Critical Care

1. Objectives

1. Develop awareness of what patients endure during insertion, use, and removal of devices.

2. Recognize patient safety issues related to procedures (including post-transfer to med-surg units).

3. Provide patient education about expectations.

2. Arterial Line

• Indications

  • Continuous BP monitoring.

  • Frequent arterial blood sampling.

  • Thumb - atrial and rest of fingers from the ulnar artery.

• Pre-insertion

  • Perform Allen test (radial site).

• Positioning

  • Align 1st thumb metacarpal with radius for easier insertion.

  • Kerlix/washcloth support.

• Post-insertion Assessment

  • Aspirate blood easily.

  • Check distal perfusion (fingers or toes).

  • Monitor insertion site for bleeding/hematoma.

  • Dressing intact.

  • Immobilization board (avoid excessive tightness).

• Use & Management

  • Transducer placement.

  • Flushing with heparinized saline.

  • NO medications via arterial line.

  • Routine dressing change q7 days (with Biopatch if no drainage).

• Complications

  • Compromised blood flow → notify provider immediately.

  • Arterial spasm, poor distal perfusion, thromboembolism.

  • Hematoma during insertion/removal.

• Removal

  • Slide catheter out, apply firm pressure 5 minutes.

  • If not hemostatic, repeat another 5 minutes.

  • Apply pressure dressing for 24 hrs.

3. Central Venous Catheter (CVC)

• Indications

  • Pharmacotherapy, volume resuscitation, nutritional support, pressure monitoring.

• Insertion

  • Follows CVC bundle (infection control):

  

  • Sedation/pain management.

  • Seldinger technique used:

• Post-insertion Assessment

  • Aspirate/flush ports.

  • Check transducer/waveform if monitoring pressure.

  • Auscultate breath sounds (subclavian/ IJ risk for pneumothorax, hemothorax).

    • Back pain = pneumothorax (also superclavical risk of infection)

• Use & Management

  • Dedicated port for TPN.

  • Ensure blood return from all lumens.

  • Thrombolytic therapy if no return.

  • Administer blood products.

  • Routine flushing (push–pause–push).

  • Dressing changes weekly/PRN.

• Removal

  • Clean gloves acceptable.

  • Instruct patient: Valsalva maneuver.

  • Pull out completely and apply pressure.

4. Intraosseous (IO) Line

• Indications

  • Vascular access when IV inaccessible.

  • Used in cardiac arrest, trauma.

• Insertion

  • Drill-assisted or manual bone marrow needle.

• Locations

  • Long bones (marrow vasculature doesn’t collapse).

• Checking Placement

  • Aspirate marrow (like CVL).

• Contraindications

  • Local infection, nearby fracture.

• Use

  • Bolus meds (with flush).

  • Blood products.

  • IV fluids and drips.

  • Patients with shock, time is valuable. No time for IV

  • Adenosine can’t administered. It wouldn’t be as effective.

5. Endotracheal Intubation

• Indications

  • Acute respiratory failure.

  • Altered LOC.

  • Airway protection for procedures.

• Insertion

  • Position: supine, “sniffing” position.

  • Preoxygenation.

  • Sedation/pain meds/movemen; administration of 2+ meds.

  • Sellick maneuver.

  • Monitor VS (oximeter tone).

  • Equipment check (laryngoscope or fiber optic).

• Post-insertion

  • Assess breath sounds (lungs & stomach).

  • Confirm placement (ETCO₂, CXR).

  • Expect transient tachycardia/HTN.

    • If not resolved, MORE SEDATION/PAIN meds needed

  • Verify lip depth measurement.

  • Ventilator settings, ABG after 20–30 min.

• Management

  • Ensure patency & securement.

  • Sedation/pain management.

  • “Sedation holiday.”

    • Helps us know when they are not sedated, what they can do on their own (their strength and how successful they will be without help)

• Extubation

  • Stop NMB, reduce sedation.

  • Have re-intubation supplies ready.

  • High Fowler’s, suction airway.

  • Care team roles:

    • RT performs extubation.

    • RN supports patient comfort.

    • All assess status (WOB, SpO₂, ABG, breath sounds, stridor).

      • Stridor - vocal cords (coup); inflammation from the tube.

        • EPINEPHRINE NEBULIZER

      • Hoarseness is normal, will go away in a couple of days

6. Chest Tubes

• Indications

  • Remove fluid (hemothorax, effusion, empyema).

  • Remove air (pneumothorax).

  • Remove both air & fluid.

• Types

  • Trocar

  • Pigtail

  • Silastic

• Insertion

  • Requires sedation, local anesthesia, possibly systemic pain management analgesia/anxiolytic.

  • Sterile technique.

    • Hat and mask for everyone; sterile gown for providers only

  • Placement guided by anatomical landmarks.

• Post-insertion

  • Monitor breath sounds, SpO₂, WOB, RR, drainage.

  • CXR confirmation.

  • Document drainage characteristics, suction setting, water seal bubbling, dressing status.

• Collection Device

  • 3-chamber system: suction regulator, water seal, drainage.

  • If its a hemothorax, no bubbling

  • If its a pneumothorax, yes to bubbling until sealed off

• Transport

  • Can use collection system without suction OR Heimlich valve.

  • Never clamp chest tube!

7. Dialysis/Pheresis Catheter

• Indications

  • Bedside RRT, plasma exchange.

• Insertion

  • Same as CVC.

• Post-insertion

  • Same assessments as CVC.

  • Ports clamped & packed with high-concentration heparin.

• Use

  • For RRT or plasmapheresis only.

8. Cardioversion/Defibrillation

• Indications

  • Shockable rhythm with symptoms.

• Procedure

  • Chest pad or esophageal electrode placement.

  • Sedation/pain control.

• Monitoring

  • Team safety, airway maintenance, patient monitoring.