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2013 Pediatric Subspecialty Boot Camp_Central venous access
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2013 Pediatric Subspecialty Boot Camp_Central venous access

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  • xxx00.#####.ppt 07/16/13 02:15 AM P. Text Text Text Text
  • 8min 48s xxx00.#####.ppt 07/16/13 P.
  • Incorporate the use of ultrasound guidance when inserting central venous catheters as recommended by governing/certifying bodies xxx00.#####.ppt 07/16/13 P.
  • These lists are not necessarily exhaustive but just capture the more common ones xxx00.#####.ppt 07/16/13 P.
  • Relative Few, if any, absolute contraindicatons (i.e. refusal of consent) R isks vs. Benefits Last bullet assoc w/SC CVC xxx00.#####.ppt 07/16/13 P.
  • Vital to your success xxx00.#####.ppt 07/16/13 P.
  • Descends form skull base into carotid sheath post. to ICA and then runs post/lat to ICA/CCA, then at its end is lateral and sltly anterior to CCA xxx00.#####.ppt 07/16/13 P.
  • xxx00.#####.ppt 07/16/13 P.
  • slight trendelenburg reduces risk of air embolism also attempt to puncture during exhalation (spont breathing pt so as not to entrain air) Guidewire introduced during insp (MV) or exh (spont breathing) xxx00.#####.ppt 07/16/13 P.
  • Each subclavian vein is a continuation of the axillary vein and runs from the outer border of the first rib to the border of anterior scalene muscle. From here it joins with the IJ to form the brachiocephalic vein (also known as "innominate vein"). The subclavian vein follows the subclavian artery and is separated from the subclavian artery by the insertion of anterior scalene. Thus, the subclavian vein lies anterior to the anterior scalene while the subclavian artery lies posterior to the anterior scalene (and anterior to the middle scalene). xxx00.#####.ppt 07/16/13 P.
  • Supine  trendelenburg (30) minimizes risk of air embolism  extension of neck and rolled towel along axis of T-spine  head in neutral position or slt flexion and turned towards puncture site On mech vent, someone holds pt in exp hold xxx00.#####.ppt 07/16/13 P.
  • Trendelenburg (30 degrees) minimizes risk of air embolism and engorges veins Head in neutral position OR Slight flexion and turned towards puncture site (specifically right SC) to maintain diameter of vein Shoulders in neutral position with arms at side Guidewire introduced during insp (MV) or exh (spont breathing) xxx00.#####.ppt 07/16/13 P.
  • Femoral vein lies in femoral sheath, medial to femoral artery, immediately below inguinal ligament FA is at midpoint btwn ASIS and SP FV formed by joining of deep/superficial veins of the leg, above inguinal ligament becomes external iliac and joins with internal iliac to become common iliac, both common iliacs jon to become IVC xxx00.#####.ppt 07/16/13 P.
  • Laterally to medially NAVEL is a common mnemonic used to recall the anatomy of the femoral/inguinal region xxx00.#####.ppt 07/16/13 P.
  • There are a few of ways to identify the landmarks used to perform femoral CVC: FA is at midpoint btwn ASIS and SP, 2cm below inguinal ligament and 1 cm or 1FB medial to FA pulsation Thumb over Pubic tubercle and index finger over ASIS, vessels lie within the webbed space (Use diagram) Anatomic variation (up to 20%) xxx00.#####.ppt 07/16/13 P.
  • Fem CVC bladder puncture ( DECOMPRESS BLADDER ), retroperitoneal hemorrhage Hemo/PTX with IJ and SC CVC SC avoided in coagulopathic patient Uncoop pt poses risk to themselves and proceduralist Sedation/analgesia for patient comfort, facilitate placement and reduce complications related to patient movement INEXPERIENCE or lack of supervision Last 2 bullets arent necessarily complications but can LEAD to complications xxx00.#####.ppt 07/16/13 P.
  • In adults, femoral higher risk of infection, thrombosis and art puncture w/o US The more times you attempt, the more likely you are to experience a complication, even if successful However, the more times you do attempt the more likely you are to fail Sig increased risk with 2 needle passes and 3 or more attempts leads to a 6 fold increase in complication risk xxx00.#####.ppt 07/16/13 P.
  • xxx00.#####.ppt 07/16/13 P.
  • xxx00.#####.ppt 07/16/13 P.
  • CHG reduces the risk of catheter colonization Other entering room must wear cap/mask xxx00.#####.ppt 07/16/13 P.
  • In adults, insertion ONLY reduces infxn In ped, insertion AND maintenance bundles, maint my carry more weight xxx00.#####.ppt 07/16/13 P.
  • Enter US Now there will always be proponents and opponents Bottom line is that it is starting to become standard of care and endorsed by multiple organizations xxx00.#####.ppt 07/16/13 P.
  • Agency for Healthcare Research and Quality National Institute for Clinical Excellence in the UK-both adults and children ACEP/CDC-both adults and children xxx00.#####.ppt 07/16/13 P.
  • US vs Landmark: Adult lit. mostly of IJ, limited data for femoral site and in pediatrics, however, some peds studies showed similar results with US used for IJ and suggest benefit for femoral site primarily in reducing complications Operator experience not addressed in many of these studies but two studies suggest the most benefit with inexperienced proceduralists Dynamic vs. static vs landmark PRACTICALLY SPEAKING: detect anatomic variability and avoiding unnecessary complication (i.e. presence of thrombus) xxx00.#####.ppt 07/16/13 P.
  • Not one size fits all, may consider measuring xxx00.#####.ppt 07/16/13 P.
  • Confirmation-transduction, blood gas, radiographic xxx00.#####.ppt 07/16/13 P.
  • Confirmation-transduction, blood gas, radiographic xxx00.#####.ppt 07/16/13 P.
  • Confirmation-transduction, blood gas, radiographic (in EC 2 of 3) xxx00.#####.ppt 07/16/13 P.
  • 8min 48s xxx00.#####.ppt 07/16/13 P.

Transcript

  • 1. Pediatrics Vascular Access PART ONE: Central Venous Catheterization
  • 2. Page 2 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 3. Page 3 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Objectives •By the end of this workshop, the learner will be able to: ‐Recall at least 3 indications and 3 contraindications for central venous catheterization (CVC) ‐Describe the anatomic landmarks used to guide CVC at specified sites of insertion ‐Name at least 5 complications associated with CVC ‐Choose an appropriate sized central venous catheter according to indication for placement and/or the patient’s size ‐Distinguish between properly positioned and malpositioned central venous catheters on radiographic images
  • 4. Page 4 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Indications •Peripheral access unobtainable •Medication/fluid administration •Emergency resuscitation •Monitoring of CVP and ScvO2 •Parenteral nutrition •Frequent blood sampling •Hemodialysis/hemofiltration/Apheresis
  • 5. Page 5 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Contraindications •Coagulopathy •Thrombosis •Skin infection at site of needle puncture •Trauma •Distorted anatomy •Clavicular/proximal rib fractures
  • 6. Page 6 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular •Femoral •Subclavian
  • 7. Page 7 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics •Anatomy •Surface Landmarks •Positioning
  • 8. Page 8 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics •Anatomy •Surface Landmarks •Positioning
  • 9. Page 9 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular ‐Anterior ‐Middle ‐Posterior •Subclavian •Femoral
  • 10. Page 10 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics IJ Anatomy
  • 11. Page 11 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Surface Landmarks •Upper portion: medial to SCM •Mid portion: posterior to SCM in the triangle of SCM heads and clavicle •Lower portion: behind clavicular head of SCM where it descends to join SC just above medial end of clavicle
  • 12. Page 12 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Positioning •Supine with a roll under the shoulders •Head slightly turned AWAY from puncture site •Slight trendelenburg (15-30 degrees) •Puncture @ apex of triangle aimed at ipsilateral nipple •Attempt to puncture during exhalation in spont breathing
  • 13. Page 13 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular ‐Anterior ‐Middle ‐Posterior •Subclavian •Femoral
  • 14. Page 14 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Subclavian Anatomy
  • 15. Page 15 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Surface Landmarks
  • 16. Page 16 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Positioning •Supine and in trendelenburg (30 degrees) •Head/neck positioning: ‐ Extension of neck with rolled towel along axis of T-spine ‐ Head in neutral position ‐ Slight flexion and turned towards puncture site •Attempt to puncture during exhalation in spont breathing ‐ Expiratory hold if on mechanical ventilation
  • 17. Page 17 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 18. Page 18 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular ‐Anterior ‐Middle ‐Posterior •Subclavian •Femoral
  • 19. Page 19 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Femoral Anatomy
  • 20. Page 20 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Femoral Anatomy N A V E L mpty space ymphatics Roger’sTextbookofPediatricIntensiveCare,4th ed.
  • 21. Page 21 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Surface Landmarks/Positioning •Positioning ‐ “Frog-leg appearance”: Slight external rotation at the hip and flexion at the knee ‐ ABduction of leg with external rotation at the hip ‐ External rotation at the hip •Rolled towel under the buttock Roger’sTextbookofPediatricIntensiveCare,4th ed.
  • 22. Page 22 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Complications •*Infection (F) •Thrombosis (F) •Arterial puncture •*Bladder puncture (F) •Hemorrhage •Phlebitis •Hemo/Pneumothorax (I/S) •Tracheal puncture (I/S) •Catheter fragment/ guidewire embolism •Cardiac dysrhythmias •Air embolism •Erosion/perforation •Pericardial tamponade •Uncooperative patient •Lack of experience/supervision
  • 23. Page 23 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Complications •Complication rates ‐Adults: 0.5-15%, up to 35% for inexperienced ‐Pediatrics: 0.3%-34% (lowest for femoral) •Risk increases exponentially with increasing number of attempts ‐Likelihood of failed cannulation correlates with repeated attempts Kumar et al. Ultrasound guided vascular access: efficacy and safety. Best Practice & Research Clinical Anaesthesiology 2009; 23: 299–311 Rey et al. Mechanical complications during central venous cannulations in pediatric patients. Intensive Care Med 2009; 35: 1438–1443.
  • 24. Page 24 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Catheter-Associated Bloodstream Infection (CABSI) •Most common complication of CVC •Significant cause of morbidity, mortality and healthcare costs •Substantially reduced by using a “bundle” of practices •Lower risk of infection with subclavian venous access in adults •Regardless of site, strict attention insertion technique can reduce infections Miller et al. Decreasing PICU Catheter‐Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts. Pediatrics 2010; 125: 206‐213
  • 25. Page 25 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics ED CVL Insertion Bundle
  • 26. Page 27 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics ED/PICU CVL Insertion Bundle
  • 27. Page 29 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics ED CVL Insertion Bundle
  • 28. Page 30 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics PICU Insertion Bundle
  • 29. Page 31 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Bundles of joy….
  • 30. Page 38 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Choosing a Catheter •Size? •Length? •Number of lumens? •Patient ‐Weight/size ‐Size of vessel ‐Indications
  • 31. Page 39 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Choosing a Catheter Size/Length
  • 32. Page 43 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Sequence of Events •Inform/Consent parents •Perform a “Time Out” •Position** •Insertion Checklist (“Bundle”) •Perform Procedure/Apply sterile dressing •Confirm Placement •Document
  • 33. Page 44 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Sequence of Events •Inform/Consent parents •Perform a “Time Out” •Position** •Insertion Checklist (“Bundle”) •Perform Procedure/Apply sterile dressing •Confirm Placement •Document
  • 34. Pediatrics ??????????????????????????? Correct position or Malpositioned ???????????????????????????
  • 35. Page 46 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 36. Page 47 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 37. Page 48 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 38. Page 49 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 39. Page 50 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 40. Page 51 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 41. Page 52 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 42. Page 53 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 43. Page 54 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Sequence of Events •Inform/Consent parents •Perform a “Time Out” •Position** •Insertion Checklist (“Bundle”) •Perform Procedure/Apply sterile dressing •Confirm Placement •Document
  • 44. Page 55 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
  • 45. Page 56 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Despite what Kiyetta is about to tell you… Landmarks are still IMPORTANT!!!