1.Central Venous Catheterization: From the ICU to the EC A REFRESHER COURSE Pediatrics

2. Objectives By the end of this course the participant will be able to: Combine US guidance with the landmark technique when performing femoral CVC Perform the steps for prepping and draping the femoral site prior to CVC according to the TCH vascular insertion bundle Execute the proper sequence in the placement of US guided femoral CVC according to a checklist Select an appropriate sized vascular catheter according to the indication for placement and/or the patients size Incorporate, into clinical practice, the use of US guidance when inserting central venous catheters as recommended by governing/certifying bodiesPage 1Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 3. First things first Femoral Anatomy Rogers Textbook of Pediatric Intensive Care, 4th ed.N A mpty space ymphaticsPage 2Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 4. Rogers Textbook of Pediatric Intensive Care, 4th ed.Femoral LandmarksPage 3Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 5. Indications Peripheral access unobtainable Medication/fluid administration Emergency resuscitation Monitoring of CVP and SvO2 Parenteral nutrition Frequent blood sampling Hemodialysis/hemofiltration/apheresis Page 4Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 6. Contraindications Coagulopathy Skin infection at site of needle puncture Trauma Distorted anatomy ThrombosisPage 5Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 7. Complications Common to ALL Sites InfectionMalpositionThrombosisCatheter fragment/ guidewire embolismArterial punctureCardiac dysrhythmiasArterial cannulationIJ & Subclavian CVC high femoral CVCHemorrhageAir embolismPhlebitisMore so with IJ & Subclavian CVC Page 6Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 8. FEMORAL CVC Complications Bladder puncture Retroperitoneal hemorrhage Malposition Ascending lumbar veinsMay cause complications Uncooperative patient Lack of experience/supervisionPage 7Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 9. Choosing a Catheter Size? Length? Number of lumens? Patient Weight/size Size of vessel Indications Page 8Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 10. Choosing a Catheter Size/Length Standard Catheter Lengths Available for Pediatric Use, according to booklet attached to catheter trayNOT HELPFUL Page 9Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 11. ED CVL Insertion BundlePage 10Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 12. Sequence of Events INSERTION CHECKLIST (Bundle) PREPARATION Inform/Consent parents if possiblePerform a Time Out Position patient Barrier precautions Proceduralist Patient Ultrasound Page 11Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 13. ED CVL Insertion BundlePage 12Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 14. Sequence of Events PERFORM PROCEDURE APPLY STERILE DRESSING See CVC Dressing video on moodle siteCONFIRM PLACEMENT Must use 2 methods for confirmationDOCUMENT Especially if the line was emergent and bundle was unable to be utilized Page 13Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 15. ED CVL Insertion BundlePage 14Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 16. REFERENCES Rey et al. Mechanical complications during central venous cannulations in pediatric patients. Intensive Care Med 2009; 35: 14381443. Froehlich et al. Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric Intensive care unit. Crit Care Med 2009; 37(3): 1090-1096 Miller et al. Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts. Pediatrics 2010; 125: 206-213 Wheeler et al. A Hospital-wide Quality-Improvement Collaborative to Reduce Catheter-Associated Bloodstream Infections. Pediatrics 2011; 126(4): e995-e1007 Page 15Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 17. REFERENCES Kumar et al. Ultrasound guided vascular access: efficacy and safety. Best Practice & Research Clinical Anaesthesiology 2009; 23: 299311 Srinivasan et al. Bedside ultrasound in pediatric critical care: A review. Ped Crit Care Med 2011; 12(6): 667-674McGee et al. Preventing Complications of Central Venous Catheterization. N Engl J Med 2003; 348(12): 1123-1133 Moore et al. Point-of-Care Ultrasonography. N Engl J Med 2011; 364: 749-57. CDC for the Prevention of Intravascular Catheter-Related Infections, 2011. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Page 16Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM 18. REFERENCES American College of Emergency Physicians: Emergency ultrasound guidelines. Ann Emerg Med. 2009; 53: 550-570 Costello et al. Minimizing Complications Associated with Percutaneous Central Venous Catheter Placement in Children: Recent Advances. Pediatr Crit Care Med. 2013; 14: 273-283Page 17Pediatricsxxx00.#####.ppt 2/26/2014 6:39:21 PM