Notify physician immediately if any of these signs or symptoms are present.

1. By Dr AVIJIT KUMAR PRUSTY,
DEPT OF ANAESTHESIOLOGY AND CRITICAL CARE,
SCB MEDICAL COLLEGE,CTC
GUIDE-ASSO PROF DR BASANT K PRADHAN

2.  CVP is the pressure measured at the junction of
the superior venae cavae and the right atrium.
 It reflects the driving force for filling of the
right atrium & ventricle.

3.  Normal CVP in an awake , spontaneously
breathing patient - 1-7 mmHg or
5-10 cm H2O.
 Mechanical ventilation- 3-5 cm H2O higher.

4. 1863 •Chauveau & Mary ( Paris ).
•Developed a special double lumen catheter.
•Systemic study, description & interpretation of intracardiac
pressure recordings in horse.
1876 • Claude Bernard ( France ).
• First cardiac catheterisation.
1949 •Duffy.
•Introduced a catheter into the IVC through femoral vein.

5. 1952 •Aubaniac.
•Subclavian vein cannulation.
1953 •Seldinger.
•CVP Catheter replacement method
using guidewire.
1969 •English et al.
•IJV cannulation.

6. 1. Indirect assessment-
 Inspection of jugular venous pulsations in
neck.
2. Direct assessment-
 Fluid filled manometer connected to central
venous catheter.
 Caliberated transducer.

7. 1. Inspection of jugular venous pulsations in neck.
 WHY IJV=No valves b/w rt. atrium & IJV.
 Degree of distention & venous wave form –can give
information about rt atrial cardiac function.

10.  Jugular veins may be impossible to identify in up
to 20% of patients, and the bedside diagnosis of
low, normal, or high CVP is often inaccurate,
particularly in critically ill patients.
 This problem is compounded in the perioperative
period
 As a result, direct measurement of CVP is
frequently necessary in hemodynamically
unstable patients and those undergoing major
operations

11. 1. Fluid filled manometer connected to central
venous catheter- measured using a column of
water in a marked manometer.
 CVP is the height of the column in cms of H2O
when the column is at the level of right atrium.
 Advantage- simplicity to measure.
 Disadvantage- Inability to analyze the CVP
waveform.
-Relatively slow response of the
water column to changes in intrathoracic
pressure.

14.  transducer system: enables continuous readings
which are displayed on a monitor.

15.  Transducers enable the pressure readings from
invasive monitoring to be displayed on a
monitor
 To maintain patency of the cannula a bag of
normal saline or heparinised saline should be
connected to the transducer tubing and kept
under continuous pressure of 300mmHg thus
facilitating a continuous flush of 3mls/hr or it
can be flushed intermittently manually.

18.  The CVP waveform reflects changes in right
atrial pressure during the cardiac cycle

19.  The CVP waveform consists of five phasic
events, three peaks (a, c, v) and two descents
(x, y)
TYPE OF WAVE CAUSE CARDIAC CYCLE
a wave Atrial contraction DIASTOLE
c wave Bulging of tricuspid valve
into RA during IVC
SYSTOLE
X descent Atrial relaxation SYSTOLE
V wave Filling of RA L/T rise in
pressure
SYSTOLE
Y descent Opening of Tricuspid
valve
DIASTOLE

21.  Atrial fibrillation
obliterates the a wave,
increases the c wave
and preserves the v
wave and y descent.
This arrhythmia also
causes variation in the
electrocardiographic
(ECG) R-R interval
and left ventricular
stroke volume, which
can be seen in the
ECG and arterial
(ART) pressure traces

22.  Isorhythmic
atrioventricular
dissociation. In
contrast to the normal
end-diastolic a wave
in the CVP trace (left
panel), an early
systolic cannon wave
is inscribed (*, right
panel). Reduced
ventricular filling
accompanying this
arrhythmia causes a
decreased arterial
blood pressure.

23. TRICUSPID
REGURGITATION
INCREASES CVP AND
THE WAVEFORM
DISPLAYS A TALL
SYSTOLIC C-V WAVE
THAT OBLITERATES
THE X DESCENT
TRICUSPID STENOSIS ALSO
INCREASES MEAN CVP, BUT
THE CHARACTERISTIC
VENOUS WAVEFORM IS
DIFFERENT FROM THE ONE
SEEN IN TRICUSPID
REGURGITATION. THE
DIASTOLIC Y DESCENT IS
ATTENUATED AND THE END-
DIASTOLIC A WAVE IS
PROMINENT.

24. DURING POSITIVE PRESSURE
VENTILATION, ONSET OF
INSPIRATION (ARROWS)
CAUSES AN INCREASE IN
INTRATHORACIC PRESSURE.
CVP IS STILL RECORDED AT
END-EXPIRATION (MEAN CVP
8 MMHG).
DURING SPONTANEOUS
VENTILATION, ONSET OF
INSPIRATION (ARROWS) CAUSES A
REDUCTION IN INTRATHORACIC
PRESSURE, WHICH IS TRANSMITTED
TO BOTH THE CVP AND THE
PULMONARY ARTERY PRESSURE
(PAP) WAVEFORMS. CVP SHOULD
BE RECORDED AT END-EXPIRATION
(MEAN CVP 14 MMHG).

25. It is a catheter
that provides
venous access via
the superior vena
cava or right
atrium

26.  The tip of the CVC usually rests
in the Cavo-Atrial Junction
(CAJ).
 Femorally inserted CVCs have
the tip lying in the Inferior Vena
Cava approximately at the level
of the diaphragm.

35.  In patients with severe bleeding diatheses, it is
best to choose a puncture site at which
bleeding from the vein or adjacent artery is
easily detected and controlled with local
compression. In such a patient, an internal
or external jugular approach would be
preferable to a subclavian site.
 Likewise, patients with severe emphysema
or others who would be severely
compromised by pneumothorax would be
better candidates for internal jugular than
subclavian cannulation because of the higher
risk with the latter approach.

36.  If transvenous cardiac pacing is required in an
emergency situation, catheterization of the
right internal jugular vein is recommended
because it provides the most direct route to
the right ventricle.
 Trauma patients with their necks
immobilized in a hard cervical collar are
best resuscitated via a femoral or subclavian
approach; the latter may be used even more
safely if the risk of pneumothorax is obviated
by prior placement of a thoracostomy tube.

37.  Seldinger technique
 Use introducing needle to locate vein
 Wire is threaded through the needle
 Needle is removed
 Skin and vessel are dilated
 Catheter is placed over the wire
 Wire is removed
 Catheter is secured in place

41. Location Advantage Disadvantage
Internal
Jugular
• Bleeding can be recognized
and controlled
• Malposition is rare
• Less risk of pneumothorax
• Risk of carotid artery puncture
Femoral • Easy to find vein
• No risk of pneumothorax
• Preferred site for
emergencies and CPR
• Fewer bad complications
• Highest risk of infection
• Risk of DVT
• Not good for ambulatory
patients
Subclavian • Most comfortable for
conscious patients
• Highest risk of PTX, should not
do on intubated pts
• Should not be done if < 2 years
• Vein is non-compressible

52.  After surgery, however, the position of the
catheter tip must be confirmed radiographically.
 Catheter tips located within the heart or below the
pericardial reflection of the superior vena cava
increase the risk for cardiac perforation and
fatal cardiac tamponade.
 Ideally, the catheter tip should lie within the
superior vena cava, parallel to the vessel walls, and
be positioned below the inferior border of the
clavicles and abovethe level of the third rib, the T4
to T5 interspace, the azygos vein, the tracheal
carina, or the takeoff of the right mainstem

54.  The internal jugular vein (IJV) is most
frequently chosen site for CVC insertion.
 Many approaches have been described
depending on the level of the neck at which
the vein is punctured.
 A high approach reduces the risk of
pneumothorax but increases the risk on
arterial puncture. For lower approaches the
converse is true.
 With experience this route has a low
incidence of complications

55.  Positioning
 Right side preferred
 Trendelenburg position
 Head turned slightly away
from side of venipuncture.

56.  Positioning
Right side preferred
Supine position, head neutral,
arm adducted
Trendelenburg (10-15 degrees)

57.  Positioning
 Supine
 Needle placement
 Medial to femoral artery
 Needle held at 45 degree angle
 Skin insertion 2 cm below inguinal
ligament
 Aim toward umbilicus

58. Femoral artery
Femoral nerve
Femoral Vein
NAVEL

60.  PICC
– Peripherally Inserted Central IV Catheter
 Usually inserted in the upper arm
 Catheter tip is in the distal superior vena cava
like all other central lines

67.  Hickman, Broviac, and Leonard Catheters –
Open-ended, tunneled central lines
 Hickman catheters can be 1, 2, or 3 lumen
 The lumens may all be identically sized, or
 The lumens may be of different sizes
 Broviac catheters are all single lumen catheters
 Leonard catheters have 2 lumens of identical size

69. • Implanted subcutaneously instead of patient having a port outside of body
 Mediport and Portacaths are the most common
 No dressing is required
 Accessed by a Huber needle
 Flushed with Heparin
 More expensive

72.  A portacath or "port" is comprised of two
components, a self-sealing injection port and a
catheter that enters the vein. The port and
catheter are placed entirely under the skin
using a small incision.

73.  There will be a bump on
the chest wall where the
injection port is located.
This is the site where the
access Huber needle is
placed.
 Once port is deaccessed,
it needs a MONTHLY
flush with 5ml of heparin
(100 units/ml) to keep it
patent.

74.  The Power Port
 Designed for power
injections
 Withstands injections of
5ml/sec @ 300 psi
 The unique triangular
shape
 Requires Heparin flush

76.  THIS IS AN ASEPTIC PROCEDURE
 THE PATIENT SHOULD BE SUPINE WITH HEAD TILTED
DOWN
 ENSURE NO DRUGS ARE ATTACHED AND RUNNING
VIA THE CENTRAL LINE
 REMOVE DRESSING
 CUT THE STITCHES
 SLOWLY REMOVE THE CATHETER
 IF THERE IS RESISTENCE THEN CALL FOR ASSISTANCE
 APPLY DIGITAL PRESSURE WITH GAUZE UNTIL
BLEEDING STOPS
 DRESS WITH GAUZE AND CLEAR DRESSING EG
TEGADERM

77. 1.Acute Procedural
2. Sub-acute Infection
3. Chronic
Infection,Catheterfragmentation,Non-function

78. 1. Spasm 4. Pneumothorax
2. Access failure 5. Malposition
3. Arterial puncture 6. Air embolus
7.hemothorax,chylothorax

80. 1. Respiratory distress
2. Increased heart rate
3. pulse
5. Cyanosis
4. Dip in the level of consciousness

81. 1. Left lateral decubitus (Durant’s)
Position
2 100% O2
3. Vasopressin if necessary
4. Chest compression
5. Aspiration through catheter +/-
Mortality decreases from 90% 30%
with conventional treatment

82. 1. Infection
2. Catheter fragmentation
3. Non-function

83.  Dysrhythmias
 Catheter malplacement
 Catheter rupture
 Embolus
 Cardiac tamponade
 Catheter related infection
 Thrombosis
 Hydrothorax

88. 1. Hand hygiene
2. Maximal sterile barriers
3. Chlorhexidine for skin asepsis
4. Avoid femoral lines
5. Avoid/remove unnecessary lines

89.  Cornerstone of any
infection prevention
program
 Many studies have
shown that
improvement in hand
hygiene significantly
decreases a variety of
infectious
complications

90.  Use of waterless
alcohol-base hand rub
 Most effective and
efficient method for
hand antisepsis
against bacterial
pathogens
 When hands are visibly
soiled, they should be
washed with soap and
water

91. Good Better Best
Plain Soap Antimicrobial
soap
Alcohol-based
handrub

92.  One study found a 6-fold
higher rate of catheter-
related septicemia when
minimal sterile barriers
(sterile gloves and small
drape) were used instead
of maximal sterile
barriers
Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous
catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.

93.  Studies have compared chlorhexidine
gluconate (CHG) versus povidone iodine as
a skin antiseptic for catheter insertion and
routine insertion site care
 Recent meta-analysis, the use of CHG rather
than povidone iodine was found to reduce
the risk of CLA-BSIs by approximately 50% in
hospitalized patients who required short
term catheterization
Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine
compared with povidone-iodine solution for vascular catheter-site care: a
meta-analysis. Ann Intern Med. 2002;136:792–801.

94. 1. Cutaneous - pain, erythema, swelling,
+/- exudate
2. Bacteremia - fever, leukocytosis and
positive blood cultures
3. Septic thrombophlebitis - bacteremia,
thrombosis and purulent discharge

95. Staph epidermidis 25-50%
Staph aureus 25%
Candida 5-10%

96. Septic thrombophlebitis - remove catheter
Cutaneous - local treatment
Bacteremia -
1. IV antibiotics 48 -72 hours
if improved - keep catheter
if no change, worse or recurs
remove catheter
or
2. Exchange catheter over wire,
85% cure with treatment

97. Continue to treat infection for 10 - 14 days
If ineffective - try locking with thrombolytics
between antibiotic doses and administer
antibiotics through catheters

98.  Proper handwashing and principles of
sterile technique
 Flushing and cap change procedure and
frequency
 Observation of cath and insertion site

99.  Temp of 100.5F or greater
 Chills, dyspnea, dizziness
 Pain, redness, swelling, or drainage
at site
 Unresolved resistance, pain or fluid
leaking while flushing
 Excessive bleeding at site
 Change in length of external cath
 Swelling in neck, face, chest, or arm