Tunnel provides stability and protects against endovascular infection. Dacron cuff allows fibrous ingrowth around 6 weeks Vita cuff - oftern silver impregnated to retard infection, dissolves after 6 weeks
Central venous lines and their problems
CENTRALVENOUS LINESAND THEIRPROBLEMSBySunil Agrawal1styr ResidentPediatrics, IOM
CONTENT Introduction Indications and Contraindications Access to Different Great Vessels Complications Summary References
INTRODUCTION Central venous access is defined as placement ofa catheter such that the catheter is inserted intoa venous great vessel. The venous great vessels include the superiorvena cava, inferior vena cava, brachiocephalicveins, internal jugular veins, subclavian veins,iliac veins, and common femoral veins.2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.Anesthesiology 2012; 116:539–73
INDICATION FOR USE Limited vascular access Administration of highly osmotic or caustic fluidsor medications Frequent administration of blood and bloodproducts Frequent blood sampling Measurement of CVP Hemodialysis Hemofiltration Apheresis
CONTRAINDICATIONS Distorted Anatomy Infection at the Site of Access Proximal Vascular Injury Bleeding Disorders or Anticoagulation Combative Patients
STERILE TECHNIQUE We will not review sterile technique in depth here For the physician, sterile technique means wearing asurgical cap, procedure mask, sterile gown and sterilegloves. Sterile setup for the patient should begin withadequate skin preparation with a sterilizing solution(proviodine, chlorhexidine, etc.) in a large areasurrounding your procedure site. Place a large sterile sheet on the patient following thisand then isolate the procedural field with four to sixsterile towels. This will minimize infective complications of theprocedure.
SELDINGER TECHNIQUE1. Setup of Equipment and Sterile Preparation2. Landmarking the Access Site3. Anesthesia4. Location of the Vein with a Seeker Needle [Optional]5. Placing the Introducer Needle in the Vein6. Assessment for Venous or Arterial Placement7. Insertion of the Guide Wire8. Removal of the Introducer Needle9. Skin Incision10. Insertion of the Dilator11. Placement of the Catheter12. Removal of the Guide Wire13. Flushing and Capping of the Lumens14. Secure the Catheter
ACCESS TO DIFFERENT GREATVESSELS Internal jugular vein Subclavian vein Femoral vein Umbilical vein
INTERNAL JUGULAR VEIN The right internal jugular vein (IJV) is the mostcommon site chosen for central venous access inpediatric cardiac surgery. It is large, and runs in close proximity superficialto the carotid artery along most of its length. The primary advantage of using the IJV is that itprovides a direct route to RA.
The primary disadvantage comes from difficultyin cannulation in small infants, who have largeheads and short necks, and thus difficulty inobtaining the shallow angle of approachnecessary to access the vessel. This site is also not comfortable for some awakeinfants
TECHNIQUE Placing a small roll under the shoulders, usingsteep Trendelenburg position, and rotating thehead no more than 45◦ to the left. Recent studies have demonstrated that livercompression and simulated Valsalva maneuveralso increase the diameter of the IJV, possiblyincreasing the success rate of cannulation. An ultrasound technique should be used toclearly identify the course of the vessel
SUBCLAVIAN VEIN The subclavian vein is positioned immediatelybehind the medial third of the clavicle. Advantages of this route include the subclavianvein’s relatively constant position in all ages inreference to surface landmarks and the site iscomfortable for awake patient. Disadvantages include an incidence ofpneumothorax is high. Also in 5–20% of patient,subclavian catheters will enter the contralateralbrachiocephalic vein or ipsilateral IJV, instead ofthe SVC
TECHNIQUE Small rolled towel is positioned vertically betweenthe scapulae, steep Trendelenburg position used, andthe arms are restrained in neutral position at thepatient’s sides. The right subclavian vein should always be the firstchoice. Turn the head toward the side being punctured. The puncture site that is most successful is 1–2 cmlateral to the midpoint of the clavicle, directly lateralfrom the sternal notch, with the needle directed atthe sternal notch. Advancing the needle only during expiration isrecommended to minimize the risk of pneumothorax.
Complications during subclavian catheterizationoccur when a needle angle of incidence is toocephalad, resulting in arterial puncture, or tooposterior, resulting in pneumothorax. Advancing the needle too far in infants mayresult in puncture of the trachea.
FEMORAL VEIN The femoral vein has long been used for centralvenous catheterization in pediatric patients, withno greater infection or other complication ratecompared to other sites.
TECHNIQUE the patient is positioned with a rolled towelunder the hips for moderate extension. The puncture site should be 1–2 cm inferior tothe inguinal ligament, and 0.5–1 cm medial tothe femoral artery impulse, with the needledirected at the umbilicus.
UMBILICAL VEIN The umbilical vein in the fetus is a conduit to carryoxygenated and detoxified blood from the placenta, throughthe abdominal wall, the liver, and patent ductus venosus tothe inferior vena cava (IVC) and the right atrium (RA). This vessel can usually be cannulated at the umbilicalstump for the first 3–5 days of postnatal life. Passage into the IVC depends on the patency of the ductusvenosus, which often exists for the first few days. Sterile technique without a guidewire is used to pass thecatheter blindly a premeasured distance. If no resistance topassage is met and free blood return is achieved, thecatheter tip is usually in the high IVC or RA, and functionsas a CVC.
Catheter tip position must be determined byradiography as soon as possible to determine if it isthrough the ductus venosus into the IVC or the RA.Often the ductus venosus is not patent, and thecatheter tip passes into branches of the hepatic veins,and is visible in the liver radiographically. A UVC can be left in place for as long as 14 days if nocomplications are suspected.
INFECTION TREATMENT1. Septic thrombophlebitis - remove catheter2. Cutaneous - local treatment3. Bacteremia -1. IV antibiotics 48 -72 hoursif improved - keep catheterif no change, worse or recursremove catheteror2. Exchange catheter over wire,85% cure with treatment
INFECTION: THE USE OFANTIMICROBIAL-IMPREGNATEDCATHETERSMaki, D. G. et. al. Ann Intern Med 1997;127:257-266
INFECTION: THE USE OFANTIMICROBIAL-IMPREGNATEDCATHETERS Use of these catheters decreases blood streaminfection:4.6% regular catheter1.0% antibiotic impregnated catheters Chlorhexidine-Silver sulfadiazine and Minocycline-Rifampin impregnated catheters The Use of antibiotic impregnated catheters shouldbe considered at all circumstances! The emergence of resistance is certainly of concern.N ENGL J MED 348; 12, 2003
INFECTION: INSERTION OFCATHETERS AT THESUBCLAVIAN VENOUS SITE The risk of catheter-related infection is lower withsubclavian catheterization than with internal jugularor femoral catheterization
INFECTION: AVOIDING THE USEOF ANTIBIOTIC OINTMENTS The Use of ointments such as bacitracin,mupirocin, neomycin, and polymyxin to catheterinsertion sites show: Increase the rate of colonization by fungi Promote bacterial resistance Has not shown to affect the risk of catheter relatedbloodstream infection.N ENGL J MED 348; 12, 2003
INFECTION: ROUTINECATHETER CHANGES? Scheduled, routine replacement of centralvenous catheters at a new site does notreduce the risk of catheter related infection. Scheduled, routine exchange of cathetresover guide wire is associated with a trendtoward increased catheter related infectionsand mechanical complications. META analysis of 12-RCTs do not support. CVC should not be replaced on ascheduled basis.N ENGL J MED 348; 12, 2003
INFECTION: REMOVE WHEN NOLONGER NEEDED. Theprobabilityofcolonization andcatheter-relatedbloodstreaminfectionincreasesover time.Collin, G. R. Chest 1999;115:1632-1640Antiseptic ImpregnatedcatheterNON-AntisepticImpregnated catheter
THROMBOSIS Intermittently used catheters need to be replacedfrequently due to obstruction and/or infection. Clot formation is a major source of obstruction
THROMBOTIC: INSERTION OF THECATHETER AT THE SUBCLAVIANSITE Subclavian catheterization carries a lower risk ofcatheter related thrombosis than femoral or internaljugular catheterization.N ENGL J MED 348; 12, 2003
KEEPING CENTRAL VENOUSLINES OPEN The use of anti-obstructive flushes such as heparin,citrate and Vitamin C (Germans), have associatedcomplications: Bleeding, Thrombocytopenia-heparin induced Arrhythmia (citrate)Intensive Care Med. 2002; 28:1172-6
KEEPING CENTRAL VENOUS LINES OPEN: APROSPECTIVE COMPARISON OF HEPARIN,VIT. C, AND NACL BLOCKS Signif. longer patency withheparin(5000IU/ml) Vitamin C ineffective Group of 25 low doseheparin flushes(200IU/ml)flushes showed cathetersurvival closer to salinegroup. So, high concentration ofheparin flushesrecommended.Intensive Care Med. 2002; 28:1172-6
SUMMARY Central venous access is defined as placement ofa catheter such that the catheter is inserted intoa venous great vessel. Three sites are commonly used for pediatric CVCplacement: femoral, internal jugular, andsubclavian. Should be done under sterile condition tominimize infection related complication . Seldinger Technique is used for insertion ofCVC.
SUMMARY. Use antimicrobial-impregnated catheters Avoid antibiotic ointments Do not schedule routine catheter changes Remove catheter when no longer needed