Critical Care APN

Question 1

What is a central venous catheter?

Answer 1

An indwelling catheter in a large central vein

Question 2

Indications for central venous catheter

Answer 2

• Infusions incompatible with peripheral access i.e.
  vasopressors, TPN, chemo
• Venous access in emergency/difficult peripheral
  access
• Central venous pressure monitoring
• Initiation of extra-corporal therapies i.e. renal replacement therapy, plasmapheresis
• For venous interventions i.e. trans-venous pacing, intra-venous stenting etc.

Question 3

ABSOLUTE contraindications for central venous catheter

Answer 3

active skin infection @ insertion site
vascular injury at site
presence of device at site

Question 4

Relative contraindications for central venous catheter

Answer 4

Bleeding risk
Uncooperative awake pt
Trauma/Congenital anomalies @ site
Morbid obesity

Question 5

5 main complications of central venous catheter

Answer 5

1. Pneumothorax post insertion
2. Occlusion from clot formation
3. Central Line Associated Bloodstream Infection / site infection
4. Air embolism (can occlude blood flow)
5. Dislodgement or migration of catheter

Question 6

(Pneumothorax - Central Venous Catheter Complications) Assessment

Answer 6

Observe for signs of pneumothorax

Question 7

(Pneumothorax - Central Venous Catheter Complications) Prevention/Nursing Intervention

Answer 7

• Positioning during insertion: SUPINE/TRENDELENBURG
• Prepare for chest tube insertion

Question 8

(Occlusion from clot formation - Central Venous Catheter Complications) Assessment

Answer 8

Check for backflow & ability to infuse
Assess CVC for unclamped unused lines

Question 9

(Occlusion from clot formation - Central Venous Catheter Complications) Prevention/Nursing Intervention

Answer 9

• routine flushing as per SOP
• do not flush against resistance
• keep free from kinks
• do NOT MIX MEDS that can have PRECIPATION

Question 10

(Infection - Central Venous Catheter Complications) Assessment

Answer 10

Assess catheter insertion site & surrounding area
monitor lab results

Question 11

(Infection - Central Venous Catheter Complications) Prevention/Nursing Intervention

Answer 11

• ASEPTIC technique
• CLABSI prevention bundle: valved needleless connectors, CHG dressing, CHG/antibiotic coated catheters, early removal
• early detection & treatment of CLABSI

Question 12

(Air embolism - Central Venous Catheter Complications) Assessment

Answer 12

• Monitor for S&S of air embolism: SOB, chest pain, altered mental status, seizures, LOC, cardiovascular collapse
• Assess CVC for exposed hubs and unclamped
  unused lines

Question 13

(Air embolism - Central Venous Catheter Complications) Prevention/Nursing Intervention

Answer 13

• Use valved needleless connectors
• Do not expose hubs to air
• Clamp line when not in use
• In event of air embolism, put patient on TRENDELENBURG position, administer high flow O2, code blue when necessary

Question 14

(Dislodgement/migration of catheter - Central Venous Catheter Complications) Assessment

Answer 14

• Measure and document CVC exposed length
• Assess that CVC dressing is intact
• Assess if patient is at risk for pulling out likes
• Observe for signs of migration/dislodgement: pain, arrythmias, edema, coiling under skin

Question 15

(Dislodgement/migration of catheter - Central Venous Catheter Complications) Prevention/Nursing Intervention

Answer 15

• Avoid pulling or manipulating catheter
• Restless patient: chemical or physical restraints when necessary
• Do not re-advance if migrated externally
• Escalate if migrated internally

Question 16

Central Venous Pressure Monitoring is done by measuring pressure in the ____ to estimate ___

Answer 16

Vena Cava
To estimate pre-load and right atrial pressure
*latest evidence says not accurate

Question 17

End tidal capnography clinical application

Answer 17

Verify ETT placement
Adequacy of ventilation
Continuous monitoring of ETT/Trachy tube location during transport
Effectiveness of resuscitation & prognosis during
cardiac arrest
ROSC indicator during chest compressions
Titrating ETCO2 in patients with high ICP
Prognostication in trauma

Question 18

What is the Richmond Agitation-Sedation Scale used to assess?

Answer 18

Assess lvl of alertness & agitated behaviour in ICU pts

Question 19

Scale for Richmond Agitation (Hint: -5 to 4)

Answer 19

COMA
-5 (Unarousable) - no response to voice or physical stimulation

STUPOR
-4 (Deep sedation) - no response to voice, responds to physical stimulation

DELIRIUM
-3 (Moderate sedation) - respond to voice, nil eye contact
-2 (light sedation) - respond to voice, eye contact < 10 sec
-1 (drowsy) - respond to voice, eye contact > 10 sec
0 (alert & calm)
1 (restless) - anxious, nil aggressive movements
2 (agitated) - frequent, non-purposeful movement
**3 (very agitated) - pull/remove tubes & catheters, aggressive
4 (combative) - overtly combative, violent, danger`

Question 20

Acute confusional state is characterised by:

Answer 20

Altered mental status
inability to focus
disorganised thinking

Question 21

3 types of ICU delirium

Answer 21

Hypoactive
Hyperactive
Mixed

Question 22

Assess safety for extubation

Answer 22

• Stable medical condition: root cause solved? V/S stable?
• Successful SAT (spontaneous awakening trials) and SBT (spon breathing trials): SBT –> 30 min then ABG thereafter
• Able to protect airway
• Risk for post-extubation stridor: risk factors include prolonged/traumatic intubation, large ETT, low GCS
• Potential difficulty w reintubation: Mallampati score, skilled operator
• Timing to extubate: Manpower availability (day vs night)

Question 23

Equipment for extubation

Answer 23

Oral & ETT suction apparatus
10ml syringe
Continuous V/S monitoring
Post extubation oxygen device

Question 24

How to prepare patient for extubation?

Answer 24

Position: 30-45 deg if no contraindication
Explain procedure to pt
Standby for intubation incl manpower for HIGH RISK pts