2013 Pediatric Subspecialty Boot Camp_Central venous access
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Transcript of 2013 Pediatric Subspecialty Boot Camp_Central venous access
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Pediatrics
Vascular AccessPART ONE: Central Venous Catheterization
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Objectives
•By the end of this workshop, the learner will be able to:
‐Recall at least 3 indications and 3 contraindications for central venous catheterization (CVC)
‐Describe the anatomic landmarks used to guide CVC at specified sites of insertion
‐Name at least 5 complications associated with CVC
‐Choose an appropriate sized central venous catheter according to indication for placement and/or the patient’s size
‐Distinguish between properly positioned and malpositioned central venous catheters on radiographic images
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Indications
•Peripheral access unobtainable
•Medication/fluid administration
•Emergency resuscitation
•Monitoring of CVP and ScvO2
•Parenteral nutrition
•Frequent blood sampling
•Hemodialysis/hemofiltration/Apheresis
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Contraindications
•Coagulopathy
•Thrombosis
•Skin infection at site of needle puncture
•Trauma
•Distorted anatomy
•Clavicular/proximal rib fractures
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Three common sites
•Internal jugular
•Femoral
•Subclavian
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•Anatomy
•Surface Landmarks
•Positioning
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•Anatomy
•Surface Landmarks
•Positioning
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Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Subclavian
•Femoral
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IJ Anatomy
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Surface Landmarks
•Upper portion: medial to SCM
•Mid portion: posterior to SCM in the triangle of SCM heads and clavicle
•Lower portion: behind clavicular head of SCM where it descends to join SC just above medial end of clavicle
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Positioning
•Supine with a roll under the shoulders
•Head slightly turned AWAY from puncture site
•Slight trendelenburg (15-30 degrees)
•Puncture @ apex of triangle aimed at ipsilateral nipple
•Attempt to puncture during exhalation in spont breathing
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Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Subclavian
•Femoral
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Subclavian Anatomy
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Surface Landmarks
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Positioning•Supine and in trendelenburg (30 degrees)
•Head/neck positioning:‐Extension of neck with rolled towel along axis of T-spine
‐Head in neutral position
‐Slight flexion and turned towards puncture site
•Attempt to puncture during exhalation in spont breathing
‐Expiratory hold if on mechanical ventilation
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Three common sites
•Internal jugular
‐Anterior
‐Middle
‐Posterior
•Subclavian
•Femoral
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Femoral Anatomy
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Femoral Anatomy
NAVEL
mpty space
ymphatics
Roger’s Textbook of Pediatric Intensive Care, 4th ed.
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Surface Landmarks/Positioning
•Positioning‐ “Frog-leg appearance”: Slight external rotation at the hip and flexion at the knee
‐ABduction of leg with external rotation at the hip
‐External rotation at the hip
•Rolled towel under the buttock
Roge
r’s T
extb
ook
of P
edia
tric
Inte
nsiv
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re, 4
th e
d.
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Complications
•*Infection (F)
•Thrombosis (F)
•Arterial puncture
•*Bladder puncture (F)
•Hemorrhage
•Phlebitis
•Hemo/Pneumothorax (I/S)
•Tracheal puncture (I/S)
•Catheter fragment/ guidewire embolism
•Cardiac dysrhythmias
•Air embolism
•Erosion/perforation
•Pericardial tamponade
•Uncooperative patient
•Lack of experience/supervision
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Complications
•Complication rates ‐Adults: 0.5-15%, up to 35% for inexperienced
‐Pediatrics: 0.3%-34% (lowest for femoral)
•Risk increases exponentially with increasing number of attempts
‐Likelihood of failed cannulation correlates with repeated attempts
Kumar et al. Ultrasound guided vascular access: efficacy and safety. Best Practice & Research Clinical Anaesthesiology 2009; 23: 299–311 Rey et al. Mechanical complications during central venous cannulations in pediatric patients. Intensive Care Med 2009; 35: 1438–1443.
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Catheter-Associated Bloodstream Infection (CABSI)
•Most common complication of CVC
•Significant cause of morbidity, mortality and healthcare costs
•Substantially reduced by using a “bundle” of practices
•Lower risk of infection with subclavian venous access in adults
•Regardless of site, strict attention insertion technique can reduce infections
Miller et al. Decreasing PICU Catheter-Associated Bloodstream Infections: NACHRI's Quality Transformation Efforts. Pediatrics 2010; 125: 206-213
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ED CVL Insertion Bundle
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ED/PICU CVL Insertion Bundle
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ED CVL Insertion Bundle
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PICU Insertion Bundle
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Bundles of joy….
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Choosing a Catheter
•Size?
•Length?
•Number of lumens?
•Patient
‐Weight/size
‐Size of vessel
‐Indications
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Choosing a Catheter Size/Length
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Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Position**
•Insertion Checklist (“Bundle”)
•Perform Procedure/Apply sterile dressing
•Confirm Placement
•Document
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Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Position**
•Insertion Checklist (“Bundle”)
•Perform Procedure/Apply sterile dressing
•Confirm Placement
•Document
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Pediatrics
???????????????????????????
Correct position or
Malpositioned???????????????????????????
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Sequence of Events
•Inform/Consent parents
•Perform a “Time Out”
•Position**
•Insertion Checklist (“Bundle”)
•Perform Procedure/Apply sterile dressing
•Confirm Placement
•Document
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Despite what Kiyetta is about to tell you…
Landmarks are still IMPORTANT!!!