Pediatrics
Vascular Access
PART ONE: Central Venous
Catheterization
Page 2
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 3
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Objectives
•By the end of this workshop, the learner will be able to:
...
Page 4
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Indications
•Peripheral access unobtainable
•Medication/fluid administ...
Page 5
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Contraindications
•Coagulopathy
•Thrombosis
•Skin infection at site of...
Page 6
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Three common sites
•Internal jugular
•Femoral
•Subclavian
Page 7
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
•Anatomy
•Surface Landmarks
•Positioning
Page 8
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
•Anatomy
•Surface Landmarks
•Positioning
Page 9
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Sub...
Page 10
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
IJ Anatomy
Page 11
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Surface Landmarks
•Upper portion: medial to SCM
•Mid portion: posteri...
Page 12
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Positioning
•Supine with a roll under the
shoulders
•Head slightly tu...
Page 13
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Su...
Page 14
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Subclavian Anatomy
Page 15
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Surface Landmarks
Page 16
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Positioning
•Supine and in trendelenburg (30
degrees)
•Head/neck posi...
Page 17
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 18
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Su...
Page 19
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Femoral Anatomy
Page 20
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Femoral Anatomy
N
A
V
E
L
mpty space
ymphatics
Roger’sTextbookofPedia...
Page 21
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Surface Landmarks/Positioning
•Positioning
‐ “Frog-leg appearance”: S...
Page 22
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Complications
•*Infection (F)
•Thrombosis (F)
•Arterial puncture
•*Bl...
Page 23
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Complications
•Complication rates
‐Adults: 0.5-15%, up to 35% for ine...
Page 24
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Catheter-Associated Bloodstream
Infection (CABSI)
•Most common compli...
Page 25
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
ED CVL Insertion Bundle
Page 27
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
ED/PICU CVL Insertion Bundle
Page 29
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
ED CVL Insertion Bundle
Page 30
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
PICU Insertion Bundle
Page 31
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Bundles of joy….
Page 38
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Choosing a Catheter
•Size?
•Length?
•Number of lumens?
•Patient
‐Weig...
Page 39
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Choosing a Catheter Size/Length
Page 43
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Pos...
Page 44
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Pos...
Pediatrics
???????????????????????????
Correct position
or
Malpositioned
???????????????????????????
Page 46
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 47
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 48
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 49
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 50
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 51
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 52
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 53
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 54
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Pos...
Page 55
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Page 56
xxx00.#####.ppt 07/16/13 02:15 AM
Pediatrics
Despite what Kiyetta is about to tell you…
Landmarks are still
IMPORT...
Upcoming SlideShare
Loading in...5
×

2013 Pediatric Subspecialty Boot Camp_Central venous access

564

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
564
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
34
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • 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.
  • 2013 Pediatric Subspecialty Boot Camp_Central venous access

    1. 1. Pediatrics Vascular Access PART ONE: Central Venous Catheterization
    2. 2. Page 2 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    3. 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. 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. 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. 6. Page 6 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular •Femoral •Subclavian
    7. 7. Page 7 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics •Anatomy •Surface Landmarks •Positioning
    8. 8. Page 8 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics •Anatomy •Surface Landmarks •Positioning
    9. 9. Page 9 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular ‐Anterior ‐Middle ‐Posterior •Subclavian •Femoral
    10. 10. Page 10 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics IJ Anatomy
    11. 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. 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. 13. Page 13 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular ‐Anterior ‐Middle ‐Posterior •Subclavian •Femoral
    14. 14. Page 14 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Subclavian Anatomy
    15. 15. Page 15 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Surface Landmarks
    16. 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. 17. Page 17 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    18. 18. Page 18 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Three common sites •Internal jugular ‐Anterior ‐Middle ‐Posterior •Subclavian •Femoral
    19. 19. Page 19 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Femoral Anatomy
    20. 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. 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. 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. 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. 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. 25. Page 25 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics ED CVL Insertion Bundle
    26. 26. Page 27 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics ED/PICU CVL Insertion Bundle
    27. 27. Page 29 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics ED CVL Insertion Bundle
    28. 28. Page 30 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics PICU Insertion Bundle
    29. 29. Page 31 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Bundles of joy….
    30. 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. 31. Page 39 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Choosing a Catheter Size/Length
    32. 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. 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. 34. Pediatrics ??????????????????????????? Correct position or Malpositioned ???????????????????????????
    35. 35. Page 46 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    36. 36. Page 47 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    37. 37. Page 48 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    38. 38. Page 49 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    39. 39. Page 50 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    40. 40. Page 51 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    41. 41. Page 52 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    42. 42. Page 53 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    43. 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. 44. Page 55 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics
    45. 45. Page 56 xxx00.#####.ppt 07/16/13 02:15 AM Pediatrics Despite what Kiyetta is about to tell you… Landmarks are still IMPORTANT!!!
    1. A particular slide catching your eye?

      Clipping is a handy way to collect important slides you want to go back to later.

    ×