2013 Pediatric Subspecialty Boot Camp_Central venous access

Pediatrics

Vascular AccessPART ONE: Central Venous Catheterization

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xxx00.#####.ppt 04/12/23 11:25 AMPediatrics

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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

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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

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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



•Position**




•Document

Pediatrics

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Correct position or

Malpositioned???????????????????????????

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Sequence of Events



•Position**




•Document

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Despite what Kiyetta is about to tell you…

Landmarks are still IMPORTANT!!!

Health & Medicine

2013 Pediatric Subspecialty Boot Camp_Central venous access