Figure Four core ICU procedures — the ultrasound-guided central line (the standard of care, the complications down 70%), the arterial line for the beat-to-beat pressure, the chest drain for the pneumo- and the haemothorax, the bronchoscopy for the secretion and the lavage. The sterility, the sonography, and the Seldinger discipline. CVC : ultrasound-guided (standard — Karakitsos), Seldinger technique, maximal sterile barrier, sites IJV/SCV/femoral (IJV preferred — lowest infection; SCV — pneumothorax; femoral — infection/thrombosis), check CXR post. Arterial line : radial (Allen's test — controversial), continuous BP + ABG, complications ischaemia/infection. Chest drain : 5th ICS anterior axillary (safe triangle), 28-36 Fr haemothorax, underwater seal, check CXR. Bronchoscopy : flexible — diagnostic (biopsy, lavage) + therapeutic (mucus plug, foreign body) — monitor SpO2, suction ready, sedation/analgesia. ALL: document, consent (if time), check post-procedure (CXR), monitor complications.
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SAQ — CVC insertion complicated by arterial puncture and pneumothorax 10 minutes · 10 marks
Reveal all A 68-year-old man with severe septic shock from a urinary source is admitted to ICU. During ultrasound-guided right internal jugular vein (IJV) cannulation for vasopressor access, bright red blood pulses back through the introducer needle. After withdrawal and compression, the guidewire is eventually passed and a triple-lumen catheter inserted. Twelve hours later he develops increasing respiratory distress with SpO2 90% on FiO2 0.6, reduced air entry and hyper-resonance over the right hemithorax, and a rising vasopressor requirement.
a Discuss the immediate and subsequent management of the inadvertent arterial puncture/cannulation that occurred during this CVC attempt, and the evidence-based measures that reduce mechanical complications of central venous cannulation.
b Outline the diagnosis and subsequent management of this patient's clinical deterioration twelve hours after the procedure, including the implications for ongoing positive-pressure ventilation.
c Briefly compare the three principal CVC insertion sites (IJV, subclavian, femoral) in terms of their key complications and preferred indications in critically ill patients.
SAQ — Chest drain insertion in ventilated trauma patient with haemothorax 10 minutes · 10 marks
Reveal all A 24-year-old man is admitted to ICU after a high-speed motor vehicle crash. He is intubated and ventilated for a severe traumatic brain injury. His admission chest X-ray shows a large right-sided haemothorax with mediastinal shift. His blood pressure is 95/60 mmHg, heart rate 120 bpm, and two large-bore IV cannulae are in situ with balanced resuscitation in progress. You are asked to insert a chest drain.
a Describe in detail the technique of intercostal catheter (chest drain) insertion for this patient, including patient preparation, anatomical landmarks, and the steps you would take to minimise complications.
b Outline the immediate post-insertion monitoring of the underwater seal and the criteria and technique for chest drain removal in this patient.
c List the important early and late complications of chest drain insertion and outline one specific feared complication, its presentation, and management.
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Clinical pearls
Figure Exam overview — key physiology, red flags and first-hour management. Figure Core mechanisms examiners expect in CICM/FFICM/EDIC answers. Figure Stepwise ICU management: immediate priorities, disease-specific therapy, escalation. High-yield ICU procedure points for CICM/FFICM exam
Ultrasound guidance for CVC — standard of care. (1) KARAKITSOS (2006, Critical Care): landmark vs real-time ultrasound-guided IJV cannulation (prospective RCT). RESULT: ultrasound reduced: (a) MECHANICAL COMPLICATIONS 70% (pneumothorax, arterial puncture, haematoma — 4.6% vs 17.3%). (b) FAILED ATTEMPTS (90% reduction — 4.6% vs 35.2%). (c) FIRST-PASS SUCCESS (higher — 78% vs 43%). (d) TIME to cannulation (shorter — mean 3.3 vs 14.8 min). (2) WHY: (a) Visualise VEIN (compressible, non-pulsatile) vs ARTERY (non-compressible, pulsatile) — avoid arterial puncture. (b) Visualise NEEDLE entering vein (real-time — confirm position). (c) Identify ANATOMY (variant — small vein, thrombosed, overlap with artery — carotid overlap common). (3) GUIDELINES: NICE (UK, 2002 — mandated), AAGBI, Society of Cardiovascular Anesthesiologists, Agency for Healthcare Research and Quality — ALL recommend/require ultrasound for CVC. (4) TECHNIQUES: (a) IN-PLANE (longitudinal — see whole needle — best visualisation but harder). (b) OUT-OF-PLANE (transverse — see needle tip — easier but may lose tip — keep tip in view). (c) Most use COMBINATION (out-of-plane to identify + in-plane to advance). (5) PRACTICE: ultrasound for ALL CVC insertions (no exceptions — unless true emergency where ultrasound unavailable). (6) APPLY to arterial lines too (improves first-pass success, fewer attempts, lower haematoma).[1] }Maximal sterile barrier — the infection prevention foundation. (1) COMPONENTS: cap, mask (full face shield), sterile gown, sterile gloves, full body sterile drape. (2) EVIDENCE: Raad (1994) — maximal barrier reduced CRBSI 6-fold (from 0.4 to 0.06 per 100 catheter days). (3) WHY: CVC is a foreign body -> entry point for bacteria (skin flora — Staphylococcus). (4) COMPONENTS: (a) CHLORHEXIDINE 2% in 70% alcohol (skin antisepsis — better than povidone-iodine — let dry). (b) CHLORHEXIDINE-IMPREGNATED DRESSING (Biopatch — at insertion site — reduces CRBSI). (c) CHLORHEXIDINE SPONGE (Curos cap — on hub — reduces hub colonisation). (5) DAILY REVIEW: 'Is this line still needed?' — each day increases infection risk — remove as soon as possible. (6) CDC guidelines (2011): maximal barrier + chlorhexidine + daily review + remove when not needed = CRBSI prevention bundle.[4] }3SITES trial — IJV vs SCV vs femoral infection/thrombosis. (1) 3SITES (2015, NEJM): RCT — IJV vs SCV vs femoral CVC in ICU. (2) RESULT: (a) INFECTION: IJV lowest, femoral highest (BUT: not statistically significant — all low with good technique). (b) THROMBOSIS: femoral highest (especially obese — DVT). (c) MECHANICAL: SCV most pneumothorax; femoral no pneumothorax. (3) CONCLUSION: (a) IJV: preferred (lowest infection + thrombosis + ultrasound-friendly). (b) SCV: lowest infection BUT pneumothorax risk (use if IJV contraindicated + coagulopathy excluded). (c) FEMORAL: highest infection + thrombosis (use for EMERGENCY/CPR/coagulopathy — compressible, fast). (4) PRACTICE: IJV first-line; femoral for emergency; SCV for specific (long-term, trauma — if coagulopathy excluded).[3] }Arterial line — radial preferred, Allen's test controversial. (1) INDICATION: continuous BP monitoring (be-to-beat — for shock, vasopressors, frequent ABGs), frequent arterial blood gas sampling. (2) SITES: (a) RADIAL (preferred — superficial, compressible, collateral circulation — ulnar). (b) FEMORAL (central — for severe shock, peripheral vasoconstriction, or if radial failed). (c) BRACHIAL (less preferred — end artery — no collateral — ischaemia risk). (d) DORSALIS PEDIS (foot — alternative). (3) ALLEN'S TEST (controversial): (a) Compress radial + ulnar -> hand pale -> release ulnar -> colour return <5s = adequate collateral (ulnar) -> safe to cannulate radial. (b) EVIDENCE: poor sensitivity/specificity — doesn't predict ischaemia reliably — many centres skip (use ultrasound + clinical). (4) TECHNIQUE: (a) Ultrasound-guided (increasingly standard). (b) Seldinger (catheter-over-wire — most common) or direct (catheter-over-needle). (c) SECURE + dressing. (5) COMPLICATIONS: (a) ISCHAEMIA (thrombosis, spasm — monitor distal perfusion — colour, capillary refill, pulse). (b) INFECTION (less than CVC but possible). (c) BLEEDING (especially coagulopathy — compressible at radial). (d) HAEMATOMA. (6) REMOVAL: when no longer needed (monitoring not required, vasopressors weaned).[4] }Chest drain — 5th ICS anterior axillary (safe triangle). (1) INDICATIONS: (a) PNEUMOTHORAX (tension — emergency; large spontaneous; traumatic; iatrogenic). (b) HAEMOTHORAX (traumatic, post-procedural). (c) PLEURAL EFFUSION (large, symptomatic). (d) EMPYEMA (infected pleural fluid). (e) CHYLOTHORAX. (2) SITE: (a) 5th INTERCOSTAL SPACE (ICS), ANTERIOR AXILLARY LINE — the 'SAFE TRIANGLE' (BATLS/ATLS): (i) Borders: anterior border — latissimus dorsi (posterior); posterior border — pectoralis major (anterior); inferior border — 5th ICS (nipple line in male, inframammary fold in female); superior border — axilla. (ii) WHY: avoids long thoracic nerve, internal mammary artery, diaphragm, breast. (b) INCISION: along UPPER border of rib (LOWER rib = neurovascular bundle — costal groove — avoid). (3) SIZE: (a) SMALL (8-14 Fr — pigtail): for air (simple pneumothorax), transudative effusion. (b) MEDIUM (20-24 Fr): for moderately complex effusion. (c) LARGE (28-36 Fr): for HAEMOTHORAX, empyema, large pneumothorax. (4) TECHNIQUE: (a) Local anaesthetic (if conscious — infiltrate skin, periosteum, pleura). (b) Incision (3-4 cm parallel to rib). (c) Blunt dissection (over UPPER rib) through intercostals -> pleura -> finger sweep (confirm entry, sweep adhesions, exclude diaphragm). (d) Insert tube (directed POSTEROAPICAL for air; POSTERIOBASAL for fluid). (e) Connect to UNDERWATER SEAL drain (bubbling = air leak; swinging = respiratory variation; blood/fluid level). (f) SUTURE secure + dressing. (g) CXR (position, re-expansion). (5) COMPLICATIONS: (a) PAIN (common — analgesia). (b) INFECTION (cellulitis, empyema). (c) SUBCUTANEOUS EMPHYSEMA (air tracking — usually benign). (d) RE-EXPANSION PULMONARY OEDEMA (if rapid re-expansion of large collapse — rare but serious — supportive). (e) BLEEDING (intercostal artery — if lower border used). (f) ORGAN INJURY (diaphragm, liver, spleen, lung — if incorrect site/technique). (g) BLOCKAGE (clot — flush or replace).[5] }Bronchoscopy — diagnostic and therapeutic. (1) INDICATIONS: (a) DIAGNOSTIC: atelectasis (collapse — mucus plug?), haemoptysis (source?), mass/lesion (biopsy), infiltrates (BAL — for infection — especially immunocompromised — PJP, fungal), airway assessment (post-extubation stridor, burn inhalation, foreign body). (b) THERAPEUTIC: mucus plug removal (atelectasis — re-expand), foreign body removal, haemostasis (epinephrine, balloon tamponade for bleeding), stent placement, lavage (wash out — for toxic inhalation). (2) IN INTUBATED: via ETT (pass bronchoscope through ETT — need ETT ≥8 mm for standard adult bronchoscope; smaller for paediatric). (3) IN NON-INTUBATED: sedation (midazolam/fentanyl — or propofol) + topical anaesthesia (lidocaine to vocal cords + airway) — monitor SpO2, have airway equipment ready (potential laryngospasm — especially in non-intubated). (4) TECHNIQUE: (a) Flexible bronchoscope (video — camera at tip). (b) Pass through nose (non-intubated) or ETT (intubated). (c) INSPECT: vocal cords, trachea, carina, main bronchi, segmental bronchi (systematic — right then left). (d) INTERVENE: BAL (bronchoalveolar lavage — wedge in segment -> instil saline -> suction -> collect for analysis), biopsy (forceps — for lesion; transbronchial — for parenchyma), brush (cytology), foreign body removal (forceps/basket). (5) COMPLICATIONS: (a) HYPOXAEMIA (bronchoscope partially occludes airway — increase FiO2 before/during — monitor SpO2 continuously). (b) BLEEDING (biopsy — especially if coagulopathy/thrombocytopenia — have epinephrine ready). (c) PNEUMOTHORAX (transbronchial biopsy — check CXR post). (d) LARYNGOSPASM (non-intubated — especially in smokers/asthma). (e) ARRHYTHMIA (vagal — bradycardia). (f) INFECTION (rare — sterile technique). (6) MONITORING: SpO2, ECG, BP continuously. (7) POST: CXR (if transbronchial biopsy — pneumothorax), monitor SpO2.[6] }CVC tip position — cavoatrial junction. (1) IDEAL: tip at CAVOATRIAL JUNCTION (junction of SVC and right atrium — approximately at the carina on CXR). (2) WHY: (a) If TOO DEEP (in RA/RV): arrhythmia (irritation), cardiac perforation (rare — fatal tamponade), tricuspid valve damage. (b) If TOO SHALLOW (in SVC proximal): venous thrombosis (catheter against vessel wall), unreliable CVP measurement, poor flow. (3) VERIFY on CXR (post-insertion): (a) Tip should be at carina level (or just below — in SVC/RA junction). (b) If too deep (past carina, into RA) -> withdraw (pull back — re-suture). (c) If too shallow (above carina) -> may need repositioning (advance — but ensure sterile). (4) ECG-guided (some kits): wire with ECG attachment -> P-wave changes guide tip position (largest P-wave at RA). (5) FEMORAL CVC: no CXR needed (position verified by aspiration — blood return from all ports). (6) PRACTICE: CXR after ALL IJV/SCV CVCs (pneumothorax + position).[1] }CRBSI (catheter-related bloodstream infection) — prevention + diagnosis. (1) DEFINITION: bacteraemia from infected CVC (positive blood cultures from line + peripheral — same organism — no other source). (2) ORGANISMS: Staphylococcus epidermidis (coagulase-negative — skin flora — most common), Staphylococcus aureus (more pathogenic), Enterococcus, Gram-negative (especially femoral), Candida (especially TPN). (3) RISK: longer dwell time, femoral site, TPN, immunocompromise, poor technique. (4) PREVENTION: (a) MAXIMAL BARRIER + chlorhexidine (see above). (b) DAILY REVIEW (remove when not needed). (c) SITE (IJV preferred — lowest infection). (d) CHLORHEXIDINE DRESSING (Biopatch). (e) AVOID routine replacement (not needed — increases complications — unless infection suspected). (5) DIAGNOSIS: (a) FEVER + positive blood cultures (from line + peripheral — same organism). (b) LOCAL signs (redness, pus at site — often absent in CRBSI). (c) SEMI-QUANTITATIVE CULTURE (catheter tip — roll plate — >15 colonies = significant — Maki method). (d) Paired blood cultures (line + peripheral — differential time to positivity — line positive >2h before peripheral = CRBSI). (6) MANAGEMENT: (a) REMOVE line (if infected — source control). (b) CULTURES (peripheral + line + tip). (c) ANTIBIOTICS (vancomycin — for staph — adjust based on culture; especially MRSA). (d) DURATION: 7-14 days (longer if endocarditis/septic thrombophlebitis — investigate with echo). (e) NEW LINE at DIFFERENT site (if still needed — don't reinsert at infected site).[4] }Pneumothorax from CVC — recognition and management. (1) RISK: SCV (1-5%) > IJV (<1% with ultrasound) > femoral (0%). (2) MECHANISM: needle/dilator/catheter pleura puncture -> air enters pleural space -> pneumothorax. (3) RECOGNITION: (a) SYMPTOMS: chest pain, dyspnoea, SpO2 drop (may be asymptomatic if small). (b) CXR (post-procedure — routine for IJV/SCV): pneumothorax (apex — air rises in supine). (c) IF large or tension: hypoxaemia, hypotension, tracheal deviation (away), hyperresonance, absent breath sounds. (4) MANAGEMENT: (a) SMALL (<2 cm, asymptomatic): OBSERVE (may resolve spontaneously — air absorbs). Serial CXR (enlarge? -> intervene). (b) LARGE or symptomatic: CHEST TUBE (tube thoracostomy — 5th ICS — drain air). (c) TENSION (shock): IMMEDIATE NEEDLE DECOMPRESSION (2nd ICS mid-clavicular OR 5th ICS mid-axillary — BATLS), then chest tube. (5) PREVENTION: ultrasound guidance (visualise — avoid pleura), experienced operator, correct technique (don't advance too deep).[1] }Arterial puncture during CVC — immediate management. (1) RISK: IJV (carotid — 5-10% landmark, <1% ultrasound), femoral (femoral artery), SCV (subclavian artery — rare). (2) RECOGNITION: (a) BRIGHT RED blood (arterial — vs DARK venous). (b) PULSATILE flow (arterial — spurts with heartbeat). (c) If unsure: transduce (pressure — arterial waveform = artery; venous = low pressure). (3) IMMEDIATE MANAGEMENT (needle puncture — small): (a) WITHDRAW needle immediately. (b) COMPRESS (firm pressure 5-10 min — IJV/carotid or femoral — compressible). (c) MONITOR: haematoma (expanding? -> ongoing bleeding), distal perfusion (carotid -> stroke?; femoral -> leg ischaemia?), BP/HR (shock from bleeding). (d) If stable (no haematoma, normal perfusion) -> may proceed (different site or re-attempt with ultrasound). (4) IF LARGE BORE CATHETER in artery (accidental — wire + dilator + catheter in artery): (a) DO NOT REMOVE (may exsanguinate — large hole in artery). (b) LEAVE in place. (c) CALL VASCULAR SURGERY (urgent — controlled removal + surgical repair). (d) IMAGING (CT angiography — assess injury). (e) MONITOR: distal perfusion (ischaemia?), bleeding (haematoma). (5) PREVENTION: ultrasound guidance (visualise vein vs artery — avoid). (6) This is a SERIOUS complication — recognise (bright red, pulsatile) + manage (compress / vascular surgery if large bore).[1] }Chest drain — underwater seal principles. (1) UNDERWATER SEAL: (a) Drain tube submerged 2 cm in sterile water in collection chamber. (b) Allows AIR to ESCAPE (from pleural space -> bubbbling) but PREVENTS AIR ENTRY (water seal — one-way valve — air can't be sucked back). (c) SWINGING: fluid level moves with respiration (inspiration -> level rises; expiration -> falls) — confirms drain is in pleural space + patent. (2) BUBBLING (air leak): (a) Continuous -> large bronchopleural fistula (alveolar-bronchial air leak -> ongoing). (b) Intermittent (on inspiration only) -> smaller leak. (c) No bubbling -> no air leak (good — pneumothorax resolving — BUT also check drain not blocked). (3) SUCTION (optional): -10 to -20 cmH2O (low pressure) — may help re-expansion (especially large pneumothorax with air leak). (4) CHECK: (a) SWINGING (patent — if not, check for kink/blockage). (b) BUBBLING (air leak — ongoing pneumothorax/bronchopleural fistula). (c) VOLUME/COLOUR (blood — haemothorax; pus — empyema; chyle — chylothorax). (5) REMOVAL: (a) When air leak STOPPED (no bubbling) + lung RE-EXPANDED (CXR) — for pneumothorax. (b) When drainage <200 mL/day — for effusion/haemothorax. (c) TECHNIQUE: breath-hold (Valsalva — prevent air entry on removal), rapid withdrawal, seal with occlusive dressing. (d) CXR post-removal (re-accumulation?).[5] }Bronchoscopy — when and how in ICU. (1) WHEN (INDICATIONS): (a) ATELECTASIS (lobar collapse — especially post-op, mucus plug, weak cough) -> therapeutic bronchoscopy (remove plug -> re-expand). (b) HAEMOPTYSIS (localise source — which side/lobe; therapeutic — epinephrine, balloon tamponade). (c) INVESTIGATE infiltrates (especially immunocompromised — BAL for PJP, fungal, CMV; or non-resolving pneumonia — atypicals, TB). (d) FOREIGN BODY (aspiration — remove). (e) AIRWAY ASSESSMENT (post-extubation stridor — subglottic stenosis?; burn inhalation — soot, oedema; post-transplant — anastomotic). (f) BEFORE RE-EXTUBATION (if difficult airway — assess). (2) HOW (TECHNIQUE): (a) PREPARE: sedation (midazolam/fentanyl — or propofol — ensure comfortable + cooperative if non-intubated), topical anaesthesia (lidocaine 2% to vocal cords + airway — reduces cough/gag), monitor (SpO2, ECG, BP). (b) INCREASE FiO2 to 100% (before + during — bronchoscope partially occludes airway). (c) PASS: through nose (non-intubated) or ETT (intubated — ETT ≥8 mm for adult bronchoscope — smaller for paediatric). (d) SYSTEMATIC INSPECTION: vocal cords (mobility, lesions), trachea (mucosa, rings), carina (sharp — sharp = normal; widened = subcarinal lymphadenopathy/mass), right main bronchus + segments, left main bronchus + segments. (e) INTERVENE: BAL (wedge in segment -> instil 100-200 mL saline in aliquots -> suction -> collect), biopsy (forceps — visible lesion; or transbronchial — for parenchyma — bleeding/pneumothorax risk), brush (cytology), remove foreign body (forceps/basket). (3) COMPLICATIONS: (a) HYPOXAEMIA (partial airway occlusion — monitor SpO2 — pause if desaturating). (b) BLEEDING (biopsy — especially coagulopathy/thrombocytopenia — have epinephrine 1:10,000 ready). (c) PNEUMOTHORAX (transbronchial biopsy — check CXR post). (d) LARYNGOSPASM (non-intubated — especially smokers/asthma — treat: positive pressure, suxamethonium if severe). (e) ARRHYTHMIA (vagal — bradycardia). (f) FEVER (post-BAL — transient — from cytokine release). (4) POST: monitor SpO2, CXR (if transbronchial biopsy).[6] }Daily line review — remove when not needed. (1) EACH DAY CVC is in place -> INCREASES infection risk (CRBSI — 5 per 1000 catheter days). (2) DAILY REVIEW on ward round: 'Is this line still needed?' (a) If NO longer needed (vasopressors off, antibiotics finished, TPN stopped) -> REMOVE. (b) If still needed -> continue (but ensure indication documented). (3) DON'T: (a) Keep lines 'just in case' (unnecessary infection risk). (b) ROUTINELY replace lines (not needed — increases complications — unless infection suspected). (c) Keep lines longer than needed (each day = more risk). (4) DO: (a) Remove as soon as indication resolved. (b) Change site if infection suspected. (c) Use the MINIMUM number of lines (don't insert unnecessary lines). (d) Document indication daily. (5) EVIDENCE: daily review + prompt removal reduces CRBSI (bundled with maximal barrier + chlorhexidine).[4] }Consent + documentation — medico-legal. (1) CONSENT (if time — emergency may be implied): (a) Explain PROCEDURE (what will happen). (b) RISKS (pneumothorax for CVC; ischaemia for arterial; bleeding; infection). (c) BENEFITS (monitoring, access, treatment). (d) ALTERNATIVES (peripheral IV, ultrasound, different site). (e) Document (signed consent form — or note if emergency). (2) DOCUMENTATION (post-procedure): (a) Procedure note: (i) Date, time, operator, assistant. (ii) Indication. (iii) Site (IJV/SCV/femoral; right/left). (iv) Technique (ultrasound-guided; Seldinger). (v) Attempts (number). (vi) COMPLICATIONS (immediate — arterial puncture, pneumothorax, bleeding). (vii) Post-procedure: CXR (findings — pneumothorax? position?), monitoring. (b) WHY: medico-legal (record of what was done + complications), continuity (other staff know), audit (quality). (3) TIME-OUT (pre-procedure): 'STOP' — confirm patient, procedure, site, side (prevent wrong-site). (4) SIGNATURE (operator + assistant). (5) This is the STANDARD — every procedure documented.[2] }Central line insertion bundle (IHI/Pronovost 5 components) — the CRBSI prevention checklist. (1) THE BUNDLE: five evidence-based elements, ALL applied for every CVC: (a) HAND HYGIENE before + after (WHO 5 moments). (b) MAXIMAL STERILE BARRIER (cap, mask, sterile gown + gloves, full-body drape) for operator + assistants. (c) CHLORHEXIDINE 2% in 70% alcohol skin prep (let dry — no wiping). (d) OPTIMAL SITE SELECTION — avoid femoral in adults (IJV/SCV preferred; SCV if coagulopathy excluded). (e) DAILY REVIEW of line necessity with PROMPT REMOVAL of unneeded lines. (2) EVIDENCE: PRONOVOST (2006, NEJM, Michigan Keystone ICU collaborative) — implementing the bundle + a checklist + culture of safety in 103 ICUs reduced CRBSI from 7.7 to 1.4 per 1000 catheter-days at 18 months (median 0) and sustained at 3 years (~1.1) — prevented ~1500 deaths + $200M. (3) WHY IT WORKS: bundles force consistent application of all elements — weak link (e.g. omitting barrier) breaks the chain. Checklist = cognitive aid + normalises speaking-up (anyone can stop the line). (4) ADJUNCTS: chlorhexidine-impregnated dressing (Biopatch/Tegaderm CHG) at site — reduces CRBSI ~50%; antiseptic hub caps (Curos) — reduce hub colonisation; antimicrobial-impregnated catheters (minocycline-rifampin, chlorhexidine-silver sulfadiazine) — consider if high CRBSI despite bundle. (5) EXAM: 'List the components of the central line bundle' + 'What was the Pronovost study?' — common CICM/FFICM.[7] }Arterial line waveform + zeroing + dynamic response (square-wave test) — getting accurate BP. (1) WAVEFORM COMPONENTS: (a) SYSTOLIC upstroke (anacrotic limb — ventricular ejection), (b) PEAK = systolic pressure, (c) Dicrotic notch (aortic valve closure), (d) DIASTOLIC down-slope — minimum = diastolic. MAP = area under curve (estimated = DBP + ⅓(SBP−DBP)). (2) LEVELLING (zero reference): transducer at PHLEBOSTATIC AXIS (4th ICS, mid-axillary line = right atrium). WRONG LEVEL: transducer TOO HIGH -> under-reads (BP falsely low); TOO LOW -> over-reads. Re-level when patient repositioned (head-up/down). (3) ZEROING (calibration to atmosphere): stopcock OFF to patient + OPEN to air -> press 'zero' -> reads 0 -> close to air, open to patient. Zero once per shift + after transducer change. (4) DYNAMIC RESPONSE — square-wave (fast-flush) test: snap flush valve -> observe. (a) OPTIMAL: 1-2 sharp oscillations, return to baseline in <0.2s -> accurate. (b) OVER-DAMPED: slurred upstroke, no/low oscillations, under-reads SYSTOLIC + over-reads DIASTOLIC (MAP usually OK). CAUSE: air bubble, clot, kink, long/narrow tubing, loose connection. FIX: flush, de-bubble, straighten, tighten. (c) UNDER-DAMPED: many high oscillations (ringing), over-reads SYSTOLIC + under-reads DIASTOLIC. CAUSE: long catheter/extension, narrow tubing, stiff catheter. FIX: add damping device/shorten. (5) CALIBRATION vs LEVELLING — different: calibration = sensor electronics (zero); levelling = hydrostatic column (height). MAP is least affected by damping — if you trust only one number, trust MAP.[4] }Bronchoalveolar lavage (BAL) — technique + diagnostic yield. (1) INDICATION: investigate pulmonary infiltrate (esp. immunocompromised — PJP, CMV, fungal; non-resolving pneumonia; suspected malignancy), wash out toxins, obtain lower-respiratory sample uncontaminated by upper airway. (2) TECHNIQUE: (a) Wedge bronchoscope into TARGET segment/subsegment (under direct vision — the segment most affected on imaging, or right middle lobe / lingula in diffuse disease — best yield). (b) INSTIL sterile SALINE (room temp) — typically 100-240 mL in 20-50 mL aliquots (3-5 aliquots). (c) SUCTION back gently (low suction — 100 mmHg — avoid collapse) after each aliquot -> collect in sterile trap. (d) FIRST aliquot = 'bronchial wash' (contaminated by upper airway) — discard or send separately; SUBSEQUENT aliquots pooled = true BAL. (e) RECOVER ~40-60% instilled volume (lower if obstructed/smokers). (3) SAMPLE HANDLING: send promptly (within 1-2h) — cell count + differential, Gram/culture (bacterial), AFB/TB-PCR, fungal culture/stain, viral PCR/HSV/CMV, PJP (immunofluorescence/PCR), cytology (malignancy), cell differential (eosinophils — eosinophilic pneumonia; lymphocytes — hypersensitivity pneumonitis/sarcoid; neutrophils — infection). (4) IN VENTILATED: reduce tidal volume / switch to pressure control, FiO2 = 1.0, pause ventilator alarm limits (expect transient desaturation), use sealed swivel adaptor (bronchoscope through ETT — leaks cause hypoventilation). (5) COMPLICATIONS: transient fever (common, cytokine), transient hypoxaemia (wedge reduces V/Q — lasts hours), bleeding (rare unless coagulopathy), bronchospasm. (6) PROTECTED SPECIMEN BRUSH (PSB): alternative — telescoping catheter brush (less contamination, quantitative culture >10³ CFU/mL = VAP).[6] }Bronchoscopy in the ventilated patient — technical adjustments. (1) WHY IT'S HARDER: bronchoscope occupies ~50% of an 8 mm ETT cross-section -> increases resistance + reduces effective tidal volume + raises auto-PEEP/air-trapping -> hypoxaemia + hypercapnia + barotrauma. (2) PREPARATION: (a) ETT SIZE — standard adult bronchoscope OD ~5.9 mm needs ETT ≥8.0 mm (ratio <0.5 of ETT ID); smaller ETT -> use paediatric bronchoscope (or change ETT). (b) SEDATION/MUSCLE RELAXATION — deepen (propofol/midazolam ± fentanyl); consider neuromuscular blocker to prevent coughing/bucking (reduces trauma + better views + less desaturation). (c) FEED NGT — withdraw NG tube (prevents oesophageal compression + airway trauma). (3) VENTILATOR SETTINGS during bronchoscopy: FiO2 = 1.0; increase SET pressure limit; switch to VOLUME control is BAD (bronchoscope leaks -> undelivered volume) — use PRESSURE CONTROL or increase set rate; ADD 5 cmH2O PEEP baseline (counteract leak); monitor exhaled tidal volume + plateau pressure (rise = obstruction/auto-PEEP). (4) ADAPTOR: sealed swivel connector with diaphragm port (bronchoscope passes through diaphragm — maintains circuit) — minimises leak. (5) DURING: limit scope dwell time (brief); suction intermittently (continuous suction collapses lung — desaturation); instil saline for BAL/lobar lavage. (6) POST: FiO2 wean as SpO2 recovers; CXR if transbronchial biopsy (pneumothorax); watch for laryngospasm/oedema if recently extubated.[6] }Local anaesthetic systemic toxicity (LAST) — recognise + treat. (1) MECHANISM: lidocaine/bupivacaine block neuronal + cardiac Na channels — CNS toxicity first (excitation), then cardiac (bupivacaine tightly binds — refractory arrest). (2) RISK FACTORS: high dose (lidocaine max 3 mg/kg plain, 4.5 mg/kg with adrenaline; bupivacaine 2 mg/kg), IV injection, rapid absorption (vascular site — intercostal > caudal > epidural > brachial plexus > subcutaneous), elderly, hepatic dysfunction, pregnancy. (3) PREVENT: aspirate before each injection, incremental dosing (test dose with adrenaline — HR rise = intravascular), use ultrasound for nerve blocks, respect max dose. (4) PRESENTATION: (a) EARLY/CNS: perioral tingling, metallic taste, tinnitus, agitation, twitching -> SEIZURE -> coma. (b) CARDIAC: hypertension/tachycardia -> then hypotension, bradycardia, AV block, widened QRS, prolonged PR -> VENTRICULAR ARRHYTHMIA/ASYSSTOLE (bupivacaine = 'cardiotoxic' — resistant to standard ACLS). (5) MANAGEMENT: (a) STOP injection. (b) AIRWAY + 100% O2 + VENTILATE (hypoxia + acidosis worsen toxicity). (c) SUPPRESS SEIZURE — benzodiazepine (midazolam/lorazepam); avoid propofol if cardiovascular instability (large dose worsens). (d) LIPID EMULSION 20% — the antidote: bolus 1.5 mL/kg (~100 mL in 70 kg) over 1 min, then infusion 0.25 mL/kg/min; repeat bolus x2 if no response, double infusion if unstable; max 12 mL/kg. (e) CARDIAC ARREST (bupivacaine): prolonged CPR (may need >1h — drug redistribates off receptors), AVOID vasopressin/Ca-channel blockers/β-blockers/lidocaine, low-dose adrenaline (10-100 µg boluses — high dose worsens), amiodarone for VT/VF (NOT lidocaine). (f) AFTER: admit, monitor 12h (recurrence), report to LIPID RESCUE registry.[8] }Re-expansion pulmonary oedema (RPE) — the chest-drain trap. (1) DEFINITION: non-cardiogenic pulmonary oedema occurring after RAPID re-expansion of a chronically collapsed lung (large pneumothorax or effusion drained quickly). (2) INCIDENCE: rare (~1%) but MORTALITY up to 20%. (3) RISK FACTORS: pneumothorax/effusion present >3 days, large volume (>1.5-2 L drained at one sitting), rapid drainage (negative-pressure suction), younger age. (4) MECHANISM: sudden negative intrapleural pressure -> increased pulmonary capillary pressure + reperfusion injury + inflammatory mediators -> alveolar-capillary leak -> oedema in re-expanded lung (unilateral, then may spread). (5) PRESENTATION: within 1-24h of drainage — COUGH (often first sign), chest tightness, worsening dyspnoea, hypoxaemia, pink frothy sputum, hypotension. (6) PREVENTION (key): (a) Drain LARGE effusion in STAGES — clamp after 1-1.5 L, reassess, complete next day (or stop if chest tightness/cough). (b) AVOID routine suction for pneumothorax. (c) MONITOR for symptoms during drainage — pause if cough/tightness. (7) MANAGEMENT: SUPPORTIVE — O2 (high-flow/NIV/CPAP), restrict fluids + diuretic, treat hypotension (vasopressors), bronchodilators; severe -> intubation + PEEP; ICU monitoring. Steroids/NSAIDs unproven. (8) PEARL: 'cough during tap/drain = STOP and reassess'.[5] }Venous air embolism during CVC — rare, preventable, fatal. (1) MECHANISM: air enters venous system through open needle/catheter hub when intrathoracic pressure negative (inspiration/open hub above heart level) -> travels to RA/RV -> pulmonary artery obstruction + V/Q mismatch + reflex bronchoconstriction -> hypoxaemia + pulmonary hypertension + RV failure; PARADOXICAL embolus (PFO/PA shunt) -> stroke/coronary occlusion. (2) VOLUME: as little as 5 mL/kg can be fatal; 50 mL IV air may kill; risk highest with open hub + head-up position + deep inspiration. (3) RECOGNITION (during/after insertion): sudden cough, dyspnoea, chest pain, hypoxaemia, hypotension, 'MILL-WHEEL' MURMUR (audible over precordium — churning air in RV), ECG: sinus tachycardia -> ischaemia/arrhythmia; cardiac arrest. (4) PREVENTION (standard): (a) Trendelenburg (head-down) for IJV/SCV — raises venous pressure above atmospheric. (b) NEVER leave needle/catheter hub OPEN to air — occlude with thumb/forceps/saline-filled syringe between wire/dilator exchanges. (c) Ensure all connections Luer-locked + primed. (d) Patient NOT taking deep breaths during exchanges. (5) MANAGEMENT if it happens: (a) STOP air entry (occlude hub/occlude source). (b) POSITION — Trendelenburg + LEFT LATERAL DECUBITUS (Durant's manoeuvre — air trapped in RA, away from pulmonary outflow). (c) 100% O2 (denitrogenates — speeds air absorption). (d) ASPIRATE air via CVC (advance into RA — aspirate frothy blood/air). (e) FLUID + vasopressors (support RV/BP). (f) HYPERBARIC O2 if neurologic symptoms (paradoxical embolus) — definitive for arterial air. (g) CPR standard if arrest (may break up air into smaller bubbles).[1] }Vessel ultrasound — how to tell vein from artery (transverse vs sagittal, colour Doppler, compressibility). (1) PROBE: LINEAR (high-frequency 5-15 MHz) for superficial vessels (IJV, radial, femoral). CURVILINEAR (low-frequency) for deeper (femoral in obese). (2) ORIENTATION: indicator towards operator's right (standard) — or towards patient's head for sagittal; understand 'transverse' (cross-section — vessel = circle) vs 'longitudinal/sagittal' (along vessel length — vessel = tube). (3) VEIN vs ARTERY (the 4 cardinal rules): (a) COMPRESSIBILITY — apply downward pressure; VEIN collapses completely; ARTERY remains patent (thick muscular wall) — the SINGLE most useful sign. (b) PULSATILITY — artery pulsates with each heartbeat; vein non-pulsatile (IJV may show slight pulsatility from right heart — don't be fooled). (c) WALL THICKNESS — artery = bright thick wall; vein = thin compressible wall. (d) SIZE — vein usually larger + varies with respiration/Trendelenburg (distends head-down); artery fixed. (4) COLOUR DOPPLER: ARTERY = pulsatile high-velocity colour (red/blue alternating per heartbeat, aliasing); VEIN = continuous low-velocity colour, phasic with respiration (augments with sniff/Valsalva modulates flow). (5) SPECTRAL DOPPLER: artery = high-resistance triphasic (peripheral) or low-resistance (organ); vein = continuous low-velocity phasic. (6) ANATOMY: IJV — ANTEROLATERAL to carotid (carotid deeper + medial); FEMORAL — vein MEDIAL to artery (NAVEL mnemonic lateral-to-medial: Nerve, Artery, Vein, Empty space, Lymphatic); RADIAL — paired with vein(s), lateral to radial artery. (7) CHECK FOR THROMBUS before cannulation: non-compressible vein = thrombosed — DON'T cannulate (risk embolus); choose other side. (8) KARAKITSOS (2006, Critical Care) established ultrasound-guided CVC as standard of care — apply for ALL central + increasingly arterial cannulation.[1] } Red flags
Critical ICU procedure red flags
Ultrasound guidance for CVC is standard of care (Karakitsos — reduces complications 70%).[1] }Maximal sterile barrier (cap, mask, gown, gloves, full drape) — CRBSI prevention.[4] }Check CXR after IJV/SCV CVC — pneumothorax + tip position (cavoatrial junction).[1] }Chest drain 5th ICS anterior axillary (safe triangle) — 28-36 Fr for haemothorax.[5] }Arterial puncture : bright red, pulsatile -> withdraw + compress (vascular surgery if large bore).[1] }3SITES trial : IJV lowest infection; femoral highest infection/thrombosis.[3] }Bronchoscopy : monitor SpO2 (hypoxaemia), have epinephrine ready (bleeding).[6] }Daily line review : remove when not needed (each day increases CRBSI risk).[4] }Central line bundle (5 components — Pronovost Keystone) : hand hygiene + maximal barrier + chlorhexidine + optimal site + daily review.[7] }Arterial line : zero to atmosphere + level to phlebostatic axis (4th ICS mid-axillary); square-wave test before trusting BP — MAP least affected by damping.[4] }Chest drain removal : Valsalva/breath-hold + brisk withdrawal + purse-string — for ventilated patient remove in expiration; CXR post-removal.[5] }Re-expansion pulmonary oedema : drain >1.5 L effusion in stages; STOP if cough/tightness — rare but fatal.[5] }Air embolism : occlude hub between exchanges, Trendelenburg for IJV/SCV; if it happens — Durant's (left lateral + head-down) + 100% O2 + aspirate air via CVC.[1] }Bronchoscopy in ventilated : FiO2 = 1.0, ETT ≥8 mm (OD scope ~5.9 mm), sealed swivel adaptor, watch exhaled tidal volume + plateau pressure (rise = obstruction/auto-PEEP).[6] }LAST (local anaesthetic toxicity) : stop injection, 100% O2, benzodiazepine for seizure, 20% LIPID EMULSION 1.5 mL/kg bolus then infusion (bupivacaine arrest).[8] }Large-bore catheter in artery (accidental) : DO NOT REMOVE — leave in, call vascular surgery for controlled removal + repair.[1] } Prognosis
ICU procedures evidence and outcomes Densification notes for fellowship revision
This leaf is densified to the ICU fellowship gate standard (CICM / FFICM / EDIC): embedded SAQ practice, multi-figure visual scaffolding, examiner map alignment, and MCQ coverage of definition, mechanism, first-hour management, evidence, and traps.
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Revision checkpoint 1: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 2: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 3: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 4: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 5: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 6: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 7: restate definition, one number examiners expect, and one absolute do-not-miss action.
Revision checkpoint 8: restate definition, one number examiners expect, and one absolute do-not-miss action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
[2] References [1] Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique. Critical care (London, England) , 2006.PMID 17112371 [2] Loveday HP, Wilson JA, Pratt RJ, et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. The Journal of hospital infection , 2014.PMID 24330862 [3] Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular complications of central venous catheterization by insertion site (3SITES trial). The New England journal of medicine , 2015.PMID 26398070 [4] O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections (CDC). Clinical infectious diseases , 2011.PMID 21460264 [5] Havelock T, Teoh R, Laws D, Gleeson F, on behalf of the BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society Pleural Disease Guideline 2010. Thorax , 2010.PMID 20696688 [6] Du Rand IA, Blaikley J, Booton R, et al., on behalf of the British Thoracic Society. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults. Thorax , 2013.PMID 23860341 [7] Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU (Michigan Keystone). The New England journal of medicine , 2006.PMID 17192537 [8] Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infection control and hospital epidemiology , 1994.PMID 8207189 
