Post on 17-Jan-2016
Central Venous Access
Slides Courtesy of : Joan Hoch Kinniry ACNP-BC
Lead Practitioner , Critical Care Medicine, Procedure and Resuscitation Service
Office of Graduate Medical EducationPerelman School of Medicine
University of Pennsylvania
Central Venous Line Placement Goals
Reduce anxiety about procedures Review basics
Indications Complications Mechanics
Improve familiarity with various catheter types Establish good habits and solid foundation Improve confidence and competency Ensure safe and sterile catheter placement
Central Venous Line Placement Indications
Hemodynamic monitoring CVP / Scv02 PA-Catheters (Swan-Ganz, RHC)
Administration of hyperosmolar agents, vasopressors and other medications
Temporary transvenous cardiac pacing Hemodialysis and plasmapheresis Lack of peripheral access
Central Venous Line Placement Absolute contraindications
None
Relative contraindications Coagulopathy / thrombocytopenia Anatomic abnormalities Thrombus / stenosis Localized infection over insertion site Recent pacemaker insertion
Approach Advantages DisadvantagesInternal
Jugular
Control of bleeding
PTX uncommon
Lower infection rate (vs. femoral)
PA-Cath (R) IJ
Carotid artery injury
Uncomfortable for Pt.
Maintenance of dressings
Tracheostomies
IJ vein prone to collapse
Subclavian Maintenance of dressings
More comfortable
Clearer landmarks
SC vein less collapsible
Lowest infection rate PA-Cath (L) SC
Risk of PTX
SC artery difficult to compress
(typically, SC vein is compressible)
Should be avoided in CKD/ESRD
Femoral No interference with CPR
No risk of PTX
Highest infection rate
Difficulty for PA-Cath
Femoral artery injury
DVT
NEJM 356;21 2007
Central Venous Line Placement
Complications-Immediate Failure to cannulate Pseudoaneurysm Catheter malposition Arteriovenous fistula Vessel laceration Hematoma Arrhythmia (wire or
catheter) Air embolism Pneumo / Hemo thorax
Complications-Distant Pneumo / Hemo thorax Air embolism Arrhythmia (catheter) Skin infection or bacteremia Stenosis or thrombosis of
vessel Thoracic duct injury-
chylothorax Nerve injury (brachial plexus,
sympathetic chain, phrenic) Cardiac tamponade
IJ SC Fem
Pneumothorax (%) <0.1 -0.2 1.5 - 3.1 n/a
Hemothorax (%) n/a 0.4 – 0.6 n/a
Infection (rate per 1000 catheter days) 8.6 4 15.3
Thrombus (rate per 1000 catheter days) 1.2 – 3 0 – 13 8 – 34
Arterial Puncture (%) 3 0.5 6.25
Malposition low high low
Complication Rate / Site Comparison
NEJM 356;21 2007
Central Venous Line Placement
Preprocedure Prep Informed consent process – use procedure specific consents Review procedure, indications and alternatives
Risks / Benefits Obtain written consent
Coordinate procedure timing with bedside RN Enter Bedside Procedure Order in SCM Review equipment check list for needed supplies Review Preprocedure Checklist
Procedure sign posted Procedure cart at bedside
Central Venous Line Placement Preprocedure Prep
Perform Time out at bedside with RN – document in SCM Sterile Technique
Chlorhexidine 30 second friction scrub with 60 second dry time for dry site 30 second friction scrub with 2 minute “soak” time for moist site
Maximum Barrier Precautions Sterile Gloves Long-sleeved gowns Full field drape Masks/Caps for all participants & observers
Sterilize from chin to nipple to shoulder to ear (allows both IJ and SC to be accessed on the same side)
Central Venous Line Placement
PROCEDURE All IJ lines must be done with US guidance All lines must be transduced before dilation (verified by
performing MD and RN)
DOCUMENTATION Consent Bedside Procedure Order in (SCM) Time Out (SCM) US vessel evaluation note Procedure Note
IJ Anatomical Landmarks
Sternal Notch
Posterior belly of Sternocleidomastoid
Anterior belly of Sternocleidomastoid
Clavicle
Subclavian Anatomical Landmarks
ClavicleTurn
Sternal Notch
Insertion Point and Trajectory
Femoral Anatomy Landmarks
Catheter type Description Advantages Disadvantages
Standard Triple Lumen (TLC)
7 Fr, 15 cm
• 18 gauge x 2• 16 gauge
Multiple access points Not optimal resuscitation line for hemorrhagic shock
Multi-Access Catheter (MAC)
9 Fr, 11.5 cm
•Introducer (PA-Cath, TVP, “buddy catheter”)• 12 gauge• 9 Fr.• 18 gauge x 2 (optional)
•Multiple access points•Hemorrhagic Shock Resuscitation Line•When used w/o “Buddy catheter”
•More difficult to insert•Sharper tip on dilator increases risk of misplacement•Shorter length with left sided placement
Percutaneous Introducer Sheath (Cordis)
• Introducer (PA-Cath, TVP)
• Usually 8.5 FR
Hemorrhagic Shock Resuscitation Line
Limited access points unless PA-Cath inserted
Trauma Line • Single lumen large bore central access• Usually 8.5 FR, 8.89cm
Hemorrhagic Shock Resuscitation line
•Limited access points•No introducer sheath
Hemodialysis Dual Lumen Catheter
Usually 13.5 FR Used for HD and plasmapheresis
•Not to be used except in extreme emergency for general IV access
Infusion Rate Comparison
MACDistal (9fr) 33,000 cc/hrProximal (12g) 13,000 cc/hrDistal w/ 8fr catheter 10,500 cc/hr
TLCDistal (16g) 3,400 cc/hrMedial (18g) 1,800 cc/hrProximal (18g) 1,900 cc/hr
Choosing the Catheter SizePt. Height RIGHT
SubclavianLEFT
SubclavianRIGHT Internal
JugularLEFT Internal
Jugular
4'6" - 4'9" inches 12 16 13 17
4'10"- 5'1" inches 13 17 14 18
5'2" - 5'4" inches 14 18 15 19
5'5" - 5'8" inches 15 19 16 20
5'9" - 6'0" inches 16 20 17 21
6'1" - 6'4" inches 17 21 18 22
HD Catheters: 15 cm Right IJ, 20 cm Left IJ, 24 cm FemoralCan adjust for particularly small or large patients
Choosing the Catheter Size
• When deciding which site to use, consider if the patient is a potential dialysis candidate.• Avoid SC catheter placement
• Left sided hemodialysis catheters have a greater chance of being malpositioned.• For HD catheters risk of atrial perforation
• Always use the longest catheter available for groin lines: 25” Cook CVC and 24” dual lumen HDC.
Proper Use of Adjustable Suture Wing
• Used to secure catheter when not inserted to manifold (“hub” aka - full catheter length)
• Must apply both white rubber clamp and red rigid fastener to avoid catheter migration
• secure with 4 sutures: adjustable suture wing and catheter manifold (hub)
• Do not bend catheter in excess in order to suture at catheter hub, keep straight as possible
•Dressing placed over adjustable suture wing only, manifold sutures open to air
• Provider procedure note documentation and daily RN documentations MUST include catheter depth
•catheter depth or securement concerns
Centimeter markings on catheter are used to determine catheter depth
Catheter length is printed on manifold (hub) Double hash mark equals full catheter length as indicated on
manifold Single hash marks indicate one centimeter increment Document catheter depth where catheter exits the skin in daily
access assessment
Documenting Catheter Depth
Catheter length printed on manifold
Single hash mark = one centimeter increments
5 cm increment numerical marking
Double hash mark = full catheter length
measure catheter depth at skin exit
Post-Line Insertion Chest X-ray
Delayed PTX is not unusal – have low threshold to obtain repeat CXR if clinical s/s PTX
Single plane view of ICU CXR is suboptimal to evaluate catheter malposition Transduce waveform via monitor --(can be done without
CXR, will demonstrate intravascular placement and arterial vs venous vessel or extravascular placement)
Blood gas if intravascular may be useful but clinical conditions can confound interpretation
If extravascular catheter is suspected t/c Chest CT w/ contrast
Coagulopathic Patients
Caution with INR > 2.5, PT or PTT > 2x normal, Plt < 50k, or untreated uremia (not on HD). The more parameters fulfilled, increases the cumulative effect on hemostasis.
Consider correction (FFP, platelets, ddavp, HD)
Consider IJ placement under US over SC
Coagulopathic state and /or thrombocytopenia are RELATIVE CONTRAINDICATIONS and warrant a risk/benefit discussion with attending
Helpful Reminders Recommend restraining all patients during central line placement.
(even awake or intact) Keep everything within reach (needles, wire, catheter, flush) Always place patient in trendelenberg (>15 degrees) For SC catheters, placing a rolled towel/sheet in between the
scapulae can help “open” the clavicular angle & allow easier passage of the needle underneath the clavicle
If wire does not pass: Re-attach syringe and aspirate (see if still in vessel) Lower angle of needle (and aspirate) If wire “clears” the tip of the needle, then consider structural
reason (thrombus, anatomic abnormality, ect.) If the wire does not come out easily, give GENTLE traction and try
rotating the wire. DO NOT pull firmly on the wire! Remove catheter and wire together if able If unable to remove wire call vascular
Ultrasound Guided Vascular Access
Transducer Transmits and receives the ultrasound beam Contacts the patient’s skin Takes thin slices of object being imaged Rotated or angled to change views Beam Profile
Width of the beam (1mm) Length of beam 38mm
38mm
1 mm
Ultrasound Basics
Fluid (i.e. blood) is black b/c near complete transmission of U/S waves occurs
Bone and air cause marked reflection and appear white (in B – mode)
Strong reflection creates an acoustic shadow obscuring distal imaging (bone shadow)
Ultrasound Basics
Most large vessels are easily visualized with U/S probes Arteries are pulsatile, difficult to compress and
thick walled Veins are non-pulsatile, easily compressible,
engorge w/ Trendelenburg or Valsalva and thin walled
Transverse Orientation – IJ
Longitudinal Orientation – IJ
Transverse Orientation – Subclavian
Longitudinal Orientation: Subclavian
Guide wire in Longitudinal View
Jugular Vein Thrombosis
Acute thrombus can appear “black” or “cloudy” on US exam
Always evaluate the whole neck ensuring IJ is fully compressible along the entire length
Presence of small caliber anomalous vessels can be indicative of past or present clot or stenosis
Jugular Vein Thrombosis