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Central Venous Catheter Placement

Central Venous Catheter Placement. John P. Kress, MD University of Chicago Department of Medicine Section of Pulmonary and Critical Care. Indications. Inadequate peripheral venous access Invasive monitoring Vasoactive drugs Administration of caustic agents TPN Hemodialysis

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Central Venous Catheter Placement

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  1. Central Venous Catheter Placement John P. Kress, MDUniversity of ChicagoDepartment of MedicineSection of Pulmonary and Critical Care

  2. Indications • Inadequate peripheral venous access • Invasive monitoring • Vasoactive drugs • Administration of caustic agents • TPN • Hemodialysis • Long-term venous access • Rapid volume administration

  3. Flow Rates of Various Catheters

  4. Contraindications • Coagulopathy/thrombocytopenia • Infection/burn at entry site • Known venous thrombosis at proposed site • No landmarks • Thrombolytics • Site specific

  5. Complications • INFECTION • PNEUMOTHORAX • ARTERIAL CANNULATION, PUNCTURE • Hemothorax • Dysrrhythmias, heart block • Air embolism • Venous thrombosis • Fluids/drugs into pleural space • Catheter/wire embolism • Cardiac perforation/tamponade (Collier PE, et al. Am J Surg 1998;176:212)

  6. Vascular Catheters—Infectious Complications • Infectious complications • ~ 80,000 occurrences annually in US • Mermel LA. Ann Intern Med 2000;132:391 • 2-5 BSI per 1000 catheter days • ICU mortality—35% per infection, extra ICU LOS—9.5 days • Renaud B, et al. AJRCCM 2001;163:1584 • PICC doesn’t decrease risk (Safdar N, et al. CCM 2005;128:489)

  7. Preparation • Set up: monitors, kit, gloves/towels, sterile tubing • Prep/drape for both IJ and SCV approaches • Wide prep/drape • Won’t obscure landmarks/orientation • Central line infections ~ 80,000 annually in US • Mermel LA. Ann Intern Med 2000;132:391 • Chlorhexidine, full body drape, hat, mask, sterile gown/gloves • Maki DG, et al. Lancet 1991;338:339 • Sherertz RJ et al. Ann Int Med 2000;132:641 • Pronovost P, et al. NEJM 2006;355:2725 • Trendelenburg • “Finder” needle • Keep J-wire sterile, save it “for later”

  8. CRBSI reduction • A multifaceted approach • Berenholtz SM, et al. Crit Care Med 2004;32:2014 • Cohort study • SICU with concurrent control CV surg ICU (1/1/98-12/31/02) • 5 part intervention • Educational intervention to increase CRBI awareness • Central catheter insertion cart • Ask daily whether catheters can be removed • Bedside nurse checklist • Nurses can stop procedure if guidelines not followed • Baseline: guidelines followed 62% of time • CRBSI in study ICU ↓’d from 11.3/1,000 cath days in 1st of 1998 to 0/1,000 cath days in 4th quarter of 2002 • Estimate prevention of 43 CRBSIs, 8 deaths, $1,945,922 costs/yr

  9. CRBSI reduction • A multifaceted approach • Berenholtz SM, et al. Crit Care Med 2004;32:2014 • Cohort study • SICU with concurrent control CV surg ICU (1/1/98-12/31/02) • 5 part intervention • Educational intervention to increase CRBI awareness • Central catheter insertion cart • Ask daily whether catheters can be removed • Bedside nurse checklist • Nurses can stop procedure if guidelines not followed • Baseline: guidelines followed 62% of time • CRBSI in study ICU ↓’d from 11.3/1,000 cath days in 1st of 1998 to 0/1,000 cath days in 4th quarter of 2002 • Estimate prevention of 43 CRBSIs, 8 deaths, $1,945,922 costs/yr

  10. CRBSI reduction • Pronovost P, et al. NEJM 2006;355:2725 • 5 evidence based procedures • Hank washing • Full barrier precautions • Chlorhexidine • Avoid femoral site • Ask daily whether catheter can be removed • 108 ICUs; 1981 ICU-months of data, 375,757 cath-days • Rate of CRBSI per 1000 cath-days • Baseline 2.7 → 0 (3 mo f/u) (P<0.002) • Rate of CRBSI per 1000 cath-days • Baseline 7.7 → 1.4 (16-18 mo f/u) (P<0.002)

  11. Parienti, J.-J. et al. JAMA 2008;299:2413-2422 • RCT (IJ vs. femoral) of 750 patients BMI < 45; required first catheter for RRT • More hematomas in IJ group (13/366 [3.6%] vs. [1.1%]; P = .03) • The risk of catheter colonization at removal did not differ • between the femoral and jugular groups (incidence of 40.8 vs 35.7 per 1000 • catheter-days; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.62-1.16; P=.31) • The rate of catheter-related bloodstream infection was similar in both groups • (2.3 vs 1.5 per 1000 catheter-days, respectively; P = .42) Kaplan-Meier Curves of Time to Catheter Colonization on Removal Stratified According to BMI Terciles

  12. Complications • Lefrant JY et al. Int Care Med 2002;28:1036 • > 1 attempt—independent risk factor for failure/complications (arterial puncture, PTX, misplacement of catheter) • Rec: no more than 2 attempts before stopping, considering alternative site

  13. Vascular Catheters • Pneumothorax • Meta analysis—no diff between IJ and subclavian • Ruesch S, et al. Crit Care Med 2002;30:454 • Catheter malposition • RA or RV positioning—cardiac perforation/tamponade • Collier PE, et al. American Journal of Surgery 1998;176:212 • Booth SA, et al. British Journal of Anaesthesia 2001;87:298 • Recommendation—cath tip to angle between trachea and R mainstem bronchus • FDA. Precautions necessary with central venous catheters. Task Force FDA Drug Bulletin 1989:15

  14. Vascular Catheters • Air embolism • Large bore venous catheters • Dysfunctional one-way valves, uncapped catheters may allow air entry with subatmospheric intrathoracic pressure (e.g. during inspiration) • During catheter removal, temporary communication between skin and vessel • Minimizing risk • Trendelenburg position • Valsalva maneuver during removal • Bio-occlusive dressings • Ely EW, et al. Crit Care Med 1999;27:2113

  15. Seldinger Technique

  16. Vascular Catheters • U/S guidance • Lack of benefit in early studies • Mansfield PF, et al. Complications and failures of subclavian vein catheterization. NEJM 1994;331:1735 • No real time U/S guidance in this study • Subclavian is hardest to find with U/S • Growing evidence of benefit, esp with real time guidance • Gualtieri E, et al. Crit Care Med 1995;23:692 • Lichtenstein D, et al. Intensive Care Med 2001;27:301 • Hughes P, et al. Anaesthesia 2000;55:1192 • Milling TJ, et al. CCM 2005;33:1764 • Prudent to utilize if available, esp with coagulopathy or unclear landmarks

  17. U/S guidance—Milling TJ, et al.

  18. But . . . the ultrasound is only helpful if used by experienced hands • Brush DR, et al. Housestaff Use of Ultrasound During Central Line Placement Does Not Significantly Increase Success Rates and Increases the Number of Femoral Lines. AJRCCM 2008 • Success with vs. without U/S (89% vs. 88%; p=NS) • No differences in the rate of serious complications • Increase in femoral catheter placement with U/S (33% vs. 23%; p<0.01)

  19. Advantages Better control of bleeding Can compress carotid RIJ—straight path to SVC/RA Lower failure rate with inexperienced operators Reliable landmarks ¯ ‘d risk of venous thrombosis in ESRD Schillinger F, et al. Nephrol Dila Transplant 1991;6:722 Disadvantages Carotid puncture Higher incidence of arterial puncture compared with SCV Ruesch S, et al. Crit Care Med 2002;30:454 Difficult with trach Vein collapse with hypovolemia ­’d ICP (contraindicated?) Difficult for long-term LIJ may injure thoracic duct Internal Jugular

  20. Internal Jugular • Median Approach • Locate: 2 heads of SCM muscle, carotid pulse • Start high in the triangle • Angle 60-90o from skin • Left hand holds angle of jaw, extends neck (“fix” vein) • Toward ipsilateral nipple • Vein usually 2-3 cm from skin surface

  21. 6:20-8:00; 11:06-11:49

  22. Advantages Vein stays patent with hypovolemia Reliable landmarks Better for comfort and dressing changes Disadvantages Can’t compress vein (or artery) Probably no increased pneumothorax rate? Ruesch S, et al. Crit Care Med 2002;30:454 Higher rate of catheter malposition Lower success rate with inexperienced operators “Pinch off” syndrome—compressed by clavicle and first rib. May be prelude to fracture and embolization of catheter Funaki B. AJR 2002;179:309 Subclavian Vein

  23. Subclavian Vein • Infraclavicular Approach • Towel between scapulae • Three approaches: medial, middle, lateral • Anesthetize peri-osteum of clavicle • Toward supra-sternal notch, needle parallel to clavicle and bed • Contact clavicle with needle, then “walk” the needle under it, (keep it parallel) • Stay in contact w/ underside of clavicle

  24. 2:43-3:20; 4:34-5:15

  25. IJ or SCV catheterization • Can try both on same side in case first site fails • ALWAYS obtain CXR after line placement and before contralateral attempts

  26. Advantages High success rate No pneumothorax risk Compressible vessel Disadvantages Higher Infection rate Thrombosis rate CVP, ScvO2 reliability? Peritoneal cavity entry Difficult for PA catheter insertion Femoral Vein

  27. Vascular Catheters—Femoral vs. subclavian Merrer J, et al. JAMA 2001;286:700 • Best anatomical location?? • Femoral vein (vs. subclavian vein) • More infectious complications (19.8% vs. 4.5%; P < 0.001) • More thrombotic complications (21.5% vs. 1.9%; P < 0.001) • Mechanical complicationssame (17.3% vs. 18.8% [4/289 pneumothoraces]; P = 0.74)

  28. Femoral Vein • Femoral arterial pulse just below inguinal ligament • Find the inguinal ligament • Start with angle 45-60o from skin surface

  29. 8:18-10:53

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