Upload
ganta-rajasekhar
View
332
Download
2
Embed Size (px)
Citation preview
Central Venous Central Venous CatheterizationCatheterization
by, Dr G.RAJASEKHAR MBBS,DCH MODERATORS Dr SREEDEVI MD Dr PADMAJA MD
Central venous catheterCentral venous catheterCentral venous access is the placement
of a venous catheter in a vein that leads directly to the heart.
ObjectivesObjectivesTypes of cathetersIndications and ContraindicationsTechniqueBasic principlesSpecifics by SitecomplicatonsTips
TYPE OF CENTRAL VENOUS TYPE OF CENTRAL VENOUS CATHETERCATHETERPatient’s conditionAnticipated length of therapy
Types Of Central Venous CathetersTypes Of Central Venous Catheters
Nontunneled central cathetersTunneled central cathetersPeripherally inserted central catheters
(PICC)Implantable ports
NONTUNNELED CENTRAL NONTUNNELED CENTRAL CATHETERTSCATHETERTS
NONTUNNELED CENTRAL NONTUNNELED CENTRAL CATHETERTSCATHETERTS
POLYURETHANESINGLE OR MULTIPLE LUMENSUSED FOR SHORT TERM THEARAPYEASIER PLACEMENT,REMOVAL AND
REPLACEMENTUSUALLY 6to8 INCHES IN LENGTHCAN BE QUICKLY INSERTED
Dislodged more easily
Has the highest infection rate
Dressing changes required using aseptic technique
Unused ports must be routinely flushed with heparin solution and clamped
NOT FLEXIBLE AND MAY BREAKNOT FLEXIBLE AND MAY BREAK
TUNNELED CENTRAL VENOUS TUNNELED CENTRAL VENOUS CATHETERSCATHETERS
Single or multiple lumensFlow variableLog termInserted surgicallyCuff –dacron, vitaNo dressing is required after cuff heals
unless the patient isimmunocompromised
Tunneled catheter
Peripherally Inserted Central Peripherally Inserted Central Catheters (PICC)Catheters (PICC)
Used for intermediate to long term therapy
May be single or double lumenInserted percutaneously◦ Basalic vein◦ Cephalic vein
Threaded into the superior vena cava
PICCPICCSILASTIC OR POLYURETHANE
SINGLE OR DOUBLE LUMEN
LOW FLOW
SHORT-LONGTERM
EASY ACCESS
SUBCUTANEOUS PORTSSUBCUTANEOUS PORTSSINGLE OR DOUBLELUMENFLOW-MOST COMMONLY SLOWLONG TERMACCESS REQUIRES NEEDLE PUNCTURE
LESS MAINTENANCEACTIVITY IS UNLIMETED AFTER SITE HEALSCOSMETICALLY MORE APPEALINGCONCEALED PACKET RETARDS
INFECTION
Minimizes infectionHuber needle must be used to access portMust always confirm needle placement before
med administrationUnused port is flushed every 28 days with
Heparin solution
IndicationsIndicationsCentral venous pressure monitoringVolume resuscitationInfusion of hyperalimentationInfusion of concentrated solutionsPlacement of transvenous pacemakerCardiac catheterization & pulmonary angiographyTemporary Hemodialysis Lack of peripheral access
Relative Contraindications Relative Contraindications Bleeding disordersAnticoagulation or thrombolytic therapyDistorted local anatomyCellulitis, burns, severe dermatitis at siteVasculitis
Technique Technique Seldinger technique◦ Use introducing needle to locate vein◦ Wire is threaded through the needle◦ Needle is removed◦ Skin and vessel are dilated◦ Catheter is placed over the wire◦ Wire is removed◦ Catheter is secured in place
Basic PrinciplesBasic PrinciplesDecide if the line is really necessaryKnow your anatomyBe familiar with your equipmentObtain optimal patient positioning and cooperationTake your timeUse sterile techniqueAlways have a hand on your wireAsk for helpAlways aspirate as you advance as you withdraw the needle
slowlyAlways withdraw the needle to the level of the skin before
redirecting the angleObtain chest x-ray post line placement and review it
Location Advantage Disadvantage
Internal Jugular
• Bleeding can be recognized and controlled• Malposition is rare• Less risk of pneumothorax
• Risk of carotid artery puncture• PTX possible
Femoral • Easy to find vein• No risk of pneumothorax• Preferred site for emergencies and CPR• Fewer bad complications
• Highest risk of infection• Risk of DVT• Not good for ambulatory patients
Subclavian • Most comfortable for conscious patients
• Highest risk of PTX, should not do on intubated pts• Should not be done if < 2 years• Vein is non-compressible
Subclavian Approach Subclavian Approach Positioning◦ Right side preferred◦ Supine position, head neutral, arm abducted◦ Trendelenburg (10-15 degrees) ◦ Shoulders neutral with mild retraction
Needle placement◦ Junction of middle and medial thirds of clavicle◦ At the small tubercle in the medial deltopectoral groove◦ Needle should be parallel to skin ◦ Aim towards the suprasternal notch and just under the clavicle
Internal Jugular ApproachInternal Jugular ApproachPositioning◦ Right side preferred◦ Trendelenburg position◦ Head turned slightly away from side of venipuncture
Needle placement: Central approach◦ Locate the triangle formed by the clavicle and the sternal and
clavicular heads of the SCM muscle◦ Gently place three fingers of left hand on carotid artery◦ Place needle at 30 to 40 degrees to the skin, lateral to the carotid
artery◦ Aim toward the ipsilateral nipple under the medial border of the
lateral head of the SCM muscle◦ Vein should be 1-1.5 cm deep, avoid deep probing in the neck
Internal Jugular Central Approach
Femoral ApproachFemoral ApproachPositioning◦ Supine
Needle placement◦ Medial to femoral artery ◦ Needle held at 45 degree angle ◦ Skin insertion 2 cm below inguinal ligament◦ Aim toward umbilicus
Femoral artery
Femoral nerve
Femoral Vein
NAVEL
Post-Catheter PlacementPost-Catheter PlacementAspirate blood from each portFlush with saline or sterile water
(heparinised)Secure catheter with suturesCover with sterile dressing (tega-derm)Obtain chest x-ray for IJ and SC linesWrite a procedure note
Complications Complications Vascular◦ Air embolus◦ Arterial puncture◦ Arteriovenous fistula◦ Hematoma◦ Blood clot
Infectious◦ Sepsis, cellulitis, osteomyelitis, septic arthritis
Miscellaneous ◦ Dysrhythmias◦ Catheter knotting or malposition◦ Nerve injury◦ Pneumothorax, hemothorax, hydrothorax,
hemomediastinum◦ Bowel or bladder perforation
Tips Tips After 3-4 tries, let someone else tryGet cheast x-ray after unsuccessful attempt If attempt at one site fails, try new site on same side to
avoid bilateral complicationsHalt positive pressure ventilation as the needle penetrates
the chest wall in subclavian approach If you meet resistance while inserting the guide wire,
withdraw slightly and rotate the wire and re-advanceAlign the bevel with the syringe markingsWithdraw slowly, you will often hit the vein on the way out
Ultrasound-Guided Central Venous Ultrasound-Guided Central Venous AccessAccess
Becoming standard of care
Vein is compressibleVein is not always largerVein is accessed under direct
visualizationHelpful in patients with difficult
anatomy
Needle entering IJ
FemoralVein
Femoral Artery
Compression of veinwith US probe
Catheterization KitsCatheterization Kits