Disclosures: Image Guided Procedures Pearls, Pitfalls, and Disasters. Central Venous Access. Outline:

Transcription

1 Image Guided Procedures Pearls, Pitfalls, and Disasters Disclosures: I have nothing to disclose Miles B. Conrad MD, MPH Clinical Assoc. Prof of Radiology Section: IR Outline: Image Guided Procedures Pearls, Pitfalls, and Disasters Central venous lines Thoracostomy tubes and thoracentesis Paracentesis Central Venous Access Options in difficult access cases Complications 1

2 IJ Access Subclavian Access Ultrasound is almost never used but it works well!! Standard IR practice Seems to be safer than subclav for short term access Long term subclavian access inc rates of subclav. stenosis Very low chance of ptx in experienced hands Indications Thrombosed/occluded IJ s Prior CV catheters IVDU Neck infections Tracheostomy tubes C collars Contraindications Ax node dissections Fistulas DVT Long standing catheter need *Crit Care Med Feb;30(2): US Subclavian Access Infraclavicular Subclavian Access Infraclavicular view of the Subclavian V. and A V A 2

3 Infraclavicular Subclavian Access Supraclavicular Subclavian Access When attempting this, needle tip localization is of paramount importance! Supraclavicular Subclavian Access Supraclavicular Subclavian Access Why? If you can identify subclavian v. better than with infraclav view Tiny subclavian v. Thrombosed IJ s Needle tip localization is key...or this is dangerous 3

4 78 yo F w/ ESRD, failed upper extrem grafts, R pacemaker Supraclav subclav HD cath IJ s are out Supraclavicular view of R subclav. V. Be aware of the warning signs of SVC syndrome Chest wall collaterals portend a difficult access 4

5 Catheter in azygous Catheter in azygous The azygous will reverse flow and enlarge in infraazygous SVC occlusion Very common in pts with chronic catheter pts and dialysis fistulas 5

6 Complications Dilator injuries Malpositioned lines Air embolus Arterial puncture Ptx Loss of wire Infection Kink, BC vein puncture Malpositioned line Earlier CT Catheter in Ao or L SVC? Dublicated SVC: % 6

7 Air Embolus Inadvertent Arterial Line RV Seen incidentally in up to 50% pts on CT and is usually of no significance This may be a morbid/lethal issue in cardiopulmonary dz or those with R-L shunts Jumper s/p R subclav cordis placement 7

8 R Vertebral artery 54 yo F s/p L chest wall resection R CCA Cordis tip These get filled with thrombus 8

9 Pseudoaneurysm and Brachial a. Embolus Subclavian Covered Stent s/p attempted R IJ placement 9

10 Presumed alveolar-pleural fistula w/ air leak Lung re-expanded on LCWS Likely tear injury to pleura Consider decreasing negative pressure until lung is up on waterseal 55 yo M w/ sepsis, s/p R IJ line RIJ cath still around line Wires are usually pushed in due to failure to hold the wire while advancing the dilator or catheter 10

11 Loss of wire Wire retrieval from groin Alternate IV site: Deep Brachial/Basilic Puncture The solution for IV access in skin poppers Brachial a.. Median n. Basilic v. Brachial v. Traditional angiocaths are too short! 11

12 Pleural Drainage Thoracostomy Tubes: Thoracostomy tubes/thoracentesis Empyema Efficacy of fibrinolysis of infected pleural effusions tpa and DNAse Bleeding associated with tpa Transcostal access techniques Complications Malpositioned tubes Bleeding Small bore (6-F to 16-F) Pigtail Catheter Large bore (18-F to 28-F) Thalquick Catheter Pleural fluid CT Underrepresents Septations Lung abscess: Avoid this! Likely will need fibrinolysis 12

13 MIST II Double Blind Trial 10 mg TPA alone 5 mg DNAse alone DNAse + TPA Saline alone %Δ in pleural opacity from Day 1 to 7 on CXR -17+/ (p=0.55) / (p= 0.14) / (p=0.005) / Bid tx x 3 days Clamped x 1 hr NEJM 2011;365: SFGH experience: 5% of patients develop severe chest pain and some required elevated level of care 28 yo M s/p GSW to lung s/p wedge resection w/ adjacent hematoma 53 yo F w/ ovarian CA tpa = bad idea Massive Hemoptysis Intercostal artery injury and abdominal chest tube 13

14 Intercostal artery embo There are many arteries to contend with Supracostal artery Moore E. STR 2004 Walking over a rib does not prevent all bleeding US guided chest tubes require 3 pt. confirmation to avoid abdomen 18 yo M s/p MCA 1. Visualize needle in fluid 2. Visualize wire in pleura 3. Visualize pigtail in fluid Wire Liver 14

15 Posterior tube Tube is clogged Tube in fissure Tube Malposition: Delay in Resolution of Ptx Spontaneous Ptx Blind midaxillary line pigtails often often don t go to the anterior apex 15

16 Avoid This: Paracentesis Complications: Inadvertent puncture of vessel, organ, bowel Infection: aseptic technique Post Paracentesis Circulatory Dysfunction (PCD) Case courtesy of Vishal Kumar, MD he did not do this Caput Medusa Abdominal wall varices 16

17 Arterial Injury s/p Paracentesis 41 yo M w/ hypotension, 3 pressors, tachy s/p paracentesis, severe pulm HTN, codes if supine or < 45 degrees Heme Jet 17

18 Conclusions Vs.? Lines: Alternative line access sites only when very comfortable with seeing needle tip with US Be weary of pts with long standing indwelling catheters or pacemakers look for chest wall vessels Pleural access Dynamic US method is probably safest Paracentesis Most complications are avoidable 18