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Line Insertion Technique & Follies

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  • 1. Line Complications Dalhousie University Critical Care Lecture Series
  • 2. Objectives
    • Know the indications and contraindications for central line insertion
    • Review the technique of central line insertion
    • Know the most common complications of central lines and arterial lines
    • Know how to prevent line complications
    • Know how to recognize and manage line complications
    • Examples
  • 3. CVP Catheter Indications
    • Pressure monitoring
    • Mixed venous oxygen saturation
    • Fluid administration during volume resuscitation (may not be as good as large-bore peripheral lines!!)
    • Administration of corrosive or hypertonic fluids
    • Administration of vasoactive agents
    • Lack of other sites
  • 4. CVP Contraindications
    • Severe coagulopathy
    • Obstruction or congenital abnormality
    • Patient refusal (if competent)
    • Restless and uncooperative patient, unless sedation can be utilized
    • Lack of experience and no expert supervision, OR previous failed attempt by experienced physician
    • Injury or infection at the site
  • 5. Normal CXR
  • 6. Complications
    • More than 15% of all central lines have a complication
      • Mechanical 5-19%
      • Infectious 5-26%
      • Thrombotic 2-26%
  • 7. Mechanical Complications
  • 8. Mechanical Injuries
    • Most common complications:
    Modified from Domino et al 2004 29 Misc. (PA rupture,vessel injury, air embolism etc) 14 pneumothorax 15 hemothorax 16 Carotid artery Cannulation/puncture 16 Cardiac tamponade 20 Wire/catheter embolus Number (/110) Type of complication
  • 9. Pneumothorax
    • More common in subclavian
    • Incidence ranges from 0.3 to 3% depending on experience
    • Classic presentation = hypoxemia/hypotension/pleuritic CP
    • Can be treated conservatively in non-ventilated patients
  • 10.  
  • 11. Treatment
    • Chest tube to expand lung
    • Insertion of chest tube may create hole in lung parenchyma leading to another complication:
  • 12.  
  • 13. Wrong Vessel
    • If finder needle or 18 g insertion needle in artery may remove and apply pressure
    • If CVC or PAC introducer is in artery remove catheter and apply pressure OR:
    • Consult CV surgeon/thoracic surgeon ? OR for thoracotomy, removal of catheter and repair of vessel
  • 14.  
  • 15. The Left Side is Sinister
    • Left internal jugular has unique complications – thoracic duct injury
    • Left inominate vein can be lacerated  hemothorax and  OR
    • L IJ or SC catheter too proximal can lacerate SVC  death
  • 16. Left Subclavian Artery
  • 17.  
  • 18.  
  • 19. Prevention of Mechanical Complications
  • 20. Prevention of Mechanical Complications
    • Ultrasound Guidance
    • -Useful for internal jugular
    • -Potentially prevents wrong vessel, hemo/pneumothorax
    • Pressure waveform monitor
    • -Arterial cannulation/puncture
    • CXR
    • -Cardiac tamponade
    • -Wire/catheter embolus
  • 21. Ultrasound!
    • Prevention is always better than treatment
    • Use ultrasound probe to localize vessel
    • Cannulate vessel under direct vision
  • 22. Ultrasonographic Guidance: Dynamic vs. Static
    • Dynamic
    • Consists of ultrasonic localization, and image-guided cannulation
    • More precise and “real time”
    • Difficult to keep sterility of transducer and site.
    • More hand to screen coordination, unless two persons involved
    • Static
    • Consists of ultrasonic localization and marking of landmarks only
    • Cannulation is not image-guided, but is separate
    • Time delay between marking and cannulation
    • Easy to keep sterility of transducer and site
    • Less technically demanding
  • 23. Pressure Waveforms
    • Several options:
    • Connect sterile tubing to pressure tubing and flush
    • Attach to needle in vessel and confirm venous trace
    • Remove syringe and confirm non-pulsatile blood
    • Compare arterial blood sample with your sample
  • 24. IJ Insertion Method Transverse orientation Longitudinal orientation
  • 25. Check Vein for Patency Thrombus Vein should be free of clot and freely compressible when pressure is applied with the probe
  • 26. Transverse Orientation- “Finger Wiggle” Finger on one side of probe Acoustic shadow of finger on same side of image
  • 27. Orientation- “Mock Poke”
  • 28. Orientation- “Mock Poke” Acoustic “shadow” of the needle over the vein
  • 29. Technique
    • Steps:
      • Obtain informed consent (unless emergency)
      • Check radiograph for any existing pathology (put line on the same side as pathology)
      • Check coagulation studies, if indicated
      • Position patient appropriately (see individual slides for specifics)
      • Prep/drape using sterile technique
      • Inject local, making certain not to inject intravascularly
      • Using ultrasound, assess for proper orientation, localize the vessel, and ensure patency
      • Cannulate vessel and place catheter (see steps)
      • Check radiograph to ensure correct position and to evaluate for complications (can also use ultrasound to evaluate for pneumothorax and to look for incorrect placement, i.e., subclavian to IJ positioning)
  • 30. Technique
    • Sterile technique is extremely important
    • Nosocomial bloodstream/catheter infections are very prevalent, causing significant morbidity (and costing millions of dollars)
    • Most beginners make one of three mistakes:
      • Contaminate gloves when putting them on
      • Contaminate gloves when placing drapes
      • Contaminate the wire by not paying close attention to where it is/what it’s touching at all times
    • Use of ultrasound introduces more opportunity for contamination, SO BE CAREFUL
  • 31.  
  • 32. IJ Insertion Method After flash of blood, syringe is removed and a guidewire is advanced to 20cm The needle is then removed, leaving the guidewire in place
  • 33. IJ Insertion Method Position of guidewire in relation to neck anatomy Make a small skin stab at wire insertion site. Note control of guidewire with both hands
  • 34. IJ Insertion Method Dilate. If awake, tell the patient “you’re going to feel some pressure.” Advance the catheter over the wire. NEVER let go of the wire . Grab it when it comes out the brown port
  • 35.
    • Most use infraclavicular approach (insert at “fossa” of deltopectoral groove, about 1-2 cm inferior to clavicle)
    • Poor choice in coagulopathy (difficult to compress)
    • Higher PTX risk than internal jugular (1-5%)
    • Less infection risk than IJ
    • Trendelenburg’s position with towel roll under scapulae
    • Direct needle toward sternal notch
    • Keep needle parallel to floor; DO NOT AIM UNDER CLAVICLE OR YOU WILL CAUSE PNEUMOTHORAX
    • Constant suction in and out
    • Ultrasound not as useful
    • Again, think after inserting needle 5 cm deep
    Insertion Method-Subclavian
  • 36.  
  • 37. Insertion Site-Femoral Vein is medial to femoral artery In anatomic position (legs apart), axis of vein is as pictured: toward umbilicus Note the inguinal ligament!
  • 38.
    • Reverse Trendelenburg position (legs DOWN) to reduce chance of air embolus
    • Use for emergency access
    • Try to remove after 72 hours
    • Do not use if PA catheter needs to be placed
    Insertion Method-Femoral At 45 o angle to vessel, just medial to artery
  • 39. Image and Orientation
  • 40. Infectious Complications
  • 41. Infectious Complications Prevention
  • 42. Management of Line Infections
  • 43. Pulmonary Artery Catheters
    • PAC have unique set of complications:
    • Arrhythmias inc. complete heart block
    • Knotting of the PAC
    • Pulmonary Artery infarction or rupture
  • 44. Arterial Lines
    • Most common site = radial artery
    • Rare complications
    • 1983 Slogoff and Keats prospective study
    • 1699 radial artery cannulations no ischemia or disability of hand
    • Pseudoaneurysm of the radial artery can occur
    Bowdle Anesthesiology Clinics of NA 2002: 20
  • 45. What’s Wrong With These Pictures?
  • 46.  
  • 47. ETT in too far
  • 48. Chest tube in poor position
  • 49. Left mainstem intubation
  • 50. Feeding tube in lung
  • 51. Feeding Tube in RLL
  • 52. Subclavian going In wrong direction
  • 53. Carotid Artery Insertion
  • 54.  
  • 55. Hematoma After Subclavian Artery Puncture NG ETT
  • 56.  
  • 57. CT insertion Subclavian Line NG Down Left Mainstem!!!!
  • 58. ETT Subclavian Crossing Through innominate
  • 59. Summary
    • Ultrasound guided placement is becoming standard of care.
    • Consider waveform monitoring with all line insertions.
    • Do a CXR post line insertion and review it!
    • Three poke rule (get another person to do procedure)