Centralni venski katetri kot žilni pristop za hemodializo

Transcription

1 Centralni venski katetri kot žilni pristop za hemodializo SKLOP PREDAVANJ V SPOMIN asist.dr. JANIJA KOVAČA, dr.med. Petek, Moderatorja: Vladimir Premru, Boštjan Leskovar Vladimir Premru: UZ vodeno uvajanje hemodializnih katetrov Rafael Ponikvar: Dva enolumenska HD katetra kot žilni pristop za HD Boštjan Leskovar: Diaskopsko vodena uvedba tuneliziranih Boštjan Kersnič trajnih dvolumenskih HD katetrov, lastne izkušnje Rina Rus: Dializni katetri kot akutni in dolgotrajni žilni pristop pri HD/MPF pri otrocih Nataša Škofic: Dializni katetri pri AOL Tomaž Ključevšek: Vloga interventnega radiologa pri zdravljenju zožitev in zapor centralnih ven kot zapleta dializnih katetrov Mateja Logar: Okužbe dializnih katetrov pri kronični hemodializi in pri AOL v intenzivnih enotah (preprečevanje in zdravljenje)

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3 Two single-lumen noncuffed catheters in the jugular vein as long-term vascular access: a preliminary report. Kovač J, Premru V, Buturović-Ponikvar J, Ponikvar R. Ther Apher Dial Jun;15(3): Vascular access in children on chronic hemodialysis: a Slovenian experience. Rus RR, Novljan G, Buturović-Ponikvar J, Kovač J, Premru V, Ponikvar R. Ther Apher Dial Jun;15(3):292-7 Hemodialysis catheters with citrate locking in critically ill patients with acute kidney injury treated with intermittent online hemofiltration or hemodialysis. Skofic N, Buturović-Ponikvar J, Kovac J, Premru V, Knap B, Marn Pernat A, Kersnic B, Gubensek J, Ponikvar R. Ther Apher Dial Aug;13(4): Vascular access recirculation in hemodialysis patients with two noncuffed, single-lumen, jugular catheters in the same jugular vein. Kovac J, Buturović-Ponikvar J, Ponikvar R. Ther Apher Dial Aug;13(4): KOVAČ, Janko. Ultrasound guided central venous catheter insertions for hemodialysis or apheresis procedures. V: MARN-PERNAT, Andreja (ur.). Končni program, vabljena predavanja in knjiga izvlečkov. Ljubljana: SZD - Slovensko nefrološko društvo: = Slovenian Society of Nephrology, 2008, str PREMRU, Vladimir, URBANČIČ, Alenka, KOVAČ, Janko, PONIKVAR, Rafael. Acute complications at the insertion of hemodialysis catheters. V: BUTUROVIĆ-PONIKVAR, Jadranka (ur.), BREN, Andrej (ur.). Zbornik. Ljubljana: Klinični oddelek za nefrologijo, Interna klinika, Klinični center, 2000, str KOVAČ, Janko, PREMRU, Vladimir, BUTUROVIĆ-PONIKVAR, Jadranka, PONIKVAR, Rafael. Two single-lumen non-cuffed catheters in the jugular vein as a hemodialysis vascular access for more than 100 days. Int J Artif Organs, 2011, vol. 34, issue 8, str PONIKVAR, Rafael, MALOVRH, Marko, KOVAČ, Janko, PREMRU, Vladimir, GUBENŠEK, Jakob, KERSNIČ, Boštjan, KNAP, Bojan, MARN-PERNAT, Andreja, BUTUROVIĆ-PONIKVAR, Jadranka. Vascular access activity in dialysis center UMC Ljubljana. Int J Artif Organs, 2011, vol. 34, issue 8, str KOVAČ, Janko, PONIKVAR, Rafael. Real-time ultrasound guidance versus anatomical landmark technique in femoral vein cannulations. V: MARN-PERNAT, Andreja (ur.), GUBENŠEK, Jakob (ur.), BUTUROVIĆ-PONIKVAR, Jadranka (ur.). 40-letnica kronične hemodialize in transplantacije ledvic v Sloveniji : končni program in knjiga izvlečkov, november 2010, [Bled, Slovenija] : final program and book of abstracts, November 4-5, 2010, Bled, Slovenia. Ljubljana: SZD - Slovensko nefrološko društvo: = Slovenian Society of Nephrology, 2010, str. 55. KOVAČ, Janko, PREMRU, Vladimir, PONIKVAR, Rafael. Two single-lumen pre-curved 8F catheters in the same jugular vein as a dialysis or apheresis vascular access. V: MARN-PERNAT, Andreja (ur.), GUBENŠEK, Jakob (ur.), BUTUROVIĆ-PONIKVAR, Jadranka (ur.). 40-letnica kronične hemodialize in transplantacije ledvic v Sloveniji : končni program in knjiga izvlečkov, november 2010, [Bled, Slovenija] : final program and book of abstracts, November 4-5, 2010, Bled, Slovenia. Ljubljana: SZD - Slovensko nefrološko društvo: = Slovenian Society of Nephrology, 2010, str. 56. RUS, Rina, NOVLJAN, Gregor, PREMRU, Vladimir, KOVAČ, Janko, BUTUROVIĆ-PONIKVAR, Jadranka, PONIKVAR, Rafael. Vascular accesses in children on chronic hemodialysis : Slovenian experiences ( ). V: MARN-PERNAT, Andreja (ur.), GUBENŠEK, Jakob (ur.), BUTUROVIĆ-PONIKVAR, Jadranka (ur.). 40-letnica kronične hemodialize in transplantacije ledvic v Sloveniji : končni program in knjiga izvlečkov, november 2010, [Bled, Slovenija] : final program and book of abstracts, November 4-5, 2010, Bled, Slovenia. Ljubljana: SZD - Slovensko nefrološko društvo: = Slovenian Society of Nephrology, 2010, str. 58 PERŠIČ, Vanja, PONIKVAR, Rafael, DEJANOVA, Sandra, KOVAČ, Janko, MARN-PERNAT, Andreja, KNAP, Bojan, PREMRU, Vladimir, BENEDIK, Miha, VARL, Janez, GUBENŠEK, Jakob, KERSNIČ, Boštjan, BUTUROVIĆ-PONIKVAR, Jadranka. Vascular access type and C reactive protein (CRP) levels in chronic hemodialysis patients. V: MARN-PERNAT, Andreja (ur.), GUBENŠEK, Jakob (ur.), BUTUROVIĆ-PONIKVAR, Jadranka (ur.). 40-letnica kronične hemodialize in transplantacije ledvic v Sloveniji : končni program in knjiga izvlečkov, november 2010, [Bled, Slovenija] : final program and book of abstracts, November 4-5, 2010, Bled, Slovenia. Ljubljana: SZD - Slovensko nefrološko društvo: = Slovenian Society of Nephrology, 2010, str. 60. PERŠIČ, Vanja, PONIKVAR, Rafael, DEJANOVA, Sandra, KOVAČ, Janko, MARN-PERNAT, Andreja, KNAP, Bojan, PREMRU, Vladimir, BENEDIK, Miha, VARL, Janez, GUBENŠEK, Jakob, KERSNIČ, Boštjan, BUTUROVIĆ-PONIKVAR, Jadranka. Type of vascular access and c-reactive protein (CRP) levels in chronic hemodialysis patients. Int J Artif Organs, 2010, letn. 33, št. 7, str KOVAČ, Janko, PREMRU, Vladimir, BUTUROVIĆ-PONIKVAR, Jadranka, VIDMAR, Ivan, PONIKVAR, Rafael. Intermittent hemodialysis : efficient and safe temporary treatment for children below 17 kg. Therap. apher. dial. (Print), 2010, letn. 14, št. 5, str. A3. KOVAČ, Janko, PONIKVAR, Rafael. Real-time ultrasound guidance versus anatomical landmark technique in femoral vein cannulations. Therap. apher. dial. (Print), 2010, letn. 14, št. 5, str. A3-A4. KOVAČ, Janko, PREMRU, Vladimir, PONIKVAR, Rafael. Two single-lumen pre-curved 8Fr catheters in the same jugular vein as a dialysis or apheresis vascular access. Therap. apher. dial. (Print), 2010, letn. 14, št. 5, str. A4. RUS, Rina, NOVLJAN, Gregor, PREMRU, Vladimir, KOVAČ, Janko, BUTUROVIĆ-PONIKVAR, Jadranka, PONIKVAR, Rafael. Vascular accesses in children on chronic hemodialysis : Slovenian experiences ( ). Therap. apher. dial. (Print), 2010, letn. 14, št. 5, str. A5. PERŠIČ, Vanja, PONIKVAR, Rafael, DEJANOVA, Sandra, KOVAČ, Janko, MARN-PERNAT, Andreja, KNAP, Bojan, PREMRU, Vladimir, BENEDIK, Miha, VARL, Janez, GUBENŠEK, Jakob, KERSNIČ, Boštjan, BUTUROVIĆ-PONIKVAR, Jadranka. Vascular access type and C reactive protein levels in chronic hemodialysis patients. Therap. apher. dial. (Print), 2010, letn. 14, št. 5, str. A6

4 KOVAČ, Janko, PONIKVAR, Rafael, PREMRU, Vladimir. Intermitent hemodialysis-efficient and safe temporary treatment for children below 17 kg. V: WCN'07 satellite symposium, April 2007, Hotel Pestana-Salvador, Bahia-Brazil. Acute kidney injury : emerging concepts : scientific program & abstracts. [Bahia], 2007, str. [PO20]. PERŠIČ, Vanja, PONIKVAR, Rafael, DEJANOVA, Sandra, KOVAČ, Janko, MARN-PERNAT, Andreja, KNAP, Bojan, PREMRU, Vladimir, BENEDIK, Miha, VARL, Janez, BUTUROVIĆ-PONIKVAR, Jadranka. C reactive protein (CRP) levels in chronic hemodialysis patients and type of vascular access. BANTAO Journal, 2009, letn. 7, suppl. 1, str. 25. PONIKVAR, Rafael, BENEDIK, Miha, GUBENŠEK, Jakob, GUČEK, Andrej, KERSNIČ, Boštjan, KANDUS, Aljoša, KNAP, Bojan, KOVAČ, Janko, LEŠEVIĆ, Nataša, LIKAR, Cvetka, MALOVRH, Marko, MARN-PERNAT, Andreja, PERŠIČ, Vanja, PREMRU, Vladimir, ŠKOFIC, Nataša, VARL, Janez, BUTUROVIĆ-PONIKVAR, Jadranka. Vascular access activity in Dialysis center Zaloška, University medical centerljubljana, Slovenia. J Vasc Access, 2009, vol. 10, no. 2, str RUS, Rina, BUTUROVIĆ-PONIKVAR, Jadranka, KOVAČ, Janko, PREMRU, Vladimir, PONIKVAR, Rafael. Non-cuffed catheters with citrate locking used as long-term vascular access in pediatric chronic hemodialysis patients. V: MARN-PERNAT, Andreja (ur.), BUTUROVIĆ-PONIKVAR, Jadranka (ur.). ESAO Winter School 2009, Kranjska Gora, Slovenia, March 5-7, Programme and Book of abstracts. [S. l.: s. n.], 2009, str. 16. ŠKOFIC, Nataša, BUTUROVIĆ-PONIKVAR, Jadranka, KOVAČ, Janko, PREMRU, Vladimir, MARN-PERNAT, Andreja, KNAP, Bojan, KERSNIČ, Boštjan, PONIKVAR, Rafael. Hemodialysis catheters with citrate locking in critically ill patients with acute kidney injury. V: MARN-PERNAT, Andreja (ur.), BUTUROVIĆ-PONIKVAR, Jadranka (ur.). ESAO Winter School 2009, Kranjska Gora, Slovenia, March 5-7, Programme and Book of abstracts. [S. l.: s. n.], 2009, str. 18. KOVAČ, Janko, PONIKVAR, Rafael, PREMRU, Vladimir. Intermitent hemodialysis : efficient and safe temporary treatment for children below 17 kg. Therap. apher. dial. (Print), 2009, letn. 13, št. 3, str. A2. ŠKOFIC, Nataša, KOVAČ, Janko, MARN-PERNAT, Andreja, KNAP, Bojan, PREMRU, Vladimir, BUTUROVIĆ-PONIKVAR, Jadranka, PONIKVAR, Rafael. Hemodialysis catheters in critically ill patients with acute kidney injury treated with hemodialysis. Therap. apher. dial. (Print), 2009, letn. 13, št. 3, str. A3. PONIKVAR, Rafael, BENEDIK, Miha, GUBENŠEK, Jakob, GUČEK, Andrej, KERSNIČ, Boštjan, KANDUS, Aljoša, KNAP, Bojan, KOVAČ, Janko, LEŠEVIĆ, Nataša, LIKAR, Cvetka, MALOVRH, Marko, MARN-PERNAT, Andreja, PERŠIČ, Vanja, PREMRU, Vladimir, ŠKOFIC, Nataša, VARL, Janez, BUTUROVIĆ-PONIKVAR, Jadranka. Vascular access activity in Dialysis center Zaloška. Therap. apher. dial. (Print), 2009, letn. 13, št. 3, str. A12-A13. VAJDIČ, B, KNAP, Bojan, MALOVRH, Marko, KOVAČ, Janko, BUTUROVIĆ-PONIKVAR, Jadranka, PREMRU, Vladimir, MARN-PERNAT, Andreja, KERSNIČ, Boštjan, LEŠEVIĆ, Nataša, BENEDIK, Miha, VARL, Janez, PONIKVAR, Rafael. Occlusion of jugular vein after long-term jugular catheter placement. Therap. apher. dial. (Print), 2009, letn. 13, št. 3, str. A15. VAJDIČ, B, KOVAČ, Janko, MARN-PERNAT, Andreja, BUTUROVIĆ-PONIKVAR, Jadranka, VARL, Janez, BENEDIK, Miha, KNAP, Bojan, PREMRU, Vladimir, ŠKOFIC, Nataša, KERSNIČ, Boštjan, PONIKVAR, Rafael. Critically exhausted vascular access in the patient after 18 years of hemodialysis. Therap. apher. dial. (Print), 2009, letn. 13, št. 3, str. A15-A16. KOVAČ, Janko, LIKAR, Cvetka, DEDIĆ, H, PONIKVAR, Rafael. Vascular access recirculation in hemodialysis patients with two single lumen jugular catheters in the same jugular vein. Therap. apher. dial. (Print), 2009, vol. 13, no. 3, str. A17-A18. VAJDIČ, B, KNAP, Bojan, MALOVRH, Marko, KOVAČ, Janko, BUTUROVIĆ-PONIKVAR, Jadranka, PREMRU, Vladimir, MARN-PERNAT, Andreja, KERSNIČ, Boštjan, LEŠEVIĆ, N, BENEDIK, Miha, VARL, Janez, PONIKVAR, Rafael. Occlusion of jugular vein after longterm jugular catheter placement. V: MARN-PERNAT, Andreja (ur.). Končni program, vabljena predavanja in knjiga izvlečkov. Ljubljana: SZD - Slovensko nefrološko društvo: = Slovenian Society of Nephrology, 2008, str PONIKVAR, Rafael, ŠKOFIC, Nataša, KOVAČ, Janko, PREMRU, Vladimir, KNAP, Bojan, BENEDIK, Miha, VARL, Janez, BUTUROVIĆ-PONIKVAR, Jadranka. Vascular access in critically ill patient with acute kidney injury (AKI) treated with hemodialysis/hemofiltration. Int J Artif Organs, 2007, letn. 30, št. 8, str. 741, 190 (P-52). PONIKVAR, Rafael, ŠKOFIC, Nataša, PREMRU, Vladimir, KOVAČ, Janko, BENEDIK, Miha, KNAP, Bojan, MARN-PERNAT, Andreja, MILANEZ, Tomaž, BUTUROVIĆ- PONIKVAR, Jadranka. Hemodialysis (HD) catheters in critically III patients with acute renal failure treated with hemodialysis/on-line hemofiltration (HF). J. Am. Soc. Nephrol., 2007, letn. 18, str. 268A. LIKAR, C..., BUTUROVIĆ-PONIKVAR, Jadranka, URBANČIČ, Alenka, PREMRU, Vladimir, KOVAČ, Janko, PONIKVAR, Rafael. Hemodialysis catheters : the role of the nurser's care. V: 2nd International Congress of the Vascular Access Society, London, 30th May - 1st June PREMRU, Vladimir, PONIKVAR, Rafael, URBANČIČ, Alenka, KOVAČ, Janko. Acute complications at the insertion of hemodialysis catheters. V: BUTUROVIĆ- PONIKVAR, Jadranka (ur.). 2. slovenski nefrološki kongres z mednarodno udeležbo, Slovenija, september 2000 = 2nd Slovenian Congress of Nephrology with International Participation, Brdo pri Kranju, Slovenia, September 27-30, Končni program in knjiga izvlečkov. Ljubljana: Klinični oddelek za nefrologijo, Interna klinika, Klinični center, 2000, str. 115.

5 Centralni venski katetri kot žilni pristop za hemodializo SKLOP PREDAVANJ V SPOMIN asist.dr. JANIJA KOVAČA, dr.med. Petek, Moderatorja: Vladimir Premru, Boštjan Leskovar Vladimir Premru: UZ vodeno uvajanje hemodializnih katetrov Rafael Ponikvar: Dva enolumenska HD katetra kot žilni pristop za HD Boštjan Leskovar: Diaskopsko vodena uvedba tuneliziranih Boštjan Kersnič trajnih dvolumenskih HD katetrov, lastne izkušnje Rina Rus: Dializni katetri kot akutni in dolgotrajni žilni pristop pri HD/MPF pri otrocih Nataša Škofic: Dializni katetri pri AOL Tomaž Ključevšek: Vloga interventnega radiologa pri zdravljenju zožitev in zapor centralnih ven kot zapleta dializnih katetrov Mateja Logar: Okužbe dializnih katetrov pri kronični hemodializi in pri AOL v intenzivnih enotah (preprečevanje in zdravljenje)

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8 UVAJANJE CENTRALNIH VENSKIH KATETROV ZA HEMODIALIZO S POMOČJO ULTRAZVOKA Vladimir Premru Univerzitetni Klinični Center Ljubljana Slovenija

9 UVAJANJE CENTRALNIH VENSKIH KATETROV TVEGANA PROCEDURA, ČESTO NUJNA IN VITALNO INIDICIRANA ANATOMSKE MARKACIJE ( LAND-MARKS ) NE DOVOLJ PRECIZNE VARIACIJE ŽILNEGA POTEKA BLIŽINA VITALNIH STRUKTUR USPEŠNOST ODVISNA OD IZKUŠENOSTI OPERATERJA UZ OMOGOČA REALNO SLIKO ANATOMSKIH RAZMER

10 EVOLUCIJA UPORABE ULTRAZVOKA PRI KATETERSKIH ŽILNIH PRISTOPIH Ullman JI, Stoelting RK. Internal jugular vein location with the ultrasound Doppler blood flow detector. Anesth Analg. 1978;57(1):118. Yonei A, Nonoue T, Sari A. Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein. Anesthesiology 1986;64(6): Denys BG, Uretsky BF. Anatomical variations of internal jugular vein location: impact on central venous access. Crit. Care. Med.,19(12):1516-9, Gadallah MF, White R, Vickers B, el-shahawy M, Work J. Awareness of Interna jugular, subclavian, superior vena cava and femoral venous anomalies may reduce morbidity of acute venous catheter procedures. Clin. Nephrol,44(5):345-8,1995. Dockor B, So CB, Saliken JC, Gray RR. Ultrasound monitoring in cannulation of the internal jugular vein: anatomic and technical considerations. Can Assoc Radiol J. 47(3): ,1996. Lin BS, Kong CW, Tarng DC, Huang TP, Tang GJ. Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survey in uraemic patients. Nephrol.Dial.Transplant.,13(1):134-8,1998

11 UPORABA ULTRAZVOKA PRI KATETERSKIH ŽILNIH PRISTOPIH Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Hind D, Calvert N, McWilliam R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 327(7411): 361, 2003.

12 UPORABA ULTRAZVOKA PRI KATETERSKIH ŽILNIH PRISTOPIH Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Evidence supports the use of two dimensional ultrasonography for central venous cannulation. Hind D, Calvert N, McWilliam R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 327(7411): 361, 2003.

13 Evidence Report/Technology Assessment, No. 43 Making Health Care Safer A Critical Analysis of Patient Safety Practices Prepared for: Agency for Healthcare Research and Quality Contract No The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality. Use of maximum sterile barriers while placing central intravenous catheters to prevent infections. Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections. Asking that patients recall and restate what they have been to ld during the informed consent process. Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia. Use of pressure relieving bedding materials to prevent pressure ulcers. Use of real-time ultrasound guidance during central line insertion to prevent complications. Patient self-management for warfarin (Coumadin ) to achieve appropriate outpatient anticoagulation and prevent complications. Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. Making Health Care Safer: A Critical Analysis of Patient Safety Practices AHRQ Publication No 01-EO58. Rockville, MD: Agency for Healthcare Research and Quality; 2001:

14 CLINICAL PRACTICE GUIDELINES VASCULAR ACCESS FOR HAEMODIALYSIS UK Renal Association 5th Edition, Central venous stenosis and central venous dysfunction Central venous catheter dysfunction is a common event in haemodialysis. A reduction or cessation of blood flow interrupts therapy and reduces the adequacy of solute and fluid removal. Catheter dysfunction can be minimized by careful catheter insertion techniques under fluoroscopic and or ultrasonographic guidance NKF KDOQI GUIDELINES GUIDELINES FOR VASCULAR ACCESS GUIDELINE 5 Type and Location of Tunneled Cuffed Catheter Placement D. Real-time ultrasound-guided insertion is recommended to reduce insertion-related complications. (Evidence/Opinion) GUIDELINE 6 Acute Hemodialysis Vascular Access Noncuffed Catheters F. Where available, ultrasound should be used to direct insertion of these catheters into the internal jugular position to minimize insertion-related complications. (Evidence/Opinion)

15 Insertion and Removal of Tunneled Hemodialysis Catheters Tunneled, cuffed hemodialysis catheters are inserted by, or under the supervision of, trained personnel under fluoroscopy (evidence). If fluoroscopy is not available, then insert under ultrasound guidance and perform chest x-ray prior to line use. The management of the Haemodialysis Central Venous Catheter Beaumont Hospital Dublin Department of Nephrology, Dialysis and Transplantation Oct 2010 Review Date: Nov 2012 Guideline NO Acute Access: 3.2.1: Temporary catheter placement: Inform the dialysis nursing staff as early as possible that the patient will require haemodialysis. Ensure that the patient has received the patient information leaflet Insertion of a femoral dialysis line. In general, the right or left femoral vein should be used. If these are not suitable / possible, the next best choice is the right internal jugular vein. Ensure recent blood tests are performed prior to procedure, including U+E, CBC, Coag & T+S. Prepare the sterile trolley for the procedure (See appendix) Chloraprep solution to be used to cleanse the insertion site, allow to air dry. The nurse will assist the Renal Registrar throughout the procedure. Ultrasound guidance should be used to direct insertion of the catheter and to locate the vein and minimise insertion-related complications. The Ultrasound Machine is located on St. Peters ward or in room : Permanent Access: 3.3.1: Permanent catheter placement: 3.3.2: Post insertion: Record patient's vital signs as per hospital policy. Inform medical staff of any abnormalities. Observe exit site for any signs of bleeding. Apply pressure to exit site if bleeding occurs and inform medical staff. Reassure patient if complication does occur. Observe for verbal and non-verbal signs of pain at exit site and administer analgesia as prescribed. The patient should maintain bed rest for approximately 2 hours post-insertion. Document the type and location of catheter in nursing care plan and on the central venous catheter record sheet. Ensure the radiologist has documented the position of the line and that it is ready for use in the patient's medical notes. This is sufficient documentation to commence haemodialysis (as per renal guideline meetings 2010). A post-insertion chest x-ray is not required as the line is inserted in the x-ray department.

16 National Institute for Clinical Excellence 1. Guidance on the use of ultrasound locating devices for placing central venous catheters 1.1 Two-dimensional (2-D) imaging ultrasound guidance is recommended as the preferred method for insertion of central venous catheters (CVCs) into the internal jugular vein (IJV) in adults and children in elective situations. 1.2 The use of two-dimensional (2-D) imaging ultrasound guidance should be considered in most clinical circumstances where CVC insertion is necessary either electively or in an emergency situation. 1.3 It is recommended that all those involved in placing CVCs using two-dimensional (2-D) imaging ultrasound guidance should undertake appropriate training to achieve competence. 1.4 Audio-guided Doppler ultrasound guidance is not recommended for CVC insertion

17 UPORABA UZ + IZKUŠNJE MANJ KOMPLIKACIJ Kaye AD, Fox CJ, Hymel BJ, et al. The importance of training for ultrasound guidance in central vein catheterization. MEJ Anesthesiol. 2011;21(1):61-66.

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19 Practice Guidelines for Central Venous Access American Society of Anesthesiologists Task Force on Central Venous Access Anesthesiology 2012; 116: Recommendations for Guidance and Verification of Needle, Wire, and Catheter Placement The following steps are recommended for prevention of mechanical trauma during needle, wire, and catheter placement in elective situations: Use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected for cannulation. Static ultrasound may be used when the subclavian or femoral vein is selected. Use real time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation (see fig. 1). Real-time ultrasound may be used when the subclavian or femoral vein is selected. The Task Force recognizes that this approach may not be feasible in emergency circumstances or in the presence of other clinical constraints. After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access. Methods for confirming that the catheter or thin-wall needle resides in the vein include, but arenot limited to, ultrasound, manometry, pressure-waveform analysis, or venous blood gas measurement. Blood color or absence of pulsatile flow should not be relied upon for confirming that the catheter or thin-wall needle resides in the vein.

20 STATIČNI UZ ORIENTACIJA PRED INTERVENCIJO ANATOMSKI ODNOSI, POT VENE PREHODNOST, TROMBOZA, VALVULE OCENA ŠIRINE LUMNA VENE, RESPIRATORNE VARIABILNOSTI KOLAPSIBILNOSTI UZ V REALNEM ČASU INTERVENCIJE ( REAL-TIME ) OCENA SMERI PUNKCIJSKE IGLE VIZUALIZACIJA KONTAKTA KONICE IGLE S STENO ŽILE IN VSTOPA IGLE V VENO UZ PO UVAJANJU ŽICE/KATETRA VERIFIKACIJA POZICIJE ŽICE/KATETRA V LUMNU VENE OCENA EV. HEMATOMA

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22 MOBILNI SPECIALNI ULTRAZVOČNI APARAT ZA UVAJANJE HD KATETROV SITE RITE 3 SITE RITE 5 Bard Co., USA

23 MOBILNI SPECIALNI ULTRAZVOČNI APARAT ZA UVAJANJE HD KATETROV

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28 Target vessels presented by A) transverse and B) longitudinal approach. A B J.Kovač. Ultrasonography and hemodialysis catheters. In: ULTRASONOGRAPHY AND DOPPLER IN NEPHROLOGY, DIALYSIS AND TRANSPLANTATION, The Slovenian Society of Nephrology, Ljubljana, 2009:

29 Right (A) and left (B) internal jugular vein with adjacent carotid arteries A B J.Kovač. Ultrasonography and hemodialysis catheters. In: ULTRASONOGRAPHY AND DOPPLER IN NEPHROLOGY, DIALYSIS AND TRANSPLANTATION, The Slovenian Society of Nephrology, Ljubljana, 2009:

30 The target vein (A) collapses (B) when slight pressure is applied with the ultrasonography probe to the skin above the vein. A B J.Kovač. Ultrasonography and hemodialysis catheters. In: ULTRASONOGRAPHY AND DOPPLER IN NEPHROLOGY, DIALYSIS AND TRANSPLANTATION, The Slovenian Society of Nephrology, Ljubljana, 2009:

31 A) indentation of the vein wall before the puncturing needle punctures the vein wall, B) the tip of the puncturing needle visible inside the lumen of the target vein. A B J.Kovač. Ultrasonography and hemodialysis catheters. In: ULTRASONOGRAPHY AND DOPPLER IN NEPHROLOGY, DIALYSIS AND TRANSPLANTATION, The Slovenian Society of Nephrology, Ljubljana, 2009:

32 SMER UVAJANJA KATETERA GLEDE NA POZICIJO UZ SONDE A. V UZ SNOPU B. PRAVOKOTNO NA UZ SNOP IN PLANE OUT- OF PLANE

33 SMER UVAJANJA KATETERA GLEDE NA POZICIJO UZ SONDE A. V UZ SNOPU B. PRAVOKOTNO NA UZ SNOP IN PLANE OUT- OF PLANE

34 IN PLANE AND OUT-OF PLANE NEEDLE NAVIGATION In-Plane needle orientation with tip projecting distal to needle visualized on screen Out-of-Plane needle orientation with tip projecting beyond ultrasound beam plane

35 ULTRASONIX GPS FOR NEEDLE NAVIGATION Green Orientation Bars for correct In-Plane needle position with needle trajectory projected to target Out-of-Plane ultrasound image with green Target Indicator as needle reaches beam plane

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39 The puncturing needle and guidevire inside the lumen of the vein A) longitudinal view B) cross-sectional view A B

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43 UVAJANJE KATETRA V DVIGNJENEM POLOŽAJU

44 UVAJANJE KATETRA MALIM OTROČKOM Chest roentgenogram of a pediatric patient weighing 13 kg after real-time ultrasonographically guided right jugular vein cannulation. J.Kovač. Ultrasonography and hemodialysis catheters. In: ULTRASONOGRAPHY AND DOPPLER IN NEPHROLOGY, DIALYSIS AND TRANSPLANTATION, The Slovenian Society of Nephrology, Ljubljana, 2009:

45 UVAJANJE CENTRALNIH VENSKIH KATETROV ZA HEMODIALIZO S POMOČJO ULTRAZVOKA PREDNOSTI OLAJŠA IZBIRO IN LOKALIZACIJO VENE OCENA ŠIRINE IN PREHODNOSTI LUMNA VENE POTRDITEV LEGE UVAJALNE ŽICE V VENI MANJ KOMPLIKACIJ KRAJŠE INTERVENCIJE UVAJANJE KATETRA NA POSTELJI (AT THE BEDSIDE) UVAJANJE KATETRA V DVIGNJENEM POLOŽAJU UVAJANJE KATETRA MALIM OTROČKOM OLAJŠANO IN HITREJŠE UČENJE POSTOPKA UVAJANJA UPORABA V DRUGIH OKOLJIH OP./ANESTEZIJA,INTENZIVA, NUJNA STANJA, ONKOLOGIJA (PORTI, PICC) Hvala za pozornost!