Central Line in Anesthesia
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Transcript of Central Line in Anesthesia
Central lines in anesthesia: choices, techniques & pi4alls IAN HEWER, MA, MSN, CRNA
ASSISTANT Director, WCU NURSE ANESTHESIA PROGRAM
OBJECTIVES
• IDENTIFY REASONS FOR CENTRAL LINE ACCESS • IDENTIFY COMMON SITES & MAJOR LANDMARKS FOR CENTRAL LINE PLACEMENT
• LIST FREQUENT COMPLICATIONS OF CENTRAL VENOUS ACCESS & WAYS TO AVOID THEM
HISTORY
• 1656-‐ original infusions of wine, ale, & opiuminto dog
• 1680s-‐ animal blood into humans-‐ results ledto unpopularity!
HISTORY
• 1700-‐1800s-‐ various experiments to measurearterial, venous & cardiac pressures
• First experiments in early 20th century inGermany
• Wanted a way to introduce emergency drugsclose to the heart (Forssmann, 1929)
HISTORY
• 1940s-‐ introducbon of PVC catheters for IVsrevolubonizes field
• 1956-‐ Cournand, Forssman & Richards wonNobel Prize for Medicine
Further development
• Locabons: – Infraclavicular subclavian-‐ 1952 Aubaniac – Internal jugular approach-‐ 1968 English
• Why? – Nutribon – Chemotherapy – Direct access for drugs
CVCs today
• > 5 million placed/year in the US alone (McGee & Gould, 2003)
• > 15% have complicabons
–Mechanical-‐ 5-‐19%
– Infecbous-‐ 5-‐26%
– Thrombobc-‐ 2-‐26%
implicabons
• Significant morbidity-‐ potenbally >750,000 have complicabons
• Significant cost-‐ $16,550/ infecbon (CDC, 2011)
• Reducbon in CLABSI 2001-‐2009-‐ save $2 billion in excess costs & 6000 lives
Major uses
• Access – Poor peripheral – Need for volume..?
Side note: Fr vs gauge
• French relates to external diameter, & is a mulbple of 3 – 1 Fr = .33mm OD, 3 Fr =1 mm OD, 6 Fr = 2 mm OD etc
– DOES NOT INDICATE INTERNAL DIAMETER!!
• Gauge refers to internal & external diameter..kind-‐of.. – E.g. 14 G = 2.1mm OD & 1.6mm ID. Similar to 6 Fr OD
Major uses
• Determinabon of CV funcbon
– CVP measurement
– PA catheter placement
• Nutribon
Not much of a decision
• Ultrasound vs Landmark
• Less arterial punctures
• Less overall sbcks
• Beoer first aoempt success
• Quicker
Remember..
• There is a learning curve!
Classic “central” approach • Idenbfy the triangle formed by clavicular head/ sternal head of the sternocleidomastoid Vein is typically anterior & lateral to artery at the level of cricoid carblage
• Lower down the neck, the vein becomes relabvely medial, & risk of pneumothorax
increases-‐ stay away!
• Higher up the neck, the risk of brachial plexus or phrenic nerve injury increases-stay away!
phrenic nerve injury increases-‐ stay away!
Clavicle
Jugular vein
Carotid artery
_,,___Sternal notch
A Sternocleidomastoid muscle
Who needs to see?!
Mechanical complicabons
• Arterial cannulabon/ injury – Puncture: 6.3-‐ 9.4% (McGee & Gould, 2003) – Cannulabon: most recent work, incidence of 1%, but range from .07-‐1% (Bowdle)
– Closed claims data not encouraging! • 5/14 died
– Other risks include stroke & addibonal surgery, LOS
5353
Absent internal jugular vein: Another case for ultrasound guided vascular access
Sir,We describe a case of absence of right internal jugular
vein (IJV), which is a rare form of anatomical variation of the IJV. A 65-year-old male patient was admitted to the intensive care unit (ICU) with the complaints of fever and hypotension. The ICU resident placed a central venous catheter (CVC) in left IJV as he was unable to visualize the right IJV on ultrasound. On the 10th ICU day, the CVC insertion site was found to be inflamed, and it was decided to resite the catheter on the right side.
The right side of the neck was examined carefully, and no evidence of scarring suggesting previous surgery or cannulation was seen. The ICU consultant scanned the right side of the neck carefully using a portable ultrasound (US) machine (IMAGIC Agile, Kontron Medical, WA, USA) with a linear, high frequency transducer (7.5–12 MHz). Care was taken to apply minimal pressure on the probe to prevent collapse of the IJV. Imaging showed a single pulsatile vessel, which was non compressible suggestive of the carotid artery with
no evidence of the IJV [Figure 1]. Doppler confi rmed thecharacteristic pulsatile blood flow in the carotid artery. The 2D US imaging on the left side showed normal anatomy with good size IJV [Figure 2]. Subsequently, the CVC was placed in the right axillary vein under real-time US guidance in a single attempt.
Landmark guided central venous cannulation is based on the premise of normal anatomy of the vein and its adjoining structures. In a study on long-term hemodialysis patients, the incidence of signifi cant US findings such as total occlusion, nonocclusive thrombus and stenosis was seen to be as high as 35%.[1] Agenesis or hypoplasia of the central veins though rare is another probable cause of failed cannulation in patients where US guidance is not used. In our patient, the possible absence of the vein can be explained by IJV agenesis, which represents a form of truncular venous malformation due to a developmental arrest during the later stages of embryonic development, which could lead to either aplasia or hypoplasia of the vein.[2] Denys and Uretsky studied 200 patients undergoing IJV cannulation under US guidance and found that in 2.5% of the patients, the IJV was not visualized.[3] Absence of the right sided IJV has also been reported in a 12-year-old boy during US evaluation prior to attempted cannulation.[4] In another report, IJV agenesis was discovered during neck dissection. Patients who require removal of IJV due to disease infiltration may have potentially life-threatening complication of cerebral edema if the other IJV is aplastic.[5]
Letters to the Editor
Figure 1: Ultrasound image of the right side of the neck showing absence of internal jugular vein. CA: Carotid artery
Figure 2: Ultrasound image of the left side of the neck showing normal anatomy. CA: Carotid artery; IJV: Internal jugular vein
Next step
• Scan neck up & down above “standard” entry site to visualize course of vein & artery
• Local anesthebc? • As early as possible
Next step
• Center vein, enter at 30-‐45 degree angle about 1cm away from probe
• Enter medial to guide line, aim slightly lateral
• Ideally, follow needle bp “down” to vein
• Watch screen, but aspirate as you advance
A word about sedabon..
• Less is more
• With good LA, should not be painful
Next step
• Enter vein using either “big” needle or some prefer 18G catheter; advantages to both – Catheter-‐ less prone to pop out of vein, but can be more difficult to advance
– Needle-‐ good flow, easy to advance wire BUT must keep very sbll
• Advance wire-‐ MUST THREAD EASILY
• Need to check for venous placement
Placing the line
• Triple lumen – Scalpel/dilator/line – Secure around 15cm
• Introducer/Swan – Line is on dilator – Remember the dilator is rigid & pointy! – Line goes to hub
• Both-‐ ensure wire is free as you advance line
Leu IJ lines
• Increased risk, but beoer choice in some people -Shorter length to subclavian-‐ extra care with dilator, & may need to pull back introducer for Swan -Increased risk of lung injury
• Risk of thoracic duct injury
More bad things about the leu
• Vein crosses over artery more easily with turning head
• Unfamiliarity
Subclavian lines • Small roll between shoulders-‐ improves access
• Midpoint of clavicle, 2-‐3 cm back – Aim: to avoid poinbng needle down – Some clinicians bend needle for same effect
• Point needle towards sternal notch
– Some hold leu hand on notch to keep “target”
• Advance needle with negabve pressure • unbl in vein
in vein
Subclavian bps
• Must use needle-‐ catheter may kink
• If unsuccessful, point needle more cephalad
• Keep passes to minimum; avoid bilateral aoempts
More subclavian bps
• If line is for thoracic surgery, on same side
• If pt has pathology in one lung (e.g. pneumothorax), line on same side
• Wire may not go where you want it
– If pt is awake, ear/ neck pain may indicate wire in IJ
– If pt is asleep, look for ectopy – Always X Ray
Subclavian & U/s
• Not typically recommended
• Can be useful to idenbfy normal anatomy prior to starbng procedure
No complicabons with u/s..?
Accidental Carotid Artery Catheterization
During Attempted Central Venous Catheter
Placement: A Case Report
Pauline Marie Maietta, CRNA, MS
More than 2.1 million central venous catheters are
placed annually. While carotid artery cannulation is
rare, its effects can be devastating. Anesthesia provid-
ers frequently work i/v/frt central venous catheters in
the perioperative setting. Therefore, it is imperative
that they be able to identify and react appropriately to
carotid artery injury both in preexisting central lines
and those that they have placed.
This case report details a case of accidental carotid
artery catheterization during attempted right internal
jugular vein catheterization and the steps taken to
treat the patient following its recognition. A discus-
sion of technique for central venous catheterization,
indications for suspicion of arterial puncture, methods
for confirming venous or arterial placement, appro-
priate methods for management of carotid artery
cannulation, and the benefit of ultrasound in central
venous cannulation follow. Through the appropriate
use of equipment, early detection and management
of carotid artery injury, and proper training, patient
outcomes may be improved.
Keywords: Carotid artery catheterization, central
venous catheter, complication, ultrasound.
Anesthesia professionals commonly work
with and place central venous catheters
(CVCs). Although carotid artery cannula-
tion is a rare complication associated with
central line placement, its occurrence can
be devastating to the patient. It is therefore important for
anesthesia providers to appropriately identify and manage
complications associated with an improperly placed cath-
eter and to be knowledgeable of tools and techniques that
can help prevent future carotid artery catheterizations.
CVCs are commonly placed for: central venous pressure
monitoring; infusion of ñuids, medication, and nutrition:
aspiration of air emboli; insertion of transcutaneous pac-
ing leads; insertion of pulmonary artery catheters; and
temporary hemodialysis (Table 1).
The right internal jugular (RIJ) vein has been the pre-
ferred site for central venous access'" since the central
landmark technique was first described in 1969.^ This
site is often chosen over other central line insertion
sites because of its readily identifiable landmarks, short
direct route to the junction of the superior vena cava
and right atrium, distance from the thoraeic duct, and
its ease of access for the anesthesia provider.' Although
CVCs placed in the internal jugular vein are assoeiated
with a high suecess rate, catheterization of the internal
jugular vein is also associated with various technique-
related complications.'^ Complications of internal jugular
cannulation include infection, embolism, dysrhythmia,
hematoma, pneumothorax, eardiac perforation, cardiae
tamponade, trauma to nearby nerves or arteries, throm-
bosis, and fistula formation (Table 2).'-^ According to
Tom Richardson, Northeast regional district representa-
tive of CVC manufacturer, Arrow International, Boston,
Massachusetts, via a phone conversation, more than 2.1
million CVCs are placed annually. While carotid artery
complieations are 1 of the 3 most common complieations
assoeiated with central venous eatheterization,^ eannula-
tion of the earotid artery by a large bore catheter is less
frequent, occurring in 0.1% to 0.5% of cases.**
Case Summary
A 77-year-old male presented to the emergency depart-
ment (ED) following progressive shortness of breath for
several days and chest pain upon exertion. His medical
history included diabetes mellitus, coronary artery
disease, atrial fibrillation, chronie obstructive pulmonary
disease, and ehronic bronchitis. He had an 80 pack year
smoking history and had been receiving 2.5 L of oxygen
via nasal eannula at home for 6 months before presenta-
Venous access in patients with poor or no previous access
Rapid fluid resuscitation (as in hypovolemia or shock)
Monitoring of central venous pressure and or puimonary artery
catheterization for comprehensive cardiac monitoring
Infusion of caustic drugs, vasoactive drugs, or total parenteral
nutrition
Temporary hemodialysis access
Aspiration of air emboli ¡n the event of venous air embolism
Insertion of transcutaneous pacing leads
Table 1. Indications for Central Venous
www.aarna.com/aanajournalonline
AANA Journal m August 2012 • Vol. 80, No. 4251
(Maieoa, 2012
)
U/s examined • Operator error could be an issue
• We cannot see whole length of wire • Pressure transducbon could prevent arterial
cannulabons not detected by other means-‐ approx 0.8% of all aoempted (Ezaru, 2009) – That’s potenbally 40,000 cases/yr!!
• Should we use pressure measurement for all?
residents placing the CVC in each of the six cases were credentialed by their hospital in emergencyultrasound based on American College of Emergency Physicians ultrasound criteria. All residentsreceived a 2-day introductory ultrasound course, which included 3 hours of didactic and hands-oneducation in ultrasound-guided vascular access. Table 3 summarizes each of the six cases, including asanalysis of the error based on a video review of the ultrasound-guided arterial cannulation.
Age Mechanism of injury Outcome 67 Needle went through IJ into Carotid artery Patient Died 75 Needle went though femoral vein into
femoral artery Vascular surgery for AV fistula
48 Needle went though IJ and entered carotid artery sitting underneath the IJ
Surgery for tear and focal dissection of carotid artery
67 Guidewire traveled through IJ and its posterior wall and into carotid artery
Hematoma with respiratory distress requiring emergent intubation.
69 Needle penetrated the carotid artery which was very close to the IJ
Emergency carotid artery repair; Patient died of complications
14 Needle penetrated rear wall of IJ and entered carotid artery
Central line removed and bleeding eventually stopped
Table 3: Analysis of six accidental arterial cannulations with dynamic ultrasound guidance
The mechanism of injury in 5 of the 6 cases involved passage of the needle through the vein, out itsposterior wall, and into the artery. This highlights the importance of confirming the location of the tip ofthe needle prior to inserting the guidewire. The author concluded, “In summary, the short-axis approach,as seen in this series, can provide a false sense of security to the practitioner and allows for potentiallydangerous accidental arterial cannulation…it may be prudent to not only visualize the entire path of theneedle with the long-axis approach but also confirm correct cannulation by tracing the guidewire in the long axis before line placement.” However, it is important to realize that even with multiple ultrasoundviews of needles or wires, misdiagnosis remains a possibility. For example, as noted in the case below (see Figure 6), it is possible for a needle and wire to pass through the internal jugular vein and into thesubclavian artery, which may not be possible to visualize with ultrasound because of interference fromthe clavicle.
Parsons and Alfa reported a case of inadvertent arterial cannulation despite the use of ultrasoundguidance in a 34-year old with chronic renal failure undergoing renal transplantation29. The arterialcannulation was eventually discovered by transducing the pressure in the lumen of a 7 Fr catheter. Theauthors proposed that the introducer needle was correctly placed in the internal jugular vein underultrasound guidance, but later shifted during guidewire insertion, at which point ultrasound had beendiscontinued (Figure 2). The authors noted, “Movement may still occur with migration of the needleoutside the vein during the Seldinger technique, resulting in wire malposition. We suggest that re-imagingthe vein and confirming the presence of the guidewire in the internal jugular vein prior to dilation mightprevent catheter placement into the carotid artery. We should be aware that US techniques do notremove all risks associated with CVC insertion.” Other case reports of arterial cannulation duringattempted cannulation of the internal jugular vein under ultrasound guidance have described similarerrors (passage of the introducer needle though a vein and into the underlying artery) and reached similarconclusions (confirm that the needle tip and/or guidewire are in a vein prior to placing the catheter)30,31.
Source: Bowdle, nd
Some general comments About complicabons
• Site dependent
• Provider dependent-‐ VOLUME OF PROCEDURES
• Procedure dependent
Our study
• Wanted to examine complicabon rates in CVCs placed by CRNAs vs MDs
• Easy access to QI database
• Problem – Polibcal – Numbers-‐ a vicbm of our own success
Major complicabons
• Mechanical – Vessel or nerve injury – Pneumothorax/ hemothorax
• Infecbous
• Thrombobc
Mechanical complicabons
• Vein injury – Vein is thin walled relabve to artery-‐ more prone to damage
– Can be acute during line placement – Or later as result of erosion
What we found
• Hematoma-‐ 1/359 (.003%)
• Cannulabon-‐ 0
Pneumothorax
• Incidence varies according to site (duh!)
• Commonest with subclavian (1.5-‐3.1%)
• Rare but seen with IJ (.2%)
What we found
• 9/359 pts = 2.5%
• Typical incidence = 0.1-‐0.2%
• BUT rate of ptx in cardiac surgery = 0.7-‐5.3% (higher with IMA harvest) (Weissman, 2004)
hemothorax
• Result of vessel injury, typically venous
• Rare, but significant mortality (92% in Closed Claims)
• Remember: veins are fragile
Thrombobc complicabons
• Significant issue outside of the OR
• Incidence cited varies e.g 1.9% of subclavian lines (McGee, 2003)
• With thrombosis comes risk of embolizabon
• Probably related to durabon
Thrombosis:more
• Contact with vein wall is probably a big risk for thrombosis (Fletcher & Bodenham, 2000)
• Therefore posiboning is key
• Think post-‐op CXR
Infecbous complicabons: background
• Interest in Healthcare Acquired Infecbons (HAI) has increased dramabcally-‐ in response to the problem
• Priority of WHO, IOM, CDC, TJC, & a hospital near you..
• 1.7 million infecbons & 99,000 deaths in the US from HAI (TJC, 2012)
Infecbon: cvcs
• CLABSI: Central Line-‐ Associated Blood Stream Infecbon
• Est 80,000 CLABSI/ year in ICU alone
• Mortality: difficult, but maybe 10,000 yr
• Cost significant: >$16,000 per case
• Source TJC, 2012
More specifics
• Most risk = femoral line
• Next, Internal Jugular-‐ ? Due to proximity to mouth
• Least risk = subclavian
What we found
• 2 infecbons (.006%)
• Preliminary: no associabon with “difficult inserbon”, second line(31 pabents), diabetes or line durabon
• ..but average line durabon 3.03 days
Chapter 1: Types of Central Venous Catheters and Risk Factors for and Pathogenesis of CLABSIs
5
● Heavy microbial colonization at insertion site, whichis closely related to the site chosen for insertion; den-sity of skin flora is higher at the base of the neck,where internal jugular CVCs are inserted, than at theupper chest, where subclavian CVCs areinserted.24,33,34
● Multilumen CVCs7,24
● Lack of maximal sterile barriers (cap, mask, sterilegown, sterile gloves, and a sterile full body drape) forthe insertion of CVCs or guidewire exchange35,36
● CVC insertion in an ICU or emergency depart-ment23,25,37,38
Also, as will be described in Chapter 2, staff who insert andmaintain CVCs must receive education and training to ensurecompetence and minimize the risk of CLABSI in theirpatients; a sufficient nurse-to-patient ratio is also important tominimize risks for patients with CVCs. A more in-depth dis-cussion regarding education and training and their roles inpatient safety initiatives can be found in Chapter 4.
Chapter 3 contains a comprehensive review of the recom-mended strategies and techniques for preventing CLABSIs.
Pathogenesis of CLABSIsCVCs can become contaminated with microorganisms viatwo major routes7,39–42 (also see Figure 1-1 below):1. Extraluminally:
● The patient’s skin organisms at the insertion site canmigrate along the surface of the catheter into the cuta-neous catheter tract surrounding the catheter, resultingin colonization at the catheter tip. For short-termcatheters (nontunneled CVCs in place less than 10days), this is the most common source of infection.
2. Intraluminally● Most commonly, direct contamination of the
catheter or at any point along the fluid pathwaywhen the IV system is manipulated (as might occurwhen health care personnel have hand contact withIV solution connection sites, access hubs, needlelessconnectors, or tubing junctions, or contaminationwith the patient’s own body fluids or skin). Thisroute has been associated with more prolonged CVCdwell time (for example, in place for more than 10days), including tunneled CVCs such as Hickman-and Broviac-type catheters and PICCs.
Figure 1-1. Routes for Central Venous Catheter Contamination withMicroorganismsPotential sources of infection of a percutaneous intravascular device (IVD): the contiguous skin flora, contamination of thecatheter hub and lumen, contamination of infusate, and hematogenous colonization of the IVD from distant, unrelated sites ofinfection. HCW: health care worker.
Source: Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I.Pathogenesis and short-term devices. Clin Infect Dis. 2002 May 1;34(9):1232–1242. Used with permission.
Source: TJC, 2012
What can we do? • Is the line really needed?
– Minimum number of lumens
• Hand hygiene
• Asepbc techniqueo Maximal barrier techniqueo Right prepo Antibiotic impregnated line/dsg
–
• Ultrasound-‐ diminished # of aoempts
A word about scrub the hub!
• Focus of TJC in recent years
• Anesthesia compliance…sub-‐opbmal!!
• 15 second scrub with alcohol
• ..or the “orange cap”
Miscellaneous issues
• Experience – Like surgical cases, experience counts – Sznajder et al (1986)-‐ Experience with > 50 CVCs = ½ rate of complicabon compared with < 50 CVCs
– > 3 aoempts = 8 x mechanical complicabon rate
• Quesbon: should everybody put in lines?
In closing
• U/S may not be essenbal, but does offer benefits
• Consider using manometry to check placement even with U/S
• HAND HYGIENE!! (Scrub the hub too)
references • Aljure,O., Casbll-‐Pedraza, C., Mitzova-‐Vladinov, G., Maraeta, E. (2015). Right internal jugular cross-‐secbonal area: is there an
opbmal area for cannulabon? Jnl of the Associa1on for Vascular Access 20(1): 22-‐25. • Bowdle, TA. Arterial cannula1on during central line placement: mechanisms of injury, preven1on & treatment.• Ezaru et al. (2009). Eliminabng arterial injury during central venous catheterizabon using manometry. Anesth Analg 109:
130-‐4. • Fletcher & Bodenham. (2000). Safe placement of central venous catheters: where should the bp lie? Brit Jnl Anaes 85:
188-‐91. • Hamilton & Bodenham (eds). (2009). Central venous catheters. Chichester: Wiley Blackwell.• Maieoa. (2012).Accidental carobd artery catheterizabon during aoempted central venous catheter placement: a case
report.AANA Jnl 80(4): 251-‐ 255. • McGee & Gould. (2003). Prevenbng complicabons of central venus catheterizabon. NEJM 348: 1123-‐33 • Seo et al. (2008). Perforabon of the superior vena cava during liver transplantabon: a case report. Korean Jnl Anesth 55(4):
506-‐10 • Sznajder et al. (1986). Central vein catheterizabon: failure & complicabon rates by 3 percutaneous approaches. Arch Int Med
146: 259-‐61. • The Joint Commission. (2012). Preven1ng central-‐line associated bloodstream infec1ons: a global perspec1ve. OakBrook, Il:
Joint Commission Resources