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Central Line insertion

What’s New For the Millennium?. Central Line insertion. Dr. David Easton MD FRCPC . University of Manitoba, Canada Section of Critical Care and Emergency Medicine Winnipeg Regional Health Authority Critical Care Quality Committee. Introduction.

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Central Line insertion

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  1. What’s New For the Millennium? Central Line insertion

  2. Dr. David Easton MD FRCPC University of Manitoba, Canada Section of Critical Care and Emergency Medicine Winnipeg Regional Health Authority Critical Care Quality Committee

  3. Introduction • Patient Safety in ICU is one of the “Hot” and area of focus for the New Millennium • Multiple interventions in multiple areas are being proposed and adopted to help improve care/outcomes and prevent complications • The Institute for Hospital Improvement (IHI) is a driving force in North America

  4. Introduction • Central Line Insertion is a area of focus and there are two main areas that can reduce complications and improve patient outcomes • Preventing Central Line Infections using a “Central Line Quality Bundle” • Ultrasound guided Central Line Insertion

  5. Goals & Objectives • Review components of Central Line Insertion Bundle • Review indications and evidence for ultrasound assisted vascular access • Review basic sonographic technique of ultrasound assisted line insertion

  6. Central Line Infections (CLI) Why Should I care?

  7. Central Line Infections (CLI): • CLI’s – Common! • 50% patients in ICU have Central Venous Catheter (CVC) • Infection rate is 2-5 /1000 catheter days • That equals up to 80,000 infections/yr U.S.A. • CLI’s – Costly! • 2.3 billion dollars/yr U.S.A. • CLI’s – Lethal! • 28,000 patients/yr die from infection

  8. CLI Risk Factors • Site of insertion: Subclavian vein less risky than internal jugular or femoral vein • Multiple ports/hubs: More manipulation and contamination • Parenteral feeding: TPN and/or lipids • Infection elsewhere: Remote source of sepsis already established Mermel LA, Am J Med. Sep 16 1991;91(3B):197S-205S McCarthy MC, J Parenter Enteral Nutr 1987; 11:259.

  9. Central Line Infections • Important Quality Health Care Topic! • In 2002 CDC made recommendations for insertion to help prevent infection • O’Grady, MMWR 2002 • Central Line Insertion Bundle Developed • What is a bundle? • A group of evidence based concepts/guidelines that together improve the outcome of interest

  10. The Central Line Bundle • 5 Simple Steps that have been shown to decrease rates of CLI dramatically • Hand Hygiene –Wash your hands! • Full Barrier Precautions – Fully gown/drape • Clean Skin with Chlorhexidine • Avoid Femoral Line Site – Subclavian best • Remove Unnecessary Lines ASAP

  11. What are Maximal Barrier Precautions? • For the Provider: • Hand hygiene • Non-sterile cap and mask • Sterile gown and gloves • For the Patient: • Cover patient’s head and body with a large sterile drape • “Head to Toe” coverage

  12. Barrier Precautions

  13. But, Does All This Work? ICUs that have implemented the central-line bundle have nearly eliminated CLI’s ! Berenholtz et al. Critical Care Medicine. 2004; 32:2014-2020.

  14. So…Don’t Wait Any Longer!Make a Practice Change Today!

  15. Ultrasound Assisted Central Line Insertion

  16. Background • First report of ultrasound to assist in vascular access was by Legler in 1984 in anesthesia literature • found was similar to landmark technique

  17. Background • Experience and research has grown overtime • In 2007 - Over 200 papers on subject • Currently there are numerous guidelines and statements from various organizations across the World

  18. What Is The Basic Evidence? • Adrienne and Cook et al “US guidance for placement of CVC - Meta-analysis” • Used 8 of 208 studies • Found evidence of: • decreased attempt rate • decreased complication rate • decreased failure rate • NNT = 7 to prevent one complication • NNT = 5 to prevent more than 1 attempt Crit Care Med, Dec 1996

  19. Summary of Recent Meta-Analyses on US guided CVC Insertion

  20. …Evidence • Peripheral Access? • “Ultrasound guided brachial and basilic vein cannulation in ED pts” • 100 pts with 2 previous failed attempts • 91% success on first attempt within 90 secs Keys et al, Ann EM, Dec 99

  21. National Guidelines • American - AHRQ report of patient safety 1999: • Evidence based review of new health care technologies • Reviewed 79 safety practices in detail • #8 on list was US guided CL insertion Agency for Health Research & Quality

  22. National Guidelines • UK - National Institute for Clinical Excellence (NICE) NHS - 2002 Guideline statement • 20 randomized clinical trials • Failed catheter placement risk was reduced by 86% • Associated complications reduced by 57% • First attempt success increase by 41% • “Ultrasound is recommended as preferred method of inserting central venous catheters into IJ vein”

  23. Summary • Why should you use Ultrasound? • Increased success rates • Avoids complications • Reduces time to cannulation • Reduces number of attempts • Ultimately safer • And its FUN!

  24. Technique

  25. Technique for Use • Some cautions: • We will briefly review technique • One must have dedicated time to practice and have hands on training • Complications are only reduced if operator is skilled in techniques!

  26. Orientation • Probe Position • Transverse and longitudinal • Transverse most useful – lateral orientation • Longitudinal – depth and slope • Can see back wall perforation Trans Long

  27. Transverse Axis

  28. Transducer contacts skin Deeper or away from the skin

  29. Longitudinal Axis

  30. Longitudinal Axis Groove towards Needle Orientation marker Skin surface Blood vessel Head Feet

  31. Image Interpretation • Low density objects like blood vessels appear black • High density objects like bone appear white • Medium density objects like muscle appear gray

  32. Image Interpretation • Identifying Artery vs Vein on Ultrasound • Key to success! • VEINS ARE: • Compressible • Thin and irregular walled compared to artery • Not pulsatile (IJ may have triphasic waves) • Varies with respiration

  33. Ultrasound Anatomy Review

  34. Internal Jugular Vein

  35. Transverse View of Neck

  36. IJ vein Carotid art

  37. Subclavian Vein

  38. Subclavian Anatomy • Deep to clavicle • Can be hard to image due to depth and patient habitus • Consider lateral approach using axillary vein

  39. Subclavian Anatomy • The lateral approach: • A more lateral and inferior approach • Cannulate the Axillary vein • Can see more easily with ultrasound • Avoids lung and great vessels

  40. Ax V & A Lung!

  41. Technique • Two Main Approaches: • Static • Dynamic or Real Time

  42. Technique • Static Approach • Position patient • Use u/s to locate vessels and mark skin • Avoids complicated hand position/sterile issues

  43. Technique • Dynamic Approach • Real time cannulation under ultrasound visualization • Sterile sleeve placed on probe • Often needs 2 people • Better technique

  44. Technique • In General: • Position patient and get comfortable • Place probe on neck in transverse • Sweep area and ID structures • Place vessel in middle of SCREEN - Vessel should now be in middle of PROBE

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