central venous access-1
TRANSCRIPT
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Central Venous Access
Module
Vic V. Vernenkar, D.O.
Dept. of SurgerySt. Barnabas Hospital
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Approach
Two approaches are commonly used and
will be described:
1.Right internal jugular vein
2.Right sublclavian vein
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Indications
Measurement of central venous pressure (CVP)
insertion of a pulmonary artery catheter or
transvenous pacemakeradministration of fluids and medications, e.g.,if
there is no peripheral access
administration of hyperalimentation solutions or
other fluids that are hypertonic and damageperipheral veins (such as Amphotericin B)
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CONTRAINDICATIONS
Coagulopathy
Infection over site of insertion
Distortion of landmarks
SVC syndrome
Patients unable to cooperate or tolerateTrendelenberg positioning
Pneumothorax on opposite side
Patients with high end-expiratory pressures on
mech. ventilation
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EQUIPMENT NEEDED
Commercially available set containing
needles, wires, sheaths, dilators, etc
Needles, syringes, local anesthetic, 0.9%
saline (may be heparinized with 1ml 1 in
100 heparin in 10ml 0.9% saline)Sterile gown, mask, gloves
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RIGHT INTERNAL
JUGULAR VEIN APPROACH
Three sites are described:
1. anterior - medial to the sternocleiodomastoidmuscle
2. middle - between the two heads ofsternocleidomastoid
3. posterior - lateral to the sternocleidomastoid The middle is the commonest and is the one
described here. Patient discomfort when turningthe head is the disadvantage of this technique
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Jugular Approach
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Procedure
1.Sterilize the site and drape with sterile
towels
2.Administer the local anesthetic
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Procedure
1.Whilst this is working flush all the ports of
the catheter with sterile 0.9% saline
2.Put the patient in the Trendelenburg
position (i.E.Head down)
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Procedure
1.Use a 21 gauge needle attached to a syringe
containing 0.9% saline to locate the position
of the internal jugular vein. Put your lefthand fingers on the carotid artery and pull it
medially and then introduce the needle at
the apex of the triangle formed by the twoheads of the sternocleidomastoid muscle
and the clavicle
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Procedure
The needle should enter at about 45 o to the
skin and be directed slightly laterally
towards the ipsilateral nipple (often ashallow notch can be felt in the posterior
aspect of the clavicle which can help in
locating the vein in the lateral/medial plane) Puncture of the vein is apparent by sudden
aspiration of non-pulsatile venous blood
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Procedure
If the artery is punctured remove the needle
and apply pressure for 10 minutes
Insert the introducer needle along the same
track as the first needle, which can be used
as a guide or can be removed with you
remembering the direction and depth it wasinserted
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Procedure
When this needle has been inserted into the
vein the introducer should be removed and
the guidewire introduced down it (leaveenough wire outside the patient to
accommodate the length of the intravascular
catheter
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Procedure
Nick the skin with a number 11 scalpel
blade
Thread the dilator over the guidewire thenremove it keeping the wire in situ at the
same depth
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Procedure
Thread the catheter over the guidewire keeping
hold of the wire so it does not disappear into the
patient (it is helpful to estimate the length of thecatheter needed to reach the right atrium before
placement)
When the catheter is in place there should be free
flow of venous blood (if there is no flow thecatheter is not correctly placed or is kinked)
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Procedure
Remove the guidewire and attach fluids
Suture the catheter in place with 2/0 silk,
spray with povidone iodine and apply anocclusive dressing
Observe and listen to the chest to exclude a
pneumothorax Obtain a chest radiograph to confirm its
position and exclude a pneumothorax
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Subclavian Approach
The left subclavian route has the lowestinfection rate of all central line routes.
Procedure
1.Place a liter bag of fluid between theshoulder blades
2.Sterilize a wide area and drape with a steriletowel
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Subclavian Approach
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Subclavian Approach
1.Identify the area two fingerbreadths lateral
and inferior to the point where the clavicle
and first rib cross ( about the distal third ofthe clavicle) and administer the local
anesthetic
2.Whilst this is working flush all the ports ofthe catheter with sterile 0.9% saline
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Subclavian Approach
Place the patient in the Trendelenburg position
Locate the vein using a 21 gauge needle keeping
the needle parallel to the skin and advancing it justunderneath the clavicle to a point halfway between
the sternal notch and the thyroid cartilage
Apply back pressure on the syringe until venous
blood is aspirated
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Subclavian Approach
Remove the syringe and insert the guidewire intothe vein (if there is resistance to the guidewirereposition the needle and replace the guidewire - ifthe wire is going into the head the patient maycomplain of pain in the ipsilateral ear. If the wirestill encounters resistance withdraw it and ask the
patient to turn their head towards you, then replace
the guidewire) Remove the needle and nick the skin with a
number 11 scalpel
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Subclavian Approach
Dilate the track
Thread the dilator over the guidewire then remove
it keeping the wire in situ at the same depth Thread the catheter over the guidewire keeping
hold of the wire so it does not disappear into the
patient (it is helpful to estimate the length of the
catheter needed to reach the right atrium before
placement)
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Subclavian Approach
When the catheter is in place there shouldbe free flow of venous blood (if there is no
flow the catheter is not correctly placed oris kinked)
Remove the guidewire and attach fluids
Suture the catheter in place with 2/0 silk,spray with povidone iodine and apply anocclusive dressing
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Subclavian Approach
Observe and listen to the chest to exclude a
pneumothorax
Obtain a chest radiograph to confirm itsposition and exclude a pneumothorax
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Complications
Generally safe if a small needle is used to identifythe vein first
1. Pneumothorax - suspect if air aspirated. Alwaysrule out with a CXR. Requires a chest tube. Morelikely on left because of higher dome of left
pleura.
2. Hemothorax from vascular injury3. Hydrothorax from IV fluid administration into thepleural space
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Complications
1.Catheter tip embolus - NEVER withdraw
the catheter over the needle
2.Perforation of endotracheal tube cuff.
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Complications
1.Air embolus - always cover the open end of
a central line with a finger. 50-100ml air
can be fatal. If suspected tip the patient headdown and onto their left side so the air stays
in the right atrium and get an urgent chest
radiograph to see if there is air in the heart.2.Line sepsis.
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Documentation in Medical
Record Consent
Indications
Lack of contraindications Procedure including prep, anesthesia,
technique
Complications? Who was notified of complication (family,
attending).