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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

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Central Lines

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  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

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