Line ComplicationsLine Complications

Dalhousie UniversityDalhousie University

Critical Care Lecture SeriesCritical Care Lecture Series

ICUObjectivesObjectives

Know the indications and contraindications for central line insertion

Review the technique of central line insertion

Know the most common complications of central lines and arterial lines

Know how to prevent line complications

Know how to recognize and manage line complications

Examples

ICU CVP Catheter IndicationsCVP Catheter Indications

Pressure monitoring Mixed venous oxygen saturation Fluid administration during volume

resuscitation (may not be as good as large-bore peripheral lines!!)

Administration of corrosive or hypertonic fluids

Administration of vasoactive agents Lack of other sites

ICUCVP ContraindicationsCVP Contraindications

Severe coagulopathy Obstruction or congenital abnormality Patient refusal (if competent) Restless and uncooperative patient, unless

sedation can be utilized Lack of experience and no expert

supervision, OR previous failed attempt by experienced physician

Injury or infection at the site

ICU

Normal CXR

ICUComplicationsComplications

More than 15% of all central lines have a complication Mechanical 5-19% Infectious 5-26% Thrombotic 2-26%

ICU

Mechanical Mechanical ComplicationsComplications

ICUMechanical InjuriesMechanical Injuries

Most common complications:

Type of complication

Number (/110)

Wire/catheter embolus 20

Cardiac tamponade 16

Carotid arteryCannulation/puncture

16

hemothorax 15

pneumothorax 14

Misc. (PA rupture,vessel injury, air embolism etc)

29Modified from Domino et al 2004

ICUPneumothoraxPneumothorax

More common in subclavian Incidence ranges from 0.3 to 3%

depending on experience Classic presentation =

hypoxemia/hypotension/pleuritic CP

Can be treated conservatively in non-ventilated patients

ICU

ICUTreatmentTreatment

Chest tube to expand lung

Insertion of chest tube may create hole in lung parenchyma leading to another complication:

ICU

ICUWrong VesselWrong Vessel

If finder needle or 18 g insertion needle in artery may remove and apply pressure

If CVC or PAC introducer is in artery remove catheter and apply pressure OR:

Consult CV surgeon/thoracic surgeon ? OR for thoracotomy, removal of catheter and repair of vessel

ICU

ICUThe Left Side is SinisterThe Left Side is Sinister

Left internal jugular has unique complications – thoracic duct injury

Left inominate vein can be lacerated hemothorax and OR

L IJ or SC catheter too proximal can lacerate SVC death

ICULeft Subclavian ArteryLeft Subclavian Artery

ICU

ICU

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Prevention of Mechanical Prevention of Mechanical ComplicationsComplications

ICU

Prevention of Prevention of Mechanical Mechanical

ComplicationsComplications Ultrasound Guidance -Useful for internal jugular-Potentially prevents wrong vessel,

hemo/pneumothorax Pressure waveform monitor-Arterial cannulation/puncture CXR-Cardiac tamponade-Wire/catheter embolus

ICUUltrasound!Ultrasound!

Prevention is always better than treatment

Use ultrasound probe to localize vessel

Cannulate vessel under direct vision

ICU

Ultrasonographic Guidance:Ultrasonographic Guidance:Dynamic vs. StaticDynamic vs. Static

Dynamic Consists of ultrasonic

localization, and image-guided cannulation

More precise and “real time”

Difficult to keep sterility of transducer and site.

More hand to screen coordination, unless two persons involved

Static Consists of ultrasonic

localization and marking of landmarks only

Cannulation is not image-guided, but is separate

Time delay between marking and cannulation

Easy to keep sterility of transducer and site

Less technically demanding

ICUPressure WaveformsPressure Waveforms

Several options: Connect sterile tubing to

pressure tubing and flush Attach to needle in vessel and

confirm venous trace Remove syringe and confirm

non-pulsatile blood Compare arterial blood sample

with your sample

ICUIJ Insertion MethodIJ Insertion Method

Transverse orientation Longitudinal orientation

ICU Check Vein for PatencyCheck Vein for Patency

Thrombus

Vein should be free of clot and freely compressible

when pressure is applied with the probe

ICU

Transverse Orientation- Transverse Orientation- “Finger Wiggle”“Finger Wiggle”

Finger on one side of probe

Acoustic shadow of finger on same side of image

ICU

Orientation- “Mock Orientation- “Mock Poke”Poke”

ICU

Orientation- “Mock Orientation- “Mock Poke”Poke”

Acoustic “shadow” of the needle over the vein

ICUTechniqueTechnique

Steps: Obtain informed consent (unless emergency) Check radiograph for any existing pathology (put

line on the same side as pathology) Check coagulation studies, if indicated Position patient appropriately (see individual slides

for specifics) Prep/drape using sterile technique Inject local, making certain not to inject

intravascularly Using ultrasound, assess for proper orientation,

localize the vessel, and ensure patency Cannulate vessel and place catheter (see steps) Check radiograph to ensure correct position and to

evaluate for complications (can also use ultrasound to evaluate for pneumothorax and to look for incorrect placement, i.e., subclavian to IJ positioning)

ICUTechniqueTechnique

Sterile technique is extremely important Nosocomial bloodstream/catheter infections are very

prevalent, causing significant morbidity (and costing millions of dollars)

Most beginners make one of three mistakes: Contaminate gloves when putting them on Contaminate gloves when placing drapes Contaminate the wire by not paying close

attention to where it is/what it’s touching at all times

Use of ultrasound introduces more opportunity for contamination, SO BE CAREFUL

ICU

ICUIJ Insertion MethodIJ Insertion Method

After flash of blood, syringe is removed and a guidewire

is advanced to 20cm

The needle is then removed, leaving the guidewire in place

ICU

Position of guidewire in relation to neck anatomy

Make a small skin stab at wire insertion site.

Note control of guidewire with both hands

IJ Insertion MethodIJ Insertion Method

ICU

Dilate. If awake, tell

the patient “you’re going to feel some pressure.”

Advance the catheter over the wire. NEVER let go of the wire.

Grab it when it comes out the brown port

IJ Insertion MethodIJ Insertion Method

ICU

Most use infraclavicular approach (insert at “fossa” of deltopectoral groove, about 1-2 cm inferior to clavicle)

Poor choice in coagulopathy (difficult to compress) Higher PTX risk than internal jugular (1-5%) Less infection risk than IJ Trendelenburg’s position with towel roll under scapulae Direct needle toward sternal notch Keep needle parallel to floor; DO NOT AIM UNDER

CLAVICLE OR YOU WILL CAUSE PNEUMOTHORAX Constant suction in and out Ultrasound not as useful Again, think after inserting needle 5 cm deep

Insertion Method-Insertion Method-SubclavianSubclavian

ICU

ICUInsertion Site-FemoralInsertion Site-Femoral

Vein is medial to femoral artery In anatomic position

(legs apart), axis of vein is as pictured: toward umbilicus

Note the inguinal ligament!

ICU

Reverse Trendelenburg position (legs DOWN) to reduce chance of air embolus

Use for emergency access Try to remove after 72

hours Do not use if PA catheter

needs to be placed

At 45o angle to vessel, just medial to artery

Insertion Method-Insertion Method-FemoralFemoral

ICUImage and OrientationImage and Orientation

ICUInfectious ComplicationsInfectious Complications

ICU

Infectious Complications Infectious Complications PreventionPrevention

ICU

ManagemeManagementntof of

Line Line InfectionsInfections

ICU

Pulmonary Artery Pulmonary Artery CathetersCatheters

PAC have unique set of complications:

Arrhythmias inc. complete heart block

Knotting of the PAC

Pulmonary Artery infarction or rupture

ICUArterial LinesArterial Lines

Most common site = radial artery Rare complications 1983 Slogoff and Keats

prospective study 1699 radial artery cannulations

no ischemia or disability of hand Pseudoaneurysm of the radial

artery can occur

Bowdle Anesthesiology Clinics of NA 2002: 20

What’s Wrong With What’s Wrong With These Pictures?These Pictures?

ICU

ICU

ETT in too far

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Chest tube in poor position

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Left mainstem intubation

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Feeding tube in lung

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Feeding Tube in RLL

ICU

Subclavian going In wrong direction

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Carotid Artery Insertion

ICU

ICU

HematomaAfterSubclavianArteryPuncture

NG

ETT

ICU

ICU

CTinsertionSubclavian

Line

NG Down LeftMainstem!!!!

ICU

ETT

SubclavianCrossingThroughinnominate

ICUSummarySummary

Ultrasound guided placement is becoming standard of care.

Consider waveform monitoring with all line insertions.

Do a CXR post line insertion and review it!

Three poke rule (get another person to do procedure)