EMT Podcast:

Procedural Protocols

Alice Springs ICU Procedural Protocols 2009

 

1)     Peripheral I.V lines

2)     Arterial lines

3)     Central lines

4)     Epidural Catheters

5)     Pulmonary Artery Catheters

6)     Pleural drainage

7)     Endotrachael Intubation

8)     Cricothyroidotomy

9)     Bronchoscopy

10) Tracheostomy

11) Pericardiocentesis

12) Transvenous pacing wires

13) Oesophageal tamponade tubes

 

 

Thanks to Dr Clive Woolfe from RPA in Sydney who kindly allowed me to copy his work and adapt it to Alice Springs.

Thanks to Ursula Sawyer who has the enormous job of ordering all the equipment and whose knowledge of stocks allowed the protocols to be adjusted for Alice Springs Hospital.

Thanks to Dr Siriam Sampath and Wendy Corkill for their help in editing the protocols.

 

Penny Stewart

 

 

 

 

 

 

 

 


Peripheral IV catheters

1) Indications:

A) First line IV access for resuscitation including blood transfusion
B) Stable ICU/HDU patients where a CVC is no longer necessary

2) Management protocol:

A) Remove all resuscitation lines inserted in unsterile conditions as soon as possible.
B) Generally avoid peripheral IV use in ICU patients and remove if not in use.

C) Local Anaesthesia in awake patients.

D) Aseptic technique:

I) Clinical handwash with Microshield 2® (2% Chlorhexidine) + gloves
II) BD Persist Plus prep 4% Chlorhexidine

E) Dressing: adhesive occlusive (Opsite® IV 3000)
F) Change / remove all peripheral lines after 72 hours.

3) Complications

A) Infection
B) Thrombosis

C) Extravasation in tissues


Arterial Cannulae

1) Indications:

A) Routine measurement of systemic blood pressure in ICU
B) Multiple blood gas and laboratory analysis

C) Measurement of BP during transport of patients in hostile environments (eg during retrieval)

2) Management protocol:

A) Remove and replace lines inserted in unsterile conditions as soon as possible.
B) Femoral arterial lines must be changed as soon as radial or dorsalis pedis arteries are available.
Brachial cannulae should be avoided unless no other alternative.
C) Aseptic technique: clinical handwash with BD Persist Plus 4% Chlorhexidine + gloves.
D) Local anaesthesia in awake patients.

E) Cannulae:

I) Arrow® (Seldinger technique): radial (20G X4.4 cm) or femoral kits.
II) 20G x 1 16 inch BD Insyte.

III) Femoral arterial lines BD Hydrocath 18g X 2cm Single Lumen

 

F) Sites in order of preference: radial, dorsalis pedis, ulnar, femoral, brachial
G) The femoral artery may be the sole option in the acutely shocked patient.
H) Suture in situ and Opsite® IV3000 dressing

I) There is no optimal time for an arterial line to be removed or changed.

J) IA cannulae are changed/removed only in the following settings:

I) Distal ischaemia
II) Mechanical failure (overdamped waveform, inability to aspirate blood)

III) Evidence of unexplained systemic or local infection (cf CVC lines)

IV) Invasive pressure measurement or frequent blood sampling is no longer necessary.

K) Measurement of pressure:

I) Transducers should be `zeroed' to the mid-axillary line.

L) Maintenance of lumen patency:

I) Continuous pressurised (Intraflo®)
II) N/saline flush at 3ml/h.

3) Complications

A) Infection
B) Thrombosis

C) Digital ischaemia

D) Vessel damage / aneurysm


Central Venous Catheters

1) Indications:

A) Standard IV access in ICU patients:

I) Fluid administration (including elective transfusion)
II) TPN, hypertonic solutions (amiodarone, nimodipine, etc.)

III) Vasoactive infusions

B) Monitoring of right atrial pressure (CVP)
C) Venous access for:

I) Pulmonary artery catheterisation (PAC)
II) Continuous renal replacement therapy (CVVHDF), plasmapheresis

III) Jugular bulb oximetry

IV) Transvenous pacing

V) Resuscitation

2) Management protocol (applies to all types of CVC):

A) Types:

I) Standard CVC: Braun Certofix 7Fr 3 lumen (16G, 18Gx2) 20 cm
II) Quad lumen catheters: Edwards Lifesciences 8.5Fr 4 lumen (15G, 18Gx3) 20 cm

a) Use must be approved by the Duty Consultant

III) Vascath (Gamcath Hiflow 2 lumen catheter 12Fr 2 lumen 20cm) are used for CVVHDF and plasmapheresis
IV) Pulmonary artery catheter sheath (Edwards Lifescience 8.5Fr, for 7.5Fr Catheters)

a) (iii & iv) may also be used in resuscitation for major haemorrhage

V) Antimicrobial catheters Edwards Lifesciences 8.5Fr 20 cm, 4 lumens (15G, 18G X 3) Should only be placed in patients when long term use >10 days is required. The use of these catheters requires consultant approval.

B) Sites:

I) Subclavian is the preferred route, then internal jugular.
II) Avoid femoral access unless:

a) Limited IV access (burns, prolonged CVC's),
b) Thoracic approach considered too hazardous (acute severe asthma, bullous lung disease, severe shock, or severe coagulopathy).

Note for Vascaths femoral site is preferred as better flows can be achieved.

III) Change to thoracic approach as soon as possible if feasible.

C) Coagulopathic patients:

I) INR > 2.0 or APTT > 50s - correct with FFP
II) Platelets < 50,000 - transfuse 5 units platelets

III) Failure to increment platelet count after transfusion - avoid subclavian

IV) Uncontrolled coagulopathy - use femoral approach

3) Technique policy

A) Local anaesthesia in awake patients.
B) Strict aseptic technique at insertion:

I) Hand disinfection: surgical scrub with 2% chlorhexidine for >1 minute
II) Sterile barrier: full gown, gloves and sterile drapes.

III) Skin prep with Persist plus.

C) Seldinger technique only.
D) Suture all lines

E) Dressing: non occlusive dressing; Opsite® IV3000

F) Flush all lumens with heparinised saline

G) Check CXR prior to use.

4) Maintenance

A) Change lines when catheter is changed, unless drug such as TPN or propofol requires more frequent changing.
B) Daily inspection of the insertion site and clinical examination for infection irrespective of duration of insertion.
C) Catheters are left in place as long as clinically indicated and changed when:

I) Evidence of systemic infection
II) New, unexplained fever

III) Unexplained rise in WCC

IV) Deterioration in organ function

V) Positive blood culture by venipuncture with likely organisms (S. epidermidis, candida spp.)

VI) Evidence of local infection - inflammation or pus at the insertion site.

D) Guidewire exchanges are indicated only in the following situations:

I) Mechanical problems in a new catheter (leaks or kinks) ie < 5 days old
II) Difficult or limited central access (eg burns).

E) Maintenance of lumen patency

I) Central venous catheters

a) Flush unused lumens with 1ml heparinised saline (1u/ml) 8 hourly

II) Vascath: into each lumen 8 hourly, (see printed sticker)

a) Withdraw 2ml and discard.
b) Flush with 2ml normal saline.

c) Flush 1.5ml solution (5000u heparin/2ml).

5) Complications:

A) At insertion

I) Arterial puncture
II) Pneumothorax, haemothorax, chylothorax

B) Passage of wire/catheter

I) Arrhythmias
II) Perforation of SVC, RA; tamponade

C) Presence of catheter

I) Catheter infection: rates increase under the following conditions:

a) Size of catheter - thicker catheters (pulmonary artery catheters, Vascaths)
b) Site of catheter - femoral > internal jugular > subclavian sites

c) Nature of fluid through catheters - TPN or dextrose solutions

II) Thrombosis
III) Catheter embolism

IV) Knotting of catheters (esp PAC)

V) Pulmonary infarct / arterial rupture (PAC)

Epidural catheters

Portex 16G, 18G Epidural Catheters

1) Indications

A) Post operative pain relief (usually placed in theatre)
B) Analgesia in chest trauma

2) Management protocol:

A) Notify the Acute Pain Service of any epidural placed in ICU/HDU
B) Epidural cocktails should follow the Acute Pain Service protocols

C) Strict aseptic technique at insertion.

D) Daily inspection of insertion site

E) Leave in for a maximum of 5 days and then remove.

F) Remove if

G) not in use for > 24 hours

H) clinical evidence of unexplained sepsis

I) positive blood culture by venipuncture with likely organisms

I) S.epidermidis, candida.

3) Complications

A) Hypotension from sympathetic blockade / relative hypovolaemia
B) Pruritis, nausea & vomiting, or urinary retention from opioid

C) Post-dural puncture headache

D) Infection: epidural abscess



Pulmonary artery catheters

Type: Edwards life Science Swan Ganz CCO catheter 139h75P, 7.5 F Sheath, 110cm catheter.

1) Policy:

A) Insertion of PA catheters must be authorised by the Duty Consultant.
B) Become familiar with the theory of insertion, indications, interpretation and complications of PACs

C) Insertion of PA catheters must never delay resuscitation of shocked patients.

D) Allow sufficient time for nursing staff to set up insertion trays and transducer manifolds.

E) Remove catheters once they are not being routinely used.

2) Indications:

A) Haemodynamic measurement (cardiac output, stroke volume, SVR)
B) Quantification of shock states (cardiogenic, hyperdynamic hypovolaemic)

C) Assessment of response to treatment in the above

D) Measurement of right heart pressures (RAP, PAP):

E) Acute pulmonary hypertension

F) Pulmonary embolism

G) Cardiac tamponade

H) Estimation of preload / left heart filling (PAOP)

I) LVF

J) Response to fluid loading

K) Measurement of intracardiac shunt: (Acute VSD)

L) Derivation of oxygen variables (VO2, DO2): not routinely done in this Unit.

3) Management protocol:

A) Insertion protocol as per CVC

4) Specific features of PACs

A) Insertion protocol

I) Sheath introducer (7.5 Fr) with side port, haemostatic valve and plastic contamination shield.
II) Check competence of balloon and concentric position

III) Ensure all lumens are flushed with saline prior to insertion.

IV) Ensure adequately zeroed system and appropriate scale (0-40mmHg) on monitor prior to insertion.

V) Insert catheter using changing waveforms (RA to RV to PA) on monitor with balloon inflated and locked until catheter displays pulmonary artery occlusion tracing: usually 50cm on catheter in most patients using subclavian and left IJ approach; right IJ 40 cm.

VI) Deflate balloon and ensure adequate PAP trace. Adjust catheter depth until a PAOP trace appears with 1 - 1.5ml air in balloon.

VII) Suture introducer and attach contamination shield to hub of introducer.

VIII) Non-occlusive dressing (Opsite® IV3000)

B) Ensure an adequate PA tracing is on the monitor at all times: "wedged" tracings must be corrected as soon as possible:

I) Flush distal lumen with 2ml N.Saline
II) Withdraw the catheter until a PA trace is visible

III) Measurement of pressures:

C) Reference pressures to the mid axillary line
D) Measure at end-expiration of the respiratory cycle. Do not disconnect ventilated patients to measure pressures.

E) Measurement of PAOP:

I) End expiration

a) Lowest point in ventilated patients, highest point in spontaneously ventilating patients

F) Haemodynamic measurements

I) These are routinely performed by the nursing staff, however Registrars should become familiar with the procedure.

G) Cardiac outputs: as per Baxter CCO monitor guide

I) Injectate: 10 ml 5% dextrose @ room temperature
II) Inject throughout the respiratory cycle

III) 3 measurements and ignore values > 10% from average.

H) Derived variables:

I) CO/CI and SVR are routinely recorded, 8 hly or as indicated.
II) Other variables including PVR(I), SV(I), L(R)VSWI are recorded in the haemodynamics flowsheet.

III) Oxygen variables are not routinely measured due to

a) limited clinical utility: if they are measured oxygen saturation should be directly measured with co-oximetry.

Pleural drainage

Type: Pleura-Seal Thoracocetesis kit 8F 12 cm.

1) Indications:

A) Pneumothorax
B) Tension pneumothorax may require urgent needle thoracostomy

C) Haemothorax

D) Large symptomatic pleural effusion

2) Management protocol:

A) Needle thoracostomy (tension pneumothorax):

I) 16G cannula placed in mid clavicular line, 2nd intercostal space
II) Always place an UWSD following this procedure

B) Pleurocentesis: (pleural effusion)

I) Local anaesthesia and sterile technique
II) Cannula technique:

a) 3 way tap attached to 12 - 14 G IV cannula, syringe and rubber hose (closed system)
b) Remove needle from cannula and aspirate pleural effusion until dry.

III) Seldinger technique

a) Single lumen CVC kit.
b) Insert guidewire through needle into pleural space

c) Insert catheter into pleural space over wire

d) Aspirate intermittently with closed system or attach to fluid administration set and drain by gravity

IV) Record volume removed and send for MC&S, cytology & biochemistry

C) Underwater seal drainage:

I) Local Anaesthesia in awake patients.
II) Strict aseptic technique at insertion: ie full gown/glove/mask & cap; BD persist plus skin preparation

III) Site: mid axillary line, 3 - 4 intercostal space

IV) ICU patients need large drains: 28F catheter or larger

V) Remove trochar from catheter: do not use trochar for insertion of tube.

VI) 2-3 cm incision parallel to ribs

VII) Blunt dissection to and through intercostal space with index finger or Mosquito forceps until release of intrapleural air.

VIII) Insert finger into pleural space to enlarge hole and insert tube directly into pleural space or with forceps.

IX) Connect to underwater seal apparatus

X) Insert 2 purse string sutures: to fasten the tube, and 1 (untied) to close the incision on removal.

XI) Dressing: occlusive dressing

XII) Check CXR.

3) Maintenance

A) Remove or replace drains inserted in unsterile conditions as soon as possible.
B) Leave drain in situ until radiological resolution, no further bubbling, or drainage (<150 ml/24 hours).

C) In ventilated patients, drains should be clamped for 24 hours and removed if none of the above are present.

D) Surgically placed drains (ie intraoperative placement) are the responsibility of the surgeon

4) Streptokinase (STK) Instillation

A) This may be done to improve drainage where blockage has occurred due to the presence of blood
B) 250,000U of STK is reconstitute into 50 ml N.Saline

C) Instill using aseptic technique

D) Clear UWSD tubes should be clamped for 2 hours. Pigtail catheters should be left open.

E) Patients should be positioned side-to-side each half hour for 2 hours.

F) The drain should then be unclamped and drainage volumes notes.

5) Complications: (minimized using the blunt technique)

A) Intrapulmonary placement, pulmonary laceration
B) Pneumothorax

C) Bleeding

D) Infection: empyema.

 

 

 

 

 

Endotracheal intubation

1) Policy:

A) Endotracheal intubation in ICU patients is a high risk but vital procedure:

I) Usually an emergency procedure
II) Usually indicated for acute respiratory failure

III) Patients may have cardiovascular instability and significant co-morbidities

IV) Patients are at risk of vomiting and aspirating.

B) Familiarisation with the intubation trolleys, equipment and drugs is essential.
C) Intubation should ideally not be done as a sole operator procedure. Skilled assistance should always be sought.

D) If you are alone (ie after hours): call for help. Expertise in intubation is always available.

E) The majority of ICU patients mandate rapid sequence induction or awake intubation.

2) Indications

A) Institution of mechanical ventilation
B) To maintain an airway

C) Upper airway obstruction

I) Potential eg early burns
II) Real eg epiglottitis, trauma

D) Patient transportation

I) To protect an airway
II) Patients at risk of aspiration

E) Altered conscious state
F) Loss of glottic reflexes

G) Tracheal toilet

3) Techniques

A) Orotracheal intubation is the standard method of intubation in this unit.
B) Methods:

I) Direct visualisation under rapid sequence induction
II) Fibreoptic bronchoscopic awake intubation

III) Blind nasal, awake intubation

C) Endotracheal Tubes

I) Standard tube: low pressure, high volume PVC oro-nasal tube.
II) Males 8-9 mm: secure at 21-23cm to incisors

III) Females 7-8 mm: secure at 19-21cm to incisors

IV) Do not cut tubes to less than 26 cm long.

V) Double lumen tubes: *rarely indicated in ICU:

a) Unilateral lung isolation for bronchopulmonary fistula, abscess or haemorrhage
b) These tubes should be inserted as a temporary manoeuvre prior to a definitive procedure

c) Differential lung ventilation

d) Intubated patients from theatre may have the following tubes that are not recommended for prolonged intubation. These tubes must be changed if intubation anticipated > 48 hours if safe and feasible.

VI) Plain PVC tubes: change to standard EVAC translaryngeal tube
VII) Armoured tubes: problems:

a) High pressure, low volume cuff
b) Once kinked, remain kinked: beware in patients who bite tubes.

VIII) RAE tubes: problems

a) Difficulty in suction due to bend
b) Fixed length from bend: frequently advance down right main bronchus

c) High pressure, low volume cuff

4) Protocol for endotracheal intubation in ICU

A) Personnel: Intubation is a 4 person procedure; skilled assistance is mandatory:

I) "Top end" intubator who co-ordinates the intubation
II) One person to administer drugs

III) One person to apply cricoid pressure once induction commences:

a) This is recommended as a routine for emergency intubations
b) The intubator should direct the person who is applying cricoid pressure so that pressure is correctly applied and removed if distortion of the larynx or difficulty in intubation occurs as a result of cricoid pressure.

IV) One person to provide in line cervical spine immobilisation (trauma and spinal patients only)

B) Secure adequate IV access
C) Equipment (kept in intubation trolleys, below flight deck in E6 ICU). Ensure the following equipment is available and functional:

I) Adequate light
II) Oropharyngeal airways

III) Working suction with a rigid (Yankauer) sucker

IV) Self inflating hand ventilating assembly and mask

V) 100% oxygen, ie working flowmeter at 15 l/min

VI) 2 working laryngoscopes

VII) Magill forceps

VIII) Malleable introducer and gum elastic bougie

IX) 2 Endotracheal tubes

a) Normal size + 1 size smaller

X) Check cuff competence
XI) Cricothyroidotomy equipment:

a) # 15 scalpel
b) 6.0mm cuffed endotracheal tube

XII) Access to intubating bronchoscope if indicated.
XIII) Monitoring (on all patients) :

a) Pulse oximetry
b) Capnography

c) Arterial blood pressure (place an arterial line before intubation in most patients)

d) Electrocardiograph

D) Drugs

I) Induction agent (propofol, thiopentone, fentanyl, ketamine, midazolam)
II) Suxamethonium (1-2 mg/kg) is the muscle relaxant of choice.

a) Contraindicated in:

i) Burns > 3 days
ii) Chronic spinal injuries (ie spastic plegia)

iii) Chronic neuromuscular disease (eg Guillain Barre, motor neurone disease)

iv) Hyperkalaemic states. (K + > 5.5)

III) Atropine (0.6 - 1.2 mg)
IV) Adrenaline (10 ml 1:10000 solution)

E) Procedure: Rapid sequence induction and orotracheal intubation

I) Pre oxygenate with 100% oxygen for 3-4 minutes.
II) Preload with 250-500ml colloid intravenously

III) Induction agent + suxamethonium

IV) Cricoid pressure applied

V) Direct visualisation of vocal cords and intubation

VI) Inflation of cuff until sealed

VII) Confirmation of end-tidal CO2 and chest auscultation with manual ventilation

VIII) Cricoid pressure released

IX) Secure tube at correct length

X) Connect patient to ventilator

XI) Ensure adequate sedation ± muscle relaxant

XII) Consider insertion of a naso/oro-gastric tube. Required by the majority of ICU patients and insertion will avoid repeating the CXR.

XIII) Chest X-ray

XIV) Confirm blood gas analysis and adjust FiO2 accordingly.

F) Sedation post intubation:

I) None if comatose or haemodynamically unstable
II) Morphine, midazolam, propofol, fentanyl, diazepam

G) Maintenance of endotracheal tubes

I) Tapes

a) Secure tubes with white tape after insertion.
b) Ensure that loop of tape is snug around back of neck but not too tight to occlude venous drainage. Should allow 2 fingers under tape.

H) Cuff checks

I) Volumetric (sufficient air to obtain a seal + 1 ml) tests are done following insertion and whenever a leak is detected with a manual hyperinflation once per nursing shift.
II) Seal is assessed by auscultation over trachea during normal ventilation.

III) Manometric tests are inaccurate and do not correlate with mucosal pressure. These are an adjunct only if cuff malfunction is suspected.

I) Persistent cuff leaks

I) Tubes requiring more than 5ml of air to obtain a seal or if there is a persistent cuff leak must be examined by direct laryngoscopy as soon as possible even if the tube appears to be taped at the correct distance at the teeth.
II) Ensure that:

a) The cuff has not herniated above the cords
b) Tube has not ballooned inside the oral cavity and "pulled' the cuff above the cords.

III) High risk patients for cuff leaks:

a) Inappropriately cut tubes: do not cut tubes < 26 cm
b) Facial swelling (burns, facial trauma)

c) Patients requiring high airway pressures during ventilation

5) Endotracheal tube change protocol

A) Ensure adequate skilled assistance, equipment, drugs and monitoring as for de novo intubation.
B) Procedure

I) Set the FiO2 = 1.0 and change SV modes to SIMV.
II) Ensure sufficient anaesthesia and muscle relaxation (fentanyl / propofol + neuromuscular blockade)

C) Perform laryngoscopy and carefully identify patency of upper airway after suction, anatomy of larynx, degree of laryngeal exposure and swelling.

I) Clear view of larynx and no or minimal laryngeal swelling:

a) Application of cricoid pressure by assistant and careful, graded extubation under direct laryngoscopic vision.
b) Maintain laryngoscopy and replace tube under direct vision.

II) Impaired visualisation of larynx:

a) Use gum elastic or ventilating bougie
b) Place bougie through tube under direct vision and insert to a length that would be just distal to the end of the ETT (approximately 30cm from end of tube)

c) Have an assistant control the bougie so that it does not move during movement of the endotracheal tube

III) Application of cricoid pressure by assistant and careful, graded extubation
IV) Maintain laryngoscopy and ensure bougie is through the cords on extubation

V) Replace tube over bougie and guide through larynx under available vision.

VI) Inflate cuff, check end tidal capnography, auscultation, expired tidal volume and then release cricoid pressure.

VII) Secure tube with tape.

6) Extubation protocol

A) Ensure equipment, monitoring and adequate assistance as for intubation
B) Preferentially done during daylight hours and is a medical responsibility

C) Extubation criteria:

I) Return of adequate conscious state to maintain adequate protective laryngeal reflexes and secretion clearance.
II) Adequate pulmonary reserve

III) Resp rate: < 30 bpm

IV) FVC: > 15 ml/kg

V) PaO2/FiO2:> 2 00

VI) In patients with upper airway surgery or swelling the demonstration of an adequate air leak around the deflated endotracheal tube cuff.

VII) All patients should receive supplemental oxygen post extubation.

 

 

 

 

 

Cricothyroidotomy

Types: Cook Melker Cricothyroidotomy 6.0 Catheter Kit

1) Policy

A) Cricothyroidotomy is the recommended procedure for urgent surgical airway access.
B) Call for help & skilled assistance then proceed without delay.

2) Indications:

A) Refer to the failed intubation drill.
B) Inability to maintain an airway despite basic manoeuvres

I) Jaw thrust
II) Chin lift

III) Oral / nasal airways

IV) Inability to hand ventilate.

3) Equipment

A) Size 15 scalpel + handle
B) Size 6.0 cuffed endotracheal tube

C) Oxygen delivery circuit: Laerdal bag

4) Procedure

A) Palpate cricothyroid membrane
B) 2cm horizontal incision through skin and membrane

C) Insert blade handle into wound and turn vertically to enlarge wound

D) Insert endotracheal tube directly into trachea

E) Connect oxygen circuit

F) Confirm correct placement with end-tidal CO2, auscultation and check CXR

G) Perform catheter suction as soon as possible after adequate oxygenation

H) Cricothyroidotomy is a temporary airway: arrange a definitive surgical airway (ENT surgeons) as soon as possible.

 

 

 

 

 

 

 

Fibreoptic bronchoscopy

1) Policy:

A) This is only to be used by skilled personnel and authorised by the duty consultant.
B) Expertise with bronchoscopy takes time: registrars are recommended to approach the Department of Thoracic Medicine to attend bronchoscopy clinics to become familiar with the anatomy of the tracheobronchial tree and use of the flexible fibrescope.

2) Indications:

A) Difficult intubation (trained staff only): not used as aid to failed intubation
B) Persistent lobar collapse that is refractory to physiotherapy

C) Foreign bodies

D) Diagnostic bronchoalveolar lavage (BAL)

3) Protocol for fibreoptic intubation

to be advised

4) Protocol for BAL

A) Diagnosis of nosocomial pneumonia in selected patients
B) Determination of colonisation vs infection in chronically ventilated patients.

C) These patients should ideally be off antibiotics for 24-48 hours.

D) Sufficient reserve to tolerate procedure:

I) Ideally PaO2 > 70 and FiO2 < 0.7
II) BAL will commonly result in a 10% reduction in PaO2 for up to 24 hours after procedure

E) Procedure

I) Ensure sufficient sedation
II) Place patient on 100% oxygen

III) Select lobe to be lavaged from morning CXR

IV) Local anaesthetic gel is contra-indicated (interferes with culture media)

V) If possible, do not suction through scope prior to lavage (upper airway bacterial contamination)

VI) Pass scope directly into the selected lobe

VII) Wedge scope as far as possible - ideally to 3 rd generation bronchi

VIII) Lavage with 4-6 x 20-40 ml aliquot's of sterile normal saline

IX) Aspirate between aliquot's and label aliquot's accordingly

X) Send aspirates for quantitative culture and atypical pneumonia screen as directed.

Post procedure clean bronchoscope flush suction port with saline and send for sterilization.

 

 

 


Tracheostomy

1) Policy:

A) Percutaneous tracheostomy is the preferred method for tracheostomy in suitable critically ill patients.
B) This procedure is only to be performed by experienced consultant staff or advanced vocational trainees under supervision.

C) Patients must have the option of surgical tracheostomy cleared by the admitting team (either medical or surgical). This is a basic courtesy.

D) The decision to do a percutaneous tracheostomy is at the discretion of the Duty ICU consultant.

E) Percutaneous tracheostomy is an elective procedure and has no place in urgent airway access.

2) Indications :

A) The indications for PCT are the same as surgical tracheostomy:

I) Airway maintenance
II) Prolonged intubation (> 7-10 days)

III) Prolonged upper airway obstruction (eg craniofacial #)

IV) Laryngeal pathology

V) Subglottic stenosis

VI) Airway protection

VII) Delayed return of glottic reflexes

VIII) Tracheal toilet

3) Contraindications to PCT

A) Coagulopathy

I) Platelets: < 100,000
II) APTT: > 40

III) INR: > 2.0

B) Previous neck surgery
C) Difficult anatomy: ie short fat neck

4) Procedure:

A) Equipment, monitoring and drugs as per endotracheal intubation available
B) Coagulation screen prior to procedure.

C) General Anaesthesia: the person controlling the airway must be appropriately trained.

D) Ventilate the patient on 100% oxygen.

E) The of fibreoptic bronchoscope should be available and ready to use for all cases. It may be used to confirm the correct positioning of the tracheal puncture and correct passage of the wire. It is an invaluable teaching tool.

F) Tracheostomy equipment:

I) A modified Cook Ciaglia kit using either a progessive dilator technique or "blue rhino" dilatational technique.
II) Tracheostomy tubes

a) Portex
b) Portex "Blue line"

c) Shiley, fenestrated or non fenestrated (`Blue Rhino" kit only)

d) Other tubes:

i) Foam cuffed tubes: indicated in patients with tracheomalacia or persistent air leaks
ii) Uncuffed tube (usually size 6.0) as part of weaning of tracheostomised patients to facilitate secretion clearance

iii) Fenestrated tube: these are either cuffed or uncuffed tube with a fenestration that allow patients to talk.

iv) Adjustable flange tubes: useful for patients with marked neck or soft tissue swelling.

v) Shiley long-term tubes: these tubes have a removable inner tube for tube changes.

5) Insertion technique:

A) Strict aseptic technique (goggles essential for operator and anaesthetist)
B) Local anaesthetic infiltration (1% lignocaine + 1:200000 adrenaline) over pretracheal rings.

C) Check trachy cuff, lubricate and insert dilator into trachy tube

D) 2cm horizontal or vertical incision over 1 st or 2 nd tracheal ring

E) Pretracheal tissue dissection to fascia

I) It may not be necessary to do this until after step F.
II) Look for anterior jugular vein and ligate if identified.

F) Insert a 14G cannula with saline into trachea and aspirate through saline/water to confirm intratracheal placement.
G) Reconfirm intratracheal placement by aspirating cannula after removal of stylet.

H) Insert guide-wire through cannula

I) Insert small dilator over wire into trachea and make hole large enough to accommodate the dilating instrument:

I) Tracheal dilation is achieved using progressively bigger dilators up to the required tracheostomy size.
II) "Blue Rhino": Place dilator and guide cannula over wire. Slowly insert to required ETT size, ensuring the marker (black line) on the guide cannula remains at the distal end of the dilating tube.

J) Remove the dilator and insert tracheostomy tube over wire into trachea
K) Remove dilator and wire, inflate cuff and suction trachea

L) Attach to ventilator and confirm end tidal CO2

M) Secure tracheostomy tube with tapes.

N) CXR post procedure.

O) Document procedure in case notes, consent form and complete separate operation note

6) Complications

A) False passage
B) Cricoid cartilage fracture

C) Tracheal laceration

D) Oesophageal laceration

E) Pneumothorax

F) Bleeding

 


Pericardiocentesis

Types Cook pericardiocentesis set 8.3F 40cm pig tail catheter.

1) Policy

A) This procedure must be authorised by the duty ICU consultant and performed by consultant staff, trainees under supervision, or cardiology.
B) Confirmation of pericardial effusion or tamponade must be made with echocardiography prior to procedure. Liaison with cardiology is essential.

2) Indications

A) Symptomatic pericardial effusion (tamponade).
B) Although advocated in EMST, this procedure has limited utility in traumatic pericardial tamponade.

3) Procedure

A) Strict aseptic technique.
B) Local anaesthetic infiltration if awake patient.

C) This procedure is greatly facilitated using echocardiography guidance

D) Technique: Seldinger technique and insertion of a pigtail catheter

I) Small incision under xiphisternum
II) Insert needle on syringe at 45 o from the horizontal axis and aim for tip of left shoulder

III) Advance slowly and aspirate until confirmation by aspirating blood or serous fluid

IV) Insert catheter using Seldinger technique over guidewire.

V) Confirm placement by aspiration and/or echocardiography

E) Check CXR (pneumothorax)
F) Suture and occlusive dressing if leaving for > 24 hours.

4) Complications

A) Arrhythmias
B) Cardiac tamponade!

C) Myocardial laceration

D) Pneumothorax, pneumopericardium

E) Liver laceration


Transvenous pacing

Types Arrow Bipolar Electrode Catheter 5 Fr 110cm

1) Policy:

A) The decision to insert a pacing wire is by the duty ICU consultant.
B) If inserted by ICU staff, the procedure is only to be performed by consultant staff or advanced vocational trainees under supervision.

C) Become familiar with the theory of insertion, indications, interpretation and complications of TVP.

2) Indications :

A) Medical pacing with adrenaline or transthoracic pacing is usually adequate to treat the majority of symptomatic bradycardias.
B) Symptomatic bradycardias:

I) Complete heart block
II) Bifascicular block in association with evolving (especially anterior) myocardial infarction

III) Severe beta blocker poisoning

IV) "Trifascicular" block in high-risk patients.

C) Following cardiac surgery in high-risk patients:

I) Valve replacement / repair: especially mitral
II) VSD repair / papillary muscle rupture

III) Acute myocardial infarction

D) Persistent A-V block may benefit from sequential pacing: this is done by cardiology
E) Tacharrhythmias

I) Ventricular tachycardias (especially polyphasic) may respond to overdrive suppression pacing.

3) Types

A) Bipolar pacing lead (VVI): insert under image intensification (standard TVP at RPAH)
B) Balloon flotation leads: may be inserted under ECG guidance

C) Paceport PA catheters: these have little utility.

D) Epicardial leads: placed during cardiac surgery in high risk patients these are usually unipolar ventricular, but may be bipolar, atrial or ventricular: check operative note and liaise with the surgeon.

4) Procedure protocol: (VVI lead)

I) This is preformed by cardiology in the cardiac catheterisation laboratory.

5) Floatation Catheter Insertion

A) Catheters

I) Cook bipolar pacing kit, 6Fr ballon tipped.
II) Arrow bipolar ballon electrode catheter.

B) These may be inserted either "blind", under ECG guidance (standard recommendation), or via pressure guidance for catheters having an infusion lumen (cf. PA catheter insertion).
C) Aseptic technique & local anaesthesia where appropriate

D) Insertion protocol:

I) 6F X 15.5 cm introducer (Cook), do not use a PAC introducer (8Fr) as these will leak
II) Attach V5 lead of an ECG to the distal electrode of catheter & monitor

III) Note P then QRS wave-form changes as the catheter advances to the RV

IV) Advance catheter another 2cm, deflate the balloon & advance 1cm

V) Connect to the pulse generator (switched off)

VI) Set output and sense to their minimum value, and rate 20 bpm faster than the patient's own rate.

VII) Turn the generator on and gradually increase output while watching the ECG for capture.

VIII) If there is no capture or a high output is required

a) Place on demand mode
b) Turn output right down

c) Advance or reposition the wire slightly

d) Try to capture again

e) An ideal capture setting is ~2 mA

IX) Suture wire and apply an occlusive dressing
X) Post insertion CXR.


Oesophageal tamponade tubes

1) Policy:

A) All patients with tamponade tubes should be intubated prior to insertion and managed in Intensive Care.
B) As a result, ICU staff may be requested to insert oesophageal tamponade tubes for acute upper GI bleeding.

C) The decision to insert a tube is made in conjunction with the gastroenterologist. There are a number of tamponade tubes available: ensure that the operation, balloon inflations are discussed with the gastroenterologist.

D) Become familiar with the theory of insertion, indications, and complications of these tubes.

2) Indications :

A) Variceal haemorrhage
B) Where endoscopy cannot be done due to bleeding

C) Failure of sclerotherapy, banding and/or octreotide.

3) Types of tubes:

A) Minnesota: oesophageal and gastric balloons and aspirating catheters
B) Sengstaken: oesophageal and gastric balloons and gastric catheter
16F, 20 F.
C) Linton: gastric balloon and catheter

4) Procedure:

A) Check both balloons for leaks before insertion.
B) Inflate the gastric balloon with 300ml of air and check pressure reading.

C) Deflate all balloons completely and lubricate the tube

D) Insert well in under direct vision using a laryngoscope then x-ray to ensure the tube is not folded up in the oesophagus (inflating the gastric balloon in the oesophagus is virtually 100% fatal!)

E) Inflate the gastric balloon with 300 ml of air, then pull back until resistance is felt as the balloon rests against the gastric fundus.

F) Check the pressure in the gastric balloon: this should not exceed the pre-insertion pressure by > 5mmHg if the gastric balloon is correctly placed in the stomach: higher pressures suggest incorrect (ie oesophageal) placement. If high pressures are evident, deflate the balloon, reinsert and check on x-ray.

G) Note the measurement at the lips, and fix securely with gentle traction:

I) Rope and pulley system with 500 ml bag of fluid, or
II) Adhesive tape to face.

H) Connect a pressure gauge to the oesophageal balloon, and inflate to a pressure of 40 mmHg. (inflation of the oesophageal balloon may not be required)
I) Recheck position on x-ray.

J) After 12-24 hours, the balloons should be let down and if bleeding does not recur the tube may be removed (liaise with the gastroenterologist).

K) Sclerotherapy is usually performed: (50% patients will re-bleed otherwise.)

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