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 Central venous catheterization (see Chapter 3) is a commonly performed procedure in the ICU. Complications vary with site and number of attempts at cannulation. They can be divided between infectious complications and mechanical complications such as arterial puncture, pneumothorax, and atrial/ventricular arrhythmias. Higher rates of infections have been reported with femoral sites versus either subclavian or internal jugular sites while the subclavian site has been associated with difficult to control bleeding.

 Ultrasound‐guided catheter placement has shown clear evidence in reducing the rate of the above mentioned mechanical complications. We recommend the use of ultrasound‐guided central line placement whenever possible, including wire visualization by ultrasound prior to cannulation. A quick point‐of‐care ultrasound of the lungs can also be performed post‐procedure to assess for a pneumothorax. Telemonitoring should occur throughout the procedure for detection of premature ventricular complexes, particularly while introducing the guidewire and to monitor BP and oxygenation.

 Endotracheal intubation (see Chapter 1) is a commonly performed procedure in the ICU. Circulatory collapse remains the most common and highest risk complication during the peri‐ and post‐intubation period, followed by hypoxia and aspiration. Unlike intubation performed in the operating room by an anesthesiologist, intubation performed in the ICU has not developed specific guidelines. The initial evaluation for any patient requiring airway management should begin with prediction of risk factors that would increase the risk of difficult intubation. The MOCOCHA score (Table 9.1) is a scoring system (>3 of 12 items present suggests higher risk) to predict a difficult airway. We recommend the early use of video‐assisted laryngoscopy (GlideScope™) for difficult intubation to avoid multiple attempts, airway trauma, esophageal intubation, and/or prolonged hypoxia.Table 9.1 MACOCHA score calculation worksheet.Points^*Factors related to patientMallampati score III or IV5Apnea syndrome (obstructive)2Cervical spine reduced mobility1Opening mouth <3 cm1Factors related to pathologyComa1Severe Hypoxemia (<80%)1Factor related to operatorNon‐Anesthesiologist1Total12* Score 0 to 12: 0 = easy airway, 12 = very difficult airway.

  Airway management can be divided into three parts: pre‐, peri‐, and post‐intubation. The pre‐intubation period focuses on oxygenation with 100% non‐rebreather or non‐invasive ventilation such as high flow oxygen, which we prefer over non‐invasive bilevel positive pressure ventilation. Complications with BIPAP involve ineffective seal, lung hyperinflation, and introduction of air to the stomach.In patients with GI bleed or those with emesis, we highly recommend nasogastric suctioning while setting up for intubation to remove any gastric residuals and reduce the risk of aspiration. The peri‐intubation period focuses on hemodynamic monitoring and anticipation of circulatory collapse with the administration of sedatives. Intravenous fluids should be initiated with standby vasopressor support to maintain mean arterial pressure above 65 mmHg.The post‐intubation period should focus on the immediate confirmation of the endotracheal tube with capnography, initiation of appropriate sedatives, and the initial use of lung protective ventilation. The use of point‐of‐care ultrasound pre‐ and post‐intubation to assess lung sliding can be helpful in confirming adequate endotracheal tube placement and ruling out mainstem intubation while awaiting radiographic confirmation.