What exactly can I do as an AGACNP working in an ICU? Commonly encountered question with the answer being fairly straight forward, with a little variation. Several factors exist which effect routine practice and this includes your training, your credentials (with the hospital), the comfort level of your attending, and the culture of scope allowance at your specific workplace. I’ve worked places where I do it all, and places where I do less. I find this varies most by work team structure and culture. The more staff available, including medical trainees the fewer procedures you will likely perform. Most students are aware of the common procedures we perform (central lines, dialysis catheters, and arterial lines) but there are a whole host of procedures we could perform. In this article I’ll discuss the myriad technical skills we as nurse practitioners can learn and perform to contribute to patient care.

The most common procedures an ICU APP will perform are related to vascular access (central line, art line, dialysis catheter). But there are so many more that we are capable of performing. It varies by institution, workplace culture, and the need (smaller institutions with fewer needs tend to default these procedures to trainees or attendings or even outsource to other specialized teams).

• Venous access

  • Central Line

    • Indications: lack of other access, to administer extravasant risky medications like pressors, to obtain indirect measures of cardiac output (invalid with a femoral line).

  • Temporary Dialysis Catheter aka vascath

  • Large bore introducer

    • A short fat central line for the acutely bleeding patient to facilitate extremely rapid resuscitation.

    • Or to facilitate placing an internal catheter like a swan or such. Sheaths are similar.

  • Less commonly or setting specific

    • PA catheter insertion

    • IABP Cannulation

  • All of the venous access procedures involve a needle over a wire technique (Seldinger) with the assistance of ultrasound and anatomical identification assistance.

  • Rarely, a cutdown is required to access the vein. More typical for a vascular surgery APP.

  • Site options for the above: IJ, Femoral, Subclavian

• Arterial Access

  • Arterial Sample for ABG

    • Usually we just place a line, but there are some situations you just need a one time ABG or need info quickly (cardiac arrest or rapid deterioration). Radials take a minute, femorals are super fast and can be done easily even blind without use of ultrasound and is therefore my go to in a cardiac arrest situation.

  • Arterial Line

    • Site options: radial, brachial, axillary, femoral

• Ultrasound Evaluation/POCUS (point of care ultrasound)

  • Cardiac

    • Four main cardiac windows with a wide range of utility

    • Typical: Pericardial effusion, EF estimation (very subjective and performed by non cardiologists much of the time so take this info with a grain of salt), RV dilation (telling in an PE or concern for cor pulmonale), Valvular function, Gross estimate of filling pressures (can indicate volume status), verify catheter placement (typically a TEE though).

  • IVC evaluation

    • Look for collapsibility (greater than 50% collapse during inspiration) indicates intravascular dehydration

  • Hepatic Vein evaluation

    • Look for collapsibility to further define intravascular volume status

  • Pulmonary

    • Lung sliding (look for a pneumothorax)

    • Pleural fluid evaluation (is there enough volume to attempt a thoracentesis)

  • FAST (Focused Assessment via Sonography in Trauma)

    • Basically evaluates all of the above anatomical locations for blood or injury

    • Performed very rapidly as a part of ATLS primary injury survey

• Endotrachial Intubation

  • Many institutions limit intubation to an anesthesia team or physicians.

  • Multiple visualization tools: Video assisted (McGrath, Glidoscope), Direct Lighted Blade (curved or straight blade in various lengths)

  • BTW: In my research I came across this article which I found to be very well written and helpful in regards to common technical errors of intubation: https://airwayjedi.com/2018/10/22/the-mac-blade-the-vallecula-and-the-hyoepiglottic-ligament/

• Bronchoscopy

  • Commonly: to assist a physician who is placing a tracheostomy

  • Therapeutic to clear secretions, open airways, correct atelectasis

  • Diagnostic to obtain a BAL (bronchoalveolar lavage sample for culture/cell count or other), to evaluate the general state of the airways (bleeding, long term ventilator complications), evaluate a mass/lesion, biopsy

• Chest Tube

  • Small bore/pigtail (done via Seldinger technique)

  • Large bore/surgical chest tube aka trocar involves a cut down

• Lumbar Puncture

  • Don’t underestimate how difficult this is in an intubated patient. Awake people who can sit up and lean over a table 👍🏻, tubed/semi-awake and moving and difficult to fold up like a shrimp so you can open the vertebral spaces 👎🏻

• Bone Marrow Biopsy:

  • Ok this is super niche, but, if you work on a BMT unit, you are likely doing these in house

  • I’ll spare you from my tangent about how I think this is possibly the worst thing you can do to a human being. A drill, into a hip, on an awake person - need I say more?

• Sutures

  • In an ER you’ll get real familiar with laceration repair.

  • In an ICU you will do this associated with most procedures involving skin entry; to repair bleeding sites.

• Administration of certain high risk medications. A few examples:

  • Intrathecal Nimodipine (via EVD) for cerebral vasospasm

  • Fibrinolytics into a chest tube

• Many more procedures are done by procedure specific teams like IR and interventional pulmonary. I will add a link to a YT interview I did with an IR nurse practitioner if you are interested to learn typical procedures he performs.

• Surgical APPs obviously perform a much wider range of surgical procedures from case assistance to “independent/simultaneous” work like vein harvesting for a cardiothoracic team, placement of drains, plates, and so forth by general surgery APPs.

A few general tips when learning procedures:

• Spend a little time learning how to operate an ultrasound machine. Whatever your institution supplies, put in a google search for that specific device and get some basics down: how to orient yourself, how to change windows/views, how and when to use different modes like color or doppler, how to assign depth, increase gain, figure out how to apply a midline indicator. Then go and use the device on an actual person with your only intent to familiarize yourself with ultrasound technique.

• Find a few helpful videos or articles about each procedure you will be expected to perform and save these in an easy to find spot on your PHONE. Not the computer, your phone. Why? 9/10 you have no idea you will be asked to perform a procedure and likely only have a brief time to prepare yourself. A quick 10 min video just before hand does wonders for refreshing your memory.

• Download a photo of anatomy. One about vascular sites. One about common landmarks for common procedures and refer to them as you need them.

• Find a mentor or champion who is willing to teach you the ropes.

• Ask around or educate yourself on what factors you would need to know to assess the risk benefit of the procedure. Here’s an example:

  • If a pt needs a central line I want to know why. What is the indication? A pt who just needs vascular access is a different priority than the pt who is crashing and needs blood transfusions (in that case I would elect to place an introducer rather than a central line). Knowing what the problem is helps you determine the best device to use, the best site to use, and the urgency.

  • I also want to know if the pt is going to tolerate an IJ placement (are they awake and delirious vs intubated and unconscious) - which tells me the ability to perform a risky procedure on someone who may make it difficult.

  • I also want to know bleeding risk. Do they have a coagulopathy, liver failure, low platelets, etc? Are they high risk of bleeding - then put the line in the groin where the risk of hitting an artery is lower and I can easily apply pressure if I do.

  • Are there any anatomical problems that make one site preferred over another? Is there a femoral DVT? Do they have known venous strictures, maybe avoid that area. Is there already a known pneumothorax on the right side - placing an IJ line here poses less risk as it’s already there.

  • Be acutely aware of what the potential complications are and what you would do if they occurred. If you place an IJ and develop a pneumothorax, who would place a chest tube if required. If not you and on one available, maybe elect a femoral site.