C.V.C 99 .pptx central venous access lecture

This lecture talking about central venous access I hope that it can help anyone

1. Central venous access Dr. Hanan Beshr

2. Definition Central venous line  (CVL): a vascular catheter that is inserted into a large central vein, e.g., subclavian , femoral, or internal jugular vein (IJV), usually under ultrasound guidance.

3. Properties of CVLs • Slower flow rates than peripheral venous catheters of the same diameter because they are longer • High flow rate can be achieved with large-gauge central venous catheters (e.g., dialysis catheters).

4. CVL insertion site : Anatomic location Internal jugular line (IJ line) Enters the neck via the left or right IJV Terminates at the SVC-RA junction Subclavian line Enters below the left or right clavicle via the  subclavian vein Terminates at the SVC-RA junction Femoral line Enters the femoral vein at the groin Terminates in the iliac vein or IVC

5. Internal jugular line   (IJ line) Advantages Disadvantages Good insertion landmarks Lower risk of pneumothorax than  subclavian line insertion Can compress bleeding vessels Uncomfortable for the patient Higher risk of infection than  subclavian line

6. Subclavian line Advantages Disadvantages Lowest infection rate Most comfortable for the patient Higher risk of pneumothorax than IJ line Cannot compress bleeding vessels  Ultrasound guidance is difficult.

7. Femoral line Advantages Disadvantages Easier access during ACLS Good insertion landmarks High risk of infection High risk of thrombosis

8. Special catheters  :

9. Indications Large-volume fluid resuscitation Anticipated long-term IV therapy  Poor peripheral IV access Administration of vesicants or irritant medications  Hemodynamic monitoring  Therapies requiring high-volume extracorporeal circulation    

10. Contraindications Absolute :  allergy to an antibiotic impregnated within the catheter  [1] Relative   [1] Infection or thrombosis at the site of insertion Superior vena cava syndrome (for subclavian and IJV venipuncture) Coagulopathy (especially for subclavian  venipuncture)   

11. Equipment checklist 1. Ultrasound machine 2. Sterile gown and gloves 3. Sterile full-body drape 4. Sterile ultrasound probe cover 5. Chlorhexidine skin preparation 6. 1% lidocaine without epinephrine 7. 25-gauge needle and syringe

12. 8. Thin-wall introducer needle (TWN) and syringe 9. 5 mL syringe 10. Guidewire 11. Scalpel 12. Vascular dilator 13. Central venous catheter 14. Nonabsorbable suture 15. Sterile dressing

13. Preparation   Ready the ultrasound machine.  Apply cardiac monitors to the patient. Place the patient in the  Trendelenburg position. Perform a preprocedure  ultrasound examination.  Perform skin preparation to create a sterile field. Apply a sterile full-body drape. Prepare the sterile ultrasound transducer cover. Administer single-point local anesthesia for conscious patients .

14. Procedure/application T he  Seldinger technique: 1.Center the probe above the IJV.  2.Place the needle beneath the center of the probe at a 45° angle to the skin. 3.Apply negative pressure to the syringe plunger and advance the needle until blood flashback occurs.  4.Hold the needle firmly and remove the syringe. 5.Feed 15–20 cm of wire through the needle.  

15. 6. Remove the needle while holding the wire in place. 7.Make a small skin incision over the wire. 8.Advance the vascular dilator 5–7 cm into the vein. 9.Remove the dilator and advance the catheter ∼ 16cm (right IJV) or ∼ 20 cm (left IJV) over the wire.  10.Remove the wire, aspirate blood from all ports, and flush each port with saline. 11.Secure the catheter to the skin and apply a sterile dressing.

16. Postprocedure checklist 1. Wire removed and inspected 2. All ports aspirated and flushed 3. Sterile dressing applied 4. CXR obtained 5. Correct catheter location confirmed 6. Pneumothorax ruled out 7. Procedure documented 8. Postprocedural CLABSI prevention measures ordered

17. Complications Complications of indwelling catheters Infection, e.g., CLABSI Thrombosis Complications of CVC insertion Arrhythmia Arterial injury Venous air embolism Pneumothorax Hemothorax Guidewire embolism Incorrect catheter placement