1 / 32

Central Lines

Central Lines. Dr. Peter Jones Emergency Medicine Specialist. Indications. Multiple Access Inotropes Toxic medication Volume CVP / PA pressures Dialysis Pacing wire TPN. Contraindications. Patient needs to get to definitive treatment NOW Distorted anatomy

mare
Download Presentation

Central Lines

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Central Lines Dr. Peter Jones Emergency Medicine Specialist

  2. Indications • Multiple Access • Inotropes • Toxic medication • Volume • CVP / PA pressures • Dialysis • Pacing wire • TPN

  3. Contraindications • Patient needs to get to definitive treatment NOW • Distorted anatomy • Chest wall, vessel injury, radiation • Coagulopathy • Uncooperative patient • Inexperienced operator

  4. Preparation & Position • Consent • Universal precautions • Sterile technique • Local anaesthetic

  5. Preparation & Position • Head down (IJ) • Head away (debated) • Pillow between scapulae (debated) • Injured side in chest trauma • Avoid bilateral pneumothoraces

  6. Site • SCV (1952) • Left theoretically better • IJV (1963) • Right theoretically better • EJV • Femoral

  7. Anatomy SCV

  8. Anatomy SCV

  9. Anatomy SCV

  10. Anatomy IJV

  11. Anatomy IJV

  12. EJV Wired

  13. Technique • Put a big line through a little hole • Seldinger 1953 (interventional radiology) • Needle and syringe (small hole) • Guidewire through needle (smooth and easy) • Cut skin • Introducer (big hole) • Catheter over guidewire • Flush and Secure • Check patient & position (CxR)

  14. Seldinger Equipment

  15. Seldinger Technique

  16. Seldinger Technique

  17. Seldinger Technique

  18. Seldinger Technique

  19. Complications • Infection • Malposition • Arterial puncture • Pneumothorax • Haemothorax • VTE

  20. Complications SCM IJV ICA Needle Catheter Haematoma

  21. Complications • Hydrothorax • Air embolus • Osteomyelitis clavicle • Catheter embolus • Lost guidewire • RA perforation • ETT cuff puncture

  22. IJ vs SC Crit. Care Med 2002 Feb;30(2):486-7 • Malposition • IJ 5.3%vs 9.3% SC • Infection • IJ 8.6% vs 4% SC • Arterial Puncture • IJ 3% vs 0.5% SC • VTE • IJ 0% vs 1.2% SC

  23. IJ vs SC Crit Care Med 2002 Feb;30(2):486-7 • No difference • Haemopneumothorax 1.5% • VTE 1% (trend to SCV)

  24. CVP • Zero pt = RA • MAL 4th CC Junction (mark) • 20-25cm fluid in manometer

  25. CVP • Patient • Supine • Level • Breathing normally • 0 of manometer = 0 on patient • Open to patient • New fluid level = CVP

  26. CVP • Rough idea of RV filling • But EDV determines preload • Ventricular compliance varies from patient to patient and with time in the same patient • Multiple influences

  27. CVP • Affected by • Circulating volume • RV function • Intrathoracic pressure • Systemic vascular resistance • Therefore dynamic change most useful

  28. CVP Low • <5cm H20 • Volume deplete • SVR low • Zero point too high • Patient sitting up

  29. CVP High • >12cm H20 • CHF • PPV

  30. CVP High • Cardiac tamponade • Tension pneumothorax • PE • SVR high • SVC obstruction • Head down • Kinked line • Occluded line

  31. CVL Summary • Know why • Know what • Know where • Prepare, Prepare, Prepare • Know the complications • Know how to check for them

  32. References Clinical Procedures in Emergency Medicine Roberts and Hedges 2nd Edition 1991 Complications of CVC: IJ Vs SC access a systematic review Ruesch S et al Crit Care Med 2002 30:486-7

More Related