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132  Central Line Training 2022 Bl Edits

132.1 Summary

  • Central Line Training 101
  • Objectives
  • Question 1
  • Question 2
  • Question 3
  • Question 4
  • Background
  • Case
  • Indications for Central Venous Catheters
  • Types of Central Venous Catheters
  • Risks

132.2 Slide outline

132.2.1 Slide 1

  • Central Line Training 101
  • Brian Poole, MD
  • Emily Beck, MD
  • Brian Locke, MD ### Slide 2
  • TODO: No text extracted from this slide. ### Slide 3
  • Objectives
  • Describe indications, risks, and procedural steps of central line placement
  • Become familiar with central line kit
  • Identify vessels using ultrasound to guide central line placement
  • Practice steps to successfully place a central line ### Slide 4
  • Question 1
  • Which of the following is NOT an indication for central venous catheter placement?
  • Massive transfusion
  • Administration of caustic medications
  • Total parenteral nutrition
  • Frequent lab collections ### Slide 5
  • Question 2
  • Which answer roughly matches the rate of complications from placing a R IJ triple lumen catheter?
  • Answer
  • Arterial Puncture
  • Vascular Injury
  • Symptomatic DVT
  • CLABSI
  • Pneumo-thorax
  • A
  • 1%
  • <0.1%
  • 10%
  • B
  • C
  • <1%
  • D ### Slide 6
  • Question 2
  • Which of the following is the strongest contraindication to placing a central venous catheter?
  • Uncooperative awake patient
  • Infection overlying site of catheter placement
  • Coagulopathy
  • Recent tpa administration
  • Wolfe KS, Kress PJ. Chest 2016;150(1):237-246. ### Slide 7
  • Question 3
  • Which of the following is most correct regarding the risks of central venous catheter placement?
  • Subclavian placement has the lowest risk of complications
  • Femoral catheters have a significantly higher rate of DVT
  • Incidence of pneumothorax is equal between IJ and SC placement
  • Blood-stream infection is the most common complication of centra-line placement ### Slide 8
  • Question 4
  • We currently use chlorhexidine (CHG) as the skin antiseptic prior to invasive procedures. Sterilization of the skin with CHG is dependent on:
  • A. Scrubbing technique
  • B. Duration of scrubbing
  • C. Drying time
  • D. Light activation ### Slide 9
  • Background
  • 1929 Dr. Werner Forssman inserted a ureteric catheter through his cubital vein into the right side of his heart
  • 1953 Seldinger technique was first described for arteriography
  • In the early 2000 approximately 8% of hospitalized patients required central venous access with more than 5 million catheters placed yearly in the US ### Slide 10
  • Case
  • 72 F with DMII presents to the ED with 1 week of progressive cough, dyspnea, and fevers. She recently attended a family wedding where several contacts later tested positive for COVID.
  • ED: Hypotensive to 76/48 after 2 L IVF, tachycardic to 120s. She has 2 PIVs (20 g R forearm, 22g L hand) and norepinephrine is started at .1 mcg/kg/min prior to arrival to the MICU.
  • The nurse asks if you are going to place a central line when the patient arrives in the ICU ### Slide 11
  • Indications for Central Venous Catheters ### Slide 12
  • Types of Central Venous Catheters
  • Triple (Quad) Lumen CVC
  • Introducer Sheath (Cordis, PSI) & MAC: contains port for PA-catheter or pacer) and 9 Fr (big) infusion port
  • Dialysis catheter (2 large lumens +/- an additional medication port)
  • Peripherally-Inserted Central Catheter (PICC; 1-3 lumens)
  • Tunneled lines (various; iHD, or medications e.g. Hickman) ### Slide 13
  • TODO: No text extracted from this slide. ### Slide 14
  • Risks
  • Bleeding: insertion site, subq/retroperitoneal hematoma, mediastinal, hemothorax
  • 0.5%-1.6%
  • Infection (i.e. CLABSI)
  • 0.5% - 1.4%- no statistically significant difference between insertion sites
  • Vascular injury
  • 4.2-9.3% arterial puncture, <1% arterial injury
  • Pneumothorax (requiring chest tube)
  • 0.5% IJ
  • 1.5% subclavian
  • Thrombosis (symptomatic)
  • 0.5% - 1.4% (femoral > IJ ~ subclavian)
  • Wolfe KS, Kress PJ. Chest 2016;150(1):237-246.
  • Parienti JJ, et al. New Eng J Med 2015;373(13):1220-1229. ### Slide 15
  • Contraindications
  • Few strong contraindications
  • Distorted vessel anatomy- thrombosis, vascular injury
  • Infection overlying catheter insertion site
  • Relative contraindications: alternative site
  • Coagulopathy
  • Thrombocytopenia
  • Elevated ICP
  • Hemothorax or pneumothorax risk ### Slide 16
  • Procedural Order ### Slide 17
  • Supplies
  • Central Line
  • Contains line and most of your supplies
  • Central Line Kits
  • Need: Line caps (3), Luer lock syringe, saline flushes NOT sterile
  • OR towels, extra gown, gauze
  • Line caddy
  • Sterile gloves
  • Ultrasound probe cover
  • Line dressing ### Slide 18
  • Positioning: Key to Success ### Slide 19
  • Positioning
  • Pigott et al. Bedside Ultrasonography, Central Line Placement: Treatment & Medication. eMed Updated: Oct 30, 2009 ### Slide 20
  • Anatomy
  • High Neck
  • Mid Neck ### Slide 21
  • Anatomy
  • Low Neck ### Slide 22
  • Ultrasound Color Doppler ### Slide 23
  • Always Maintain Sterility
  • Position patient
  • Open supplies onto table steriley
  • Cleanse insertion site with antiseptic
  • 30 seconds drying time
  • Don sterile gown/gloves
  • Drape patient
  • Speak up if you think you might have broken sterile field ### Slide 24
  • Seldinger Technique
  • https://www.youtube.com/watch?vhmEMUCaU1y0 ### Slide 25
  • Checking Placement ### Slide 26
  • Post procedure: CXR confirmation
  • Assess correct placement/catheter termination
  • Cavoatrial junction is 1.5-2 vertebrae below carina
  • SVC placement is generally fine
  • Assess for complication
  • Pneumothorax
  • Inappropriate vessel
  • Right side should NOT cross midline
  • Left side SHOULD cross midline ### Slide 27
  • TODO: No text extracted from this slide. ### Slide 28
  • TODO: No text extracted from this slide. ### Slide 29
  • TODO: No text extracted from this slide. ### Slide 30
  • TODO: No text extracted from this slide. ### Slide 31
  • Post-procedure: Documentation ### Slide 32
  • Post-procedure: Documentation ### Slide 33
  • Post-procedure: Documentation ### Slide 34
  • Question
  • Which of the following is NOT an indication for central venous catheter placement?
  • Massive transfusion
  • Administration of caustic medications
  • Total parenteral nutrition
  • Frequent lab collections
  • Labs are not an indication for CVC placement, nor is patient comfort. ### Slide 35
  • Question 2
  • Which answer roughly matches the rate of complications from placing a R IJ triple lumen catheter?
  • Answer
  • Arterial Puncture
  • Vascular Injury
  • Symptomatic DVT
  • CLABSI
  • Pneumo-thorax
  • A
  • 1%
  • <0.1%
  • 10%
  • B
  • C
  • <1%
  • D
  • Confirm wire placement before dilating! ### Slide 36
  • Question
  • Which of the following is the strongest contraindication to placing a central venous catheter?
  • Uncooperative awake patient
  • Infection overlying site of catheter placement
  • Coagulopathy
  • Recent tpa administration
  • Wolfe KS, Kress PJ. Chest 2016;150(1):237-246. ### Slide 37
  • Question
  • Which of the following is most correct regarding the risks of central venous catheter placement?
  • Subclavian placement has the lowest risk of complications
  • Femoral catheters have a significantly higher rate of DVT
  • Incidence of pneumothorax is equal between IJ and SC placement
  • Blood-stream infection is the most common complication of centra-line placement ### Slide 38
  • Question
  • We currently use chlorhexidine (CHG) as the skin antiseptic prior to invasive procedures. Sterilization of the skin with CHG is dependent on:
  • A. Scrubbing technique
  • B. Duration of scrubbing
  • C. Drying time
  • D. Light activation ### Slide 39
  • Learning Points
  • You must be able to consent a patient independently for a central line to meet ABIM requirements: know indications and complication rates.
  • Evaluate each confirmation x-ray: terminates between SVC-Atria?, Crosses Midline?, Pneumothorax?
  • Never be afraid to admit you broke sterility ### Slide 40
  • Questions?
  • brian.poole@hsc.utah.edu 801-691-8134
  • emily.beck@hsc.utah.edu 208-830-6514
  • brian.locke@hsc.utah.edu 406-570-6919

132.3 Learning objectives

  • Central Line Training 101
  • Objectives
  • Question 1
  • Question 2
  • Question 3

132.4 Bottom line / summary

  • Central Line Training 101
  • Objectives
  • Question 1
  • Question 2
  • Question 3

132.5 Approach

  1. TODO: Outline the initial assessment or decision point.
  2. TODO: Outline the next diagnostic or management step.
  3. TODO: Outline follow-up or escalation criteria.

132.6 Red flags / when to escalate

  • TODO: List red flags that require urgent escalation.

132.7 Common pitfalls

  • TODO: Capture common errors or missed steps.

132.8 References

TODO: Add landmark references or guideline citations.

132.9 Slides and assets

132.10 Source materials