CENTRAL VENOUS CATHETERISATION }Measurement of central venous pressure (CVP) ž ( E.G. those with hypotension not responding to normal management, requiring infusion of inotropes) } }For long term administration of drugs for pain, infection, cancer or to supply nutrition. } }Venous access for IV fluids or antibiotics or a peripheral site is unavailable/unaccessible } }Haemodialysis }Patients undergoing thrombolytic or anticoagulative therapy } }Bleeding disorders } }Vasculitis } }Distorted local anatomy } }Overlying skin infections( dermatitis), burns } }Uncooperative patient } •INFECTIOUS žSepsis (also septic arthritis, osteomyelitis) ž •VASCULAR žAir embolism, blood clot, hematoma, arterial puncture ž •OTHERS žPNEUMOTHORAX, hemothorax, arrhythmias , nerve injury žINTERNAL JUGULAR VEIN ž žSUBCLAVIAN VEIN ž žFEMORAL VEIN ž ž Length of catheters Ø Ø15cm catheters for subclavian and internal jugular lines, and 60cm catheters for femoral line žPatient on a tilting bed, trolley or operating table žStandard multiple lumen kit žGuide wire žSterile gloves žSterile gown žDrapes žDisinfectant (Povidone-iodine solution/ chlorhexidine) žSuturing needle žScalpel žLocal Anaesthetic (lidocaine) žSterile saline flush A= small syringe and vial of 1% Lidocaine (L.A) B= guide needle C= IV syringe with catheter attached- D E= Disinfectant sponge Guidewire: J-shaped tip to reduce risk of vessel perforation Dilator Triple lumen catheter }SELDINGER TECHNIQUE (most common) 1)Use guide needle to locate the vein 2)Wire threaded through needle 3)Remove needle 4)A dilator is passed over the guide wire 5) Dilator is removed and catheter is passed over wire and wire is removed 6)Catheter secured in place žAllows larger catheters to be placed in the vein after the passage of appropriate dilators along the wire and a small incision in the skin at the point of entry. Ø ØObtain informed consent and explain risks and benefits of procedure • ØOptimal patient positioning and cooperation, make sure patient is comfortable Ø ØTake your time Ø ØSterile technique Ø ØLocal anaesthetic should be used • ØAlways have a hand on your wire Ø ØAspirate while advancing as you withdraw the needle slowly Ø ØWithdraw needle to the level of the skin before redirecting the angle Ø ØDon’t poke yourself with the needle Ø ØThe tip of the catheter can lie in either the superior or inferior vena cava (SVC or IVC) or into the right atrium (RA). 1.POSTIONING : žTRENDELENBURG POSITION Ø Patient supine on surface inclined 45 degrees, head at the lower end and legs flexed over upper end. ž( This distends the central veins and prevents air embolism) ØHead turned to opposite side of central venous line ØStand at the head of the patient ž • • Ø Ø ØUltrasound and landmarks can be used Ø ØIJV is between the clavicular and sternal heads of the sternocleidomastiod muscle Ø ØPoint of needle insertion is midway between sternal head of SCM and mastoid process behind ear ØDisinfect area , apply L.A and fenestrated drape Ø ØPlace three fingers on carotid artery Ø ØPlace needle about 45 degrees to the skin, lateral to the carotid artery Ø ØDirect needle in sagittal plane angled towards feet Ø ØVein should be 1-1.5 cm deep, avoid deep probing in the neck Ø ØSeldinger technique used › ž ž ž http://www.youtube.com/watch?v=QHiuYc22pfE 1.Disinfection, L.A and sterile drape 2. Insert needle into IJV and aspirate 3. Hold tip of needle with one hand 4. Place wire through needle and remove needle 5. Insert catheter over wire then remove wire 6. Once catheter is in place , secure and apply dressing ž POSITIONING ØTrendelenburg postion (10-15 degrees) ØSupine position, head and shoulders neutral with arm slightly abducted ØStand beside the patient at the side ž žPROCEDURE ØDisinfect area and apply local anaesthetic ØCover procedure area with fenestrated sterile drape ØUse seldinger technique ž ž LOCATION AND ACCESS TO VEIN ØIdentify the midclavicular point and sternal notch ØInsert needle into the skin 1cm below and lateral to the midclavicular point Ø Direction of needle should be parallel to skin ØAdvance posterior to the clavicle aiming for the sternal notch (Do not pass the needle further than the sternal head of the clavicle) subclavian http://video.google.com/videoplay?docid=2421324986948418582# ž ž POSITIONING ØSupine patient ØExtend the patient’s leg and abduct slightly at the hip Ø žPROCEDURE ØDisinfect area and apply local anaesthetic ØCover procedure area with fenestrated sterile drape ØUse seldinger technique Ø žLOCALISATION AND ACCESS TO VEIN ØVein is medial to femoral artery ØIdentify the pulsation of the femoral artery 1-2 cm below the inguinal ligament. ØPosition needle at 45 degree angle and about 1cm medial to pulsation ØNeedle inserted at skin about 2 cm below inguinal ligament ØAiming towards the umbilicus ž(In adults, the vein normally found 2-4cm from the skin. In small children reduce elevation on the needle to 10-15° as the vein is more superficial) http://www.4shared.com/file/61538831/b1027127/Placement_of_a_Femoral_Venous_.html 1)Aspirate blood from each port 2)Flush with saline / sterile water 3)Secure the catheter with sutures 4)Apply sterile dressing 5)Dispose of used gloves, needles, syringe etc 6)Wash hands 7)Chest x-ray for IJ and SC lines 8) ž LOCATION BENEFITS RISKS INTERNAL JUGULAR VEIN •Bleeding can be seen and controlled •Decreased risk of pneumothorax •Risk of Carotid artery puncture •Pneumothorax SUBCLAVIAN VEIN •Most comfortable for concious patients •Increased risk of pneumothorax •Should not be done on less than 2yrs •Vein is non- compressible FEMORAL VEIN •Easy to locate •Less bad complications •No risk of pneumothorax •Preffered in emergencies •Highest risk of infection •Risk of DVT ž THANX FOR LISTENING!