CENTRAL VENOUS LINES AND THEIR PROBLEMS Dr Hicham

CENTRAL VENOUS LINES AND THEIR PROBLEMS Dr Hicham Al Mawla MD. Emergency

CONTENT Introduction Indications and Contraindications Access to Different Great Vessels Complications Summary References

INTRODUCTION Central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. The venous great vessels include the superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, iliac veins, and common femoral veins. 2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2012; 116: 539– 73

INDICATION FOR USE Limited vascular access Administration of highly osmotic or caustic fluids or medications Frequent administration of blood and blood products Frequent blood sampling Measurement of CVP Hemodialysis Hemofiltration Apheresis

CONTRAINDICATIONS Distorted Anatomy Infection at the Site of Access Proximal Vascular Injury Bleeding Disorders or Anticoagulation Combative Patients

CONTENTS OF THE TRIPLE LUMEN CENTRAL LINE KIT.

STERILE TECHNIQUE We will not review sterile technique in depth here For the physician, sterile technique means wearing a surgical cap, procedure mask, sterile gown and sterile gloves. Sterile setup for the patient should begin with adequate skin preparation with a sterilizing solution (proviodine, chlorhexidine, etc. ) in a large area surrounding your procedure site. Place a large sterile sheet on the patient following this and then isolate the procedural field with four to six sterile towels. This will minimize infective complications of the procedure.

SELDINGER TECHNIQUE 1. Setup of Equipment and Sterile Preparation 2. Landmarking the Access Site 3. Anesthesia 4. Location of the Vein with a Seeker Needle [Optional] 5. Placing the Introducer Needle in the Vein 6. Assessment for Venous or Arterial Placement 7. Insertion of the Guide Wire 8. Removal of the Introducer Needle 9. Skin Incision 10. Insertion of the Dilator 11. Placement of the Catheter 12. Removal of the Guide Wire 13. Flushing and Capping of the Lumens 14. Secure the Catheter

ACCESS TO DIFFERENT GREAT VESSELS Internal jugular vein Subclavian vein Femoral vein Umbilical vein

INTERNAL JUGULAR VEIN The right internal jugular vein (IJV) is the most common site chosen for central venous access in pediatric cardiac surgery. It is large, and runs in close proximity superficial to the carotid artery along most of its length. The primary advantage of using the IJV is that it provides a direct route to RA.

CATHETERIZATION: INTERNAL JUGULAR APPROACH

The primary disadvantage comes from difficulty in cannulation in small infants, who have large heads and short necks, and thus difficulty in obtaining the shallow angle of approach necessary to access the vessel. This site is also not comfortable for some awake infants

TECHNIQUE Placing a small roll under the shoulders, using steep Trendelenburg position, and rotating the head no more than 45◦ to the left. Recent studies have demonstrated that liver compression and simulated Valsalva maneuver also increase the diameter of the IJV, possibly increasing the success rate of cannulation. An ultrasound technique should be used to clearly identify the course of the vessel

SUBCLAVIAN VEIN The subclavian vein is positioned immediately behind the medial third of the clavicle. Advantages of this route include the subclavian vein’s relatively constant position in all ages in reference to surface landmarks and the site is comfortable for awake patient. Disadvantages include an incidence of pneumothorax is high. Also in 5– 20% of patient, subclavian catheters will enter the contralateral brachiocephalic vein or ipsilateral IJV, instead of the SVC

CATHETERIZATION: SUBCLAVIAN APPROACH

TECHNIQUE Small rolled towel is positioned vertically between the scapulae, steep Trendelenburg position used, and the arms are restrained in neutral position at the patient’s sides. The right subclavian vein should always be the first choice. Turn the head toward the side being punctured. The puncture site that is most successful is 1– 2 cm lateral to the midpoint of the clavicle, directly lateral from the sternal notch, with the needle directed at the sternal notch. Advancing the needle only during expiration is recommended to minimize the risk of pneumothorax.

Complications during subclavian catheterization occur when a needle angle of incidence is too cephalad, resulting in arterial puncture, or too posterior, resulting in pneumothorax. Advancing the needle too far in infants may result in puncture of the trachea.

FEMORAL VEIN The femoral vein has long been used for central venous catheterization in pediatric patients, with no greater infection or other complication rate compared to other sites.

TECHNIQUE the patient is positioned with a rolled towel under the hips for moderate extension. The puncture site should be 1– 2 cm inferior to the inguinal ligament, and 0. 5– 1 cm medial to the femoral artery impulse, with the needle directed at the umbilicus.

UMBILICAL VEIN The umbilical vein in the fetus is a conduit to carry oxygenated and detoxified blood from the placenta, through the abdominal wall, the liver, and patent ductus venosus to the inferior vena cava (IVC) and the right atrium (RA). This vessel can usually be cannulated at the umbilical stump for the first 3– 5 days of postnatal life. Passage into the IVC depends on the patency of the ductus venosus, which often exists for the first few days. Sterile technique without a guidewire is used to pass the catheter blindly a premeasured distance. If no resistance to passage is met and free blood return is achieved, the catheter tip is usually in the high IVC or RA, and functions as a CVC.

Catheter tip position must be determined by radiography as soon as possible to determine if it is through the ductus venosus into the IVC or the RA. Often the ductus venosus is not patent, and the catheter tip passes into branches of the hepatic veins, and is visible in the liver radiographically. A UVC can be left in place for as long as 14 days if no complications are suspected.

COMPLICATIONS 1. Acute Procedural 2. Sub-acute Infection 3. Chronic Infection Thrombosis

COMPLICATIONS: ACUTE 1. Local Hematoma 4. Pneumothorax, Hemothorax, Chylothorax 2. Local Cellulitis 3. Arterial puncture 5. Malposition 6. Air embolus

AIR EMBOLUS SYMPTOMS 1. Respiratory distress 2. Increased heart rate 3. Cyanosis 4. Decrease level of consciousness

AIR EMBOLUS: TREATMENT 1. Left lateral decubitus Position 2 100% O 2 3. Vasopressin if necessary 4. Chest compression 5. Aspiration through catheter

COMPLICATIONS: CHRONIC 1. Infection 2. Thrombosis

TYPES OF INFECTION 1. Cutaneous - pain, erythema, swelling, +/- exudate 2. Bacteremia - fever, leukocytosis and positive blood cultures 3. Septic thrombophlebitis - bacteremia, thrombosis and purulent discharge

INFECTION CAUSATIVE ORGANISMS Staph epidermaidis 25 -50% Staph aureus 25% Candida 5 -10%

INFECTION TREATMENT 1. Septic thrombophlebitis - remove catheter 2. Cutaneous - local treatment 3. Bacteremia 1. IV antibiotics 48 -72 hours if improved - keep catheter if no change, worse or recurs remove catheter or 2. Exchange catheter over wire, 85% cure with treatment

INFECTION: THE USE OF ANTIMICROBIAL-IMPREGNATED CATHETERS Maki, D. G. et. al. Ann Intern Med 1997; 127: 257 -266

INFECTION: THE USE OF ANTIMICROBIALIMPREGNATED CATHETERS Use of these catheters decreases blood stream infection: 4. 6% regular catheter 1. 0% antibiotic impregnated catheters Chlorhexidine-Silver sulfadiazine and Minocycline-Rifampin impregnated catheters The Use of antibiotic impregnated catheters should be considered at all circumstances! The emergence of resistance is certainly of concern. N ENGL J MED 348; 12, 2003

INFECTION: INSERTION OF CATHETERS AT THE SUBCLAVIAN VENOUS SITE The risk of catheter-related infection is lower with subclavian catheterization than with internal jugular or femoral catheterization

INFECTION: AVOIDING THE USE OF ANTIBIOTIC OINTMENTS The Use of ointments such as bacitracin, mupirocin, neomycin, and polymyxin to catheter insertion sites show: Increase the rate of colonization by fungi Promote bacterial resistance Has not shown to affect the risk of catheter related bloodstream infection. N ENGL J MED 348; 12, 2003

INFECTION: ROUTINE CATHETER CHANGES? Scheduled, routine replacement of central venous catheters at a new site does not reduce the risk of catheter related infection. Scheduled, routine exchange of cathetres over guide wire is associated with a trend toward increased catheter related infections and mechanical complications. META analysis of 12 -RCTs do not support. CVC should not be replaced on a scheduled basis. N ENGL J MED 348; 12, 2003

INFECTION: REMOVE WHEN NO LONGER NEEDED. NON-Antiseptic Impregnated catheter The probability of colonization and catheterrelated bloodstream infection increases over time. Collin, G. R. Chest 1999; 115: 1632 -1640

THROMBOSIS Intermittently used catheters need to be replaced frequently due to obstruction and/or infection. Clot formation is a major source of obstruction

THROMBOTIC: INSERTION OF THE CATHETER AT THE SUBCLAVIAN SITE Subclavian catheterization carries a lower risk of catheter related thrombosis than femoral or internal jugular catheterization. N ENGL J MED 348; 12, 2003

KEEPING CENTRAL VENOUS LINES OPEN The use of anti-obstructive flushes such as heparin, citrate and Vitamin C (Germans), have associated complications: Bleeding, Thrombocytopenia-heparin Arrhythmia (citrate) induced Intensive Care Med. 2002; 28: 1172 -6

KEEPING CENTRAL VENOUS LINES OPEN: A PROSPECTIVE COMPARISON OF HEPARIN, VIT. C, AND NACL BLOCKS Signif. longer patency with heparin(5000 IU/ml) Vitamin C ineffective Group of 25 low dose heparin flushes(200 IU/ml) flushes showed catheter survival closer to saline group. So, high concentration of heparin flushes recommended. Intensive Care Med. 2002; 28: 1172 -6

SUMMARY Central venous access is defined as placement of a catheter such that the catheter is inserted into a venous great vessel. Three sites are commonly used for pediatric CVC placement: femoral, internal jugular, and subclavian. Should be done under sterile condition to minimize infection related complication. Seldinger Technique is used for insertion of CVC.

SUMMARY. Use antimicrobial-impregnated catheters Avoid antibiotic ointments Do not schedule routine catheter changes Remove catheter when no longer needed

REFERENCES Roger's Textbook of Pediatric Intensive Care, 4 th Edition 2008 Lippincott Williams & Wilkins The American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2012; 116: 539– 73 Anesthesia for Congenital Heart Disease Edited by Dean B. Andropoulos, Stephen A. Stayer, Isobel Russell and Emad B. Mossad © 2010 Blackwell Publishing Ltd. ISBN: 978 -1 -405 -18634 -6 N Engl J Med 2003; 348: 1123 -33. 2003 Massachusetts Medical Society.

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