Chapter 11 Intensive Care Unit

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SECTION 1 • Techniques and Methods in Critical Care

Management of Pseudoaneurysms Pseudoaneurysms may form due to trauma, infec- tion, penetrating ulcer, or iatrogenic misadventure. Treatment of these depends upon location, etiology, and morphology. Infectious (mycotic) lesions gen- erally require vascular surgery. On the other hand, IR is particularly well suited to address arterial site access anatomically amenable anomalies at the groin, where US-guided thrombin injection may be a good option. Large vessels may be appropriate for stent graft or embolization. Traumatic aortic injuries or transections may often be addressed by thoracic stent grafting. Worrisome vascular injuries and tan- gles in branch vessels of solid organs are generally approached by embolization. Larger feeding vessels are often stented. Nonvascular Indications for IR Nephrostomy tubes may be required to address renal obstruction, pyonephrosis, and/or urosepsis if urologic placement of a retrograde stent is not possi- ble or desirable. Abdominal or pelvic drains may best be inserted and positioned radiographically under CT or US guidance. Follow-up imaging is very fre- quently indicated (e.g., abscessograms and fistula assessment). Complicated abscesses of the lung can be externally drained, but the commonly result- ing bronchopleural fistula may require later surgi- cal intervention, mandating early thoracic surgical consultation to choose the best treatment option. Similarly, though chest tubes are deftly placed into empyema pockets, an open surgical approach is sometimes a better option for complicated spaces. Early surgical consultation is again advised. Tubes to drain pneumothorax tend to be better positioned, smaller, and more flexible when placed in IR using fluoroscopic or CT guidance, promoting patient tolerance (Fig. 11-31). Poorly functioning drainage tubes that serve any purpose (air/fluid/pus) can be replaced or repositioned in IR to optimize performance. After placement, decisions and man- agement of drainage systems can be assigned to the interventional radiologist or to the bedside provider. This decision should be made at the time of tube insertion and followed through. A variety of indications for IR involve- ment with tube placement relate to the GI tract. Cholecystostomy tube placement in IR is commonly a first-line intervention for the critically ill at pro- hibitively high risk for immediate cholecystectomy.

Patients with acalculous cholecystitis may undergo initial drainage, with tube removal occurring 4 to 6 weeks later without the need for surgery at all, pro- vided that the cystic and bile ducts are patent. Biliary drains are also commonly placed when obstruction cannot be effectively managed by endoscopy. Percutaneous feeding tubes include gastrostomy (G tube) and gastrojejunostomy (GJ tube) variants. The former are placed to vent and drain the stom- ach and can be used for feeding. The latter may be more appropriate for patients predisposed to reflux and/or inclined to aspirate by gastric dysmotility or outlet obstruction. Insertion of nasal G and J tubes is often relegated to IR in patients in whom this can- not be successfully accomplished at the bedside, for those at unusually high risk for procedural problems or tissue trauma, and for those in whom appropriate tube placement must be unequivocally assured. Other useful applications of IR services include pain management and suprapubic catheter place- ment to address bladder outlet obstruction that can- not be otherwise resolved by transurethral insertion. Challenging anatomy and failed attempts at lumbar puncture may sometimes prove successful under IR imaging guidance. Precise site localization before local anesthetic injection may be the only reason- able approach to such intractable pain problems as radiculopathy and abdominal pain addressable by celiac plexus block or ablation (e.g., secondary to FIGURE 11-31. Pigtail catheter inserted by IR into a locu- lated right apical space ( yellow arrow ). A necrotic abscess is evident on this fluoroscopic image ( red arrow ).