2012 vascular access pt 2

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  • xxx00.#####.ppt 07/10/12 03:53 PM P. Text Text Text Text
  • 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 07/10/12 P.
  • xxx00.#####.ppt 07/10/12 03:53 PM P. Text Text Text Text
  • Thrombosis and emboli can lead to ischemia and necrosis but is dependent on adequacy of collateral flow Thrombosis longer duration and size of cath relative to arterial lumen diameter leads to greater incidence of thrombosis. Also increased incidence w/repeated punctures and intermittent flushing Emboli More common w/manual intermittent flushing Skin necrosis Prox to radial art insertion site, blood supply to to skin of distal forearm arises directly from branches of rad art. w/o ANY collateral circulation. If cath tip interferes w/these branches then ischemia to skin occurs Prevention: 1) most distal insertion site 2) smallest sized catheter so as to cause the least amt of luminal obstruction 3) prolonged catheterization xxx00.#####.ppt 07/10/12 P.
  • Brachial artery not recommended due to absence of collateral circulation xxx00.#####.ppt 07/10/12 P.
  • Palpate artery just prox to radial head Insert needle about 30 degrees to surface of skin Dorsiflex wrist for insertion then place in neutral position Suture 3-0 silk xxx00.#####.ppt 07/10/12 P.
  • Hyperabducted & externally rotated 90 degrees from pt’s body Insert needle just parallel to lateral edge of pectoralis major muscle xxx00.#####.ppt 07/10/12 P.
  • Positioned similarly as for CVC 2cm below inguinal ligament 3 fingers along pulse, index/middle/ring finger, insert in between index and middle finger Insert at 45 degree angle Puncture over maximal pulsation xxx00.#####.ppt 07/10/12 P.
  • mid plantar flexion Occlude DP art  blanch toe by Compressing toenail  release pressure on nail and observe for flushing  rapid return of color indicates adequate collateral flow xxx00.#####.ppt 07/10/12 P.
  • Foot dorsiflexed xxx00.#####.ppt 07/10/12 P.
  • 2012 vascular access pt 2

    1. 1. Vascular AccessPART DEUX: Subclavian CVC &Arterial catheterization Pediatrics
    2. 2. Subclavian CVC •Anatomy •Positioning •Landmarks Page 2Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    3. 3. SKILLSSTATIONS Pediatrics
    4. 4. Objectives •By the end of this workshop, the learner will: ‐ Describe the anatomic landmarks used to guide arterial catheterization at specified sites of insertion ‐ List at least 3 indications and 3 contraindications for arterial catheterization ‐ List at least 5 complications associated with arterial catheterization common to all sites of insertion ‐ Identify the potential sites for arterial vascular catheterization Page 4Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    5. 5. Objectives •Choose the appropriate sized vascular catheter according to the patient’s size •Perform the steps for prepping and draping a site prior to arterial catheterization •Execute the proper sequence in the placement of arterial catheterization according to an itemized checklist Page 5Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    6. 6. REFLECTION Pediatrics
    7. 7. Indications •Arterial blood sampling ‐ Oxygenation ‐ Ventilation •Frequent blood sampling •Continuous monitoring of blood pressure Page 7Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    8. 8. Contraindications •Known deficiencies of collateral circulation •Infection at site of insertion •Trauma injury •Coagulopathy Page 8Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    9. 9. Complication •Arterial spasm •Infection •Thrombosis ‐ Low incidence ‐ Mottling proximal/distal •Skin necrosis to catheter site •Fistula •Emboli •Aneurysm •Hemorrhage •Brachial plexus injury ‐ Axillary sheath hematoma Page 9Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    10. 10. Sites of insertion •Radial/Ulnar •Axillary •Dorsalis pedis •Posterior tibial •Femoral Page 10Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    11. 11. Radial •Most common site •Lies in longitudinal groove formed by FCRM and distal radius •Check for collateral flow •Thrombosis is common Page 11Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    12. 12. Axillary •Large artery •Excellent collateral flow •Air/thrombus embolism can cause brain/hand ischemia Page 12Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    13. 13. Femoral •Also large artery •May still be palpable with marked hypotension •Lack of collateral flow •Air/thrombus embolism can cause foot/toe ischemia Page 13Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    14. 14. Dorsalis pedis •Descends down dorsum of foot parallel & lateral to EHLT •Check for collateral flow ‐ Occlude artery ‐ Blanch great toe for several seconds ‐ Release pressure & observe for flushing Page 14Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    15. 15. Posterior tibial Page 15Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    16. 16. •Confirm via pressure transduction •Tubing used for pressure monitoring should include a Luer-lock design •Papaverine-containing heparin solution prolongs arterial catheter life •If you cannot transduce…… Page 16Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    17. 17. TAKE IT OUT! TAKE IT OUT!!TAKE IT OUT!!! Page 17Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    18. 18. SKILLSSTATIONS Pediatrics
    19. 19. IJ/Femoral Page 19Pediatrics xxx00.#####.ppt 07/10/12 03:53 PM
    20. 20. REFLECTION Pediatrics

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