5. Placing the catheter, finding the vein :a. Choose the appropriate catheterb. Mark the length of catheter to achieve the

proper placec. Attach the entry needle to a small 1-3ml

syringe and rinsed with hep/saline solutiond. Once through the skin, apply a small

negative pressure to aid blood return as the needle is advanced

e. When blood return is apparent, advance the needle an additional 1-2mm until a free flow of blood is obtained.

f. Use a 23-25G, 1.5inch needle as a finder needle if difficulties appear, or change the rolled towell with a smaller one, or repositioned the patient

g. Inadvertent arterial puncture should be suspected whenever the blood appears redder or shows a pulsatile flow

h. Use non-Luer-Lock syringe

5. Placing the catheter, inserting the catheter (Seldinger technic )

a. Detach the syringe carefully, once the needle successfully enters the vessel

b. Occlude the needle lumen with the thumb after the syringe is removed

c. Insert the guide wire, keep the proximal end visible

d. Remove the entry needle and enlarge the skin puncture site using a scalpel blade (No.11). A stiff dilator might be needed.

e. Place the catheter over the guide wire, again, keep the proximal end of the wire visible outside the catheter hub.

f. Advance the catheter with a steady gentle pressure, and a slow, twisting motion, until the expected length of the catheter were inside the vessel

g. Ensure that the tip is properly positioned by doing a radiograph.

Ensure that the tip is properly positioned by doing a radiograph.

Trouble shooting, guide wire insertion:1. Remove guide wire if the guide wire does not

pass easily / with minimal resistance2. Reconfirm the needle position3. Redirect or rotate the needle bevel or just be

patient, wait untill the spasm is gone4. Reinsert the guide wire.5. If there is a resistance during wire removal,

withdraw the needle and the wire together immediately

Trouble shooting, catheter insertion :If resistance is met at this stage,1. If fraying is present, change the

catheter2. Repeat the scalpel incision3. Use the stiff dilator to create a

tract

Arterial blood ?:• Colour• Pulsation• Blood Gas

Analysis• Pressure wave

6. Securing and Dressing the catheter

a. Securing with stichingb. Povidone-iodine c. Sterile gauze and tape

vs transparent

7. Documentationa. Date and time of insertionb. Catheter type, gauge, lengthc. Any complication encounteredd. Catheter placement confirmatione. The patient’s condition

1. Clean surgical gloves from powder2. Use the smallest catheter to fit the indication3. Do not take the catheter out of the additional sterile plastic sack (sterility sleeve?)4. Reconfirm catheter tip position regularly5. Do not use alcohol or aceton to clean6. In multilumen catheters,

i. End hole : blood products / CVP monitoringii. Side hole : medication, TPN, blood sampling

7. Do saline flushing when changing infusate solution

8. Do not secure the catheter too tight, as thrombosis will easily occur

Thank you forYour attention

Sumsum tulang panjang dapat berfungsi sebagai vena yang tidak pernah kolaps.

Darah mengalir dari sinusoid vena ke kanal vena sentral dan selanjutnya melalui vena emisari / nutrisi masuk ke sirkulasi sentral.

Absorbsi dlm sumsum tlg cukup cepat wlp tentu tidak secepat akses perifer/sentral ( 11-45ml/menit)

AKSES INTRAOSSEOUS

AKSES INTRAOSSEOUS

Lokasi :1. Mediocaudal Tuberositas Tibia, kira-kira 2cm. ( smp 3-4thn)2. Cranial malleolus medial , kira-kira 2 cm.(diatas 3-4thn) 3. Distal femur, 1-2cm diatas patela.

Tibia proximal

Indikasi : Henti jantung paru dan syok

Indikasi kontra : recent fracture, osteogenesis imperfecta, osteoporosis.

Indikasi Kontra relatif : selulitis dan luka bakar

Akses Intraosseous

Aspirat dapat untuk pemeriksaan elektrolit, glukosa, ureum , kreatinin. Juga untuk sample kros-darah. Tapi tidak untuk darah lengkap.

Komplikasi : tergantung lama penggunaan, usahakan < 24jam. : furunkulosis, osteokondritis, osteomielitis,selulitis , abses subkutan, sindrom ruang, emboli lemak, kerusakan tulang, sepsis dan bakteriemia.

Alat :Jarum khusus dengan mandrijnJarum untuk pungsi sum-sum tulangJarum pungsi lumbal yang terbesarJarum no. 16

Akses Intraosseous