2014 vascular access art
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This document provides information on arterial catheterization for medical practitioners. It outlines the objectives, indications, contraindications and complications of arterial catheterization. Potential sites for insertion are described along with landmarks, anatomy and positioning. The preparation, consent, equipment and steps for performing arterial catheterization are explained. Practitioners are instructed to confirm proper placement and document the procedure. Stations are provided for hands-on practice of skills related to vascular access procedures.
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2014 vascular access art
- 2. Page 2 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Objectives •By the end of this workshop, the learner will be able to: ‐Recall at least 3 indications and 3 contraindications for arterial catheterization ‐Name at least 5 complications associated with arterial catheterization ‐Describe the anatomic landmarks used to guide arterial catheterization at specified sites of insertion ‐Identify the potential sites for arterial catheterization ‐Choose the appropriate sized vascular catheter according to the patient’s size
- 3. Page 3 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics 3 Simple Steps Obtain Prepare Perform
- 4. Page 4 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics 3 Simple Steps Obtain informed consent Prepare Perform
- 5. Page 5 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Indications •Arterial blood sampling ‐Oxygenation ‐Ventilation •Frequent blood sampling •Continuous monitoring of blood pressure
- 6. Page 6 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Contraindications •Known deficiencies of collateral circulation •Infection at site of insertion •Trauma injury •Coagulopathy
- 7. Page 7 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Complications •Arterial spasm •Thrombosis ‐Mottling proximal/distal to catheter site •Emboli •Hemorrhage ‐Axillary sheath hematoma •Infection ‐Low incidence •Skin necrosis •Fistula •Aneurysm •Brachial plexus injury
- 8. Page 8 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics 3 Simple Steps Obtain informed consent Prepare for placement Perform
- 9. Page 9 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Preparation •Proceduralist •Patient •Equipment
- 10. Page 10 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Preparation •Proceduralist •Patient •Equipment
- 11. Page 11 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Proceduralist Flickr.com
- 12. Page 12 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Timeout •Right procedure •Right patient •Right side Flickr.com
- 13. Page 13 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Sterile gowning Flickr.com
- 14. Page 14 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Preparation •Proceduralist •Patient •Equipment
- 15. Page 15 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Sites for Insertion •Radial/Ulnar •Axillary •Dorsalis pedis •Posterior tibial •Femoral
- 16. Page 16 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics •Anatomy •Surface Landmarks •Positioning
- 17. Page 17 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Radial •Most common site •Lies in longitudinal groove formed by FCRM and distal radius •Check for collateral flow •Thrombosis is common
- 18. Page 18 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics 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
- 19. Page 19 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Posterior tibial
- 20. Page 20 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Axillary •Large artery •Excellent collateral flow •Air/thrombus embolism can cause brain/hand ischemia
- 21. Page 21 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Femoral •Also large artery •May still be palpable with marked hypotension •Lack of collateral flow •Air/thrombus embolism can cause foot/toe ischemia
- 22. Page 22 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Patient
- 23. Page 23 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Preparation •Proceduralist •Patient •Equipment
- 24. Page 24 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Choosing a Catheter •2.5 F and 2.5 cm •2.5 F and 5 cm •3 F and 5 cm
- 25. Page 25 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics 3 Simple Steps Obtain informed consent Prepare for placement Perform the procedure
- 26. Page 26 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Administer medications
- 27. Page 27 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Sequence of Events Inform/Consent parents Perform a “Time Out” Position •Perform Procedure/Apply sterile dressing •Confirm Placement •Document
- 28. Page 28 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Sequence of Events Inform/Consent parents Perform a “Time Out” Position Perform Procedure/Apply sterile dressing •Confirm Placement •Document
- 29. Page 29 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics •Confirm via pressure transduction and blood gas •Tubing used for pressure monitoring should include a Luer-lock design •Papaverine-containing heparin solution prolongs arterial catheter life •If you cannot transduce……
- 30. Page 30 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics TAKE IT OUT!!! TAKE IT OUT! TAKE IT OUT!!
- 31. Page 31 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics Sequence of Events Inform/Consent parents Perform a “Time Out” Position Perform Procedure/ Apply dressing Confirm Placement •Document
- 32. Page 32 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics
- 33. Page 33 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics STATIONS •Ultrasound/PIV/IO •US-guided CVC •Arterial line placement •CVC via landmark technique
- 34. Page 34 xxx00.#####.ppt 07/01/16 12:57 AM Pediatrics •Practice : ‐PIV and IO placement using a task trainer ‐the steps for prepping and draping a site prior to: •Central venous catheterization according to TCH PICU insertion bundle •Arterial catheterization •Execute the proper sequence in the placement of: ‐Ultrasound-guided central venous catheters ‐Arterial catheters according to an itemized checklist •Integrate the “landmark technique” and use of ultrasound when performing central venous catheterization as recommended by governing/certifying bodies
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- 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
- 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 The Modified Allen's Test has been the most frequently used method to clinically assess adequacy of ulnar artery collateral flow despite the lack of evidence that it can predict ischemic complications in the setting of radial artery occlusion.
- 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
- Foot dorsiflexed
- Hyperabducted & externally rotated 90 degrees from pt’s body Insert needle just parallel to lateral edge of pectoralis major muscle
- 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
- THE ADMINISTRATION OF MEDICATIONS SHOULD BE DONE PRIOR TO NEEDLE PUNCTURE. IT IS MY PRACTICE TO ADMINISTER A LOCAL ANESTHETIC TO ALL PATIENTS UNDERGOING CENTRAL LINE PLACEMENT REGARDLESS OF WHETHER SYSTEMIC SEDATION/ANALGESIA IS GIVEN AS LOCAL ANESTHESIA POTENTIALLY REDUCES THE NEED OR QUANTITY OF SYSTEMIC MEDICATION.
- THE REST OF THE STEPS IN PERFORMANCE OF THIS PROCEDURE WILL BE THE FOCUS OF THE SKILLS STATIONS AT THE BOOT CAMP. RECOGNIZE THAT THE AFOREMENTIONED DESCRIPTION OF NEEDLE PUNCTURE FOR IJ AND FEMORAL INSERTION WAS BASED ON THE LANDMARK TECHNIQUE. WITH THIS BASIC FOUNDATION, DR. ALADE WILL SHOW YOU HOW TO INTEGRATE US GUIDANCE WITH THESE TECHNIQUES FOR SUCCESSFUL AND SAFE PLACEMENT OF CVL’S. AS FAR AS “APPLYING A STERILE DRESSING”, I HAVE A VIDEO ON THE VASCULAR ACCESS WIKI PAGE THAT ELABORATES ON THE APPLICATION OF THIS STERILE DRESSING.
- THE REST OF THE STEPS IN PERFORMANCE OF THIS PROCEDURE WILL BE THE FOCUS OF THE SKILLS STATIONS AT THE BOOT CAMP. RECOGNIZE THAT THE AFOREMENTIONED DESCRIPTION OF NEEDLE PUNCTURE FOR IJ AND FEMORAL INSERTION WAS BASED ON THE LANDMARK TECHNIQUE. WITH THIS BASIC FOUNDATION, DR. ALADE WILL SHOW YOU HOW TO INTEGRATE US GUIDANCE WITH THESE TECHNIQUES FOR SUCCESSFUL AND SAFE PLACEMENT OF CVL’S. AS FAR AS “APPLYING A STERILE DRESSING”, I HAVE A VIDEO ON THE VASCULAR ACCESS WIKI PAGE THAT ELABORATES ON THE APPLICATION OF THIS STERILE DRESSING.
- THE REST OF THE STEPS IN PERFORMANCE OF THIS PROCEDURE WILL BE THE FOCUS OF THE SKILLS STATIONS AT THE BOOT CAMP. RECOGNIZE THAT THE AFOREMENTIONED DESCRIPTION OF NEEDLE PUNCTURE FOR IJ AND FEMORAL INSERTION WAS BASED ON THE LANDMARK TECHNIQUE. WITH THIS BASIC FOUNDATION, DR. ALADE WILL SHOW YOU HOW TO INTEGRATE US GUIDANCE WITH THESE TECHNIQUES FOR SUCCESSFUL AND SAFE PLACEMENT OF CVL’S. AS FAR AS “APPLYING A STERILE DRESSING”, I HAVE A VIDEO ON THE VASCULAR ACCESS WIKI PAGE THAT ELABORATES ON THE APPLICATION OF THIS STERILE DRESSING.