central venous catheterization

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Central Venous Catheterization. UNC Emergency Medicine Medical Student Lecture Series. Objectives. Indications and Contraindications Complications Technique Basic principles Specifics by Site Tips Basic materials. Indications. Central venous pressure monitoring Volume resuscitation - PowerPoint PPT Presentation

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  • Central Venous CatheterizationUNC Emergency MedicineMedical Student Lecture Series

  • ObjectivesIndications and ContraindicationsComplicationsTechniqueBasic principlesSpecifics by SiteTips Basic materials

  • IndicationsCentral venous pressure monitoringVolume resuscitationCardiac arrestLack of peripheral accessInfusion of hyperalimentationInfusion of concentrated solutionsPlacement of transvenous pacemakerCardiac catheterization, pulmonary angiographyHemodialysis

  • Relative Contraindications Bleeding disordersAnticoagulation or thrombolytic therapyCombative patientsDistorted local anatomyCellulitis, burns, severe dermatitis at siteVasculitis

  • Complications VascularAir embolusArterial punctureArteriovenous fistulaHematomaBlood clotInfectiousSepsis, cellulitis, osteomyelitis, septic arthritisMiscellaneous DysrhythmiasCatheter knotting or malpositionNerve injuryPneumothorax, hemothorax, hydrothorax, hemomediastinumBowel or bladder perforation

  • Technique Seldinger techniqueUse introducing needle to locate veinWire is threaded through the needleNeedle is removedSkin and vessel are dilatedCatheter is placed over the wireWire is removedCatheter is secured in place

  • Basic 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

  • Subclavian Approach PositioningRight side preferredSupine position, head neutral, arm abductedTrendelenburg (10-15 degrees) Shoulders neutral with mild retractionRight side preferredNeedle placementJunction of middle and medial thirds of clavicleAt the small tubercle in the medial deltopectoral grooveNeedle should be parallel to skin Aim towards the supraclavicular notch and just under the clavicle

  • Internal Jugular ApproachPositioningRight side preferredTrendelenburg positionHead turned slightly away from side of venipuncture

    Needle placement: Central approachLocate the triangle formed by the clavicle and the sternal and clavicular heads of the SCM muscleGently place three fingers of left hand on carotid arteryPlace needle at 30 to 40 degrees to the skin, lateral to the carotid arteryAim toward the ipsilateral nipple under the medial border of the lateral head of the SCM muscleVein should be 1-1.5 cm deep, avoid deep probing in the neck

  • Internal Jugular Central Approach

  • Femoral ApproachPositioningSupineNeedle placementMedial to femoral artery Needle held at 45 degree angle Skin insertion 2 cm below inguinal ligamentAim toward umbilicus

  • Femoral arteryFemoral nerveFemoral VeinNAVEL

  • Post-Catheter PlacementAspirate blood from each portFlush with saline or sterile waterSecure catheter with suturesCover with sterile dressing (tega-derm)Obtain chest x-ray for IJ and SC linesWrite a procedure note

  • Procedure NoteName of procedureIndication for procedureComment on consent, if applicableDescribe what you did, including prepComment on aspiration/flushing of portsHow did patient tolerate procedureAny complications

  • Tips After 3-4 tries, let someone else tryGet chest x-ray after unsuccessful attemptIf 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 approachIf you meet resistance while inserting the guide wire, withdraw slightly and rotate the wire and re-advanceAlign the bevel with the syringe markingsUse the vein on the same side as the pneumothoraxWithdraw slowly, you will often hit the vein on the way out

  • Ultrasound-Guided Central Venous AccessBecoming standard of careVein is compressibleVein is not always largerVein is accessed under direct visualizationHelpful in patients with difficult anatomy

  • Needle entering IJ

  • FemoralVeinFemoral ArteryCompression of veinwith US probe

  • Catheterization Kits

  • References Clinical Procedures in Emergency Medicine, Roberts and Hedges, 4th edition, 2004Clinicians Pocket Reference, Leonard Gomella, 8th edition, 1997Atlas of Human Anatomy, Frank Netter, 2nd edition, 1997

    Basic materials section involves going through an actual catheter kit with them and demonstrating techniqueCentral venous pressure monitoring for those whose volume status needs to be managed closely

    Volume loading flow rate through a 14 gauge peripheral line is twice that of a 20cm 16 gauge central venous catheter

    Concentrated solutions potassium chloride, hyperosmolar saline, chemo agents. Or vasoactive substances like epi, dopamine. All can cause tissue irritation or necrosis if extravasated in peripheral line

    Bleeding disorders even with platelet counts

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