CVC Workshop (short)

Prereading

• Introduction to CVC• Basic ultrasound• Equipment List• Seldinger technique• CVC insertion

Introduction

Indications• IV access (especially if difficult peripheral access)

• CVP monitoring

• Central venous oxygen saturation (ScvO2 ) monitoring/sampling

• Infusions of irritant substances (e.g. vasoactive agents, calcium, chemotherapy or TPN administration)

• Renal replacement therapy, plasmapheresis and apheresis

• Transvenous pacing

Contra-indications• coagulopathy

• respiratory failure (patient positioning and ability to tolerate procedure)

• raised ICP (cannot tilt head down)

– can use femoral approach in all the situations above

• obstructed vein (e.g. thrombus, tumour etc)

• overlying skin infection, burn or other disease process

• hemorrhage from target vessel

• uncooperative patient

Complications• Infectious Complications

– Catheter related bloodstream infections – approximately 1.5% in Jugular CVC

• Vascular Complications– Carotid puncture/cannulation– Haematoma from multiple attempts

• Equipment– Catheter related thrombosis

• Pulmonary– Pneumothorax– Venous air embolism

Sites for CVC placement• 3 main sites are used for CVC placement

– Internal jugular, subclavian and femoral

• All have the option for either left or right sided placement

• All are associated with infectious, thrombotic, and mechanical complications.

• The rate of total complications is similar for all three sites although the exact composition of the complications may differ

• Surface Anatomy– How internal structures relate

to surface anatomy

Ultrasound

3 Ps of VASCULAR Ultrasound

• Patient• Enter patient details• Ensure patient is positioned

adequately and comfortable as possible

• Probe• Choose the high frequency linear

probe for vascular ultrasound (6-13mhz)

• Preset• Each probe can be used for multiple

tissue ie. muscle, nerves, blood vessels

• Choose the vascular setting (location of this menu will on each machine)

Depth

• Depth determines how deep from the skin that you can visualise• Ideally get the object you want

in the center of the screen as demonstrated by the 4cm image to the right• This way structures below can

been seen and avoided when inserting a needle

Depth

• Too much depth as demonstrated by these images results in decrease resolution• This will result in increased

difficulty in trying to needle the object of interest

Gain

• This function is very similar to a brightness control• Too much or too little gain will make visualisation of objects

difficult (too bright or too dark)• Most ultrasound have an auto gain function that will attempt to

calibrate the ideal gain

Gain

Gain too high can result in blurring of the walls of the structure. This is impact visualisation of the needle going through vessel walls.

Gain too low can result in structures not being seen

Different ways of imaging the needle

Transverse view of the right neck

Medial Lateral

Seldinger Technique

Steps

• Needle inserted into blood vessel while aspirating on the syringe

• Syringe is removed and guidewire is inserted through the needle

• Needle is removed

• Dilator is inserted over guidewire to make the tract larger and then removed.

• Catheter is inserted over guidewire

• Note guidewire comes out of brown port

• Catheter is inserted to appropriate length

Securing the central line

• Use at least O nylon, deep 1 cm bite of skin

• Secure the clip, and then sandle tie the hub so that it is secured to the skin via the clip

After Care

• Following insertion of CVC:– CXR to check for complications (eg.pneumothorax)

and adequate position of CVC – tip of CVC should be in the lower Superior Vena CAVA

– Documentation of CVC insertion – including number of needle passes and any other complications

• CVC need to be changed between 10 – 14 days due to increasing risk of catheter related sepsis and thrombus formation around the catheter.

• Daily review of the CVC should be implemented to check for signs of sepsis or thrombus formation and CVC not being used should be removed to reduce these risks

Summary

• CVC introduction– Indication and Contraindications– Complications– Anatomy

• Basic Ultrasound• Seldinger technique• After Care