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Irwin and rippes intensive care medicine 7th edition download pdf
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A special section on Nursing Considerations has been added which contains chapters on the use of nursing sensitive quality indicators, the role of advanced practice nurses in the ICU, effective collaborative practices in the critical care team, and ICU nursing and telemedicine. The new edition will be presented in full color for the first time.
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Alternatively, a control-tip endotracheal tube can be used. This tube has a Nasotracheal Intubation nylon cord running the length of the tube attached to a ring Many of the considerations concerning patient preparation and at the proximal end, which allows the operator to direct the positioning outlined for orotracheal intubation apply to nasal tip of the tube anteriorly.
Another aid is a stylet with a light intubation as well. Blind nasal intubation is more difficult to light wand. With the room lights dimmed, the endotracheal perform than oral intubation, because the tube cannot be ob- tube containing the lighted stylet is inserted into the orophar- served directly as it passes between the vocal cords.
However, ynx and advanced in the midline. When it is just superior to nasal intubation is usually more comfortable for the patient and the larynx, a glow is seen over the anterior neck. The stylet is is generally preferable in the awake, conscious patient. Nasal advanced into the trachea, and the tube is threaded over it. The intubation should not be attempted in patients with abnor- light intensity is diminished if the wand enters the esophagus mal bleeding parameters, nasal polyps, extensive facial trauma, [44].
The gum elastic bougie flexible stylet is another alterna- cerebrospinal rhinorrhea, sinusitis, or any anatomic abnormal- tive device that can be passed into the larynx; once in place, the ity that would inhibit atraumatic passage of the tube. As previously discussed in Airway Adjuncts section, after Endotracheal tubes and stylets are now available that have a the operator has alternately occluded each nostril to ascertain fiberoptic bundle intrinsic to the tube or the stylet that can be that both are patent, a topical vasoconstrictor and anesthetic attached to a video monitor.
If the attempt to intubate is still un- are applied to the nostril that will be intubated. The nostril successful, the algorithm that is described in the Management may be dilated with lubricated nasal airways of increasing size of the Difficult Airway section should be followed.
The Proper depth of tube placement is clinically ascertained by patient should be monitored with a pulse oximeter, and sup- observing symmetric expansion of both sides of the chest and plemental oxygen should be given as necessary. The patient auscultating equal breath sounds in both lungs. The stomach may be either supine or sitting with the head extended in the should also be auscultated to ensure that the esophagus has sniffing position. The tube is guided slowly but firmly through not been entered.
If the tube has been advanced too far, it the nostril to the posterior pharynx. Here the tube operator will lodge in one of the main bronchi particularly the right must continually monitor for the presence of air movement bronchus , and only one lung will be ventilated. If this error through the tube by listening for breath sounds with the ear goes unnoticed, the nonventilated lung may collapse.
A use- near the open end of the tube. The tube must never be forced ful rule of thumb for tube placement in adults of average size or pushed forward if breath sounds are lost, because damage is that the incisors should be at the cm mark in men and to the retropharyngeal mucosa can result.
If resistance is met, the cm mark in women [45]. Palpation of the an- turn still cannot be negotiated, the other nostril or a smaller terior trachea in the neck may detect cuff inflation as air is tube should be tried.
Attempts at nasal intubation should be injected into the pilot tube and can serve as a means to ascer- abandoned and oral intubation performed if these methods fail. Measurement of end-tidal carbon Once positioned in the oropharynx, the tube should be ad- dioxide by standard capnography if available or by means of vanced to the glottis while listening for breath sounds through a calorimetric chemical detector of end-tidal carbon dioxide the tube.
If breath sounds cease, the tube is withdrawn several e. Passage through the vocal cords should intubation. The latter device is attached to the proximal end be timed to coincide with inspiration.
Chapter 1: Airway Management and Endotracheal Intubation The cuff should be inflated and proper positioning of the tube ascertained as previously outlined. Occasionally, blind nasal intubation cannot be accom- plished. In this case, after adequate topical anesthesia, laryn- goscopy can be used to visualize the vocal cords directly and Magill forceps used to grasp the distal end of the tube and guide it through the vocal cords Fig.
Assistance in pushing the tube forward is essential during this maneuver, so that the op- erator merely guides the tube. The balloon on the tube should not be grasped with the Magill forceps. Occasionally, one may not be able to successfully place the endotracheal tube in the trachea. The technique of managing a difficult airway is detailed later. Management of the Difficult Airway A difficult airway may be recognized anticipated or unrecog- nized at the time of the initial preintubation airway evaluation.
Difficulty managing the airway may be the result of abnormali- ties such as congenital hypoplasia, hyperplasia of the mandible or maxilla, or prominent incisors; injuries to the face or neck; FIGURE 1.
Magill forceps may be required to guide the endo- acromegaly; tumors; and previous head and neck surgery. Dif- tracheal tube into the larynx during nasotracheal intubation. When a difficult air- way is encountered, the algorithm as detailed in Figure 1. Airway management necessary. Call senior physician for assistance. Invasive airway Noninvasive airway management management.
Yes, pt in Supralaryngeal ventilation No respiratory arrest as conduit for intubation. Direct Laryngoscopy Ablation vs. Modification of the difficult air- Intubating-, video- way algorithm. Chest 2 —, , with per- mission. When a difficult airway is recognized If the operator is able to maintain mask ventilation in a before the patient is anesthetized, an awake tracheal intuba- patient with an unrecognized difficult airway, a call for expe- tion is usually the best option.
Multiple techniques can be used rienced help should be initiated Fig. If mask ventilation and include after adequate topical or local anesthesia direct cannot be maintained, a cannot ventilate—cannot intubate sit- laryngoscopy, LMA or variants , blind or bronchoscopic oral uation exists and immediate lifesaving rescue maneuvers are or nasal intubation, retrograde technique, rigid bronchoscopy, required.
Options include an emergency cricothyrotomy or in- lighted stylet, or a surgical airway. Puritan Bennett, Pleasanton, CA. Flexible Bronchoscopic Intubation Other Airway Adjuncts Flexible bronchoscopy is an efficacious method of intubat- The LMA is composed of a plastic tube attached to a shal- ing the trachea in difficult cases. It may be particularly useful low mask with an inflatable rim Fig.
When properly when the upper airway anatomy has been distorted by tumors, inserted, it fits over the laryngeal inlet and allows positive- trauma, endocrinopathies, or congenital anomalies. This tech- pressure ventilation of the lungs. An intubating LMA not be manipulated. After ad- tion as well as to intubate the trachea with or without the aid equate topical anesthesia is obtained as described in the sec- of a flexible bronchoscope Fig.
The Combitube Puritan tion Anesthesia before Intubation, the bronchoscope can be Bennett, Pleasanton, CA combines the features of an endotra- used to intubate the trachea via either the nasal or oral route.
Personnel who are unskilled in airway tube that has been preloaded onto the bronchoscope is ad- management can easily learn how to use the LMA and the vanced through the vocal cords into the trachea and positioned Combitube together [50].
The flexible bronchoscope has also been used as a stent over which endotracheal tubes are exchanged and as a means to assess tracheal damage period- Cricothyrotomy ically during prolonged intubations. A detailed discussion of In a truly emergent situation, when intubation is unsuccess- bronchoscopy is found in Chapter 9. Intubation by this tech- ful, a cricothyrotomy may be required. The technique is de- nique requires skill and experience and is best performed by a scribed in detail in Chapter The quickest method, needle fully trained operator.
Technique for insertion of the laryngeal mask airway. Tincture of benzoin sprayed on the skin provides greater fixation. Care must be taken to prevent B occlusion of neck veins. Other products e. A bite block can be positioned in patients who are orally intubated to prevent them from biting down on the tube and occluding it.
The cuff should be inflated shorter tube than a conventional LMA. A special endotracheal tube just beyond the point where an audible air leak occurs. Mainte- B [without the adapter C ] is advanced through the LMA-Fastrach nance of intracuff pressures between 17 and 23 mm Hg should into the trachea. The extender D is attached to the endotracheal tube, allow an adequate seal to permit mechanical ventilation under and the LMA-Fastrach is removed.
After the extender is removed, the most circumstances while not compromising blood flow to the adapter is placed back on the tube. The intracuff pressure should be checked pe- riodically by attaching a pressure gauge and syringe to the cuff port via a three-way stopcock. The need to add air continually i. When air is aspirated, the needle is in tube valve is broken or cracked, or c the tube is positioned the airway and the catheter is passed over the needle into the incorrectly, and the cuff is between the vocal cords.
The tube trachea. The needle is attached to a high-frequency jet venti- position should be reevaluated to exclude the latter possibility. Alternatively, a 3-mL syringe barrel can be If the valve is broken, attaching a three-way stopcock to it will connected to the catheter. Following this, a 7-mm inside diam- solve the problem. If the valve housing is cracked, cutting the eter endotracheal tube adapter is fitted into the syringe and is pilot tube and inserting a blunt needle with a stopcock into the connected to a high-pressure gas source or a high-frequency jet lumen of the pilot tube can maintain a competent system.
A ventilator. An algorithm with suggestions for the management hole in the cuff necessitates a change of tube. Routine suctioning should not be performed in patients Any patient with multiple trauma who requires intubation in whom secretions are not a problem. Suctioning can produce should be treated as if cervical spine injury were present. In a variety of complications, including hypoxemia, elevations the absence of severe maxillofacial trauma or cerebrospinal in intracranial pressure, and serious ventricular arrhythmias.
However, in Preoxygenation should reduce the likelihood of arrhythmias. If oral intubation is required, an risk of hypoxemia but have not been shown to reduce the rate assistant should maintain the neck in the neutral position by of ventilator-associated pneumonia VAP compared to open ensuring axial stabilization of the head and neck as the patient suction systems [52].
A cervical collar also assists in immobiliz- ing the cervical spine. In a patient with maxillofacial trauma Humidification and suspected cervical spine injury, retrograde intubation can Intubation of the trachea bypasses the normal upper airway be performed by puncturing the cricothyroid membrane with structures responsible for heating and humidifying inspired air. The wire see Chapter Alternatively, the Tube Replacement wire can be threaded through the suction port of a 3.
At times, endotracheal tubes may need to be replaced because of an air leak, obstruction, or other problems. Before attempting to change an endotracheal tube, one should assess how difficult Airway Management in the Intubated Patient it will be. After obtaining appropriate topical anesthesia or IV sedation and achieving muscle relaxation, direct laryngoscopy can be performed to ascertain whether there will be difficulties Securing the Tube in visualizing the vocal cords.
If the cords can be seen, the defec- Properly securing the endotracheal tube in the desired posi- tive tube is removed under direct visualization and reintubation tion is important for three reasons: a to prevent accidental performed using the new tube.
Although the complication rates on the regular hospital floor and in the ICU appear to Table 1. Factors implicated in the etiol- ified with standardized algorithms as outlined previously. The ogy of complications include tube size, characteristics of the most frequent complications encountered in these two settings tube and cuff, trauma during intubation, duration and route are multiple intubation attempts and esophageal intubation in of intubation, metabolic or nutritional status of the patient, the general hospital units, and severe hypoxemia and hemody- tube motion, and laryngeal motor activity.
Presence of acute respiratory failure During endotracheal intubation, traumatic injury can occur and presence of shock appear to be an independent risk factor to any anatomic structure from the lips to the trachea.
Pos- for the occurrence of complications in the latter setting [55,56]. Ventricular tachycardia and ventric- Complications during intubation ular fibrillation are uncommon but have been reported. Pa- Spinal cord injury tients with myocardial ischemia are susceptible to ventricular Excessive delay of cardiopulmonary resuscitation arrhythmias, and lidocaine prophylaxis mg IV bolus be- Aspiration fore intubation may be warranted in such individuals.
Brad- Damage to teeth and dental work yarrhythmias can also be observed and are probably caused Corneal abrasions by stimulation of the laryngeal branches of the vagus nerve. Hypotension or hypertension can oc- Larynx cur during intubation. In the patient with myocardial ischemia, Trachea short-acting agents to control blood pressure nitroprusside, Dislocation of an arytenoid cartilage nicardipine and heart rate esmolol during intubation may be Passage of endotracheal tube into cranial vault needed.
Epistaxis Cardiovascular problems Ventricular premature contractions Complications While the Tube is in Place Ventricular tachycardia Bradyarrhythmias Despite adherence to guidelines designed to minimize damage Hypotension from endotracheal intubation, the tube can damage local struc- Hypertension tures. Microscopic alterations to the surface of the vocal cords Hypoxemia can occur within 2 hours after intubation.
Evidence of macro- Complications while tube is in place scopic damage can occur within 6 hours. As might be expected, Blockage or kinking of tube clinically significant damage typically occurs when intubation Dislodgment of tube is prolonged. The sudden appearance of blood in tracheal se- Advancement of tube into a bronchus cretions suggests anterior erosion into overlying vascular struc- Mechanical damage to any upper airway structure tures, and the appearance of gastric contents suggests poste- Problems related to mechanical ventilation rior erosion into the esophagus.
Both situations require urgent see Chapter 58 bronchoscopy, and it is imperative that the mucosa underlying Complications following extubation the cuff be examined. Other complications include tracheoma- Immediate complications lacia and stenosis and damage to the larynx. Failure to secure Laryngospasm the endotracheal tube properly or patient agitation can con- Aspiration tribute to mechanical damage.
Intermediate and long-term complications Another complication is blockage or kinking of the tube, Sore throat resulting in compromised ventilation. Suctioning can usually solve Laryngitis blockage from secretions, although changing the tube may be Vocal cord paralysis unilateral or bilateral necessary. Laryngeal edema Unplanned extubation and endobronchial intubation are Laryngeal ulcerations potentially life threatening.
Judicious use of sedatives and Laryngeal granuloma analgesics and appropriately securing and marking the tube Vocal cord synechiae should minimize these problems. Daily chest radiographs with Tracheal stenosis the head always in the same position can be used to assess the position of the tube.
Using a The patient should be alert, lying with the head of the bed smaller endotracheal tube may decrease the incidence of pos- elevated to at least a degree angle.
The posterior pharynx textubation sore throat and hoarseness. Ulcerations of the lips, must be thoroughly suctioned. The procedure is explained to mouth, or pharynx can occur and are more common if the ini- the patient. The cuff is deflated, and positive pressure is applied tial intubation was traumatic.
Pressure from the endotracheal to expel any foreign material that has collected above the cuff as tube can traumatize the hypoglossal nerve, resulting in numb- the tube is withdrawn.
Supplemental oxygen is then provided. Uni- bled at the bedside. The utility of this procedure is limited in routine prac- Some degree of laryngeal edema accompanies almost all en- tice, but for patients with certain risk factors e.
In adults, this is usually clinically in- intubation, prolonged intubation, and previous accidental ex- significant. Laryngeal ulcerations are commonly observed after dor [57]. Probably the safest means to extubate the patient if extubation. They are more commonly located at the posterior there are concerns about airway edema or the potential need to portion of the vocal cords, where the endotracheal tube tends reintubate a patient with a difficult airway is to use an airway to rub.
Ulcerations become increasingly common the longer the exchange catheter. This device is inserted through the endo- tube is left in place. The incidence of ulceration is decreased by tracheal tube, and then the tube is removed over the catheter. Laryngeal granulomas and synechiae of patient, and the catheter can be used as a stent for reintubation the vocal cords are extremely rare, but these complications can if necessary.
Surgical treatment is of- One of the most serious complications of extubation is ten required to treat these problems. The application of positive pressure can some- cheal stenosis. This occurs much less frequently now that high- times relieve laryngospasm.
If this maneuver is not successful, volume, low-pressure cuffs are routinely used. Symptoms can a small dose of succinylcholine by the IV or intramuscular occur weeks to months after extubation. In mild cases, the pa- route can be administered. Succinylcholine can cause severe tient may experience dyspnea or ineffective cough. If the airway hyperkalemia in a variety of clinical settings; therefore, only is narrowed to less than 5 mm, the patient presents with stridor.
Ventilation with a mask and bag unit is needed until the surgical intervention is necessary. The reader is referred to from mechanical ventilation see Chapter 60 , b recovery of Chapter 12 for details on tracheostomy. References 1. Crit Care Med —, Fowler RA, Pearl RG: The airway: emergent management for nonanesthesi- diction in patients intubated in the emergency department.
Ann Emerg Med ologists. West J Med —50, Mort TC: The incidence and risk factors for cardiac arrest during emergency J Clin Anesth —, Mort TC: Emergency tracheal intubation: complications associated with re- difficulty at intubation in the emergency department?
Emerg Med J — peated laryngoscopic attempts. Anesth Analg —, , table of , Anesthesiology tation and emergency cardiovascular care. Circulation IV-1—IV-5, Can Anaesth Soc J —, and performance. Anesthesiology —27, Lewis M, Keramati S, Benumof JL, et al: What is the best way to determine tending anesthesiologists on complications of emergency tracheal intubation. Anesthesiology —75, Philadel- related to endotracheal intubation in the intensive care unit: a prospective, phia, PA, Churchill Livingstone, , pp — Intensive Care Med —, Anesth Analg —, Anesthesi- Anaesthesia —, Anesthesiology —37, in obliterating the esophageal lumen in the presence of a nasogastric tube.
Anesthesiology —, Hagberg CA: Current concepts in the management of the difficult airway. New York, McMahon Publishing, Br J Anaesth —, Anaesthe- for awake fiberoptic endotracheal intubation. Anesth Analg —, sia —, The value of Anaesthesist —50, latory responses to laryngoscopy and tracheal intubation.
Crit Care Med Can J Anaesth —, adrenocortical deficiency in intensive care patients needing mechanical ven- Lancet —, J Clin N Engl J Med —, Reynolds SF, Heffner J: Airway management of the critically ill patient: rapid- during emergency airway management. Chest —, Mace SE: Challenges and advances in intubation: rapid sequence intubation. Emerg Med Clin North Am —, x, The Combitube and laryngeal mask. Anaes- Mort TC: Preoxygenation in critically ill patients requiring emergency tra- Cochrane Am J Respir Crit Care Chest —, the 25 degrees head-up position than in the supine position in severely obese A prospective investi- J Clin Anesth —24, Anesthesiology —86, Sellick BA: Cricoid pressure to control regurgitation of stomach contents care unit patients.
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Irwin and rippes intensive care medicine 7th edition download pdf
Editors Richard S. Irwin, MD, James M. Irwin, M. Rippe, M. Cerra, M. Fink, M. Alpert, M. Dalen, M. All rights reserved.
This book is rrippes by copyright. No part of this book may be reproduced in any form or by any downpoad, including photocopying, or utilized by any information storage and retrieval system without written permission from the publisher, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official смотрите подробнее as U.
Irwin, James M. Intensive care medicine Includes bibliographical references and index. ISBN alk. Critical care medicine. Irwin, Richard S. Rippe, James M. Title: Intensive downooad medicine. Intensive Care—methods. Intensive Care Units.
WX ] RC I Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. Downloaf, irwin and rippes intensive care medicine 7th edition download pdf authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no editon, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional responsibility of ddownload practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance узнать больше здесь current recommendations and practice at the time of publication.
However, in view of ongoing research, changes in government regulations, and the constant flow of information relating irwin and rippes intensive care medicine 7th edition download pdf drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions.
This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this irwi have Food and Drug Administration FDA clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.
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Louis, MO Thaddeus C. Ednan K. Daniel T. Baran, MD Mary T. Contributors vii. Michael C. Bonnie J. Bidinger, MD Traci L. Burns, MD Robert M. Vincent Hospital Scott W. Cannon, MD Suzanne F. Caplan, MD William F. Raphael A. Carandang, MD Victor G. Co, MD Paul A. Contributors ix. Frederick J. Curley, MD Gregory J. Frank F. Jennifer S. Daly, MD Akshay S. Paul F. Dellaripa, MD David A.
David F. Aand, PhD Timothy A. Contributors xi. Alan M. Michael A. Fifer, MD Shrawan G. John G. Gianopoulos, MD Damian J. Michael M. Louis, MO. Contributors xiii. Stephen B. Hanauer, MD Thomas L. Hollingsworth, MD Lawrence J. Heffner, MD Rolf Inensive. Jeremy S. Robert J. Heyka, MD Intensuve L. Richard S. Paul G. Jodka, MD Eric M. Rao R. Ivatury, MD Scott B. Sreenivasa S. Eric W. Jacobson, MD Bryan S. Eias E. Contributors xv. Louis, MO Christoph R.
Phillip A. Letourneau, MD Mark S. Howard B. Craig M. Contributors xvii. Robert B. Matthew W.
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