By Dr AVIJIT KUMAR PRUSTY,

DEPT OF ANAESTHESIOLOGY AND CRITICAL CARE,

SCB MEDICAL COLLEGE,CTC

GUIDE-ASSO PROF DR BASANT K PRADHAN

CVP is the pressure measured at the junction of the superior venae cavae and the right atrium.

It reflects the driving force for filling of the right atrium & ventricle.

Normal CVP in an awake , spontaneously breathing patient - 1-7 mmHg or

5-10 cm H2O.

Mechanical ventilation- 3-5 cm H2O higher.

1863 •Chauveau & Mary ( Paris ). •Developed a special double lumen catheter. •Systemic study, description & interpretation of intracardiacpressure recordings in horse.

1876 • Claude Bernard ( France ). • First cardiac catheterisation.

1949 •Duffy. •Introduced a catheter into the IVC through femoral vein.

1952 •Aubaniac.•Subclavian vein cannulation.

1953 •Seldinger.•CVP Catheter replacement method using guidewire.

1969 •English et al.•IJV cannulation.

1. Indirect assessment-

Inspection of jugular venous pulsations in neck.

2. Direct assessment-

Fluid filled manometer connected to central venous catheter.

Caliberated transducer.

1. Inspection of jugular venous pulsations in neck.

WHY IJV=No valves b/w rt. atrium & IJV.

Degree of distention & venous wave form –can give information about rt atrial cardiac function.

Jugular veins may be impossible to identify in up to 20% of patients, and the bedside diagnosis of low, normal, or high CVP is often inaccurate, particularly in critically ill patients.

This problem is compounded in the perioperative period

As a result, direct measurement of CVP is frequently necessary in hemodynamicallyunstable patients and those undergoing major operations

1. Fluid filled manometer connected to centralvenous catheter- measured using a column ofwater in a marked manometer.

CVP is the height of the column in cms of H2Owhen the column is at the level of right atrium.

Advantage- simplicity to measure.

Disadvantage- Inability to analyze the CVPwaveform.

-Relatively slow response of thewater column to changes in intrathoracicpressure.

transducer system: enables continuous readings which are displayed on a monitor.

Transducers enable the pressure readings from invasive monitoring to be displayed on a monitor

To maintain patency of the cannula a bag of normal saline or heparinised saline should be connected to the transducer tubing and kept under continuous pressure of 300mmHg thus facilitating a continuous flush of 3mls/hr or it can be flushed intermittently manually.

The CVP waveform reflects changes in right atrial pressure during the cardiac cycle

The CVP waveform consists of five phasic events, three peaks (a, c, v) and two descents (x, y)

TYPE OF WAVE CAUSE CARDIAC CYCLE

a wave Atrial contraction DIASTOLE

c wave Bulging of tricuspid valve into RA during IVC

SYSTOLE

X descent Atrial relaxation SYSTOLE

V wave Filling of RA L/T rise in pressure

SYSTOLE

Y descent Opening of Tricuspid valve

DIASTOLE

Atrial fibrillation obliterates the a wave, increases the c wave and preserves the v wave and y descent. This arrhythmia also causes variation in the electrocardiographic (ECG) R-R interval and left ventricular stroke volume, which can be seen in the ECG and arterial (ART) pressure traces

Isorhythmicatrioventriculardissociation. In contrast to the normal end-diastolic a wave in the CVP trace (left panel), an early systolic cannon wave is inscribed (*, right panel). Reduced ventricular filling accompanying this arrhythmia causes a decreased arterial blood pressure.

TRICUSPID REGURGITATION INCREASES CVP AND THE WAVEFORM DISPLAYS A TALL SYSTOLIC C-V WAVE THAT OBLITERATES THE X DESCENT

TRICUSPID STENOSIS ALSO INCREASES MEAN CVP, BUT THE CHARACTERISTIC VENOUS WAVEFORM IS DIFFERENT FROM THE ONE SEEN IN TRICUSPID REGURGITATION. THE DIASTOLIC Y DESCENT IS ATTENUATED AND THE END-DIASTOLIC A WAVE IS PROMINENT.

DURING POSITIVE PRESSURE VENTILATION, ONSET OF INSPIRATION (ARROWS) CAUSES AN INCREASE IN INTRATHORACIC PRESSURE. CVP IS STILL RECORDED AT END-EXPIRATION (MEAN CVP 8 MMHG).

DURING SPONTANEOUS VENTILATION, ONSET OF INSPIRATION (ARROWS) CAUSES A REDUCTION IN INTRATHORACICPRESSURE, WHICH IS TRANSMITTED TO BOTH THE CVP AND THE PULMONARY ARTERY PRESSURE (PAP) WAVEFORMS. CVP SHOULD BE RECORDED AT END-EXPIRATION (MEAN CVP 14 MMHG).

It is a catheter that provides venous access via the superior vena cava or right atrium

The tip of the CVC usually rests in the Cavo-Atrial Junction (CAJ).

Femorally inserted CVCs have the tip lying in the Inferior Vena Cava approximately at the level of the diaphragm.

In patients with severe bleeding diatheses, it is best to choose a puncture site at which bleeding from the vein or adjacent artery is easily detected and controlled with local compression. In such a patient, an internal or external jugular approach would be preferable to a subclavian site.

Likewise, patients with severe emphysema or others who would be severely compromised by pneumothorax would be better candidates for internal jugular than subclavian cannulation because of the higher risk with the latter approach.

If transvenous cardiac pacing is required in an emergency situation, catheterization of the right internal jugular vein is recommended because it provides the most direct route to the right ventricle.

Trauma patients with their necks immobilized in a hard cervical collar are best resuscitated via a femoral or subclavianapproach; the latter may be used even more safely if the risk of pneumothorax is obviated by prior placement of a thoracostomy tube.

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

Location Advantage Disadvantage

Internal

Jugular

• Bleeding can be recognized

and controlled

• Malposition is rare

• Less risk of pneumothorax

• Risk of carotid artery puncture

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

After surgery, however, the position of the catheter tip must be confirmed radiographically.

Catheter tips located within the heart or below the pericardial reflection of the superior vena cava increase the risk for cardiac perforation and fatal cardiac tamponade.

Ideally, the catheter tip should lie within the superior vena cava, parallel to the vessel walls, and be positioned below the inferior border of the clavicles and abovethe level of the third rib, the T4 to T5 interspace, the azygos vein, the tracheal carina, or the takeoff of the right mainstembronchus

The internal jugular vein (IJV) is most frequently chosen site for CVC insertion.

Many approaches have been described depending on the level of the neck at which the vein is punctured.

A high approach reduces the risk of pneumothorax but increases the risk on arterial puncture. For lower approaches the converse is true.

With experience this route has a low incidence of complications

PositioningRight side preferred Trendelenburg positionHead turned slightly away

from side of venipuncture.

Positioning

Right side preferred

Supine position, head neutral, arm adducted

Trendelenburg (10-15 degrees)

Positioning

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

PICC

– Peripherally Inserted Central IV Catheter

Usually inserted in the upper arm

Catheter tip is in the distal superior vena cavalike all other central lines

Hickman, Broviac, and Leonard Catheters –Open-ended, tunneled central lines

Hickman catheters can be 1, 2, or 3 lumen

The lumens may all be identically sized, or

The lumens may be of different sizes

Broviac catheters are all single lumen catheters

Leonard catheters have 2 lumens of identical size

• Implanted subcutaneously instead of patient having a port outside of body

Mediport and Portacaths are the most common

No dressing is required

Accessed by a Huber needle

Flushed with Heparin

More expensive

A portacath or "port" is comprised of two components, a self-sealing injection port and a catheter that enters the vein. The port and catheter are placed entirely under the skin using a small incision.

There will be a bump on the chest wall where the injection port is located. This is the site where the access Huber needle is placed.

Once port is deaccessed, it needs a MONTHLY flush with 5ml of heparin (100 units/ml) to keep it patent.

The Power Port

Designed for power injections

Withstands injections of 5ml/sec @ 300 psi

The unique triangular shape

Requires Heparin flush

THIS IS AN ASEPTIC PROCEDURE THE PATIENT SHOULD BE SUPINE WITH HEAD TILTED

DOWN ENSURE NO DRUGS ARE ATTACHED AND RUNNING

VIA THE CENTRAL LINE REMOVE DRESSING CUT THE STITCHES SLOWLY REMOVE THE CATHETER IF THERE IS RESISTENCE THEN CALL FOR ASSISTANCE APPLY DIGITAL PRESSURE WITH GAUZE UNTIL

BLEEDING STOPS DRESS WITH GAUZE AND CLEAR DRESSING EG

TEGADERM

1.Acute Procedural

2. Sub-acute Infection

3. Chronic Infection,Catheterfragmentation,Non-function

1. Spasm 4. Pneumothorax

2. Access failure 5. Malposition

3. Arterial puncture 6. Air embolus

7.hemothorax,chylothorax

1. Respiratory distress

2. Increased heart rate

3. pulse

5. Cyanosis

4. Dip in the level of consciousness

1. Left lateral decubitus (Durant’s) Position

2 100% O2

3. Vasopressin if necessary

4. Chest compression

5. Aspiration through catheter +/-

Mortality decreases from 90% 30%

with conventional treatment

1. Infection

2. Catheter fragmentation

3. Non-function

Dysrhythmias

Catheter malplacement

Catheter rupture

Embolus

Cardiac tamponade

Catheter related infection

Thrombosis

Hydrothorax

1. Hand hygiene

2. Maximal sterile barriers

3. Chlorhexidine for skin asepsis

4. Avoid femoral lines

5. Avoid/remove unnecessary lines

Cornerstone of any infection prevention program

Many studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications

Use of waterless alcohol-base hand rub Most effective and

efficient method for hand antisepsis against bacterial pathogens

When hands are visibly soiled, they should be washed with soap and water

Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

One study found a 6-fold higher rate of catheter-related septicemia when minimal sterile barriers (sterile gloves and small drape) were used instead of maximal sterile barriers

Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous

catheter-related infections by using maximal sterile barrier precautions

during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.

Studies have compared chlorhexidinegluconate (CHG) versus povidone iodine asa skin antiseptic for catheter insertion androutine insertion site care

Recent meta-analysis, the use of CHG ratherthan povidone iodine was found to reducethe risk of CLA-BSIs by approximately 50% inhospitalized patients who required shortterm catheterization

Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine

compared with povidone-iodine solution for vascular catheter-site care: a

meta-analysis. Ann Intern Med. 2002;136:792–801.

1. Cutaneous - pain, erythema, swelling,+/- exudate

2. Bacteremia - fever, leukocytosis andpositive blood cultures

3. Septic thrombophlebitis - bacteremia,thrombosis and purulent discharge

Staph epidermidis 25-50%

Staph aureus 25%

Candida 5-10%

Septic thrombophlebitis - remove catheter

Cutaneous - local treatmentBacteremia -

1. IV antibiotics 48 -72 hoursif improved - keep catheterif no change, worse or recursremove catheter or2. Exchange catheter over wire, 85% cure with treatment

Continue to treat infection for 10 - 14 days

If ineffective - try locking with thrombolyticsbetween antibiotic doses and administerantibiotics through catheters

Proper handwashing and principles of sterile technique

Flushing and cap change procedure and frequency

Observation of cath and insertion site

Temp of 100.5F or greater

Chills, dyspnea, dizziness Pain, redness, swelling, or drainage

at site Unresolved resistance, pain or fluid

leaking while flushing Excessive bleeding at site Change in length of external cath Swelling in neck, face, chest, or arm