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the right side of the neck carefully using a portable
ultrasound (US) machine (IMAGIC Agile, Kontron
Medical, WA, USA) with a linear, high frequency
transducer (7.5–12 MHz). Care was taken to apply
minimal pressure on the probe to prevent collapse of the
IJV. Imaging showed a single pulsatile vessel, which was
non compressible suggestive of the carotid artery with
right sided IJV has also been reported in a 12-year-old boy
during US evaluation prior to attempted cannulation.[4]
In
another report, IJV agenesis was discovered during neck
dissection. Patients who require removal of IJV due to
disease infiltration may have potentially life-threatening
complicationofcerebraledemaiftheotherIJVisaplastic.[5]
Figure 1: Ultrasound image of the right side of the neck showing absence
of internal jugular vein. CA: Carotid artery
Figure 2: Ultrasound image of the left side of the neck showing normal
anatomy. CA: Carotid artery; IJV: Internal jugular vein](https://image.slidesharecdn.com/centralline-ncana-150930202125-lva1-app6892/85/Central-Line-in-Anesthesia-19-320.jpg)
Uploaded byNC Association of Nurse Anesthetists
Central Line in Anesthesia
This document discusses central line placement, including: 1) It provides a brief history of central line development and discusses their increasing common use today. 2) Major uses of central lines include access for volume infusion, determination of cardiovascular function, and nutrition. 3) Potential complications include mechanical issues like arterial puncture or cannulation in 5-19% of cases, and infectious complications in 5-26% of cases.
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Central Line in Anesthesia
- 1. Central lines in anesthesia: choices, techniques & pi4alls IAN HEWER, MA, MSN, CRNA ASSISTANT Director, WCU NURSE ANESTHESIA PROGRAM
- 2. OBJECTIVES • IDENTIFY REASONS FOR CENTRAL LINE ACCESS • IDENTIFY COMMON SITES & MAJOR LANDMARKS FOR CENTRAL LINE PLACEMENT • LIST FREQUENT COMPLICATIONS OF CENTRAL VENOUS ACCESS & WAYS TO AVOID THEM
- 4. HISTORY • 1656-‐ original infusions of wine, ale, & opium into dog • 1680s-‐ animal blood into humans-‐ results led to unpopularity!
- 5. HISTORY • 1700-‐1800s-‐ various experiments to measure arterial, venous & cardiac pressures • First experiments in early 20th century in Germany • Wanted a way to introduce emergency drugs close to the heart (Forssmann, 1929)
- 6. HISTORY • 1940s-‐ introducbon of PVC catheters for IVs revolubonizes field • 1956-‐ Cournand, Forssman & Richards won Nobel Prize for Medicine
- 7. Further development •Locabons: – Infraclavicular subclavian-‐ 1952 Aubaniac – Internal jugular approach-‐ 1968 English • Why? – Nutribon – Chemotherapy – Direct access for drugs
- 8. CVCs today •> 5 million placed/year in the US alone (McGee & Gould, 2003) • > 15% have complicabons – Mechanical-‐ 5-‐19% – Infecbous-‐ 5-‐26% – Thrombobc-‐ 2-‐26%
- 9. implicabons • Significant morbidity-‐ potenbally >750,000 have complicabons • Significant cost-‐ $16,550/ infecbon (CDC, 2011) • Reducbon in CLABSI 2001-‐2009-‐ save $2 billion in excess costs & 6000 lives
- 10. Major uses •Access – Poor peripheral – Need for volume..?
- 11. Side note: Fr vs gauge • French relates to external diameter, & is a mulbple of 3 – 1 Fr = .33mm OD, 3 Fr =1 mm OD, 6 Fr = 2 mm OD etc – DOES NOT INDICATE INTERNAL DIAMETER!! • Gauge refers to internal & external diameter..kind-‐of.. – E.g. 14 G = 2.1mm OD & 1.6mm ID. Similar to 6 Fr OD
- 12. Major uses •Determinabon of CV funcbon – CVP measurement – PA catheter placement • Nutribon
- 13. Not much of a decision • Ultrasound vs Landmark • Less arterial punctures • Less overall sbcks • Beoer first aoempt success • Quicker
- 14. Remember.. • There is a learning curve!
- 15. Classic “central” approach • Idenbfy the triangle formed by clavicular head/ s ternal head of the sternocleidomastoid Vein is typically anterior & lateral to artery at the level of cricoid carblage • Lower down the neck, the vein becomes relabvely medial, & risk of pneumothorax increases-‐ stay away! • Higher up the neck, the risk of brachial plexus or phrenic nerve injury increases-stay away!
- 16. Clavicle Jugular vein Carotid artery _,,___Sternal notch ASternocleidomastoid muscle
- 17. Who needs to see?!
- 18. Mechanical complicabons •Arterial cannulabon/ injury – Puncture: 6.3-‐ 9.4% (McGee & Gould, 2003) – Cannulabon: most recent work, incidence of 1%, but range from .07-‐1% (Bowdle) – Closed claims data not encouraging! • 5/14 died – Other risks include stroke & addibonal surgery, LOS
- 19. 5353 the right sideof the neck carefully using a portable ultrasound (US) machine (IMAGIC Agile, Kontron Medical, WA, USA) with a linear, high frequency transducer (7.5–12 MHz). Care was taken to apply minimal pressure on the probe to prevent collapse of the IJV. Imaging showed a single pulsatile vessel, which was non compressible suggestive of the carotid artery with right sided IJV has also been reported in a 12-year-old boy during US evaluation prior to attempted cannulation.[4] In another report, IJV agenesis was discovered during neck dissection. Patients who require removal of IJV due to disease infiltration may have potentially life-threatening complicationofcerebraledemaiftheotherIJVisaplastic.[5] Figure 1: Ultrasound image of the right side of the neck showing absence of internal jugular vein. CA: Carotid artery Figure 2: Ultrasound image of the left side of the neck showing normal anatomy. CA: Carotid artery; IJV: Internal jugular vein
- 20. Next step •Scan neck up & down above “standard” entry site to visualize course of vein & artery • Local anesthebc? • As early as possible
- 21. Next step • Center vein, enter at 30-‐45 degree angle about 1cm away from probe • Enter medial to guide line, aim slightly lateral • Ideally, follow needle bp “down” to vein • Watch screen, but aspirate as you advance
- 23. A word about sedabon.. • Less is more • With good LA, should not be painful
- 24. Next step •Enter vein using either “big” needle or some prefer 18G catheter; advantages to both – Catheter-‐ less prone to pop out of vein, but can be more difficult to advance – Needle-‐ good flow, easy to advance wire BUT must keep very sbll • Advance wire-‐ MUST THREAD EASILY • Need to check for venous placement
- 31. Placing the line • Triple lumen – Scalpel/dilator/line – Secure around 15cm • Introducer/Swan – Line is on dilator – Remember the dilator is rigid & pointy! – Line goes to hub • Both-‐ ensure wire is free as you advance line
- 33. Leu IJ lines • Increased risk, but beoer choice in some people -Shorter length to subclavian-‐ extra care with dilator, & may need to pull back introducer for Swan -Increased risk of lung injury • Risk of thoracic duct injury
- 34. More bad things about the leu • Vein crosses over artery more easily with turning head • Unfamiliarity
- 35. Subclavian lines •Small roll between shoulders-‐ improves access • Midpoint of clavicle, 2-‐3 cm back – Aim: to avoid poinbng needle down – Some clinicians bend needle for same effect • Point needle towards sternal notch – Some hold leu hand on notch to keep “target” • Advance needle with negabve pressure • unbl in vein
- 36. Subclavian bps •Must use needle-‐ catheter may kink • If unsuccessful, point needle more cephalad • Keep passes to minimum; avoid bilateral aoempts
- 37. More subclavian bps • If line is for thoracic surgery, on same side • If pt has pathology in one lung (e.g. pneumothorax), line on same side • Wire may not go where you want it – If pt is awake, ear/ neck pain may indicate wire in IJ – If pt is asleep, look for ectopy – Always X Ray
- 38. Subclavian & U/s • Not typically recommended • Can be useful to idenbfy normal anatomy prior to starbng procedure
- 39. No complicabons with u/s..? Accidental Carotid Artery Catheterization During Attempted Central Venous Catheter Placement: A Case Report Pauline Marie Maietta, CRNA, MS 2.1 million central venous catheters are hile carotid artery cannulation is stating. Anesthesia provid- ous catheters in perative sion of technique for central venous catheterization, indications for suspicion of arterial puncture, methods for confirming venous or arterial placement, appro- priate methods for management of carotid artery cannulation, and the benefit of ultrasound in centra venous cannulation follow. Through the appropria f equipment, early detection and manageme ry injury, and proper training, pat roved. tion, c (Maieoa, 2012)
- 40. U/s examined •Operator error could be an issue • We cannot see whole length of wire • Pressure transducbon could prevent arterial cannulabons not detected by other means-‐ approx 0.8% of all aoempted (Ezaru, 2009) – That’s potenbally 40,000 cases/yr!! • Should we use pressure measurement for all?
- 41. residents placing theCVC in each of the six cases were credentialed by their hospital in emergency ultrasound based on American College of Emergency Physicians ultrasound criteria. All residents received a 2-day introductory ultrasound course, which included 3 hours of didactic and hands-on education in ultrasound-guided vascular access. Table 3 summarizes each of the six cases, including as analysis of the error based on a video review of the ultrasound-guided arterial cannulation. Age Mechanism of injury Outcome 67 Needle went through IJ into Carotid artery Patient Died 75 Needle went though femoral vein into femoral artery Vascular surgery for AV fistula 48 Needle went though IJ and entered carotid artery sitting underneath the IJ Surgery for tear and focal dissection of carotid artery 67 Guidewire traveled through IJ and its posterior wall and into carotid artery Hematoma with respiratory distress requiring emergent intubation. 69 Needle penetrated the carotid artery which was very close to the IJ Emergency carotid artery repair; Patient died of complications 14 Needle penetrated rear wall of IJ and entered carotid artery Central line removed and bleeding eventually stopped Table 3: Analysis of six accidental arterial cannulations with dynamic ultrasound guidance The mechanism of injury in 5 of the 6 cases involved passage of the needle through the vein, out its posterior wall, and into the artery. This highlights the importance of confirming the location of the tip of the needle prior to inserting the guidewire. The author concluded, “In summary, the short-axis approach, as seen in this series, can provide a false sense of security to the practitioner and allows for potentially dangerous accidental arterial cannulation…it may be prudent to not only visualize the entire path of the needle with the long-axis approach but also confirm correct cannulation by tracing the guidewire in the long axis before line placement.” However, it is important to realize that even with multiple ultrasound views of needles or wires, misdiagnosis remains a possibility. For example, as noted in the case below (see Figure 6), it is possible for a needle and wire to pass through the internal jugular vein and into the Source: Bowdle, nd
- 42. Some general comments About complicabons • Site dependent • Provider dependent-‐ VOLUME OF PROCEDURES • Procedure dependent
- 43. Our study •Wanted to examine complicabon rates in CVCs placed by CRNAs vs MDs • Easy access to QI database • Problem – Polibcal – Numbers-‐ a vicbm of our own success
- 44. Major complicabons • Mechanical – Vessel or nerve injury – Pneumothorax/ hemothorax • Infecbous • Thrombobc
- 45. Mechanical complicabons •Vein injury – Vein is thin walled relabve to artery-‐ more prone to damage – Can be acute during line placement – Or later as result of erosion
- 46. What we found • Hematoma-‐ 1/359 (.003%) • Cannulabon-‐ 0
- 47. Pneumothorax • Incidence varies according to site (duh!) • Commonest with subclavian (1.5-‐3.1%) • Rare but seen with IJ (.2%)
- 48. What we found • 9/359 pts = 2.5% • Typical incidence = 0.1-‐0.2% • BUT rate of ptx in cardiac surgery = 0.7-‐5.3% (higher with IMA harvest) (Weissman, 2004)
- 49. hemothorax • Result of vessel injury, typically venous • Rare, but significant mortality (92% in Closed Claims) • Remember: veins are fragile
- 50. Thrombobc complicabons •Significant issue outside of the OR • Incidence cited varies e.g 1.9% of subclavian lines (McGee, 2003) • With thrombosis comes risk of embolizabon • Probably related to durabon
- 51. Thrombosis:more • Contact with vein wall is probably a big risk for thrombosis (Fletcher & Bodenham, 2000) • Therefore posiboning is key • Think post-‐op CXR
- 52. Infecbous complicabons: background • Interest in Healthcare Acquired Infecbons (HAI) has increased dramabcally-‐ in response to the problem • Priority of WHO, IOM, CDC, TJC, & a hospital near you.. • 1.7 million infecbons & 99,000 deaths in the US from HAI (TJC, 2012)
- 53. Infecbon: cvcs •CLABSI: Central Line-‐ Associated Blood Stream Infecbon • Est 80,000 CLABSI/ year in ICU alone • Mortality: difficult, but maybe 10,000 yr • Cost significant: >$16,000 per case
- 54. More specifics •Most risk = femoral line • Next, Internal Jugular-‐ ? Due to proximity to mouth • Least risk = subclavian
- 55. What we found • 2 infecbons (.006%) • Preliminary: no associabon with “difficult inserbon”, second line(31 pabents), diabetes or line durabon • ..but average line durabon 3.03 days
- 56. patient safety initiativescan be found in Chapter 4. Chapter 3 contains a comprehensive review of the recom- mended strategies and techniques for preventing CLABSIs. route has been associated with more prolonged CVC dwell time (for example, in place for more than 10 days), including tunneled CVCs such as Hickman- and Broviac-type catheters and PICCs. Figure 1-1. Routes for Central Venous Catheter Contamination with Microorganisms Potential sources of infection of a percutaneous intravascular device (IVD): the contiguous skin flora, contamination of the catheter hub and lumen, contamination of infusate, and hematogenous colonization of the IVD from distant, unrelated sites of infection. HCW: health care worker. Source: Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis. 2002 May 1;34(9):1232–1242. Used with permission. Source: TJC, 2012
- 58. What can we do? • Is the line really needed? – Minimum number of lumens • Hand hygiene • Asepbc technique o Maximal barrier technique o Right prep o Antibiotic impregnated line/dsg – • Ultrasound-‐ diminished # of aoempts
- 59. A word about scrub the hub! • Focus of TJC in recent years • Anesthesia compliance…sub-‐opbmal!! • 15 second scrub with alcohol • ..or the “orange cap”
- 60. Miscellaneous issues •Experience – Like surgical cases, experience counts – Sznajder et al (1986)-‐ Experience with > 50 CVCs = ½ rate of complicabon compared with < 50 CVCs – > 3 aoempts = 8 x mechanical complicabon rate • Quesbon: should everybody put in lines?
- 61. In closing •U/S may not be essenbal, but does offer benefits • Consider using manometry to check placement even with U/S • HAND HYGIENE!! (Scrub the hub too)
- 62. references • Aljure,O., Casbll-‐Pedraza, C., Mitzova-‐Vladinov, G., Maraeta, E. (2015). Right internal jugular cross-‐secbonal area: is there an opbmal area for cannulabon? Jnl of the Associa1on for Vascular Access 20(1): 22-‐25. • Bowdle, TA. Arterial cannula1on during central line placement: mechanisms of injury, preven1on & treatment. • Ezaru et al. (2009). Eliminabng arterial injury during central venous catheterizabon using manometry. Anesth Analg 109: 130-‐4. • Fletcher & Bodenham. (2000). Safe placement of central venous catheters: where should the bp lie? Brit Jnl Anaes 85: 188-‐91. • Hamilton & Bodenham (eds). (2009). Central venous catheters. Chichester: Wiley Blackwell. • Maieoa. (2012).Accidental carobd artery catheterizabon during aoempted central venous catheter placement: a case report.AANA Jnl 80(4): 251-‐ 255. • McGee & Gould. (2003). Prevenbng complicabons of central venus catheterizabon. NEJM 348: 1123-‐33 • Seo et al. (2008). Perforabon of the superior vena cava during liver transplantabon: a case report. Korean Jnl Anesth 55(4): 506-‐10 • Sznajder et al. (1986). Central vein catheterizabon: failure & complicabon rates by 3 percutaneous approaches. Arch Int Med 146: 259-‐61. • The Joint Commission. (2012). Preven1ng central-‐line associated bloodstream infec1ons: a global perspec1ve. OakBrook, Il: Joint Commission Resources