Central venous catheterization

CV line

1. Welcome to weekly Scientific Seminar Venue: Casualty block 1 Dhaka Medical College Hospital

2. Central Venous Catheterization & Venous cut down Technique Presented by Dr. Mominul Haider Resident (Phase A) Department of Urology BSMMU

3. Central Venous Catheterization

4. Introduction Central venous access refers to lines placed into the large veins of the neck, chest, or groin and is a frequently performed invasive procedure which carries a significant risk of morbidity and even mortality.

5. This procedure should be carried out in operating theatre or high-dependency care areas, always using a fully aseptic technique.

6. Indications Monitoring of central venous pressure in critically ill patient and after major surgery Infusion of irritant drugs that may damage smaller veins. Insertion of pacing wires. Renal replacement therapy. Emergency venous access. Parenteral feeding. Resuscitation of patients who are intravascularly depleted.

7. Relative Contraindications Uncorrected coagulopathy Thrombocytopenia Skin infection over the site of access Obscure anatomical landmarks Haemo or pneumothorax on the contralateral side Recent surgery to other structures nearby such as carotidendartectomy

8. Sites Right Subclavian Vein Internal Jugular vein Femoral Vein

9. Site Advantage Disadvantage Subclavian Lower risk of infection Does not require movement of patient’s head and can be accessed during c-spine immobilisation Useful in emergencies Vein does not collapse fully in hypovolaemic states Highest chance of pneumothorax Puncture of tracheostomy or ET tube cuff Cannot apply pressure to stop bleeding Can be painful even with good skin anaesthesia Less easy to visualise with USG

10. Site Advantaqge Disadvantage Internal jugular Anatomy readily visible with ultrasound Can be adapted to accommodate patient size and position Easily accessed surface of patient Puncture of internal carotid or misplaced line in the internal carotid Pneumothorax is a recognised complication Difficult to nurse long term.

11. Site Advantaqge Disadvantage Femoral Safest vein to place large lines, for example for veno–veno haemofiltration because there are fewer important structures nearby. Puncture of femoral artery can usually be treated with pressure Femoral artery puncture leading to retroperitoneal bleed Femoral nerve damage Difficult to nurse and keep clean Highest likelihood of infection

12. . Central line kit containing: Additional items: • needle or a cannula over needle • central venous catheter • guidewire • dilator • anchoring clips. • suture • scalpel • appropriate dressing • syringes • blue and green needles • three-way taps, one for each lumen • drapes • cleaning fluid (2% chlorhexidine gluconate in 70% isopropyl alcohol is recommended) • swabs • Gallipot or similar • sterile ultrasound probe sheath • 0.9% normal saline Equipments needed

13. Basic Principles Must Decide if the line is really necessary Should know the anatomy Should be familiar with the equipments Must obtain optimal patient positioning and cooperation Should not try to do it fast Must use sterile technique Always have a hand on the guide wire Should ask for help Always aspirate as you advance as you withdraw the needle slowly Always withdraw the needle to the level of the skin before redirecting the angle Obtain chest x-ray post line placement and review it

14. Subclavian Approach Positioning Right side preferred Supine position, head neutral, arm abducted Trendelenburg (10-15 degrees) Shoulders neutral with mild retraction Right side preferred Needle placement Junction of middle and medial thirds of clavicle At the small tubercle in the medial deltopectoral groove Needle should be parallel to skin Aim towards the supraclavicular notch and just under the clavicle

15. Internal Jugular Approach Positioning Right side preferred Trendelenburg position Head turned slightly away from side of venipuncture Needle placement: Central approach the triangle formed by the clavicle and the sternal and clavicular heads of the SCM muscle is located three fingers of left hand are gently palced on carotid artery Needle should be placed at 30 to 40 degrees to the skin, lateral to the carotid artery Aim toward the ipsilateral nipple under the medial border of the lateral head of the SCM muscle Vein should be 1-1.5 cm deep, deep probing in the neck should be avoided.

17. Internal Jugular Central Approach

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

19. Femoral artery Femoral nerve Femoral Vein

20. Post-Catheter Placement Aspirate blood from each port Flush with saline or sterile water Secure catheter with sutures Cover with sterile dressing (tega-derm) Obtain chest x-ray for IJ and SC lines Write a procedure note

21. Procedure Note Name of procedure Indication for procedure Comment on consent, if applicable Describe what you did, including prep Comment on aspiration/flushing of ports How did patient tolerate procedure Any complications

22. Maintenance of CV line Hepsol flush 8 hourly Central Short channel is used for measuring CVP Rest two channels are used for medication and TPN The dressing should be changed at regular interval Catheter should not be kept for more tha 3 weeks

23. Ultrasound-Guided Central Venous Access Becoming standard of care Vein is compressible Vein is not always larger Vein is accessed under direct visualization Helpful in patients with difficult anatomy                                                                                   

24.                                                                                                                                                                      Needle entering IJ

25.                                                                                    Femoral Vein Femoral Artery Compression of vein with US probe

26. Complications Vascular Air embolus Arterial puncture Arteriovenous fistula Hematoma Blood clot Infectious Sepsis, cellulitis, osteomyelitis, septic arthritis Miscellaneous Dysrhythmias Catheter knotting or malposition Nerve injury Pneumothorax, hemothorax, hydrothorax, hemomediastinum

27. Venous cut down

28. Venous cutdown is a surgical technique by which a selected vein is exposed and mobilised and then cannulated under direct vision. It has been largely replaced by central venous and intraosseous access, but remains a useful alternative when other methods fail or are not available.

29. Cutdown sites Basilic vein (antecubital fossa) Adult: 2–3 cm lateral to the medial epicondyle of the humerus. Child: 1–2 cm lateral to the medial epicondyle of the humerus.

30. Cutdown sites Long saphenous vein (groin) Adult: 4 cm inferior and lateral to the pubic tubercle. Long saphenous vein (ankle) Adult: 2 cm anterior and superior to the medial malleolus. Child: 1 cm anterior and superior to the medial malleolus.

31. Step-by-step cutdown method Place a venous tourniquet proximal to intended cutdown site where possible. Identify cutdown site and inject local anaesthetic along the intended incision line if the patient is conscious. Make a transverse incision through skin being careful not to damage the underlying vein Spread the skin and identify the vein lying at right angles to the line of the incision.

32. Mobilise a 2-cm length of vein by blunt dissection using curved forceps Pull a loop of suture (e.g. 2/0 vicryl) under vein. Cut the loop to form proximal and distal sutures.

33. Tie off distal suture and transfix vein with a needle Make a vertical stab incision down onto the transfixing needle to produce a hole (venotomy) in the anterior vein wall Insert a cannula or the cut end of a sterile giving set through venotomy into vein Tie off proximal suture around vein and inserted cannula. Suture and dress wound.

34. Complications of venous cutdown Damage to adjacent structures Posterior wall perforation Haematoma Extravasation of fluid or drugs Local cellulites Phlebitis Venous thrombosis Scarring

35. Thank you