, 1992. 33:230, 1987. 36. Doering RB, Stemmer EA, Connolly JE: Complications of indwelling ve- 16. Firek AF, Cutler RE, St John H ammond PG: Reappraisal of femoral vein nous catheters, with particular reference to catheter embolus. A m J Surg cannulation for temporary hemodialysis vascular access. N ephron 47:227, 114:259, 1967. 1987. 37. O rebaugh SL: Venous air embolism: clinical and experimental considera- 17. Doer er M E, Kaufman B, Goldenberg AS: Central venous catheter place- tions. [Review] [94 refs]. Crit Care M ed 20:1169, 1992. ment in patients with disorders of hemostasis. Chest 110:185, 1996. 38. Ely EW, H ite RD, Baker AM , et al: Venous air embolism from central ve- 18. Dripps RD, Eckenhoff JE, Vandam LD: Introduction to A nesthesia: T he nous catheterization: a need for increased physician awareness. Crit Care Principles of Safe Practice. 6th ed. Philadelphia, PA, WB Saunders, 1982. M ed 27:2113, 1999. 19. Emerman CL, Pinchak AC, H ancock D, et al: Effect of injection site on 39. M umtaz H , Williams V, H auer-Jensen M , et al: Central venous catheter circulation times during cardiac arrest. Crit Care M ed 16:1138, 1988. placement in patients with disorders of hemostasis. Am J Surg 180:503, 2000. 20. H ilty WM , H udson PA, Levitt M A, et al: Real-time ultrasound-guided 40. Brismar B, H ardstedt C, Jacobson S: Diagnosis of thrombosis by catheter femoral vein catheterization during cardiopulmonary resuscitation. A nn phlebography after prolonged central venous catheterization. A nn Surg Em erg M ed 3:331–336, 1997. 194:779, 1981. tahir99-VRG & vip.persianss.ir 34 Section I: Procedures, Techniques, and Minimally Invasive Monitoring 41. Efsing H O , Lindblad B, M ark J, et al: Thromboembolic complications from 74. Bansmer G, Keith D, Tesluk H : Complications following use of indwelling central venous catheters: a comparison of three catheter materials. W orld J catheters of inferior vena cava. JA M A 167:1606, 1958. Surg 7:419, 1983. 75. Dailey RH : “ Code Red” protocol for resuscitation of the exsanguinated 42. Axelsson CK, Efsen F: Phlebography in long-term catheterization of the patient. J Em erg M ed 2:373, 1985. subclavian vein. A retrospective study in patients with severe gastrointesti- 76. Kruse JA, Carlson RW: Infectious complications of femoral vs internal nal disorders. Scand J G astroenterol 13:933, 1978. jugular and subclavian vein central venous catheterization. Crit Care M ed 43. Bonnet F, Loriferne JF, Texier JP, et al: Evaluation of Doppler examination 19:843, 1991. for diagnosis of catheter-related deep vein thrombosis. Intensive Care M ed 77. O ’Grady N P, Alexander M , Burns LA, et al: Guidelines for the prevention 15:238, 1989. of catheter-related infections. M orb M ortal W eek ly R ep, in press. 44. Prandoni P, Polistena P, Bernardi E, et al: Upper-extremity deep vein throm- 78. Deshpande KS, H atem C, Ulirch H L, et al: The incidence of infectious com- bosis. Risk factors, diagnosis, and complications. A rch Intern M ed 157:57, plication of central venous catheters at the subclavian, internal jugular, and 1997. femoral sites in an intensive care unit population. Crit Care M ed 33:13, 45. Raad II, Luna M , Khalil SA, et al: The relationship between the thrombotic 2005. and infectious complications of central venous catheters. JA M A 271:1014, 79. Dailey RH : Femoral vein cannulation: a review. [Review] [26 refs]. J Em erg 1994. M ed 2:367, 1985. 46. M unoz FJ, M ismeti P, Poggio R, et al: Clinical outcome of patients with 80. Sharp KW, Spees EK, Selby LR, et al: Diagnosis and management of upper-extremity deep vein thrombosis. Results from the RIETE registry. retroperitoneal hematomas after femoral vein cannulation for hemodial- Chest 133:143–148, 2008. ysis. Surgery 95:90, 1984. 47. Timsit JF, Farkas JC, Boyer JM , et al: Central vein catheter-related throm- 81. Fuller TJ, M ahoney JJ, Juncos LI, et al: Arteriovenous stula after femoral bosis in intensive care patients: incidence, risks factors, and relationship vein catheterization. JA M A 236:2943, 1976. with catheter-related sepsis. Chest 114:207, 1998. 82. N orwood S, Wilkins H E 3rd, Vallina VL, et al: The safety of prolonging the 48. N g PK, Ault M J, M aldonado LS: Peripherally inserted central catheters in use of central venous catheters: a prospective analysis of the effects of using the intensive care unit. J Intensive Care M ed 11:49, 1996. antiseptic-bonded catheters with daily site care. Crit Care M ed 28:1376, 49. M errell SW, Peatross BG, Grossman M D, et al: Peripherally inserted central 2000. venous catheters. Low-risk alternatives for ongoing venous access. W est J 83. Goetz AM , Wagener M M , M iller JM , et al: Risk of infection due to cen- M ed 160:25, 1994. tral venous catheters: effect of site of placement and catheter type. Infect 50. N etter FH : A tlas of H um an A natom y. N ew Jersey, Summit, 1989. Control H osp Epidem iol 19:842, 1998. 51. Williams PL, Warwick R: G ray’s A natom y. 8th ed. Philadelphia, PA WB 84. Parienti JJ, Thirion M , M egarbane B, et al: Femoral vs jugular venous Saunders, 1980. catheterization and risk of nosocomial events in adults requiring acute re- 52. Raad I, Davis S, Becker M , et al: Low infection rate and long durability nal replacement therapy. A randomized controlled trial. JA M A 299:2413– of nontunneled silastic catheters. A safe and cost-effective alternative for 2422, 2008. long-term venous access. A rch Intern M ed 153:1791, 1993. 85. Stenzel JP, Green TP, Fuhrman BP, et al: Percutaneous femoral venous 53. Duerksen DR, Papineau N , Siemens J, et al: Peripherally inserted central catheterizations: a prospective study of complications. J Pediatr 114:411, catheters for parenteral nutrition: a comparison with centrally inserted 1989. catheters. J Parenter Enteral N utr 23:85, 1999. 86. Russell JA, Joel M , H udson RJ, et al: Prospective evaluation of radial and 54. Gustavsson B, Curelaru I, H ultman E, et al: Displacements of the soft, femoral artery catheterization sites in critically ill adults. Crit Care M ed polyurethane central venous catheters inserted by basilic and cephalic veins. 11:936, 1983. A cta A naesthesiol Scand 27:102, 1983. 87. Lorente L, Jimenez A, Santana M , et al: M icroorganisms responsible for in- 55. M alatinsky J, Faybik M , Grif th M , et al: Venipuncture, catheterization travascular catheter-related bloodstream infection according to the catheter and failure to position correctly during central venous cannulation. R esus- site. Crit Care M ed 35:2424–2427, 2007. citation 10:259, 1983. 88. Lynn KL, M aling TM : A major pulmonary embolus as a complication of 56. Goldfarb G, Lebrec D: Percutaneous cannulation of the internal jugular vein femoral vein catheterization. Br J R adiol 50:667, 1977. in patients with coagulopathies: an experience based on 1,000 attempts. 89. M oosman DA: The anatomy of infraclavicular subclavian vein catheteriza- A nesthesiology 56:321, 1982. tion and its complications. Surg G ynecol O bstet 136:71, 1973. 57. Johnson FE: Internal jugular vein catheterization. N Y State J M ed 78:2168, 90. Eerola R, Kaukinen L, Kaukinen S: Analysis of 13 800 subclavian vein 1978. catheterizations. A cta A naesthesiol Scand 29:193, 1985. 58. Sznajder JI, Z veibil FR, Bitterman H , et al: Central vein catheterization. 91. James PM Jr, M yers RT: Central venous pressure monitoring: misinterpre- Failure and complication rates by three percutaneous approaches. A rch tation, abuses, indications and a new technique. A nn Surg 175:693, 1972. Intern M ed 146:259, 1986. 92. M acDonnell JE, Perez H , Pitts SR, et al: Supraclavicular subclavian vein 59. Tripathi M , Pandey M : Anchoring of the internal jugular vein with a pi- catheterization: modi ed landmarks for needle insertion. A nn Em erg M ed lot needle to facilitate its puncture with a wide bore needle: a randomised, 21:421, 1992. prospective, clinical study. A naesthesia 61:15, 2006. 93. Dronen S, Thompson B, N owak R, et al: Subclavian vein catheteriza- 60. Eisenhauer ED, Derveloy RJ, H astings PR: Prospective evaluation of cen- tion during cardiopulmonary resuscitation. A prospective comparison of tral venous pressure (CVP) catheters in a large city-county hospital. A nn the supraclavicular and infraclavicular percutaneous approaches. JA M A Surg 196:560, 1982. 247:3227, 1982. 61. Klineberg PL, Greenhow DE, Ellison N : H ematoma following internal jugu- 94. Sterner S, Plummer DW, Clinton J, et al: A comparison of the supraclavicu- lar vein cannulation. A nesth Intensive Care 8:94, 1980. lar approach and the infraclavicular approach for subclavian vein catheter- 62. Briscoe CE, Bushman JA, M cDonald WI: Extensive neurological damage ization. A nn Em erg M ed 15:421, 1986. after cannulation of internal jugular vein. Br M ed J 1:314, 1974. 95. Park H P, Jeon Y, H wang JW, et al: In uence of orientations of guidewire tip 63. Schwartz AJ, Jobes CR, Greenhow DE, et al: Carotid artery puncture with on the placement of subclavian venous catheters. A cta A naesthesiol Scand internal jugular cannulation. A nesthesiology 51:S160, 1980. 49:1460, 2005. 64. N icholson T, Ettles D, Robinson G: M anaging inadvertent arterial catheteri- 96. M cGee WT, Ackerman BL, Rouben LR, et al: Accurate placement of cen- zation during central venous access procedures. Cardiovasc Interven R adiol tral venous catheters: a prospective, randomized, multicenter trial. Crit Care 27:21, 2004. M ed 21:1118, 1993. 65. Shah PM , Babu SC, Goyal A, et al: Arterial misplacement of large-caliber 97. Seneff M G: Central venous catheterization: a comprehensive review. J In- cannulas during jugular vein catheterization: case for surgical management. tensive Care M ed 2:218, 1987. J A m Coll Surg 198:939, 2004. 98. Simpson ET, Aitchison JM : Percutaneous infraclavicular subclavian vein 66. Ruesch S, Walder B, Tramer M R: Complications of central venous catheters: catheterization in shocked patients: a prospective study in 172 patients. internal jugular versus subclavian access—a systematic review. [Review] [53 J Traum a-Injury Inf Crit Care 22:781, 1982. refs]. Crit Care M ed 30:454, 2002. 99. H erbst CA Jr: Indications, management, and complications of percutaneous 67. N agai K, Kemmotsu O : An inadvertent insertion of a Swan-Ganz catheter subclavian catheters. An audit. A rch Sur 113:1421, 1978. into the intrathecal space. A nesthesiology 62:848, 1985. 100. Bernard RW, Stahl WM : Subclavian vein catheterizations: a prospective 68. Schwartz AJ, Jobes DR, Levy WJ, et al: Intrathoracic vascular catheteriza- study. I. N on-infectious complications. A nn Surg 173:184, 1971. tion via the external jugular vein. A nesthesiology 56:400, 1982. 101. Taylor RW, Palagiri AV: Central venous catheterization. Crit Care M ed 69. Blitt CD, Carlson GL, Wright WA, et al: J-wire versus straight wire for cen- 35:1390–1396, 2007. tral venous system cannulation via the external jugular vein. A nesth A nalg 102. Despars JA, Sassoon CS, Light RW: Signi cance of iatrogenic pneumotho- 61:536, 1982. races. Chest 105:1147, 1994. 70. Giesy J: External jugular vein access to central venous system. JA M A 103. M atz R: Complications of determining the central venous pressure. N Engl 219:1216, 1972. J M ed 273:703, 1965. 71. Riddell GS, Latto IP, N g WS: External jugular vein access to the central 104. M aki DG, Weise CE, Sara n H W: A semiquantitative culture method for venous system – a trial of two types of catheter. Br J A naesth 54:535, identifying intravenous-catheter-related infection. N Engl J M ed 296:1305, 1982. 1977. 72. Jobes DR, Schwartz AJ, Greenhow DE, et al: Safer jugular vein cannula- 105. Raad I, H anna H A, Alakech B, et al: Differential time to positivity: a useful tion: recognition of arterial puncture and preferential use of the external method for diagnosing catheter-related bloodstream infections [see com- jugular route. A nesthesiology 59:353, 1983. ment] [summary for patients in A nn Intern M ed 2004;140(1):I39; PM ID: 73. M oncrief JA: Femoral catheters. A nn Surg 147:166, 1958. 14706995]. A nn Intern M ed 140:18, 2004. tahir99-VRG & vip.persianss.ir Chapter 2: Central Venous Catheters 35 106. Cooper GL, H opkins CC: Rapid diagnosis of intravascular catheter- 129. Veenstra DL, Saint S, Sullivan SD: Cost-effectiveness of antiseptic- associated infection by direct Gram staining of catheter segments. N Engl impregnated central venous catheters for the prevention of catheter-related J M ed 312:1142, 1985. bloodstream infection. JA M A 282:554, 1999. 107. Z ufferey J, Rime B, Francioli P, et al: Simple method for rapid diagnosis of 130. H anley EM , Veeder A, Smith T, et al: Evaluation of an antiseptic catheter-associated infection by direct acridine orange staining of catheter triple-lumen catheter in an intensive care unit. Crit Care M ed 28:366, tips. J Clin M icrobiol 26:175, 1988. 2000. 108. M aki DG, Kluger DM , Crnich CJ: The risk of bloodstream infection in 131. Flowers RH 3rd, Schwenzer KJ, Kopel RF, et al: Ef cacy of an attachable adults with different intravascular devices: a systematic review of 200 pub- subcutaneous cuff for the prevention of intravascular catheter-related in- lished prospective studies. M ayo Clin Proc 81:1159–1171, 2006. fection. A randomized, controlled trial. JA M A 261:878, 1989. 109. Edwards JR, Peterson KD, Banerjee S, et al: N ational H ealthcare Safety 132. Kamal GD, Pfaller M A, Rempe LE, et al: Reduced intravascular catheter in- N etwork (N H SN ) report: data summary fro 2006 through 2008, issued fection by antibiotic bonding. A prospective, randomized, controlled trial. December 2009. A m J Infect Control 37:783–805, 2009. JA M A 265:2364, 1991. 110. Warren DK, Q uadir WW, H ollenbeak CS, et al: Attributable cost of 133. Collin GR: Decreasing catheter colonization through the use of an catheter-associated bloodstream infections among intensive care patients antiseptic-impregnated catheter: a continuous quality improvement project. in a nonteaching hospital. Crit Care M ed 34:2084–2089, 2006. Chest 115:1632, 1999. 111. Blot SI, Depuydt P, Amnemans L, et al: Clinical and economic outcomes 134. Clarke DE, Raf n TA: Infectious complications of indwelling long-term in critically ill patients with nosocomial catheter-related bloodstream infec- central venous catheters. [Review] [48 refs]. Chest 97:966, 1990. tions. Clin Infect D is 41:1591–1598, 2005. 135. M cCarthy M C, Shives JK, Robison RJ, et al: Prospective evaluation of sin- 112. Wenzel RP, Edmond M B: The impact of hospital-acquired bloodstream in- gle and triple lumen catheters in total parenteral nutrition. JPEN : J Parenter fections. Em erg Infect D is 7:172–177, 2001. Enteral N utr 11:259, 1987. 113. H arbarth S, Sax H , Gastmeier P: The preventable proportion of nosocomial 136. Clark-Christoff N , Watters VA, Sparks W, et al: Use of triple-lumen sub- infections: an overview of published reports. J H osp Infect 54:258–266, clavian catheters for administration of total parenteral nutrition. JPEN : J 2003. Parenter Enteral N utr 16:403, 1992. 114. Passerini L, Lam K, Costerton JW, et al: Bio lms on indwelling vascular 137. Randolph AG, Cook DJ, Gonzales CA, et al: Tunneling short-term central catheters. Crit Care M ed 20:665, 1992. venous catheters to prevent catheter-related infection: a meta-analysis of 115. O lson M E, Lam K, Bodey GP, et al: Evaluation of strategies for central randomized, controlled trials. Crit Care M ed 26:1452, 1998. venous catheter replacement. Crit Care M ed 20:797, 1992. 138. Farkas JC, Liu N , Bleriot JP, et al: Single- versus triple-lumen central 116. M aki DG, Cobb L, Garman JK, et al: An attachable silver-impregnated catheter-related sepsis: a prospective randomized study in a critically ill cuff for prevention of infection with central venous catheters: a prospective population. A m J M ed 93:277, 1992. randomized multicenter trial. A m J M ed 85:307, 1988. 139. Eyer S, Brummitt C, Crossley K, et al: Catheter-related sepsis: prospective, 117. M oro M L, Vigano EF, Cozzi Lepri A: Risk factors for central venous randomized study of three methods of long-term catheter maintenance. Crit catheter-related infections in surgical and intensive care units. The Cen- Care M ed 18:1073, 1990. tral Venous Catheter-Related Infections Study Group [erratum appears in 140. Cobb DK, H igh KP, Sawyer RG, et al: A controlled trial of scheduled re- Infect Control H osp Epidem iol 1994;15(8):508–509]. Infect Control H osp placement of central venous and pulmonary-artery catheters. N Engl J M ed Epidem iol 15:253, 1994. 327:1062, 1992. 118. Raad I, Costerton W, Sabharwal U, et al: Ultrastructural analysis of in- 141. Badley AD, Steckelberg JM , Wollan PC, et al: Infectious rates of central dwelling vascular catheters: a quantitative relationship between luminal venous pressure catheters: comparison between newly placed catheters and colonization and duration of placement. J Infect D is 168:400, 1993. those that have been changed. M ayo Clin Proc 71:838, 1996. 119. Raad II, H ohn DC, Gilbreath BJ, et al: Prevention of central venous catheter- 142. Rello J, Coll P, N et A, et al: Infection of pulmonary artery catheters. Epi- related infections by using maximal sterile barrier precautions during inser- demiologic characteristics and multivariate analysis of risk factors. [Re- tion. Infect Control H osp Epidem iol 15:231, 1994. view] [37 refs]. Chest 103:132, 1993. 120. M imoz O , Pieroni L, Lawrence C, et al: Prospective, randomized trial of 143. M oss AH , Vasilakis C, H olley JL, et al: Use of a silicone dual-lumen catheter two antiseptic solutions for prevention of central venous or arterial catheter with a Dacron cuff as a long-term vascular access for hemodialysis patients. colonization and infection in intensive care unit patients. Crit Care M ed A m J Kidney D is 16:211, 1990. 24:1818, 1996. 144. Kalfon P, de Vaumas C, Samba D, et al: Comparison of silver-impregnated 121. M aki DG, Ringer M , Alvarado CJ: Prospective randomised trial of with standard multi-lumen central venous catheters in critically ill patients. povidone-iodine, alcohol, and chlorhexidine for prevention of infection as- Crit Care M ed 35:1032–1039, 2007. sociated with central venous and arterial catheters. L ancet 338:339, 1991. 145. Brun-Boisson C, Doyon F, Sollet JP, et al: Prevention of intravascu- 122. Parras F, Ena J, Bouza E, et al: Impact of an educational program for the lar catheter-related infection with newer chlorhexidine-silver sulfadiazine- prevention of colonization of intravascular catheters. Infect Control H osp coated catheters: a randomized controlled trial. Intensive Care M ed 30: Epidem iol 15:239, 1994. 837–843, 2004. 123. M aki DG, Botticelli JT, LeRoy M L, et al: Prospective study of replacing 146. Darouiche RO , Raad II, H eard SO , et al: A comparison of two administration sets for intravenous therapy at 48- vs 72-hour intervals. 72 antimicrobial-impregnated central venous catheters. Catheter Study Group. hours is safe and cost-effective. JA M A 258:1777, 1987. N Engl J M ed 340:1, 1999. 124. M aki DG, Cobb L, Garman JK, et al: An attachable silver-impregnated 147. Berenholtz SM , Pronovost PJ, Lipsett PA, et al: Eliminating catheter-related cuff for prevention of infection with central venous catheters: a prospective bloodstream infections in the intensive care unit. Crit Care M ed 32:2014– randomized multicenter trial. A m J M ed 85:307, 1988. 2020, 2004. 125. Timsit JF, Schwebel C, Bouadma L, et al: Chlorhexadine-impregnated 148. Centers for Disease Control and Prevention (CDC): Reduction in central sponges and less frequent dressing changes for prevention of catheter- line-associated bloodstream infections among patients in intensive care related infections in critically ill adults. JA M A 301:1231–1241, 2009. units–Pennsylvania, April 2001-M arch 2005. M M W R M orb M ortal W k ly 126. H ill RL, Fisher AP, Ware RJ, et al: M upirocin for the reduction of coloniza- R ep 54:1013, 2005. tion of internal jugular cannulae—a randomized controlled trial. J H osp 149. Krein SL, H ofer TP, Kowalski CP, et al: Use of central venous catheter- Infect 15:311, 1990. related bloodstream infection prevention practices by US hospitals. M ayo 127. M iller JJ, Venus B, M athru M : Comparison of the sterility of long-term cen- Clin Proc 82:672–676, 2007. tral venous catheterization using single lumen, triple lumen, and pulmonary 150. O ’Grady N P, Barie PS, Bartlett JG, et al: Guidelines for evaluation of new artery catheters. Crit Care M ed 12:634, 1984. fever in critically ill adult patients: 2008 update from the American College 128. Arnow PM , Q uimosing EM , Beach M : Consequences of intravascular of Critical Care M edicine and the Infectious Diseases Society of America. catheter sepsis. Clin Infect D is 16:778, 1993. Crit Care M ed 36:1330–1349, 2008. tahir99-VRG & vip.persianss.ir 36 Section I: Procedures, Techniques, and Minimally Invasive Monitoring CH APTER 3 ■ ARTERIAL LIN E PLACEM EN T AN D CARE JASON LEE-LLACER AN D MICHAEL G. SEN EFF Arterial catheterization remains an extremely important skill nostic. Waveform inspection can rapidly diagnose electrocar- for critical care physicians. The most common indications for diogram lead disconnect, indicate the presence of aortic valve inserting an arterial catheter remain the need for close blood disease, help determine the effect of dysrhythmias on perfusion, pressure monitoring and frequent blood gas sampling in unsta- and reveal the impact of the respiratory cycle on blood pres- ble and ventilated patients. N ewer technologies that necessitate sure (pulsus paradoxus). In addition, in mechanically ventilated arterial access continue to mature. For example, arterial pulse patients, responsiveness to uid boluses may be predicted by contour analysis can now be used to predict uid responsive- calculating the systolic pressure variation (SPV) or pulse pres- ness and compute cardiac output more reliably and less inva- sure variation (PPV) from the arterial waveform, and stroke sively in appropriately selected patients [1]. Although it is likely volume variation (SVV) from the pulse contour analysis. In pa- that advancements in current noninvasive technology, such as tients on volume-controlled mechanical ventilation, all of these transcutaneous PCO 2 monitoring and pulse oximetry, will de- techniques have been shown to predict, with a high degree of crease the need for arterial catheter placement, intensivists will accuracy, patients likely to respond (with an increase in stroke always need to be knowledgeable in the setup and interpreta- volume) to uid volume challenge [1]. tion of arterial catheter systems. In this chapter, we review the Recent advances allow continuous CO monitoring using principles of hemodynamic monitoring and discuss the indica- arterial pulse contour analysis. This method relies on the as- tions, routes, and management of arterial cannulation. sumption that the contour of the arterial pressure waveform is proportional to the stroke volume [6]. This, however, does not take into consideration the differing impedances among the arteries of individuals and different disease states and there- IN DICATION S FOR ARTERIAL fore requires calibration with another method of determining CAN N ULATION cardiac output [7]. This is usually done with lithium dilution or transpulmonary thermodilution methods. A different pulse Arterial catheters should be inserted only when they are specif- contour analysis device has been introduced which does not re- ically required and removed immediately when no longer quire an additional method of determining CO for calibration, needed. Too often they are left in place for convenience to al- but instead estimates impedance based upon a proprietary for- low easy access to blood sampling, which leads to increased mula that uses waveform and patient demographic data [7]. laboratory testing and excessive diagnostic blood loss [2,3]. This method has signi cant limitations (i.e., atrial brillation) Protocols incorporating guidelines for arterial catheterization and there is concern that the device may not be accurate in and alternative noninvasive monitoring, such as pulse oxime- clinical situations with dynamic changes in vascular tone (i.e., try and end tidal CO 2 , have realized signi cant improvements sepsis) [8]. Further data and comparison among the methods in resource utilization and cost savings, without impacting the in authentic and diverse clinical situations are required before quality of care [4]. de nitive recommendations can be made. The indications for arterial cannulation can be grouped into M anagement of complicated patients in critical care units four broad categories (Table 3.1): (1) hemodynamic monitor- typically requires multiple laboratory and arterial blood gas de- ing (blood pressure and/or cardiac output/pulse contour anal- terminations. In these situations, arterial cannulation permits ysis); (2) frequent arterial blood gas sampling; (3) diagnostic routine laboratory tests without multiple needle sticks and ves- or therapeutic/interventional radiology procedures, including sel trauma. In our opinion, an arterial catheter for blood gas intra-aortic balloon pump (IABP) use, arterial administration determination should be placed when a patient requires two or of drugs, vascular stenting and embolization, and (4) continu- more measurements daily. ous cardiac output monitoring. N oninvasive, indirect blood pressure measurements deter- mined by auscultation of Korotkoff sounds distal to an occlud- EQUIPMEN T, MON ITORIN G, ing cuff (Riva–Rocci method) are generally accurate, although systolic readings are consistently lower compared to a si- TECHN IQUES, AN D multaneous direct measurement. In hemodynamically unstable SOURCES OF ERROR patients, however, indirect techniques may signi cantly under- estimate blood pressure. Automated noninvasive blood pres- The equipment necessary to display and measure an arterial sure measurement devices can also be inaccurate, particularly waveform has not changed and includes (a) an appropriate in- in rapidly changing situations, at the extremes of blood pres- travascular catheter; (b) uid- lled noncompliant tubing with sure, and in patients with dysrhythmias [5]. For these reasons, stopcocks; (c) transducer; (d) a constant ush device; and (e) direct blood pressure monitoring is usually required for unsta- electronic monitoring equipment. Using this equipment, in- ble patients. Rapid beat-to-beat changes can easily be mon- travascular pressure changes are transmitted through the hy- itored and appropriate therapeutic modalities initiated, and draulic ( uid- lled) elements to the transducer, which converts variations in individual pressure waveforms may prove diag- mechanical displacement into a proportional electrical signal. tahir99-VRG & vip.persianss.ir Chapter 3: Arterial Line Placement and Care 37 T A B LE 3 . 1 The damping coef cient is a measure of how quickly an oscillating system comes to rest. A system with a high damp- IN DICATION S FOR ARTERIAL CAN N ULATION ing coef cient absorbs mechanical energy well (i.e., compliant tubing), causing a diminution in the transmitted waveform. H emodynamic monitoring Conversely, a system with a low damping coef cient results in Acutely hypertensive or hypotensive patients underdamping and systolic overshoot. Damping coef cient and Use of vasoactive drugs resonant frequency together determine the dynamic response M ultiple blood sampling of a recording system. If the resonant frequency of a system Ventilated patients is less than 7.5 H z, the pressure waveform will be distorted Limited venous access no matter what the damping coef cient. O n the other hand, a resonant frequency of 24 H z allows a range in the damping Diagnostic or interventional radiology procedures coef cient of 0.15 to 1.1 without resultant distortion of the Intra-arterial drugs pressure waveform [9]. Vascular stenting Although there are other techniques [12], the easiest method Intra-aortic balloon pump use to test the damping coef cient and resonant frequency of a Arterial embolization monitoring system is the fast- ush test (also known as the Continuous cardiac output monitoring square wave test). This is performed at the bedside by brie y opening and closing the continuous ush device, which pro- duces a square wave displacement on the monitor followed by a return to baseline, usually after a few smaller oscillations The signal is ampli ed, processed, and displayed as a waveform (Fig. 3.1). Values for the damping coef cient and resonant fre- by the monitor. Undistorted presentation of the arterial wave- quency can be computed by printing the wave on graph paper form is dependent on the performance of each component, and [9], but visual inspection is usually adequate to ensure a proper an understanding of potential problems that can interfere with frequency response. An optimum fast- ush test results in one overall delity of the system. undershoot followed by small overshoot, then settles to the The major problems inherent to pressure monitoring with patient’s waveform. a catheter system are inadequate dynamic response, improper For peripheral pulse pressure monitoring, an adequate fast- zeroing and zero drift, and improper transducer/monitor cali- ush test usually corresponds to a resonant frequency of 10 bration. M ost physicians are aware of zeroing techniques but to 20 H z coupled with a damping coef cient of 0.5 to 0.7. To do not appreciate the importance of dynamic response in ensur- ensure the continuing delity of a monitoring system, dynamic ing system delity. Catheter-tubing-transducer systems used for response validation by fast- ush test should be performed fre- pressure monitoring can best be characterized as underdamped quently: at least every 8 hours, with every signi cant change in second-order dynamic systems with mechanical parameters of patient hemodynamic status, after each opening of the system elasticity, mass, and friction [9]. O verall, the dynamic response (zeroing, blood sampling, tubing change), and whenever the of such a system is determined by its resonant frequency and waveform appears damped [9]. damping coef cient (zeta). The resonant or natural frequency With consideration of the above concepts, components of of a system is the frequency at which it oscillates when stimu- the monitoring system are designed to optimize the frequency lated. When the frequency content of an input signal (i.e., pres- response of the entire system. The 18- and 20-gauge catheters sure waveform) approaches the resonant frequency of a system, used to gain vascular access are not a major source of distortion progressive ampli cation of the output signal occurs—a phe- but can become kinked or occluded by thrombus, resulting in nomenon known as ringing [10]. To ensure a at frequency re- overdamping of the system. Standard, noncompliant tubing is sponse (accurate recording across a spectrum of frequencies), provided with most disposable transducer kits and should be the resonant frequency of a monitoring system should be at as short as possible to minimize signal ampli cation [10]. Air least ve times higher than the highest frequency in the input bubbles in the tubing and connecting stopcocks are a notori- signal [9]. Physiologic peripheral arterial waveforms have a ous source of overdamping of the tracing and can be cleared fundamental frequency of 3 to 5 H z and therefore the resonant by ushing through a stopcock. Currently available disposable frequency of a system used to monitor arterial pressure should transducers incorporate microchip technology, are very reli- ideally be greater than 20 H z to avoid ringing and systolic able, and have relatively high resonant frequencies [13]. The overshoot. transducer is attached to the electronic monitoring equipment The system component most likely to cause ampli cation by a cable. M odern monitors have internal calibration, lter of a pressure waveform is the hydraulic element. A good hy- artifacts, and print the display on request. The digital readout draulic system will have a resonant frequency between 10 and display is usually an average of values over time and therefore 20 H z, which may overlap with arterial pressure frequencies. does not accurately represent beat-to-beat variability. M oni- Thus ampli cation can occur, which may require damping to tors provide the capability to freeze a display with on-screen accurately reproduce the waveform [11]. calibration to measure beat-to-beat differences in amplitude FIGURE 3.1. Fast- ush test. A: O verdamped system. B: Underdamped system. C: O ptimal A B C damping. tahir99-VRG & vip.persianss.ir 38 Section I: Procedures, Techniques, and Minimally Invasive Monitoring precisely. This allows measurement of the effect of ectopic beats super cial temporal arteries. Peripheral sites are cannulated on blood pressure, PPV, SPV, or assessment of the severity of percutaneously with a 2-inch, 20-gauge, nontapered Te on pulsus paradoxus. catheter-overneedle and larger arteries using the Seldinger tech- When presented with pressure data or readings believed to nique with a prepackaged kit, typically containing a 6-inch, be inaccurate, or which are signi cantly different from indirect 18-gauge Te on catheter, appropriate introducer needles, and readings, a few quick checks can ensure system accuracy. Im- guidewire. proper zeroing of the system, because of either change in patient Arterial catheterization is performed by physicians from position or zero drift, is the single most important source of er- many different specialties and usually the procedure to be per- ror. Z eroing can be checked by opening the transducer stopcock formed dictates the site chosen. For example, insertion of an to air and aligning with the midaxillary line, con rming that the IABP is almost always performed through the femoral artery monitor displays zero. Z eroing should be repeated with patient regardless of the specialty of the physician performing the pro- position changes, (a transducer that is below the zero reference cedure. Critical care physicians need to be facile with arterial line will result in falsely high readings and vice versa), when sig- cannulation at all sites, but the radial and femoral arteries are ni cant changes in blood pressure occur, and routinely every 6 used successfully for more than 90% of all arterial catheteri- to 8 hours because of zero drift. Disposable pressure transduc- zations performed in the ICU. Although each site has unique ers incorporate semiconductor technology and are very small, complications, available data do not indicate a preference for yet rugged and reliable, and due to standardization, calibration any one site [15–17]. Radial artery cannulation is usually at- of the system is not necessary [13]. Transducers are faulty on tempted initially unless the patient is in shock, on high dose va- occasion, however, and calibration may be checked by attach- sopressors, and/or pulses are not palpable. If this fails, femoral ing a mercury manometer to the stopcock and applying 100, artery cannulation should be performed. If catheterization at 150, and/or 200 mm H g pressure. A variation of ± 5 mm H g these two sites proves unsuccessful or not appropriate, then is acceptable. If calibration is questioned and the variation is the dorsalis pedis, brachial, and axillary artery are the recom- out of range, or a manometer is not available for testing, the mended alternative sites. Which of these is chosen depends on transducer should be replaced. the exact clinical situation and the experience and expertise of If zero referencing and calibration are correct, a fast- ush the operator. test will assess the system’s dynamic response. O verdamped tracings are usually caused by problems that are correctable, such as air bubbles, kinks, clot formation, overly compliant tubing, loose connections, a de ated pressure bag, or anatom- Use of Portable Ultrasound ical factors affecting the catheter. An underdamped tracing re- Bedside ultrasound has not had as great an impact on arterial sults in systolic overshoot and can be secondary to excessive as it has on venous catheterization because vessel puncture is tubing length or patient factors such as increased inotropic or based on a palpable “ landmark” that guides needle placement, chronotropic state. M any monitors can be adjusted to lter and the complication rate during insertion is much lower. H ow- out frequencies above a certain limit, which can eliminate fre- ever, we have found ultrasound guidance to be very useful and quencies in the input signal causing ringing. H owever, this may ef cient in assisting with brachial and femoral artery catheteri- also cause inaccurate readings if important frequencies are ex- zations, and have even used it successfully for selected dif cult cluded. radial artery procedures. In our experience, ultrasound has the same impact with arterial as it does with venous catheteriza- tions; higher success rate with less procedure time, number of TECHN IQUE OF ARTERIAL attempts, and complications. O perator technique of ultrasound CAN N ULATION for arterial is the same as for venous catheterization and the reader is referred to Chapter 2 for a description of ultrasound equipment and technique. Ultrasound images for each of the Site Selection major arterial routes are shown in Figure 3.2. Several factors are important in selecting the site for arterial cannulation. The ideal artery has extensive collateral circula- tion that will maintain the viability of distal tissues if throm- Radial Artery Cannulation bosis occurs. The site should be comfortable for the patient, accessible for nursing care and insertion, and close to the mon- A thorough understanding of normal arterial anatomy and itoring equipment. Sites involved by infection or disruption in common anatomical variants greatly facilitates insertion of the epidermal barrier should be avoided. Certain procedures, catheters and management of unexpected ndings at all sites. such as coronary artery bypass grafting, may dictate preference The radial artery is one of two nal branches of the brachial for one site over another. Larger arteries and catheters provide artery. It courses over the exor digitorum sublimis, exor pol- more accurate (central aortic) pressure measurements. Physi- licis longus, and pronator quadratus muscles and lies just lat- cians should also be cognizant of differences in pulse contour eral to the exor carpi radialis in the forearm. As the artery recorded at different sites. As the pressure pulse wave travels enters the oor of the palm, it ends in the deep volar arterial outward from the aorta, it encounters arteries that are smaller arch at the level of the metacarpal bones and communicates and less elastic, with multiple branch points, causing re ections with the ulnar artery. A second site of collateral ow for the of the pressure wave. This results in a peripheral pulse contour radial artery occurs via the dorsal arch running in the dorsum with increased slope and amplitude, causing recorded values of the hand (Fig. 3.3). to be arti cially elevated. As a result, distal extremity artery The ulnar artery runs between the exor carpi ulnaris and recordings yield higher systolic values than central aortic or exor digitorum sublimis in the forearm, with a short course femoral artery recordings. Diastolic pressures tend to be less over the ulnar nerve. In the hand the artery runs over the trans- affected, and mean arterial pressures measured at the different verse carpal ligament and becomes the super cial volar arch, sites are similar [14]. which forms an anastomosis with a small branch of the radial The most commonly used sites for arterial cannulation in artery. These three anastomoses provide excellent collateral adults are the radial, femoral, axillary, dorsalis pedis, and ow to the hand [18]. A competent super cial or deep pal- brachial arteries. Additional sites include the ulnar, axillary and mar arch must be present to ensure adequate collateral ow. tahir99-VRG & vip.persianss.ir Chapter 3: Arterial Line Placement and Care 39 A B C D FIGURE 3.2. Portable ultrasound images. A. Radial artery longitudinal view. B. Brachial artery axial view. C. Femoral artery axial view. D. Axillary artery axial view. See text for details. At least one of these arches may be absent in up to 20% of catheter that suggests decreased perfusion (color or tempera- individuals. ture change, paresthesias, loss of capillary re ll) should prompt im m ediate removal of the catheter and further investigation if the changes do not reverse. Modi ed Allen’s Test H and ischemia is a rare but potential devastating complication of radial artery catheterization that may require amputation [19]. H and ischemia is rare because of the rich collateral cir- Percutaneous Insertion culation described earlier that insures perfusion even if one of the main arteries thrombose. H istorically, the modi ed Allen’s The hand is positioned in 30 to 60 degrees of dorsi exion with test [20], described in previous editions of this text, was used the aid of a roll of gauze and armband, avoiding hyperabduc- prior to radial catheterization to detect patients’ in whom the tion of the thumb. The volar aspect of the wrist is prepared collateral circulation may not be intact and presumably at in- (alcoholic chlorhexidine) and draped using sterile technique, creased risk for hand ischemia. H owever, as a screening tool and approximately 0.5 mL of lidocaine is in ltrated on both the Allen’s test has never had very good predictive value [21] sides of the artery through a 25-gauge or smaller needle. Lido- and our institution, as well as many others, has abandoned its caine serves to decrease patient discomfort and may decrease routine use. The best way to prevent hand ischemia is to avoid the likelihood of arterial vasospasm [22]. The catheter over the radial catheterization in patients at increased risk (i.e., high needle approach (e.g., radial or brachial site) necessitates cap, dose vasopressor therapy, scleroderma, vasculopathy) and to mask, sterile gloves and a small fenestrated drape; whereas, the perform clinical evaluation of hand perfusion at each nursing Seldinger technique (i.e., femoral approach) requires maximum shift change. A ny change in the hand distal to a radial artery barrier precautions. A time out con rming correct patient, tahir99-VRG & vip.persianss.ir 40 Section I: Procedures, Techniques, and Minimally Invasive Monitoring Catheters with self-contained guidewires to facilitate pas- sage of the cannula into the artery are available (Fig. 3.4). Percutaneous puncture is made in the same manner, but when blood return is noted in the catheter hub the guidewire is passed through the needle into the artery, serving as a stent for subse- quent catheter advancement. The guidewire and needle are then removed and placement con rmed by pulsatile blood return. The cannula is then secured rmly, attached to transducer tub- ing, and the site bandaged. Video instruction for the insertion of a radial arterial line is available at www.nejm.org [24]. Dorsalis Pedis Artery Cannulation Dorsalis pedis artery catheterization is uncommon in most crit- ical care units; compared with the radial artery, the anatomy is less predictable and the success rate is lower [25]. The dor- salis pedis artery is the main blood supply of the dorsum of the foot. The artery runs from the level of the ankle to the great toe. It lies very super cial and just lateral to the tendon of the extensor hallucis longus. The dorsalis pedis anastomoses with branches from the posterior tibial (lateral plantar artery) and, to a lesser extent, peroneal arteries, creating an arterial arch network analogous to that in the hand. Use of a catheter with self-contained guidewire is recom- mended for dorsalis pedis catheterization. The foot is placed in plantar exion and prepared in the usual fashion. Vessel entry is obtained approximately halfway up the dorsum of the foot where the palpable pulse is strongest; advancement is the same as with cannulation of the radial artery. Patients usually nd insertion here more painful but less physically limiting. Sys- tolic pressure readings are usually 5 to 20 mm H g higher with dorsalis pedis catheters than radial artery catheters, but mean pressure values are generally unchanged. FIGURE 3.3. Anatomy of the radial artery. N ote the collateral circula- tion to the ulnar artery through the deep volar arterial arch and dorsal Brachial Artery Cannulation arch. The brachial artery is cannulated in the bicipital groove prox- imal to the antecubital fossa at a point where there is no correct site, correct equipment and informed consent is nec- collateral circulation (Fig. 3.2B). In theory, clinical ischemia essary before the procedure begins. should be a greater risk, but in most series brachial artery A 20-gauge, nontapered, Te on 1 1/ 2 - or 2-inch catheter- catheters have complication rates comparable to other routes overneedle apparatus is used for puncture. Entry is made at [17,18,26,27]. Even when diminution of distal pulses occurs, a 30- to 60-degree angle to the skin approximately 3 to 5 cm because of either proximal obstruction or distal embolization, proximal to the distal wrist crease. Ultrasound image of the clinical ischemia is unlikely [26]. An additional anatomic con- radial artery at this position is shown in Figure 3.2A. The sideration is that the median nerve lies in close proximity to the needle and cannula are advanced until blood return is noted brachial artery and may be punctured in 1% to 2% of cases in the hub, signifying intra-arterial placement of the tip of the [27]. This usually causes only transient paresthesias, but me- needle. A small amount of further advancement is necessary for dian nerve palsy has been reported. M edian nerve palsy is a par- the cannula to enter the artery as well. With this accomplished, ticular risk in patients with coagulopathy because even minor needle and cannula are brought at to the skin and the cannula bleeding into the fascial planes can produce compression of the advanced to its hub with a rm, steady rotary action. Correct median nerve [28]. Coagulopathy should be considered a rela- positioning is con rmed by pulsatile blood return on removal tive contraindication to brachial artery cannulation. Given all of the needle. If the initial attempt is unsuccessful, subsequent these considerations, brachial artery cannulation should only attempts should be more proximal, rather than closer to the be considered if the radial, femoral, and dorsalis pedis sites are wrist crease, as the artery is of greater diameter [18], although not available or appropriate. this may increase the incidence of catheters becoming kinked Cannulation of the brachial artery is best performed using a or occluded [23]. prepackaged kit designed for larger arteries (see femoral artery If dif culty is encountered when attempting to pass the cannulation). The brachial artery is punctured by extending the catheter, carefully replacing the needle and slightly advancing arm at the elbow and locating the pulsation a few centimeters the whole apparatus may remedy the problem. Alternately, a proximal to the antecubital fossa, just medial to the bicipi- xation technique can be attempted (Fig. 3.3). Advancing the tal tendon. O nce the catheter is established, the elbow must be needle and catheter through the far wall of the vessel purposely kept in full extension to avoid kinking or breaking the catheter. trans xes the artery. The cannula is then pulled back with the Clinical examination of the hand, and Doppler studies if indi- needle partially retracted within the catheter until vigorous ar- cated, should be repeated daily while the brachial catheter is terial blood return is noted. The catheter can then be advanced in place. The catheter should be promptly removed if diminu- into the arterial lumen, using the needle as a reinforcing stent. tion of any pulse occurs or there is evidence of embolism. An tahir99-VRG & vip.persianss.ir Chapter 3: Arterial Line Placement and Care 41 A C B D FIGURE 3.4. Cannulation of the radial artery. A: A towel is placed behind the wrist, and the hand is immobilized with tape. B: The catheter-needle-guidewire apparatus is inserted into the skin at a 30- to 60-degree angle. C: The guidewire is advanced into the artery after pulsatile blood ow is obtained. D: The catheter is advanced over the guidewire into the artery. [From Irwin RS, Rippe JM : M anual of Intensive Care M edicine. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006:17, with permission.] additional concern is air embolism (see later) since placement and the middle third of a straight line drawn between the pu- of a 6-inch catheter puts the tip in the axillary artery. bis and the anterior superior iliac spine (Fig. 3.2C). The artery is cannulated using the Seldinger technique and any one of several available prepackaged kits. Kits contain the equivalent Femoral Artery Cannulation of a 19-gauge thin-wall needle, appropriate guidewire, and a 6-inch, 18-gauge Te on catheter. The patient lies supine with The femoral artery is usually the next alternative when ra- the leg extended and slightly abducted. Skin puncture should dial artery cannulation fails or is inappropriate [15–17]. The be 3 to 5 cm caudal to the inguinal ligament to minimize femoral artery is large and often palpable when other sites are the risk of retroperitoneal hematoma or bowel perforation, not, and the technique of cannulation is easy to learn. The most which can occur when needle puncture of the vessel is cepha- common reason for failure to cannulate is severe atheroscle- lad to the inguinal ligament. The thin-wall needle is directed, rosis or prior vascular procedures involving both femoral ar- bevel up, cephalad at a 45-degree angle. When arterial blood teries, in which case axillary or brachial artery cannulation is return is con rmed, the needle and syringe may need to be appropriate. Complications unique to this site are rare but in- brought down against the skin to facilitate guidewire passage. clude retroperitoneal hemorrhage and intra-abdominal viscus The guidewire should advance smoothly, but minor manip- perforation. These complications occur because of poor tech- ulation and rotation is sometimes required if the wire meets nique (puncture above the inguinal ligament) or in the presence resistance at the needle tip or after it has advanced into the of anatomical variations (i.e., large inguinal hernia). Ischemic vessel. Inability to pass the guidewire may be due to an inti- complications from femoral artery catheters are very rare. mal ap over the needle bevel or atherosclerotic plaques in the The external iliac artery becomes the common femoral vessel. In the latter instance, cannulation of that femoral artery artery at the inguinal ligament (Fig. 3.5). The artery courses may prove impossible. When the guidewire will not pass be- under the inguinal ligament near the junction of the medial yond the needle tip it should be withdrawn and blood return tahir99-VRG & vip.persianss.ir 42 Section I: Procedures, Techniques, and Minimally Invasive Monitoring is enclosed in a neurovascular bundle, the axillary sheath, with the medial, posterior, and lateral cords of the brachial plexus. M edial to the medial cord is the axillary vein. N ot surprisingly, brachial plexus neuropathies have been reported from axillary artery cannulation [30]. Coagulopathy is a relative contraindi- cation, as the axillary sheath can rapidly ll with blood from an uncontrolled arterial puncture, resulting in a compressive neuropathy. The axillary artery is cannulated using the Seldinger tech- nique and a prepackaged kit. The arm is abducted, externally rotated, and exed at the elbow by having the patient place the hand under his or her head. The artery is palpated at the lower border of the pectoralis major muscle and xed against the shaft of the humerus. After site preparation and local in- ltration with lidocaine, the thin-wall needle is introduced at a 30- to 45-degree angle to the vertical plane until return of arterial blood. The remainder of the catheterization proceeds as described for femoral artery cannulation. COMPLICATION S OF ARTERIAL CAN N ULATION Arterial cannulation is a relatively safe invasive procedure. Al- though estimates of the total complication rate range from 15% to 40% , clinically relevant complications occur in 5% or less (Table 3.2). Risk factors for infectious and noninfectious com- plications have been identi ed [31,32] (Table 3.3), but the clin- ical impact of most of these factors is minimal, given the overall low incidence of complications. Thrombosis FIGURE 3.5. Anatomy of the femoral artery and adjacent structures. Thrombosis is the single most common complication of intra- The artery is cannulated below the inguinal ligament. arterial catheters. The incidence of thrombosis varies with the site, method of detection, size of the cannula, and duration of reestablished by advancing the needle or repeat vascular punc- ture. The guidewire is then inserted, the needle withdrawn T A B LE 3 . 2 and the catheter threaded over the guidewire to its hub. The guidewire is withdrawn, the catheter sutured securely and con- COMPLICATION S ASSOCIATED WITH ARTERIAL nected to the transducer tubing. CAN N ULATION Site Complication Axillary Artery Cannulation All sites Pain and swelling Thrombosis Axillary artery catheterization in the ICU occurs infrequently, Asymptomatic but centers experienced with it report a low rate of compli- Symptomatic cations [15,17,29]. The axillary artery is large and frequently Embolization palpable when all other sites are not and has a rich collateral H ematoma circulation. The tip of a 6-inch catheter inserted through an H emorrhage axillary approach lies in the subclavian artery, and thus ac- Limb ischemia curate central pressures are obtained. The central location of Catheter-related infection including the tip makes cerebral air embolism a greater risk, therefore bacteremia left axillary catheters are preferred for the initial attempt, since Diagnostic blood loss air bubbles passing into the right subclavian artery are more Pseudoaneurysm likely to traverse the aortic arch. Caution should be exercised H eparin-associated thrombocytopenia in ushing axillary catheters, which is best accomplished man- Radial artery Cerebral embolization ually using low pressures and small volumes. Peripheral neuropathy The axillary artery begins at the lateral border of the rst Femoral artery Retroperitoneal hemorrhage rib as a continuation of the subclavian artery and ends at the Bowel perforation inferior margin of the teres major muscle, where it becomes Arteriovenous stula the brachial artery. The optimal site for catheterization is the Axillary artery Cerebral embolization junction of the middle and lower third of the vessel, which usu- Brachial plexopathy ally corresponds to its highest palpable point in the axilla. At Brachial artery M edian nerve damage this point, the artery is super cial and is located at the inferior Cerebral embolization border of the pectoralis major muscle (Fig. 3.2D). The artery tahir99-VRG & vip.persianss.ir Chapter 3: Arterial Line Placement and Care 43 T A B LE 3 . 3 in a sitting patient), injection site, and ush rate. Air embolism has been cited as a risk mainly for radial arterial catheters but FACTORS PREDISPOSIN G TO COMPLICATION S WITH logically could occur with all arterial catheters, especially ax- ARTERIAL CAN N ULATION illary and brachial artery catheters. The risk is minimized by clearing all air from tubing before ushing, opening the ush Large tapered cannulas (> 20 gauge except at the large valve for no more than 2 to 3 seconds, and avoiding overag- artery sites) gressive manual ushing of the line. H ypotension Coagulopathy Low cardiac output Diagnostic Blood Loss M ultiple puncture attempts Use of vasopressors Diagnostic blood loss (DBL) is patient blood loss that occurs Atherosclerosis due to frequent blood sampling obtained for laboratory testing. H ypercoagulable state The signi cance of DBL is underappreciated. It is a particular Placement by surgical cutdown problem in patients with standard arterial catheter setups that Site in ammation are used as the site for sampling, because 3 to 5 mL of blood is Intermittent ushing system typically wasted (to avoid heparin/saline contamination) every Bacteremia time a sample is obtained. In patients with frequent arterial blood gas determinations, DBL can be substantial and result in a transfusion requirement [37]. There are several ways to minimize DBL, including tubing systems employing a reser- cannulation. Thrombosis is common with radial and dorsalis voir for blood sampling, continuous intra-arterial blood gas pedis catheters, but clinical sequelae are rare because of the col- monitoring, point of care microchemistry analysis and the use lateral circulation [31,32]. When a 20-gauge nontapered Te on of pediatric collection tubes. Given the expense and risks of catheter with a continuous 3 mL per hour heparinized-saline blood component therapy, every ICU should have a blood con- ush is used to cannulate the radial artery for 3 to 4 days, servation policy in place that includes minimizing DBL. Proto- thrombosis of the vessel can be detected by Doppler study in cols that are designed to optimize laboratory utilization have 5% to 25% of cases [32]. Use of a ush solution containing resulted in signi cant cost savings and reduced transfusion re- heparin is no longer standard at our institution because of con- quirements [38]. cern for heparin-induced thrombocytopenia; the incidence of thrombosis does not appear to be signi cantly higher using saline ush [33,34]. Other Mechanical and Technical Thrombosis often occurs after catheter removal. Women Complications represent a preponderance of patients who experience ow ab- normalities following radial artery cannulation, probably be- O ther noninfectious complications reported with arterial cause of smaller arteries and a greater tendency to exhibit va- catheters are pseudoaneurysm formation, hematoma, local ten- sospasm [23]. M ost patients eventually recanalize, generally derness, hemorrhage, neuropathies, and catheter embolization by 3 weeks after removal of the catheter. Despite the high inci- [17]. H eparin-associated thrombocytopenia (H AT) is a risk of dence of Doppler-detected thrombosis, clinical ischemia of the any arterial catheter in institutions where heparin is still used hand is rare and usually resolves following catheter removal. as a standard continuous ush solution [39]. Although heparin Symptomatic occlusion requiring surgical intervention occurs containing ush solutions may have a slightly reduced rate of in fewer than 1% of cases, but can be catastrophic with tissue vessel thrombosis and catheter occlusions [40] (especially ra- loss or amputation of the hand [19]. M ost patients who develop dial), in our opinion the risk of H AT outweighs any bene t. clinical ischemia have an associated contributory cause, such as O ur institution has used saline-only ush solutions for many prolonged circulatory failure with high-dose vasopressor ther- years and we have not noticed an increase in thrombotic or apy [31]. We consider the femoral artery the most appropriate other complications. rst choice in these patients. Regular inspection of the extremity for unexplained pain or signs of ischemia and immediate removal of the catheter mini- Infection mize signi cant ischemic complications. If evidence of ischemia persists after catheter removal, anticoagulation, thrombolytic Infectious sequelae are the most important clinical compli- therapy, embolectomy, surgical bypass, or cervical sympathetic cations occurring because of arterial cannulation, and many blockade are treatment options and should be pursued aggres- of the concepts and de nitions applied to central venous sively [19,31]. catheter–related infection (Chapter 2) are also relevant to arte- rial catheters. Catheter-associated infection is usually initiated by skin Cerebral Embolization ora that invades the intracutaneous tract, causing coloniza- tion of the catheter, and ultimately, bacteremia. An additional Continuous ush devices used with arterial catheters are de- source of infection from pressure-monitoring systems is con- signed to deliver 3 mL per hour of uid from an infusion bag taminated infusate, which is at greater risk for infection than pressurized to 300 mm H g. Lowenstein [35] demonstrated that central venous catheters because (a) the transducer can become with rapid ushing of radial artery lines with relatively small colonized because of stagnant ow, (b) the ush solution is in- volumes of radiolabeled solution, traces of the solution could fused at a slow rate (3 mL per hour) and may hang for several be detected in the central arterial circulation in a time frame days, and (c) multiple blood samples are obtained by several representative of retrograde ow. Chang [4,36] demonstrated different personnel from stopcocks in the system, which can that injection of greater than 2 mL of air into the radial artery serve as entry sites for bacteria. of small primates resulted in retrograde passage of air into the Appreciation of the mechanisms responsible for initiating vertebral circulation. Factors that increase the risk for retro- arterial catheter–related infection is important in understand- grade passage of air are patient size and position (air travels up ing how to minimize infection. Thorough operator and site tahir99-VRG & vip.persianss.ir 44 Section I: Procedures, Techniques, and Minimally Invasive Monitoring preparation is paramount and triple barrier protection is ap- 7- to 14-day course of appropriate antibiotics. In complicated propriate for all larger artery insertions. Chlorhexadine should cases, longer courses are sometimes necessary. be used for skin preparation [41] and use of a chlorhexidine The optimal evaluation of febrile catheterized patients can soaked dressing at the insertion site is excellent practice. Breaks be a challenging problem (see Chapter 2). If the site appears ab- in sterile technique during insertion mandate termination of normal or the patient is in septic shock with no other etiology, the procedure and replacement of compromised equipment. the catheter should be removed. M ore speci c guidelines are N ursing personnel should follow strict guidelines when draw- dif cult to recommend, and individual factors should always ing blood samples or manipulating tubing. Blood withdrawn be considered. In general, arterial catheters in place less than 5 to clear the tubing prior to drawing samples should not be rein- days will not be the source of fever unless insertion was contam- jected unless a specially designed system is in use [42]. Inspec- inated. Catheters in place 7 days or longer should be changed tion of the site at the start of every nursing shift is mandatory, to a different site given the safety of arterial cannulation and and the catheter should be removed promptly if abnormalities the small but measurable chance of infection. Guidewire ex- are noted. Routine change of the pressure monitoring system changes should only be used to change a malfunctioning or does not reduce infectious complications and may simply be damaged catheter. another opportunity to introduce colonization. H istorically, it was always felt that arterial catheters had a lower risk for infection than central venous catheters, but that is probably no longer true. Impressive reductions in over- RECOMMEN DATION S all Catheter Related Infections (CRI) have occurred as a result of increased research, better technology, and an emphasis on Either the radial or femoral artery is an appropriate initial site patient safety, leading to a convergence of infectious risks for for percutaneous arterial cannulation. M ost centers have more arterial and central venous catheters [43,44]. Using modern experience with radial artery cannulation, but femoral artery techniques, arterial catheter–related colonization may occurs catheters are reliable and have a comparable incidence of com- in up to 5% to 10% of catheters but the incidence of catheter- plication. In our opinion, the femoral artery should be used related bacteremia should be in the range of 0.5 to 2.0 per rst in shocked patients, especially when vasopressors are in- 1,000 catheter-days [15,16,43–45]. The site of insertion does fusing, because of the risk of tissue loss with radial or dorsalis not appear to be an important factor impacting on the inci- pedis catheters. In more than 90% of patients, the radial or dence of infection [15–17,25] but duration is likely important femoral site is adequate to achieve arterial pressure monitor- [44]. We believe 7 days is an appropriate time to reassess the ing. When these sites are not appropriate, the dorsalis pedis need for and the location of arterial catheterization [44] but artery is a good alternative, but cannulation is frequently not each institution should determine its own catheter-associated possible, especially if radial artery cannulation failed because infection rate so that rational policies can be formulated based of poor perfusion. Under these circumstances, the brachial fol- on existing local infection rates. lowed by the axillary artery can be safely cannulated; when a When arterial catheter infection does occur, Staphylococ- coagulopathy is present, ultrasound guidance should be used to cus species are commonly isolated. Gram-negative organisms avoid complications. Arterial catheters can be left in place until are less frequent, but predominate in contaminated infusate there is clinical indication to remove them, but infection rate or equipment-related infection. Infection with Candida species increases proportionally. Iatrogenic anemia and overutilization is a greater risk in prolonged catheterization of the glucose- of blood tests are a real phenomenon associated with arterial intolerant patient on multiple systemic broad-spectrum antibi- catheters, which should be discontinued promptly when no otics. Catheter-associated bacteremia should be treated with a longer required for patient management. References 1. M arik PE, Cavallazzi R, Vasu T, et al: Dynamic changes in arterial wave- 12. Billiet E, Colardyn F: Pressure measurement evaluation and accuracy valida- form derived variables and uid responsiveness in mechanically ventilated tion: the Gabarith test. Intensive Care M ed 24:1323, 1998. patients: A systematic review of the literature. Crit Care M ed 37:2642–2647, 13. Gardner RM : Accuracy and reliability of disposable pressure transducers 2009. coupled with modern pressure monitors. Crit Care M ed 24:879, 1996. 2. Low LL, H arrington GR, Stoltzfus DP. The effect of arterial lines on blood- 14. Pauca AL, Wallenhaupt SL, Kon N D, et al: Does radial artery pressure ac- drawing practices and costs in intensive care units. Chest 108:216, 1995. curately re ect aortic pressure? Chest 102:1193, 1992. 3. Z immerman JE, Seneff M G, Sun X, et al: Evaluating laboratory usage in 15. Gurman GM , Kriemerman S: Cannulation of big arteries in critically ill pa- the intensive care unit: patient and institutional characteristics that in uence tients. Crit Care M ed 13:217, 1985. frequency of blood sampling. Crit Care M ed 25:737, 1997. 16. Russell JA, Joel M , H udson RJ, et al: Prospective evaluation of radial and 4. Clark JS, Votteri B, Ariagno RL, et al: N oninvasive assessment of blood femoral artery catheterization sites in critically ill adults. Crit Care M ed gases. A m R ev R espir D is 145:220, 1992. 11:936, 1983. 5. Bur A, H irschl M M , H erkner H , et al: Accuracy of oscillometric blood pres- 17. Scheer BV, Perel A, Pfeiffer UJ: Clinical review: complications and risk fac- sure measurement according to the relation between cuff size and upper-arm tors of peripheral arterial catheters used for haemodynamic monitoring in circumference in critically ill patients. Crit Care M ed 28:371, 2000. anaesthesia and intensive care medicine. Critical Care 6;199–204, 2002. 6. H irschl M M , Kittler H , Woisetschlager C, et al: Simultaneous comparison of 18. M athers LH : Anatomical considerations in obtaining arterial access. J Inten- thoracic bioimpedance and arterial pulse waveform-derived cardiac output sive Care M ed 5:110, 1990. with thermodilution measurement. Crit Care M ed 28:1798, 2000. 19. Valentine RJ, M odrall JG, Clagett GP: H and ischemia after radial artery 7. Chaney JC, Derdak S: M inimally invasive hemodynamic monitoring for cannulation. J A m Coll Surg 201:18, 2005. the intensivist: current and emerging technology. Crit Care M ed 30:2338, 20. Allen EV: T hrom boangiitis obliterans: M ethod of diagnosis of chronic oc- 2002. clusive arterial lesions distal to the wrist with illustrative cases. A m J M ed 8. M ayer J, Boldt J, Poland R, et al: Continuous arterial pressure waveform- Sci 178:237, 1929. based cardiac output using the FloTrac/Vigileo: a review and meta-analysis. 21. Glavin RJ, Jones H M : Assessing collateral circulation in the hand—four J Cardiothorac Vasc A nesth 23:401–406, 2009. methods compared. A naesthesia 44:594, 1989. 9. Gardner RM : Direct arterial pressure monitoring. Curr A naesth Crit Care 22. Giner J, Casan P, Belda J, et al: Pain during arterial puncture. Chest 110:1443, 1:239, 1990. 1996. 10. Boutros A, Albert S: Effect of the dynamic response of transducer-tubing 23. Kaye J, H eald GR, M orton J, et al: Patency of radial arterial catheters. A m system on accuracy of direct blood pressure measurement in patients. Crit J Crit Care 10:104, 2001. Care M ed 11:124, 1983. 24. Tegtmeyer K, Brady G, Lai S, et al: Videos in clinical medicine. Placement of 11. Rothe CF, Kim KC: M easuring systolic arterial blood pressure. Possible er- an arterial line. N Engl J M ed 354:e13, 2006. rors from extension tubes or disposable transducer domes. Crit Care M ed 25. M artin C, Saux P, Papazian L, et al: Long-term arterial cannulation in ICU 8:683, 1980. patients using the radial artery or dorsalis pedis artery. Chest 119:901, 2001. tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 45 26. Barnes RW, Foster EJ, Janssen GA, et al: Safety of brachial arterial catheters as 37. Smoller BR, Kruskall M S: Phlebotomy for diagnostic laboratory tests in monitors in the intensive care unit–prospective evaluation with the Doppler adults. Pattern of use and effect on transfusion requirements. N Engl J M ed ultrasonic velocity detector. A nesthesiology 44:260, 1976. 314:1233, 1986. 27. M ann S, Jones RI, M illar-Craig M W, et al: The safety of ambulatory intra- 38. Roberts DE, Bell DD, O stryzniuk T, et al: Eliminating needless testing in arterial pressure monitoring: a clinical audit of 1000 studies. Int J Cardiol intensive care–an information-based team management approach. Crit Care 5:585, 1984. M ed 21:1452, 1993. 28. M acon WL IV, Futrell JW: M edian-nerve neuropathy after percutaneous 39. Warkentin TE, Greinacher A: H eparin-induced thrombocytopenia: recog- puncture of the brachial artery in patients receiving anticoagulants. N Engl nition, treatment, and prevention: the Seventh ACCP Conference on An- J M ed 288:1396, 1973. tithrombotic and Thrombolytic Therapy. Chest 126:311S, 2004. 29. Brown M , Gordon LH , Brown O W, et al: Intravascular monitoring via the 40. Randolph AG, Cook DJ, Gonzales CA, et al: Bene t of heparin in periph- axillary artery. A nesth Intensive Care 13:38, 1984. eral venous and arterial catheters: systematic review and meta-analysis of 30. Sabik JF, Lytle BW, M cCarthy PM , et al: Axillary artery: an alternative site of randomised controlled trials. BM J 316:969, 1998. arterial cannulation for patients with extensive aortic and peripheral vascular 41. M imoz O , Pieroni L, Lawrence C, et al: Prospective, randomized trial of two disease. J T horac Cardiovasc Surg 109:885–891, 1995. antiseptic solutions for prevention of central venous or arterial catheter colo- 31. Wilkins RG: Radial artery cannulation and ischaemic damage: a review. nization and infection in intensive care unit patients. Crit Care M ed 24:1818, A naesthesia 40:896, 1985. 1996. 32. Weiss BM , Gattiker RI: Complications during and following radial artery 42. Peruzzi WT, N oskin GA, M oen SG, et al: M icrobial contamination of cannulation: a prospective study. Intensive Care M ed 12:424, 1986. blood conservation devices during routine use in the critical care set- 33. Clifton GD, Branson P, Kelly H J, et al: Comparison of normal saline and ting: results of a prospective, randomized trial. Crit Care M ed 24:1157, heparin solutions for maintenance of arterial catheter patency. H eart L ung 1996. 20:115, 1990. 43. M aki DG, Kluger DM , Crnich CJ. The risk of bloodstream infection in adults 34. H ook M L, Reuling J, Luettgen M L, et al: Comparison of the patency of with different intravascular devices: a systematic review of 200 published arterial lines maintained with heparinized and nonheparinized infusions. prospective studies. M ayo Clin Proc 81:1159–1171, 2006. The Cardiovascular Intensive Care Unit N ursing Research Committee of 44. Lucet JC, Bouadma L, Z ahar JR, et al: Infectious risk associated with arterial St. Luke’s H ospital. H eart L ung 16:693, 1987. catheters compared with central venous catheters. Crit Care M ed 38:1030– 35. Lowenstein E, Little JW 3rd, Lo H H : Prevention of cerebral embolization 1035, 2010. from ushing radial-artery cannulas. N Engl J M ed 285:1414, 1971. 45. Traore O , Liotier J, Souweine B: Prospective study of arterial and central ve- 36. Chang C, Dughi J, Shitabata P, et al: Air embolism and the radial arterial nous catheter colonization and of arterial-and central venous catheter-related line. Crit Care M ed 16:141, 1988. bacteremia in intensive care units. Crit Care M ed 33:1276, 2005. CH APTER 4 ■ PULM O N ARY ARTERY CATH ETERS HARVEY S. REICH Since their introduction into clinical practice in 1970 by Swan the ow-directed PA catheter, there was no way to assess all et al. [1], balloon-tipped, ow-directed pulmonary artery (PA) of these by using one instrument in a clinically useful way at catheters have found widespread use in the clinical manage- bedside. The catheter allows the re ection of right ventricular ment of critically ill patients. H owever, in recent years, both (RV) preload (right atrial pressure), RV afterload (PA pressure), the safety and ef cacy of these catheters have been brought left ventricular preload—PA occlusion pressure (PAO P) or pul- into question. In this chapter, I review the physiologic basis for monary capillary wedge pressure (PCWP)—and contractility their use, some history regarding their development and use, (stroke volume or CO ). Left ventricular afterload is re ected the concerns raised about their use, and suggestions for appro- by the systemic arterial pressure. This information allows the priate use of the catheters and the information obtained from calculation of numerous parameters, including vascular resis- them. tances. N o other tool allows the gathering of such a large amount of information. PHYSIOLOGIC RATION ALE FOR USE OF THE PULMON ARY CON TROVERSIES REGARDIN G ARTERY CATHETER USE OF THE PULMON ARY ARTERY CATHETER In unstable situations, during which hemodynamic changes often occur rapidly, clinical evaluation may be misleading Despite all of the advantages of the PA catheter, a number of [2]. PA catheters allow for direct and indirect measure- clinical studies have been published in the past decade that ment of several major determinants and consequences of car- have shown either no bene t or an increased risk of morbidity diac performance—preload, afterload, cardiac output (CO )— or mortality associated with its use. (See Table 4.1 for a sum- thereby supplying additional data to aid in clinical decision mary of the evidence for its utility.) Consequently, a number of making [3]. clinicians have elected to minimize the use of this monitoring Cardiac function depends on the relationship between mus- device. cle length (preload), the load on the muscle (afterload), and Furthermore, the relationship of central venous (CV) pres- the intrinsic property of contractility. Until the development of sure and PA pressure to predict ventricular lling was studied tahir99-VRG & vip.persianss.ir 46 Section I: Procedures, Techniques, and Minimally Invasive Monitoring TA B LE 4 . 1 EVIDEN CE BASIS FOR THE PA CATHETER Authors Year N Design Outcomes Lower morbidity/ mortality Rao et al. [4] 1983 733/364 H istorical controls/cohort Lower mortality H esdorffer et al. [5] 1987 61/87 H istorical controls/cohort Lower mortality Shoemaker et al. [6] 1988 146 RCT Lower mortality Berlauk et al. [7] 1991 89 RCT Lower morbidity Fleming et al. [8] 1992 33/34 RCT Lower morbidity Tuchschmidt et al. [9] 1992 26/25 RCT Decreased LO S; trend toward lower mortality Boyd et al. [10] 1993 53/54 RCT Lower mortality Bishop et al. [11] 1995 50/65 RCT Lower mortality Schiller et al. [12] 1997 53/33/30 Retrospective cohort Lower mortality Wilson et al. [13] 1999 92/46 RCT Lower mortality Chang et al. [14] 2000 20/39 Prospective retrospective cohort Lower morbidity Polonen et al. [15] 2000 196/197 RCT Decreased morbidity Friese et al. [16] 2006 51379 (no PAC)/ Retrospective analysis of Improved survival in patients 1933 (PAC) N ational Trauma Data Bank older than 60 or with ISS 25—75 and severe shock N o difference Pearson et al. [17] 1989 226 RCT N o difference Isaacson et al. [18] 1990 102 RCT N o difference Joyce et al. [19] 1990 40 RCT N o difference Yu et al. [20] 1993 35/32 RCT N o difference Gattinoni et al. [21] 1995 252/253/257 RCT N o difference Yu et al. [22] 1995 89 RCT N o difference Durham et al. [23] 1996 27/31 Prospective cohort N o difference Afessa et al. [24] 2001 751 Prospective observational N o difference Rhodes et al. [25] 2002 201 RCT N o difference Richard [26] 2003 676 RCT N o difference Yu et al. [27] 2003 1,010 Prospective cohort N o difference Sandham et al. [28] 2003 997/997 RCT N o difference in mortality; increased risk of pulmonary embolism in PA group Sakr et al. [29] 2005 3,147 O bservational cohort N o difference H arvey et al. [30] 2005 519/522 RCT N o difference in mortality Binanay et al. [31] 2005 433 RCT N o difference in mortality The N ational H eart, 2006 513/487 RCT N o difference in Lung and Blood mortality or organ function Institute ARDS Clinical Trials N etwork [32] Higher or worse morbidity/ mortality Tuman et al. [33] 1989 1094 Controlled prospective cohort Increased ICU stay with PAC Guyatt [34] 1991 33/148 RCT H igher morbidity H ayes et al. [35] 1994 50 RCT H igher mortality Connors et al. [36] 1996 5,735 Prospective cohort H igher mortality Valentine et al. [37] 1998 60 RCT Increased morbidity Stewart et al. [38] 1998 133/61 Retrospective cohort Increased morbidity Ramsey et al. [39] 2000 8,064/5,843 Retrospective cohort H igher mortality Polanczyk et al. [40] 2001 215/215 Prospective cohort Increased morbidity Chittock et al. [41] 2004 7,310 O bservational cohort Increased mortality in low severity; decreased mortality in high severity Peters et al. [42] 2003 360/690 Retrospective case control Increased risk of death Cohen et al. [43] 2005 26,437/735 Retrospective cohort Increased mortality ICU, intensive care unit; ISS, injury security score; LO S, length of stay; PA, pulmonary artery; PAC, pulmonary artery catheter; RCT, randomized control trial. tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 47 TA B LE 4 . 2 GEN ERAL IN DICATION S FOR PULMON ARY ARTERY CATHETERIZATION M anagement of complicated myocardial infarction H ypovolemia versus cardiogenic shock Ventricular septal rupture versus acute mitral regurgitation Severe left ventricular failure Right ventricular infarction Unstable angina Refractory ventricular tachycardia Assessment of respiratory distress Cardiogenic versus noncardiogenic (e.g., acute respiratory distress syndrome) pulmonary edema Primary versus secondary pulmonary hypertension Assessment of shock Cardiogenic H ypovolemic Septic Pulmonary embolism Assessment of therapy in selected individuals Afterload reduction in patients with severe left ventricular function Inotropic agent Vasopressors Beta-blockers Temporary pacing (ventricular vs. atrioventricular) Intra-aortic balloon counterpulsation M echanical ventilation (e.g., with positive end-expiratory pressure) M anagement of postoperative open-heart surgical patients Assessment of cardiac tamponade/constriction Assessment of valvular heart disease Perioperative monitoring of patients with unstable cardiac status during noncardiac surgery Assessment of uid requirements in critically ill patients Gastrointestinal hemorrhage Sepsis Acute renal failure Burns Decompensated cirrhosis Advanced peritonitis M anagement of severe preeclampsia Adapted from JM Gore, JS Alpert, JR Benotti, et al: H andbook of H em odynam ic M onitoring. Boston, M A, Little, Brown, 1984. in normal volunteers by Kumar et al. [44] who found there was tions in which PA catheterization may be useful are character- a poor correlation between initial CV pressure and PAO P, with ized by a clinically unclear or rapidly changing hemodynamic both respective end diastolic ventricular volume and stroke vol- status. Table 4.2 is a partial listing of the indications. Use of ume indices. Their data call into question the basic tenet of the PA catheters in speci c disease entities is discussed in other theoretical bene t of the PA catheter. chapters. IN DICATION S FOR PULMON ARY CATHETER FEATURES AN D ARTERY CATHETER USE CON STRUCTION Clinicians who use a PA catheter for monitoring should under- The catheter is constructed from polyvinylchloride and has a stand the fundamentals of the insertion technique, the equip- pliable shaft that softens further at body temperature. Because ment used, and the data that can be generated. The Pulmonary polyvinylchloride has a high thrombogenicity, the catheters are Artery Catheter Education Program (PACEP) has been devel- generally coated with heparin. H eparin bonding of catheters, oped by seven specialty organizations, along with the N H LBI introduced in 1981, has been shown to be effective in reduc- and the FDA and is available at http://www.pacep.org. ing catheter thrombogenicity [45,46] but can cause heparin- The use of the PA catheter for monitoring has four central induced thrombocytopenia. The standard catheter length is objectives: (a) to assess left or right ventricular function, or 110 cm, and the most commonly used external diameter is both, (b) to monitor changes in hemodynamic status, (c) to 5 or 7 French (Fr) (1 Fr = 0.0335 mm). A balloon is fastened guide treatment with pharmacologic and nonpharmacologic 1 to 2 mm from the tip (Fig. 4.1); when in ated, it guides agents, and (d) to provide prognostic information. The condi- the catheter (by virtue of uid dynamic drag) from the greater tahir99-VRG & vip.persianss.ir 48 Section I: Procedures, Techniques, and Minimally Invasive Monitoring FIGURE 4.1. Q uadruple-lumen pulmonary artery catheter. A: Connection to thermodilution cardiac out- put computer. B: Connection to distal lumen. C: Connection to proximal lumen. D: Stopcock connected to balloon at the catheter tip for balloon in ation. E: Thermistor. F: Balloon. N ote that the catheter is marked in 10-cm increments. intrathoracic veins through the right heart chambers into the (e.g., dopamine, epinephrine) are used. Figure 4.2 shows the PA. When fully in ated in a vessel of suf ciently large caliber, balloon on the tip in ated. the balloon protrudes above the catheter tip, thus distributing Several special-purpose PA catheter designs are available. tip forces over a large area and minimizing the chances for Pacing PA catheters incorporate two groups of electrodes on endocardial damage or arrhythmia induction during catheter the catheter surface, enabling intracardiac electrocardiographic insertion (Fig. 4.2). Progression of the catheter is stopped when (ECG) recording or temporary cardiac pacing [48]. These it impacts in a PA slightly smaller in diameter than the fully in- catheters are used for emergency cardiac pacing, although it is ated balloon. From this position, the PAO P is obtained. Bal- often dif cult to position the catheter for reliable simultaneous loon capacity varies according to catheter size, and the opera- cardiac pacing and PA pressure measurements. A ve-lumen tor must be aware of the individual balloon’s maximal in ation catheter allows passage of a specially designed 2.4-Fr bipolar volume as recommended by the manufacturer. The balloon is pacing electrode (probe) through the additional lumen (located usually in ated with air, but ltered carbon dioxide should be 19 cm from the catheter tip) and allows emergency temporary used in any situation in which balloon rupture might result in intracardiac pacing without the need for a separate central ve- access of the in ation medium to the arterial system (e.g., if a nous puncture. The pacing probe is Te on coated to allow easy right-to-left intracardiac shunt or a pulmonary arteriovenous introduction through the pacemaker port lumen; the intracavi- stula is suspected). If carbon dioxide is used, periodic de ation tary part of the probe is heparin impregnated to reduce the risk and rein ation may be necessary, since carbon dioxide diffuses of thrombus formation. O ne report demonstrated satisfactory through the latex balloon at a rate of approximately 0.5 cm 3 per ventricular pacing in 19 of 23 patients using this catheter de- minute. Liquids should never be used as the in ation medium. sign (83% success rate) [49]. When a pacing probe is not in A variety of catheter constructions is available, each use, the fth lumen may be used for additional central venous designed for particular clinical applications. Double-lumen access or continuous RV pressure monitoring. catheters allow balloon in ation through one lumen, and a dis- Continuous mixed venous oxygen saturation measurement tal opening at the tip of the catheter is used to measure intravas- is clinically available using a beroptic ve-lumen PA catheter cular pressures and sample blood. Triple-lumen catheters have [50]. Segal et al. [51] described a catheter that incorpo- a proximal port terminating 30 cm from the tip of the catheter, rates Doppler technology for continuous CO determinations. allowing simultaneous measurement of right atrial and PA or Catheters equipped with a fast-response (95 milliseconds) occlusion pressures. The most commonly used PA catheter in thermistor and intracardiac ECG-monitoring electrodes are the ICU setting is a quadruple-lumen catheter, which has a lu- also available. These catheters allow determination of the men containing electrical leads for a thermistor positioned at RV ejection fraction and RV systolic time intervals in criti- the catheter surface 4 cm proximal to its tip (Fig. 4.1) [47]. The cally ill patients [52–55]. The calculated RV ejection fraction thermistor measures PA blood temperature and allows ther- has correlated well with simultaneous radionuclide rst-pass modilution CO measurements. A ve-lumen catheter is also studies [54]. available, with the fth lumen opening 40 cm from the tip of Aside from the intermittent determination of CO by bo- the catheter. The fth lumen provides additional central venous lus administration of cold injectate, PA catheters have been access for uid or medication infusions when peripheral access adapted to determine near continuous CO by thermal pulses is limited or when drugs requiring infusion into a large vein generated by a heating lament on the catheter to produce tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 49 FIGURE 4.2. Balloon properly in ated at the tip of a pulmonary artery catheter. N ote that the balloon shields the catheter tip and prevents it from irritating cardiac chambers on its passage to the pulmonary artery. temperature changes [56]. The accuracy and reliability of CO Threading the catheter into the PA is more dif cult from the determination by this heating–cooling cycle have been con- basilica, brachial, or femoral vein. rmed by several studies [57–60]. Typical Catheter Insertion Procedure Pressure Transducers The procedures for typical catheter insertion are as follows: H emodynamic monitoring requires a system able to convert 1. Prepare and connect pressure tubing, manifolds, stop- changes in intravascular pressure into electrical signals suitable cocks, and transducers. Remove the sterile balloon-tipped for interpretation. The most commonly used hemodynamic catheter from its container. Balloon integrity may be tested monitoring system is a catheter-tubing–transducer system. A by submerging the balloon in a small amount of uid and uid- lled intravascular catheter is connected to a transducer checking for air leaks as the balloon is in ated (using the by a uid- lled tubing system. (For more details, see the dis- amount of air recommended by the manufacturer). De ate cussion in Chapters 3 and 26.) the balloon. 2. After a time out, insert a central venous cannula or nee- dle into the vein as described in Chapter 2. Using the Seldinger technique, thread the guidewire contained in the IN SERTION TECHN IQUES catheter kit into the vein and remove the catheter or needle (Figs. 4.3 and 4.4). General Considerations 3. M ake a small incision with a scalpel to enlarge the punc- ture site (Fig. 4.5). While holding the guidewire stationary, M anufacturers’ recommendations should be carefully fol- thread a vessel dilator-sheath apparatus (the size should lowed. All catheter manufacturers have detailed insertion and be 8 Fr if a 7-Fr catheter is to be used) over the guidewire training materials. and advance it into the vessel, using a twisting motion to PA catheterization can be performed in any hospital loca- get through the puncture site (Fig. 4.6). The dilator and tion where continuous ECG and hemodynamic monitoring are sheath should only be advanced until the tip of the sheath possible and where equipment and supplies needed for car- is in the vessel—estimated by the original depth of the can- diopulmonary resuscitation are readily available. Fluoroscopy nula or needle required to access the vein. At that point, the is not essential, but it can facilitate dif cult placements. Prop- dilator and guidewire are held stationary and the sheath erly constructed beds and protective aprons are mandatory for is advance off the dilator into the vessel. Advancing the safe use of uoroscopic equipment. M eticulous attention to dilator further may cause great vessel or cardiac damage. sterile technique is of obvious importance; all involved person- 4. Remove the guidewire and vessel dilator, leaving the intro- nel must wear sterile caps, gowns, masks, and gloves, and the ducer sheath in the vessel (Fig. 4.7). Suture the sheath in patient must be fully covered by sterile drapes. place. The catheter should be inserted percutaneously (not by cut- 5. Pass the proximal portion of the catheter to an assistant down) into the basilic, brachial, femoral, subclavian, or inter- and have that person attach the stopcock-pressure tubing- nal jugular veins by using techniques described in Chapter 2. transducer system to the right atrial and PA ports of the tahir99-VRG & vip.persianss.ir 50 Section I: Procedures, Techniques, and Minimally Invasive Monitoring A B C D FIGURE 4.3. A: Easy blood aspiration has been demonstrated using the guidewire introducer needle. B: The inner needle is removed. C: The spring guidewire is advanced, soft end rst, through the cannula into the vessel. D: With the guidewire held in place, the cannula is withdrawn from the vessel by being pulled over and off the length of the guidewire. PA catheter. Flush the proximal and distal catheter lumens distal end of the sleeve adapter to the introducer sheath with normal saline. hub. 6. If a sterile sleeve adapter is to be used, insert the catheter 7. Pass the catheter through the introducer sheath into the through it and pull the adapter proximally over the vein (Fig. 4.8). Advance it, using the marks on the catheter catheter to keep it out of the way. O nce the catheter is shaft indicating 10-cm distances from the tip, until the advanced to its desired intravascular location, attach the tip is in the right atrium. This requires advancement of FIGURE 4.4. The spring guidewire, stiff end protruding, is now FIGURE 4.5. A small incision is made with a scalpel to enlarge the located in the subclavian vein. puncture site. tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 51 A B FIGURE 4.6. A: The vessel dilator-sheath apparatus is threaded over the guidewire and advanced into the vessel. B: A twisting motion is used to thread the apparatus into the vessel. FIGURE 4.7. The guidewire and vessel dilator are removed, leaving FIGURE 4.8. The catheter is passed through the introducer sheath the introducer sheath in the vessel. into the vein. tahir99-VRG & vip.persianss.ir 52 Section I: Procedures, Techniques, and Minimally Invasive Monitoring A B C D E FIGURE 4.9. A: With the catheter tip in the right atrium, the balloon is in ated. B: The catheter is ad- vanced into the right ventricle with the balloon in ated, and right ventricle pressure tracings are obtained. (Center): Waveform tracings generated as the balloon-tipped catheter is advanced through the right heart chambers into the pulmonary artery. [Adapted from Wiedmann H P, M atthay M A, M atthey RA: Cardio- vascular pulmonary monitoring in the intensive care unit (Part 1) Chest 85:537;1984, with permission.] C: The catheter is advanced through the pulmonary valve into the pulmonary artery. A rise in diastolic pressure should be noted. D: The catheter is advanced to the pulmonary artery occlusion pressure position. A typical pulmonary artery occlusion pressure tracing should be noted with a and v waves. E: The balloon is de ated. Phasic pulmonary artery pressure should reappear on the monitor. (See text for details.) tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 53 approximately 35 to 40 cm from the left antecubital fossa, to supplement pressure monitoring and checks on balloon 10 to 15 cm from the internal jugular vein, 10 cm from the in ation volumes. An initial cross-table lateral radiograph subclavian vein, and 35 to 40 cm from the femoral vein. may be obtained in patients on positive end-expiratory A right atrial waveform on the monitor, with appropriate pressure (PEEP) to rule out superior placements. uctuations accompanying respiratory changes or cough, con rms proper intrathoracic location (Fig. 4.9, center). If desired, obtain right atrial blood for oxygen saturation Special Considerations from the distal port. Flush the distal lumen with saline and record the right atrial pressures. (O ccasionally, it is neces- In certain disease states (right atrial or RV dilatation, severe sary to in ate the balloon to keep the tip from adhering to pulmonary hypertension, severe tricuspid insuf ciency, low the atrial wall during blood aspiration.) CO syndromes), it may be dif cult to position a ow-directed 8. With the catheter tip in the right atrium, in ate the bal- catheter properly. These settings may require uoroscopic guid- loon with the recommended amount of air or carbon diox- ance to aid in catheter positioning. Infusion of 5 to 10 mL of ide (Fig. 4.9A). In ation of the balloon should be associ- cold saline through the distal lumen may stiffen the catheter and ated with a slight feeling of resistance—if it is not, suspect aid in positioning. Alternatively, a 0.025-cm guidewire 145 cm balloon rupture and do not attempt further in ation or long may be used to stiffen the catheter when placed through advancement of the catheter before properly reevaluating the distal lumen of a 7-Fr PA catheter. This manipulation should balloon integrity. If signi cant resistance to balloon in a- be performed only under uoroscopic guidance by an expe- tion is encountered, suspect malposition of the catheter in rienced operator. Rarely, non ow-directed PA catheters (e.g., a small vessel; withdraw the catheter and readvance it to Cournand catheters) may be required. Because of their rigidity, a new position. Do not use liquids to in ate the balloon, these catheters have the potential to perforate the right heart as they might be irretrievable and could prevent balloon and must be placed only under uoroscopy by a physician ex- de ation. perienced in cardiac catheterization techniques. 9. With the balloon in ated, advance the catheter until a RV pressure tracing is seen on the monitor (Fig. 4.9, center). O btain and record RV pressures. Catheter passage into PHYSIOLOGIC DATA and through the RV is an especially risky time in terms of arrhythmias. M aintaining the balloon in ated in the M easurement of a variety of hemodynamic parameters and RV minimizes ventricular irritation (Fig. 4.9B), but it is oxygen saturations is possible using the PA catheter. A sum- important to monitor vital signs and ECG throughout the mary of normal values for these parameters is found in Tables entire insertion procedure. Elevating the head of the bed to 4.3 and 4.4. 5 degrees and a right tilt position will facilitate the passage of the catheter through the right ventricle and minimize the generation of arrhythmias [61]. Pressures 10. Continue advancing the catheter until the diastolic pres- sure tracing rises above that in the RV (Fig. 4.9, center), Right Atrium indicating PA placement (Fig. 4.9C). If a RV trace still ap- With the tip of the PA catheter in the right atrium (Fig. 4.9A), pears after the catheter has been advanced 15 cm beyond the balloon is de ated and a right atrial waveform recorded the original distance needed to reach the right atrium, sus- (Fig. 4.10). N ormal resting right atrial pressure is 0 to 6 mm pect curling in the ventricle; de ate the balloon, withdraw H g. Two major positive atrial pressure waves, the a wave and it to the right atrium, then rein ate it and try again. Ad- v wave, can usually be recorded. O n occasion, a third positive vancement beyond the PA position results in a fall on the wave, the c wave, can also be seen. The a wave is due to atrial pressure tracing from the levels of systolic pressure noted contraction and follows the simultaneously recorded ECG P in the RV and PA. When this is noted, record the PAO P wave [62,63]. The a wave peak generally follows the peak of (Fig. 4.9, center, D) and de ate the balloon. Phasic PA pres- sure should reappear on the pressure tracing when the bal- loon is de ated. If it does not, pull back the catheter with the de ated balloon until the PA tracing appears. With T A B LE 4 . 3 the balloon de ated, blood may be aspirated for oxygen N ORMAL RESTIN G PRESSURES OBTAIN ED DURIN G saturation measurement. Watch for intermittent RV trac- RIGHT HEART CATHETERIZATION ings indicating slippage of the catheter backward into the ventricle. Cardiac chamber Pressure (mm Hg) 11. Carefully record the balloon in ation volume needed to change the PA pressure tracing to the PAO P tracing. If Right atrium PAO P is recorded with an in ation volume signi cantly Range 0–6 lower than the manufacturer’s recommended volume, or M ean 3 if subsequent PAO P determinations require decreasing amounts of balloon in ation volume as compared with an Right ventricle initial appropriate amount, the catheter tip has migrated Systolic 17–30 too far peripherally and should be pulled back immedi- Diastolic 0–6 ately. Pulmonary artery 12. Secure the catheter in the correct PA position by suturing or Systolic 15–30 taping it to the skin to prevent inadvertent advancement. Diastolic 5–13 Apply a transparent dressing with a chlorhexidine sponge M ean 10–18 if indicated. Pulmonary artery occlusion (mean) 2–12 13. O rder a chest radiograph to con rm catheter position; the catheter tip should appear no more than 3 to 5 cm from the Adapted from JM Gore, JS Alpert, JR Benotti, et al: H andbook of midline. To assess whether peripheral catheter migration H em odynam ic M onitoring. Boston, M A, Little, Brown, 1984. has occurred, daily chest radiographs are recommended tahir99-VRG & vip.persianss.ir 54 Section I: Procedures, Techniques, and Minimally Invasive Monitoring T A B LE 4 . 4 APPROXIMATE N ORMAL OXYGEN SATURATION AN D CON TEN T VALUES Chamber sampled Oxygen content (vol%) Oxygen saturation (%) Superior vena cava 14.0 70 Inferior vena cava 16.0 80 Right atrium 15.0 75 Right ventricle 15.0 75 Pulmonary artery 15.0 75 Pulmonary vein 20.0 98 Femoral artery 19.0 96 Atrioventricular oxygen 3.5–5.5 — content difference Adapted from JM Gore, JS Alpert, JR Benotti, et al: H andbook of H em odynam ic M onitoring. Boston, M A, Little, Brown, 1984. the electrical P wave by approximately 80 milliseconds [64]. diastolic volume index and RV ejection fraction can be accu- The v wave represents the pressure generated by venous lling rately measured [66–69]. of the right atrium while the tricuspid valve is closed. The peak of the v wave occurs at the end of ventricular systole when the Pulmonary Artery atrium is maximally lled, corresponding to the point near the end of the T wave on the ECG. The c wave is due to the sud- With the catheter in proper position and the balloon de ated, den motion of the atrioventricular valve ring toward the right the distal lumen transmits PA pressure (Fig. 4.9E). N ormal rest- atrium at the onset of ventricular systole. The c wave follows ing PA pressure is 15 to 30/5 to 13 mm H g, with a mean pres- the a wave by a time equal to the ECG P–R interval. The c wave sure of 10 to 18 mm H g. The PA waveform is characterized by is more readily visible in cases of P–R prolongation [64]. The x a systolic peak and diastolic trough with a dicrotic notch due descent follows the c wave and re ects atrial relaxation. The y to closure of the pulmonic valve. The peak PA systolic pressure descent is due to rapid emptying of the atrium after opening occurs in the T wave of a simultaneously recorded ECG. of the tricuspid valve. The mean right atrial pressure decreases Since the pulmonary vasculature is normally a low- during inspiration with spontaneous respiration (secondary to resistance circuit, PA diastolic pressure (PADP) is closely re- a decrease in intrathoracic pressure), whereas the a and v waves lated to mean PAO P (PADP is usually 1 to 3 mm H g higher and the x and y descents become more prominent. O nce a than mean PAO P) and thus can be used as an index of left ven- multilumen PA catheter is in position, right atrial blood can tricle lling pressure in patients in whom an occlusion pressure be sampled and pressure monitored using the proximal lumen. is unobtainable or in whom PADP and PAO P have been shown It should be noted that the pressures obtained via the proxi- to correlate closely. H owever, if pulmonary vascular resis- mal lumen may not accurately re ect right atrial pressure due tance is increased, as in pulmonary embolic disease, pulmonary to positioning of the lumen against the atrial wall or within brosis, or reactive pulmonary hypertension (see Chapter 56), the introducer sheath. The latter problem is more frequently PADP may markedly exceed mean PAO P and thus become an encountered in shorter patients [65]. unreliable index of left heart function [64]. Similar provisos ap- ply when using PA mean pressure as an index of left ventricular Right Ventricle function. The normal resting RV pressure is 17 to 30/0 to 6 mm H g, recorded when the PA catheter crosses the tricuspid valve (Fig. Pulmonary Artery Occlusion Pressure 4.9B). The RV systolic pressure should equal the PA systolic An important application of the balloon otation catheter is pressure (except in cases of pulmonic stenosis or RV out ow the recording of PAO P. This measurement is obtained when tract obstruction). The RV diastolic pressure should equal the the in ated balloon impacts a slightly smaller branch of the PA mean right atrial pressure during diastole when the tricuspid (Fig. 4.9D). In this position, the balloon stops the ow, and the valve is open. Introduction of the catheter with a pacing lumen catheter tip senses pressure transmitted backward through the allows continuous monitoring of RV hemodynamics when the static column of blood from the next active circulatory bed— pacing wire is not in place. Using special catheters, RV end- the pulmonary veins. Pulmonary venous pressure is a prime de- terminant of pulmonary congestion and thus of the tendency for uid to shift from the pulmonary capillaries into the in- terstitial tissue and alveoli. Also, pulmonary venous pressure and PAO P closely re ect left atrial pressure (except in rare in- stances, such as pulmonary veno-occlusive disease, in which there is obstruction in the small pulmonary veins), and serve as indices of left ventricular lling pressure [70,71]. The PAO P is required to assess left ventricular lling pressure, since mul- tiple studies have demonstrated that right atrial (e.g., central venous) pressure correlates poorly with PAO P [72]. The PAO P is a phase-delayed, amplitude-dampened ver- FIGURE 4.10. Stylized representation of a right atrial waveform in sion of the left atrial pressure. The normal resting PAO P is 2 relation to heart sounds. (See text for discussion of a, c, and v waves to 12 mm H g and averages 2 to 7 mm H g below the mean and x and y descents.) S1 , rst heart sound; S2 , second heart sound. PA pressure. The PAO P waveform is similar to that of the tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 55 right atrium, with a, c, and v waves and x and y descents (Fig. 4.10). H owever, in contradistinction to the right atrial waveform, the PAO P waveform demonstrates a v wave that is slightly larger than the a wave [14]. Because of the time required for left atrial mechanical events to be transmitted through the pulmonary vasculature, PAO P waveforms are further delayed when recorded with a simultaneous ECG. The peak of the a wave follows the peak of the ECG P wave by approximately 240 milliseconds, and the peak of the v wave occurs after the ECG T wave has been inscribed. O cclusion position is con- rmed by withdrawing a blood specimen from the distal lu- men and measuring oxygen saturation. M easured oxygen sat- uration of 95% or more is satisfactory [71]. The lung segment from which the sample is obtained will be well ventilated if the patient breathes slowly and deeply. A valid PAO P measurement requires a patent vascular chan- nel between the left atrium and catheter tip. Thus, the PAO P FIGURE 4.11. Pulmonary artery and pulmonary artery occlusion approximates pulmonary venous pressure (and therefore left tracings with giant v waves distorting with pulmonary artery recording. atrial pressure) only if the catheter tip lies in zone 3 of the lungs ECG, electrocardiogram. [62,73]. (The lung is divided into three physiologic zones, de- pendent on the relationship of PA, pulmonary venous, and alve- olar pressures. In zone 3, the PA and pulmonary venous pres- sure exceed the alveolar pressure, ensuring an uninterrupted The position of the catheter can be misinterpreted in patients column of blood between the catheter tip and the pulmonary with the presence of giant v waves. The most common cause veins.) If, on portable lateral chest radiograph, the catheter tip of these v waves is mitral regurgitation. During this condition, is below the level of the left atrium (posterior position in supine left ventricular blood oods a normal-sized, noncompliant left patients), it can be assumed to be in zone 3. This assumption atrium during ventricular systole, causing giant v waves in the holds if applied PEEP is less than 15 cm H 2 O and the patient occlusion pressure tracing (Fig. 4.11). The giant v wave of mi- is not markedly volume depleted. Whether the catheter is posi- tral regurgitation may be transmitted to the PA tracing, yielding tioned in zone 3 may also be determined by certain physiologic a bi d PA waveform composed of the PA systolic wave and the characteristics (Table 4.5). A catheter occlusion outside zone v wave. As the catheter is occluded, the PA systolic wave is 3 shows marked respiratory variation, an unnaturally smooth lost, but the v wave remains. It is important to note that the vascular waveform, and misleading high pressures. PA systolic wave occurs earlier in relation to the Q RS com- With a few exceptions [74], estimates of capillary hydro- plex of a simultaneously recorded ECG (between the Q RS and static ltration pressure from PAO P are acceptable [75]. It T waves) than does the v wave (after the T wave). should be noted that measurement of PAO P does not take into Although a large v wave is not diagnostic of mitral regur- account capillary permeability, serum colloid osmotic pressure, gitation and is not always present in this circumstance, acute interstitial pressure, or actual pulmonary capillary resistance mitral regurgitation remains the most common cause of giant [75,76]. These factors all play roles in the formation of pul- v waves in the PAO P tracing. Prominent v waves may occur monary edema, and the PAO P should be interpreted in the whenever the left atrium is distended and noncompliant due context of the speci c clinical situation. to left ventricular failure from any cause (e.g., ischemic heart M ean PAO P correlates well with left ventricular end- disease, dilated cardiomyopathy) [77,78] or secondary to the diastolic pressure (LVEDP), provided the patient has a normal increased pulmonary blood ow in acute ventricular septal de- mitral valve and normal left ventricular function. In myocar- fect [79]. Acute mitral regurgitation is the rare instance when dial infarction, conditions with decreased left ventricular com- the PA end-diastolic pressure may be lower than the computer- pliance (e.g., ischemia, left ventricular hypertrophy), and con- measured mean occlusion pressure [64]. ditions with markedly increased left ventricular lling pressure End expiration provides a readily identi able reference (e.g., dilated cardiomyopathy), the contribution of atrial con- point for PAO P interpretation because pleural pressure returns traction to left ventricular lling is increased. Thus, the LVEDP to baseline at the end of passive de ation (approximately equal may be signi cantly higher than the mean left atrial pressure to atmospheric pressure). Pleural pressure can exceed the nor- or PAO P [62]. mal resting value with active expiratory muscle contraction or TA B LE 4 . 5 CHECKLIST FOR VERIFYIN G POSITION OF PULMON ARY ARTERY CATHETER Zone 3 Zone 1 or 2 PAO P contour Cardiac ripple (A + V waves) Unnaturally smooth PAD versus PAO P PAD > PAO P PAD < PAO P PEEP trial PAO P < 1/2 PEEP PAO P > 1/2 PEEP Respiratory variation of PAO P < 1/2 PALV ≥ 1/2 PALV Catheter-tip location LA level or below Above LA level LA, left atrium; PAD, pulmonary artery diastolic pressure; PALV , alveolar pressure; PAO P, pulmonary artery occlusion pressure; PEEP, positive end-expiratory pressure. Adapted from RJ Schultz, GF Whit eld, JJ LaM ura, et al: The role of physiologic monitoring in patients with fractures of the hip. J Traum a 25:309, 1985. tahir99-VRG & vip.persianss.ir 56 Section I: Procedures, Techniques, and Minimally Invasive Monitoring use of PEEP. H ow much PEEP is transmitted to the pleural is adequate), the resultant cooling curve recorded at a down- space cannot be estimated easily, since it varies depending on stream site allows calculation of net blood ow. CO is inversely lung compliance and other factors. When normal lungs de ate proportional to the integral of the time-versus-temperature passively, end-expiratory pleural pressure increases by approx- curve. imately one half of the applied PEEP. In patients with reduced In practice, a known amount of cold or room temperature lung compliance (e.g., patients with acute respiratory distress solution (typically 10 mL of 0.9% saline in adults and 5 mL of syndrome; ARDS), the transmitted fraction may be one-fourth 0.9% saline in children) is injected into the right atrium via the or less of the PEEP value. In the past, PEEP levels greater than catheter’s proximal port. The thermistor allows recording of 10 mm H g were thought to interrupt the column of blood be- the baseline PA blood temperature and subsequent temperature tween the left atrium and PA catheter tip, causing the PAO P to change. The resulting curve is usually analyzed by computer, re ect alveolar pressure more accurately than left atrial pres- although it can be analyzed manually by simple planimetric sure. H owever, two studies suggest that this may not hold true methods. Correction factors are added by catheter manufac- in all cases. H asan et al. [80] concluded that the PAO P left turers to account for the mixture of cold indicator with warm atrial uid column was protected by lung injury, and Teboul residual uid in the catheter injection lumen and the heat trans- et al. [81] could nd no signi cant discrepancy between PAO P fer from the catheter walls to the cold indicator. and simultaneously measured LVEDP at PEEP levels of 0, 10, Reported coef cients of variation using triplicate determi- and 16 to 20 cm H 2 O in patients with ARDS. They hypothesize nations, using 10 mL of cold injectate and a bedside computer, that (a) a large intrapulmonary right-to-left shunt may provide are approximately 4% or less. Variations in the rate of injec- a number of microvessels shielded from alveolar pressure, al- tion can also introduce error into CO determinations, and it lowing free communication from PA to pulmonary veins, or (b) is thus important that the solution be injected as rapidly as in ARDS, both vascular and lung compliance may decrease, possible. Careful attention must be paid to the details of this reducing transmission of alveolar pressure to the pulmonary procedure; even then, changes of less than 10% to 15% above microvasculature and maintaining an uninterrupted blood col- or below an initial value may not truly establish directional va- umn from the catheter tip to the left atrium. lidity. Thermodilution CO is inaccurate in low-output states, Although it is dif cult to estimate precisely the true transmu- tricuspid regurgitation, and in cases of atrial or ventricular sep- ral vascular pressure in a patient on PEEP, temporarily discon- tal defects [84]. necting PEEP to measure PAO P is not recommended. Because N ormal values for arterial–venous oxygen content differ- the hemodynamics have been destabilized, these measurements ence, mixed venous oxygen saturation, and CO can be found will be of questionable value. Venous return increases acutely in Table 4.6. after discontinuation of PEEP [81], and abrupt removal of PEEP will cause hypoxia, which may not reverse quickly on Analysis of Mixed Venous Blood reinstitution of PEEP [82]. Additional discussion of measure- ment and interpretation of pulmonary vascular pressures on CO can be approximated merely by examining mixed venous PEEP is found in Chapter 58. (PA) oxygen saturation. Theoretically, if CO rises, then the mixed venous oxygen partial pressure will rise, since peripheral tissues need to exact less oxygen per unit of blood. Conversely, if CO falls, peripheral extraction from each unit will increase Cardiac Output to meet the needs of metabolizing tissues. Serial determinations of mixed venous oxygen saturation may display trends in CO . N ormal mixed venous oxygen saturation is 70% to 75% ; val- Thermodilution Technique ues of less than 60% are associated with heart failure and values A catheter equipped with a thermistor 4 cm from its tip al- of less than 40% with shock [85]. Potential sources of error in lows calculation of CO by using the thermodilution principle this determination include extreme low- ow states where poor [47,83]. The thermodilution principle holds that if a known mixing may occur, contamination of desaturated mixed venous quantity of cold solution is introduced into the circulation and blood by saturated pulmonary capillary blood when the sam- adequately mixed (passage through two valves and a ventricle ple is aspirated too quickly through the nonwedged catheter T A B LE 4 . 6 SELECTED HEMODYN AMIC VARIABLES DERIVED FROM RIGHT HEART CATHETERIZATION Hemodynamic variable N ormal range Arterial–venous content difference 3.5–5.5 mL/100 mL Cardiac index 2.5–4.5 L/min/m 2 Cardiac output 3.0–7.0 L/min Left ventricular stroke work index 45–60 g/beat/m 2 M ixed venous oxygen content 18.0 mL/100 mL M ixed venous saturation 75% (approximately) O xygen consumption 200–250 mL/min Pulmonary vascular resistance 120–250 dynes/sec/cm − 5 Stroke volume 70–130 mL/contraction Stroke volume index 40–50 mL/contraction/m 2 Systemic vascular resistance 1,100–1,500 dynes/sec/cm 2 Adapted from JM Gore, JS Alpert, JR Benotti, et al: H andbook of H em odynam ic M onitoring. Boston, M A, Little, Brown, 1984. tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 57 T A B LE 4 . 7 HEMODYN AMIC PARAMETERS IN COMMON LY EN COUN TERED CLIN ICAL SITUATION S (IDEALIZED) RA RV PA PAOP AO CI SVR PVR N ormal 0–6 25/0–6 25/6–12 6–12 130/80 ≥ 2.5 1,500 ≤ 250 H ypovolemic shock 0–2 15–20/0–2 15–20/2–6 2–6 ≤ 90/60 < 2.0 > 1,500 ≤ 250 Cardiogenic shock 8 50/8 50/35 35 ≤ 90/60 < 2.0 > 1,500 ≤ 250 Septic shock Early 0–2 20–25/0–2 20–25/0–6 0–6 ≤ 90/60 ≥ 2.5 < 1,500 < 250 Latea 0–4 25/4–10 25/4–10 4–10 ≤ 90/60 < 2.0 > 1,500 > 250 Acute massive pulmonary embolism 8–12 50/12 50/12–15 ≤ 12 ≤ 90/60 < 2.0 > 1,500 > 450 Cardiac tamponade 12–18 25/12–18 25/12–18 12–18 ≤ 90/60 < 2.0 > 1,500 ≤ 250 AM I without LVF 0–6 25/0–6 25/12–18 ≤ 18 140/90 ≤ 2.5 1,500 ≤ 250 AM I with LVF 0–6 30–40/0–6 30–40/18–25 > 18 140/90 > 2.0 > 1,500 > 250 Biventricular failure secondary to LVF >6 50–60/ > 6 50–60/25 18–25 120/80 2.0 > 1,500 > 250 RVF secondary to RVI 12–20 30/12–20 30/12 < 12 ≤ 90/60 < 2.0 > 1,500 > 250 Cor pulmonale >6 80/ > 6 80/35 < 12 120/80 2.0 > 1,500 > 400 Idiopathic pulmonary hypertension 0–6 80–100/0–6 80–100/40 < 12 100/60 < 2.0 > 1,500 > 500 Acute ventricular septal ruptureb 6 60/6–8 60/35 30 ≤ 90/60 < 2.0 > 1,500 > 250 a H emodynamic pro le seen in approximately one third of patients in late septic shock. b Con rmed by appropriate RA–PA oxygen saturation step-up. See text for discussion. AM I, acute myocardial infarction; AO , aortic; CI, cardiac index; LVF, left ventricular failure; PA, pulmonary artery; PAO P, pulmonary artery occlusion pressure; PVR, pulmonary vascular resistance; RA, right atrium; RV, right ventricle; RVF, right ventricular failure; RVI, right ventricular infarction; SVR, systemic vascular resistance. Adapted from Gore JM , Alpert JS, Benotti JR, et al: H andbook of H em odynam ic M onitoring. Boston, M A, Little, Brown, 1984. [86] or in certain disease states (e.g., sepsis) where microcircu- cular basis to explain abnormal symptoms or signs and as a latory shunting may occur. Fiberoptic re ectance oximetry PA baseline to gauge a patient’s disease progression or response to catheters can continuously measure and record mixed venous therapy. Right atrial pressures of 0 to 6 mm H g, PA systolic oxygen saturations in appropriate clinical situations [50,87]. pressures of 15 to 30 mm H g, PADPs of 5 to 12 mm H g, PA mean pressures of 9 to 18 mm H g, PAO P of 5 to 12 mm H g, and a cardiac index exceeding 2.5 L per minute per m 2 characterize Derived Parameters a normal cardiovascular state at rest. Table 4.7 summarizes speci c hemodynamic patterns for a Useful hemodynamic parameters that can be derived using data variety of disease entities in which PA catheters have been indi- with PA catheters include the following: cated and provide clinical information that can impact patient care. 1. Cardiac index = CO (L/minute)/BSA (m 2 ) 2. Stroke volume = CO (L/minute)/heart rate (beats/minute) 3. Stroke index = CO (L/minute)/[heart rate (beats/minute) × BSA (m 2 )] COMPLICATION S 4. M ean arterial pressure (mmH g) = [(2 × diastolic) + M inor and major complications associated with bedside bal- systolic]/ 3 loon otation PA catheterization have been reported (Table 5. Systemic vascular resistance (dyne/second/cm − 5 ) = ([mean 4.8). During the 1970s, in the rst 10 years of clinical catheter arterial pressure − mean right atrial pressure (mm H g)] × use, a number of studies reported a relatively high incidence 80)/CO (L/minute) of certain complications. Consequent revision of guidelines for 6. Pulmonary arteriolar resistance (dyne/second/cm − 5 ) = PA catheter use and improved insertion and maintenance tech- ([mean PA pressure − PAO P (mm H g)] × 80)/CO (L/minute) niques resulted in a decreased incidence of these complications 7. Total pulmonary resistance (dyne/second/cm − 5 ) = ([mean PA pressure (mm H g)] × 80)/CO (L/minute) 8. Left ventricular stroke work index = 1.36 (mean arterial T A B LE 4 . 8 pressure − PAO P) × stroke index/100 9. Do 2 (mL/minute/m 2 ) = cardiac index × arterial O 2 content COMPLICATION S OF PULMON ARY ARTERY × 10 CATHETERIZATION N ormal values are listed in Table 4.6. Associated with central venous access Balloon rupture Knotting CLIN ICAL APPLICATION S OF THE Pulmonary infarction PULMON ARY ARTERY CATHETER Pulmonary artery perforation Thrombosis, embolism Arrhythmias N ormal Resting Hemodynamic Pro le Intracardiac damage Infections The nding of normal CO associated with normal left and right M iscellaneous complications heart lling pressures is useful in establishing a noncardiovas- tahir99-VRG & vip.persianss.ir 58 Section I: Procedures, Techniques, and Minimally Invasive Monitoring in the 1980s [88]. The majority of complications are avoid- in an attempt to restore an apparently damped pressure trace. able by scrupulous attention to detail in catheter placement Pulmonary embolic phenomena resulting from thrombus for- and maintenance. mation around the catheter or over areas of endothelial damage can also result in pulmonary infarction. The reported incidence of pulmonary infarction secondary Complications Associated with Central to PA catheters in 1974 was 7.2% [101], but recently reported rates of pulmonary infarction are much lower. Boyd et al. [103] Venous Access found a 1.3% incidence of pulmonary infarction in a prospec- tive study of 528 PA catheterizations. Sise et al. [104] reported The insertion techniques and complications of central venous no pulmonary infarctions in a prospective study of 319 PA cannulation are discussed in Chapter 2. Reported local vascu- catheter insertions. Use of continuous saline ush solutions and lar complications include local arterial or venous hematomas, careful monitoring of PA waveforms are important reasons for unintentional entry of the catheter into the carotid system, atri- the decreased incidence of this complication. oventricular stulas, and pseudoaneurysm formation [89–91]. Adjacent structures, such as the thoracic duct, can be damaged, with resultant chylothorax formation. Pneumothorax can be a serious complication of insertion, although the incidence is Pulmonary Artery Perforation relatively low (1% to 2% ) [64,89,92]. The incidence of pneu- A serious and feared complication of PA catheterization is rup- mothorax is higher with the subclavian approach than with the ture of the PA leading to hemorrhage, which can be massive and internal jugular approach in some reports [93], but other stud- sometimes fatal [105–107]. Rupture may occur during inser- ies demonstrate no difference between the two sites [94,95]. tion or may be delayed a number of days [107]. PA rupture or The incidence of complications associated with catheter inser- perforation has been reported in approximately 0.1% to 0.2% tion is generally considered to be inversely proportional to the of patients [93,108,109], although recent pathologic data sug- operator’s experience. gest the true incidence of PA perforation is somewhat higher [110]. Proposed mechanisms by which PA rupture can occur in- clude (a) an increased pressure gradient between PAO P and PA Balloon Rupture pressure brought about by balloon in ation and favoring distal catheter migration, where perforation is more likely to occur; Balloon rupture occurred more frequently in the early 1970s (b) an occluded catheter tip position favoring eccentric or dis- than it does now and was generally related to exceeding rec- tended balloon in ation with a spearing of the tip laterally and ommended in ation volumes. The main problems posed by through the vessel; (c) cardiac pulsation causing shearing forces balloon rupture are air emboli gaining access to the arterial and damage as the catheter tip repeatedly contacts the vessel circulation and balloon fragments embolizing to the distal pul- wall; (d) presence of the catheter tip near a distal arterial bifur- monary circulation. If rupture occurs during catheter insertion, cation where the integrity of the vessel wall against which the the loss of the balloon’s protective cushioning function can pre- balloon is in ated may be compromised; and (e) simple lateral dispose to endocardial damage and attendant thrombotic and pressure on vessel walls caused by balloon in ation (this tends arrhythmic complications. to be greater if the catheter tip was occluded before in ation be- gan). Patient risk factors for PA perforation include pulmonary hypertension, mitral valve disease, advanced age, hypothermia, Knotting and anticoagulant therapy. In patients with these risk factors and in whom PADP re ects PAO P reasonably well, avoidance Knotting of a catheter around itself is most likely to occur when of subsequent balloon in ation altogether constitutes prudent loops form in the cardiac chambers and the catheter is repeat- prophylaxis. edly withdrawn and readvanced [96]. Knotting is avoided if Another infrequent but life-threatening complication is false care is taken not to advance the catheter signi cantly beyond aneurysm formation associated with rupture or dissection of the distances at which entrance to the ventricle or PA would the PA [111]. Technique factors related to PA hemorrhage are ordinarily be anticipated. Knotted catheters usually can be ex- distal placement or migration of the catheter; failure to remove tricated transvenously; guidewire placement [97], venotomy, or large catheter loops placed in the cardiac chambers during in- more extensive surgical procedures are occasionally necessary. sertion; excessive catheter manipulation; use of stiffer catheter Knotting of PA catheters around intracardiac structures [98] designs; and multiple overzealous or prolonged balloon in a- or other intravascular catheters [99] has been reported. Rarely, tions. Adherence to strict technique may decrease the incidence entrapment of a PA catheter in cardiac sutures after open-heart of this complication. In a prospective study reported in 1986, surgery has been reported, requiring varying approaches for no cases of PA rupture occurred in 1,400 patients undergoing removal [100]. PA catheterization for cardiac surgery [94]. PA perforation typically presents with massive hemoptysis. Emergency management includes immediate occlusion arteri- Pulmonary Infarction ogram and bronchoscopy, intubation of the unaffected lung, and consideration of emergency lobectomy or pneumonec- Peripheral migration of the catheter tip (caused by catheter tomy. PA catheter balloon tamponade resulted in rapid control softening and loop tightening over time) with persistent, unde- of bleeding in one case report [112]. Application of PEEP to tected wedging in small branches of the PA is the most common intubated patients may also tamponade hemorrhage caused by mechanism underlying pulmonary ischemic lesions attributable a PA catheter [113,114]. to PA catheters [101]. These lesions are usually small and asymptomatic, often diagnosed solely on the basis of changes in the chest radiograph demonstrating an occlusion-shaped Thromboembolic Complications pleural-based density with a convex proximal contour [102]. Severe infarctions are usually produced if the balloon is left Because PA catheters constitute foreign bodies in the cardio- in ated in the occlusion position for an extended period, thus vascular system and can potentially damage the endocardium, obstructing more central branches of the PA, or if solutions are they are associated with an increased incidence of thrombo- injected at relatively high pressure through the catheter lumen sis. Thrombi encasing the catheter tip and aseptic thrombotic tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 59 vegetations forming at endocardial sites in contact with the plete heart block during catheter insertion, and some have ad- catheter have been reported [103,115]. Extensive clotting vocated the insertion of a temporary transvenous pacing wire, around the catheter tip can occlude the pulmonary vasculature a PA catheter with a pacing lumen, or pacing PA catheter with distal to the catheter, and thrombi anywhere in the venous sys- the pacing leads on the external surface of the catheter [129]. tem or right heart can serve as a source of pulmonary emboli. H owever, use of an external transthoracic pacing device should Subclavian venous thrombosis, presenting with unilateral neck be suf cient to treat this complication. vein distention and upper extremity edema, may occur in up to 2% of subclavian placements [116,117]. Venous thrombo- sis complicating percutaneous internal jugular vein catheter- Intracardiac Damage ization is fairly commonly reported, although its clinical importance remains uncertain [118]. Consistently damped Damage to the right heart chambers, tricuspid valve, pul- pressure tracings without evidence of peripheral catheter mi- monic valve, and their supporting structures as a consequence gration or pulmonary vascular occlusion should arouse suspi- of PA catheterization has been reported [130–133]. The re- cion of thrombi at the catheter tip. A changing relationship of ported incidence of catheter-induced endocardial disruption PADP to PAO P over time should raise concern about possible detected by pathologic examination varies from 3.4% [115] to pulmonary emboli. 75% [134], but most studies suggest a range of 20% to 30% If an underlying hypercoagulable state is known to exist, if [117,131,132]. These lesions consist of hemorrhage, sterile catheter insertion was particularly traumatic, or if prolonged thrombus, intimal brin deposition, and nonbacterial throm- monitoring becomes necessary, one should consider cautiously botic endocarditis. Their clinical signi cance is not clear, but anticoagulating the patient. there is concern that they may serve as a nidus for infectious H eparin-bonded catheters reduce thrombogenicity [45] and endocarditis. are commonly used. H owever, an important complication of Direct damage to the cardiac valves and supporting chordae heparin-bonded catheters is heparin-induced thrombocytope- occurs primarily by withdrawal of the catheters while the bal- nia (H IT) [119,120]. Routine platelet counts are recommended loon is in ated [1]. H owever, chordal rupture has been reported for patients with heparin-bonded catheters in place. Because despite balloon de ation [113]. The incidence of intracardiac of the risk of H IT, some hospitals have abandoned the use of and valvular damage discovered on postmortem examination heparin-bonded catheters. is considerably higher than that of clinically signi cant valvular dysfunction. Rhythm Disturbances Infections Atrial and ventricular arrhythmias occur commonly during in- Catheter-related septicemia (the same pathogen growing from sertion of PA catheters [121]. Premature ventricular contrac- blood and the catheter tip) was reported in up to 2% of pa- tions occurred during 11% of the catheter insertions originally tients undergoing bedside catheterization in the 1970s [135]. reported by Swan et al. [1]. H owever, the incidence of septicemia related to the catheter ap- Studies have reported advanced ventricular arrhythmias pears to have declined in recent years, with a number of studies (three or more consecutive ventricular premature beats) in ap- suggesting a septicemia rate of 0% to 1% [93,136,137]. In situ proximately 30% to 60% of patients undergoing right heart time of more than 72 to 96 hours signi cantly increases the catheterization [93,117,122–124]. M ost arrhythmias are self- risk of catheter-related sepsis. Right-sided septic endocarditis limited and do not require treatment, but sustained ventricular has been reported [133,138], but the true incidence of this com- arrhythmias requiring treatment occur in 0% to 3% of pa- plication is unknown. Becker et al. [130] noted two cases of tients [103,123,124]. Risk factors associated with increased left ventricular abscess formation in patients with PA catheters incidence of advanced ventricular arrhythmias are acute my- and Staphylococcus aureus septicemia. Incidence of catheter ocardial ischemia or infarction, hypoxia, acidosis, hypocal- colonization or contamination varies from 5% to 20% , de- cemia, and hypokalemia [92,123]. A right lateral tilt position pending on the duration of catheter placement and the criteria (5-degree angle) during PA catheter insertion is associated with used to de ne colonization [137–139]. In situ catheter-related a lower incidence of malignant ventricular arrhythmias than is bloodstream infection may be diagnosed by either differential the Trendelenburg position [61]. time to positivity or quantitative blood cultures [140]. With Although the majority of arrhythmias occur during catheter the former method, paired blood cultures are drawn from a insertion, arrhythmias may develop at any time after the peripheral vein and the catheter. If the catheter blood culture catheter has been correctly positioned. These arrhythmias are turns positive two or more hours sooner than the peripheral due to mechanical irritation of the conducting system and may blood culture, the catheter is the likely cause of the bacteremia. be persistent. Ventricular ectopy may also occur if the catheter With the other method, positive quantitative blood cultures tip falls back into the RV out ow tract. Evaluation of catheter- drawn from the catheter are sensitive, speci c, and predictive induced ectopy should include a portable chest radiograph to of catheter-related bacteremia [141]. evaluate catheter position and assessment of the distal lumen Pressure transducers have also been identi ed as an occa- pressure tracing to ensure that the catheter has not slipped into sional source of infection [142]. The chance of introducing the RV. Lidocaine may be used but is unlikely to ablate the ec- infection into a previously sterile system is increased during in- topy because the irritant is not removed [125]. If the arrhythmia jections for CO determinations and during blood withdrawal. persists after lidocaine therapy or is associated with hemody- Approaches to reduce the risk of catheter-related infection in- namic compromise, the catheter should be removed. Catheter clude use of a sterile protective sleeve and antibiotic bonding removal should be performed by physicians under continuous to the catheter [94,143,144]. Scheduled changes of catheters ECG monitoring, since the ectopy occurs almost as frequently do not reduce the rate of infection [145]. during catheter removal as during insertion [126,127]. Right bundle branch block (usually transient) can also com- plicate catheter insertion [128]. Patients undergoing anesthesia Other Complications induction, those in the early stages of acute anteroseptal my- ocardial infarction, and those with acute pericarditis appear Rare miscellaneous complications that have been reported in- particularly susceptible to this complication. Patients with pre- clude (a) hemodynamically signi cant decreases in pulmonary existing left bundle branch block are at risk for developing com- blood ow caused by balloon in ation in the central PA in tahir99-VRG & vip.persianss.ir 60 Section I: Procedures, Techniques, and Minimally Invasive Monitoring postpneumonectomy patients with pulmonary hypertension in after each PAO P recording. There is never an indication the remaining lung [146], (b) disruption of the catheter’s in- for continuous PAO P monitoring. traluminal septum as a result of injecting contrast medium un- b. Constant pressure monitoring is required each time the der pressure [147], (c) artifactual production of a midsystolic balloon is in ated. It should be in ated slowly, in small click caused by a slapping motion of the catheter against the increments, and must be stopped as soon as the pressure interventricular septum in a patient with RV strain and para- tracing changes to PAO P or damped. doxic septal motion [148], (d) thrombocytopenia secondary c. If an occlusion is recorded with balloon volumes signif- to heparin-bonded catheters [119,120], and (e) dislodgment of icantly less than the in ation volume recommended on pacing electrodes [149]. M ultiple unusual placements of PA the catheter shaft, withdraw the catheter to a position catheters have also been reported, including in the left peri- where full (or nearly full) in ation volume produces the cardiophrenic vein, via the left superior intercostal vein into desired trace. the abdominal vasculature, and from the superior vena cava d. Anticipate catheter tip migration. Softening of the through the left atrium and left ventricle into the aorta after catheter material with time, repeated manipulations, and open-heart surgery [150–152]. cardiac motion make distal catheter migration almost in- evitable. i. Continuous PA pressure monitoring is mandatory, and the trace must be closely watched for changes GUIDELIN ES FOR SAFE USE OF from characteristic PA pressures to those indicating PULMON ARY ARTERY a PAO P or damped tip position. ii. Decreases over time in the balloon in ation volumes CATHETERS necessary to attain occlusion tracings should raise suspicion regarding catheter migration. M ultiple revisions and changes in emphasis to the original iii. Con rm satisfactory tip position with chest radio- recommended techniques and guidelines have been published graphs immediately after insertion and at least daily. [88,153,154]. These precautions are summarized as follows: e. Do not use liquids to in ate the balloon. They may pre- vent de ation, and their relative incompressibility may 1. Avoiding complications associated with catheter insertion. increase lateral forces and stress on the walls of pul- a. Inexperienced personnel performing insertions must be monary vessels. supervised. M any hospitals require that PA catheters be f. H emoptysis is an ominous sign and should prompt an inserted by a fully trained intensivist, cardiologist, or urgent diagnostic evaluation and rapid institution of ap- anesthesiologist. Use of ultrasound guidance is recom- propriate therapy. mended. g. Avoid injecting solutions at high pressure through the b. Keep the patient as still as possible. Restraints or sedation catheter lumen on the assumption that clotting is the may be required but the patient should be fully monitored cause of the damped pressure trace. First, aspirate from with ECG and pulse oximetry. the catheter. Then consider problems related to catheter c. Strict sterile technique is mandatory. A chlorhexidine position, stopcock position, transducer dome, transduc- skin prep solution and maximum barrier precautions are ers, pressure bag, ush system, or trapped air bubbles. recommended. N ever ush the catheter in the occlusion position. d. Examine the postprocedure chest radiograph for pneu- 5. Avoiding thromboembolic complications. mothorax (especially after subclavian or internal jugular a. M inimize trauma induced during insertion. venipuncture) and for catheter tip position. b. Consider the judicious use of anticoagulants in patients 2. Avoiding balloon rupture. with hypercoagulable states or other risk factors. a. Always in ate the balloon gradually. Stop in ation if no c. Avoid ushing the catheter under high pressure. resistance is felt. d. Watch for a changing PADP–PAO P relationship, as well b. Do not exceed recommended in ation volume. At the as for other clinical indicators of pulmonary embolism. recommended volume, excess air will automatically be 6. Avoiding arrhythmias. expelled from a syringe with holes bored in it that is con- a. Constant ECG monitoring during insertion and main- stantly attached to the balloon port. M aintaining recom- tenance, as well as ready accessibility of all supplies mended volume also helps prevent the accidental injec- for performing cardiopulmonary resuscitation, de bril- tion of liquids. lation, and temporary pacing, are mandatory. c. Keep the number of in ation–de ation cycles to a mini- b. Use caution when catheterizing patients with an acutely mum. ischemic myocardium or preexisting left bundle branch d. Do not reuse catheters designed for single usage, and do block. not leave catheters in place for prolonged periods. c. When the balloon is de ated, do not advance the catheter e. Use carbon dioxide as the in ation medium if communi- beyond the right atrium. cation between the right and left sides of the circulation d. Avoid over manipulation of the catheter. is suspected. e. Secure the introducer in place at the insertion site. 3. Avoiding knotting. Discontinue advancement of the catheter f. Watch for intermittent RV pressure tracings when the if entrance to right atrium, RV, or PA has not been achieved catheter is thought to be in the PA position. An unex- at distances normally anticipated from a given insertion site. plained ventricular arrhythmia in a patient with a PA If these distances have already been signi cantly exceeded, catheter in place indicates the possibility of catheter- or if the catheter does not withdraw easily, use uoroscopy provoked ectopy. before attempting catheter withdrawal. N ever pull force- 7. Avoiding valvular damage. fully on a catheter that does not withdraw easily. a. Avoid prolonged catheterization and excessive manipu- 4. Avoiding damage to pulmonary vasculature and paren- lation. chyma. b. Do not withdraw the catheter when the balloon is in- a. Keep recording time of PAO P to a minimum, particularly ated. in patients with pulmonary hypertension and other risk 8. Avoiding infections. factors for PA rupture. Be sure the balloon is de ated a. Use meticulously sterile technique on insertion. tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 61 b. Avoid excessive number of CO determinations and blood concludes that the use of the PA catheter neither increased over- withdrawals. all mortality or hospital days nor conferred bene t. The authors c. Avoid prolonged catheterization. conclude that despite nearly 20 years of randomized clinical tri- d. Remove the catheter if signs of phlebitis develop. Culture als involving the PA catheter, there has not been a clear strategy the tip and use antibiotics as indicated. in its use which has lead to improved survival [155]. Although there are open trials involving the PA catheter listed in the clinical trials registry, these are focused on ele- SUMMARY ments of catheter data interpretation or comparisons of hemo- dynamics obtained from the PA catheter to other methods of H emodynamic monitoring enhances the understanding of obtaining these measurements [156]. There are no further ran- cardiopulmonary pathophysiology in critically ill patients. domized clinical trials looking at the PA catheter and patient N onetheless, the risk-to-bene t pro le of PA catheterization in outcomes recruiting patients at this time. various clinical circumstances remains uncertain. Recent large Until the results of future studies are available, clinicians us- trials have concluded that there may be no outcome bene t to ing hemodynamic monitoring should carefully assess the risk- patients with PA catheters used as part of clinical decision mak- to-bene t ratio on an individual patient basis. The operator ing. There is increasing concern that PA catheterization may be should understand the indications, insertion techniques, equip- overused and that the data obtained may not be optimally used, ment, and data that can be generated before undertaking PA or perhaps in speci c groups may increase morbidity and mor- catheter insertion. PA catheterization must not delay or replace tality. A recent meta-analysis of 13 randomized clinical trials bedside clinical evaluation and treatment. References 1. Swan H JC, Ganz W, Forrester J, et al: Catheterization of the heart in man 20. Yu M , Levy M , Smith P: Effect of maximizing oxygen delivery on morbidity with use of a ow-directed balloon-tipped catheter. N Engl J M ed 283:447, and mortality rates in critically ill patients. Crit Care M ed 21:830, 1993. 1970. 21. Gattinoni L, Brazzi L, Pelosi P, et al: A trial of goal-oriented hemodynamic 2. Connors AF, M cCaffree DR, Gray BA: Evaluation of right heart catheter- therapy in critically ill patients. N Engl J M ed 333:1025, 1995. ization in the critically ill patient without acute myocardial infarction. 22. Yu M , Takanishi D, M yers SA, et al: Frequency of mortality and myocardial N Engl J M ed 308:263, 1983. infarction during maximizing oxygen delivery: a prospective, randomized 3. Gorlin R: Current concepts in cardiology: practical cardiac hemodynamics. trial. Crit Care M ed 23:1025, 1995. N Engl J M ed 296:203, 1977. 23. Durham RM , N eunaber K, M azuski JE, et al: The use of oxygen consump- 4. Rao TK, Jacobs KH , El-Etr AA: Reinfarction following anesthesia in pa- tion and delivery as endpoints for resuscitation in critically ill patients. tients with myocardial infarction. A nesthesiology 59:499, 1983. J Traum a 41:32, 1996. 5. H esdorffer CS, M ilne JF, M eyers AM , et al: The value of Swan-Ganz 24. Afessa B, Spenser S, Khan W, et al: Association of pulmonary artery catheter catheterization and volume loading in preventing renal failure in patients use with in-hospital mortality. Crit Care M ed 29:1145, 2001. undergoing abdominal aneurysmectomy. Clin N ephrol 28:272, 1987. 25. Rhodes A, Cusack RJ, N ewman PJ, et al: A randomized, controlled trial of 6. Shoemaker WC, Appel PL, Kram H B, et al: Prospective trial of supranor- the pulmonary artery catheter in critically ill patients. Intensive Care M ed mal values of survivors as therapeutic goals in high-risk surgical patients. 28:256, 2002. Chest 94:1176, 1988. 26. Richard C: Early use of the pulmonary artery catheter and outcomes in 7. Berlauk JF, Abrams JH , Gilmour IL, et al: Preoperative optimization patients with shock and acute respiratory distress syndrome: a randomized of cardiovascular hemodynamics improves outcome in peripheral vascu- controlled trial. JA M A 290:2713, 2003. lar surgery: a prospective, randomized clinical trial. A nn Surg 214:289, 27. Yu DT, Platt R, Lanken PN , et al: Relationship of pulmonary artery catheter 1991. use to mortality and resource utilization in patients with severe sepsis. Crit 8. Fleming A, Bishop M , Shoemaker W, et al: Prospective trial of supernor- Care M ed 31:2734, 2003. mal values as goals of resuscitation in severe trauma. A rch Surg 127:1175, 28. Sandham JD, H ull RD, Brant RF, et al: A randomized, controlled trial of 1992. the use of pulmonary-artery catheters in high-risk surgical patients. N Engl 9. Tuchschmidt J, Fried J, Astiz M , et al: Elevation of cardiac output J M ed 348:5, 2003. and oxygen delivery improves outcome in septic shock. Chest 102:216, 29. Sakr Y, Vincent JL, Reinhart K, et al: Use of the pulmonary artery catheter 1992. is not associated with worse outcome in the ICU. Chest 128:2722, 2005. 10. Boyd O , Grounds RM , Bennett ED: A randomized clinical trial or the ef- 30. H arvey S, H arrison DA, Singer M , et al: Assessment of the clinical effective- fect of deliberate perioperative increase of oxygen delivery on mortality in ness of pulmonary-artery catheters in management of patients in intensive high-risk surgical patients. JA M A 270:2699, 1993. care (PAC-M an): a randomized controlled trial. L ancet 366:472, 2005. 11. Bishop M H , Shoemaker WC, Appel PL, et al: Prospective randomized trial 31. Binanay C, Califf RM , H asselblad V, et al: Evaluation study of conges- of survivor values of cardiac index, oxygen delivery, and oxygen consump- tive heart failure and pulmonary artery catheterization effectiveness: the tion as resuscitation endpoints in severe trauma. J Traum a 38:780, 1995. ESCAPE trial. JA M A 294:1625, 2005. 12. Schiller WR, Bay RC, Garren RL, et al: H yperdynamic resuscitation im- 32. The N ational H eart, Lung and Blood Institute ARDS Clinical Trials N et- proves in patients with life-threatening burns. J Burn Care R ehabil 18:10, work: Pulmonary artery versus central venous catheter to guide treatment 1997. of acute lung injury. N ew Engl J M ed 354:2213, 2006. 13. Wilson J, Woods I, Fawcett J, et al: Reducing the risk of major elective 33. Tuman KJ, M cCarthy RJ, Spiess BD, et al: Effect of pulmonary artery surgery: randomized controlled trial of preoperative optimization of oxy- catheterization on outcome in patients undergoing coronary artery surgery. gen delivery. BM J 318:1099, 1999. A nesthesiology 70:199, 1989. 14. Chang M C, M eredith JW, Kincaid EH , et al: M aintaining survivors’ of left 34. Guyatt G: A randomized control trial of right heart catheterization in criti- ventricular power output during shock resuscitation: a prospective pilot cally ill patients. O ntario Intensive Care Study Group. J Intensive Care M ed study. J Traum a 49:26, 2000. 6:91, 1991. 15. Polonen P, Ruokonen E, H ippelainen M , et al: A prospective, randomized 35. H ayes M A, Timmins AC, Yau H , et al: Elevation of systemic oxygen de- study of goal-oriented hemodynamic therapy in cardiac surgical patients. livery in the treatment of critically ill patients. N Eng J M ed 330:1717, A nesth A nalg 90:1052, 2000. 1994. 16. Friese RS, Sha S, Gentilello LM : Pulmonary artery catheter use is associ- 36. Connors AF, Speroff T, Dawson N V, et al: The effectiveness of right heart ated with reduced mortality in severely injured patients: a N ational Trauma catheterization in the initial care of critically ill patients. JA M A 276:889, Data Bank analysis of 53,312 patients. Crit Care M ed 34:1597, 2006. 1996. 17. Pearson KS, Gomez M N , M oyers, JR, et al: A cost/bene t analysis of 37. Valentine RJ, Duke M L, Inman M H , et al: Effectiveness of pulmonary artery randomized invasive monitoring for patients undergoing cardiac surgery. catheters in aortic surgery: a randomized trial. J Vasc Surg 27:203, 1998. A nesth A nalg 69:336, 1989. 38. Stewart RD, Psyhojos T, Lahey SJ, et al: Central venous catheter use in low 18. Isaacson IJ, Lowdon JD, Berry AJ, et al: The value of pulmonary artery and risk coronary artery bypass grafting. A nn T horac Surg 66:1306, 1998. central venous monitoring in patients undergoing abdominal aortic recon- 39. Ramsey SD, Saint S, Sullivan SD, et al: Clinical and economic effects of structive surgery: a comparative study of two selected, randomized groups. pulmonary artery catheterization in nonemergent coronary artery bypass J Vasc Surg 12:754, 1990. graft surgery. J Cardiothorac Vasc A nesth 14:113, 2000. 19. Joyce WP, Provan JL, Ameli FM , et al: The role of central hemodynamic 40. Polanczyk CA, Rohde LE, Goldman L, et al: Right heart catheterization monitoring in abdominal aortic surgery: a prospective randomized study. and cardiac complications in patients undergoing noncardiac surgery: an Eur J Vasc Surg 4:633, 1990. observational study. JA M A 286:348, 2001. tahir99-VRG & vip.persianss.ir 62 Section I: Procedures, Techniques, and Minimally Invasive Monitoring 41. Chittock DR, Dhingra VK, Ronco JJ, et al: Severity of illness and risk of 72. Forrester JS, Diamond G, M cH ugh TJ, et al: Filling pressures in the right death associated with pulmonary artery catheter use. Crit Care M ed 32:911, and left sides of the heart in acute myocardial infarction. N Engl J M ed 2004. 285:190, 1971. 42. Peters SG, Afessa B, Decker PA, et al: Increased risk associated with pul- 73. O ’Q uin R, M arini JJ: Pulmonary artery occlusion pressure: clinical physiol- monary artery catheterization in the medical intensive care unit. J Crit Care ogy, measurement, and interpretation. A m R ev R espir D is 128:319, 1983. 18:166, 2003. 74. Timmis AD, Fowler M B, Burwood RJ, et al: Pulmonary edema without 43. Cohen M G, Kelley RV, Kong DF, et al: Pulmonary artery catheterization in critical increase in left atrial pressure in acute myocardial infarction. BM J acute coronary syndromes: insights from the GUSTO IIb and GUSTO III 283:636, 1981. trials. A m J M ed 118:482, 2005. 75. H olloway H , Perry M , Downey J, et al: Estimation of effective pulmonary 44. Kumar A, Anel R, Bunnell E: Pulmonary artery occlusion pressure and capillary pressure in intact lungs. J A ppl Physiol 54:846, 1983. central venous pressure fail to predict ventricular lling volume, cardiac 76. Dawson CA, Linehan JH , Rickaby DA: Pulmonary microcirculatory hemo- performance, or the response to volume infusion in normal subjects. Crit dynamics. A nn N Y A cad Sci 384:90, 1982. Care M ed 32:691, 2004. 77. Pichard AD, Kay R, Smith H , et al: Large V waves in the pulmonary occlu- 45. H oar PF, Wilson RM , M angano DT, et al: H eparin bonding reduces sion pressure tracing in the absence of mitral regurgitation. A m J Cardiol thrombogenicity of pulmonary-artery catheters. N Engl J M ed 305:993, 50:1044, 1982. 1981. 78. Ruchs RM , H euser RR, Yin FU, et al: Limitations of pulmonary occlusion 46. M angano DT: H eparin bonding long-term protection against thromboge- V waves in diagnosing mitral regurgitation. A m J Cardiol 49:849, 1982. nesis. N Engl J M ed 307:894, 1982. 79. Bethen CF, Peter RH , Behar VS, et al: The hemodynamic simulation of mi- 47. Forrester JS, Ganz W, Diamond G, et al: Thermodilution cardiac output tral regurgitation in ventricular septal defect after myocardial infarction. determination with a single ow-directed catheter. A m H eart J 83:306, Cathet Cardiovasc D iagn 2:97, 1976. 1972. 80. H asan FM , Weiss WB, Braman SS, et al: In uence of lung injury on 48. Chatterjee K, Swan JH C, Ganz W, et al: Use of a balloon-tipped otation pulmonary occlusion-left atrial pressure correlation during positive end- electrode catheter for cardiac monitoring. A m J Cardiol 36:56, 1975. expiratory pressure ventilation. A nnu R ev R espir D is 131:246, 1985. 49. Simoons M L, Demey H E, Bossaert LL, et al: The Paceport catheter: a new 81. Teboul JL, Z apol WM , Brun-Buisson C, et al: A comparison of pulmonary pacemaker system introduced through a Swan–Ganz catheter. Cathet Car- artery occlusion pressure and left ventricular end diastolic pressure during diovasc D iagn 15:66, 1988. mechanical ventilation with PEEP in patients with severe ARDS. A nesthe- 50. Baele PL, M cM echan JC, M arsh H M , et al: Continuous monitoring of siology 70:261, 1989. mixed venous oxygen saturation in critically ill patients. A nesth A nalg 82. DeCampo T, Civetta JM : The effect of short-term discontinuation of high- 61:513, 1982. level PEEP in patients with acute respiratory failure. Crit Care M ed 7:47, 51. Segal J, Pearl RG, Ford AJ, et al: Instantaneous and continuous cardiac out- 1979. put obtained with a Doppler pulmonary artery catheter. J A m Coll Cardiol 83. Ganz W, Swan H JC: M easurement of blood ow by thermodilution. A m J 13:1382, 1989. Cardiol 29:241, 1972. 52. Vincent JL, Thirion M , Bumioulle S, et al: Thermodilution measurement 84. Grossman W: Blood ow measurement: the cardiac output, in Grossman of right ventricular ejection fraction with a modi ed pulmonary artery W (ed): Cardiac Catheterization and A ngiography. Philadelphia, Lea & catheter. Intensive Care M ed 12:33, 1986. Febiger, 1985; p 116. 53. Guerrero JE, M unoz J, De Lacalle B, et al: Right ventricular systolic time 85. Goldman RH , Klughaupt M , M etcalf T, et al: M easurement of central ve- intervals determined by means of a pulmonary artery catheter. Crit Care nous oxygen saturation in patients with myocardial infarction. Circulation M ed 20:1529, 1992. 38:941, 1968. 54. Dhainaut JF, Brunet F, M onsallier JF, et al: Bedside evaluation of right ven- 86. Pace N L: A critique of ow-directed pulmonary artery catheterization. tricular performance using a rapid computerized thermodilution mode. Crit A nesthesiology 47:455, 1977. Care M ed 15:148, 1987. 87. Rayput M A, Rickey H M , Bush BA, et al: A comparison between a con- 55. Vincent JL: M easurement of right ventricular ejection fraction. Intensive ventional and a beroptic ow-directed thermal dilution pulmonary artery Care W orld 7:133, 1990. catheter in critically ill patients. A rch Intern M ed 149:83, 1989. 56. N elson, LD: The new pulmonary arterial catheters: Right ventricular ejec- 88. M atthay M A, Chatterjee K: Bedside catheterization of the pulmonary tion fraction and continuous cardiac output. Critical Care Clin 12:795, artery: risks compared with bene ts. A nn Intern M ed 109:826, 1988. 1996. 89. M cN abb TG, Green CH , Parket FL: A potentially serious complication 57. Boldt J, M endes T, Wollbruck M , et al: Is continuous cardiac output mea- with Swan-Ganz catheter placement by the percutaneous internal jugular surement using thermodilution reliable in the critically ill patient? Crit Care route. Br J A naesth 47:895, 1975. M ed 22:1913, 1994. 90. H ansbroyh JF, N arrod JA, Rutherford R: Arteriovenous stulas following 58. H aller M , Z ollner C, Briegel J, et al: Evaluation of a new continuous ther- central venous catheterization. Intensive Care M ed 9:287, 1983. modilution cardiac output monitor in critically ill patients: a prospective 91. Shield CF, Richardson JD, Buckley CJ, et al: Pseudoaneurysm of the bra- criterion standard study. Crit Care M ed 23:860, 1995. chiocephalic arteries: a complication of percutaneous internal jugular vein 59. M ihaljevic T, von Segesser L, Tonz M , et al: Continuous verses bolus ther- catheterization. Surgery 78:190, 1975. modilution cardiac output measurements: a comparative study. Crit Care 92. Patel C, LaBoy V, Venus B, et al: Acute complications of pulmonary artery M ed 23:944, 1995. catheter insertion in critically ill patients. Crit Care M ed 14:195, 1986. 60. M unro H , Woods C, Taylor B, et al: Continuous invasive cardiac output 93. Damen J, Bolton D: A prospective analysis of 1,400 pulmonary artery monitoring: The Baxter/Edwards Critical-Care Swan Ganz IntelliCath and catheterizations in patients undergoing cardiac surgery. A cta A naesthesiol Vigilance system. Clin Intensive Care 5:52, 1994. Scand 14:1957, 1986. 61. Keusch DJ, Winters S, Thys DM : The patient’s position in uences the inci- 94. Senagere A, Waller JD, Bonnell BW, et al: Pulmonary artery catheteriza- dence of dysrhythmias during pulmonary artery catheterization. A nesthe- tion: a prospective study of internal jugular and subclavian approaches. siology 70:582, 1989. Crit Care M ed 15:35, 1987. 62. M arini JJ: H emodynamic monitoring with the pulmonary artery catheter. 95. N embre AE: Swan-Ganz catheter. A rch Surg 115:1194, 1980. Crit Care Clin 2:551, 1986. 96. Lipp H , O ’Donoghue K, Resnekov L: Intracardiac knotting of a ow- 63. Barry WA, Grossman W: Cardiac catheterization, in Braunwald E (ed): directed balloon catheter. N Engl J M ed 284:220, 1971. H eart D isease: A Tex tbook of Cardiovascular M edicine. Vol 1. Philadel- 97. M ond H G, Clark DW, N esbitt SJ, et al: A technique for unknotting an phia, PA, WB Saunders, 1988; p 287. intracardiac ow-directed balloon catheter. Chest 67:731, 1975. 64. Sharkey SW: Beyond the occlusion: clinical physiology and the Swan-Ganz 98. M eister SG, Furr CM , Engel TR, et al: Knotting of a ow-directed catheter catheter. A m J M ed 83:111, 1987. about a cardiac structure. Cathet Cardiovasc D iagn 3:171, 1977. 65. Bohrer H , Fleischer F: Errors in biochemical and haemodynamic data ob- 99. Swaroop S: Knotting of two central venous monitoring catheters. A m J M ed tained using introducer lumen and proximal port of Swan-Ganz catheter. 53:386, 1972. Intensive Care M ed 15:330, 1989. 100. Loggam C, Sanborn TA, Christian F: Ventricular entrapment of a Swan- 66. H uford WE, Z apol WM : The right ventricle and critical illness: a review of Ganz catheter: a technique for nonsurgical removal. J A m Coll Cardiol anatomy, physiology, and clinical evaluation of its function. Intensive Care 13:1422, 1989. M ed 14:448, 1988. 101. Foote GA, Schabel SI, H odges M : Pulmonary complications of the ow- 67. Diebel LN , Wilson RF, Tagett M G, et al: End diastolic volume: a better directed balloon-tipped catheter. N Engl J M ed 290:927, 1974. indicator of preload in the critically ill. A rch Surg 127:817, 1992. 102. Wechsler RJ, Steiner RM , Kinori F: M onitoring the monitors: the radiology 68. M artyn JA, Snider M T, Farago LF, et al: Thermodilution right ventricu- of thoracic catheters, wires and tubes. Sem in R oentgenol 23:61, 1988. lar volume: a novel and better predictor of volume replacement in acute 103. Boyd KD, Thomas SJ, Gold J, et al: A prospective study of complications thermal injury. J Traum a 21:619, 1981. of pulmonary artery catheterizations in 500 consecutive patients. Chest 69. Reuse C, Vincent JL, Pinsky M R, et al: M easurements of right ventricular 84:245, 1983. volumes during uid challenge. Chest 98:1450, 1990. 104. Sise M J, H ollingsworth P, Bumm JE, et al: Complications of the ow di- 70. Lange RA, M oore DM , Cigarroa RG, et al: Use of pulmonary capillary rected pulmonary artery catheter: a prospective analysis of 219 patients. occlusion pressure to assess severity of mitral stenosis: is true left atrial Crit Care M ed 9:315, 1981. pressure needed in this condition? J A m Coll Cardiol 13:825, 1989. 105. Barash PG, N ardi D, H ammond G, et al: Catheter-induced pulmonary 71. Alpert JS: The lessons of history as re ected in the pulmonary capillary artery perforation: mechanisms, management and modi cations. J T horac occlusion pressure. J A m Coll Cardiol 13:830, 1989. Cardiovasc Surg 82:5, 1981. tahir99-VRG & vip.persianss.ir Chapter 4: Pulmonary Artery Catheters 63 106. Pape LA, H affajee CI, M arkis JE, et al: Fatal pulmonary hemorrhage after 131. Lange H W, Galliani CA, Edwards JE: Local complications associated with use of the ow-directed balloon-tipped catheter. A nn Intern M ed 90:344, indwelling Swan-Ganz catheters. A m J Cardiol 52:1108, 1983. 1979. 132. Sage M D, Koelmeyer TD, Smeeton WM I: Evolution of Swan-Ganz catheter 107. Lapin ES, M urray JA: H emoptysis with ow-directed cardiac catheteriza- related pulmonary valve nonbacterial endocarditis. A m J Forensic M ed tion. JA M A 220:1246, 1972. Pathol 9:112, 1988. 108. M cDaniel DD, Stone JG, Faltas AN , et al: Catheter induced pulmonary 133. Rowley KM , Clubb KS, Smith GJW, et al: Right sided infective endocarditis artery hemorrhage: diagnosis and management in cardiac operations. J T ho- as a consequence of ow directed pulmonary artery catheterization. N Engl rac Cardiovasc Surg 82:1, 1981. J M ed 311:1152, 1984. 109. Shah KB, Rao TL, Laughlin S, et al: A review of pulmonary artery catheter- 134. Ford SE, M anley PN : Indwelling cardiac catheters: an autopsy study of ization in 6245 patients. A nesthesiology 61:271, 1984. associated endocardial lesions. A rch Pathol L ab M ed 106:314, 1982. 110. Fraser RS: Catheter-induced pulmonary artery perforation: pathologic and 135. Prochan H , Dittel M , Jobst C, et al: Bacterial contamination of pulmonary pathogenic features. H um Pathol 18:1246, 1987. artery catheters. Intensive Care M ed 4:79, 1978. 111. Declen JD, Friloux LA, Renner JW: Pulmonary artery false-aneurysms sec- 136. Pinella JC, Ross DF, M artin T, et al: Study of the incidence of intravascular ondary to Swan-Ganz pulmonary artery catheters. A JR A m J R oentgenol catheter infection and associated septicemia in critically ill patients. Crit 149:901, 1987. Care M ed 11:21, 1983. 112. Thoms R, Siproudhis L, Laurent JF, et al: M assive hemoptysis from iatro- 137. M ichel L, M arsh H M , M cM ichan JC, et al: Infection of pulmonary artery genic balloon catheter rupture of pulmonary artery: successful early man- catheters in critically ill patients. JA M A 245:1032, 1981. agement by balloon tamponade. Crit Care M ed 15:272, 1987. 138. Greene JF, Fitzwater JE, Clemmer TP: Septic endocarditis and indwelling 113. Slacken A: Complications of invasive hemodynamic monitoring in the in- pulmonary artery catheters. JA M A 233:891, 1975. tensive care unit. Curr Probl Surg 25:69, 1988. 139. M yers M L, Austin TW, Sibbald WJ: Pulmonary artery catheter infections: 114. Scuderi PE, Prough DS, Price JD, et al: Cessation of pulmonary artery a prospective study. A nn Surg 201:237, 1985. catheter-induced endobronchial hemorrhage associated with the use of 140. H anna R, Raad II: Diagnosis of catheter-related bloodstream infection. PEEP. A nesth A nalg 62:236, 1983. Curr Infect D is R ep 7:413, 2005. 115. Pace N L, H orton W: Indwelling pulmonary artery catheters: their relation- 141. Chatzinikolaou I, H anna R, Darouiche R, et al: Prospective study of the ship to aseptic thrombotic endocardial vegetations. JA M A 233:893, 1975. value of quantitative culture of organisms from blood collected through cen- 116. Dye LE, Segall PH , Russell RO , et al: Deep venous thrombosis of the upper tral venous catheters in differentiating between contamination and blood- extremity associated with use of the Swan-Ganz catheter. Chest 73:673, stream infection. J Clin M icrobiol 44:1834, 2006. 1978. 142. Weinstein RA, Stamm WE, Kramer L: Pressure monitoring devices: over- 117. Elliot CG, Z immerman GA, Clemmer TP: Complications of pulmonary looked source of nosocomial infection. JA M A 236:936, 1976. artery catheterization in the care of critically ill patients: a prospective study. 143. Singh SJ, Puri VK: Prevention of bacterial colonization of pulmonary artery Chest 76:647, 1979. catheters. Infect Surg 1984;853. 118. Chastre J, Cornud F, Bouchama A, et al: Thrombosis as a complication 144. H eard SO , Davis RF, Sherertz RJ, et al: In uence of sterile protective sleeves of pulmonary artery catheterization via the internal jugular vein. N Engl J on the sterility of pulmonary artery catheters. Crit Care M ed 15:499, 1987. M ed 306:278, 1982. 145. Cobb DK, H igh KP, Sawyer RG, et al: A controlled trial of scheduled re- 119. Laster JL, N ichols WK, Silver D: Thrombocytopenia associated with placement of central venous and pulmonary artery catheters. N Engl J M ed heparin-coated catheters in patients with heparin-associated antiplatelet 327:1062, 1992. antibodies. A rch Intern M ed 149:2285, 1989. 146. Berry AJ, Geer RT, M arshall BE: Alteration of pulmonary blood ow by 120. Laster JL, Silver D: H eparin coated catheters and heparin-induced throm- pulmonary artery occluded pressure measurement. A nesthesiology 51:164, bocytopenia. J Vasc Surg 7:667, 1988. 1979. 121. Geha DG, Davis N J, Lappas DG: Persistent atrial arrhythmias associated 147. Schluger J, Green J, Giustra FX, et al: Complication with use of ow- with placement of a Swan-Ganz catheter. A nesthesiology 39:651, 1973. directed catheter. A m J Cardiol 32:125, 1973. 122. Sprung CL, Jacobs JL, Caralis PV, et al: Ventricular arrhythmias during 148. Isner JM , H orton J, Ronan JAS: Systolic click from a Swan-Ganz catheter: Swan-Ganz catheterization of the critically ill. Chest 79:413, 1981. phonoechocardiographic depiction of the underlying mechanism. A m J Car- 123. Sprung CL, Pozen PG, Rozanski JJ, et al: Advanced ventricular arrhythmias diol 42:1046, 1979. during bedside pulmonary artery catheterization. A m J M ed 72:203, 1982. 149. Lawson D, Kushkins LG: A complication of multipurpose pacing pul- 124. Iberti TJ, Benjamin E, Grupzi L, et al: Ventricular arrhythmias during pul- monary artery catheterization via the external jugular vein approach [let- monary artery catheterization in the intensive care unit. A m J M ed 78:451, ter]. A nesthesiology 62:377, 1985. 1985. 150. M cLellan BA, Jerman M R, French WJ, et al: Inadvertent Swan-Ganz 125. Sprung CL, M arical EH , Garcia AA, et al: Prophylactic use of lidocaine catheter placement in the left pericardiophrenic vein. Cathet Cardiovasc to prevent advanced ventricular arrhythmias during pulmonary artery D iagn 16:173, 1989. catheterization: prospective, double blind study. A m J M ed 75:906, 1983. 151. Allyn J, Lichtenstein A, Koski EG, et al: Inadvertent passage of a pulmonary 126. Johnston W, Royster R, Beamer W, et al: Arrhythmias during removal of artery catheter from the superior vena cava through the left atrium and left pulmonary artery catheters. Chest 85:296, 1984. ventricle into the aorta. A nesthesiology 70:1019, 1989. 127. Damen J: Ventricular arrhythmia during insertion and removal of pul- 152. Lazzam C, Sanborn TA, Christian F: Ventricular entrapment of a Swan- monary artery catheters. Chest 88:190, 1985. Ganz catheter: a technique for nonsurgical removal. J A m Coll Cardiol 128. M orris D, M ulvihill D, Lew WY: Risk of developing complete heart block 13:1422, 1989. during bedside pulmonary artery catheterization in patients with left bundle 153. Ginosar Y, Sprung CL: The Swan–Ganz catheter: twenty- ve years of mon- branch block. A rch Intern M ed 147:2005, 1987. itoring. Crit Care Clin 12:771, 1996. 129. Lavie CJ, Gersh BJ: Pacing in left bundle branch block during Swan-Ganz 154. Wiedermann H P, M atthay M A, M atthay RA: Cardiovascular-pulmonary catheterization [letter]. A rch Intern M ed 148:981, 1988. monitoring in the intensive care unit, 2. Chest 85:656, 1984. 130. Becker RC, M artin RG, Underwood DA: Right-sided endocardial lesions 155. Shah M R, H asselblad V, Stevenson LW, et al: Impact of the pulmonary and ow-directed pulmonary artery catheters. Cleve Clin J M ed 54:384, artery catheter in critically ill patients. JA M A 294:1664, 2005. 1987. 156. http://www.clinicaltrials.gov. Accessed January 23, 2011. tahir99-VRG & vip.persianss.ir 64 Section I: Procedures, Techniques, and Minimally Invasive Monitoring CH APTER 5 ■ TEM PO RARY CARDIAC PACIN G SETH T. DAHLBERG Temporary cardiac pacing may be urgently required for the onds) are important in the successful conversion of atrial utter treatment of cardiac conduction and rhythm disturbances com- to sinus rhythm. monly seen in patients treated in the intensive care unit (ICU). In some clinical situations, pacing termination of atrial ut- Therefore, ICU personnel should be familiar with the indica- ter may be preferable to synchronized cardioversion, which tions and techniques for initiating and maintaining temporary requires sedation with its attendant risks. Pacing termination cardiac pacing as well as the possible complications of this pro- is the treatment of choice for atrial utter in patients with epi- cedure. Recommendations for training in the performance of cardial atrial wires in place after cardiac surgery. It may be transvenous pacing have been published by a Task Force of preferred as the means to convert atrial utter in patients on the American College of Physicians, American H eart Associ- digoxin and those with sick sinus syndrome, as these groups ation and American College of Cardiology [1]. Competence often demonstrate prolonged sinus pauses after DC cardiover- in the performance of transvenous pacing also requires the op- sion. erator to have training in central venous access (Chapter 2) and Temporary pacing may be required for the prevention of hemodynamic monitoring (Chapters 4 and 26) [2–5]. paroxysmal polymorphic ventricular tachycardia in patients with prolonged Q T intervals (torsades de pointes), particularly when secondary to drugs [9,10]. Temporary cardiac pacing is IN DICATION S FOR TEMPORARY the treatment of choice to stabilize the patient while a type I antiarrhythmic agent exacerbating ventricular irritability is CARDIAC PACIN G metabolized. In this situation, the pacing rate is set to provide a mild tachycardia. The effectiveness of cardiac pacing proba- As outlined in Table 5.1, temporary pacing is indicated in the bly relates to decreasing the dispersion of refractoriness of the diagnosis and management of a number of serious rhythm and ventricular myocardium (shortening the Q T interval). conduction disturbances. Temporary ventricular pacing may be successful in termi- nating ventricular tachycardia. If ventricular tachycardia must be terminated urgently, cardioversion is mandated (Chapter 6). Bradyarrhythmias H owever, in less urgent situations, conversion of ventricular tachycardia via rapid ventricular pacing may be useful. The The most common indication for temporary pacing in the ICU success of this technique depends on the setting in which ven- setting is a hemodynamically signi cant or symptomatic brad- tricular tachycardia occurs. “ O verdrive” ventricular pacing is yarrhythmia such as sinus bradycardia or high-grade atrioven- often effective in terminating monomorphic ventricular tachy- tricular (AV) block. cardia in a patient with remote myocardial infarction or in Sinus bradycardia and AV block are commonly seen the absence of heart disease. This technique is less effective in patients with acute coronary syndromes, hyperkalemia, when ventricular tachycardia complicates acute myocardial in- myxedema, or increased intracranial pressure. Infectious pro- farction or cardiomyopathy. Rapid ventricular pacing is most cesses such as endocarditis or Lyme disease [6] may impair successful in terminating ventricular tachycardia when the ven- AV conduction. Bradyarrhythmias also result from treatment tricle can be “ captured” (asynchronous pacing for 5 to 10 beats or intoxication with digitalis, antiarrhythmic, beta-blocker, or at a rate of 50 beats per minute greater than that of the under- calcium channel blocker medications and may also result from lying tachycardia). Extreme caution is advised, as pacing may exaggerated vasovagal reactions to ICU procedures such as suc- result in acceleration of ventricular tachycardia or degenera- tioning of the tracheobronchial tree in the intubated patient. tion to ventricular brillation; a cardiac de brillator should be Bradycardia-dependent ventricular tachycardia may occur in immediately available at the bedside. association with ischemic heart disease. Tachyarrhythmias DIAGN OSIS OF RAPID RHYTHMS Temporary cardiac pacing is used less often for the preven- tion and termination of supraventricular and ventricular tach- Temporary atrial pacing electrodes may be helpful for the di- yarrhythmias. agnosis of tachyarrhythmias when the morphology of the P Atrial pacing may be effective in terminating atrial ut- wave and its relation to the Q RS complexes cannot be deter- ter and paroxysmal nodal supraventricular tachycardia [7,8]. mined from the surface electrocardiogram (ECG) [11–13]. A Atrial pacing in the ICU setting is most frequently performed recording of the atrial electrogram is particularly helpful in a when temporary epicardial electrodes have been placed during rapid, regular, narrow-complex tachycardia in which the dif- cardiac surgery. A critical pacing rate (usually 125% to 135% ferential diagnosis includes atrial utter with rapid ventricular of the utter rate) and pacing duration (usually about 10 sec- response, and AV nodal reentrant or other supraventricular tahir99-VRG & vip.persianss.ir Chapter 5: Temporary Cardiac Pacing 65 TA B LE 5 . 1 IN DICATION S FOR ACUTE (TEMPORARY) CARDIAC PACIN G A. Conduction disturbances 1. Symptomatic persistent third-degree AV block with inferior myocardial infarction 2. Third-degree AV block, new bifascicular block (e.g., right bundle branch block and left anterior hemiblock, left bundle branch block, rst-degree AV block), or alternating left and right bundle branch block complicating acute anterior myocardial infarction 3. Symptomatic idiopathic third-degree AV block, or high-degree AV block B. Rate disturbances 1. H emodynamically signi cant or symptomatic sinus bradycardia 2. Bradycardia-dependent ventricular tachycardia 3. AV dissociation with inadequate cardiac output 4. Polymorphic ventricular tachycardia with long Q T interval (torsades de pointes) 5. Recurrent ventricular tachycardia unresponsive to medical therapy AV, atrioventricular. tachycardia. This technique may also assist in the diagnosis of wide-complex tachycardias in which the differential diagnosis EQUIPMEN T AVAILABLE FOR includes supraventricular tachycardia with aberrant conduc- TEMPORARY PACIN G tion, sinus tachycardia with bundle branch block, and ventric- ular tachycardia. Several methods of temporary pacing are currently available for To record an atrial ECG, the ECG limb leads are connected use in the ICU. Transvenous pacing of the right ventricle or right in the standard fashion and a precordial lead (usually V1 ) is con- atrium with a pacing catheter or modi ed pulmonary artery nected to the proximal electrode of the atrial pacing catheter or catheter is the most widely used technique; intraesophageal, to an epicardial atrial electrode. A multichannel ECG rhythm transcutaneous, and epicardial pacing are also available. strip is run at a rapid paper speed, simultaneously demonstrat- ing surface ECG limb leads as well as the atrial electrogram obtained via lead V1 . This rhythm strip should reveal the con- Transvenous Pacing Catheters duction pattern between atria and ventricles as antegrade, si- multaneous, retrograde, or dissociated. Some of the many transvenous pacing catheters available for use in the critical care setting are illustrated in Figure 5.1. Pac- ing catheters range in size from 4 Fr (1.2 mm) to 7 Fr (2.1 mm). In urgent situations, or where uoroscopy is unavailable, ACUTE MYOCARDIAL a ow-directed exible balloon-tipped catheter (Fig. 5.1, top) IN FARCTION may be placed in the right ventricle using ECG guidance. After gaining access to the central venous circulation, the catheter Temporary pacing may be used therapeutically or prophylac- is passed into the vein and the balloon in ated. After advanc- tically in acute myocardial infarction [14]. Recommendations ing the catheter into the right ventricle, the balloon can be for temporary cardiac pacing have been provided by a Task de ated and the catheter tip advanced to the right ventricular Force of the American College of Cardiology and the Ameri- apex. Although the balloon-tipped catheter may avoid the need can H eart Association (Table 5.2) [15]. Bradyarrhythmias un- for uoroscopy, placement may be ineffective in the setting of responsive to medical treatment that result in hemodynamic low blood ow during cardiac arrest or in the presence of se- compromise require urgent treatment. Patients with anterior in- vere tricuspid regurgitation. Stiff catheters (Fig. 5.1, middle) are farction and bifascicular block or M obitz type II second-degree easier to manipulate but require insertion under uoroscopic AV block, while hemodynamically stable, may require a tem- guidance. porary pacemaker, as they are at risk for sudden development A exible J-shaped catheter (Fig. 5.1, bottom), designed for of complete heart block with an unstable escape rhythm. temporary atrial pacing, is also available [23]. This lead is po- Prophylactic temporary cardiac pacing has aroused debate sitioned by “ hooking” it in the right atrial appendage under for the role it may play in complicated anterior wall myocardial uoroscopic guidance, providing stable contact with the atrial infarction [16]. Thrombolytic therapy or percutaneous coro- endocardium. Either the subclavian or internal jugular venous nary intervention, when indicated, should take precedence over approach may be used. placement of prophylactic cardiac pacing, as prophylactic pac- A multilumen pulmonary artery catheter is available with a ing has not been shown to improve mortality. Transthoracic right ventricular lumen. Placement of a small (2.4 Fr) bipolar (transcutaneous) cardiac pacing is safe and usually effective pacing lead through the right ventricular lumen allows intracar- [17–20] and would be a reasonable alternative to prophylactic diac pressure monitoring and pacing through a single catheter transvenous cardiac pacing, particularly soon after the admin- [24]. Details on its use and insertion are described in Chapter 4. istration of thrombolytic therapy. When right ventricular involvement complicates inferior myocardial infarction, cardiac output may be very sensitive Esophageal Electrode to ventricular preload and AV synchrony. Therefore, AV se- quential pacing is frequently the pacing modality of choice in An esophageal “ pill” electrode allows atrial pacing and record- patients with right ventricular infarction [21,22]. ing of atrial depolarizations without requiring central venous tahir99-VRG & vip.persianss.ir 66 A D T C U A C R B / I A N L H G E A S 5 T R . E E 2 M C O I M M E N D A T I O N S F O R T R E A T M E N T O F A T R I O V E N T R I C U L A R A N D I N T R A V E N T R I C U L A R C O N D U C T I O N D I S T U R B A N C E S N O O N I c n o o l l e f ( t d d n w a L r r d m a s A o B c v u B r a B i F e c c B l n B n B t u i B e t o l r w o a n i r r c u L b l l P a o F r c B k ) A O A T T O A T T O A T T O A T T C V C V C V C V c B B B B t i o N n o r m a l C 3 3 3 3 3 3 2 3 2 3 1 2 1 1 1 3 B B B l a s s A A A A A T T T T T T T T O O O O C V V V C C C V c B B B B t i o n A M F I i r s C 3 3 3 3 2 3 3 2 1 1 1 2 1 2 3 3 t B B B A - l a d s e s g r e e A A A A A A T T T T T T T O T O O O V V V C C C C V V c B B B B b t i N l o o n o c n k - A M C 3 3 3 3 3 3 1 2 2 1 2 2 2 1 3 3 I B A B B A l a s s A A A A A T T T T O T T T T O O O A V V C C C C V V c * * * * B B B B V t M i o c n o o A b n M i d t z u I c I C 3 3 3 3 3 3 1 1 2 1 1 2 2 2 3 3 t s i B B A B o e l a c n s o s n d - d e A A A A A T T T T O T T T O T O O g r V V C C C C V V c B B B B e t e i N o A n o V n - b A l o M c C 3 3 3 3 3 3 1 1 2 1 1 2 2 2 3 3 k I B B A A l a s s A A A A A T T T T O T T O T T O O V V C C C C V V c B B B B t M i o o n A b i M t z I I I C 3 3 3 3 2 2 2 1 1 1 3 2 3 1 3 3 s A A B A l e a c s o s n d - d e A A A A A T T T T T T O O T T O O g C V V C C C V V r c B B B B e t i N e o A n o V n - A b l M o C 3 3 3 3 1 2 2 2 1 1 3 1 2 3 3 3 c I k A B B A l a s s tahir99-VRG & vip.persianss.ir F A a l t R r s er i c g B i n c h B u a t B l t B a i ng r B b B l l ef o c t k a + n d O A T T O A T T C V C V B B 1 2 2 1 3 3 3 3 B B T T O O A A T T C V V C B B 1 1 3 3 3 3 2 2 A B T T A A O O T T C V V C B B 1 1 3 3 2 2 3 3 A B T T A A T T O O C V V C * * B B 1 1 3 3 2 2 3 3 A B T T T T O O A A C V V C B B 1 1 3 3 2 2 3 3 A B T T A A T T O O C V V C B B 1 2 3 3 2 1 3 3 B B T T T O O T A A V C V C B B 1 2 1 2 3 3 3 3 B B N S L t m A 1 2 t 3 4 i C L f r H E 1 2 3 4 F C i n n e h r e T . . . . . . . . r A e x o c l o m y o c o f e o a v e O A T T R F F N t E a a m o l r F o t w s m i l f e p r i i e e m M C V o m e B s f B c b o n n l c a o s e : g a n t : i t B , s t : t d d : p o n A m c s r h I e o r E i e e : T B l A a , T t o l f d d e n e r t t s e a T e o e t r U t n h h a E v y h f i p : t h n c i m h y p A f a h t s m ) s e e e m i v p h s 5 a d e r l . s e C : a * t e p i t a l e 4 t c “ a a p r J i d r i h p n c p t : o r a n n o c a - t e A t “ n a t e o e t e o A o h y A i r a r f l o n b O e n o p a i n c u d a a s e s E t e m n p m s r t l c t n s r i s e r a t m r i r e v b i M o i t a T o e i e i i c y r o s r o o a b r n b e s t : n f C t - n i l a r a f p n t n e i i s u o i o u l t l , T o e i n e o b e v r o r i o ” o f f c s g l e A n d n a u v h a n e d o l i l f d t u t y t e o e t l n b n e e a h n s r r i . r h / : s t s s m c ” n e C n s r i A t E b e r i p a i “ s i r v a a s p g r t a d c e C a a d m o a i e F a e d a t t a n n c u t r n m r n m s r n b D G i “ p y a u c e e d s a l r a s d o a l C c i b c e r d i l s e i i . i T e n n s a b n a i r u o u m t u n l “ l T , c s - e g r t r w l i a t t l a s t b D a f o s e A A o d ; i a h s e d c i 4 t c n l p o a s n n s i S e e o r a t o e r su m 4 a s ” a p r o r g T r m e r i c C c H n o t : e c e e t o r p d i t t k 6 m o E d c i d t i . s p i d e h e u o t e n a ; o t e 7 r t u M e i a i a m e v r s i l n r t g o a LP n n 1 c l n r d o t o e e A s s . t n p s e t – a I t g l n w , i V , , ” I n o w 7 r t a 0 a F o A , t g i a h i S o o p d t 1 s i . 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