Checklists

Central line insertion

CLABSI prevention bundle

Before

• Time-out: patient, site, procedure, consent
• Hand hygiene
• Ultrasound ready; avoid femoral if possible
• Chlorhexidine-alcohol skin prep, dried 30 seconds

During

• Cap, mask, sterile gown and gloves for the operator
• Full-body sterile drape
• Assistant masked; observer empowered to stop the procedure
• Guidewire removed and counted

After

• Chlorhexidine dressing, dated
• Tip position confirmed (x-ray or ultrasound) before use
• Document site, depth, ultrasound use
• Daily review of line need

Intubation (RSI)

Prepare, preoxygenate, confirm

Prepare

• Two working IVs; BP cuff cycling; monitor and EtCO₂ ready
• Suction working at the head of the bed
• Video laryngoscope and direct blade; tubes two sizes; bougie; stylet
• Supraglottic airway and front-of-neck kit in the room
• Drugs drawn and labeled; push-dose pressor ready
• Plan A, B, C stated out loud

Preoxygenate

• Head up; ear-to-sternal-notch position
• 3 minutes or 8 vital-capacity breaths of 100% O₂ (NIV or HFNC if hypoxemic)
• Apneic oxygenation by nasal cannula 15 L/min

After

• Waveform capnography confirms
• Bilateral breath sounds; tube depth noted
• Post-intubation sedation and analgesia started
• Chest x-ray; OG tube; vent settings documented

Intrahospital transport

Leaving the ICU for CT, IR or the OR

• Receiving area ready; the trip is worth the risk
• Monitor with ECG, SpO₂, BP and EtCO₂; batteries charged
• Transport ventilator tested on the patient before leaving; bag-valve mask and PEEP valve
• Oxygen supply for twice the expected time
• Infusions on pumps with enough volume; nonessential drips capped
• Emergency drugs and airway kit
• Lines, tubes and drains secured; chest tubes on water seal unless told otherwise
• Two trained staff (RN plus RT for ventilated patients)
• Chart and consent with the patient

Prone positioning

Turning, checks and pressure care

Before the turn

• Enough staff: one at the airway plus 4–5
• Pre-oxygenate on FiO₂ 1.0; suction the airway
• Secure ETT and lines; note tube depth
• Hold tube feeds; empty stomach
• ECG leads moved to the back; eye care and protection
• Pressure padding ready for face, chest, pelvis, knees

After the turn

• Tube depth and EtCO₂ checked
• Head turned with the face off the tube; arms in swimmer position, alternating every 2 hours
• Pressure points padded; no pressure on eyes
• ABG in 1 hour
• Restart tube feeds: prone position is no reason to stop feeding (ESICM 2017, ESPEN 2023)
• Prone for at least 16 hours

Starting CRRT

Before the pump runs

• Order: modality, dose (mL/kg/h), fluid removal goal, anticoagulation
• Catheter position confirmed; both lumens draw and flush easily
• Circuit primed; correct fluids hung and labeled
• Baseline BMP, Mg, phosphate, iCa, CBC
• Citrate: post-filter and patient iCa schedule set
• Warmer on
• BP plan for start-up (fluid or pressor ready)
• Drug doses reviewed with pharmacy for CRRT clearance

ECMO shift check

Start-of-shift circuit and patient check

Circuit

• Flow and RPM against the target; chatter?
• Sweep and FdO₂; gas line connected
• Pressures charted (drainage, pre- and post-oxygenator)
• Flashlight check of the circuit and oxygenator for clot and fibrin
• Clamps, hand crank and backup console at the bedside
• Heater on and set

Patient

• Cannula sites, sutures and depth marks
• Distal limb perfusion and NIRS (VA femoral)
• Right-hand SpO₂ for differential hypoxemia (VA femoral)
• Neuro check and pupils
• Anticoagulation labs and bleeding check
• Hemolysis check: urine color, free Hgb

EVD care

External ventricular drain each hour and each move

• Transducer leveled at the tragus (foramen of Monro)
• Drain height (cm H₂O) matches the order
• Open or clamped as ordered; clamp before moving or repositioning
• CSF output, color and clarity recorded hourly
• ICP waveform present; drain dripping when open
• Dressing dry and intact; no kinks; sterile system closed
• Neuro check and pupils

Brain death: prerequisites

Before the clinical exam (2023 guideline)

• Known, irreversible catastrophic brain injury on imaging
• Enough time since the injury (at least 24 hours after anoxic injury)
• Core temperature 36 °C or higher
• Adults: SBP 100 or higher and MAP 75 or higher (MAP alone on VA-ECMO)
• No sedative or paralytic effect (levels or half-lives; train-of-four)
• No severe metabolic or endocrine disturbance that could explain coma
• Family informed; organ procurement organization notified per policy

Thoracentesis

Assisting at a pleural tap (BTS 2023)

Before

• Time-out: patient, side, site and consent; side confirmed on recent imaging
• Coagulation tests only if anticoagulated or known coagulopathy (BTS 2023)
• Elective (BTS 2023): warfarin to INR 1.5 or less, DOAC held 24–48 h; aspirin and prophylactic heparin continue
• Sitting up, leaning on a padded table; if ventilated, supine or rolled as the operator scans
• Ultrasound marks the site in that position; no moving the patient before the needle
• Baseline SpO₂, HR, BP and RR; oxygen, suction and atropine at hand

During

• SpO₂, HR and BP watched; vasovagal slowing, pallor or hypotension called out
• Drained slowly by syringe or gravity; no vacuum bottle or wall suction (BTS 2023)
• Stop at 1.5 L, or sooner for chest tightness, pain, persistent cough or breathlessness
• Samples: protein and LDH (serum sent at the same time), glucose, cell count, culture, cytology
• pH (suspected infection): capped heparinized syringe, no air, run on the blood gas analyzer

After

• Vital signs and SpO₂ soon after, then per policy; site dry; volume and color charted
• First hour: cough, frothy sputum or falling SpO₂ suggests re-expansion edema
• Chest film for symptoms, air aspirated or several passes; not routine after a simple tap (BTS 2023)
• Ventilated: watch peak pressure, SpO₂ and BP for a pneumothorax turning into tension

Paracentesis

Diagnostic or large-volume tap (AASLD 2021)

Before

• Time-out and consent; bladder emptied (void or catheter)
• No routine plasma or platelets for a high INR or low platelets (AASLD 2021); flag DIC or oozing
• Ultrasound marks a pocket, usually left lower quadrant, lateral to the rectus (inferior epigastric artery)
• Baseline BP, HR, weight and girth; 25% albumin ready for a large-volume tap
• Supine, head slightly up, tilted toward the tap side

During

• BP and HR watched through a large-volume tap; slow or stop for hypotension
• Cell count with differential, albumin, total protein; culture bottles inoculated at the bedside
• Same-day serum albumin for the gradient (SAAG 1.1 g/dL or more: portal hypertension)
• Volume, color and clarity recorded; cloudy or bloody fluid reported

After

• Albumin 6–8 g per liter removed when over 5 L (AASLD 2021): 8 L calls for 48–64 g
• BP, HR and urine output for 2–4 h: hypotension or low output after a big tap is reported
• Site leak: ostomy bag over the site, patient on the opposite side, provider told
• Neutrophils 250/mm³ or more is SBP: antibiotics plus albumin 1.5 g/kg day 1 and 1 g/kg day 3

Lumbar puncture

Screening, position, tubes, opening pressure, headache

Before

• Suspected meningitis: cultures, dexamethasone and antibiotics before CT, or before LP if the tap is delayed
• CT first for immunocompromise, CNS lesion, seizure within a week, papilledema, low GCS, focal deficit (IDSA)
• Platelets: transfuse under 20,000 (AABB 2025); UK 2016 defers LP under 40,000 or INR over 1.4
• Anticoagulants held: prophylactic LMWH 12 h, therapeutic 24 h (UK 2016); others per protocol
• Pencil-point (atraumatic) needle on the tray: headache 4% vs 11% (Nath 2018)
• Side-lying at the bed edge, knees to chest, chin down, shoulders and hips stacked vertically
• Sitting forward is easier in obesity, but opening pressure is valid only lying on the side

During

• Opening pressure lying on the side, legs relaxed, once the column settles; normal 10–25 cm H₂O (Whiteley 2006)
• Tubes numbered 1–4 in order; lab map often 1 chemistry, 2 Gram stain and culture, 3 cell count, 4 hold
• SAH question: cell count on tubes 1 and 4; last tube shielded from light for xanthochromia
• Serum glucose drawn now for the CSF-to-serum ratio
• Culture tube to the lab at room temperature, never refrigerated

After

• Site checked for CSF leak or bleeding; neuro checks per policy
• No routine flat bed rest: it does not prevent headache (Cochrane 2016)
• Back pain with leg weakness, numbness or new incontinence: possible spinal hematoma, call now
• Headache within 5 days, worse upright, eased lying flat: analgesia, caffeine; blood patch if severe

Pericardiocentesis

Echo-guided tap, pericardial drain and reaccumulation

Before

• Echo (or fluoroscopy) guides the needle (ESC 2015); a blind subxiphoid tap is for arrest only
• Large-bore IV; arterial line, coagulation tests and platelets when time allows
• Continuous ECG and SpO₂, defibrillator pads on, resuscitation cart in the room
• Atropine drawn up and fluid ready for a vagal reaction (bradycardia, hypotension)
• Preload and heart rate kept: no diuretics, vasodilators or β-blockers; no sedation or intubation if avoidable
• Head of bed up 30–45° so the fluid pools forward and down

During

• Ectopy or ST change as the needle advances called out (myocardial contact)
• BP, HR and pulsus trended; pressure should rise as fluid comes off
• Specimens: cell count, glucose, protein, Gram stain and culture, cytology, TB tests
• Drain sutured to a closed sterile system; first volume and color recorded

After

• Echo for residual fluid; chest film for pneumothorax and drain position
• Vital signs and drain output every 15 min at first, then hourly; volume and color charted
• Reaccumulation: rising HR or CVP, falling BP or pulse pressure, pulsus over 10 mmHg: echo now
• Drain stops while BP falls or CVP rises: clot, kink or reaccumulation until proven otherwise
• After a large drainage, sudden pulmonary edema or shock may be decompression syndrome (rare)
• Removal usually once output is below about 25–50 mL/day and echo shows no fluid

Bronchoscopy on the ventilator

FiO₂, PEEP and pressure limits, sedation, adapter, after-checks

Before

• Time-out and consent; tube feeds held per policy, OG to suction
• ETT inner diameter at least 2 mm wider than the scope; 8.0 or more for a standard adult scope
• Baseline vent settings, SpO₂ and blood gas noted; FiO₂ 1.0 started before the scope goes in
• Swivel adapter with a sealed scope port on the circuit; suction and bag-valve mask ready
• Sedation and analgesia deepened (often propofol and fentanyl); paralytic only if ordered, after sedation
• Topical lidocaine tallied: total under 8.2 mg/kg (BTS 2013)

During

• Volume control usual; high-pressure limit raised as the team directs (peaks climb with the scope in)
• Exhaled Vt, peak pressure and auto-PEEP watched: the scope narrows the tube and traps gas (AARC 2007)
• PEEP: lowering it limits auto-PEEP but risks derecruitment in ARDS; follow the stated plan
• SpO₂ under 90%, falling Vt, arrhythmia or BP change called out: scope out and ventilate
• Suction bursts kept short: each one pulls volume out of the lung
• Specimens labeled by site and type (wash, BAL, brush, biopsy); lavage in and out recorded

After

• Vent back to baseline: FiO₂ weaned, PEEP restored, alarm limits reset
• Blood gas within 30–60 min, or sooner if SpO₂ fell
• Chest film: pneumothorax (1 h after transbronchial biopsy, AARC 2007), atelectasis, tube position
• Tube depth and cuff pressure rechecked; tube secured
• Watch 24–48 h for bleeding, bronchospasm, fever (common after BAL) and new infiltrates

Arterial line

Site, Allen test, leveling, zeroing, square wave, removal

Before

• Site: radial first (CDC prefers it to femoral for infection); femoral when radial fails or in deep shock
• Allen test optional per policy: it predicts hand ischemia poorly (Brzezinski 2009); check hand perfusion
• No arm with a dialysis fistula or graft, burns, infection or poor perfusion
• Pressure bag at 300 mmHg with saline (heparin only per policy); tubing and transducer purged of air
• Short, stiff tubing with few stopcocks; wrist on an armboard, slightly extended

During

• Cap, mask, sterile gloves and a small sterile drape; full barrier for femoral or axillary (CDC 2011)
• Chlorhexidine-alcohol prep, allowed to dry
• Waveform seen before the catheter is secured; sterile dressing, dated

After

• Stopcock leveled to the phlebostatic axis (4th intercostal space, mid-chest); re-leveled after moves
• Zeroed to air at setup, after disconnection and when numbers do not fit the patient
• Square wave: fast flush shows 1.5–2 oscillations, then baseline; fewer is overdamped, more underdamped
• Waveform: brisk upstroke and dicrotic notch; MAP within about 10 mmHg of the cuff
• Alarms on; line labeled arterial; no drugs through it, no dextrose or nutrition in the flush (CDC 2011)
• Hand color, warmth, capillary refill, sensation and movement checked hourly
• Transducer and tubing changed every 96 h (CDC 2011); line out when no longer needed
• Removal: firm pressure 5 min radial, 10 min femoral, longer if anticoagulated; then site and pulse checks