Transcript Central Venous Access - Penn Medicine

Central Venous Access
Office of Graduate Medical Education
Perelman School of Medicine
University of Pennsylvania
Slides Courtesy of : Joan Hoch Kinniry ACNP-BC
Lead Practitioner , Critical Care Medicine, Procedure and Resuscitation Service
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
Disadvantages
Internal
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 PACath (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 injurychylothorax
Nerve injury (brachial plexus,
sympathetic chain, phrenic)
Cardiac tamponade
Complication Rate / Site Comparison
IJ
Pneumothorax (%)
SC
Fem
<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
1.2 – 3
0 – 13
8 – 34
3
0.5
6.25
low
high
low
Thrombus (rate per 1000 catheter days)
Arterial Puncture (%)
Malposition
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
Posterior belly of
Sternocleidomastoid
Clavicle
Anterior belly of
Sternocleidomastoid
Sternal Notch
Subclavian Anatomical Landmarks
Clavicle
Turn
Insertion Point
and Trajectory
Sternal Notch
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
•Multiple
•More
Percutaneous
Introducer Sheath
(Cordis)
•
Trauma Line
•
Hemodialysis Dual
Lumen Catheter
(PA-Cath, TVP,
“buddy catheter”)
• 12 gauge
• 9 Fr.
• 18 gauge x 2 (optional)
access
points
•Hemorrhagic Shock
Resuscitation Line
•When used w/o
“Buddy catheter”
difficult to insert
•Sharper tip on dilator
increases risk of
misplacement
•Shorter length with left
sided placement
Introducer (PA-Cath,
TVP)
Usually 8.5 FR
Hemorrhagic Shock
Resuscitation Line
Limited access points
unless PA-Cath
inserted
Single lumen large bore
central access
• Usually 8.5 FR, 8.89cm
Hemorrhagic Shock
Resuscitation line
•Limited
Usually 13.5 FR
Used for HD and
plasmapheresis
•Not
•
access points
•No introducer sheath
to be used except
in extreme emergency
for general IV access
Infusion Rate Comparison
MAC
Distal (9fr)
Proximal (12g)
Distal w/ 8fr catheter
33,000 cc/hr
13,000 cc/hr
10,500 cc/hr
TLC
Distal (16g)
Medial (18g)
Proximal (18g)
3,400 cc/hr
1,800 cc/hr
1,900 cc/hr
Choosing the Catheter Size
Pt. Height
RIGHT
Subclavian
LEFT
Subclavian
RIGHT Internal
Jugular
LEFT 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 Femoral
Can 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
Documenting Catheter Depth





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
Double hash mark =
full catheter length
Catheter length printed
on manifold
Single hash mark = one
centimeter increments
5 cm increment
numerical
marking
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
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
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