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Although there is little evidence demonstrating a reduction in pneumothorax rates when fluoroscopic guidance is used for TBLB, this is a common practice in the ICU. Due to the complexities and potential complications, it is recommended that bronchoscopy in the ICU be performed by an experienced physician so as to minimize complications and maximize benefits.
PDT employs the modified Seldinger technique by introducing sequential dilators through the skin into the trachea to create a tract for the tracheostomy tube. Indications While the benefits of early tracheostomy versus endotracheal intubation to facilitate faster weaning from mechanical ventilation and the optimal timing for tracheostomy are still being debated, it is accepted worldwide that PDT plays an important role in the ICU.
Complications and recommendations The main early complications of tracheostomy are bleeding, pneumothorax, pneumomediastinum, subcutaneous emphysema, tracheal wall injury and false passage.
This is due to the fact that the pleural cavity extends around the lateral tracheal wall to the posterior tracheal wall, and can be lacerated if the posterior tracheal wall is punctured. Another mechanism of pneumothorax after PDT is due to pneumomediastinum leaking through the mediastinal pleura. Other advantages include cost reduction attributable to avoidance of operating room costs and elimination of risky transport of critically ill patients to the operating room.
Thoracentesis and chest tube insertion are frequently performed and generally safe. However, these procedures are more challenging in the critically ill patient, who may have severe respiratory compromise requiring high levels of positive pressure mechanical ventilation, or bleeding disorders.
Indications The indications of pleural procedures can be broadly divided into diagnostic and therapeutic purposes. For example, simple transudative effusions usually resolve with medical management alone. Conversely, diagnosing a complicated parapneumonic effusion or emphysema in a critically ill patient necessitates urgent drainage or even surgery to control the septic process. The importance of diagnostic thoracentesis is illustrated by a prospective study reporting that this procedure led to a change in diagnosis and therapy in more than half of the patients in three medical ICUs.
In particular, the ICU patient with ARDS on high levels of positive pressure mechanical ventilation may tolerate pneumothorax poorly, and be more prone to bleeding complications due to bleeding disorders. Additionally, it is often not possible to position these patients optimally for the procedure, thus making it more challenging to identify the best entry site.
The traditional approach to diagnose pleural effusion or pneumothorax in the ICU patient via physical examination and portable supine chest radiography has limited sensitivity and specificity.
It can differentiate an effusion from atelectasis, consolidation, mass or an elevated diaphragm, thus allowing the safest and best insertion sites for needles and tubes to be identified Fig. Figure 2 Open in figure viewer PowerPoint Ultrasound image of pleural effusion. In addition, adequate training and credentialing is important as the effectiveness and complication rates depend on the competency of the operator.
These include measurement of central venous pressure for optimization of fluid status of the patient, infusion of vasoactive drugs and parenteral nutrition, emergency venous access and central venous oxygen saturation ScvO2 sampling. This is especially pertinent in ICU patients, many of whom present with difficult or complicated venous access.
With the application of distal tip balloon floatation, introduced by Ganz in the , it became available to the bedside clinician. However, until the early s PACs were used almost exclusively for diagnostic purposes in catheterization laboratories to identify potential cardiac surgical cases. Indications The PAC is used to obtain hemodynamic parameters to guide physiologic support for example cardiac output, pulmonary artery occlusion pressure, pulmonary artery pressure and mixed venous oxygenation.
Complications and recommendations The benefit of PACs was assumed until Connors conducted a retrospective observational study and questioned the safety of PAC use.
Other complications include infection 2. There were no complications leading to deaths in these studies. Once you've submitted all documents and fees, you should receive your registration in the mail within weeks.
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