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Cateterizacion Venosa Central

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Cateterizacion Venosa Central

  1. 1. Cateterización venosa central(técnicas y complicaciones) y Presión venosa central Dr. Sergio Abraham Mejía Valero R2CG IMSS UMAE CMN MAC Puebla
  2. 2. Datos generales• Por primera vez descrita en 1953• Mayor longevidad sin infección• Evita flebitis• Lúmenes más largos• Múltiples lúmenes E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  3. 3. Cateterización venosa central• Piedra angular de resucitación y cuidados críticos – Monitoreo hemodinámico avanzado – Marcapasos transvenosos – Infusión rápida de fluidos – Nutrición parenteral – Medicamentos selectos Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  4. 4. Principales accesos• Subclavio• Femoral• Yugular Interno Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  5. 5. Otros accesos• Yugular externa – Difícil y consume tiempo• Basílica y Cefálica – Diversas bifurcaciones – Ángulos cerrados – Válvulas Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  6. 6. INDICACIONES CATETER VENOSOCENTRAL
  7. 7. PVC Y MONITOREO OXIMETRIA• Resucitación en sepsis – Medición de saturación O2• Infusión de líquidos rápida Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  8. 8. Acceso venoso de emergencia• Localizaciones anatómicas predecibles – Subclavio – Femoral• Durante paros cardiacos – RCP Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  9. 9. Acceso venoso de rutina• Abuso de drogas ilÍcitas• Quemaduras mayores• Obesidad• Hospitalización prolongada Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  10. 10. Toma de muestras sanguíneas seriadas• No se deben colocar para éste propósito• PERO• Pueden ser utilizados si YA están colocados• EXTRAER 0.3ml mínimo antes para evitar dilución – Cerrar linea 2 a 3 minutos antes Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  11. 11. NPT y soluciones concentradas• NPT• Cloruro de potasio – >40 mmol / L• Solución salina hiperosmolar• Cloruro de calcio• Infusiones dextrosa 10% Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  12. 12. NPT y Soluciones concentradas• Quimioterapia• Fenitoina – por riesgo de síndrome guante morado• Sustancias vasoactivas – Dopa y Norepix necrosis en caso de extravasación Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  13. 13. Otras indicaciones• Colocación de catéter arterial pulmonar• Marcapasos transvenoso• Cateterización cardiaca• Angiografía pulmonar• Hemodiálisis Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  14. 14. INDICACIONES POR LUGAR
  15. 15. Subclavio• El más frecuente• En trauma el mas usado por presencia de collarín• Supraclavicular en caso de RCP para no interferir con maniobras – Usado en pacientes sentados con ortopnea• SV izquierdo  ruta directa a cava superior para colocación marcapasos. E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  16. 16. Yugular interna• Riesgo de complicación 5 a 10%• Complicaciones – Mayores • Laceración de vasos en cuello • Punción de arteria carotida con tromboembolismo • Embolismo • Laceración pleural + pneumotórax • Hemotórax • Trombosis • Infección. Bradford L. Waters, et. Al. Central Venousaccessvia posterior approachtointernal yugular vein. 2011.
  17. 17. Yugular interna• Complicaciones – Menores • Punción de arteria carótida con hematoma • Lesión de plexo braquial y nervios periféricos• La más preferida• Punciones arteriales de fácil acceso para compresión. Bradford L. Waters, et. Al. Central Venousaccessvia posterior approachtointernal yugular vein. 2011.
  18. 18. Yugular interna• Menor incidencia pneumotórax• Hematoma fácil de diagnosticar por proximidad con la piel• YI derecha paso directo a cava superior y aurícula derecha – Marcapasos• Alta incidencia de punción arteria carótida Bradford L. Waters, et. Al. Central Venousaccessvia posterior approachtointernal yugular vein. 2011.
  19. 19. Femoral• Acceso venoso• Puerto de entrada• Marcapasos transvenosos• Monitorización de presión.• Otras – Hemoperfusión con carbón  sobredosis – Accesos de diálisis• Contraindicado en paciente ambulatorio Neelu Pal, et. Al. Femoral Central Venous Access. 2012. Medscape
  20. 20. CONTRAINDICACIONES
  21. 21. Contraindicaciones generales• Anatomía local distorsionada• Extremos de peso• Vasculitis• Cateterización venosa previa crónica• Inyección de agentes esclerosantes• Sospecha de lesión vascular proximal• Terapia de radiación• Coagulopatías• Terapia anticoagulante o trombolítica• Pacientes combativos• POCA experiencia o sin supervisión. Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  22. 22. Contraindicaciones SV• Deformidad de pared torácica• Pneumotórax de lado contralateral• EPOC Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  23. 23. Contraindicaciones Vena yugular• Abuso de drogas vía sistema yugular• Trauma cervical• Aterosclerosis de arteria carótida por riesgo de punción y liberación de placa Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  24. 24. Vena femoral• Deambulación• Sospecha de hemorragia intra abdominal• Lesión de pelvis, ingle o vasos iliacos Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  25. 25. Contraindicación absoluta• Colocación de catéter impregnado con antibiótico si el paciente tiene antecedente de alergia Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  26. 26. DATOS CLAVE
  27. 27. Datos clave• SV tiene diámetro de 10 a 20 mm y no tiene válvulas• Después de cruzar la primera costilla la vena se encuentra JUSTO posterior al tercio medio de la clavícula• Si la guía no pasa fácil  reacomodar aguja• Sangre pulsátil y roja  arterial• Burbujas = Pneumotórax E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  28. 28. Puntos clave• Plasma y plaquetas si es necesario• En caso de riesgo de sangrado, elegir lugar comprimible – Yugular interna o vena femoral• Px PO pneumonectomia o enfermedad pulmonar unilateral  elegir este lado• Si la guía no avanza  retirar levemente , girar y volver a avanzar
  29. 29. COMPLICACIONES
  30. 30. Complicaciones E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  31. 31. Complicaciones SV• Infecciones locales o sistémicas• Punción arterial – NO ES POSIBLE LA COMPRESIÓN – Se debe evitar en anticoagulados• Hematoma solo requiere monitoreo• Hemotórax• Pneumotórax• Trombosis relacionada al catéter• Embolismo aire• Disrritmias E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  32. 32. Complicaciones SV• Punción de pared auricular• Guía perdida• Anafilaxia• Catéter muy adentro E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  33. 33. Complicaciones Yugular• Lesión pulmonar – Pneumotórax• Hematoma por punción de carótida.• Perdida de guía• Laceración de vaso Bradford L. Waters, et. Al. Central Venousaccessvia posterior approachtointernal yugular vein. 2011. Medscape
  34. 34. Complicaciones Femorales• Punción arterial• Formación pseudoaneurisma• Formación hematoma• Penetración intestinal (hernias inguinales)• Punción vesical• Absceso psoas• Artritis séptica ( contaminación capsula ósea)• Infección• Trombosis 21.5% VS 1.9% SV Neelu Pal, et. Al. Femoral Central Venous Access. 2012. Medscape.
  35. 35. Errores en la colocación Neelu Pal, et. Al. Femoral Central Venous Access. 2012. Medscape.
  36. 36. Infección de catéter central• Riesgo 2 - 8%• Staphylococcusaureus
  37. 37. TÉCNICAS DE COLOCACIÓN
  38. 38. Técnicas de colocación• Paciente en posición supina• Rosier?• Asepsia y antisepsia lugar E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  39. 39. Subclavio• Tercio medio y tercio medial de clavícula• 1 cm por debajo• Bisel caudal• Succión continua• Dirección supraesternal• Cambio después de tres intentos• Aspiración de sangre venosa  técnica de Seldinger• http://www.youtube.com/watch?v=D8OppkEb9Q A E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  40. 40. Yugular interno posterior• Seldinger – Posición Trendelemburg para evitar embolismo y dilatar venas 10 a 15 grados – La más usada lado derecho – Identificar músculo esternocleidomastoideo – Identificar vena yugular externa , palpar arteria carótida para garantizar posición – Introducción de aguja un tercio de la distancia entre mastoides y clavicula por detrás de M. ECM – Apuntando a manubrio esternal – -- resto técnica de Seldinger. Bradford L. Waters, et. Al. Central Venousaccessvia posterior approachtointernal yugular vein. 2011. Medscape
  41. 41. Bradford L. Waters, et. Al. Central Venousaccessvia posteriorapproachtointernal yugular vein. 2011. Medscape
  42. 42. Femoral• Seldinger – Paciente posición supina – Regioninguinal expuesta – Asepsia y antisepsia – Identificar ligamento inguinal y pulsos femorales – Identificar punto 1 cm por debajo de ligamento inguinal y 0.5 – 1 cm medial a pulso femoral Neelu Pal, et. Al. Femoral Central Venous Access. 2012. Medscape.
  43. 43. Femoral– Infiltrar– Identificar vena– Aguja entra la piel a 45º endirección cefálica– Succión negativa continua– Sangre venosa en jeringa– Resto técnica de Seldinger– http://www.youtube.com/ watch?v=GHfGdpVJuMA Neelu Pal, et. Al. Femoral Central Venous Access. 2012. Medscape.
  44. 44. Revisión• RX de tórax• Monitoreo cardiaco• US• “Back flow” E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape
  45. 45. Correcta posición via YI
  46. 46. PneumotóraxE Jedd Roe III, et. Al. Central Venous accessvia subclavian approach to subclavian vein. 2011. Medscape
  47. 47. PRESIÓN VENOSA CENTRAL
  48. 48. Presión venosa central• Primera vez descrita por Forssman 1931• Uso generalizado hasta 1960• Qué es? – Presión ejercida por la sangre contra la pared de la vena cava intratorácica – Refleja la presión en la que la sangre regresa a la aurícula derecha• Interacción entre volumen intravascular, función auricular y ventricular, tono venomotor y presión intratorácica Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  49. 49. Presión venosa central• Razones – Presión en auricula derecha = PVC• Medición con manómetro• Medición con paciente en posición supina 90º• Nivel 4º esp. Intercostal• 5cm por debajo esternón Izakovic M. Central Venous Pressure. University of Iowa. Mercy Hospital. 2008.
  50. 50. Indicaciones para medir PVC• Falla circulatoria aguda• Transfusión anticipada masiva para terapia de reemplazo de fluidos• Reemplazo de fluidos preventivo en pacientes con status cardiovascular comprometido• Tamponade cardiaco sospechado• Resucitación con fluidos durante sepsis severa. Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  51. 51. Presión venosa central• Normal 5-10 cm H2O (2-6 MM Hg)• Describe la presion de la vena cava torácica• Precarga• Cambio en PVC es determinado por cambio e nvolumen• Aumenta en caso de aumento de volumen o disminución de la complianza venosa Izakovic M. Central Venous Pressure. University of Iowa. Mercy Hospital. 2008.
  52. 52. Cambios en PVC• Embarazo eleva de 5 a 8 cm H2O• Menor a 6 cmH2O presión auricula derecha baja refleja disminución del retorno venoso – Restitución de fluidos?• Menor a 6 cuando tono vasomotor esta disminuido – Sepsis, lesion medular u otras interrupciones simpatéticas. Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  53. 53. Cambios PVC• Mayor a 12 cm H2O falla cardiaca? – Hipertrofia ventricular – Sobrehidratación – Sobretransfusión• Falla de bomba – Tamponade cardiaco – Pericarditis restrictiva – Estenosis pulmonar – Embolia pulmonar• VMA 12 – 15 cm H2O Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.
  54. 54. Fuentes• Bradford L. Waters, et. Al. Central Venousaccessvia posterior approachtointernal yugular vein. 2011. Medscape• E Jedd Roe III, et. Al. Central Venous access via subclavian approach to subclavian vein. 2011. Medscape• Neelu Pal, et. Al. Femoral Central Venous Access. 2012. Medscape.• Roberts: Clinical Procedures in Emergency Medicine 5th Ed. Ch. 22 Central Venous Catheterization and Central Venous Pressure Monitoring. Saunders. 2009.• Izakovic M. Central Venous Pressure. University of Iowa. Mercy Hospital. 2008.• Townsend., Sabiston. Tratado de Cirugía. Ed. Elsevier. 18a Edición. Barcelona, España 2009. 96-98 Capitulo 5 Shock , Electrolitosylíquidos.

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