Invasive procedures

Iv access is mandatory in anesthesia

1. Invasive Procedures
Venous Cannulation
Dr. Samir A al Kafrawy
MD Anaesthesia & Pain Relief.

2. Overview
•Peripheral Venous Cannulation
•Central Lines
•Blood Gases/Arterial Lines
•Interosseous Infusion

3. Peripheral Cannulation

4. Conditions that affect the position Conditions that affect the position
of the cannula: of the cannula:
•Amputation
•Stroke
•Mastectomy or other Breast / Lymph Surgery
•Renal Fistula
•Lymphoedema or Cellulitsis
•Diabetes / Vascular Disease / Arthritis
•Trauma / Fractures / Burns
•Social History

5. Questions to ask the patientQuestions to ask the patient
•OBTAIN CONSENT
•Have you had a cannula / blood test before?
•Were there any complications / adverse
reactions?
•Do you have any allergies?
•Consider needle phobia
•Would you like a local topical anaesthetic before
I insert the cannula or take blood?
•Which is your dominant arm?

6. Attributes of an ideal vein are: Attributes of an ideal vein are:
•Be engorged, bouncy & soft
•Refill after it has been depressed
•Be visible
•Feel round
•Be well supported by surrounding structures
•Be straight & ‘free of valves’

7. Veins to be avoided: Veins to be avoided:
•Thrombosed, fibrosed or sclerosed
•Inflamed or bruised or painful
•Thin or fragile
•Mobile
•Near bony prominences and joints
•Near sites of infection or oedema
•AVOID THE VALVES
•For venesection avoid the arm with an IV line
running

8. Methods for improving venous Methods for improving venous
access:access:
•Apply a disposable tourniquet
•Lower the level of the arm below the heart
•Ask the patient to open and close their fist
•Light tapping / rubbing of the veins
•Warm compresses over the selected vein
•Warm water
•Relax the patient / consider the environment

10. Antecubital FossaAntecubital Fossa
Brachial Artery
Ulnar Artery
Radial
Artery
Basillic
Cephalic
Median
Cubital
Vein
Veins Arteries Nerves
Radial
1st Intercostal
Ulnar
Median

11. BASILLIC
VEIN
DORSAL
VENOUS
NETWORK
CEPHALIC
VEIN
DORSAL
METACARPAL
VEINS
DIGITAL
DORSAL
VEIN

12. CANNULA
SELECTION

13. Selecting the right cannulaSelecting the right cannula
Two key points to consider:
•What is the cannula going to be used for?
•The condition, location and size of the vein
selected?
You should try to select the smallest gauge
possible that will accommodate the
intravenous therapy that is prescribed.

14. ColourColourSizeSizeFlowFlow
Ml/minMl/min
UsesUses
BrownBrown1414 275275
Rapid transfusions of whole Rapid transfusions of whole
blood. Emergency situations.blood. Emergency situations.
GreyGrey 1616 173173
Rapid transfusions of whole Rapid transfusions of whole
blood. Emergency situationsblood. Emergency situations
GreenGreen1818 100100
Blood transfusionsBlood transfusions
PinkPink 2020 6060
IV infusions. Bolus’IV infusions. Bolus’
BlueBlue 2222 2525
Bolus’. Maintenance infusionsBolus’. Maintenance infusions
YellowYellow2424 1313
Bolus medications. Short term Bolus medications. Short term
infusions. Neonatesinfusions. Neonates
PurplePurple2626
NeonatesNeonates

15. Patients ConditionPatients Condition Cannula SizeCannula Size
All obstetric patientsAll obstetric patients GreyGrey
Active gastrointestinalActive gastrointestinal
(GI bleed)(GI bleed)
BrownBrown oror GreyGrey
At risk of GI bleedAt risk of GI bleed GreyGrey
At risk of epileptic fitAt risk of epileptic fit GreenGreen
At risk of cardiac eventAt risk of cardiac event GreenGreen
At risk of neurological eventAt risk of neurological event GreenGreen

16. Central Lines
•Types
•Indications
•Contraindications
•Equipment
•Techniques
–Subclavian
–Internal Jugular
–Femoral

17. TYPES OF
CENTRAL VENOUS ACCESS
1. Non tunneled external catheters
a. Central line
b. PICC line
2. Tunneled catheters
3. Subcutaneous Ports
a. chest
b. arm

18. Types of Central Lines
•CVL
–Single Lumen
•16 Gauge
•Useful for A-line only
–Double Lumen
(Dialysis Catheters)
–Triple Lumen
•7 Fr
•Multiple Medications

19. CHOOSING THE ACCESS DEVICE
Patients disease and status
Number and type of solutions, osmolality
Flow required
Frequency accessed
Duration of use- days vs months
Preferences - Dr. / Patient

20. NUMBER AND
COMPATIBILITY OF
INFUSATES
Determine true number of lumens that are
required based on the number of infusates
when they are given and if they are
compatible

21. FLOW
Internal Diameter (ID)
vs
Outer Diameter (OD)
The outer diameter is not always directly proportional to
flow. Some catheters are just thick walled and although
large yield slow flow. For high flow - check the ID.
Remember, larger catheters cause more irritation
potentiating stenosis and thrombosis.

22. FREQUENCY
OF
ACCESS
Frequent access and infusion - tunneled catheter
Infrequent access (every week or month)-port

23. DURATION
> 7 days - PICC Line
1- 12 Weeks - PICC line / tunneled catheter
12 weeks - 6 months or greater - tunneled
catheter
> 6 months - Port

24. PREFERENCES
Patient:
Some patients may prefer a port for
aesthetics, no restrictions on activities
Operator:
If the operator can’t place a port
choose an alternative!!!!!!!

27. Tunneled catheter with cuffs

28. Tunneled catheter with cuff

29. Tunneled catheter

30. Port

31. Dual Port

32. Indications For CVL
•Unable to obtain peripheral access
•Fluid Resuscitation
•Invasive Monitoring
•Transvenous Pacemaker
•Swan-Ganz Insertion

33. Contraindications for CVL
•Absolute - None
•Relative
–Coagulopathy
–Local trauma to area of insertion
–Infection at site of insertion

34. Sites for CVL
•Internal Jugular
•Subclavian
•Femoral

35. Equipment
•Central Line Kit
–Single lumen, Triple lumen, or Introducer Kit
•Betadine solution
•Lidocaine
•Sterile Drapes
•Sterile Dressing
•Sterile Gloves
•Normal Saline Flush

36. Seldinger Technique

37. Seldinger Technique

38. Subclavian CVL

39. SUBCLAVIAN VEIN
COMPLICATIONS
STENOSIS THROMBOSIS
PINCH OFF
SYNDROME
Subclavian vein (SCV) access is prone to more complications than
internal jugular vein (IJV)

40. Internal Jugular CVL

41. ADVANTAGES OF THE
RIGHT IJ
1. Larger
2. More superficial
3. Further from the lung
4. More direct route to the heart
5. Acute and chronic complications are reduced

42. Femoral CVL

43. METHODS OF CVP
MONITORING
•There are two methods of CVP monitoring
–manometer system: enables intermittent
readings and is less accurate than the transducer
system
–transducer system:enables continuous readings
which are displayed on a monitor.

44. THE CVP WAVEFORM
•The CVP waveform reflects changes in
right atrial pressure during the cardiac cycle

45. Mark JB, CV Monitoring, in Miller 5th Edition, 2000, pg 1153
CVP Waveform Components
Component Phase of CycleEvent
a wave End diastole Atrial cont
c wave Early systoleIsovol vent cont
x descent Mid systole Atrial relaxation
v wave Late systole Filling of atrium
y descent Early diastoleVent filling

46. NORMAL CVP
MEASUREMENTS
•Central venous presure monitoring should
normally show measurements as follows:
•Mid Axilla: 0 - 8 mmHg (Woodrow 2000)
•An isolated CVP reading is of limited value; a
trend of readings is much more significant and
should be viewed in conjuncton with other
parameters e.g. BP and urine output.

47. COMPLICATIONS
1. Acute Procedural
2. Sub-acute Infection
3. Chronic
Infection
Catheter fragmentation
Non-function

48. COMPLICATIONS:
ACUTE
1. Spasm 4. Pneumothorax
2. Access failure 5. Malposition
3. Arterial puncture 6. Air embolus

49. PREVENTING ACUTE
COMPLICATIONS
1. Micropuncture - 21ga needle, .018”wire
2. Imaging - US, Fluoro, Contrast, CO2
3. Right Internal Jugular vein approach
4. Tilting table, Valsalva, Pinch Sheath

50. AIR EMBOLUS: SYMPTOMS
1. Respiratory distress
2. Increased heart rate
3. Cyanosis
4. Poor pulse
5. Change in the level of consciousness

51. AIR EMBOLUS: TREATMENT
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

52. PREVENTING INFECTION
1. Sterile environment
2. Periprocedural antibiotics
3. Number of lumens incidence of infection
4. Prep
5. Skin fixation
6. Dry dressing vs. Occlusive dressing
7. Ointments - Iodophor vs antibiotic
8. Special instructions

53. Summary
•CVL indicated for access and fluids
•The kit does not contain all the equipment
needed for the procedure
•The site chosen is the one you are most
comfortable with.
•Benefits must be balanced with risk of
complications.

55. Arterial Line Placement
•Indications
•Contraindications
•Required Equipment
•Placement Techniques
•Complications

56. Indications
•Continuos Blood Pressure Monitoring
•Blood Gas Sampling
•Frequent Blood Draw
•Diagnostic Angiography
•Therapeutic Procedures

57. Contraindications
•Absence of collateral flow
•Raynaud's disease and cold infusions
•Angiopathy, coagulopathy (recent anti-coag. or
thrombolytic infusion increases risk of hematoma and
compressive neuropathy), atherosclerosis: Use Caution!
•Avoid locating near A-V fistula, and inserting through
synthetic graft
•Diabetics at increased risk of complications
•Avoid local infection, burn or traumatic sites
•Avoid extremities with carpal tunnel syndrome

58. Equipment
•Catheter
–Angiocath
–Single Lumen Central Line
•Preparation and Fixation Supplies
•Pressure Tubing/Pressure Bag
•Heparinized Saline Bag
•Transducer Wires
•Monitor

59. General Technique
•Select a Site
•Prep and Drape Skin in Sterile Fashion
•Cannulate Artery
•Attach to Monitoring Apparatus
•Suture in Place
•Zero and Adjust Parameters

60. Radial Artery Cannulation
•Perform Allen Test prior to cannulation
•Have roll of cling and arm board ready
•Advance catheter 1-2mm after flash
•Slide catheter off IV stylet

61. Use of Radial Artery Set

62. Allen Test

63. Alternative Arterial Line Sites
•Femoral Artery
•Brachial Artery
•Dorsalis Pedis Artery
•Umbilical Artery (neonates)

64. Femoral Artery
•Use single lumen central line kit
•Do nick skin with scalpel blade
•Do not dilate artery
•Remember to compress if you miss

65. Brachial Artery

66. Dorsalis Pedis

67. Arterial Cut Down
•Additional Supplies:
–Extra Sutures
–Scalpel
•N.B. The cannula should be in line with the vessel

70. The Pressure-pulse
•1st shoulder (the Inotropic Component): early systole,
opening of aortic valve, transfer of energy from
contracting LV to aorta
•2nd shoulder (the Volume Displacement Component):
produced by continuous ejection of stroke volume from
LV, displacement of blood, and distention of the arterial
wall
•Diastole: when the rate of peripheral runoff exceeds
volume input to the arterial circulation

71. Possible Information gained from
a pressure waveform
•Systolic, diastolic, and mean pressure
•Myocardial contractility (dP/dt)
•Peripheral vascular resistance (slope of
diastolic runoff)
•Stroke volume (area under the pulse
pressure curve)
•Cardiac output (SV x HR)

72. Complications
•Bleeding
•Arterial Spasm
•Thrombosis
•Infection
•Skin Breakdown

73. Summary
•Arterial lines are indicated for:
–Patient Monitoring
–Blood Sampling
•Preparation is the Key to Success
•Radial artery is preferred cannulation site
•Complications are rare and avoidable

75. Intraosseous Infusion
•Indications
•Contraindications
•Technique
•Complications

76. Intraosseous Cannulation
•Placement of cannula into long bone
intramedullary canal (marrow space)

77. Intraosseous Cannulation
•Indication
–Vascular access required
–Peripheral site cannot be obtained
•In two attempts, or
•After 90 seconds

78. Intraosseous Cannulation
•Devices
–16 gauge hypodermic needle
–Spinal needle with stylet
–Bone marrow needle (preferred)

79. Intraosseous Cannulation
•Site
–Anterior tibia
–1 - 3 cm below knee
–Medial to tibial tuberosity

80. Intraosseous Cannulation
•Contraindications
–Fractures
–Osteogenesis imperfecta
–Osteoporosis
–Failed attempt on same bone

81. Technique Interosseous Infusion
•Insert needle2 finger
breaths below tibial
tuberosity
•Gently push with
twisting motion until a
pop is felt.
•Infuse small amount of
fluid to test prior to
use.

82. Intraosseous Cannulation
•Needle in place if:
–Lack of resistance felt
–Needle stands without support
–Bone marrow aspirated
–Infusion flows freely

83. What can be put thru an IO?
Anything that can be put through an IV!

84. Complications
•Incomplete penetration of bone marrow
•Clot formation with in needle
•Fracture of bone
•Infection
•Skin break down at site