CVC workshop

CVC Workshop

CVC Workshop

Right Internal Jugular Central Venous Catheter Insertion WorkshopPre-reading

IntroductionThe placement of central venous catheters (CVC) is an essential skill for any clinician working with critically ill patients.The widespread access to ultrasound (USS) and multiple studies showing the superiority of real time ultrasound in CVC placement compared to landmarks alone has meant that the use of realtime USS in CVC placement is now the gold standard.

IndicationsIV access (especially if difficult peripheral access)CVP monitoring Central venous oxygen saturation (ScvO2 ) monitoring/samplingInfusions of irritant substances (e.g. vasoactive agents, calcium, chemotherapy or TPN administration)Renal replacement therapy, plasmapheresis and apheresisTransvenous pacing

Contra-indicationscoagulopathyrespiratory failure (patient positioning and ability to tolerate procedure)raised ICP (cannot tilt head down)can use femoral approach in all the situations aboveobstructed vein (e.g. thrombus, tumour etc)overlying skin infection, burn or other disease processhemorrhage from target vesseluncooperative patient

ComplicationsInfectious ComplicationsCatheter related bloodstream infections approximately 1.5% in Jugular CVC (3SITES Study1)Vascular ComplicationsCarotid puncture/cannulationHaematoma from multiple attemptsEquipmentCatheter related thrombosisPulmonaryPneumothoraxVenous air embolism

See the attached paper Preventing Complications of Central Venous Catheterisation(alternatively double click on icon to the right)

1 Parienti, J., et al. (2015). Intravascular Complications of Central Venous Catheterization by Insertion Site. New England Journal of Medicine N Engl J Med, 373(13), 1220-1229. doi:10.1056/nejmoa1500964

Sites for CVC placement3 main sites are used for CVC placementInternal jugular, subclavian and femoralAll have the option for either left or right sided placementAll are associated with infectious, thrombotic, and mechanical complications.The rate of total complications is similar for all three sites although the exact composition of the complications may differ

3SITES1 Study SummaryRandomised Multicenter Trial with 3471 CVC insertedCompared Catheter Related infections in Femoral, Internal Jugular(IJ) and Subclavian lines.Subclavian was shown to have significant less infections. While the Femoral and IJ had comparable infection rates with no significant statistical difference

To Read full article click on icon to the right1 Parienti, J., et al. (2015). Intravascular Complications of Central Venous Catheterization by Insertion Site. New England Journal of Medicine N Engl J Med, 373(13), 1220-1229. doi:10.1056/nejmoa1500964To read full article double click on icon to the right (optional)

Now lets review the surface anatomy of the 3 sites for CVC placement

Subclavian vein

Anatomy

CVC insertion to this vein is usually done using land mark technique as it is not easy to ultrasoundThe infra clavicular approach is most commonly used

Femoral VeinAnatomy

Ultrasound Image

SV= saphenous vein, CFV = Common Femoral Vein, CFA = Common Femoral Artery

NAVY

NAVY pneumonic used to remember the structures going from lateral to medial (Y=y-fronts i.e. midline)

Right Internal JugularThis site has been selected for this workshop because:Most commonly used site in this institutionWhy the right side?Convenient for right handed operators as they can palpate artery/hold ultrasound probe in their non-dominant hand.Less likely to slide into brachiocephalic vein in comparison to leftAmenable to real time USS guidance especially compared to subclavianLess likely to become obstructed when patient sits up or mobilises in comparison to femoral

Right Internal JugularLandmarks: Surface Anatomy

Surface AnatomyHow internal structures relate to surface anatomyLies between two heads of sternocleidomastoid musclesLateral (occasionally posterior) to carotid.

SummaryReview Of Indications and Contra-indicationsPossible complications of central line insertion3 common sites for CVC insertion

Ultrasound Basics

Ultrasound (USS)Realtime USS in CVC placement is recognised as the gold standard as opposed to using the landmark technique alone .Guidelines highlightening this: NICE guidelines Guidance on the use of ultrasound locating devices for placing central venous catheter 1 International evidence-based recommendations on ultrasound-guided vascular access 2Proficiency with the use of ultrasound is essential to becoming competent at placing real-time USS guided CVCs.1 Guidance on the use of ultrasound locating devices for placing central venous catheters. (n.d.). October 4 2002, from https://www.nice.org.uk/guidance/ta49

2 Lamperti M, Bodenham A, Pittiruti M, Blaivas M, Augoustides J, Elbarbary M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012 2012/07/01;38(7):1105-17.

Basics of USS Physics

Basic USS physicsA pulse of sound is sent out by a transducer, hits an object and then bounces back

Basic USS physicsUltrasound waves show up on the screen anywhere from black to white in color. Why?Different tissues attenuate the sound waves differentlyFluid has low attenuation, fat has high attenuation and bone has very high attenuation

FluidFatBone

Basic USS physicsImportantly the quality of the image is degraded as the sound waves pass through areas of high attenuationThe image to the right demonstrates how below the bone no further objects can be seen

Bone

3 Ps of Ultrasound

3 Ps of VASCULAR UltrasoundPatientEnter patient detailsEnsure patient is positioned adequately and comfortable as possibleProbeChoose the high frequency linear probe for vascular ultrasound (6-13mhz)PresetEach probe can be used for multiple tissues i.e. muscle, nerves, blood vesselsChoose the vascular setting (The location of the preset menu will vary on each machine)

Other Settings

DepthDepth determines how deep from the skin that you can visualiseIdeally get the object you want in the center of the screen as demonstrated by the 4cm image to the rightThis way structures below can been seen and avoided when inserting a needle

DepthToo much depth as demonstrated by these images results in decrease resolutionThis will result in increased difficulty in trying to needle the object of interest

GainThis function is very similar to a brightness controlToo much or too little gain will make visualisation of objects difficult (too bright or too dark)Most ultrasound have an auto gain function that will attempt to calibrate the ideal gain

Gain

Gain too high can result in blurring of the walls of the structure. This may impact visualisation of the needle going through the vessel wall.Gain too low can result in structures not being seen

ColorThis mode can be activated to visualise flow through the blood vesselsBlue indicates flow away from the probe and red indicates flow towards the probe (BART: blue away, red towards)Arterial blood (red in this picture) will be pulsatileVenous Blood (blue in this picture) will be laminar

Now lets look at an Ultrasound of the Neck Structures

Nomenclature for imaging vascular structuresLongitudinalTransverse

Transverse view of the right neck vesselsMedialLateralLegend:SCM = SternocleidomastoidCA = Carotid arteryIJV = Internal jugular veinNotice the different shadesComplete black is fluid (blood in this instance)Muscle has a grainy appearance

Different ways of imaging the needle

Different ways of imaging the needleBoth in-plane and out-of-plane are used for CVC placementLocally the out-of-plane approach is favoured and that is what will be taught in the workshopThe greatest benefit with out-of-plane imaging is it gives a better view of adjacent structuresOne of the biggest risks in this procedure is puncture of the adjacent carotid artery - this is best avoided whilst using an out-of-plane approach

Out-of-plane approach

Out-of-plane approach gives this viewThe arrow is pointing to the needle

Out-of-plane approachThe biggest downside to the out-of-plane approach is that the white dot on the screen representing the needle could represent anywhere along the needle.Therefore the technique is to advance the needle into the plane, see the needle on the ultrasound screen then fan the ultrasound probe until the needle is lost and then advance the needle again until it breaks the plane and is then seen on the screen.Repeat this until the needle is where you want it to be

Video on in-plane versus out-of-plane imaging

https://www.youtube.com/watch?v=FpXCj4I-CSQ38

Equipment List For CVC insertion

Personal Protective EquipmentHat and Glasses

Face Shield

Personal Protective EquipmentSurgical MaskGown

Personal Protective EquipmentGloves

Get to know your glove size as appropriately fitting gloves are important when undertaking surgical skills

Major Anaethesia Pack

Major Anaesthesia Pack

Major Anaesthesia Pack ContentsGown

Major Anaesthesia Pack ContentsAperture Drape used to isolate surgical field

Major Anaesthesia Pack ContentsGallipot: Good for emptying Chlorhexidine in when prepping surgcial area (to be thrown away after patient prep)Kidney Bowels: Good Place to put sharps on your tray.Galipot: Good for emptying normal saline vials in if needed

Major Anaesthesia Pack ContentsTube ClampStraight ScissorsRampley Forceps: Used to dip gauze in chlorhexidine and prepare surgical area

Major Anaesthesia Pack ContentsGauze: Pick up with forceps and soaked in chlorhexidine then used to prepare surgical fieldHuck Wipes

Items for Preparing surgical FieldRampley Forceps: Used to dip gauze in chlorhexidine and prepare surgical areaAperture Drape used to isolate surgical fieldGauze: Pick up with forceps and soaked in chlorhexidine then used to prepare surgical field

Chlorhexidine 2% (tinted red)

Items for Preparing Surgical fieldPlace Chlorhexidine in one Gallipot and Saline in the other.

Chlorhexidine is tinted red (sometimes blue)

Various kits: main difference is number size of lumens

This Course will use 3 lumen 7Fr CVCs

Note the lumen gauges and their expected flow rates

Back of Central Venous Catheter (CVC) KitNote: You will need to replace the injection caps (needle) that come with the kit with needleless injection cap connectorsNeedle injection caps

CVC Kit ContentsSpring-Wire Guide (Marked) with Arrow Advancer Multi-lumen CVCFastener: Catheter ClampFrom Left to Right:Tissue DilatorSpring-Wire introducer syringe (5cc)Introducer Needle (18Ga x 2.5 inch)

Catheter 18Ga 2.5 inch Radiopaque over 20Ga Needle (Not Generally Used)

CVC Kit ContentsArrow Advancer for Spring -WireSpring-Wire with J Tip

CVC Kit Contents

Spring-Wire: Note gradation markers every 10 cm

CVC Kit ContentsSpring-Wire introducer syringe (5cc) attached to Introducer Needle (18Ga x 2.5 inch)

CVC Kit ContentsHole through introducer Syringe plunger for Spring-wire to be inserted

CVC Kit ContentsYou may choose to insert Spring-Wire directly through introducer syringe when vein puncture confirmed (shown)ORYou may remove introducer syringe and insert spring wire directly through introducer needle hub (as will be demonstrated in course)

Triple Lumen CVCCVC Clamp to as additional point to suture in place

Triple Lumen CVCNeedleless Injection Capsneedle injection cap connectors that come pre-connected

Triple Lumen CVCRemove old caps and replace with new needless caps

Triple Lumen CVC

Triple Lumen CVCConnect 10ml Syringe with Normal Saline and flush each port to ensure patency

Triple Lumen CVCEnsure catheter flushes from each port

Anaesthetic EquipmentIMPORTANT NOTE: Using a 5ml syringe prevents mix up with normal saline syringe (10ml) and other syringesDrawing up needle2 5ml Lignocaine 1% vials5ml Syringe1 23G Needle 1 25G Needle

Retractable blade for insertion of tissue dilator preparing dilation

Suture SetMany will use a 0 silk suture (pictured above) which does not usually require the equipment in the suture set and can be done by hand alone. If using 3-0 prolene you will need a suture set (fine forceps, needle holder forceps and scissors)

Materials for suturing CVC in place

From suture setAnaesthesia equipment

Suture Kit0 Silk SutureSuture Set

Normal Saline (Flush)1 Draw Needle3 10ml vial normal saline1 - 10 ml Syringe

Ultrasound Probe Cover1 Probe Cover KitProbe cover sleeveSterile ultrasound gelElastics

1 Probe Cover KitProbe cover sleeveSterile ultrasound gelElastics

Ultrasound Probe Cover Opened1 Sterile Gel1 Elastics1 Probe cover sleeve

Chlorhexidine (Skin Preparation)1 2 pack 10 cm2 Gauze1 30ml bottle chlorhexidine 2%

Anaesthetic equipment1 Drawing-up needle1 3ml Syringe2 5ml Lignocaine 1% vials1 25G NeedleIMPORTANT NOTE: Using a 3-5ml syringe prevents mix up with normal saline syringe (10ml) and other syringes

Dressings for CVC exit site1 Fixomull1 Transparent Film Dressing1 BiopatchApply print side up around exit site of catheter

Dressings for CVC exit siteNB ICU has started using chlorhexidine patch dressings which have replaved the IV 3000 and biopatch

Seldinger Technique

The Seldinger technique, also known as Seldinger wire technique, is a procedure to obtain safe access to blood vessels and other hollow organs. It is named after Dr.Sven-Ivar Seldinger, a Swedish radiologist who introduced the procedure in 1953

StepsNeedle inserted into blood vessel while aspirating on the syringe

Syringe is removed and guidewire is inserted through the needle hub

Needle is removed

Dilator is inserted over guidewire to make the tract larger Dilator is then removed.

Catheter is inserted over guidewireNote that the guidewire comes out of the brown port

Catheter is inserted to appropriate length

UsesThe Seldinger technique is used for:Angiographyinsertion of chest drains and central venous cathetersinsertion of the leads for an pacemaker/implantable defibrillatorand numerous other interventional medical procedures.

CVC Insertion Technique

88

NOTE: Images in this PPT are using an older CVC kit which ARROW has modified recently.

Equipment Preparation

http://note3.blogspot.com.au/2004/02/central-line-placement-procedure-guide.html90















Surface Anatomy Review

Preparing the Patient



Drape the patient, leaving the area of insertion exposed

Preparing the Ultrasound

http://note3.blogspot.com.au/2004/02/central-line-placement-with-ultrasound_01.html109






Pre-needle Ultrasound

Pre-needle Ultrasound

Image of right internal jugular. Colour can be applied to confirm internal jugular vein (IJV ) and common carotid artery (CCA)

Local Anaesthetic

Anesthetize the area with Lignocaine. This can be guided using the ultrasound.

Needling the Internal Jugular (IJV)

Using the ultrasound to locate the IJV the needle is inserted aspirating as you advance (note the probe here is in the in-plane position. The course will focus on out-of-plane insertion of needle)


Ultrasound confirmation of needle in the IJV is an essential step


Guidewire Insertion

Guidewire Insertion

Guidewire Insertion

Guidewire Insertion

Guidewire Insertion

Guidewire Insertion

Guidewire Insertion

Ultrasound confirmation of guidewire in the IJV must be performed prior to proceedingOut of plane imageIn plane image

Dilator Insertion

Make a small incision using the scalpel at the guidewire entry point

Dilator insertion

Dilator insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Catheter Insertion

Securing the Central Line



Securing the Central LineThe traditional way that most people have been shown to fix a line is shown to the leftThis is problematic in that the line often kinks, resulting in occlusion of the lumen, failure to deliver drugs or sudden purges when it unblocks, see arrow


Use at least O nylon, deep 1 cm bite of skinSecure the clip, and then sandal tie the hub so that it is secured to the skin via the clip

Sutured to patientNot sutured to patient

After CareFollowing insertion of CVC:CXR to check for complications (eg.pneumothorax) and adequate position of CVC tip of CVC should be in the lower Superior Vena CAVADocumentation of CVC insertion including number of needle passes and any other complications

After CareCVC need to be changed between 10 14 days due to increasing risk of catheter related sepsis and thrombus formation around the catheter.Daily review of the CVC should be implemented to check for signs of sepsis or thrombus formation and CVC not being used should be removed to reduce these risks

CVC insertion Video(Click below to start video)

n engl j med

348;12

www.nejm.org march

20, 2003

The

new england journal

of

medicine

1123

review article

current concepts

Preventing Complications of Central Venous Catheterization

David C. McGee, M.D., and Michael K. Gould, M.D.

From the Division of Pulmonary and Criti-cal Care Medicine (D.C.M., M.K.G.), theDepartment of Health Research and Policy(M.K.G.), and the Center for Primary Careand Outcomes Research (M.K.G.), StanfordUniversity School of Medicine, Stanford,Calif.; and the Health Services Research andDevelopment Service and Center for HealthCare Evaluation, Veterans Affairs Palo AltoHealth Care System, Palo Alto, Calif. (M.K.G.).Address reprint requests to Dr. Gould at thePulmonary and Critical Care Section (111P),Veterans Affairs Palo Alto Health Care Sys-tem, 3801 Miranda Ave., Palo Alto, CA 94304.

N Engl J Med 2003;348:1123-33.

Copyright 2003 Massachusetts Medical Society.

n the united states, physicians insert more than 5 million cen-

tral venous catheters every year.

1

Central venous catheters allow measurement ofhemodynamic variables that cannot be measured accurately by noninvasive means

and allow delivery of medications and nutritional support that cannot be given safelythrough peripheral venous catheters. Unfortunately, the use of central venous cathetersis associated with adverse events that are both hazardous to patients and expensive totreat.

2-4

More than 15 percent of patients who receive these catheters have complica-tions.

5-7

Mechanical complications are reported to occur in 5 to 19 percent of patients,

5,6,8

infectious complications in 5 to 26 percent,

5,7,9

and thrombotic complications in 2 to 26percent.

5

In this review, we explain methods for reducing the frequency of complica-tions in adult patients.

antimicrobial-impregnated catheters

Catheters impregnated with chlorhexidine and silver sulfadiazine and catheters impreg-nated with minocycline and rifampin are the most frequently used types of antimicro-bial-impregnated catheters. In randomized clinical trials, the use of these catheters hasbeen shown to lower the rate of catheter-related bloodstream infections

9,10

(Table 1).The use of catheters impregnated with chlorhexidine and silver sulfadiazine lowered therate of catheter-related bloodstream infections from 7.6 infections per 1000 catheter-days (4.6 percent of catheters) to 1.6 infections per 1000 catheter-days (1.0 percent) (rel-ative risk, 0.21; 95 percent confidence interval, 0.03 to 0.95; P=0.03).

10

A cost-effective-ness analysis concluded that using these catheters would decrease direct medical costsby $196 per catheter inserted.

11

The use of antimicrobial-impregnated catheters should be considered in all circum-stances, especially when the institutional rate of catheter-related bloodstream infectionsis higher than 2 percent, which is the threshold at which chlorhexidine-and-silver-sul-fadiazineimpregnated catheters may reduce overall costs.

10

Current evidence suggeststhat minocycline-and-rifampinimpregnated catheters are even more effective for mini-mizing the risk of infection than those that are impregnated with chlorhexidine and sil-ver sulfadiazine.

29

However, this evidence comes from a single randomized trial, and thecost effectiveness of these catheters relative to those that are impregnated with chlorhex-idine and silver sulfadiazine has not been formally evaluated. Thus, either chlorhexidine-and-silver-sulfadiazineimpregnated catheters or minocycline-and-rifampinimpreg-nated catheters may be used.

The emergence of resistant organisms resulting from the use of antimicrobial-impregnated catheters remains a potentially important concern. Continued surveillancewill be needed as the use of antimicrobial-impregnated catheters increases.

i

types of catheters

The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF WESTERN AUSTRALIA on January 24, 2016. For personal use only. No other uses without permission.

Copyright 2003 Massachusetts Medical Society. All rights reserved.

n engl j med

348;12

www.nejm.org march

20

,

2003

The

new england journal

of

medicine

1124

single-lumen and multilumen catheters

The number of lumina does not directly affect therate of catheter-related complications.

30-32

There-fore, the choice of either a single-lumen or a multi-lumen catheter should be made according to thetype required to deliver the needed medications ornutritional support.

characteristics of patients

There are multiple approaches for internal jugular,subclavian, and femoral venous catheterization.

33

Successful catheterization by either the internal jug-ular or the subclavian route relies on a thorough un-

insertion sites

Table 1. Interventions to Prevent Complications.

Type of Complication and Intervention Rationale

Infectious

Use antimicrobial-impregnated catheters The use of antimicrobial-impregnated catheters reduces the risk of catheter-related bloodstream infections and reduces costs when the rate of catheter-related bloodstream infection >2%

9-11

Insert catheters at the subclavian venous site

The risk of catheter-related infection is lower with subclavian catheter-ization than with internal jugular or femoral catheterization

5,9,12,13

Use maximal sterile-barrier precautions during catheter insertion

Use of a mask, cap, sterile gown, sterile gloves, and large sterile drape reduces the rate of infections and reduces costs

14

Avoid the use of antibiotic ointments The application of antibiotic ointments increases the rate of coloniza-tion by fungi,

15

promotes the development of antibiotic-resistant bacteria,

16

and has not been shown to affect the risk of catheter-related bloodstream infections

17

Disinfect catheter hubs Catheter hubs are common sites of catheter contamination

18

Do not schedule routine catheter changes Scheduled, routine replacement of central venous catheters at a new site does not reduce the risk of catheter-related bloodstream infection

19,20

; scheduled, routine exchange of catheters over a guide wire is associated with a trend toward increased catheter-related infections

19

Remove catheters when they are no longer needed

The probability of colonization and catheter-related bloodstream infec-tion increases over time

9,10,21

Mechanical

Recognize risk factors for difficult catheter-ization

A history of failed catheterization attempts or the need for catheteriza-tion at sites of prior surgery, skeletal deformity, or scarring suggests that catheterization may be difficult

8

Seek assistance from an experienced clinician

Insertion by a physician who has performed 50 catheterizations is half as likely to result in a mechanical complication as insertion of a catheter by a physician who has performed

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CVC workshop