When you can measure what you are speaking about, ane expres it in number, you know something about i but when you cannot measure it, when you cannot express it in numbers, your knowledge is of 2 meager and unsatisfactory kind it may be the beginning of lnowledge, but you have scarcely in your thoughts, advanced to the state of sine William Thompion, Lond Kein Isee907 Invasive Montrorinc AND ITS. ComPLICATIONS IN THE Intensive Care Unir ARNOLD SLADEN, M.D. Profesor of Anesthesiology aed Critical Care Medicine, Asocate Profesor of Surgery, Univesity of Pitsburgh School of Medicine; Director, Surgical Intensive Care Unit Montene Hospital Pisburgh, Pensyvania With 205 illastrations Tur C. V. Mossy Company St Louis # Bahimore + Philadelphia * Toronto 1990 seersEPEC TOE r rere errr eres Cleese site) CONTENTS cure, 1 EVOLUTION OF MONITORING, 1 Diagnosis in the early seventeenth century, 1 Edocation ofthe seventeenth-century physician, 3 Leaders in. mor toring from the late seventeenth century, 7 Evolution ofthe intensive care units, 36 ARTERIAL PRESSURE MONITORING, 47 Auterial cannulation, 47 Arterial pressure monitoring, 49 Arterial catheters and plumbing, 52 Site selection, 53 4 Preparation for arterial cannulatio Anatomy of radial and uln palmar anteties and superficial and deep 5, 56 Radial or ulnar artery cannulation, 61 Complications of radial and ulnar artery catheterization, 67 Femoral artery, 78 Femoral artery cannulation, 79 Complications of femoral artery catheterization, 85 Auillay artery, 86 Axillary artery cannulation, 57 Complications of axillary artery cannulation, 93Brachial artery cannulation, 94 Arterial blood sampling (arterial phlebotomy), 4 cuvrrer 3 CENTRAL VENOUS CATHETERIZATION, 99 Indications for central venous catheterization, 101 Subelavian vein, 102 Internal jugular vein, 103 Cannulation, 105, Complications of central venous catheterization, 114 4 PULMONARY ARTERY CATHETERIZATION, 125 Indications for pulmonary artery catheter Re Pulmonary artery catheter, 129 te selection, 131 Pulmonary artery catheterization, 132 Complications of pulmonary artery catheterization, 161 Frequeney of complications, 161 Complications at insertion sites, 162 Errors and artifacts, 163 Knotting, entanglement, and embolic fragments, 166 Arhythmias, 168 Intracardia lesions, 172 Perforation of the pulmonary artery, 178 TTheombus formation, 180 Pheumonectomy, 183, Other complications, 183 Lack of corelation between PAWP and left ventricular end diastolic volume post coronary bypass procedures, 184 I S222IIIIDIZIQIIIITTITIT TEE eit contents wii corre 5 INFECTION-COMPLICATING INTRAVASCULAR DEVICES, 191 Identification of intravascular catheter-related infections, 193, CCatheterelated infections, 193, Mechanical equipment and infection, 197 compre 6 INTRACRANIAL PRESSURE MONITORIN' Indications for ICP monitoring, 200 Complications of ICP monitoring, 211 cuarreR 7 URINARY BLADDER CATHETERIZATION, Indications for urinary eatheteization, 215 Infection and complications of urinary catheterization, 216, Prevention of infection, 217 a ‘THE ROLE OF INVASIVE MONITORING, zuCHAPTER 1 EVOLUTION OF MONITORING Monitoring had is genesis inthe late seventeenth century, when science became independent of philosophy, when precise measure- ‘ment and exact methodology became as important tothe physician as empiricism had been. In the last three centuries scientific know cedge and understanding of the frailty and complesty of the hu- rman body has inereased steadily and unbounded, Consequently, ‘monitoring techniques have been advanced and refined. However, what advancements have been made toward beter patient: physician communication? Has the advent of sophisticated moni toring equipment and the data derived from it inthe intensive care tunit (ICU) produced physicians who look only at waveforms and rmumbers, are remote from the bedside, and ignore the patient” DIAGNOSIS IN ‘THE EARLY SEVENTEENTH CENTURY ‘Three centuries ago, the early seventeenth-century physician at tended his patient primarily by listening to his narrative and then prescribing therapy." Diagnosis was made by allowing the patent to fully describe his symptoms, when necessary supplemented by in {errogative remarks of the physician. This remains the typical method of obtaining a medical history, even in the twentieth cen- tury. From the history the seventeenth-centry physician would se lect specific point as indicators of current ot even pas illnes. The physician became skilled in studying the patient's overall physical, appearance and behavior pattern, and it was unusual for any phys: ical contact to take place between physician and patient46 INVASIVE MONITORING AND ms COM 51. Lasen HCA: A preliminary reprt on the 1952 epidemic of pions clits in Copenhagen with special reference tothe treatment of acute respiratory mnslcency, Lancet 137, 1953, Itven Bs Anaesthetists viewpoint ofthe treatment of respiratory com. pliations in poliomyelitis daring the epidemic in Copenhagen, 1952. Poe R'Sec Med 14:72, 1954 53, Fainky HB: The Toronto Genctal Hospital piratory unit, Anaesthe- sia 16.267, 1961 54, Holmudahl MH: The esptatory cae unit, Anethesiology 23559, 1962 55, Sar P et al The intensive care unit, Anaesthesia 16275, 1961 56, Waklund PE: Intensive care nits: design, locaton, stafing ancillary atas, equipment, Anesthesiology 31:122, 1969. Shoemaker WC, Een DH, and Rosen AL: Development and goal ‘of trauma apd shock research center, Mt Sinai } Med 35451, 1968, 58. Brown KWG et al: Coronary unit an inlensvecarecente for acute rvocardal infarction, Lancet 2349, 1963 tein A-and Scheiner ME The eadotachoscope, Anesthesia 2, 1952. (60, Safar P and Grenvik A: Crcal care medicine: onganizing and safing intensive care units, Chest INNA CHAPTER 2 ARTERIAL PRESSURE MONITORING. ARTERIAL CANNULATION Although the direct invasive technique for measuring arterial blood pressure was used on a animal ay ealy as 1733, it was not ‘until 1856 that it was used on a human being. The technique was teed by a French physician named Fuivte, who cannulated the leg antery ofan amputee." “Many factors have impeded the progres of diet invasive mea: surement, but the discovery of heparin in 1917 greatly facilitated the technique, whieh wsed a metal needle, a heparinized saline ‘ridge, and a mercury oF aneroid manometer." In 1947 the stain gauge ransdcer was introduced‘ The transducer functions on the basis that stretch force applied toa wite changes both length and ‘ros Sectional area and in turn electrical resistance. Using four ‘utes to form a Wheattone bridge, one ean calibrate changes in ‘output voltage to represent pressures applied to the transduce’ dh aphragm. The strain gauge tansducet and introduction of paste tubing allowed direct inteaatesal pressure measurement to be uscd more requenty in clinical practice, Peterson, Deipps, and Risman, working sn the Hanson Depurtment of Surgical Research atthe University of Pennsylvania School of Medicine, disked both the id metal needle and the need to proces the photographic paper of the atrial tracing before the data could be analyzed—a tet spective clinical evaluation.” To overcome these hurdles they de- signed and made intaarteval plastic cannulae, which they used in conjunction with an amplificr and ink recorder. This provided a4 INVASIVE MONITORING AND TS GoMRLICATIONS dynamic, visible, and perm: ng of the arterial pulse contour. ‘The catheters were made by heating polyvinyl resin tubing and drawing itout to the desived length and diameter, ‘The cathe ters were cut to size and, until requited, left to soak in Zephiran Chloride solution. Even at that time Peterson and Dripps were concemed with end pressure, turbulence, and capacity. They were aware that pressure monitoring conduits were under damped sys tems of natural frequeney that could produce overshoot of pressure measurement. ‘The pressure ttacings reproduced from their text clearly demonstrate in clinical situations the effects of hemorshage and failure to contol the hemorrhage (Figure 2-1) In 1961, Barr fist described the percutaneous puncture of the radial artery with a Teflon catheter that could be used for contin ‘ous monitoring and arterial blood sampling." ‘The thrust for direct blood pressure monitoring came with the rapid expansion of eatdion vascular surgery in the 1950s and 19606. Previously used classic noninvasive techniques were useless during the nonpubatile low of Blond being replaced-stll Bleeding FIGURE 2.1. Brachial atery tracings frm a 55-year-old male undergoing pneumonectomy for bronchogenic carcinoma, 1157: Peicadiar ‘pened. 1201: Masive hemorshage fom lung hil. 12.2%: Tal of 3000 rl of blocd given by syringe. 1250 Hemonhage continued, heat slopped. and presure decreased to 23 mm Hg. from Peteran LH Dripps RD and Risman GC: A method fr mconding the arterial presune pulse and Blood prsur in man, Am Hert 137.771, 1949) NNR ARTERIAL PRESSURE MONITORING ” cardiopulmonary bypass. Continuous intaarteril pressure moni- toring became indispensable, ARTERIAL PRESSURE MONITORING Its essential to be aware at the outset that there isa lack of eor- relation between the acquired data of arterial pressure measured by the inditeet classic method and by the direct invasive method, since the two techniques do not measure the same functions. Indirect blood pressure measurements depend on blood flow and are deter: ‘mined by using an inflatable cuff and either a stethoscope or Dop pler system, ‘The return of blood flow in the artery as the cull is deflated indicates systole, and subsequent changes in sound indi- cate diastole. An intraarterial catheter measures presses ditcely ‘One technique measures flow; the other measures pressure. There- fore it is not surprising that direct measurements of systolic and di- astolic pressures corteate rather poorly with indirect measure- rents, Bruner and co-workers, using the most extensive review to date, coupled with their own clinica studies, conclude that auscul- tatory systolic pressure is usually lower than direct, but there are ‘numerous instances in which Riva-Rocei readings are 20 mun Hg for more higher than direct readings.” Similanly, indirect diastolic pressure is lower than direct, but because of the narrow range of diastolic pressures, the differences are less than those that occur in systole. One would expect direct pressure measurement to be sim ple and yield correct values. A variety of complex and complicating factors interfere with the determination of true values, producing terrors and therefore inherent complications in both primary mea- ‘surements and subsequent therapy, ‘To display arterial blood pressure on a monitor digitally, one re- ‘quires, in addition to the monitor, an indwelling arterial catheter, tubing containing a heparinized solution, a transducer and stop: cock’). Each of these, because oftheir ox natural frequency and damping effects, changes what the monitor finally records from within the intraarteral system, The natural fequency refers to how rapidly the system oscillaes, and the damping coefficient refers to Thow quickly the system comes to rest. The underdamped catheter transducer system overestimates the systolic prssute, frequently by as much as 15 to 30 mim Hg, A presure transducer consists of a chamber with a stiff, low ‘compliance, pressure-snsing diaphragm capable of bending and creating a small volume change in response to an applied pressure50 INVASIVE MONITORING AND IS COMRUICATIONS change. ‘The mechanical movement then is converted into an elee- trical signal by changing the resistance in a Wheatstone bridge This apparatus is very sensitive and will provide false values if dam. aged. Recently developed silicon erystals have redced the errors inherent inthe older wite transducers, which were easily subject to damage, The transducer dome should be stall, made of tratspar- ‘ent material to disclose air bubbles, and designed for easy removal The transducer requires an orifice to which a stopcock can be at tached. Its at this site, opaque and invisible, that air bubbles ac cumulate, Periodically, transducers should be calibrated directly with a mereury manometer, From the transducer the electrical sig nal enters the preamplifier and amplifier, where the transducers cean be zeroed and calibrated. Finally, the signal is displayed on a cathode ray tube or sercen. Resonance in the Auidicssstem, which consists of tab 1g and its fluid content, results in the production of autifets. These artifcts are filtered out in the electronic hardware to give an acceptable systole contour. Because of the use of high frequency filtering in pressure monitors, diferences may become apparent between direct prestre measiements, and indivect or marked differences in systole pressures can be observed if a patent is moved from one monitor to another with high-frequency filers of diferent physical characteristics, ‘The system is calibrated when filled with « heparinized solution fiom a pressurized bag. As the solution enters the flow chamber and is depressurized, air bubbles accumulate—a major source of pressure measurement errors, ‘These bubbles become sequestered in the transducer dome, in the connecting tubing, or within the ‘opaque stopcock; they depres oscillation and in turn overdampen the sytem. Another cause of etror is overpresurizing the transdue- cers with ud either while the system is being set up or during cal: ibration. Depressurizing by leakage from the system results in a progressive downward drift of the shape ofthe waveform, which in tum is reflected by inaccurate recordings and subsequent misman- agement, Finally the transducer has to be leveled, Arterial pressure is ef cerenced, usally tothe left ventricle, and itis to this position the transducer must be leveled and with the stopeock open (atmo- spheric pressure). Failure to have a comrect zero reference point will provide useless data, A transducer set too low will record pressures that ate too high. A transducer set too high will dacument pressures that are too low. Incorrect leveling may not be catastrophic in the cae of arterial pressure, but it will result in significant diserepan RMN ARTERINL PRESSURE MONTTORING SI cies when low-pressure sstems such as pulmonary artery presures are involved, With correct setup and balancing ofthe monitor and transducer, inherent errors may sill occur because of the inertia and fition of the uid in the tubing and elasticity of the tubing Using high-compliance tubing reals in lowering ofthe fequent response of the sstem, distortion of the presure waveform and ‘overshoot ofthe sstolie pressure. It is possible to overcome this robles by using noncompliant pressure conneetng tubing Bedford has demoratrated thatthe aerial puise-pressure wave- fons changes progresvely fom the ascending ast to peripheral sites (Figure 22)" Wis believed that these changes in areal wave fore, particularly the systolic component, account forthe difer- ceces between diet and initcet arterial pressures measured a the Sane site and diferences in dinect pressures bericen diferent sts “The systolic presre in the aorta i ar lower than the systolic pres- sure inthe radial artery. Indeed, the aortic pressure represents the tive aferlod against which the heat works. As the pube-pressure ‘wave moves dtl, at about 10 meters per second, the ial up- stroke becomes steeper and the systolic maximum becomes progres- Sutcoven mn ait FIGURE 2-2. Arterial alee presure waveform tracings demonstating pro sresive changes fom the ascending aot tothe femoral arterysively peaked. As the waveform becomes narrower, the systolic and pulse pressures increase and the diastolic and mean pressures de crease. ‘The major modifying factors in the systolic component of the pule-pressure waveforms are wave reflections from the periph cry. As the pulse-pressure wave hits the arterioles, much of itis re- Acted backwards, These reflected waves alter the tue value of the pulse-pressure wave in the peripheral pulses. Because of is proxim= ity to the peripheral arterioles, the radial artery will indicate a higher dicect systolic pressure than that measured indirectly at the brachial artery. It should be noted that if the lumen of an arterial catheter becomes occluded, the reflected waveform is initiated at the occlusion point (Other factors that alter the configuration of the pulse-pressure waveform include a dectease in elastic tissue and an increase in muscle tise as the arterial tree progresses distally as well as the narrowing of the artery that amplifies the pulse wave. The develop ‘ment of arteriosclerosis and the loss of elasticity with age accounts, for the decrease in both ditect and indirect systolic pressure mea surements at distal sites. ARTERIAL CATHETERS AND PLUMBING The Cournand needle was used for intraatterial cannulation in the physiologic laboratory and cardiac catheterization suite and later introduced into other clinical areas. It consisted of a metal needle with two wings a right angles tothe long axis ofthe needle and adjacent to the hub, and an inner metal stylet, Subsequently, with the development of plastics, the plastic catheter placed over a metal needle has become a common} used tool for access into pe- ripheral narow arteries such a the radial. Larger vésels, for exam- ple, the femoral, are usually cannulated by using the Seldinger guide wire technique, ‘The technique consists of intially inserting a thin-walled, narrow needle into the vessel. When acces is gained, a flexible smooth-tipped wite i fed through the needle, which is, then withdrawn, An introducer or larger bore catheter then can be threaded over the wire into the artery. A Seldinger-ype sytem has been designed for radial artery cannulation Arterial catheters have been manufactured from polypropylene, polyvinyl chloride, and Teflon. Fach has its own characteristics with respect to stiffness, kinking, and thrombus formation, The ‘most commonly used catheter at this time, though, is manufac- tured from ‘Teflon. To have optimum frequency response with PEPER ERPECEIEIEETEEerrrITTrreeeee ARTTRIAL PRESSURE MONITORING 3 iminimam distortion of the pulespesure wave, itis best to use ‘wide bore catheter. However, small bore catheters are efficient be- Cause although they have some high-Fequeney response, their dmsping ceticients ae high. The sal eather dampens the un- derdamped catheter-estension tube system, resulting in less ringing or hypetesonance in response t0 repetitive pulse waveforms, The result that stole pessre is measured more accurately Extension tubing promot ringing or bypetesonance, which ne cases with the length ofthe tubing. Indeed, the ation of 5 Feet fof tubing will provide a systolic pressure 16% greater than that of brachial arterial presire. Hence, every attempt should be made to reduce the connecting tubing t the minimum. ‘Air bubbles inthe plumbing system are the greats source of er tor in measuring direct atrial presure. Large bubbles darnpen the pulsepresite wave; small bubbles produce ringing or hypereso- france: The addition of 0.05 to D.25 ml of arin an arterial pressure Tine will augment sstlie pressure fom 150 o 190 mm Hg. Dias tole and electronic mean remain unchanged. It is impossible 10 prevent the formation of air bubbles. When fluid moves fom the High-pressure heparin flow hag to the low-pressure hyalie system, air bubbles alway ill accumulate. Stet and frequent attention 1 ‘eteting alteration in Frequeney response and damping is essential fd should be of major concern to the ICU physician and nurse. ‘One should seatch for ar bubbles and remove them prompl SITE SELECTION Any sup sey cn be xa for lial we, The wood ariel uated al, ag, ne ps dis, and, in children, the temporal artery. In our surgical ICU the Se ee maa ped oscar doy Th ow, aerate bach and the oul ate these ce oaphatans mel tik po. cere ee dine eae han fe ae he el SO rotamer we, lose a cil hc ga tation dead en reas te ther coats palog, shen Set ee es ieee been Te ee ee etal he ous ce Senay taeda bed ine inane wen tc aniited el cettztan wl be osha ree Pein Sabah igh oregon ta sno