Transcript Central Venous Access - Sunderland ICCU Medical Education

Central Venous Access
Indications
• Peripheral access impossible.
• Administration of irritant medications inc. TPN.
• Measurement of mixed venous oxygen saturations.
• Right heart catheterisation.
• RRT / ECMO etc.
• NB - NOT fluid status
Assessment
What aspects of the patient examination and
investigations need to be taken into
account before inserting a central line?
Monitoring and Environment
Where should a central line be inserted?
What monitoring is required?
Infection Control
Site
What sites are available for central access?
What are the advantages / disadvantages of
each?
Internal Jugular
External Jugular
Subclavian
Femoral
PICC
Ultrasound
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Position the ultrasound screen on the other side of the patient to
allow easy viewing
•
Touch the side of the probe while observing the image to orientate
the probe. (Some probes have a mark that corresponds to one
side of the screen for this purpose)
•
Alter the gain to produce a relatively dark image that will help
discriminate the white of the needle tip
•
Use sterile gel inside the probe sheath (and between the sheath
and the patient’s skin) to provide acoustic coupling
•
Throughout the procedure, maintain a sterile environment. (The
operator should be wearing a sterile gown, mask, hat and the
area should be cleaned before drapes are applied)
Short vs Long Axis View
How can you differentiate between vein and
artery?
Veins are (usually)….
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Where you expect then to be
Compressible
Non-pulsatile
Varying in size with respiration, valsalva,
fluid loading
Seldinger Technique
Complications
What complications are related to insertion
of the line (immediate complications)?
• Arrhythmias
• Venous bleeding
• Arterial bleeding
• Pneumothorax
• Cardiac perforation
• Embolisation (air or thrombus)
• Retained wire
What adjacent structures can be damaged
when attempting IJV cannulation?
• Thoracic duct
• Vagus nerve
• Brachial plexus
• Phrenic nerve
• Stellate Ganglion
• Glossopharyngeal nerve
What are the potential delayed
complications?
• Sepsis
• Extravasation (dislodgement)
• Thrombosis
CXR Position
Good Position
Abutting SVC