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Catheterization Kits

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Advantage of S.C cannulaion

Consistent identifiable landmarksLow infection rate

Relatively high patient comfortEasier long term catheter maintenanceIdeal site in hypovolaemic shock patients as

the vein does not collapse due to fibrousattachments

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anatomy

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Indications

CVP, PA pressure, wedge pressuremeasurement

Emergency pacemaker insertionVolume resuscitation in shock patientsAdministering TPN, KCL, Ionotropes, soda

bicarb etcSvO2 measurement in sepsis

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contraindications

No absolute contraindicationsIpsilateral AV fistulaInfection of the siteVenous thrombosis at or near the site of insertionPresence of venous filters(guidewire should not

be inserted more than 20 cm)Severe coagulopathy and thrombocytopenia.(femoral route is preferred)combative patients

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Technique

Seldinger techniqueUse introducing needle to locate veinWire is threaded through the needleNeedle is removedSkin and vessel are dilatedCatheter is placed over the wire

Wire is removedCatheter is secured in place

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The procedure

ConsentPositioning vertical shoulder roll between theshoulder, this opens up the deltopectoral groove

and makes more parallel access to the vein ,tredelenberg, arm adducted +/_ pulled towardsfoot, head turned to oppsite sideMaximal barrier protection gown, cap, mask,glovesStand on the shoulder side of the patientSterile skin preparation with 2% chlorhexideineLarge drape with a central opening

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Approach

Infraclavicular or supraclavicularOpen (usually by a surgeon) or percutaneous

Local anaesthesia 1% solution at the puncturesiteInfraclavicular approach - Needle inserted 2

cm below the mid point of clavicle directingtowards suprasternal notch, angle should beparallel to the floorThreading of the guidewire not > 20 cm

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Dilatation of skin and s.c tissuesThreading the catheterAim to insert the catheter upto atrio caval junctionAll port aspirated and flushed with heparinisedsaline

Suturing to the skin with nylon sutureSterile, transparent dressingChest x ray for checking positionWriting a note

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Tips

After 3-4 tries, let someone else tryGet chest x-ray after unsuccessful attemptIf attempt at one site fails, try new site on same side toavoid bilateral complicationsHalt positive pressure ventilation as the needle penetratesthe chest wall in subclavian approachIf you meet resistance while inserting the guide wire,withdraw slightly and rotate the wire and re-advance

Align the bevel with the syringe markingsUse the vein on the same side as the pneumothoraxWithdraw slowly, you will often hit the vein on the way out

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Ultrasound-Guided Central

Venous AccessBecoming standard of careVein is compressibleVein is not always largerVein is accessed under directvisualization

Helpful in patients withdifficult anatomy

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complications

Atrial arrhythmiaArterial puncture, haemorrhage ( extrapleural hematoma orhaemothorax)Pnumothorax

Venous thrombosis, embolism of air / thrombus/ catheter partMalposition of catheter into opposite sv, ijv or ipsilateral ijv or ivcMisposition subcutaneous tissue, thorax, heartGuidewire related - trauma to artery, vein, ,RA puncture l/thaemopericardium or tamponade, kinking of guidewire,

arrhthmia,Infection local or blood streamCatheter shearing

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complications

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