1.1. Role of accessRole of access

• Why?– Appreciate the requirements of the

user increasing efficacy of selling• Essential characteristics

– Material– Length– French– Position

Role of accessRole of access

1. Revise blood pathway and significance of blood flow rates

2. Translate flow rates to access product

3. Understand requirements to use1. Video2. CD

Selection criteriaSelection criteria• Resistance to outflow

– Negative pressure required to generate a specific flow

– Larger size, less resistance to flow– Dependent upon

• Length• Size• Design

DesignDesign• Double lumen

– 360° A&V side holes for high flow catheter – co-axial– D- lumen– Split

• Side holes– ↑risk sucking against vessel wall– Risk becomes greater as blood flows ↑

CharacteristicsCharacteristics

Materials•Urethanes - Polyurethane

- Tecothane- Tecoflex- Carbothane

*Silicone

LengthLength

• Length– Too short, only low flows possible– Too long - ↑resistance to flow

SizeSize

• Dependent upon resistance to flow

Possible insertion Possible insertion sites*sites*

*Medcomp training manual 1999

Possible insertion Possible insertion sites*sites*

Technical difficulty

Pt.comfort& mobility

Compl. risk

R. Subclavian Low Medium High R. Int. Jugul. Low High Low L. Int. Jugul. High High Medium L. Subclavian Medium Medium High R. Femoral Low Low Low R. Femoral Low Low Low

*Medcomp training manual 1999

SiteSite

• Clinician skill/preference• Patient anatomy/condition• Coagulation status• Other CVC punctures• Intra-abdominal / thoracic

pressures

Insertion sitesInsertion sites

*Medcomp training manual 1999

•Subclavian

•Femoral

•Jugular

Proper tip placementProper tip placementRight internal jugular*Right internal jugular*

At the junction of the superior vena cava and the right atrium

*Medcomp training manual 1999

Proper tip placement*Proper tip placement*

Left subclavian vein Right femoral vein

*Medcomp training manual 1999

Seldinger insertion Seldinger insertion technique*technique*

*Medcomp training manual 1999

Seldinger insertion Seldinger insertion technique*technique*

*Medcomp training manual 1999

Seldinger insertion Seldinger insertion technique*technique*

*Medcomp training manual 1999

PositionPosition

• ICU scenario– PAC– Coagulopathy– FlatFemoral access common

• 2-3cms below & 1cm medial• Positioning may be difficult owing to femoral

artery• Impractical if pt mobile

PositionPosition

• Subclavian• Commonly inadequate• Catheter curves under clavical• Hits SVC – vein collapses • Position changes affects filling pressures

• RJ• Preferable• Soft tip• Length to reach RA

SITE CARE*SITE CARE*

*Medcomp training manual 1999

• Short term – infection rare– Standard dressing for CV access

• Malfunction– Flush– Assess resistance

• High: clotting, positional• Switch limbs - ↑recirculation risk

Potential patient related Potential patient related complicationscomplications 11**

• Air embolism• Bacteremia• Cardiac arrhythmia• Cardiac tamponade• Central Venous Thrombus• Endocarditis

*Medcomp training manual 1999

Potential patient related Potential patient related ccomplicationsomplications 2 2 **

• Exit site infections• Hematoma• Haemorrage• Haemothorax• Vessel laceration• Pericardial rub• Pneumothorax• Retroperitoneal bleed

*Medcomp training manual 1999

Potential patient related Potential patient related complications*complications*

• Right arterial puncture• Septicemia• SVC puncture• Tunnel infection• Vessel puncture

*Medcomp training manual 1999

Catheter related Catheter related complications*complications*

1. General catheter related problems2. Specific catheter related problems

– Silicone– Removal of catheter– Miscellaneous

*Medcomp training manual 1999

Catheter related Catheter related complications*complications*Symptoms Possible Causes Suggestions

Catheter can be flushed butnot aspirated

One way obstruction,possible fibrin sheathsformation. Catheter may beup against the wall of thevessel.

Reposition patient, havepatient cough, reverse thebloodlines during treatment.

Diminished flows Kink in blood lines, catheterclot

Check all bloodlines, flushwith saline. Repositionpatient and/or catheter.Reverse blood lines

High arterial pressure Kink in catheter, clot formingin filter or line behind filter.

Check for kinks, flushcatheter, check the filter.

High venous pressures Kink in catheter, clot formingat the tip of the catheter, clotin venous bubble trap.

Check for kinks, flushcatheter, check thebloodlines.

Inability to either flush oraspirete

Thrombus formation Urokinase as per physician’sorder.

*Medcomp training manual 1999

Catheter Catheter

occlusions/obstructionsocclusions/obstructions**

• Mechanical obstructions• Thrombotic obstructions

*Medcomp training manual 1999

Catheter Catheter

occlusions/obstructionsocclusions/obstructions**Intraluminal obstruction

*Medcomp training manual 1999

Catheter Catheter occlusions/obstructions*occlusions/obstructions*

Fibrin Sleeve

*Medcomp training manual 1999

Catheter Catheter occlusions/obstructions*occlusions/obstructions*

Fibrin Tail

*Medcomp training manual 1999

Catheter Catheter occlusions/obstructions*occlusions/obstructions*

Venous Thrombosis

*Medcomp training manual 1999