For patients in ICU, such indwelling needles are not enough. First, the ordinary indwelling needles are not fast enough for relieving fluids. For patients who need rescue, the refill speed is very critical. Secondly, it is best not to use some vasoactive drugs (such as pressure boosters) for ordinary superficial indwelling needles, thinking that once the drug leaks, it may cause local tissue necrosis. 2

Based on the above two reasons, ICU patients usually need to get a deeper vein (deep vein puncture), such as femoral vein, subclavian vein, internal jugular vein, etc. These veins are deeper and thicker, which is very conducive to rescue and medication.

It still requires certain technology to pierce veins deep in these locations, which is also a unique skill for ICU and anesthesiologists. Because they are both blindly pierced, doctors first empirically find the approximate vein position and then insert a piercing needle at this site. With the advancement of medicine, ultrasound can now be used to assist pierce. Ultrasound can find the veins and watch the veins enter the needle.

In order to reduce the patient's pain, the doctor will definitely have local anesthesia and even sedate the whole body to fully relax the patient. In order to reduce the possibility of puncture infection, the doctor will fully disinfect and lay a towel.

Only by establishing this deep vein pathway can it be more convenient to use vasoactive drugs such as adrenaline, dopamine, norepinephrine and other vasoactive drugs during rescue, and it is possible to quickly drip 500ml or even more liquid within 20 minutes. Only by saving the patient's endangered life!

Six, Continuous renal replacement therapy

If the patient has serious infection or has renal insufficiency, this critical illness may cause a new blow to the kidneys, causing acute renal failure, anuria, and internal environmental disorders. At this time, renal replacement therapy (CRRT) is needed.

The so-called continuous kidney replacement therapy requires a machine (a bedside blood filter). The doctor will first pierce a deep vein and place a catheter about 4mm into the vein. This catheter will connect the blood filter pipe, turn on the blood filter, and the blood filter pulls out the blood through the catheter, filter it cleanly (simulates the function of the kidney) and then inject it back into the body. This process is called kidney replacement therapy. Sometimes this treatment can also clear away the inflammatory mediators in the blood, so some people call this treatment blood purification therapy.

(This is Baxter blood filter)

The blood filters in ICU are similar in principle to those in nephrology, and they all work instead of the kidneys. However, ICUs have special features, which are the bleeding speed and the working speed are relatively slow, and they often operate continuously for 24 hours. The advantage of this is to reduce the impact on the blood pressure of critically ill patients.

The dialysis machine in the nephrology department is done three times a week, each time for 4-5 hours, and then go home after finishing. This dialysis speed is very fast and can be withstood by ordinary patients. However, critically ill patients may not be able to withstand it. I have tried many times when critically ill patients have had cardiac arrest in this dialysis opportunity, which is very dangerous.

7. ECMO (extracorporeal     membrane     oxygenation)

When a patient with severe respiratory failure, such as acute respiratory distress syndrome, cannot meet the patient's basic oxygen needs through a ventilator, it must be further supported. At this time, only ECMO (extracorporeal model lung oxygenation, simply understood as artificial lung). ECMO is the ultimate means of lung support. The principle is to lead the patient's blood to the machine, oxygenate on the machine, and then return to the body after the oxygen enters the red blood cells. The entire oxygenation process is no longer dependent on the lungs.

The ventilator can only be said to be a ventilator. The ventilator is only responsible for injecting oxygen into the airway and lungs. If the lungs still have functions, the ventilator can still play a role. If the lungs are completely damaged, it is useless for the ventilator to inject gas into it. At this time, ECMO can only be used.

ECMO allows many people to continue their lives. After the underlying cause improves, they will take off ECMO and use it back to the ventilator. However, if it is a patient in the final stage, it is not recommended to use ECMO. Because ECMO is not a treatment method, it is just a support method. If the cause cannot be removed, should patients use ECMO forever? It is unrealistic.

(Schematic diagram of ECMO)

Do you know the cost of ECMO? The startup fee is 60,000 yuan, and 20,000 yuan per day in the future, which is about this amount, and the medical insurance will not be reimbursed. If it is an acute condition and there is hope for reversal, it is OK to transition the ECMO in a few days. If it is a terminal condition, then there is no need.

After all, ECOM also requires puncture of the patient's arteries and veins. These are all traumatic, although they are minimally invasive.

Eight, Arterial puncture

For patients with critical condition, we need to measure blood pressure. If it is an ordinary sleeve bag, it can only be measured once every ten minutes or several minutes, and there may be errors and it is impossible to promptly reflect the patient's condition. You should know that the degree of life danger of patients in ICU is sometimes calculated in seconds or minutes, so we need to see the patient's real-time blood pressure at all times.

This requires puncture of the artery and directly measure the arterial blood pressure. After puncture into the artery, insert a puncture needle into the artery. The tail of the puncture needle is connected to the wire, catheter, etc., and directly connect it to the electrocardiogram monitor at the head of the bed. Adjust the mode and you can directly measure the patient's arterial blood pressure. Every heartbeat will have a blood pressure. This is called continuous arterial blood pressure monitoring.

With the patient's blood pressure, our ICU doctors know it. Otherwise, if you don't see the blood pressure after a few minutes, it will make people feel restless. Data, data, are very important.

After puncture the artery and place the indwelling needle, you need to draw blood in the future to do arterial blood and qi, etc. There is no need to frequently slap the needle, just draw the arterial blood from here. It will be enough to hurt once. In order to reduce the pain, sometimes the nurse asks some local anesthetics to apply to the puncture site.

Nine, Thoracic puncture

If the patient has pneumonia, lung cancer, tuberculosis, or heart failure, it may lead to pleural effusion. The so-called pleural effusion means that fluid accumulates in the chest cavity. Under normal circumstances, there should not be a lot of fluid in the chest cavity, only a little fluid. However, in a disease state, such as lung cancer, there will be a lot of fluid, and these fluids will fall into the chest cavity, leading to pleural effusion or blood accumulation.

The existence of pleural effusion will affect lung expansion and ventilation, and the patient will feel that it is hypoxia and insufficient gas. In order to solve this problem, we need to perform a thoracic apnea to extract the liquid inside. At the same time, the liquid can be used for testing to understand the properties of the liquid, and thus speculate the cause of the pleural effusion. Then treat the cause.

The process of thoracic puncture is relatively simple. It is to insert a needle between two ribs and directly penetrate into the chest cavity. If there is liquid coming out, it is called piercing the right place. In rare cases, it may penetrate the blood vessels and cause heavy bleeding. It may also penetrate the lungs, poke the lungs or abdominal surgery (such as gallbladder, pancreas, stomach, and knots).
Chapter completed!