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
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
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
Simulation Session Central line placement Focus on US IJ Discussion of sterile procedure and trouble shooting
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
Tip # 1 Solo Sterility One handed sterile technique
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
CDC Recommends When and How to place a CVC That we assess this knowledge Need training
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
Indications For CVC Inadequate peripheral venous access Inability Administering noxious substances (pressors, TPN) Measurement of cardiac filling pressures Measurement of ScvO2
Contraindications Absolute Operator inexperience Uncooperative patients Uncorrected coagulopathy in a STABLE patient
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
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
Tip # 2 The Guidewire
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
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
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
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
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
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)
Site Selection - Femoral Higher risk of thrombotic or infectious complications avoid when possible No risk of pneumothroax Compressible Unreliable CVP
CVC Placement NEJM Videos Available online for your review Femoral Line Subclavian Internal Jugular
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
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
Subclavian Line - Supraclavicular Pocket Shot 1 cm lateral to SCM 1cm posterior to SCM Bisect lateral SCM and clavicle 10-15 degrees from horizontal
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
Tip # 5 -Manometry
Femoral Line - Temporary
Femoral Line Placement
Femoral Line Placement Follow the link to the video will need advocate access or a personal account: http://www.nejm.org/doi/full/10.1056/nejmvcm 0801006
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
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?
Suturing Securing the Line
Stat Lock Securing the Line
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
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
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
See you in the Sim Lab!