(1)
Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
Keywords
ProceduresCentral linesArterial linesOrogastric tubeFeeding tubeParacentesisParacentesisCoagulopathy
The tradition of “See one, Do one, Teach one” can no longer be condoned. The safety and well being on the patient is one’s overriding concern.
If you don’t know how to do it, don’t do it!
Before doing a procedure make sure you have all the equipment required.
Make sure you know how to get out of trouble should the procedure “go wrong”
If you fail after two to three attempts at the procedure STOP. Ask a more experienced operator for help
Check the platelet count, PTT and INR before any invasive procedure (see Chap. 38)
As a general rule the risk of bleeding is related to the skill of the operator rather the ability of the blood to clot (however this helps)
Patients receiving therapeutic anticoagulants tend to bleed; stop anticoagulants prior to the procedure
Generally it is safe to do a procedure with a platelet count >50,000 and an INR <2.0. However the risk depends on the type of procedure.
Evaluate the risk/benefit ratio in coagulopathic patients and the urgency of the procedure.
Obtain informed consent from the patient (or surrogate), unless an emergency. Explain the benefits and risks (including death).
Murphy’s Laws of Procedures
Murphy’s First Law of Procedures
Nature sides with the hidden flaw
Murphy’s Second Law of Procedures
If a procedure can go wrong it will go wrong usually at the most inopportune time
Murphy’s Third Law of Procedures
If a patient can bleed he/she will bleed
Murphy’s Fourth Law of Procedures
Never “force” a patient into a procedure they decline or are hesitant about; these are the patients that will suffer a complication
Murphy’s Fifth Law of Procedures
Never “force” a device into a patient; if it does not “go in easily” it will go into the wrong place
Central Venous Access
Many ICU patients require a central line. Indications include:
High doses of vasopressor agents. In select circumstances low dose vasopressors may be given via a well secured and flowing peripheral catheter (see Chap. 12)
Multiple mediations, infusions, antibiotics, etc
Patient requiring volume/blood resuscitation with inadequate peripheral venous access
Placement
A fully stocked procedure cart is highly recommended
ICU nurse should be at bed-side to assist (and observe) the operator
The operator should be fully gowned and gloved
Full body drape
Clean skin with chlorhexidine
Don’t shave skin with razor, can use hair clipper
An antibiotic/antimicrobial coated catheter is recommended in units which have a high baseline incidence of catheter related blood stream infection (>3/1,000 catheter days)
Clean up your mess after you are completed; don’t leave it up to the nurse. Dispose of all sharps
Document procedure in patients chart (with date and time)
Site of placement
Site of choice should depend on patient’s body habitus, existing and previous lines and your degree of comfort with each site
Ultrasound guidance is highly recommended for placement of internal jugular lines (IJ) and visualization of the inguinal anatomy in obese patients
The femoral site is suggested in highly coagulopathic patients, in emergency situations, in patients with severe bullous lung disease, etc.
The femoral site is compressible should the artery be accidentally stuck (as apposed to the IJ or subclavian).
It is also nearly impossible to cause a pneumothorax or hemothorax when placing a femoral line. Caution should be used when placing an IJ or subclavian line in patients with ALI/ARDS or severe COPD. A pneumothorax can be fatal
Despite a common misconception femoral lines are not associated with a greater risk of infection [1]. However the risk of infection may be higher at the femoral site in morbidly obese patients.
Femoral catheters have a significantly higher risk of thrombosis. “Aggressive” DVT prophylaxis is indicated in these patients.
Do not replace old lines over a guidewire. This is an outdated practice
A CXR is required after a IJ/subclavian to confirm correct placement and to exclude a pneumothorax.
? Arterial placement of venous catheter
Transduce the line
Check a blood gas
If you think the line is in an artery, don’t remove. Call a vascular surgeon stat to evaluate the situation. The line may need to be removed surgically and a tear repaired.
The Do NOT’S
DO NOT PLACE A FEMORAL LINE IN A KIDNEY TRANSPLANT PATIENT
DO NOT PLACE A CENTRAL LINE ON THE SAME SIDE AS A DIALYSIS FISTULA (femoral or subclavian CVC)
DO NOT remove a CVC (subclavian or IJ) in an upright patient (may cause air embolism)
Subclavian Vein Catheterization
ADVANTAGES—consistent identifiable landmarks, easier long term catheter maintenance, relatively high patient comfort
DISADVANTAGES
pneumothorax (1–2 %)
subclavian artery puncture (1 %)
difficult to perform under ultrasound guidance
CONTRAINDICATIONS
Subclavian puncture is a relative contraindication in patients with a coagulopathy and/or pulmonary compromise (dependent on the expertise of the operator).
ANATOMY—It is continuation of axillary vein, beginning the at outer border of first rib, extending 3–4 cm along the undersurface of clavicle and joining ipsilateral internal jugular vein behind the sternoclavicular jointRelated posts:
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