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Pericardiocentesis

Preprocedure Indications Pericardial tamponade Pericardiocentesis is the first treatment option in patients with overt tamponade because only the removal of fluid allows normal ventricular filling and restores adequate cardiac output. If the patient is hemodynamically stable, the procedure should be performed within 12–24 hours from diagnosis, after obtaining laboratory results including the blood counts. A scoring index has been proposed in patients with a suspicion of…

Ventricular assist device implantation

Before the procedure Indications Postcardiotomy failure (left ventricular assist device [LVAD]) Elevated left atrial pressure (LAP) and cardiogenic shock despite inotropic support and intraaortic balloon pump (IABP) LAP >25 mm Hg Cardiac index (CI) <2 L/min/m 2 Severe left ventricular (LV) dysfunction on echocardiogram Intractable ventricular arrhythmias Ongoing myocardial ischemia despite revascularization Postcardiotomy failure (bilateral ventricular assist device [BiVAD]) Evidence of an elevated central venous pressure…

Transvenous and transcutaneous cardiac pacing

Before the procedure Indications Treatment of symptomatic bradycardia Sinus bradycardia Second-degree or third-degree atrioventricular block Prophylaxis Bradycardia-induced ventricular tachyarrhythmias (e.g., torsades de pointes) Increased risk of advanced atrioventricular block (e.g., acute myocardial infarction, infective endocarditis, surgery in patients with underlying conduction defects) Overdrive pacing for termination of tachyarrhythmias Supraventricular tachycardia Ventricular tachycardia Improving hemodynamic function Sequential atrioventricular pacing Contraindications Specific advance directives (e.g., do not attempt…

Cardioversion and defibrillation

Before the procedure Indications Emergency re-establishment of an organized electrical rhythm Hemodynamically unstable polymorphic ventricular tachycardia Ventricular fibrillation Pulseless ventricular tachycardia Narrow or wide QRS complex tachycardia (ventricular rate >150) associated with hemodynamic instability, chest pain, or pulmonary edema Elective reestablishment of sinus rhythm Atrial fibrillation Atrial flutter Hemodynamically stable ventricular tachycardia unresponsive to medical treatment Others Contraindications Specific advance directives (e.g., do not attempt resuscitation…

Bedside pulmonary artery catheterization

Before the procedure Indications Need for continuous monitoring of pulmonary artery (PA) and right atrial (RA) pressures, cardiac output, and mixed venous oxygen saturation (SvO 2 ), providing that: The data collected will help in the management of the patient The same measurements cannot be reliably obtained by a less invasive method Contraindications Absolute contraindications: Tricuspid or pulmonary valve endocarditis Relative contraindications: Tricuspid or pulmonary valve…

Arterial cannulation and invasive blood pressure measurement

Peripheral artery cannulation is one of the most commonly performed invasive procedures in the intensive care unit (ICU), and the resulting arterial line is an integral part of intensive care patient management. Arterial line usage varies according to unit type, patient age, and severity of illness, ranging from approximately 22% of medical ICU patients to over 50% of surgical ICU patients. There are three main indications…

Central venous catheterization

Before the procedure Indications Inability to achieve the clinical goal by peripheral intravenous catheterization Relatively fast flow rate is required Rapid, massive intravascular volume resuscitation 3.5-inch, 8.5F introducer catheter offers the fastest flow rate. However, a 2-inch, 16-gauge peripheral catheter has a faster flow rate than the longer 16-gauge, centrally inserted triple-lumen catheter. Peripheral venous access cannot be found Cardiopulmonary resuscitation and shock states Peripheral catheters…

Bedside ultrasonography

Advances in ultrasound technology continue to enhance its diagnostic applications in daily medical practice. Constantly evolving, this tool has become invaluable for properly trained cardiologists, anesthesiologists, intensivists, surgeons, obstetricians, and emergency department physicians. Ultrasound can enable rapid, accurate, and noninvasive diagnosis of a broad range of medical conditions. Patients in the intensive care unit (ICU) present daily diagnostic and therapeutic challenges to the medical team. The…

Difficult airway management for intensivists

The critically ill patient, particularly the critically ill difficult airway patient, presents unique airway challenges in emergency situations outside the operating room. The risk of life-threatening complications, including anoxic brain injury, death, and long-term disability, are exaggerated in this patient group when undergoing urgent/emergent airway management in the remote location. Physical examination of the patient is helpful to identify difficult airway characteristics, yet many remain subtle…

Teaching critical care

Introduction As a specialty, critical care medicine has many unique challenges when it comes to teaching trainees. The intensive care unit (ICU) is an environment with high stakes and time-sensitive decision making for acutely ill patients with multiple competing demands for time balanced against learners across multiple levels of training (medical students, residents, fellows) and backgrounds (internal medicine, surgery, anesthesia, emergency medicine, neurology, nurse practitioners, physician…

Telemedicine in intensive care

Worldwide, there is a need for novel strategies to alleviate the lack of specialized medical care, including critical care medicine. Societal changes in demographics, epidemiology, and culture, in addition to significant technologic advances, have positioned telemedicine as a useful tool to narrow the gap between available and needed medical care. Thus far, it has proved to be a disruptive technology, potentially altering traditional paradigms in the…

Mass critical care

Natural and man-made disasters have always been a part of life and are occurring with increasing frequency. They create varied degrees of chaos owing to mismatch of resources and needs, and they place a huge burden on healthcare systems. Restoring an affected society to its present status requires extraordinary efforts and incurs substantial costs. Thousands of people are injured physically and emotionally as the result of…

Early ambulation in the ICU

Bedrest has historically been prescribed as an adjunct to the treatment of acute illness and to rehabilitation after surgery. Even as physicians and researchers began to realize the “evil sequelae of complete bed rest” in both medical and surgical patients, this therapy remained commonplace in the intensive care unit (ICU). Indeed, healthcare providers in the ICU have traditionally focused their attention on normalizing the physiologic derangements…

Long-term outcomes of critical illness

Despite a continuous increase in the incidence of critical illness syndromes such as sepsis and acute respiratory distress syndrome (ARDS), improvements in supportive care have resulted in improved survival over the past few decades. For example, sepsis is estimated to affect between 30 and 50 million people each year worldwide. , Global sepsis mortality has declined from 30% in 1990 to 20% in 2017, resulting in…

Severity of illness indices and outcome prediction

Predicting outcome is a time-honored duty of physicians, dating back at least to the time of Hippocrates. The need for a quantitative approach to outcome prediction, however, is more recent. Although a patient or family members will still want to hear a prognosis, there is increasing pressure to measure and publicly report medical care outcomes and assess the value of care. , deliver comparative information website…

Building teamwork to improve outcomes

The intensive care unit (ICU) is a complex environment with multiple professionals practicing together to provide patient care. Although technology and care options for critically ill patients have advanced, resulting in improved patient outcomes, they add to the complexity of care and knowledge needed by critical care providers. Nontechnical skills, such as teamwork and communication, are also essential for effective, efficient, and safe care provided by…

Basic ethical principles in critical care

Background Since the inception of the practice of medicine, there have been ethical challenges for doctors and other health care professionals. Many of the challenges, such as who has the authority to make key decisions (autonomy vs. paternalism) and what the boundaries of life are at the beginning and the end, have existed for a long time. However, the ever-changing landscape of modern technology has presented…

Resource allocation in the intensive care unit

Introduction Two truisms of economics are that the supply of goods and services is finite and that supply is never sufficient to meet all demands. The tension between supply and demand for food, water, energy, education, and other goods and services creates economies. All societies must determine how goods and services will be allocated to individuals. Although the term rationing connotes a specific process of allocation…

Conversations with families of critically ill patients

Nearly a quarter of the deaths in the United States occur in the intensive care unit (ICU), and the majority of patients who die in the ICU have had life-sustaining measures limited or withdrawn. , A decision to withhold or withdraw life support is often preceded by a family conference addressing the goals of care and treatment plans. Family conferences addressing the care of critically ill…

Donation after cardiac death (non–heart-beating donation)

Historical perspective The increasing gap between the number of organs available for transplantation and the number of patients listed for transplantation has become a rate-limiting step in reducing both wait times and wait list deaths in patients awaiting transplantation. Before the passage of the first US brain death law in the state of Kansas in 1970, donation after cardiac death (DCD, or donation after circulatory death)…