2. Objectives
•By the end of this workshop, the learner will:
‐ Describe the anatomic landmarks used to guide central
venous catheterization (CVC) at specified sites of insertion
‐ List at least 5 indications and 5 contraindications for CVC
‐ List at least 5 complications associated with CVC common to
all sites of insertion
‐ Operate the basic functions of the ultrasound to assist in CVC
‐ Incorporate the use of ultrasound guidance when inserting
central venous catheters as recommended by
governing/certifying bodies
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7. Femoral Anatomy
N
Roger’s Textbook of Pediatric Intensive Care, 4th ed.
A
V
Empty space
L ymphatics
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8. Femoral Landmarks
Roger’s Textbook of Pediatric Intensive Care, 4th ed.
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9. IJ Anatomy
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10. IJ Anatomy
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11. IJ Anatomy
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16. 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.
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18. Ultrasound Guidance
•Governing/certifying bodies recommendations:
‐ AHRQ (2001) - dynamic US guided CVC for patient safety
‐ NICE (2002) - elective 2D US guidance for IJ CVC
‐ ACEP (2009) - use of US in CVC
‐ CDC (2011) - use of US-guided CVC
•Technique
‐ Dynamic
‐ Static
Kumar et al. Ultrasound guided vascular access: efficacy and safety. Best Practice & Research Clinical Anaesthesiology 2009; 23: 299–311
Srinivasan et al. Bedside ultrasound in pediatric critical care: A review. Ped Crit Care Med 2011; 12(6): 667‐674
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19. WHY USE ULTRASOUND?
•Reduce
‐ Cannulation failure rate
‐ Number of attempts (increased first-attempt success)
‐ Number of complications
‐ Procedure time
•Anatomic variability
•Avoiding unnecessary complications
Kumar et al. Ultrasound guided vascular access: efficacy and safety. Best Practice & Research Clinical Anaesthesiology 2009; 23: 299–311
Srinivasan et al. Bedside ultrasound in pediatric critical care: A review. Ped Crit Care Med 2011; 12(6): 667‐674
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20. Use of Ultrasound
•Comparison of US use vs. “Landmark” technique
‐ Failure rate
‐ Number of attempts
‐ Arterial puncture
•Can reduce time to procedural completion
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21. Use of Ultrasound
•Reported to reduce complications and failed
placement in infants and children during IJ
cannulation
•Static vs. Dynamic techniques
• Higher success rate with dynamic technique
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25. Objectives
•By the end of this workshop, the learner will:
‐ Choose the appropriate sized vascular catheter according to
indication for placement and/or the patient’s size
‐ Perform the steps for prepping and draping a site prior to
CVC according to TCH PICU insertion bundle
‐ Execute the proper sequence in the placement of
ultrasound-guided central venous catheters
‐ Combine the “landmark technique” and use of ultrasound
when performing central venous catheterization
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26. Choosing a Catheter
•Size?
•Length?
•Number of lumens?
•Patient
‐ Weight/size
‐ Size of vessel
‐ Indications
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30. would be placed here, as would still images
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31. Catheter Associated Bloodstream
Infection (CABSI)
•Infection
‐ Most common complication of CVC
‐ 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
•Vessel cannulation complications can be reduced
using visualization techniques
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32. 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
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xxx00.#####.ppt 07/10/12 03:52 PM P. Text Text Text Text
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 07/10/12 P.
Laterally to medially NAVEL is a common mnemonic used to recall the anatomy of the femoral/inguinal region xxx00.#####.ppt 07/10/12 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 07/10/12 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 07/10/12 P.
Upper part medial to SCM Mid post to SCM in the triangle of SCM heads and clavicle Lower part behind clavicular head of SCM where it descends to join SC just above medial end of clavicle xxx00.#####.ppt 07/10/12 P.
Supine slight trendelenburg (15-30degrees)[reduces risk of air embolism roll under shoulders head slightly turned AWAY from puncture site Apex of triangle aimed at ipsilateral nipple Attempt to puncture during exhalation (spont breathing pt so as not to entrain air) xxx00.#####.ppt 07/10/12 P.
These lists are not necessarily exhaustive but just capture the more common ones xxx00.#####.ppt 07/10/12 P.
Relative Few, if any, absolute contraindicatons (i.e. refusal of consent) R isks vs. Benefits Last bullet assoc w/SC CVC xxx00.#####.ppt 07/10/12 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 07/10/12 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 This segways into the use of US in CVC xxx00.#####.ppt 07/10/12 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 07/10/12 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 07/10/12 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 07/10/12 P.
Not one size fits all, may consider measuring xxx00.#####.ppt 07/10/12 P.
xxx00.#####.ppt 07/10/12 03:52 PM P. Text Text Text Text
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In adults, insertion ONLY reduces infxn In ped, insertion AND maintenance bundles, maint my carry more weight xxx00.#####.ppt 07/10/12 P.
Position-hip abduction/external rotation Confirmation-transduction, blood gas, radiographic xxx00.#####.ppt 07/10/12 P.
