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SELDINGER TECHNIQUE FOR CATHETER INSERTION

NOTES AND TIPS ON THE SELDINGER TECHNIQUE Straight tip wires are preffered to flexible tip wires if the contact with the vessel is tangential: for example, with the infraclavicular subclavian approach Flexible tips are preferred if the entrance to the vessel is at a more acute angle, if the vessels is tortuous, or if valves are expected Flexible tips (J wires) decrease the rate of vessel perforation by the guide wire Seldinger technique commonly used for central lines but also can be used for peripheral access; could use to replace an 18 guage with a 14 guage peripheral iv Wires BEND easily and when bent will lead to shearing off bits of wire when it is removed from the needle thus wire emboli................always thread and remove wires with gentle force; wires should always thread easily and smoothly If resistance is encountered when threading or removing the entire unit should be removed; ie, remove the needle and the wire (most people don't do this and are thus risking wire emboli) Gentle rotation of a wire may help with threading a vessel if it is difficult If the wire doesn't thread easily, pull the needle back just a bit to bring the needle tip off the vessel wall and allow easier passage of the wire Never loose control of the end of the wire (use a clamp or keep a hand on it at all times) Don't forget to occlude the needle hub when the vessel is entered to prevent air embolism A trick with right subclavian lines is to make a gentle bend in the dilator to help direct the line down the SVC instead of up into the IJ Complications of Seldinger Technique Wire emboli Lost wires Air emboli Vessel perforation

VENOUS CUTDOWNS

GENERAL Largely replaced by central lines Distal saphenous is most reliable for consistent location Ankle venous cutdown best in pediatrics as well Indications: volume, pressures, no other access Contraindications: (all are relative) less invasive access available, overlying infection, coagulation disorders Essentially any peripheral vein can be used: saphenous and Basilic are the most common; cephalic vein, brachial vein, external jugular, proximal saphenous, femoral vein have all been used DISTAL SAPHENOUS VENOUS CUTDOWN Location: 1cm anterior to medial malleolus Lies adjacent to the periosteum Superficial and consistent location makes it the cutdown location of choice

BASILIC VEIN CUTDOWN Preferred site for venous cutdown in upper extremity Median vein of forearm and median cubital vein join Location: 2 cm above and 2 cm lateral to the medial epicondyle on the anterior surface of the upper arm Note the brachial artery and median nerve are deep to the basilic vein so don't cut too deep TECHNIQUE Prep skin and drape Lidocaine in conscious patient Skin incision transverse to the direction of the vessel Make incision all the way through the skin; sub cutaneous fat should be visible Use hemostat to bluntly dissect through fat; dissect in parallel course of the vein to decrease the risk of damaging the vein from the blunt dissection Tissue retractor to increase exposure Isolate the vein from the adjacent tissue for a span of 3 cm Pass two silk ties, one proximal and one distal Tie off the distal tie but don't cut it Elevate the vein with the distal tie Cut the vessel 1/3 of the way through (NO incision needed if using an iv catheter) Make a distal skin stab or pass needle through distal skin Thread the catheter into the vein; may use hemostat or elevator to help entrance into vein Tie proximal suture Suture wound and catheter in place Apply secure dressing "Mini-cutdown" Refers to simply making an incision over the vessel and using the incision to directly visualize the entrance of the iv catheter into the vein (doesn't use the two sutures) COMPLICATIONS Hematoma Infection Arterial damage Nerve damage Venous insufficiency Phlebiits Embolization Wound dehiscence Deterioration of patient during time of procedure

INDICATIONS FOR CENTRAL VENOUS ACCESS Volume Loading Note flow rates; can get a lot through peripheral 14-16 guage thus the time required to insert a central line should not be the initial focus Small difference in volume between the 14 gauge peripheral access and the 8 Fr. central access will not make a difference in outcome

CATHETER 14 guage X 2 inch peripheral iv 16 guage X 2 inch peripheral iv 8 French central line introducer, 5.5 inches 14 gauge central line angiocath, 5 inches

200 mmHg pressure 400 ml/min 230 ml/min 540 ml/min 341 ml/min

Gravity 175 ml/min 108 ml/min 245 ml/min 155 ml/min

Central Venous Pressure Monitoring Emergency Venous Access: no other access Transvenous pacemaker required PA catheter required Hemodialysis line TPN Infusion of concentrated solutions (Hypertonic saline, Kcl)

GENERAL CONTRAINDICATIONS TO CENTRAL LINES Distorted local anatomy Vasculitis Prior injection of sclerosing agents Suspected proximal vascular injury Previous radiation therapy Bleeding disorders Anticoagulation or thrombolytic therapy Combative patients Subclavian Chest wall deformity COPD IJ Venous drug abuse to IJ Femoral Need for patient mobility

SUBCLAVIAN CENTRAL LINES

ADVANTAGES Good external landmarks Supraclavicular approach can be done during CPR DISADVANTAGES "Blind" procedure Higher incidence of pneumothorax Infraclavicular approach cannot be easily done during CPR Non-compressible site if bleeding occurs CONTRAINDICATIONS Chest wall deformity COPD (high risk of pneumothorax) Coagulopathies (non-compressible site) Previous surgery or trauma to clavicle, first rib, or subclavian vessels Previous radiation to the areas Local infection over the site Suspected injury to subclavian vessels or SVC (use femoral instead) Not generally recommended in small children RELEVANT ANATOMY Vein lies posterior to the medial third of the clavicle Anterior scalene muscle lies posterior to the vein and anterior to subclavian artery Phrenic nerve passes on anterior surface of scalene and can be injured Thoracic duct on left and lymphatic duct on right are also on anterior surface of scalene and can be injured Dome of the left lung extends above the first rib; dome of the right lung usually doesn't Why is right subclavian preferred over left? Dome of right lung isn't as high, thoracic duct is on the left NOTES ON THE INFRACLAVICULAR SUBCLAVIAN LINE Trendelenberg position will decrease the risk of air embolism but doesn't change the vessel size very much (as compared to IJ) Abduction of the arm will decrease the deltoid buldge Pillow or towel under the shoulder/scapula will make the clavicle more prominent and get the deltoid out of the way but MAY make things WORSE by causing compression of the subclavian vessels between the first rib and the clavicle (has been studied) Needle point entry is debatable: most use the junction of the middle and medial thirds of the clavicle; left hand has thumb on the medial clavicle and index finger in sternal notch; AIM just posterior and superior to the tip of the index finger Note that the needle entry should not be too lateral on the chest wall Orientate the BEVEL INFEROMEDIALLY (line bevel up with markings on syringe to help); this will decrease the chance of the wire/catheter going up the IJ Halt ventilations during venipuncture to decrease chest wall movement

NOTES ON THE SUPRACLAVICULAR SUBCLAVIAN LINE Goal is to enter the vessel at the junction of the IJ and SC veins Right side preferred for same reasons as above Identify the clavicular head of the sternocleidomastoid: enter 1cm lateral and 1 cm posterior and AIM for posterior to the contralateral nipple; bevel should be aimed medially COMPLICATIONS General Air embolism Catheter embolism AV fistula Mural thrombus Large vein obstruction Local hematoma Local infection, line sepsis Catheter malposition Catheter knotting Dysrhythmias Subclavian Specific Complications (think arteries, veins, nerves, etc in area) Pneumothorax Hemothorax Chylothorax Pneumomediastinum Hemomediastinum Neck hematoma Airway obstruction Tracheal perforation Endotracheal cuff perforation Phrenic nerve injury Brachial plexus injury Clavicle osteomyelitis Sternoclavicular joint septic arthritis

INTERNAL JUGULAR CENTRAL LINES

ADVANTAGES Good external landmarks Less risk of pneumo than subclavian Compressible site for bleeding Malposition of catheter is rare Straight course into SVC Useful in children DISADVANTAGES "Blind" procedure Slightly higher incidence of failures than SC Harder to secure CONTRAINDICATIONS (relative) Anatomic distortion of the neck Local infection over the site Severe bleeding diathesis (go femoral) Carotid artery disease Previous radiation to the area Suspected injury to subclavian vessels or SVC (use femoral instead) IVDA using the IJ system RELEVANT ANATOMY IJ lies anterior and lateral in the carotid sheath in a fixed position The vein is just deep to the SCM but is NOT VERY DEEP; ie, you should enter the vein at 1-2cm depth so if you haven't hit it by 3-4 cm you need to re-adjust Nearby structures that can be injured: brachial plexus, phrenic nerve, carotid artery, airway, dome of the lung, stellate ganglion of sympathetic chain NOTES ON THE IJ CENTRAL LINE IJ is very distensible (ALWAYS use trendelengburg); compression of the abdomen during venipuncture can also help distend the vein Prolonged compression of the carotid can decrease the venous return and decrease the IJ size Head rotation 90 degrees doesn't usually change anatomic relationship but extreme head rotation does and can increase the rate of carotid puncture Diameter of the IJ increases below the cricoid ring (2-2.5cm) Valsalva maneuver in an awake patient will also cause venous distention Approaches: anterior, medial (central), posterior Medial approach seems to be preferred by most (entrance at tip of triangle); enter at 30 - 45 degree angle; start by aiming at the ipsilateral nipple and work medially; some advocate starting by aiming just lateral to the carotid artery pulsation Anterior approach: enter skin at midpoint of SCM along medial border and direct needle at a 45 degree angle toward the ipsilateral nipple; keep fingers of left hand on carotid pulsation Posterior approach: enter skin at lateral edge of SCM on third of the way from the clavicle to the

mastoid process and aim for sternal notchScout needles should be used if there is time (22 gauge) If you hit the carotid with the locator needle: stop the procedure, hold pressure for few minutes; can re-attempt at the same site If you hit the carotid with the placement needle: stop procedure, hold pressure for 10 min; can reattempt at the same site If you insert the cordis into the carotid: stop procedure, leave cordis IN-PLACE, call a vascular surgeon

COMPLICATIONS General Air embolism Catheter embolism AV fistula Mural thrombus Large vein obstruction Local hematoma Local infection, line sepsis Catheter malposition Catheter knotting Dysrhythmias IJ Specific Complications (think arteries, veins, nerves, etc in area) Carotid artery puncture Carotid artery dissection Cerebral infarct Pneumothorax Hemothorax Chylothorax Pneumomediastinum Hemomediastinum Neck hematoma Airway obstruction Tracheal perforation Endotracheal cuff perforation Phrenic nerve injury Brachial plexus injury Clavicle osteomyelitis Sternoclavicular joint septic arthritis

FEMORAL VEIN CENTRAL LINES

ADVANTAGES Good external landmarks Best location for those with coagulopathies or on anticoagulaton Easiest site to compress Easy access during CPR, etc Easiest central line in peds DISADVANTAGES Limits ambulation "Dirty" site, more prone to infection, especially with the "pannus" CONTRAINDICATIONS Need for patient mobility RELEVANT ANATOMY Psoas muscle and hip lie posterior to the vein NOTES ON THE FEMORAL LINE Note that CPR will produce venous and arterial pulsations that may be palpable: if vein isn't located medial to the pulsations, try directly over the pulsations COMPLICATIONS General Air embolism Catheter embolism AV fistula Mural thrombus Large vein obstruction Local hematoma Local infection, line sepsis Catheter malposition Catheter knotting Dysrhythmias Subclavian Specific Complications (think arteries, veins, nerves, etc in area) Femoral artery laceration Leg arterial embolism after artery puncture Psoas abscess Bowel perforation Bladder perforation Septic hip Femoral osteomyelitis

EXTERNAL JUGULAR CENTRAL LINES

Time consuming to thread the wire and catheter Same position as for IJ Trendelenburg will dilate the EJ Place slight traction on the vein Enter the skin at a 10 degree angle from the skin Insert a J shaped guide wire Advance wire into thorax by rotating, teasing, or twisting the wire Guide wire advancement is the most difficult aspect of the procedure Skin traction and exaggerated head tilt may help thread the wire Threading of the catheter and dilator can also be difficult

CENTRAL VENOUS PRESSURE MONITORING

CVP = pressure exerted by the blood against the wall of the intrathoracic vena cava Repressents the preload to the right ventricle Measurement of pressure from SVC or IVC is preferred to right atrial measurement because of right of perforation of RA, RV, dysrhythmias, tamponade Indications: shock, massive fluid replacement, suspected tamponade CVP does NOT reflect left sided pressures (need PCWP for that) Measurement by manometry column See figure 24-19 in Roberts and Hedges Zero mark aligned with the tricuspid valve (midaxillary line in supine pt) Stopcock turned to direct flow to the patient Must flush tubing prior to measurement Stopcock opend to fill the manometer to 25 cm Stopcock opened to the patient, column of water equilibrates and measurement take Errors in CVP measurement Increased intrathoracic pressure: straining, coughing, ventilator asynchrony Reference point error Malposition of the catheter tip Blocking of catheter Air bubbles in the circuit Reading during wrong phase of ventilation (should be at end inspiration) Reading by different observers Vasopressers

Measurement by electronic transducer : nipple valve attached to a bag of saline to allow easy flushing of the system

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