Advocate Christ Medical Center CVC Placement Certification Course

Transcription

1 Advocate Christ Medical Center CVC Placement Certification Course July 12th, 2012 Hannah Watts, MD Medical Simulation Director Modified August 10, 2017 Taajwar Khan, MD Chief Resident of Internal Medicine

2 Objectives Review indications for CVC Placement Review sterile technique for CVC Placement Review landmarks and technique for CVC Placement US guidance for CVC placement Tips and Tricks for CVC Placement

3 New Hospital Requirements For CVC Placement Lecture Central Line Procedure Simulator Training mixed in with your Sim Curriculum Successful completion of a post -test Yearly review CVC placement may not be performed by residents who have not completed this training no exceptions

4 Simulation Session Central line placement Focus on US IJ Discussion of sterile procedure and trouble shooting

5 Why? - CLABSI Central Line Insertion Blood Stream Infections are preventable (CLABSI) Rates are reports to the state and are accessible to health consumers Patients with CLABSI have increased LOS and hospital costs Careful and experienced technique, US guidance for IJ, and maximum sterile barrier reduce CLABSI line care, insertion

6 Tip # 1 Solo Sterility One handed sterile technique

7 CDC Recommends 1. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Category IA 2. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Category IA 3. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. Category IA

8 CDC Recommends When and How to place a CVC That we assess this knowledge Need training

9 Types of Central Access Dual lumen or Triple lumen catheter Dialysis or Trialysis catheter Emergency dialysis or bridge to permanent access Apheresis/exchange transfusions Percutaneous introducer sheath (Cordis) Rapid Transfusion Pulmonary artery catheter, pacemaker ECLS Cannulation Typically done in the OR

10 Indications For CVC Inadequate peripheral venous access Inability Administering noxious substances (pressors, TPN) Measurement of cardiac filling pressures Measurement of ScvO2

11 Contraindications Absolute Operator inexperience Uncooperative patients Uncorrected coagulopathy in a STABLE patient

12 Contraindications Relative Coagulopathy in an UNSTABLE patient Cellulitis over insertion site Inability to tolerate pneumothorax Peripheral access adequate Morbid obesity Congenital heart disease (Glenn/Fontan, increased risk of clotting with upper body lines, femoral) Presence of a pacemaker or ICD Vasculitis

13 Contraindications -Key Points CVC NEVER indicated when peripheral IVs suffice Operator inexperience = ABSOLUTE contraindication without supervision Volume resuscitation 14/16 gauge IV, OR 18 gauge x2 is more effective

14 Tip # 2 The Guidewire

15 Complications Air Embolus Arrhythmia Arterial Puncture AV fistula Central vein perforation Chylothorax Guidewire embolization Hemothorax Infection Injury to nerves Malposition of the catheter tip Pneumothorax Subcutaneous fluid infiltration Tamponade Tracheal perforation Venous thrombosis Hydrothorax Hemomediastinum

16 Tip # 3 Avoiding Embolism Reducing complications Air embolism Flush all lumens of the CVC Finger over needle hub Reducing Complications Wire embolism If ANY resistance is felt when removing wire from needle (if you are repositioning etc.) Remove needle/wire as a unit

17 Hand Washing and Maximum Barrier Hand hygiene immediately before the procedure Use maximum sterile barrier Cap Mask Sterile gown Sterile gloves LARGE sterile drape Prep skin with 2% chlorhexidene antiseptic Skin to dry prior to procedure

18 Site Selection -IJ Lowest risk of pneumothorax Straight path to the SVC Compressible Facilitates passage of PA catheters or pacemakers Can measure CVP Use US guidance

19 Tip # 4 Patient Position Vaslsalva may maximize size Difficult to coordinate Position the patient at a 14- degree Trendelenburg angle Be careful not to over-rotate the patient's neck, because this may compress the IJ Over rotation may move the IJ over the carotid

20 Site Selection - Subclavian More easily identifiable by boney landmarks More comfortable for the patient Not compressible Increased risk of pneumothorax Avoid in patients with renal disease (access for dialysis)

21 Site Selection - Femoral Higher risk of thrombotic or infectious complications avoid when possible No risk of pneumothroax Compressible Unreliable CVP

22 CVC Placement NEJM Videos Available online for your review Femoral Line Subclavian Internal Jugular

23 Internal Jugular Runs with the Carotid Typically anterolateral Can be found at the apex of the triangle formed by: Clavicle 2 heads of the SCM Easily accessed with US Guidance

24 Subclavian Line Placement Subclavian vein - course The subclavian arteries are located posterior to the veins and are separated from them by the scalene muscles The right pleural dome is lower than the left and the thoracic duct is located on the left, thus making the right side preferred over the left

25 Subclavian Line - Supraclavicular Pocket Shot 1 cm lateral to SCM 1cm posterior to SCM Bisect lateral SCM and clavicle degrees from horizontal

26 Subclavian Line- Infraclavicular Position Trendelenberg Right side is preferred Junction of medial and middle third of clavicle Index finger on notch Aim caudal to the finger

27 Tip # 5 -Manometry

28 Femoral Line - Temporary

29 Femoral Line Placement

30 Femoral Line Placement Follow the link to the video will need advocate access or a personal account:

31 Tip # 6 How Far? How far do you go in? Measure on the chest wall prior to procedure 2cm below manubrosternal junction 2 nd intercostal space/manubrosternal junction Formulas? Measure on Chest radiograph Needle insertion to the clavicular notch Notch to the carina 14-20cm

32 After Line Placement Place biopatch Blue to the sky Wash hands Order a Chest X-Ray Write a procedure note Look at the chest X-Ray Line tip? Guide wire? Pneumothorax?

33 Suturing Securing the Line

34 Stat Lock Securing the Line

35 Dealing With Complications Pneumothorax No distress, not ventilated- serial CXR s Needle decompression, chest tube Air embolization suspect if patient decompensates Occlude any open lumen Left lateral decubitus and trendelenberg High fio 2 Attempt to aspirate Air

36 Arterial Dilation? 1. Do not remove the catheter prior to consultation with a vascular specialist (vascular surgeon or interventional radiologist) 2. Urgent consultation of vascular specialist 3. Obtain CBC, PT/PTT if recent test values are not available. 4. Consider type and cross match for 2 units of blood (10 ml/kg in children) 5. Clinical decision making should occur in consultation with the consultant vascular specialist

37 Things To Remember Always get a CXR post procedure and look at it NEVER let go of the guidewire Maximum sterile barrier The biopatch Avoid femoral cannulation Increased risk for patients Should be removed after 24 hours

38 See you in the Sim Lab!