Tải bản đầy đủ

3 marinos the little icu book 2017


PaulL.Marino,MD,PhD,FCCM
ClinicalAssociateProfessor
WeillCornellMedicalCollege
NewYork,NewYork
Withcontributionsfrom:

SamuelM.GalvagnoJr.,DO,PhD,MS,FCCM
AssociateProfessor
DivisionChief,CriticalCareMedicine
AssociateMedicalDirector,SurgicalIntensiveCareUnit
ShockTraumaCenter
PrograminTraumaandDivisionofCriticalCareMedicine
DepartmentofAnesthesiology
TheUniversityofMarylandSchoolofMedicine
Baltimore,Maryland
Lt.Col,USAFR,MC,SFS
DirectorofCriticalCareAirTransportTeam(CCATT)Operations
943rdAerospaceMedicineSquadron
943rdRescueGroupDavis-MonthanAirForceBase,Arizona


IllustrationsbyPatriciaGast





AcquisitionsEditor:KeithDonnellan
ProductDevelopmentEditor:KateHeaney
ProductionProjectManager:BridgettDougherty
ManufacturingCoordinator:BethWelsh
MarketingManager:DanDressler
DesignCoordinator:TeresaMallon
ProductionService:Aptara,Inc.
Copyright©2017WoltersKluwer
Allrightsreserved.Thisbookisprotectedbycopyright.Nopartofthisbookmaybereproducedortransmittedinanyformorbyanymeans,
includingasphotocopiesorscanned-inorotherelectroniccopies,orutilizedbyanyinformationstorageandretrievalsystemwithoutwritten
permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book
preparedbyindividualsaspartoftheirofficialdutiesasU.S.governmentemployeesarenotcoveredbytheabove-mentionedcopyright.To
request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at
permissions@lww.com,orviaourwebsiteatlww.com(productsandservices).
987654321
PrintedinChina
LibraryofCongressCataloging-in-PublicationData
Names:Marino,PaulL.,author.|Galvagno,SamuelM.,Jr.,author.|Supplementto(work):Marino,PaulL.Marino’stheICUbook.4e.
Title:Marino’sthelittleICUbook/PaulL.Marino;withcontributionsfromSamuelM.Galvagno,Jr.;illustrationsbyPatriciaGast.
Othertitles:LittleICUbookoffactsandformulas|Marino’sthelittleintensivecareunitbook|LittleICUbook
Description:2ndedition.|Philadelphia:WoltersKluwer,[2017]|PrecededbyThelittleICUbookoffactsandformulas/PaulL.Marino;
withcontributionsfromKennethM.Sutin.c2008.|Includesbibliographicalreferencesandindex.
Identifiers:LCCN2016047340|ISBN9781451194586(alk.paper)
Subjects:|MESH:CriticalCare|IntensiveCareUnits|Handbooks
Classification:LCCRC86.7|NLMWX39|DDC616/.028–dc23
LCrecordavailableathttps://lccn.loc.gov/2016047340
Thisworkisprovided“asis,”andthepublisherdisclaimsanyandallwarranties,expressorimplied,includinganywarrantiesastoaccuracy,
comprehensiveness,orcurrencyofthecontentofthiswork.
Thisworkisnosubstituteforindividualpatientassessmentbaseduponhealthcareprofessionals’examinationofeachpatientandconsideration
of,amongotherthings,age,weight,gender,currentorpriormedicalconditions,medicationhistory,laboratorydataandotherfactorsuniqueto
thepatient.Thepublisherdoesnotprovidemedicaladviceorguidanceandthisworkismerelyareferencetool.Healthcareprofessionals,and
notthepublisher,aresolelyresponsiblefortheuseofthisworkincludingallmedicaljudgmentsandforanyresultingdiagnosisandtreatments.
Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses,
indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should
consultavarietyofsources.Whenprescribingmedication,healthcareprofessionalsareadvisedtoconsulttheproductinformationsheet(the
manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and
identifyanychangesindosagescheduleorcontraindications,particularlyifthemedicationtobeadministeredisnew,infrequentlyusedorhasa
narrowtherapeuticrange.Tothemaximumextentpermittedunderapplicablelaw,noresponsibilityisassumedbythepublisherforanyinjury
and/ordamagetopersonsorproperty,asamatterofproductsliability,negligencelaworotherwise,orfromanyreferencetoorusebyany
personofthiswork.


ToDanielJosephMarino,
my29year-oldson,
whoiswellintomanhood,
butdidn’tforget
tobringtheboyalong.


Seeksimplicity,anddistrustit.
ALFREDNORTHWHITEHEAD
TheConceptofNature,1919


Acknowledgements

ThisbookowesitslookandtexturetotheconsiderableskillsofPatriciaGast,whoisresponsibleforall
theillustrations,tables,andpagelayoutsinthebook.Thisisourfourthbooktogether,andIcontinueto
marvelathertalentandworkethic.
Also to Keith Donnellan, my editor at Wolters Kluwer, who has that rare capacity to understand the
exigenciesofanauthorandhiswork.Heisatrueprofessional,anditshows.Andfinally,toKateHeaney,
projectdevelopmenteditor,forherfirmfootinginguidingthegestationofthisbook.


Preface

ThesecondeditionofTheLittleICUBookretainstheintentofthefirstedition;i.e.,tocreateadistilled
version of the parent textbook, The ICU Book, that presents the essentials of critical care practice in a
succinctandeasilyretrievableformat.Theorganizationandchaptertitlesinthe“littlebook”mirrorthose
in the “big book”, but all the chapters have been rewritten and updated, with heavy emphasis on the
recommendations in evidence-based clinical practice guidelines. This edition also bears the fruits of a
collaboration with Sam Galvagno, DO, PhD, who lent his wisdom and encyclopedic knowledge to
severalchaptersinthetext.
TheLittleICUBookmaybeshortinstature,butitisadenselypacked,genericresourceforthecareof
criticallyilladultsinanyICU.


TableofContents

I.

VascularAccess
1CentralVenousAccess
2TheIndwellingVascularCatheter

II.

PreventivePractices
3AlimentaryProphylaxis
4VenousThromboembolism

III.

HemodynamicMonitoring
5ThePulmonaryArteryCatheter
6SystemicOxygenation

IV.

DisordersofCirculatoryFlow
7HemorrhageandHypovolemia
8AcuteHeartFailure(s)
9SystemicInfectionandInflammation

V.

ResuscitationFluids
10ColloidandCrystalloidResuscitation
11AnemiaandErythrocyteTransfusions
12PlateletsandPlasma

VI.

CardiacEmergencies
13Tachyarrhythmias
14AcuteCoronarySyndromes
15CardiacArrest

VII.

PulmonaryDisorders
16Ventilator-AssociatedPneumonia
17AcuteRespiratoryDistressSyndrome
18AsthmaandCOPDintheICU

VIII. MechanicalVentilation
19ConventionalMechanicalVentilation
20AlternativeModesofVentilation
21TheVentilator-DependentPatient
22DiscontinuingMechanicalVentilation

IX.

Acid-BaseDisorders
23Acid-BaseAnalysis


24OrganicAcidoses
25MetabolicAlkalosis

X.

Renal&ElectrolyteDisorders
26AcuteKidneyInjury
27OsmoticDisorders
28Potassium
29Magnesium
30CalciumandPhosphorus

XI.

TheAbdomen&Pelvis
31PancreatitisandLiverFailure
32AbdominalInfections
33UrinaryTractInfections

XII.

TemperatureDisorders
34ThermoregulatoryDisorders
35FeverintheICU

XIII. Nutrition&Metabolism
36NutritionalRequirements
37EnteralTubeFeeding
38ParenteralNutrition
39AdrenalandThyroidDysfunction

XIV. NervousSystemDisorders
40DisordersofConsciousness
41DisordersofMovement
42AcuteStroke

XV.

Pharmacotherapy
43Analgesia&Sedation
44AntimicrobialTherapy
45HemodynamicDrugs

XVI. ToxicologicEmergencies
46PharmaceuticalDrugOverdoses
47NonpharmaceuticalToxidromes

XVII. Appendices
1UnitsandConversions
2MeasuresofBodySize
3NeedlesandCatheters
4Miscellany


Index


Chapter1

CentralVenousAccess
Vascularaccessincriticallyillpatientsofteninvolvestheinsertionoflong,flexiblecathetersintolarge
veins entering the thorax or abdomen. This type of central venous access is the focus of the current
chapter.

I.INFECTIONCONTROL
TheinfectioncontrolmeasuresrecommendedforcentralvenouscannulationareshowninTable1.1(1,2).
Whenusedtogether(asa“bundle”),thesefivemeasureshavebeeneffectiveinreducingtheincidenceof
catheter-related bloodstream infections (3). The following is a brief description of these preventive
measures.

A.SkinAntisepsis
1.

Handwashing is recommended before and after palpating catheter insertion sites, and before and
after glove use (1). Alcohol-based hand rubs are preferred if available (1,4); otherwise,
handwashingwithsoap(plainorantimicrobialsoap)andwaterisacceptable(4).

2.

Theskinaroundthecatheterinsertionsiteshouldbedecontaminatedjustpriortocannulation,and
thepreferredantisepticagentischlorhexidine(1).
a.

Theadvantageofchlorhexidineisitsprolongedantimicrobialactivity,whichlastsforatleast
6hoursafterasingleapplication.

b.

Antimicrobialactivityismaximizedifchlorhexidineitisallowedtoair-dryontheskinforat
leasttwominutes(1).


B.SterileBarriers
All central venous (and arterial) cannulation procedures should be performed using full sterile barrier
precautions,whichincludescaps,masks,sterilegloves,sterilegowns,andasteriledrapefromheadto
foot(1).

C.SiteSelection
Accordingtopublishedguidelines(1)femoralveincannulationshouldbeavoidedtoreducetherisk of
catheter-associatedsepticemia.However,clinicalstudiesindicatethattheincidenceofsepticemiafrom
femoral vein catheters (2–3 infections per 1000 catheter days) is no different than the incidence of
septicemiafromsubclavianorinternaljugularveincatheters(5,6).

II.CATHETERS
A.CatheterSize
1.

Thesizeofvascularcathetersisexpressedintermsoftheiroutsidediameter.Sizecanbeexpressed
inametric-basedFrenchsizeorawire-basedgaugesize.


a.

TheFrenchsizeisaseriesofwholenumbersthatincreasesinincrementsof0.33millimeters
(e.g.,1French=0.33mm,2French=0.66mm).

b.

Thegaugesize(originallydevelopedforsolidwires)hasnodefinablerelationshiptoother
unitsofmeasurement,andrequiresatableofreferencevalues(liketheoneinAppendix3).

B.CentralVenousCatheters
1.

The term central venous catheter (CVC) refers to catheters inserted into the internal jugular,
subclavian,orfemoralveinsandadvancedintooneofthevenacavae.

2.

Modern CVCs have multiple infusion channels, like the popular triple-lumen catheter shown in
Figure 1.1. This catheter has an outside diameter of 2.3 mm (French size 7), and is available in
lengthsof16cm(6in),20cm(8in),and30cm(12in).(Dimensionsmayvarybymanufacturer.)

FIGURE1.1Triple-lumencentralvenouscatheter,showingthegaugesizeofeachlumenandtheposition
oftheoutflowportsatthedistalendofthecatheter.

C.AntimicrobialCoating
1.

CVCs are available with two types of antimicrobial coating: (a) chlorhexidine and silver
sulfadiazine (available from Arrow International), and (b) minocylcine and rifampin (available
from Cook Critical Care). Each of these coatings can reduce the risk of catheter-related
bloodstreaminfections(7).

2.

Accordingtopublishedguidelines(1),antimicrobial-coatedcathetersshouldbeconsideredifthe
expecteddurationofcatheterizationis>5daysandiftheincidenceofcatheter-relatedinfectionsin
anICUisunacceptablyhigh.

D.Peripherally-InsertedCentralCatheters


1.

The term peripherally-inserted central catheter (PICC) refers to long catheters that are inserted
intothebasilicorcephalicveininthearm(justabovetheantecubitalfossa)andadvancedintothe
superiorvenacava.

2.

PICCsareavailablewithmultipleinfusionchannels,likeCVCs,buttheyarenarrowerthanCVCs
(typically5Frenchor1.65mmindiameter),andareconsiderablylongerthanCVCs.PICCSare
availableinlengthsof50cm(19.5in)and70cm(27.5in).

3.

AsaresultofthesmallerdiameterandlongerlengthofPICCs,flowthroughPICCsisconsiderably
slowerthanflowthroughCVCs.(SeeAppendix3forchartsshowingtheflowratesthroughPICCs
andCVCs.)

III.CANNULATIONSITES
Thefollowingisabriefdescriptionofcentralvenouscannulationatfourdifferentaccesssites:i.e.,the
internaljugularvein,thesubclavianvein,thefemoralvein,andtheveinsemergingfromtheantecubital
fossa.

A.InternalJugularVein
1. Anatomy
a.

The internal jugular vein (IJV) is located under the sternocleidomastoid muscle (see Figure
1.2), and runs obliquely down the neck along a line drawn from the pinna of the ear to the
sternoclavicular joint. In the lower neck region, the vein is often located just anterior and
lateraltothecarotidartery,butanatomicrelationshipscanvary(16).

b.

Atthebaseoftheneck,theIJVjoinsthesubclavianveintoformtheinnominatevein,andthe
convergenceoftherightandleftinnominateveinsformsthesuperiorvenacava.

c.

The right side of the neck is preferred for cannulation of the IJV because the vessels run a
straight course to the right atrium. The distance from cannulation site to the right atrium is
about15cm,sotheshortestCVCs(~15cm)shouldbeusedforright-sidedcannulations(to
avoidadvancingthecathetertipintotherightatrium).


FIGURE1.2Thelargeveinsenteringthethorax.

2. Positioning
a.

Ahead-downbodytiltto15°belowhorizontal(Trendelenburgposition)resultsina20–25%
increase in the diameter of the IJV (8). Further increases in the degree of body tilt has no
incrementaleffect(8).

b.

A head-down body tilt of 15° can be used to facilitate IJV cannulation, particularly in
hypovolemic patients, but is not necessary in patients with venous congestion, and is not
advisedinpatientswithincreasedintracranialpressure.

c.

Theheadshouldbeturnedslightlyintheoppositedirectiontostraightenthecourseofthevein,
but turning the head beyond 30° from midline is counterproductive because it stretches the
veinandreducesitsdiameter(16).

3. LocatingtheVein
a.

Ultrasoundimaginghasbeenrecommendedasastandardpracticeforlocatingandcannulating
theIJV(9). Ultrasound guidance is associated with a higher success rate, fewer cannulation
attempts,ashortertimetocannulation,andareducedriskofcarotidarterypuncture(9-11).

b.

To obtain a cross-sectional image of the IJV and carotid artery, place the ultrasound probe
across the triangle created by the two heads of the sternocleidomastoid muscle (see Figure
1.2).ThisproducesimagesliketheonesshowninFigure1.3.Theimageontheleftshowsthe
IJV situated anterior and lateral to the carotid artery. The image on the right shows the IJV
collapsingwhendownwardpressureisappliedtotheoverlyingskin(asimplemaneuverfor
distinguishingbetweenarteriesandveins).


FIGURE1.3Ultrasoundimagesoftheinternaljugularvein(IJV)andcarotidartery(CA)ontheright
sideoftheneck.Theimageontherightshowscollapseoftheveinwhenpressureisappliedtothe
overlyingskin.Thegreendotsmarkthelateralsideofeachimage.(ImagescourtesyofCynthiaSullivan,
RNandShaunNewvine,RN)

4. Complications
a.

Carotid artery puncture is the most feared complication of IJV cannulation. The reported
incidence is 0.5–11% when surface landmarks are used (10-12), and 1% when ultrasound
imagingisemployed(10).

b.

Pneumothorax is not expected at the IJV cannulation site (because it is located in the neck),
however this complication is reported in 1.3% of IJV cannulations when surface landmarks
areusedtoguidecannulation(10).

B.TheSubclavianVein
1. Anatomy
a.

Thesubclavianvein(SCV)isacontinuationoftheaxillaryveinasitpassesoverthefirstrib
(seeFigure1.2).Itrunsmostofitscoursealongtheundersideoftheclavicleandcontinuesto
thethoracicinlet,whereitjoinstheinternaljugularveintoformtheinnominatevein.

b.

The underside of the SCV sits on the anterior scalene muscle along with the phrenic nerve,
whichcomesincontactwiththeveinalongitsposteroinferiorside.Ontheundersideofthe
anteriorscalenemuscleisthesubclavianarteryandbrachialplexus.

c.

The diameter of the SCV (7–12 mm in the supine position) does not vary with respiration
(unlike the IJV), which is attributed to strong fascial attachments that fix the vein to
surroundingstructuresandholditopen(13).Thisisalsothebasisfortheclaimthatvolume
depletiondoesnotcollapsetheSCV(14),whichisunproven.

2. Positioning
a.

Thehead-downbodytiltdistendstheSCVby8–10%(13),andcouldfacilitatecannulation.


b.

Othermaneuversbelievedtofacilitatecannulation,suchasarchingtheshouldersorplacinga
rolled towel under the shoulder, actually cause a decrease in the cross-sectional area of the
SCV(13,15).

3. LocatingtheVessel
a.

The SCV is difficult to visualize with ultrasound imaging because the overlying clavicle
blockstransmissionofultrasoundwaves.Asaresult,theuseofsurfacelandmarkscontinues
tobethestandardmethodofcannulatingtheSCV.

b.

TheSCVcanbelocatedbyidentifyingtheclavicularheadofthesterno-cleidomastoidmuscle
(seeFigure1.2):theveinliesjustunderneaththeclavicleatthispoint,andcanbecannulated
from above or below the clavicle. This portion of the clavicle can be marked with a small
rectangle,asshowninFigure1.2,toguideinsertionoftheprobeneedle.

4. Complications
a.

ComplicationsofSCVcannulation(usingthelandmarkmethodoflocation)includepuncture
of the subclavian artery (≤5%), pneumothorax (≤5%), brachial plexus injury (≤3%), and
phrenicnerveinjury(≤1.5%)(11,14).

b.

Stenosis of the SCV can appear days or months after catheter removal, and has a reported
incidence of 15–50% (16). This complication is the principal reason to avoid SCV
cannulationinpatientswhomightrequirehemodialysisaccess(viaanarteriovenousfistula)in
theipsilateralarm(16).


FIGURE1.4Anatomyofthefemoraltriangle.

C.FemoralVein
1. Anatomy
Thefemoralvein(FV)isacontinuationofthelongsaphenousveininthegroin,whereitislocated
inthefemoraltrianglealongwiththefemoralarteryandnerve,asshowninFigure1.4.Atthelevel
oftheinguinalcrease,theveinliesjustmedialtotheartery,andisonlyafewcentimetersfromthe
skin.TheFViseasiertocannulatewhenthelegisplacedinabduction.

2. LocatingtheVein
TheFViseasiertocannulatewhenthelegisplacedinabduction.
a.

LocatingtheFVbeginsbypalpatingthefemoralarterypulse,whichistypicallylocatedjust
belowandmedialtothemidpointoftheinguinalcrease.

b.

Ifavailable,anultrasoundprobeshouldbeplacedatthepointwherethefemoralarterypulse
is palpable to obtain cross-sectional images of the underlying vessels. The vein is then
identifiedbyitscompressibility,asdemonstratedinFigure1.3.

c.

If ultrasound imaging is not available, first palpate the femoral artery pulse, and insert the
probe needle (with the bevel at 12 o’clock) 1–2 cm medial to the pulse; the FV should be
enteredatadepthof2–4cmfromtheskin.

3. Complications
a.

The principal complications of FV cannulation are femoral artery puncture, FV thrombosis,
andcath-eter-relatedsepticemia.

b.

Catheter-related thrombosis is more common than suspected, but is clinically silent in most
cases.InonestudyofindwellingFVcatheters,thrombosiswasdetectedbyultrasoundin10%
ofpatients,butclinicallyapparentthrombosisoccurredin<1%ofpatients(17).

c.

Asmentionedearlier(SectionI,C),theriskofsepticemiafromFVcannulationisnodifferent
thantheriskatothersitesofcentralvenouscannulation(5,6).

D.Peripherally-InsertedCentralCatheters
1.

Peripherally-inserted central catheters (PICCs) are long catheters (50–70 cm) inserted into the
basilicorcephalicveininthearm(seeFigure1.5)andadvancedintothesuperiorvenacava.The
basilicvein,whichrunsupthemedialaspectofthearm,ispreferredforPICCplacementbecause
ithasalargerdiameterthanthecephalicvein,anditrunsastraightercourseupthearm.


FIGURE1.5Themajorveinsintheregionoftheantecubitalfossaoftherightarm.
2.

ThebenefitsofPICCsoverCVCsincludeenhancedpatientcomfortandmobility,andeliminating
certainrisksassociatedwithCVCplacement(e.g.,pneumothorax).

3.

The most common complication of PICCs is catheter-induced thrombosis of the axillary and
subclavian veins. Occlusive thrombosis with swelling of the upper arm is reported in 2–11% of
patientswithindwellingPICCs(18,19);thehighestincidenceoccursinpatientswithahistoryof
venousthrombosis(18)andincancerpatients(19).

4.

Septicemia from PICCs occurs at a rate of one infection per 1000 catheter days (20), which is
similartotherateofinfectionfromCVCs.

IV.IMMEDIATECONCERNS
A.VenousAirEmbolism
Airentryintothecentralveinsisapotentiallylethalcomplicationofcentralvenouscannulation(21,22).

1. Pathophysiology
a.

When a vascular catheter is advanced into the thorax, the negative intrathoracic pressure
generatedduringspontaneousbreathingcandrawairintothevenouscirculationifthecatheter
hubisopentotheatmosphere.

b.

Boththevolumeandrateofairentrydeterminetheconsequencesofvenousairembolism.The


consequences can be fatal when air entry reaches 200–300 mL (3–5 mL/kg) over a few
seconds(22).
c.

Theadverseconsequencesofvenousairembolismincludeacuterightheartfailure(froman
air lock in the right ventricle), leaky-capillary pulmonary edema, and acute embolic stroke
(fromairbubblesthatpassthroughapatentforamenovale)(22).

2. PreventiveMeasures
Positive-pressureventilationisadeterrenttovenousairembolism,andcaneliminatetheproblem
if the intrathoracic pressure remains positive throughout the respiratory cycle. In spontaneously
breathing patients, head-down body tilt (Trendelenburg position) can reduce the risk of air entry
duringinternaljugularandsubclavianveincannulation.Usingappropriateprecautions,theriskof
symptomaticvenousairembolismis<1%(21).

3. ClinicalPresentation
a.

Venousairembolismcanbeclinicallysilent(21).

b.

In symptomatic cases, the earliest manifestation is sudden onset of dyspnea, which may be
accompaniedbyadistressingcough.

c.

In severe cases, there is rapid progression to hypo-tension, oliguria, and depressed
consciousness(fromcardiogenicshock).Themixingofairandbloodintherightventriclecan
produceadrum-like,millwheelmurmurjustpriortocardiovascularcollapse(22).

4. Diagnosis
a.

Venousairembolismisusuallyaclinicaldiagnosis.

b.

Iftimepermits,transthoracicDopplerultrasoundisasensitivemethodofdetectingairinthe
heart (22). (Doppler ultrasound converts flow velocities into sounds, and air in the cardiac
chambersproducesacharacteristichigh-pitchedsound.)

5. Management
The management of venous air embolism primarily involves cardiorespiratory support. The
followingmaneuversdeservemention,althougheachiswithoutdocumentedbenefit(22).
a.

Ifairentrainmentissuspectedthroughanindwellingcatheter,youcanattachasyringetothe
hubofthecatheterandattempttoaspirateairfromthebloodstream.

b.

Pureoxygenbreathingcanreducethevolumeofairinthepulmonarycirculationpromotingthe
egressofnitrogenfromthepulmonarycapillaries.

c.

Placing the patient in the left lateral decubitus position is a traditional maneuver aimed at
relievinganairlockattheoutflowoftherightventricle.

d.

Chest compressions can help to force air out of the pulmonary outflow tract and into the
pulmonarycirculation.


B.Pneumothorax
1.

Pneumothoraxisprimarilyaconcernwithsubclavianveincatheterization;thereportedincidenceis
≤5%(11,14).

2.

Portable chest x-rays are insensitive for the detection of pleural air, particularly in the supine
position,whereaircollectsanteriortothelung(23).

3.

Ultrasonography is a much more sensitive method of detecting pleural air when compared with
portablechestradiography(24).Ifimmediatelyavailable,bedsideultrasonographyisthemethodof
choiceforthedetectionofpleuralairinICUpatients.

C.CatheterLocation
Becausemalpositionofcathetersoccursin5–25%ofCVCandPICCinsertions(11,20),post-procedural
chestx-raysareobtainedroutinelytoevaluatecatheterlocation.

1. ProperPlacement
AproperlyplacedCVCorPICCshouldbeinthesuperiorvenacava,withthecathetertip1–2cm
abovetherightatrium.Thetrachealcarina(i.e.,thebifurcationofthetracheatoformtherightand
left mainstem bronchi) is located just above the junction between the superior vena cava and the
right atrium, which makes it a useful landmark for evaluating catheter tip location (26). The
appropriatepositionofaCVCisshowninFigure1.6.Notethatthetipofthecatheterisjustabove
thetrachealcarina.

2. CatheterTipinRightAtrium
Acathetertipthatextendsbelowthetrachealcarinaonaportablechestx-rayislikelytobeinthe
rightatrium.Thiscreatesariskofrightatrialperforationandcardiactamponade(27),soretraction
of catheters is generally advised when the tip is located below the carina. However, right atrial
placement of CVCs is a common occurrence, with an incidence of 25% in one study (28), while
right atrial perforation is a rare complication of CVC placement (27), so the need to reposition
cathetersadvancedintotherightatriumisquestionable.


FIGURE1.6Portablechestx-rayshowingtheproperplacementofacentralvenouscatheter,withthetip
justabovethetrachealcarina.(Catheterimagedigitallyenhanced.)

REFERENCES
1.

2.

3.

4.
5.

6.

O’GradyNP,AlexanderM,BurnsLA,etal.andtheHealthcareInfectionControlPracticesAdvisory
Committee (HICPAC). Guidelines for the Prevention of Intravascular Catheter-related Infections.
ClinInfectDis2011;52:e1–e32.
Institute for Healthcare Improvement. Implement the central line bundle. Available at
www.ihi.org/resources/Pages/Changes/ImplementtheCentralLineBundle.aspx (Accessed July 11,
2014).
FuruyaEY,DickA,PerencevichEN,etal.CentrallinebundleimplementationinU.S.intensivecare
units and impact on bloodstream infection. PLoS ONE 2011; 6(1):e15452. (Open access journal
availableatwww.plosone.org(AccessedNovember5,2011).)
Tschudin-Sutter S, Pargger H, and Widmer AF. Hand hygiene in the intensive care unit. Crit Care
Med2010;38(Suppl):S299–S305.
DeshpandeK,HatemC,UlrichH,etal.Theincidenceofinfectiouscomplicationsofcentralvenous
catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population.
CritCareMed2005;33:13–20.
ParientiJ-J,ThirionM,MegarbaneB,etal.Femoralvsjugularvenouscatheterizationandriskof
nosocomial events in adults requiring acute renal replacement therapy. JAMA 2008; 299:2413–
2422.


7.

CaseyAL,MermelLA,NightingaleP,ElliottTSJ.Antimicrobialcentralvenouscathetersinadults:
asystematicreviewandmeta-analysis.LancetInfectDis2008;8:763–776.

8.

ClenaghanS,McLaughlinRE,MartynC,etal.RelationshipbetweenTrendelenburgtiltandinternal
jugularveindiameter.EmergMedJ2005;22:867–868.
9. Feller-KopmanD.Ultrasound-guidedinternaljugularaccess.Chest2007;132:302–309.
10. Hayashi H, Amano M. Does ultrasound imaging before puncture facilitate internal jugular vein
cannulation? Prospective, randomized comparison with landmark-guided puncture in ventilated
patients.JCardiothoracVascAnesth2002;16:572–575.
11. RueschS,WalderB,TramerM.Complicationsofcentralvenouscatheters:internaljugularversus
subclavianaccess–Asystematicreview.CritCareMed2002;30:454–460.
12. Reuber M, Dunkley LA, Turton EP, et al. Stroke after internal jugular venous cannulation. Acta
NeurolScand2002;105:235–239.
13. Fortune JB, Feustel. Effect of patient position on size and location of the subclavian vein for
percutaneouspuncture.ArchSurg2003;138:996–1000.
14. FragouM,GravvanisA,DimitriouV,etal.Real-timeultrasound-guidedsubclavianveincannulation
versusthelandmarkmethodincriticalcarepatients:Aprospectiverandomizedstudy.CritCareMed
2011;39:1607–1612.
15. RodriguezCJ,BolanowskiA,PatelK,etal.Classicpositioningdecreasescross-sectionalareaof
thesubclavianvein.AmJSurg2006;192:135–137.
16. Hernandez D, Diaz F, Rufino M, et al. Subclavian vascular access stenosis in dialysis patients:
Naturalhistoryandriskfactors.JAmSocNephrol1998;9:1507–1510.
17. ParientiJ-J,ThirionM,MegarbaneB,etal.Femoralvsjugularvenouscatheterizationandriskof
nosocomial events in adults requiring acute renal replacement therapy. JAMA 2008; 299:2413–
2422.
18. Evans RS, Sharp JH, Linford LH, et al. Risk of symptomatic DVT associated with peripherally
insertedcentralcatheters.Chest2010;138:803–810.
19. Hughes ME. PICC-related thrombosis: pathophysiology, incidence, morbidity, and the effect of
ultrasoundguidedplacementtechniqueonoccurrenceincancerpatients.JAVA2011;16:8–18.
20. NgP,AultM,EllrodtAG,MaldonadoL.Peripherallyinsertedcentralcathetersingeneralmedicine.
MayoClinProc1997;72:225–233.
21. VeselyTM.Airembolismduringinsertionofcentralvenouscatheters.JVascIntervRadiol2001;
12:1291–1295.
22. MirskiMA,LeleAV,FitzsimmonsL,ToungTJK.Diagnosisandtreatmentofvascularairembolism.
Anesthesiology2007;106:164–177.
23. TocinoIM,MillerMH,FairfaxWR.Distributionofpneumothoraxinthesupineandsemirecumbent
criticallyilladult.AmJRadiol1985;144:901–905.
24. Collin GR, Clarke LE. Delayed pneumothorax: a complication of central venous catheterization.
SurgRounds1994;17:589–594.
25. XirouchakiN,MagkanasE,VaporidiK,etal.Lungultrasoundincriticallyillpatients:comparison
withbedsidechestradiography.IntensiveCareMed2011;37:1488–1493.


26. StonelakePA,BodenhamAR.Thecarinaasaradiologicallandmarkforcentralvenouscathetertip
position.BrJAnesthesia2006;96:335–340.
27. BoothSA,NortonB,MulveyDA.Centralvenouscatheterizationandfatalcardiactamponade.BrJ
Anesth2001;87:298–302.
28. Vezzani A, Brusasco C, Palermo S, et al. Ultrasound localization of central vein catheter and
detectionofpostproceduralpneumothorax:analternativetochestradiography.CritCareMed2010;
38:533–538.


Tài liệu bạn tìm kiếm đã sẵn sàng tải về

Tải bản đầy đủ ngay

×

×