central venous access. indications peripheral access impossible. administration of irritant...

Central Venous Access

Indications

• Peripheral access impossible.

• Administration of irritant medications inc. TPN.

• Measurement of mixed venous oxygen saturations.

• Right heart catheterisation.

• RRT / ECMO etc.

• NB - NOT fluid status

Assessment

What aspects of the patient examination and investigations need to be taken into

account before inserting a central line?

Monitoring and Environment

Where should a central line be inserted?

What monitoring is required?

Infection Control

Site

What sites are available for central access?

What are the advantages / disadvantages of each?

Internal Jugular

External Jugular

Subclavian

Femoral

PICC

Ultrasound• Position the ultrasound screen on the other side of the patient to

allow easy viewing

• Touch the side of the probe while observing the image to orientate the probe. (Some probes have a mark that corresponds to one side of the screen for this purpose)

• Alter the gain to produce a relatively dark image that will help discriminate the white of the needle tip

• Use sterile gel inside the probe sheath (and between the sheath and the patient’s skin) to provide acoustic coupling

• Throughout the procedure, maintain a sterile environment. (The operator should be wearing a sterile gown, mask, hat and the area should be cleaned before drapes are applied)

Short vs Long Axis View

How can you differentiate between vein and artery?

Veins are (usually)….

• Where you expect then to be

• Compressible

• Non-pulsatile

• Varying in size with respiration, valsalva, fluid loading

Seldinger Technique

Complications

What complications are related to insertion of the line (immediate complications)?

• Arrhythmias

• Venous bleeding

• Arterial bleeding

• Pneumothorax

• Cardiac perforation

• Embolisation (air or thrombus)

• Retained wire

What adjacent structures can be damaged when attempting IJV cannulation?

• Thoracic duct

• Vagus nerve

• Brachial plexus

• Phrenic nerve

• Stellate Ganglion

• Glossopharyngeal nerve

What are the potential delayed complications?

• Sepsis

• Extravasation (dislodgement)

• Thrombosis

CXR Position

Good Position Abutting SVC