Access Flashcards
Ways to optimise rapid infusion:
1- Short catheter
2- Large bore (RIC, CVC)
3- Pressure differential (rapid infuser/ pressure bag/ manual squeeze)
Pros/cons for various CVC insertion sites:
*NECK: *mobility, less infection, allow for pacing, direct (good for high conc)
But:
Patient must lie semi-flat. Bleeds less compressible.
IJV
- (Right preferred)
- Thoracic duct injury if L
- Uncomfortable, head mobility
SUBCLAVIAN
- Comfort, mobility, hidden: preferred long-term option
- Higher PTx rate
- Incompressible bleed!!
- Less familiar
FEMORAL
- Quick + accessible
- Compressible if bleed
- -> Best if coagulopathic/ being lysed
- Can do with pt sitting up
- -> Best in raised ICP, resp failure etc.
- Not if mobile
- Infection risk
- Less direct: care with high conc. infusions
Method of IJV CVC insertion:
RIGHT side preferred:
- -> Straighter
- -> Lung apex lower
- -> No thoracic duct
Approaches:
Central
- Trendelenberg at 30 degr (air embolism)
- Rotate head away
- USS: enter IJV halfway down neck (1cm above apex of triangle made by the 2 SCM heads)
- Expect blood within 3cm
- Enter 30-60 degr
- Towards ipsi nipple
Anterior
Enter anterior to SCM (+head to nipple)
Posterior
Enter posterior to SCM (+head to nipple)
- Seeker, wire, cut, dilate, thread
- Insert to 15cm
- Aspirate and flush all lumens
- Gas to check venous
- Suture and dress
- CXR
Method of Femoral CVC insertion:
Identify inguinal ligament (ASIS to pubis)
USS: identify femoral vein (NAVY)
Or pulse, for landmark.
- Enter inferior to inguinal ligament:
–> 1-2cm child
–> 2-4cm adult
45-60 degr
Direct straight up thigh
Risk of retroperitoneal haemorrhage if puncture through, above ing lig
Method of Subclavian CVC insertion:
Approaches:
- *Infraclavicular**
- Most familiar, easier, lower PTx risk*
- Trendelenberg 30 degr (air embolism)
- USS inferior to clavicle
- Enter immediately inferior to mid clavicle
- Insertion is shallow ++
- Direct needle along clavicle, towards sternal notch
- *Supraclavicular**
- Enter 1cm above clavicle, and lateral to SCM
- Direct towards contra nipple
General complications of CVCs:
- Air embolism
- Arrhythmia (guidewire/catheter)
- Failure
- Malposition/ extravasation
- -> Incl. intra-arterial
- Thrombosis
- Infection (femoral)
- Haemorrhage
- -> Haemothorax (IJV, subclav)
- -> Retroperitoneal (femoral)
- -> Incompressible (subclav)
- Pneumothorax (supraclavic subclav)
- Thoracic duct (L sided IJV/subclav)
- Pain/ discomfort /limited mobility
Correct CVC position on CXR:
Distal SVC** or **Cavoatrial junction
AT carina, or one vertebrae above or below it
Not IN RA- easily perforated/ arrhythmia.
How to access a central lines:
- Port
- CVCs
Risks:
-Infection
-Clotting
-Air embolism
__________
SUBCUT PORT
- STERILE
- Saline prime + access with a non-coring Huber needle
–>
- Sterile saline flush
- Heparin lock
EXTERNAL CVC:* (incl PICC, Hickmann)
- ASEPTIC non-touch with sterile gloves
- 30 second scrub hub
- Access Leuer
- Small flush + drawback to ensure patency first
–>
- Scrub hub again
- Sterile saline flush
Intraosseus access (IO) insertion sites:
Based on PATIENT fingers
In resus, humeral head best. More central, more rapid and bypasses abdo/pelvis in trauma.
________
HUMERAL HEAD- best, adults only
- Rest arm across abdomen
- Find greater tuberosity
- Insert 1cm above this
- ALWAYS IN TRAUMA
PROXIMAL TIBIA - preferred for kids
- Find 2 fingers medial to tibial tuberosity
- If under 2yo, won’t feel tib tub. Will be 2 fingers under patella
DISTAL TIBIA
- 3 fingers above medial mall
DISTAL FEMUR
- 3 fingers above patella
STERNUM
Intraosseus (IO): what CAN’T be given/done as compared to CVC
Can give any fluid, blood product or medication
CAN’T:
- Run a blood gas
- Pace
- Measure CVP
- Use multiple lumens
Intraosseous (IO): contraindications
- Skin burned/cellulitic/ contaminated
- Bone diseased (OP, osteogenesis etc.)
- Bone fractured (risk extravasation/ compartment Sx)
EZ-IO sizes:
Pink (<40kg)
Blue (>40kg)
Yellow (humerus, or obese)
Describe EJV PIVC insertion:
- Trendelenberg to distend
- Occlude EJV at clavicle with thumb/finger
- ALWAYS COVER HUB- cannot allow air in (embolism)
- Cannulate
Peripheral venous cut-down
Great Saphenous- ANKLE:
- 2.5cm ABOVE and IN FRONT of MEDIAL malleolus
- Incise SKIN only across width of tibia
- Scrape Curved haemostats along bone
- Open: this will dissect vein up and off
- Pass straight haemostats underneath to lift
Great Saphenous- GROIN:
- Find intersection of MONS PUBIS and SCROTAL/LABIAL fold
- Horizontal 6cm incision
- Blunt dissect
Other: cubital.
__________
Ways to cannulate:
- IVC
- Suture in IV tubing
- Seldinger
Scalp IV access:
-
Umbilical line:
Up to 10 days old
________
- Chlorhex + dry
- Tie off base of cord
- Cut a fresh surface
- Identify vein (x1) and arteries (x2)
- Hold cord with forceps
- Insert 5F line until blood free-flowing (3-5cm)
- Suture to base
- Confirm on Xray
–> IVC, central at diaphragm
–> if off to side, has deviated into liver circ
