Central Venous Catheterization and Central Venous Pressure Monitoring 30/9/87 majidi alireza beheshti EMR CLINICAL PROCEDURES IN EMERGENCY MEDICINE

INDICATIONS 30/9/87 majidi alireza beheshti EMR

Emergency Venous Access The predictable anatomic locations of the subclavian and femoral veins, and the speed with which they can be cannulated (often within 30 seconds) have prompted their use in cardiac arrest and other emergency situations. The need for a central line during CPR is controversial 30/9/87 majidi alireza beheshti EMR

Routine Venous Access Patients with a history of IV drug abuse, major burns, or obesity and those requiring long-term care may have inadequate peripheral IV sites. Central venous cannulation may be indicated as a means of venous access in these patients even under nonemergent conditions 30/9/87 majidi alireza beheshti EMR

Infusion of Hyperalimentation and Other Concentrated Solutions by way of the subclavian vein is safe and reliable. IC technique is therefore well suited to longterm applications. Hyperosmolar or irritating solutions that have the potential to cause thrombophlebitis frequently infused by way of the subclavian vein. Examples are potassium chloride (>40 mmol/L), hyperosmolar saline, 10% dextrose infusions, chemotherapeutic agents, and acidifying solutions such as ammonium chloride Some clinicians prefer to obtain central access because of the potential harm of extravasation of vasoactive substances (dopamine, norepinephrine), which may result in soft tissue necrosis 30/9/87 majidi alireza beheshti EMR

INDICATIONS? Central Venous Pressure Monitoring Volume Loading Emergency Venous Access Routine Venous Access Routine Blood Drawing Infusion of Hyperalimentation and Other Concentrated Solutions 30/9/87 majidi alireza beheshti EMR

Other Indications? placement of a pulmonary artery catheter transvenous pacemaker, performance of cardiac catheterization pulmonary angiography, hemodialysis. Catheters such as the Uldall or Quinton device can be inserted within minutes, permitting use of the subclavian vein for emergency or short-termhemodialysis. 30/9/87 majidi alireza beheshti EMR

Differents Approaches? Internal jugular approach Subclavian approaches. External Jugular Approach Basilic and Cephalic Approach Femoral Approach 30/9/87 majidi alireza beheshti EMR

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A true central venous location is the subclavian SC approach? is superior to the IC approach and long peripheral line insertion techniques because of the low incidence of catheter tip malposition performed in the sitting position in patients with severe orthopnea. Placement of a central line with the patient in a sitting position is virtually impossible with other central venous access routes Finally, the low complication rate reported 30/9/87 majidi alireza beheshti EMR

Internal jugular approach . As is true of the SC subclavian approach, the IJ technique is useful for routine central venous access and for emergency venous access during CPR 30/9/87 majidi alireza beheshti EMR

cont When easily obtained, central venous cannulation is preferred over peripheral venous access, because it provides a rapid and reliable route for the administration of drugs to the central circulation of the patient in cardiac arrest. 30/9/87 majidi alireza beheshti EMR

subclavian SC approach may be preferable during CPR because it minimizes physical interference with the functions of chest compression and airway management. IC approach requires deep penetration of a moving chest wall and frequently demands an interruption of chest compression. An SC subclavian venipuncture can be performed without cessation of CPR and involves superficial penetration of the relatively motionless neck. 30/9/87 majidi alireza beheshti EMR

GeneralContraindications? Distorted local anatomy Extremes of weight Vasculitis Prior long-term venous cannulation Prior injection of sclerosis agents Suspected proximal vascular injury Previous radiation therapy Bleeding disorders Anticoagulation or thrombolytic therapy Combative patients Inexperienced. unsupervised physician Relative 30/9/87 majidi alireza beheshti EMR

contra Jugular vein? Intravenous drug abuse via the jugular system Relative 30/9/87 majidi alireza beheshti EMR

contra Subclavian vein? Chest wall deformities Pneumothorax~ Chronic obstructive pulmonary disease Relative 30/9/87 majidi alireza beheshti EMR

contra Basilic-cephalic veins? Cardiac arrest Anticipated future use of these vessels Relative 30/9/87 majidi alireza beheshti EMR

contra Femoral vein? Need for patient Immobility Relative 30/9/87 majidi alireza beheshti EMR

ANATOMY 30/9/87 majidi alireza beheshti EMR

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patient is tilted 15 to 30 degrees in Trendelenburg position and the head is turned slightly away from the side of venipuncture. The IJ vein is distensible, and tilting the patient increases the diameter of the vessel. If the patient is awake, he or she should be instructed to perform a Valsalva maneuver during vessel cannulation. In the unconscious patient, abdominal compression by an assistant can be used to help distend the vein. position 30/9/87 majidi alireza beheshti EMR

position 30/9/87 majidi alireza beheshti EMR

Venipuncture site. . Familiarity with the anatomy of the neck is important to increase the probability of successful cannulation and to minimize complications 30/9/87 majidi alireza beheshti EMR

Right side? 1/direct route to the SVC and avoids the 2/thoracic duct. the cupola of the 3/pleura is also slightly lower on the right side. The 4/left IJ approach is more circuitous and, when used with a stiff Teflon catheter, may less5/ result in a major venous puncture leading to hydrothorax, hydro mediastinum, or even pericardial tamponade. 30/9/87 majidi alireza beheshti EMR

Air embolus? Care must be taken to cover the needle hub with a gloved thumb whenever the needle lumen is exposed to air. This practice will prevent an air embolus when the patient inspires. 30/9/87 majidi alireza beheshti EMR

central approach has been used in children The central approach has been used in children with good success The vessel is usually entered at a depth of 1 to 2 cm. The locator needle is then withdrawn, and a 17- to 19-ga needle is inserted into the skin until the IJ vein is penetrated.? 30/9/87 majidi alireza beheshti EMR

Central route believe that the incidence of cannulation of the carotid artery is decreased and the cupola of the lung is avoided with this method. . The triangle formed by the clavicle and th sternal and clavicular heads of the sternocleidomastoid is first palpated and identified 30/9/87 majidi alireza beheshti EMR

cont can mark the lateral border of the carotid pulse, and all subsequent needle punctures can be performed laterally to that point. 30/9/87 majidi alireza beheshti EMR

cont usually encountered at a depth of 1.0 to 1.5 cm. If the IJ vein is not entered a depth of 3 to 5 cm, the needle should to just below the skin surface and directed be withdrawn toward the ipsilateral nipple underneath the medial border of the lateral (clavicular) head of the sternocleidomastoid 30/9/87 majidi alireza beheshti EMR

cont The vein should be entered at 1 to 3 em, and dark blood should be easily aspirated (bright red blood indicates carotid artery penetration and the need for needle repositioning After locating the IJ vein, the locator needle is withdrawn and replaced with a 14-ga, 5-cm needle attached to a syringe 30/9/87 majidi alireza beheshti EMR

Central route 1.0 to 1.5 cm. Max3 to 5 cm, 30-40* Depth? 30/9/87 majidi alireza beheshti EMR

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Anterior routes. Ipsilateral nipple 30-45* 1/2 30/9/87 majidi alireza beheshti EMR

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Posterior routes 1/3 30/9/87 majidi alireza beheshti EMR

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TECHNIQUE AND EQUIPMENT Seldinger Techniques 30/9/87 majidi alireza beheshti EMR

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Needle 30/9/87 majidi alireza beheshti EMR

Device 30/9/87 majidi alireza beheshti EMR

Two basic types of guidewires are used: straight or J-shaped. The straight wires are for use in vessels with a linear configuration, whereas the J wires are for use in tortuous vesse The standard size for guidewires is from 0.025 to 0.035 in.(0.064 to 0.089 cm) in diameter, permitting introduction through an 18-ga thin-walled needle 30/9/87 majidi alireza beheshti EMR Guidewire

Guidewire 30/9/87 majidi alireza beheshti EMR

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Catheters A number of different catheter and introducer devices have been developed and the method of passage into the vessel varies accordingly. Single-, double-, and triple-lumen catheters generally are placed by sliding the catheter directly over the guidewire into the intended vessel 30/9/87 majidi alireza beheshti EMR

depth of catheter insertion The depth of catheter insertion is an important consideration. The SVC begins at the level of the manubriosternal junction and terminates in the right atrium, approximately 5 cm lower. For lines placed in the subclavian, jugular, basilic,and cephalic systems, the proper position of the catheter is in the SVC, not the right atrium or ventricle 30/9/87 majidi alireza beheshti EMR

Therefore, the catheter should be threaded approximately 2 cm below the manubriosternal junction. Many commonly used catheters are long enough to reach the atrium or ventricl 30/9/87 majidi alireza beheshti EMR

standard catheters marketed for subclavian venipuncture are often 20 to 30 cm long Catheters 15 to 16cm in length are recommended to avoid unintended placement to an excessive depth. The proper distance to advance the catheter can be estimated by placing the catheter parallel to the chest wall before insertion. 30/9/87 majidi alireza beheshti EMR

Alternatively, formulas to determine optimal insertion length basd on patient's height . 30/9/87 majidi alireza beheshti EMR

right atrium, approximately 5 cm lower. 2 cm lower manubriosternal joint tip of cathter? 30/9/87 majidi alireza beheshti EMR

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