Critical Care Pearls


Careful consideration should be given for indications and routes of placement of central venous catheters (CVCs). Full barrier precautions must be observed during the procedure to avoid infectious complications. The internal jugular vein (IJV) site is most commonly used. Subclavian vein catheterization has the advantage of decreased incidence of catheter-related bloodstream infection (CRBSI); however, it has increased incidence of pneumothorax. Ultrasound guidance has decreased the incidence of complications during central venous catheterization. CRBSI is one of the most common complications associated with CVCs and a common cause for nosocomial blood stream infections (BSIs). Clinical signs are unreliable because of poor sensitivity and specificity for establishing the diagnosis of CRSBI. Two paired sets of blood cultures are recommended with at least one percutaneously drawn to establish the diagnosis of CRSBI. Antibiotic therapy is often initiated empirically when CRBSI is suspected and tailored according to blood cultures and sensitivity. Persistence of positive blood culture after three days of removal of catheter needs further investigation to rule out infective endocarditis and metastatic septic foci. Mechanical complications can be avoided with adequate precautions and proper technique. Central Venous Catheterization Patients in intensive care units in the United States receive 15 million central venous catheter (CVC) days per year (1). Placement of a central venous catheter is a routine event in the ICU, but should not occur without careful consideration of indications and route of placement. The most common indications for placement of CVCs are hemodynamic monitoring, administration of vasoactive agents, parentera

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