Reference Guide

Procedural Skills

Echocardiography, emergency resternotomy, bronchoscopy, and vascular access

Hemodynamic instability: Assess LV/RV function, wall motion abnormalities, pericardial effusion/tamponade
Post-operative assessment: Valve function (prosthetic regurgitation, paravalvular leak), regional wall motion
MCS troubleshooting: Impella position, ECMO cannula position, LV distension assessment, VAD ramp studies
Acute new murmur: Acute MR (papillary rupture, SAM), VSD, endocarditis
Volume status assessment: IVC collapsibility (spontaneously breathing), LV cavity size, E/e' ratio
TEE advantages: Superior image quality, intraoperative guidance, better visualization of prosthetic valves, LA appendage thrombus

Step 1 – Parasternal Long Axis: LV/RV size and function, pericardial effusion, aortic/mitral valve
Step 2 – Parasternal Short Axis: Regional wall motion, RV free wall, septal motion (D-sign in RV overload)
Step 3 – Apical 4-Chamber: Biventricular function, MR/TR assessment, TAPSE for RV function (normal >17 mm)
Step 4 – Subcostal: Pericardial effusion, IVC size and collapsibility, RV free wall
Step 5 – LVOT VTI: Stroke volume estimation (SV = LVOT area × VTI); track response to interventions
Key Measurements: LVEF (visual or biplane Simpson), TAPSE, S' (RV), E/A ratio, E/e', LVOT VTI, IVC diameter

Indication: Cardiac arrest within 10 days of sternotomy that does not respond to initial resuscitation (3 cycles of CPR/defibrillation)
Timeline: Resternotomy should be performed within 5 minutes of arrest onset in the CVICU
External CPR considerations: May be less effective or harmful post-sternotomy (wire disruption, graft injury)
Step 1: Call for help; ensure resternotomy tray is at bedside (wire cutters, rib spreader, internal paddles)
Step 2: Prep skin with antiseptic (betadine splash); don sterile gloves
Step 3: Cut sternal wires; use rib spreader to open sternum
Step 4: Evacuate clot/blood; identify cause (tamponade, hemorrhage, graft kinking)
Step 5: Internal cardiac massage (two-handed technique); internal defibrillation (10–20 J)
Step 6: Address surgically correctable cause; call CT surgery for definitive repair
All CVICU staff must be trained in resternotomy tray location and setup

Endotracheal Intubation: RSI with hemodynamic-sparing agents (etomidate, ketamine); avoid propofol bolus in shock
Difficult Airway: Video laryngoscopy first-line; bougie readily available; have supraglottic airway and surgical airway plan
Diagnostic Bronchoscopy: Mucus plugging (common post-op), hemoptysis evaluation, assess airway patency
Therapeutic Bronchoscopy: Clot evacuation, BAL for infection diagnosis, difficult secretion management
Thoracentesis: Ultrasound-guided; common for persistent pleural effusions post-cardiac surgery
Chest Tube Insertion: For pneumothorax, hemothorax, or large effusions; confirm placement with CXR
Percutaneous Tracheostomy: Consider at day 10–14 if prolonged ventilation anticipated; discuss timing with surgical team

Ultrasound-guided CVC: IJ (preferred), subclavian, femoral; real-time guidance mandatory (reduces complications)
Arterial Line: Radial (first-line), femoral (more accurate in shock), brachial. Allen test or pulse oximetry before radial
PA Catheter Insertion: Ideally IJ approach; use pressure waveform guidance for floating
Transvenous Pacemaker: Femoral or IJ approach; fluoroscopy or echo guidance for positioning
Large-Bore Access for MCS: 15–21 Fr sheaths for ECMO/Impella; plan access site with team
Line Care: Chlorhexidine dressing; daily review of line necessity; bundle compliance to prevent CLABSI

S.K.

The World-Class Cardiac Intensivist

This content is for educational reference only. Always follow institutional protocols and exercise clinical judgment.

Advanced Echocardiography (TTE & TEE)