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Line Insertion Technique & Follies


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Line Insertion Technique & Follies

  1. 1. Line Complications Dalhousie University Critical Care Lecture Series
  2. 2. Objectives <ul><li>Know the indications and contraindications for central line insertion </li></ul><ul><li>Review the technique of central line insertion </li></ul><ul><li>Know the most common complications of central lines and arterial lines </li></ul><ul><li>Know how to prevent line complications </li></ul><ul><li>Know how to recognize and manage line complications </li></ul><ul><li>Examples </li></ul>
  3. 3. CVP Catheter Indications <ul><li>Pressure monitoring </li></ul><ul><li>Mixed venous oxygen saturation </li></ul><ul><li>Fluid administration during volume resuscitation (may not be as good as large-bore peripheral lines!!) </li></ul><ul><li>Administration of corrosive or hypertonic fluids </li></ul><ul><li>Administration of vasoactive agents </li></ul><ul><li>Lack of other sites </li></ul>
  4. 4. CVP Contraindications <ul><li>Severe coagulopathy </li></ul><ul><li>Obstruction or congenital abnormality </li></ul><ul><li>Patient refusal (if competent) </li></ul><ul><li>Restless and uncooperative patient, unless sedation can be utilized </li></ul><ul><li>Lack of experience and no expert supervision, OR previous failed attempt by experienced physician </li></ul><ul><li>Injury or infection at the site </li></ul>
  5. 5. Normal CXR
  6. 6. Complications <ul><li>More than 15% of all central lines have a complication </li></ul><ul><ul><li>Mechanical 5-19% </li></ul></ul><ul><ul><li>Infectious 5-26% </li></ul></ul><ul><ul><li>Thrombotic 2-26% </li></ul></ul>
  7. 7. Mechanical Complications
  8. 8. Mechanical Injuries <ul><li>Most common complications: </li></ul>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. 9. Pneumothorax <ul><li>More common in subclavian </li></ul><ul><li>Incidence ranges from 0.3 to 3% depending on experience </li></ul><ul><li>Classic presentation = hypoxemia/hypotension/pleuritic CP </li></ul><ul><li>Can be treated conservatively in non-ventilated patients </li></ul>
  10. 11. Treatment <ul><li>Chest tube to expand lung </li></ul><ul><li>Insertion of chest tube may create hole in lung parenchyma leading to another complication: </li></ul>
  11. 13. Wrong Vessel <ul><li>If finder needle or 18 g insertion needle in artery may remove and apply pressure </li></ul><ul><li>If CVC or PAC introducer is in artery remove catheter and apply pressure OR: </li></ul><ul><li>Consult CV surgeon/thoracic surgeon ? OR for thoracotomy, removal of catheter and repair of vessel </li></ul>
  12. 15. The Left Side is Sinister <ul><li>Left internal jugular has unique complications – thoracic duct injury </li></ul><ul><li>Left inominate vein can be lacerated  hemothorax and  OR </li></ul><ul><li>L IJ or SC catheter too proximal can lacerate SVC  death </li></ul>
  13. 16. Left Subclavian Artery
  14. 19. Prevention of Mechanical Complications
  15. 20. Prevention of Mechanical Complications <ul><li>Ultrasound Guidance </li></ul><ul><li>-Useful for internal jugular </li></ul><ul><li>-Potentially prevents wrong vessel, hemo/pneumothorax </li></ul><ul><li>Pressure waveform monitor </li></ul><ul><li>-Arterial cannulation/puncture </li></ul><ul><li>CXR </li></ul><ul><li>-Cardiac tamponade </li></ul><ul><li>-Wire/catheter embolus </li></ul>
  16. 21. Ultrasound! <ul><li>Prevention is always better than treatment </li></ul><ul><li>Use ultrasound probe to localize vessel </li></ul><ul><li>Cannulate vessel under direct vision </li></ul>
  17. 22. Ultrasonographic Guidance: Dynamic vs. Static <ul><li>Dynamic </li></ul><ul><li>Consists of ultrasonic localization, and image-guided cannulation </li></ul><ul><li>More precise and “real time” </li></ul><ul><li>Difficult to keep sterility of transducer and site. </li></ul><ul><li>More hand to screen coordination, unless two persons involved </li></ul><ul><li>Static </li></ul><ul><li>Consists of ultrasonic localization and marking of landmarks only </li></ul><ul><li>Cannulation is not image-guided, but is separate </li></ul><ul><li>Time delay between marking and cannulation </li></ul><ul><li>Easy to keep sterility of transducer and site </li></ul><ul><li>Less technically demanding </li></ul>
  18. 23. Pressure Waveforms <ul><li>Several options: </li></ul><ul><li>Connect sterile tubing to pressure tubing and flush </li></ul><ul><li>Attach to needle in vessel and confirm venous trace </li></ul><ul><li>Remove syringe and confirm non-pulsatile blood </li></ul><ul><li>Compare arterial blood sample with your sample </li></ul>
  19. 24. IJ Insertion Method Transverse orientation Longitudinal orientation
  20. 25. Check Vein for Patency Thrombus Vein should be free of clot and freely compressible when pressure is applied with the probe
  21. 26. Transverse Orientation- “Finger Wiggle” Finger on one side of probe Acoustic shadow of finger on same side of image
  22. 27. Orientation- “Mock Poke”
  23. 28. Orientation- “Mock Poke” Acoustic “shadow” of the needle over the vein
  24. 29. Technique <ul><li>Steps: </li></ul><ul><ul><li>Obtain informed consent (unless emergency) </li></ul></ul><ul><ul><li>Check radiograph for any existing pathology (put line on the same side as pathology) </li></ul></ul><ul><ul><li>Check coagulation studies, if indicated </li></ul></ul><ul><ul><li>Position patient appropriately (see individual slides for specifics) </li></ul></ul><ul><ul><li>Prep/drape using sterile technique </li></ul></ul><ul><ul><li>Inject local, making certain not to inject intravascularly </li></ul></ul><ul><ul><li>Using ultrasound, assess for proper orientation, localize the vessel, and ensure patency </li></ul></ul><ul><ul><li>Cannulate vessel and place catheter (see steps) </li></ul></ul><ul><ul><li>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) </li></ul></ul>
  25. 30. Technique <ul><li>Sterile technique is extremely important </li></ul><ul><li>Nosocomial bloodstream/catheter infections are very prevalent, causing significant morbidity (and costing millions of dollars) </li></ul><ul><li>Most beginners make one of three mistakes: </li></ul><ul><ul><li>Contaminate gloves when putting them on </li></ul></ul><ul><ul><li>Contaminate gloves when placing drapes </li></ul></ul><ul><ul><li>Contaminate the wire by not paying close attention to where it is/what it’s touching at all times </li></ul></ul><ul><li>Use of ultrasound introduces more opportunity for contamination, SO BE CAREFUL </li></ul>
  26. 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
  27. 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
  28. 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
  29. 35. <ul><li>Most use infraclavicular approach (insert at “fossa” of deltopectoral groove, about 1-2 cm inferior to clavicle) </li></ul><ul><li>Poor choice in coagulopathy (difficult to compress) </li></ul><ul><li>Higher PTX risk than internal jugular (1-5%) </li></ul><ul><li>Less infection risk than IJ </li></ul><ul><li>Trendelenburg’s position with towel roll under scapulae </li></ul><ul><li>Direct needle toward sternal notch </li></ul><ul><li>Keep needle parallel to floor; DO NOT AIM UNDER CLAVICLE OR YOU WILL CAUSE PNEUMOTHORAX </li></ul><ul><li>Constant suction in and out </li></ul><ul><li>Ultrasound not as useful </li></ul><ul><li>Again, think after inserting needle 5 cm deep </li></ul>Insertion Method-Subclavian
  30. 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!
  31. 38. <ul><li>Reverse Trendelenburg position (legs DOWN) to reduce chance of air embolus </li></ul><ul><li>Use for emergency access </li></ul><ul><li>Try to remove after 72 hours </li></ul><ul><li>Do not use if PA catheter needs to be placed </li></ul>Insertion Method-Femoral At 45 o angle to vessel, just medial to artery
  32. 39. Image and Orientation
  33. 40. Infectious Complications
  34. 41. Infectious Complications Prevention
  35. 42. Management of Line Infections
  36. 43. Pulmonary Artery Catheters <ul><li>PAC have unique set of complications: </li></ul><ul><li>Arrhythmias inc. complete heart block </li></ul><ul><li>Knotting of the PAC </li></ul><ul><li>Pulmonary Artery infarction or rupture </li></ul>
  37. 44. Arterial Lines <ul><li>Most common site = radial artery </li></ul><ul><li>Rare complications </li></ul><ul><li>1983 Slogoff and Keats prospective study </li></ul><ul><li>1699 radial artery cannulations no ischemia or disability of hand </li></ul><ul><li>Pseudoaneurysm of the radial artery can occur </li></ul>Bowdle Anesthesiology Clinics of NA 2002: 20
  38. 45. What’s Wrong With These Pictures?
  39. 47. ETT in too far
  40. 48. Chest tube in poor position
  41. 49. Left mainstem intubation
  42. 50. Feeding tube in lung
  43. 51. Feeding Tube in RLL
  44. 52. Subclavian going In wrong direction
  45. 53. Carotid Artery Insertion
  46. 55. Hematoma After Subclavian Artery Puncture NG ETT
  47. 57. CT insertion Subclavian Line NG Down Left Mainstem!!!!
  48. 58. ETT Subclavian Crossing Through innominate
  49. 59. Summary <ul><li>Ultrasound guided placement is becoming standard of care. </li></ul><ul><li>Consider waveform monitoring with all line insertions. </li></ul><ul><li>Do a CXR post line insertion and review it! </li></ul><ul><li>Three poke rule (get another person to do procedure) </li></ul>