Marino’s The Little ICU Book

Book Preface

The second edition of The Little ICU Book retains the intent of the first edition; i.e., to create a distilled version of the parent textbook, The ICU Book, that presents the essentials of critical care practice in a succinct and easily retrievable format. The organization and chapter titles in the “little book” mirror those in the “big book”, but all the chapters have been rewritten and updated, with heavy emphasis on the recommendations in evidence-based clinical practice guidelines. This edition also bears the fruits of a collaboration with Sam Galvagno, DO, PhD, who lent his wisdom and encyclopedic knowledge to several chapters in the text.
The Little ICU Book may be short in stature, but it is a densely packed, generic resource for the care of critically ill adults in any ICU.

Vascular access in critically ill patients often involves the insertion of long, flexible catheters into large veins entering the thorax or abdomen. This type of central venous access is the focus of the current chapter.
I. INFECTION CONTROL
The infection control measures recommended for central venous cannulation are shown in Table 1.1 (1,2). When used together (as a “bundle”), these five measures have been effective in reducing the incidence of catheter-related bloodstream infections (3). The following is a brief description of these preventive measures.
A. Skin Antisepsis

1. Handwashing is recommended before and after palpating catheter insertion sites, and before and after glove use (1). Alcohol-based hand rubs are preferred if available (1,4); otherwise, handwashing with soap (plain or antimicrobial soap) and water is acceptable (4).
2. The skin around the catheter insertion site should be decontaminated just prior to cannulation, and the preferred antiseptic agent is chlorhexidine (1).
a. The advantage of chlorhexidine is its prolonged antimicrobial activity, which lasts for at least 6 hours after a single application.
b. Antimicrobial activity is maximized if chlorhexidine it is allowed to air-dry on the skin for at least two minutes (1).

B. Sterile Barriers
All central venous (and arterial) cannulation procedures should be performed using full sterile barrier precautions, which includes caps, masks, sterile gloves, sterile gowns, and a sterile drape from head to foot (1).
C. Site Selection
According to published guidelines (1) femoral vein cannulation should be avoided to reduce the risk of catheter-associated septicemia. However, clinical studies indicate that the incidence of septicemia from femoral vein catheters (2–3 infections per 1000 catheter days) is no different than the incidence of septicemia from subclavian or internal jugular vein catheters (5,6).