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- 1. Dr Debasish Swain DrSidhartha sraban Routray Associate Professor, Dept of anaesthesiology Dr Debadas Biswal Assistant Professor, Dept of anaesthesiology
- 9. Central venous accessdevices in COVID patients PICC (peripherally inserted central catheters) CICC (centrally inserted central catheters) FICC (femorally inserted central catheters)
- 10. Principles Preferably u/sguided with wireless ultrasound probes Avoid radiology after central venous cannulation Catheter tip location-intracavitary electrocardiography (IC-ECG) and transthoracic echocardiography (TTE). Consider the use of subcutaneously anchored securement, which will make the dislocation less likely especially in the agitated patient or in the patient undergoing periodic pronation.
- 11. PICC (peripherally insertedcentral catheters) No risk of pleuropulmonary complications (pneumothorax, hemothorax) PICC can be given in any position.(supine /sitting /pronated) PICC is theoretically safer for the operator than the insertion of a CICC, where the operator dangerously close to the patient's face and to his oral, nasal and tracheal secretions Risk-thrombosis
- 13. Can be useful In patients on non-invasive ventilation (with mask or helmet), keeping the neck free In the pronated COVID-19 patient, the dressing is comfortable, easy to monitor the exit site the connection/disconnection of the infusion lines and not flooded by the patient's oral and tracheal secretions In tracheostomized patients In heavily anticoagulated patient PICCs offer longer life expectancy
- 14. Central insertion catheters(CICCs) In case of specific contraindications and s an alternative to PICCs In the absence of specifically trained personnel Indication - preferential use of CICCs is the need for a central route with more than three lumens. Supraclavicular/ an infra-clavicular approach In the presence of helmets, face masks, tracheostomies, etc., (ultrasound-guided puncture and cannulation of the axillary vein) provide greater protection and stability of the catheter at the exit site. Use U/S to verify the absence of pneumothorax
- 15. FICC (femorally insertedcentral catheters) Minimizes the risk of operator contamination by the patient's oral, nasal and tracheal secretions The exit site can be (a) by puncturing the common femoral vein and then tunneling to mid-thigh, or (b) by directly puncturing the superficial femoral vein at mid-thigh; For CVP- tip must be in atrium For others - in the middle tract of the inferior vena cava (above the bifurcation of the iliac veins and below the renal veins).
- 16. COVID-19 patient- due to his hyper-coagulability status - may have a high risk of catheter-related thrombosis (either after PICC, CICC or FICC insertion). In the absence of contraindications, then, for all central venous catheters in COVID-19 patients, subcutaneous administration of low molecular weight heparin at prophylactic (100 units/kg/24h) or even therapeutic (100 units/kg/12h or 150 units/kg/24h) dose should be considered.
- 26. Femoral Vein CentralVenous Access The insertion of a central venous line is potentially life-saving as, in emergent situations, it allows rapid administration of high-volume isotonic fluids and medications that would otherwise be caustic to peripheral veins
- 27. Anatomy In theleg, popliteal vein drains to the superficial femoral vein. The superficial femoral vein is joined by the deep femoral vein in the upper thigh becoming the common femoral vein The great saphenous vein then joins the common femoral vein near the inguinal ligament. Superior to the inguinal ligament, the common femoral vein becomes the external iliac vein. The internal iliac vein drains into the external iliac vein becoming the common iliac vein, and the common iliac veins join to become the inferior vena cava
- 28. The commonfemoral vein is the ideal vein to puncture when performing central venous access at the femoral site. The common femoral vein lies within the “femoral triangle” in the inguinal-femoral region which is bordered by the inguinal ligament superiorly, the adductor longus medially, and the sartorius muscle laterally. Mnemonic “NAVEL.” Moving laterally to medially, (N) femoral nerve, (A) femoral artery, (V) femoral vein, (E) empty space, (L) lymphatics.
- 30. In mostinstances, central venous access with ultrasound-guidance is considered the standard of care.
- 31. Indications Peripheral accessis unobtainable Medication to be infused is known to induce peripheral phlebitis High volume fluid and/or parenteral nutrition administration is required Emergency resuscitation is warranted Monitoring of central venous oxygen saturation and central venous pressure is indicated Frequent blood sampling needs to be performed Access is required to perform hemodialysis, hemofiltration, or apheresis.
- 32. Contraindications Potential contraindications tocentral venous access via the femoral vein are the following: Thrombosis Skin infection at the site of needle puncture Trauma Distorted anatomy Coagulopathy
- 33. Equipment Central venouscatheter Introducer needle and a slip-tip syringe Guidewire Dilator Scalpel Gauze (4x4) Hubs for access ports on catheter Normal saline for flushing catheter Facemask and hair capChlorhexidine gluconate (e.g., chloraprep) or povidone-iodine solution for topical cleaning Topical anesthesia (e.g., 1% lidocaine)
- 34. 25-gauge needleand a syringe for administration of topical anesthesia Sterile gown and gloves Sterile drape that is long enough to cover patient from head to toe Needle holder and silk sutures If using ultrasound-guidance: ultrasound, sterile ultrasound probe cover, sterile and non-sterile ultrasound gel For line dressing: Tranparent dressing to allow for visualization of the insertion site (e.g., Tegaderm).
- 37. Preparation Informed consentof the patient by explaining the risks and benefits of the procedure Choose an appropriately sized central venous catheter for the patient. This decision may be influenced by the clinical indication, patient size and/or vessel caliber. Consider the following: Catheter size in French (F) (e.g., 4F, 7F) Catheter length (in centimeters) Number of lumens required
- 38. Positioning The patientcan be placed in a reverse Trendelenburg position to engorge the femoral vein which could potentially increase the vessel’s caliber The patient’s leg can be positioned in one of three ways: frog-leg position, external rotation at the hip with full leg extension, abduction of a fully extended leg with external rotation at the hip. Operator washes hands with soap and water Operator dons sterile personal protective equipment (PPE) (i.e., cap, facemask, sterile gown and gloves) European Centre of Disease Prevention and Control (ECDC) strongly recommend the use of a double mask (N95mask + surgical mask) for the insertion of vascular access devices, considering the high risk of aerosol in the environment,
- 39. Sterile preppingof the skin at the site of insertion with chlorhexidine gluconate or povidone-iodine solution Place a sterile drape over the patient ensuring coverage from head to toe Administer local anesthetic as an effort to minimize the use of systemic analgesia/sedation Flush all lumens of the central venous catheter with normal saline.
- 41. landmark technique Useyour index finger to locate the arterial pulsation along the inguinal ligament at the midpoint between the anterior superior iliac spine and the pubic symphysis. Then move 1 cm to 2 cm inferior to this position as the needle puncture must be performed below the inguinal ligament. Next, move 1 cm to 2 cm medially as the vein lies medial to the artery. Puncture just medial to your index finger in a direction just medial to your middle finger
- 42. Complications Early Arterialpuncture which could result in formation of a hematoma Hematoma formation could also result from routine placement Bladder puncture. At our institution, we catheterize or insert a foley catheter prior to placement of a femoral central line Hemorrhage Catheter fragment resulting in a guidewire embolism Cardiac dysrhythmias, particularly from high-lying central lines
- 43. LATE Central LineAssociated Bloodstream Infection (CLABSI) Phlebitis Thrombosis Erosion/perforation The following are not complications, per se, but can lead to complications: Uncooperative patient Lack of experience/supervision
- 65. Care of centralline
- 70. Disposal of BMW CategoryType of bag/container Type of waste Treatment disposal options Yellow Non chlorinated colour coded bags in coloured bins Separate collection system leading to ETP • Human anatomical waste • Animal anatomical waste • Soiled waste • Expired or discarded medicines • Chemical waste • Micro, biotech & clinical lab waste • Chemical liquid waste Incineration/deep burial Red Non chlorinated plastic bags in coloured bins/ containers Contaminated waste (recyclable) tubing, bottles, urine bags, syringes (without needles) and gloves Auto/micro/hydro and then sent to recycling White Translucent, puncture, leak & tamper proof Waste sharps including metals Auto/dry heat sterilization followed by shredding /mutilation/encapsulation Blue Water proof card board boxes/containers Glassware waste Disinfection or auto/micro /hydro then sent to recycling *Disposal by deep burial is permitted only in rural or remote areas where there is no access to common bio- medical waste treatment facility. This will be carried out with prior approval from the prescribed authority