All about central line

-infect rate Subclavian< int jug < femeral

-misplacement of the catheter tip in the internal jugular vein. occurs in approximately 5% of patients,increase the risk of thrombophlebitis, thrombosis, and inaccurate measurements of central venous pressure.

-Subclavian v thrombosis also called paget schroetterนะจ้ะ

Rt IJ กะ Rt subclavian v. ลึก 13 cm เท่ากัน

complication ไม่ต่างกัน จากเล่มนี้

Approacho f internal jugular
Anterior approach: insert the needle at the medial edge of the sternocleidomastoid muscle at about the level of the thyroid cartilage. Insert the needle at about 45 degrees. Aim for the ipsilateral nipple.
Central approach: insert the needle at the superior aspect of the sternocleidomastoid triangle. Insert the needle at about 45 – 60 degrees. Aim for the ipsilateral nipple.
Posterior approach: insert the needle at the lateral edge of the sternocleidomastoid muscle at about the level that is 1/3 the distance from the clavicle to the mastoid. Insert the needle at about 45 – 60 degrees. Aim for the sternal notch.

ลากเส้นสมมุติจาก ASIS to pubic tubercle
แบ่งเป็น 3 ส่วน
femoral a. อยู่จุดต่อระหว่าง middle & medial part
femoral v. อยู่ medial ต่อจุดนั้น 1-2 cm

วิธีป้องกันแทบ subclavian ขึ้นคอ
The Ambesh maneuver, which involves manual occlusion of the internal jugular vein during subclavian-vein cannulation, helps to determine whether the catheter tip is in the internal jugular vein.2

Another maneuver is to flush the catheter with 10 ml of normal saline and ask the patient whether there is a sensation of fluid gushing in the neck or a ringing in the ear.

Orthostatic hypotension

Orthostatic hypotension
วัดความดันท่า นอน แล้วเปลี่ยนเป็นท่ายืน (ถ้ายืนไม่ได้อาจใช้ท่านั่ง)
วัดก่อนและหลังยืน 1-3 นาที
วินิจฉัยว่าเป็น postural hypotension เมื่อ
Ps drop > 20 mmHg and/or Pd drop > 10 mmHg
นอกจากนี้ ถ้าเปลี่ยนท่าแล้ว HR ขึ้นน้อยกว่า 10 ครั้งต่อนาทีแสดงว่าเป็น autonomic dysfunction
ถ้า HR > 100 min หรือ เพ่ิม > 30 min แสดงว่า hypovolemia

Phlebostatic axis

phlebostatic axis
[-stat′ik]
Etymology: Gk, phleps + stasis, standing still

the approximate location of the right atrium, found at the intersection of the midaxillary and a line drawn from the fourth intercostal space at the right side of the sternum. The phlebostatic axis is used extensively in hemodynamics.

Underdamped overdamped

Half life of IV fluid

NSS or RL 1 liter given- 200 cc intravascular expansion lasting for about 2 hours (cheap)
Albumin 5%- give 1 liter, expand by 500 cc. Lasts 24 hours. Expensive.
Albumin 25%- give 100cc, expand by 500 cc.
Hetastarch- give 1 liter, expand by 750 cc. Lasts 24-36 hours.
D40 – give 1 liter, expand by 800 cc. Lasts 24 hours.
D70 – give 1 liter, expand by 1000cc. Lasts 24 hours.

Post intubate laryngeal edema

-ไม่ recommend NPPV
-effectiveness of glucocorticoids in post-extubation laryngeal edema has not been confirmed in randomized controlled trials. In our experience, however, the potential benefit out- weighs the risk of adverse events.
-CTs that prove efficacy of epinephrine in post-extubation laryngeal edema in adults are again lacking. Likewise, there is no consensus about the potentially effective dosage of epinephrine nebulization. A dose of 1 mg epinephrine in 5 ml normal saline has proved successful in some cases of upper airway obstruction in adults [51]. Rebound edema is known to occur and close observation is essential
-The use of non-invasive positive pressure ventilation in patients with laryngeal edema might therefore be harmful, as laryngeal edema progresses and further obstructs the remaining airway – making reintubation more difficult, if not impossible.

Intraabdominal hypertension

Severity
Mild 12-15
Mod 15-20
Severe 20-25
Very severe >25
compartment > 20

Intra-abdominal hypertension (IAH) is defined as a sustained or repeated pathologic elevation of IAP > 12 mmHg.

Normal IAP is approximately 5-7 mmHg in the critically ill, but varies by disease severity with an IAP of 20-30 mmHg being common in patients with severe sepsis or an acute abdomen

Abdominal compartment syndrome (ACS) is defined as a sustained increase in IAP > 20 mmHg (with or without an APP 25 mmHg.

TREATMENT
Abdominal compartment syndrome resulting from tense ascites
is an indication for immediate paracentesis. Pre- and
postparacentesis measurements of IABP, urine output, hemodynamics, and airway pressures help confirm ACS and
demonstrate the benefit of therapeutic intervention. In most
other cases of ACS, prompt surgical decompression is indicated.
Determining the appropriate timing for surgical intervention
is challenging and may require serial measurement
of IABP and assessment of organ function. It is vital to intervene
before the development of critical organ dysfunction. To
aid in the determination of timing of surgery, some surgeons
assess abdominal perfusion pressure (APP = MAP − IABP).
An APP <50 mm Hg is associated with a poor outcome and
the need for quick intervention.58 While the operating room
is prepared, volume resuscitation and low tidal volume ventilation are useful temporizing measures.

Role of albumin in sepsis

Crit Care Med. 2011 Feb;39(2):386-91.
The role of albumin as a resuscitation fluid for patients with sepsis: a systematic review and meta-analysis.
Delaney AP, Dan A, McCaffrey J, Finfer S.
Source

Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia. adelaney@med.usyd.edu.au
Abstract
OBJECTIVE:

To assess whether resuscitation with albumin-containing solutions, compared with other fluids, is associated with lower mortality in patients with sepsis.
DATA SOURCES:

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases, the metaRegister of Controlled Trials, and the Medical Editors Trial Amnesty Register.
STUDY SELECTION:

Prospective randomized clinical trials of fluid resuscitation with albumin-containing solutions compared with other fluid resuscitation regimens, which included a population or subgroup of participants with sepsis, were included.
DATA EXTRACTION:

Assessment of the validity of included studies and data extraction were conducted independently by two authors.
DATA SYNTHESIS:

For the primary analysis, the effect of albumin-containing solutions on all-cause mortality was assessed by using a fixed-effect meta-analysis.
RESULTS:

Seventeen studies that randomized 1977 participants were included in the meta-analysis. There were eight studies that included only patients with sepsis and nine where patients with sepsis were a subgroup of the study population. There was no evidence of heterogeneity, I² = 0%. The use of albumin for resuscitation of patients with sepsis was associated with a reduction in mortality with the pooled estimate of the odds ratio of 0.82 (95% confidence limits 0.67-1.0, p = .047).
CONCLUSIONS:

In this meta-analysis, the use of albumin-containing solutions for the resuscitation of patients with sepsis was associated with lower mortality compared with other fluid resuscitation regimens. Until the results of ongoing randomized controlled trials are known, clinicians should consider the use of albumin-containing solutions for the resuscitation of patients with sepsis.
Comment in

Crit Care Med. 2011 Feb;39(2):418-9.

Normal value in hemodynamics