Central Venous Access

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Central Venous Access and Catheters. Their indications and contraindications, Different types of central catheters and their advantages and disadvantages, Technique of insertion, and Complications related to central venous lines.

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Central Venous Access

  1. 1. Central Venous Access & Catheters G.D.A.Samaranayaka
  2. 2. Definition A Central Venous Catheter (CVC) is an indwelling intravenous device that is inserted into a vein of the central vasculature.
  3. 3. Uses 1. Difficult Peripheral Vascular Access Ex - patients with burns, previous vein injuries (such as IV drug use) 2. Volume Loading Time-consuming to insert and are associated with high complication rates. Flow rate is determined by the calibre and length of the catheter (Poiseuille’s law) Shorter and greater calibre catheters delivering greater volumes over equivalent amounts of time
  4. 4. 3. Provision of Caustic Medications or Solutions Vasoactive medications (vasopressors or inotropes) Irritant substances (chemotherapeutic agents, cytotoxic drugs or high concentration solutions) Total parenteral nutrition
  5. 5. 4. Central Venous Pressure Monitoring The central venous pressure (CVP) is the pressure measured in the central veins close to Right atrium. It indicates mean right atrial pressure and is frequently used as an estimate of right ventricular preload. Being used as a guide for fluid management, though some researches suggest otherwise (http://www.ncbi.nlm.nih.gov/pubmed/18628220)
  6. 6. 5.Repeated Blood Sampling 6. Introduction of Pacemakers or Pulmonary Artery Catheters 7.For haemodialysis/haemofiltration - For acute and chronic haemodialysis access
  7. 7. Contraindications Absolute Overlying skin or soft tissue infection Thrombophlebitis
  8. 8. Contraindications .cont Relative 1. Distorted Anatomy – Trauma, deformity, burns. 2. Infection at the Site of Access – cellulitis 3. Uncooperative patients 4. Proximal Vascular Injury 5. Bleeding disorders & anticoagulation or thrombolytic therapy. 3% complication rate as long as there are no arterial punctures (Mumatz et al) Absolute contraindication for subclavian access Ultrasound guidance is recommended
  9. 9. Types Of Central Venous Catheters 1. Non-tunneled central catheters 2. Tunneled central catheters 3. Peripherally inserted central catheters (PICC) 4. Implantable ports
  10. 10. Types Of CentralVenous Catheters.cont Single & multi-lumen catheters are available in all catheter types Each lumen must be treated as a separate catheter
  11. 11. Types Of CentralVenous Catheters.cont Open–ended The catheter is open at the distal tip The catheter requires clamping before entry into the system Clamps are usually built into the catheter Requires periodic flushing
  12. 12. Types Of CentralVenous Catheters.cont Closed-ended A valve is present at the tip of the catheter (eg. Groshong®) or at the hub of the catheter(eg. PAS-V®) Clamping is not required as the valve is closed except during infusion or aspiration
  13. 13. Types Of CentralVenous Catheters.cont Composition Silicone Polyurethane Coatings ♦ Antimicrobial or antiseptic coating ♦ Heparin coating ♦ Radiopaque to confirm tip placement
  14. 14. The type of CVC inserted depends on the Type of therapy to be administered Length of therapy (Short term or Long term) Previous devices and complications Patient preference
  15. 15. Non Tunnelled Catheters
  16. 16. Polyurethane Single or multiple lumens Flow varies depending on size and ID Inserted percutaneously Internal jugular vein Subclavian vein Femoral vein
  17. 17. Advantages Easier placement, removal and replacement Economical Disadvantages Highest risk of infections Unused ports must be routinely flushed with heparin solution and clamped Dislodged more easily Temporary - requires frequent exchanges
  18. 18. Insertion Informed Consent Sterile technique Adequate skin preparation with sterilizing solution Setup of Equipment Positioning and identifying the landmarks Adequate local analgesia
  19. 19. Internal Jugular Vein Right side preferred-lower pleural dome and thoracic duct on left Trendelenburg position(10-15 degrees) Head rotated approximately 150 to the left At the cricoid level while palpating the carotid pulse, introducer needle into the apex of the sternocleidomastoid- clavicular triangle at a 30-400 angle to the skin. Aim the needle caudally towards the patient’s ipsilateral nipple.
  20. 20. Subclavian Vein Right side preferred - Supine position, head neutral, arm abducted - Trendelenburg position (10-15 degrees) - Shoulders neutral with mild retraction Junction of the medial and middle thirds of the clavicle. The site of needle insertion lies about 1 cm inferior to the clavicle allowing for the needle to pass under the clavicle. • Needle should be parallel to skin • Aim towards the supraclavicular notch
  21. 21. Femoral Vein Supine/Flat position Palpate the femoral artery’s pulse just distal to the inguinal ligament. The femoral vein lies just medial to this.
  22. 22. 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
  23. 23. Post-Catheter Placement Aspirate blood from each port Flush with saline or sterile water Secure catheter with sutures Cover with sterile dressing (tega-derm) Obtain chest x-ray for IJ and SC lines
  24. 24. Location Advantage Disadvantage Internal Jugular • Bleeding can be recognized and controlled • Malposition is rare • Less risk of pneumothorax • Risk of carotid artery puncture • Pneumothorax is possible Subclavian • Most comfortable for conscious patient • Highest risk of bleeding • Vein is non-compressible/deep vein • Highest risk of Pneumothorax Femoral • Easy to find vein • No risk of Pneumothorax • Preferred site for emergencies •Highest risk of infection • Risk of DVT • Not good for ambulatory patients
  25. 25. Tunnelled Catheters
  26. 26. Single or multiple lumens Used for long term therapy Inserted surgically Small Dacron (Polyethylene terephthalate) cuff sits in subcutaneous tunnel facilitates anchoring of the catheter through granulation and acts as a barrier to infection
  27. 27. Advantages Can be left in place indefinitely (if no infection, blockage or thrombosis) Self-care by patient External portion can be repaired
  28. 28. Disadvantages Inserted in the OR Requires a dressing & frequent assessments External device Physician must remove
  29. 29. Peripherally Inserted Central Catheters
  30. 30. Silicone or polyurethane Single or multi-lumen Approximately 40-60 cm long Used for intermediate to long term therapy Inserted percutaneously Basalic vein Cephalic vein The tip rests in the superior vena cava at the cavo-atrial junction.
  31. 31. Advantages Can remain in place for several weeks to a year Can be easily removed Low infection rates External portion can be repaired
  32. 32. Disadvantages Low flows Requires a dressing & frequent assessments External device Small gauge PICC not recommended for blood sampling
  33. 33. IMPLANTABLE VENOUS ACCESS DEVICE (IVAD)
  34. 34. long-term (months to years) single or dual chamber “port” surgically implanted in the subcutaneous tissue, usually in the upper chest Single or double lumen. Each chamber must be managed separately.
  35. 35. A non-coring point needle is required to access the device Unused port is flushed every 28 days with Heparin solution
  36. 36. Advantages Internal device, no dressing or site care Can be permanent Unrestricted activity Decreased risk of infection No external components to break May be used as long as the device is required, functional.
  37. 37. Disadvantages Needle access is required Surgical procedure required to insert/remove Cost
  38. 38. Complications Associated With Central Venous Catheters
  39. 39. Complications Acute Chronic Complication rate depends on Site Patient factors (illnesses, variations in anatomy) Operator skill and experience.
  40. 40. Acute complications Cardiac Dysrhythmias Due to cardiac irritation by the wire or catheter tip. Withdraw the line into the superior vena cava. Always use a cardiac monitor. Haematoma formation – Arterial/Venous puncture Mechanical injury to nearby structures Pneumothorax/Haemothoarx Atrial wall puncture - pericardial tamponade. Bowel penetration, Bladder puncture, Femoral nerve injury Air embolus Malposition Lost Guide-wire
  41. 41. Chronic complications Infections Catheter fragmentation Non-function/Blockage - fibrin builds on and around the catheter and vessel, drug precipitates, lipid deposits Thrombosis/Thromboembolism
  42. 42. Air embolism Deadly complication associated with CVC’s Signs and Symptoms Respiratory changes: sudden shortness of breath, cyanosis CVS changes: sudden onset of chest pain, ↑HR, ↓BP CNS changes: altered neurological signs, dizziness, confusion, loss of Consciousness
  43. 43. Management Left lateral decubitus with head low Position (Durant maneuver and Trendelenburg position) Clamp the Central Venous Catheter 100% O2 Direct removal of air from the venous circulation by aspiration from a central venous catheter in the right atrium may be attempted
  44. 44. To minimize the chance of air entering the system: Ensure the lumen is clamped prior to opening the system Position the patient so that the insertion site is at or below the level of the heart during insertion and removal of catheter
  45. 45. Infections Most frequent and serious complications. Types Local infection – Cellulitis Central Line-Associated Bloodstream Infections (CLABSI)
  46. 46. Causative Organisms Staph epidermidis 25-50% Staph aureus 25% Candida 5-10% Risk Factors Cutaneous colonization of the insertion site Moisture under the dressing Prolonged catheter time Technique of care and placement of the central line
  47. 47. Evidence-BasedStrategiesSelected to Reduce CLA-BSIs 1. Hand hygiene 2. Maximal sterile barriers 3. Chlorhexidine for skin asepsis 4. Avoid femoral lines 5. Avoid/remove unnecessary lines
  48. 48. Thank You Refenrences 1. http://emedicine.medscape.com/article/80336-overview#a05 2. http://emedicine.medscape.com/article/80355-overview#aw2aab6c10 3. http://emedicine.medscape.com/article/80279-overview 4. Central Venous Access (Ian Rigby, Daniel Howes, Jason Lord, Ian Walker, Resuscitation Education Consortium/Kingston Resuscitation Institute)

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