kettering section d: special procedures Flashcards
1
Q
Kettering rough criteria for selecting mode of transport for inter-hospital transport.
A
- Ambulance (ground):
– Traveling 0-80 miles for usual patient
– < 30 miles if patient in critical condition - Helicopter (rotary wing aircraft):
–Traveling 80-150 miles - Airplane (fixed wing aircraft)
–Traveling over 150 miles
2
Q
Kettering–How does clinician decide whether or not to transport patient?
A
Transport–when benefit of transport outweighs risk of death.
3
Q
Kettering on risks of transporting patients
A
- Complications/adverse events that occur during transport
- Different/new healthcare providers
- Back-end discontinuation of care
- Failure to follow-up on previously identified problems
4
Q
Kettering on benefits of transporting patients
A
- To give patient access to specialists
- To give patient access to diagnostic equipment
- To give patient access to otherwise unavailable treatment
- To maximize patient opportunity to receive “best possible care”
- To give patient chance to identify undiagnosed problem, allowing appropriate care
5
Q
Kettering on prevention of adverse events during in-house transports.
A
- Stabilize patient before transport
- Prepare patient thoroughly before transport
- Communicate well between personnel and departments
- Use checklists and protocols
- Check equipment frequently during transport
- Sedate patient appropriately
- Design hospitals to minimize distance for typical transports
6
Q
Kettering list of major adverse events during transports.
A
- Cardiac arrest
- Pneumothorax
- Death
7
Q
Kettering list of minor adverse events during transports.
A
- Oxygen desaturation
- Hypotension
- Acute changes in heart rate (tachycardia or bradycardia)
- Patient/ventilator asynchrony
- Accidental extubation
- Physiologic instability calling for medication–e.g., vasopressors
- Movement of PA catheter
8
Q
Kettering: Why avoid BVM ventilation during transports?
A
- BVM leaves no control over PIP or Vt (could result in hypo-/hyperventilation–with respiratory acidosis/alkalosis
- BVM could exacerbate lung injury (which could lead to ALI/ARDS–better to use lung protective ventilation)
- BVM increases risk of hemodynamic compromise–resulting in increased WOB in patients breathing spontaneously
- Avoiding BMV consistent with AARC clinical practice guidelines
9
Q
Kettering: Why might transport increase incidence of VAP?
A
- Supine positioning during transport or diagnostics
- Manipulation of endotracheal tube or circuit may raise risk of microaspiration
10
Q
Kettering: How are ventilators monitored safely during transport?
A
- Require standard, real-time monitors and alarms
- Maintain equivalent level of monitoring at all times
- Check equipment frequently during transport
11
Q
Kettering: How does the AARC stand on using ventilators during transports?
A
AARC, through a position statement, recommends using ventilators for transports when possible.
12
Q
Kettering: What areas are at issue when using a ventilator to transport a patient?
A
- Running out of oxygen
- Running out of battery power
- Maintaining ventilator settings equivalent to ICU
13
Q
Kettering notes on oxygen use during ventilator transport.
A
- Calculate tank duration prior to transport
- Determine true flow requirements by accounting for patient Ve and ventilator bias flow
14
Q
How does is that tank duration calculated again?
A
PSIG x tank factor / L/m of flow
15
Q
What are the popular tank factors?
A
0.28 for e cylinder
3.14 for H/K tank
16
Q
Kettering: What factors will influence battery duration during transport?
A
- Battery type
- Operating characteristics
- Drive mechanisms: continuous vs. variable speed turbine or compressor
17
Q
Kettering–What ventilator settings and capabilities influence quality of ventilation during transport?
A
- Mode
- Rate
- Trigger
- Graphics
- FiO2
18
Q
Kettering on issues that arise from ventilators for MRI transports.
A
- Ferrous/ferric effects of metal
- The types of ventilator
–MRI safe ventilator poses no hazard
–MRI conditional ventilator is suitable only under specific conditions
–MRI unsafe cannot be use in MRI suite
19
Q
Kettering on Issues MRI ventilation raise for ventilators delivering consistent performance for patients.
A
- Patient movement in and out of MRI machine requires long ventilator circuit
- Expect to increase Vt to account for volume lost in circuit
- Calculate lost volume using tubing compliance factor
- Correct for volume lost
20
Q
Kettering notes on iNO during patient transport.
A
- May be used while transporting patients–for example, en route to OR
- Plan either for acquiring specialized transport iNO or for handling bulky standard equipment
21
Q
Kettering on pulmonary artery catheter during transport.
A
Swan-Ganz catheters should be monitored with pulmonary arterial pressure (PAP) waveform during transport.
22
Q
Kettering notes on capnography during transport
A
- Standard of care in ED, PACU, ambulance, intubations, and for cpr effectiveness
- Use capnography to confirm intubations
- Use capnography for all ventilator transports
- Attend closely to capnography for patients needing tight control fo PaCO2, such as patients with traumatic brain injury
23
Q
Kettering definition of ventilator-associated pneumonia.
A
PNA that develops 48 hours after a patient is placed on mechanical ventilation.
24
Q
What about hospital acquired pneumonia? What’s that?
A
K–HAP occurs 48 or more hours after admission to hospital and results from an infection that was not incubating at time of admission. Note that VAP is a version of HAP.
25
What does K say is healthcare-associated pneumonia?
Pneumonia in a patient who resides in a long-term care facility
*or*
In a patient in an acute care hospital for a specified time before developing pneumonia in the LTC
26
What does K say is a ventilator-associated event?
An event triggered by sustained increase in FiO2 or sustained increase in PEEP after a period of stability in a patient receiving invasive ventilation.
27
What is a healthcare/hospital-acquired infection?
An infection that began after hospitalization.
28
What classes of bugs are behind ventilator-associated pneumonia?
* Usually bacteria
* Sometimes fungi
* Rarely viral--if so, from epidemic--SARS (K)
29
How is the timing of VAP categorized? How does timing affect otcomes?
* Early onset pneumonia--48-72 hours after intubation
* Late-onset pneumonia-- >72 hours after intubation, with a worse outcome than early-onset
30
What is the impact of VAP (K)?
* Prolonged hospital stay (increases length of stay)
* Increased healthcare costs
* Mortality rates 25-50%
* VAP accounted for 60% of all hospital-associated infections
31
What is incidence of VAP (K)?
* 8-28% for all intubated patients
* 100,000 lives compaign by Heathcare Inprovement (IHI) has decreased occurrence rate
32
With what phenomena is VAP linked? (K)
* Oropharyngeal secretions
* Esophageal or gastric contents
33
How should VAP influence our cuff pressure practices? (K)
* Minimal leak technique or minimal occluding volume should *not* be used
34
What specific bug is most often behind VAP? (K)
Most often a gram positive bacilli--MRSA most common
35
What bugs are behind VAP for specific co-morbidities?
COPD: H. influenzae, Staph pneumonia, Moraxella catarrhalis
Cystic fibrosis: pseudomonas, Staph aureus
Head trauma or diabetes: MRSA
36
What pharmacology is associated with VAP? (K)
* Concurrent steroid therapy
* Excessive sedation and paralytics
* Inappropriate antibiotic therapy
* HIstamine antagonists
* Antacids for gastric protection
37
What non-pharmacological factors increase risk of VAP? (K)
* Artificial airway (ETT or tracheostomy tube--while mask NPPPV, LMA, obturators do not cause VAP because the do not pass the vocal cords)
* Ventilator circuits
* Humidifiers
* Respirometers
* Nebulizers
* Reusable ventilator probes (e.g. temperature probe)
* Bronchoscopes
* Suction equipment
* Endoscopes
38
Why is VAP difficult to diagnose accurately?
* Sputum sample may have contaminates
* Previous antibiotics can alter results
* CXR infiltrates may arise from other complications
39
K: After 48 hours of mechanical ventilation, two or more of what findings suggest VAP?
* Presence of new or persistent lung opacity on CXR
* Fever > 38.3ºC
* Hypothermia < 36ºC
* WBC > 10,000 mm3 or < 5000mm3 (leukocytosis or leukopenia
* Purulent endotracheal aspirate
40
What sampling can be performed to support a suspicion of VAP?
* Bronchoalveolar lavage
* Protected specimen brush
* Mini-BAL
*Order gram stain and C&S on aspirate*
41
K's odd requirement for BAL.
"Requires Carlens (double lumen) ET tube." ??
42
K's description of protected specimen brush (PSB) method
* Insert catheter with sealed plug down bronchoscopes
* Remove plug
* Obtain sample
* Can be done without a bronchoscope
43
K description of Mini-BAL technique
* Insert small catheter (usually a plugged telescopic catheter) into trachea
* Instill fluid
* Suction fluid back for sample
44
Where does K say Mini-BAL is often done?
In the ED to rule out VAP
45
How does K describe blind bronchial sampling?
* Wedge blindly a catheter into a distal bronchus
* Instill fluid
* Aspirate fluid immediately for sample
46
K's measures to prevent VAP
* Keep head of bed at 30-45 degrees
* Gastric prophylaxis
* Perform regular oral care
* Use lung protective strategy
* Use weaning protocols
* Use heated wire circuit to reduce condensation
47
Does doe K describe weaning protocols to prevent VAP?
* RT- & RN-driven weaning
* Daily sedation vacation/sedation holiday
* Initiate weaning when RSBI < 100
* Spontaneous breathing trial
48
How K describes spontaneous breathing trial
* AKA Spontaneos Awake Trial (SAT)
* 30-120 minutes is minimum and maximum for SBT
* If patient fails SBT, then rest patient for 24 hours--don't repeat SBT "in a few hours"
49
K types of capnography.
* Colormetric or chemical capnography
* Capnograph
* Volumetric capnography
50
K on colormetric capnography
* Brand name EasyCap II
* Chemically changes color from purple (no CO2) to yellow (increased CO2)
51
K on capnograph
* Quantifies PetCO2
* Shows or does not show capnogram waveform
* Measures exhaled carbon dioxide values using infrared absorption
52
K on volumetric capnography
* Integrated with ventilator volume delivery to measure volumes along the capnograph curve
* Use volumes at a given PetCO2 to calculate values such as VD/VT, VCO2, etc.
53
K's highlights of AARC CPG for capnography/capnometry
* Use continuous waveform capnography to monitor correct placement of ETT (colormetric if waveform not available)
* Use PetCO2 to guide management of patients requiring mechanical ventilation
* Use continuous capnography during transport of patients receiving mechanical ventilation
* Apply volumetric capnography to assess CO2 elimination & VD/VT to optimize mechanical ventilation
54
How is quantitative capnography used in intubated patients during CPR?
* To assess cardiopulmonary status
* To assess effectiveness of chest compressions
* To monitor for return of spontaneous circulation
55
In broad strokes, how does K say PetCO2 reflects PaCO2?
* Both are directly influenced by VCO2 (CO2 production)
* VCO2 is a component of basic metabolic rate (BMR)
* PetCO2 lags below PaCOs by 4-6 mmHg
56
K--What increases basic metabolic rate?
* Fever
* Sepsis
* Shivers
* Seizures
* Hyperthyroidism
57
K--What decreases basic metabolic rate?
* Sedation
* Hypthermia
* Inadequate nutrition/starvation
58
K--How do normal numbers for PaCO2 and PetCO2 compare?
PaCO2 is normally 40 mmHg
PetCO2 is normally 34-36 mm Hg
59
K--What is one European convention for expressing PetCO2?
* As exhaled CO2 percent
* Normal PetCO2 is 3-5%
60
K--Under what conditions does PetCO2 decrease (suggesting a decrease in PaCO2)?
* Hyperventilation
* Hypocapnia
* Respiratory alkalosis
61
K--Under what conditions does PetCO2 increase (suggesting an increase in PaCO2)?
* Hypoventilation
* Hypercapnea
* Respiratory acidosis
62
K--What does low PetCO2 immediately after intubation suggest?
Esophageal intubation, which must be immediately corrected.
63
K--What does PetCO2 decreasing toward zero indicate?
A leak or disconnect with the ventilator.
64
K--What can capnography be used to monitor?
* Severity of pulmonary disease
* Response to therapies
* Correct ETT placement
* Ventilator/ETT leaks or disconnects
* Both pulmonary and cardiac blood flow
* The effect of neuromuscular blocking agents
65
K--How does capnography show response to therapies?
* Improved VD/VT
* Improved V/Q matching
66
K--How does capnography monitor pulmonary and cardiac blood flow?
* Decreased cardiac output results in sudden, low PetCO2 (indicating early cardiac failure/MI/CHF
* Decreased pulmonary blood flow results in sudden low PetCO2 (as an early indication of pulmonary embolism)
67
K--How does capnography monitor neuromuscular blocking agents?
As NMBA wears off, PetCO2 increases.
68
K--How can volumetric capnography be used for monitoring?
* Increasing VCO2 may indicate patient fever or NMBA is wearing off
* Decreasing PetCO2 may indicate VD/VT, cardiac failure, or decreased cardiac output
* Increasing VA shows improving ventilator status--patient may be ready for weaning
* Decreasing VD/VT shows improving ventilator status--Patient may be ready for weaning if VD/VT <60%
69
How should capnography be used to confirm ETT intubation?
AHA/ACLS Guidelines recommend quantitative waveform capnography.
70
How would waveform capnography detect ventilator circuit or ETT leak or disconnect?
PetCO2 would suddenly decrease to zero.
71
How would capnography monitor cardiac blood flow?
Sudden lowering of PetCO2 could be an early indicator of cardiac failure/MI/CHF.
72
How would capnography monitor pulmonary blood flow?
A sudden lowering of PetCO2 could indicate pulmonary embolism.
73
What may increasing VCO2 indicate?
* Fever
* NMBA wearing off
74
What might decreasing VCO2 indicate?
* Decreasing VD/Vt
* Decreasing cardiac output
* Cardiac failure
75
What might increasing VA show?
* Improving ventilator status
* Readiness for weaning
76
What does decreasing VD/VT show?
* Improving ventilator status
* Readiness for weaning if VD/VT < 60%
77
K: What is nutrition?
The interaction between diet and metabolism.
78
K: What is malnutrition or undernutrition?
A condition where dietary intake does not meet metabolic demand
79
K: Some ways undernutrition increase morbidity and mortality
* Five days of starvation reduces muscle strength
* Respiratory muscles can be compromised
* Undernutrition may contribute to failure to wean patient from ventilator
80
K: How does carbohydrate consumption affect the respiratory system?
* Increases CO2 requiring clearance (increased VCO2)
* Increases oxygen demand (decreased VO2)
81
K: How do excessive calories from any nutritional source affect respiratory system?
Excess calories bring excess CO2 production.
82
K: Which nutritional component has the highest energy yield?
Lipids
83
K: How does malnutrition arise from serious illness?
Through abnormal nutrient processing.
84
K: In critically ill patients, how do nutrients serve as toxins?
5% of glucose is normally metabolized into lactate.
In acutely ill patients, up to 85% of glucose is metabolized into lactate.
85
K: What is a reasonable caloric target?
25 kcal/kg/day
For a 70 kg patient: 70 x 25 = 1750 kcal/day
86
K: How quickly should nutritional therapy be initiated after ICU admission?
24-48 hours
87
K: Name three relevant complications of malnutrition.
* Protein wasting
* Respiratory muscle catabolism
* Hypoglycemia
88
K: What are two common tools to assess nutritional status?
* Serum albumin concentration
* Nutritional studies using anthropometric data
89
K: What common anthropometric calculation is used to assess nutritional status?
Body Mass Index
90
How do you calculate BMI?
Weight (lbs)/[Height (inches)]2 x 703 (CDC)
91
Interpret BMI numbers
< 18.5 = underweight
18.5-24.9 = normal or healthy weight
> 30 = obese
(CDC)
92
K: Name 3 routes for giving patients nutritional support
* Enteral nutritional support ("tube feed")
* Total parenteral nutrition (TPN)
* Peripherally Inserted Central Catheter (PICC) Line
93
K: How is tube feed administered?
Tube feed is administered through nasogastric tube, which requires normal digestion via the GI tract.
94
K: How do tube feeding and TPN compare?
Tube feeding is far superior for the critical care patient.
95
K: What is one reason for the superiority of tube feeding over TPN?
Without ingesting food, the bowel starts to break down in 1-3 days.
96
K: If the bowel breaks down for lack of ingesting food, what hazards could arise?
* Could lead to sepsis
* Could lead to paralytic ileus, especially if they have severe burns
97
K: Can tube feed be delivered in some fashion other than a g-tube?
Yes--enteral feedings could be given via jejunum tube (j-tube), which could be helpful in patients with pancreatitis.
98
K: Name contraindications for tube feeding.
* Circulatory shock
* Intestinal ischemia
* Complete mechanical bowel obstruction
* Ileus (from intestinal obstruction, decreased intestinal motility, mechanical obstruction)
99
K: Name two complications of tube feeding
* Incorrect placement of NG tube
* Retrograde aspiration
100
K: How should NG tube placement be confirmed?
* CXR should confirm NG tube placement
* Auscultation has proven to be unreliable
101
K: Describe the danger of incorrect NG tube placement
NG tubes could inadvertently intubate the lung
* NG tube pushes past ET tube cuff and into lungs
* Incorrectly placed tube delivers feedings directly into the lungs
102
K: What are possible consequences of NG tube intubating the lung?
* Pneumothorax
* Hydrothorax
* Hemothorax
* Pneumonia
* Abscess
* Death
103
K: Other than accidental placement of NG tube into lungs, how can NG complicate patient respiratory status?
Retrograde aspiration, which is potentially fatal.
104
K: How can patients be tested for aspiration of tube feed?
* Add dye to tube feeding
* Test tracheal aspirate using glucose oxidase reagent strips and glucometer
105
K: What is total parental nutrition?
The intravenous delivery of nutrients.
106
K: What is the purpose of TPN?
To supplement or replace enteral nutrition.
107
K: When should TPN be recommended?
When full nutritional support is not possible with enteral (tube) feedings.
108
K: How does TPN provide daily protein requirements?
With amino acid solutions with dextrose
109
K: How is TPN administered?
Through large central vein, preferably in the superior vena cava.
110
K: What are complications of TPN?
* Catheter-related sepsis
* Pneumothorax during insertion
* Metabolic complications
111
Kettering notes on PICC line
* Line is inserted in upper arm and advanced to vena cava, usually with ultrasound guidance
* Line has lower risk of complications than other lines
* Line can remain in place longer than other IV or central access devices
112
K: Indications for PICC line
* Need for prolonged antibiotic treatment
* Need for TPN
* Need for chemotherapy
* Need to extend treatment for patients being discharged to home or subacute care facility
113
K: Complications of PICC line
Catheter-related sepsis (remove PICC at signs of infection)
114
K: Define indirect calorimetry.
A method of calculating resting energy expenditure (REE) by measuring the whole body VO2 and VCO2.
115
K: How is indirect calorimetry carried out?
* A metabolic cart measures the exchange of O2 and CO2 across the lungs through exhaled gas analysis.
* Gas exchange measurements are obtained over 15-30 minutes and extrapolated to 24 hours.
116
K: Why resort to indirect calorimetry?
* Daily caloric needs are often estimated using predictive formulae
* Indirect calorimetry is the most accurate method for determining the daily energy requirements of patients in ICU
117
K: Why bother with indirect calorimetry when we have predictive formulae?
* Total daily energy expenditure (TEE) is equivalent to REE -- in *normal* patients.
* In hypermetabolic patients, TEE can be up to 40% higher than extrapolated REE.
(I think that's the point they're getting at.)
118
K What are the limitations of indirect calorimetery?
* Requires specialized equipment
* Requires specially trained personnel
* Equipment and personnel not universally available
* Lacks reliability in patients with FiO2 > 0.5 d/t limitations of O2 sensors
119
K: Indirect calorimetry will generate a respiratory quotient, but how should it be interpreted?
* Normal: 0.67-1.3
* Possible over-feeding: > 1.1
* Possible under-feeding: < 0.7
120
K: Name three end-of-life negotiations critical care practitioners might become involved in.
* The limits of therapy and/or resuscitation attempts
* The withdrawal of life support
* Triage decisions in allocating physical and personnel resources, particularly when demand exceeds supply
121
K: What is the goal of end-of-life care?
To allow patients to die with dignity and respect and to let them exercise some control over their death
122
K describes what typical bind in end-of-life care?
Patients ideally make all decisions regarding their care; critically ill patients are often not capable of making those decisions.
123
K: What is a durable power of attorney for healthcare?
A statement that assigns someone to perform specified actions on behalf of the patient.
124
K: What is a healthcare proxy?
A person appointed by the patient specifically for the purpose of making healthcare decisions.
125
K: Who is next of kin?
In some states, the next of kin are authorized to speak on behalf of an incapacitated patient. Hierarchies are defined by law.
126
K: What is a DNR order?
Explicit instructions from the patient to guide their care in the event of cardiopulmonary arrest.
127
What issues, in K's view, are covered in DNR orders?
My reading:
Intubation
Compressions
Medications
Electricity
Blood
Kettering:
* Blood transfusions
* Intubation
* Mechanical ventilation
* Defibrillation
* Cardiopulmonary resuscitation
128
K: What issues should be considered when formulating healthcare decisions for critically ill patients?
* Which persons should be involved in discussions regarding the patient's care?
* What additional information is needed to make decisions?
* What is the best way to communicate information to decision-makers?
* What values are most important to the patient and family?
129
K: What is palliative care?
Control of pain and other symptoms (e.g., dyspnea) of terminally ill patients and maximizing the psychological, social, and spiritual well-being of patients nearing the end of life. (K--references WHO definition)
130
K: What is hospice care?
A philosophy of care which helps support the efforts of terminally ill patients by providing clinician coverage and equipment at home (K--refences WHO definition)
131
K: What is withdrawal of care and associated points?
* Removal of life support and unwanted medical interventions when the goals of therapy have changed
* Requires a DNR be in place
* Elevates comfort of patient to primary goal of care, embracing anxiolytics and analgesics
132
K: What id terminal weaning and how should it be carried out?
* Terminal weaning is discontinuation of mechanical ventilation in the face of irreversible illness
* Accomplished by disconnection rather than progressive weaning
* Treats tachypnea or dyspnea with benzodiazepines or barbiturates
133
K: Who presents as a potential organ donor?
* Someone brain dead
* Someone with catastrophic injury to brain with family's and physician's intention to withdraw life support
134
K: What is goal of care once potential organ donor is confirmed?
To maximize and maintain the health of donor organs prior to transplantation.
135
K: What criteria should be followed to preserve health of organs in potential donor?
* Maintain adequate ventilation (PaCO2 35-45mmHg)
* Maintain adequate oxygenation (PaO2 > 100mmHg, SaO2 >95%
* Maintain circulation and perfusion
* Keep hemoglobin >10g/dL and Hct. >30%
* Maintain temperature 36.5-37.5 degrees C
* Maintain normal electrolytes
* Maintain serum glucose 120-180 mg/dL
* Keep eyelids taped shut; apply eye drops
136
K: What are criteria for adequate circulation and perfusion for organ donor?
* Systolic blood pressure > 90mmHg
* Mean arterial pressure > 60-65mmHg
* Cardiac output > 3.8 L/m
* Cardiac index > 2.4 L/min/m2
* Central venous pressure 4-10mmHg
* Urine output 100-200mL/hr.
137
K: Consequences of poor communication behaviors among interdisciplinary teams
* Medication errors
* Infections
* Falls
* Increased complications of disease and its treatment potentially leading to the death of the patient
138
K: Problems with team member interactions that contribute to poor patient outcomes.
* Broken rules
* Mistakes
* Lack of support
* Incompetence
* Poor teamwork
* Disrespect
* Micromanagement
139
K: The Joint Commission identifies what as the primary factor in sentinel events (e.g. preventable deaths)
Poor communication
140
K: Define collaboration
A process of working together towards common goals through joint communication and joint decision making.
141
K: What paradox characterizes high level of collaboration?
High levels of assertiveness and cooperation
142
K: Name barriers to collaboration
* Unhealthy power dynamics
* Poor communication patterns
* Lack of understanding of one's own and other's roles and responsibilities
* Conflicts due to varied approaches that are inherent within diverse clinical teams
143
K: What do truly collaborative relationships require?
* Skilled communication
* Trust
* Knowledge
* Shared Responsibility
* Mutual Respect
* Optimism
* Coordination
144
K: Name categories of ethical behavior of concern to critical care professionals.
* Professional conduct
* Acknowledgement of others
* Cooperation
* Collaboration
* Conflict management
145
K: What long-winded suggestions address conflicts that arise from differences of perspective based on professional position?
* Share models of collaboration that can provide common definitions and common language
* Avoid making assumptions about the prospective of other professionals
* Employ "time out" activities where teams can discuss details of procedures so that errors are reduced and teamwork is improved
146
K: What are the elements of interprofessional collaboration and teamwork?
* Interdependence
* Professional activities (work structures, processes, procedures)
* Flexibility in traditional roles
* Collective ownership of goals
* Reflection on how well team works together
147
K: What are behaviors essential to interprofessional collaboration and teamwork?
* Team communication
* Team leadership
* Team coordination
* Team decision making
148
K: What are the elements of effective interprofessional practice? (Short)
* Relational qualities
* Personal characteristics
* Skills and activities
* Collaborative practice
149
K: How the Society for Critical Care Medicine describes the attributes of interprofessional teams
* Trust and transparency
* Communication and collaboration
* Appreciation of complementary roles for a shared purpose
* Leadership
* Action and accountability
150
K: What issues commonly lead to conflict in critical care units?
* Role boundaries
* Perceptions of unfair decision-making processes
* Autonomy vs. team needs
* Contributions not valued
* Miscommunication of information
* Inappropriate use of hierarchy
151
K: What are the best means to address conflicts in critical care settings?
* Remember that not all conflicts are bad
* Remain professional in conduct--no personal attacks, focus on patient's needs
* "Agree to disagree" if required
* Resolve differences using a third party
152
K: What third parties may be appropriate figures to resolve conflict in ICU?
* Supervisor/manager, following the chain of command
* Physician/intensivist/pulmonologist--following chain of command up to medical director or chief of medical department
153
K: What are indications for arterial line?
* Need to continuously monitor blood pressure
* Need for frequent arterial blood draws
154
K: What equipment is required for an arterial line?
* IV bag with NS (remove all air to prevent possible air embolism)
* Transducer kit with stopcock (ensure system is totally air-free)
* Flush system (pressure bag) (ensure system can reach optimum flush pressure of 300mmHg)
* Arterial line kit (ensure aseptic procedure)
155
K: Give steps, in brief, of procedure to place arterial line.
* Calibrate arterial pressure monitor transducer
* Select radial, brachial, or femoral artery
* Clean site
* Palpate and locate artery for insertion
* Attempt needle insertion in up to two attempts
* Connect transducer flush system to a-line catheter hub
* Cover a-line with transparent dressing
* Secure excess tubing with tape
* Check for passive blood return
* Flush system briefly
* Dispose of needle in sharps container
156
K: Points to remember about a-line transducer.
* Transducer should be placed at the level of the heart
* Transducer placed above the heart will read falsely low
* Transducer place below the heart will read falsely high
157
K: What is preferred site for arterial line placement?
Radial
158
K: How is site for arterial line insertion site prepared?
* Swab with alcohol with circular motion, moving outward
* 2% lidocaine to anesthetize area
* Chlorhexidine swabs
159
K: How can artery for a-line placement be located?
* Palpate to feel the site
* Use doppler to hear the site
* Use portable ultrasound to visualize the site
160
What does K suggest if needle insertion fails in two attempts?
* Consider new site and new personnel
* If need exits skin, replace needle
161
K: What category of disorders merit BAL for diagnosis and treatment?
"Alveolar filling disorders"
162
K: Name specific disorders that can be diagnosed with BAL.
* Alveolar proteinosis
* Interstitial pneumonia
* Cystic fibrosis
* Pneumocystis pneumonia
* VAP
163
K: What is therapeutic lavage?
A larger volume of saline is employed to lavage a lung segment, lobe, or an entire lung
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K: What instrument should be used for therapeutic lavage of a lung segment or lobe?
Flexible bronchoscope
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K: What airway should be used for therapeutic lavage of an entire lung?
Carlens tube.
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K: How should therapeutic lavage for both lungs be timed?
Therapeutic lavage should be applied to one lung; several days later the other lung can be lavaged in the same manner
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K: What is the purpose of the mini-BAL procedure?
To obtain distal lung specimen for VAP diagnosis
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K How are the catheters used for mini-BAL protected from specimen contamination?
Catheter is protected in a sheath with a sealed plug at the distal end.
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K: What is the absolute contraindication for mini-BAL?
Thrombocytopenia, as defined by a platelet count <60,000.
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K: What are the relative contraindications for mini-BAL procedure?
* Hemodynamic instability
* Recent surgery
* High PEEP or FiO2
* High level of ventilator support
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What equipment does K list for a mini-BAL procedure?
* Combicath Kit (13 Fr.)
* Sterile and non-sterile gloves
* Suction equipment
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K: How does one set up for a mini-BAL?
* Pre-oxygenate with 100% O2 for at least 3 minutes
* With non-sterile gloves, aspirate at least 50mL of non -bacteristatic saline into 20 mL syringes
* Suction patient prior to procedure
* Attach kit’s airway adaptor between ETT and vent circuit
* Place Combicath on sterile towel
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K: Once set-up is completed, what procedure for mini-BAL should be followed?
* With sterile gloves, insert catheter into airway
* Insert catheter to last mark (56 cm)
(If resistance is met, do not force catheter—
Withdraw 2 cm and attempt to advance again
Advance until past 56 cm marker)
* Retract catheter 3 cm to allow room for inner catheter to advance
* Remove plastic protective spacer which separates inner and outer catheters
* Advance inner catheter and twist to dislodge polyethylene glycol plug at distal end
* Immediately repeat with 20mL saline
(If extreme backpressure is met, reposition catheter to resolve kink or occlusion in the tubing)
* Aspirate 3-4 mL into specimen container—taking care to avoid any contact contamination
* Label sample mini-BAL and patient information
* Suction remaining lavage fluid
* Reassess patient
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K: How does one clean bronchoscope after procedure?
* Wipe exterior surface with soft cloth or brush
* Irrigate and flush suction channel and port with detergent solution
* Rinse entire instrument with tap water
* Immerse the scope in alkaline glutaraldehyde to disinfect
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How does K define thoracentesis?
“A diagnostic and/or therapeutic procedure in which a needle is inserted into the chest to remove air/fluid from the pleural space”
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K: How can the presence of a pleural effusion be established?
* Physical exam: Flatness to percussion, diminished breath sounds, tracheal shift away from the site
* Radiography: Lateral decubitus film shows concave upper border or a continual line from the diaphragm to spices
* Ultrasound
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K: What position is most favored for thoracentesis?
Patient sitting up and leaning forward
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K: How is site prepared for thoracentesis?
3-10mL of 2% lidocaine is injected with 25 gauge needle to anesthetize the site
A longer and larger needle is then used to anesthetize the thickness of the chest wall
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K: Describe thoracentesis procedure on the prepared site
* Locate 7th or 8th intercostal space at the site of maximal dulllness
* Insert needle just ABOVE the RIB to avoid nerves and blood vessels that run just beneath each rib
* Advance needle until fluid can be withdrawn
* Clamp needle to prevent further advance to the lung
* Aspirate 100-300mL of pleural fluid for diagnostic purposes with a 50mL syringe
* Withdraw needle
*Pinch puncture hole to prevent entry of air (suture puncture hole closed or close with adhesive tape)
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K: Interpret appearance of fluid drawn during thoracentesis.
Clear with light straw color: Transudate
Cloudy or opaque: Exudate
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K: What condition is associated with transudate pleural fluid?
Congestive heart failure
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K: What sort of pleural fluid collection is associated with infection?
Yellow or milky exudate fluid
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K: Describe the species of exudate and associated causes
Opaque: Empyema/pyothorax
Yellow or milky: Infection
Bloody (hemothorax; serosanguineous): malignancy or cancer
Purulent: Pus-filled
Mucopurulent: Containing mucus and pus
Chyle: Containing lymphatic fluid
Loculated: Trapped in an enclosed space
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K: What level of pH is considered significant for an exudate in pleural fluid?
<7.3
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K: Name the abnormal conditions that require chest tubes
* Pneumothorax (more specifically, tension pneumothorax)
* Hemothorax
* Pleural effusion
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K: What immediate action is required in an unstable patient with tension pneumothorax or hemothorax?
Insert large-bore needle into pleural space to relieve pressure
Then insert a chest tube and attach a chest-tube drainage system
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K: Where is a chest tube inserted to collect air?
In the anterior chest in the second intercostal space in the midclavicular line
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K: Where is a chest tube inserted to collect fluid?
Between the fourth and fifth intercostal space at the midaxillary line
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K: under what circumstances is wall suction applied to the three-bottle water seal suction drainage system?
When a large amount of fluid, such as blood, must be drained
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K: What is the function of the third bottle in the three-bottle water seal drainage system?
Suction control
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K: How is the suction level controlled in three-bottle water seal drainage system?
The central tube, immersed in fluid, controls the overall suction applied to the system
Any suction applied over the water seal that is greater than the depth of the central tube in the suction control bottle will provoke bubbling that relieves the excess pressure
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K: What is the significance of bubbling in the third bottle of the three-bottle water seal suction drainage system?
A pressure is applied to the bottle that is greater than the pressure of the depth of the tube
If tube is 10cm in the fluid, suction lower than 10cm H2O will provoke bubbling in the system
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K: What is the function of the middle bottle in the three-bottle water seal drainage system?
The middle bottle holds the water seal that prevents air from entering the pleural cavity
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K: What is the significance of bubbling in the central bottle of the three-bottle water seal drainage system?
* Little to no bubbling is normal
* Continuous bubbling should be reported; this finding suggests an air leak in either the system or the pleural/pulmonary space
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K: What bottle in the three-bottle water seal drainage system is usually marked? Why?
* The first bottle, the collection bottle
* It is marked to allow measurement of pleural drainage
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K: How should the water in the water seal bottle of the three-bottle water seal drainage system be monitored?
* Prevent any sudden change in pleural pressure
* Sudden re-expansion of the lung can create pulmonary edema
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K: What action is required if the water seal in the three-bottle water seal drainage system is lost?
* Submerge chest tube in a glass of water
* If patient is receiving mechanical ventilation, leave the tube open to air until a new system can be set up
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K: What troubleshooting is required for marked continuous bubbling in the water seal chamber?
* Check all tubing connections
* Order chest radiograph to verify position of the tube port
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K: What is a disposable drainage unit?
A single unit consisting of three parts and resembling the three-bottle water seal drainage system
200
K: How much water is typically placed in the water-seal chamber of a disposable drainage unit?
Approximately 2cm. water
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K: During spontaneous breathing, how does water in water seal of chest tube move?
* Inspiration: Water rises toward the patient side of the chamber
* Expiration: Water returns to the other side
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K: How much does water in water seal move during spontaneous breathing? Why?
* Water moves 2-6 cm
* Movement represents change in intrapleural pressure
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K: What does the height of the water in the suction control chamber determine?
The amount of suction applied to the pleural cavity
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K: How should water in the suction control chamber be managed?
* Approximately 20 cm water should be added to chamber
* Water should be monitored for evaporation "and changes in the amount of suction"
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K: How should vent management be coordinated with chest tube?
* Estimate the volume lost through the chest drainage system
* Adjust ventilator settings based on abg results
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K: What do you do with the disposable chest drain system when it gets full?
Replace the unit.
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K: How does one manage chest tube when preparing for removal?
* Clamp chest tube for 24 hours (to assume normal intrapleural pressure)
* Observe patient for any respiratory distress (because air or fluid may still occupy the pleural space)
* Take CXR after 24 hours to determine reaccumulation of air or fluid
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K: Patient has clamped chest tube in preparation for its removal. Patient exhibits signs of respiratory distress. What should practitioner do?
Unclamp chest tube.
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K: Patient has clamped chest tube in preparation for its removal. CXR shows pneumothorax or pleural effusion. What should practitioner do?
Unclamp chest tube.
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K notes on process of actual removal of chest tube.
* Instruct patient to take a deep breath and bear down without exhaling (Valsalva maneuver)
* Remove tube
* Place gauze dressing with Vaseline over opening
* Repeat CXR
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K: Patient has pneumothorax of <20%. How should it be treated?
No treatment--unless patient exhibits significant distress.
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K: Patient has a pneumothorax of >20%. How should it be treated?
Chest tube.
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K: Aside from size of pneumothorax, what factors should guide management?
* Basic bedside assessment (vital signs, color, breath sounds, etc.)
* Basic labs (CXR, ABG, EKG, etc.)
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K: What does a hospital disaster plan need to do?
Identify individual and department responsibilities.
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K: The disaster plan needs what in addition to its formulation?
To be practiced periodically.
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K: 6 recommendations for the therapist/departmental role in a disaster--
* Establish a call-in list
* Keep adequate supply of humidifiers, cannulas, masks, and flowmeters
* Be prepared to assist in treatment areas
* Keep resuscitation equipment in working order and in easy access
* Be prepared to transfer ventilator-dependent patients in case of power shortage
* Be prepared to obtain additional equipment needed for the situation
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K: Recommendations for fire disaster response.
* Evacuate the immediate area
* Report the fire and precise location
* Close all doors
* Shut off the main oxygen valves
* Shut off all electrical equipment
* Prepare patients for further evacuation
* Stand by for further instruction from authorized personnel
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K: The acronym procedure in case of fire
Rescue
Alert emergency system
Contain
Extinguish
219
K: The acronym procedure for fire extinguisher use
Pull
Aim
Squeeze
Sweep at base of fire
220
How does K describe bronchial artery embolization?
As a non-surgical, minimally invasive procedure
221
K: Who performs bronchial artery embolization?
Interventional radiologist
222
K: How is bronchial artery embolization performed?
A catheter is inserted into a bronchial artery and particles are injected to create a blood clot.
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K: when is bronchial artery embolization indicated?
Acute hemoptysis in the presence of bilateral infiltrates
