Advanced Vascular Access Flashcards
Indications for a Central Line Placement
6
- Hemodynamic monitoring
- need to get CVP & SVO2 levels
- need to get pulmonary artery catheter, swan-ganz, RHC - Fluid resuscitaion & deliver blood products
- Administer hyperosmolar agents, vasopressors & medications (which may be a vesicant & cause necrosis at peripheral vessels)
- temporary transvenous cardiac pacing
- Hemodialysis & plasmapheresis
- lack peripheral access
Contraindications for Central Line Placements
risk/benefit contraindications?
- Trauma to the area/altered anatomy
- infection overlaying the sight
- thrombus within the vein
weight risk/benefits?
- coag. disorder/thrombocytopenia
- anatomic abnormalities
- thrombus/stenosis in the vessel
- localized skin infection/breakdown at site
- recent pacemaker insertion
sizing system for CVC & indications for specific types
Larger French = larger catheter
larger gauge = smaller size
Types
- Standard Triple: 3 lumens (standard use)
- HD Cath: for HD only
- trialysis: HD with extra med port
- MAC: for hemorrhagic shock pts.
- PICC: can be used PA-cath placement
- Trauma Line
- RICC: not used for central access
Anatomical Sites for Central Access
- postives & negatives about each site
Internal Jugular
+: good bleeding control, low infection rates
-: carotid artery injury, uncomfortable for pts., IJ vein prone to collapse
Subclavian Vein
+: good maintence of dressing (easy), clear landmarks for placement, SC less prone to collapse, lowest infection rates
-: highest risk of a PTX, difficult to compress SC during a bleed
Femoral
+: good placement for CPR pts, can be used immediately after placement
-: HIGHEST INFECTION RATE, difficult for PA-Cath, femoral arterial injury, DVT
what are the anatomical locations for a CVC?
- inside the body when doing an xray– where should it be
within the DISTAL SVC (the lower 1/3)
but
NOT within the RA (can cause arrythmias)
can be in proximal RA
- will appear just below the carina on xray
Subclavian central Lines
- when is it used
- risk with this site
can be placed emergently (without US) if the femoral is not avalible –> but most all use US for placement
risks: PTX
step-by-step placement for a central line in the subclavian
- insert needle 1cm below medial 1/3 clavicle
- insert at an angle in which you can touch clavicle –> then advance along inferior border
- direct tip towards suprasternal notch and aspirate blood
Femoral Line Placements
- indications
- risks
- how
easiest and quickest placement
- done with landmarks (NAVEL) so US not needed, but still used
- best sight during a code
Risks: Infection (HIGHEST)
How: insert 1-3 cm below inguinal ligament &1cm medial to femoral artery
Femoral Line Placements
- indications
- risks
- how
easiest and quickest placement
- done with landmarks (NAVEL) so US not needed, but still used
- best sight during a code
Risks: Infection (HIGHEST)
How: insert 1-3 cm below inguinal ligament &1cm medial to femoral artery
complicaions of central line placements
Acute and subacute
Acute
- failure to canulate
- pseudoaneurysum (injury to the vessel lining)
- cathether malposition
- AV fistula
- hematoma
- arrythmia (wire too deep)
- air embolism
- pneumo/hemothorax
Subacute
- hemo/pneumothorax
- air embolism
- arrythmia
- skin infection –> bacteremia
- nerve injry
- chylothorax injury
- stenosis/thrombosis of the vessel
- cardiac tamponade
Step-by step guide to a Central Line Placement
pre-procedure
- consent!
- ensure tele. is on
- 2nd person present
peri-procedure
- sterile technique!
- cholorahexadine (30sec. x 3 with 60 sec. dry) & (30 sec. x3 with 2 min. soak at moist)
- sterlize chin to nipple & shoulder to ear
Procedure –seldinger technique
- IJ: must have US guide
- transduce prior to lin eplacement to see vessels
post-procedure
- documnet (guidewire MUST be removed& confirmed via second person there)
- eval with US picture and confirm with xray
selinger technique for CVC
- identify vessel with US
- puncture vessel with needle & aspirate to confirm vein
- insert guidewire through needle lumen (to approx. 20-30 cm.) then remove needle (leave wire)
- dilator slide on then off
- place central line (uncapped distal lumen) and remove guidewire
- flush and aspirate all sports with saline and cap
- suture line in place
IJ placement: position
femoral?
IJ: trendelenburg
femoral: frog leg
when visualziing vessel – what would a thrombus look like at the sight on US?
where do you want to see the carotid in relation to the IJ?
- thormbous: will look “cloudy” opaque
- ensure entire IJ is compressible prior to sticking
carotid should be to the SIDE of the IJ– not underneath
Indications for Arterial Line Placement
- invasive hemodynamic monitoring in critically ill pts.
- frequent arterial blood samples needed (ventilation adjustments)
- arterial admin. of TPA
- placement of balloon-pumps
- real time monitoring of cardiac output/stroke volume/fluid responsiveness
not for medications (besides TPA) but for MONITORING
Contracindications for Arterial Line Placements
- peripheral vascular insufficiency
- failed allen test (cant place a radial line)
- infection
+/- on coagulopathies
how to place an arterial lin e
- technique
- locations
- equiptment needed
- specfifics for a radial line?
- specifics for a femoral line?
technique: selingers
loacations: radial, femoral, axillary
equiptment: US, catheter for arterial lines & monitoring cables
Radial Line:
- perform ALLEN TEST with POCUS
- palpate pulse
- insert cathether
- secure with suture and board
Femoral Line:
- palpate femoral pulse or US guided
- goe .5-1cm LATERAL to the central line
- secure with suture
what is Venous Cut Down?
when is it used?
what site?
Venous Cut Down: surgical exposure and visualization of the vein to administer medications
When? in Trauma hypovolemic shock –> emergency access
(not widely used because of interosseous lines and US technique to guide)
Where: Saphenous vein most commonly
What is an Interosseous Line?
when is it used?
where is it ususally done? kids v adults?
a direct needle placement and catheter into the bone
when: done when there is difficulty placing a central line (burns, trauma, edema, CPR – vascular access is poor)
where:
KIDS: distal & proximal tibia, distal femur
ADULTS: distal & proximal tibia, distal femur, humerus , sternum, calcaneus
contraindications for an IO placement?
technique for placement
contraindications
- infection, burn or trauma at site
- fracture on same extremity
- osteopenia, osteoperosis, osteogensis imperfecta
- a previous sterneotomy
Technique
- sterilize
- stab limb and needle to the bone & away from joint
- apply pressure until resistance is decrease & you enter the marrow cavitiy
- confirm placement with aspiration
