Central Venous Catheterization 15 Rachel McDonald and Adam Anderson Central venous catheterization is commonly performed in the intensive care unit when peripheral access is inadequate. Indications for central venous catheterization include administration of noxious medications, hemodynamic monitoring, therapies requiring rapid blood flow rates (hemodialysis, plasmapheresis), insertion of invasive devices, rapid large-volume fluid or blood product administration, and emergency venous access, Noxious ‘medications that require infusion into large central veins include vasopressors, chemotherapy, and total parenteral nutrition (TPN). Hemodynamic ‘monitoring and invasive devices requiring central access include monitoring of central venous pressure, measurement of central venous hemoglobin saturation, and insertion of pulmonary artery catheters or transvenous pacemakers. Contraindications for central venous catheterization include known thrombosis of the target vessel and infection over the site of entry, There is no definitive cutoff for the insertion of @ central venous catheter in coagulopathic or thrombocytopenic patients; however, the subclavian site is generally avoided in coagulopathic patients due to inability to monitor for bleeding or adequately compress the site should bleeding occur. Use of @ micropuncture kit or correction of the coagulopathy with freshsfrozen plasma and platelet transfusion may be useful prior tothe procedure, Complications of central venous catheterization include mechanical complications (arterial puncture, pneumothorax, hemothorax, air embolus, retroperitoneal hemorthage), infectious complications (central venous catheter-associated bacteremia, cellulitis), and catheter-assaciated thrombosis or stenosis. Although conflicting data exist, general consensus is that the risk of infection is least with subclavian cannulation and highest with femoral cannulation. In addition to avoiding the femoral site due to infectious complications, the Centers for Disease Contvol and Prevention (CDC) guideline for cannulation site selection recommend avoiding femoral cannulation in adult patients because of increased rates of venous thrombosis and restriction of patient mobility. Subclavian cannulation should be avoided in patients with coagulopathies for the aforementioned reasons or in patients with advanced kidney disease due to the risk of subclavian stenosis, ‘The use of ultrasound guidance to aid in the placement of central venous catheters has been shown to decrease complication rates, decrease the rnumber of attempts necessary to carmulate the vein, and decrease the amourt of time necessary to perform the procedure, Ultrasound is used both to identify the location of the target vein and its accompanying artery and to assess the vein for thrombosis or stenosis. In general, the internal jugular vein typically anterolateral to the carotid artery, and the femoral vein is medial to the femoral artery. The vein can further be identified on ultrasound by its compressibility. Veins should be completely compressible (the anterior and posterior walls of the vessel should approximate) with pressure applied with the ultrasound probe. Ifthe vein is not compressible, there should be suspicion for a venous thrombosis, Veins ean also be identified using spectral color or pulsed wave Doppler, as flow in arteries is typically pulsatile and flow in veins is not. However, this can be misleading in certain clinical conditions, such as in patients with severe tricuspid regurgitation. Before performing central venous catheterization, obtain informed consent based on the policies of each institution. All present must agree on the patient identification, the procedure being performed, and the site of the procedure. Sterile precautions must be observed, including hand hygiene, full sterile drape, sterile gloves, sterile gown, mask with face shield, and hair covers. All present in the room should wear masks and hair covers. It is, helpful to have a nonsterile assistant present during the procedure. The following guidelines are forthe placement of central venous catheters using commercially available kits via Seldinger’s guidewire technique. INTERNAL JUGULAR CENTRAL VENOUS CATHETER PLACEMENT (Note: ultrasound guidance is preferred.) 1. Place the patient in Trendelenburg position, and have the patient turn his or her head 45 degrees to the direction opposite the site of catheter placement. 2, If ultrasound is available, use ultrasound to identify the vascular structures prior to sterilizing the procedure site. Evaluate the vein for patency and compressibility as described above to ensure that there are no contraindications to catheterization (e.g, venous thrombosis or stenosis). 3. Prepare the ultrasound for sterile use by applying nonsterile gel to the ultrasound transducer, (Alternatively, this may be performed by a nonsterile assistant.) Don sterile gown, sterile gloves, mask with face shield, and hair cover. Prepare the skin with antiseptic solution (e.g, chlorhexidine or Betadine) ‘Use a sterile full-body drape witha site hole or surgical towels to cover the body, head, and face, exposing only the necessary skin. Flush all ports of the catheter to ensure appropriate functioning, (If ultrasound is not available, proceed step 14.) ‘With help froma nonsterile assistant, lower the ultrasound transducer into the sterile plastic sheath, Make sure to avoid contact between the transducer ard the outer surface ofthe plastic sheath. The nonsterile assistant should then pull the plastic sheath to cover the length of the transducer probe that will come into contact with the sterile field, 9, Place sterile gel on the procedure site. Confirm location ofthe vessels using ultrasound again, 0. Once the site is confirmed, anestbetize the skin and subcutaneous tissue LL, Use ultrasound fo maintain a transverse view of the vein and artery. While holding the ultrasound probe over the vein with the nondominant hand, we the dominant hand to hold the introducer needle. 2. Enter the skin withthe introducer needle, bevel up, just cephalad to the ultrasound transducer at a 45-degree angle. FB:Cardiologia Siglo XXIDoppler probe ‘Skin surface Vein Figure 75.1. Needle inserton using ultrasound guidance. (From DeFer TMThe Washing Manual Ifemship Suraval Gude tne. Philadelphia, PA: Wels Klawer Healtvppicot Willams & Wik, 2013), 3. With the ultrasound transducer, locate the tip of the introducer needle. Move the ultrasound transducer and introducer needle together in order to visualize the tip of the introducer needle throughout its approach tothe target vein, aspirating while advancing. Once the vein is cannulated, dark blood will enter the syringe. (Skip to step 18 if using direct ultrasound guidance.) (Fig. 75.1) |4, Identify the triangle formed by the two heads of the sternocleidomastoid muscle and the sternum, and palpate the carotid pulse (Fig. 75.2) |S. Anesthetize the skin and subcutaneous tissue 16. Palpate the carotid pulse. Lateral tothe carotid pulse, advance the 22-gauge needle (finder needle), bevel up, ata 30- to 45-degree angle to the patient, directed atthe ipsilateral nipple while aspirating, Ifno venous blood return is noted, withdraw the needle and change the angle to a more lateral and then more medial position. Maintain palpation of the carotid pulse. When venous blood is aspirated, make note ofthe angle and depth of | the finder needle, and remove the finder needle. Ifthe carotid artery is entered (bright red and/or pulsatile blood), remove the needle and hold pressure. 17. tthe same site and angle as the internal jugular vein was entered with the finder needle, insert the introducer needle until free flow of dark venous blood is noted (Fig. 75.3), 8, Securely hold the needle, remove the syringe (placing @ finger over the needle hub to reduce the risk of air embolism), and insert the guidewire, The ‘guidewire should advance with litle resistance. Always maintain control ofthe guidewire, 19. While holding the guidewire, remove the introducer needle, Once the introducer needle is outside the patient's skin, bold the guidewire atthe entry site and slide the needle off the guidewire. 20. Use ultrasound fo confirm correct placement of the guidewire within the lumen ofthe target vein. Obtain a transverse view of te internal jugular vein, and identify the wire within the lumen of the vein. Trace the tract of te guidewire from the skin insertion site into the insertion into the vein, Move the ultrasound transducer in the caudal direction to follow the course of the guidewire toward the superior vena cava. Continue moving the transducer caudally confirming the guidewire remains within the lumen ofthe vein for its entre course through the neck. The ultrasound transducer probe can then be rotated 90 degrees to confirm the guidewire is within the lumen of the vein inthe longitudinal axis (Fig. 75.4.Figure 75.2 Internal jugular ven tomy. (From Lin TL, Mohart JM, Sakura! KAThe Washington Mnua!Intemship Survival Guide 2nd ed, Philadelphia, PA: Lippincot Witams & Wiking 008-181) Using a scalpel, make a small incision in the skin atthe entry site, Ensure that the cutting edge ofthe scalpel is facing away from the guidewire and performa stabbing motion to make the incision, Pass the dilator over the guidewire, dilate the tract to the depth ofthe target vein, and remove the dilator. Ensure that the distal port ofthe catheter is open. Pass the catheter over the guidewire, When the catheter is near the entry site, feed the guidewire out until it emerges from the distal port on the catheter. Grasp the guidewire distally, and insert the catheter to the desired depth (15 to 16 em for the right subclavian vein, 18 to 20 em for the left subclavian vein, 16 to 17 em forthe right IJ vein, 17 to 18 om for the left II vein) Hold the catheter in place, and withdraw the guidewire, Ensure thatthe guidewire is intact once itis completely removed. Figure 75.3. Cannulaton ofthe internal jugular vein, (From Lin TL, Mabart JM, Sakurai KAThe Washington Manual! Internship Survival Guile 2nd ed. Phila, PA Lpprest Willams & Wikis; 200182, 2s. %6. M7. 28. Flush all ports to ensure that they are functioning properly, and place caps on ll ports. Secure the cathoter with suture or a commercially available sutureless ki Cleanse the site with antiseptic solution and place a sterile dressing. CObiain a chest radiograph for placement and to evaluate for pneumothorax. The tip of the catheter should reside in the superior vena cava. FEMORAL CENTRAL VENOUS CATHETER PLACEMENT (Note: ultrasound guidance if preferred.) 1, Place the patient inthe supine position, with the ipsilateral thigh slightly abducted and externally rotated. 2. If using ultrasound, follow steps 2 to 13, followed by steps 18 to 27 from internal jugular venous catheter placement. Remember when locating the femoral vein with ultrasound thatthe femoral vein typical lies medial to femoral artery. If ultrasound is unavailable, follow steps 4 to 7 from internal {jugular venous catheter placement above, followed by the steps below. Palpate the femoral arterial pulse inferior to the inguinal ligament. The femoral vein is medial to the femoral artery (Fig. 75.5). With the introducer needle bevel up, enter the skin I em medial tothe pulse, inferior to the inguinal ligament, ata 30- to 45-degree angle (Fig. 75.6). Continue to aspirate as the needle is advanced until the return of venous blood. Ifthe needle is advanced 5 em with no return of venous blood, withdraw while continuing to aspirate, angle more medially, and try again. Ifthe femoral artery is entered (bright red and/or pulsatile blood), hold pressure. FB:Cardiologia Siglo XXIFigure 764. tera jugular vein with varfcaton of guidwre placement. A Transverse view. 8: Longitudinal aw, Arrowhead: carci arary,Astrsk internal jugular ‘oh, Wie arrow: gudewie win tral ger ve FB:Cardiologia Siglo XXIFigure 75.5. Femoral vin anatomy. (From Lin TL, Moka JM, Saiaral KAThe Washington Manual Itomship Survival Guido 2nd ed, Pitadebhia, PA: Lipinctt Witams & Witkin: 2007-188) 4, Follow steps 18 through 27 for internal jugular central venous catheter placement. For the fernoal sit, the entire Length ofthe catheter is inserted (20 em) and secured in plac. SUBCLAVIAN CENTRAL VENOUS CATHETER PLACEMENT 1, Place the patient in Trendelenburg position, and place a towel roll between the scapulae, Keep the head in neutral position or toward the side of line placement to help direct the guidewire inferiorly. FB:Cardiologia Siglo XXIFigure 755. Femoral ven cannulation (Ftom Lin TL, Mehart JM, Sakural KATHe Washington Manus Inemship Survival Guide 2nd ed. Piadetia, PA: Lipinatt Witams & Witkin; 2007-187) 2. Donsterile gown, sterile gloves, mask with face shield, and hair cover. 3. Prepare the skin with antiseptic solution (e.,, chlorhexidine or Betadine). 4, Use a sterile full-body drape with a site hole or surgical towels to cover the body, head, and face, exposing only the necessary skin 5, Flush all ports ofthe catheter to ensure appropriate functioning, 6. Place the index finger of the nondominant hand at the sternal notch and the thumb of the same hand on the clavicle where it bends over the first rib (approximately where the lateral third and medial two-thirds of the claviele meet). The subclavian vein should traverse a line between the index finger and the thumb (Fig. 75.7). 7. Anesthetize the skin and subcutaneous tissue just inferior tothe claviele and lateral fo the thumb. 8, With the introducer needle, bevel up, enter the skin lateral to the thumb and inferior to the clavicle (~2 em inferior and 2 em lateral to the bend in the clavicle), Aim atthe index finger (sternal notch), aspirating while advancing. It is imperative to keep the needle parallel to the floor during advancement, Ifthe clavicle is contacted, depress the entire needle with the thumb unlit passes under the clavicle, rather than changing the angle of | approach, Dark blood will enter the syringe when the vein is cannulated, If there is no blood return ater advancing the needle 5 em, withdraw the needle while continuing to aspirate (Frequently the vein has been pierced, and successful blood flow will be obtained during withdrawal). Redirect the needle more cephalad, and try again. Multiple repeated attempts are not recommended. Once appropriate venous return is noted, rotate the bevel of the needle 90 degrees inferior (bevel now pointing toward the patients fee) Figure 757, Sulaian von anaiomy and eannulaon (From Lin TL, Mahar JM. Sakurai KAThe Washington Manual internship Survival Guide 2nd. Phindebhia, PA Lapinost Willams & Wikis: 2008195) 9. Follow steps 18 through 28 for internal jugular central venous catheter placement. SUGGESTED READINGS FB:Cardiologia Siglo XXIHind D, Calvert N, MeWilliams R, etal, Ultrasonic locating devices for central venous cannulation: meta-analysis, BMJ. 2003;327:361, Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian an internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med, 2012;40(8):2479-2485, MeGee DC, Gould MK. Preventing complications of central venous catheterization. NV Engl J Med. 2003;348:1123-1133. O°Grady N, Aloxander M, Burns L, et al. Guidelines for the prevention of intravascular eathetererclated infections.Clin Infect Dis 2011;52(9):e162— 193. Centers for Disease Control and Prevention. lntps:/www.cde.gov/hiepac/pat!guidelines/bsi-guidelines-201 1 pdf Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular complications of central venous catheterization by insertion siteN Engl J Med 2015;373(13):1220-1229, FB:Cardiologia Siglo XXIEndotracheal Intubation 76 ‘Adam Anderson Endotracheal intubation maintains airway patency, assures delivery of mechanical ventilator defined breaths, facilitates pulmonary toilet, and helps prevent aspiration. Usual indications for endotracheal intubation include airway obstruction, encephalopathy, respiratory failure, and cardiopulmonary arrest Risks include trauma to the oropharynx, hypoxemia from prolonged attempts, emesis with aspiration of gastric contents, unrecognized misplacement of the endotracheal tube, and death. The incidence of complications increases when an inadequately trained or inexperienced provider attempts intubation. These providers should attempt to achieve adequate ventilation and oxygenation using bag-valve-mask devices or other airway devices that, do not require visualization ofthe vocal cords. REQUIRED PREPARATIONS Assessment of the airway anatomy facilitates recognition of potentially difficult intubations. An abbreviated assessment should be performed even in cmergent cases. A commonly uilized assessment tool follows the “LEMON” mncmonic (Table 76.1). Clinicians should pay particular attention to dentition and dental appliances, the mobility of the tongue and it size relative tothe oropharynx or Mallampati score (Fig. 76.1), range of extension and Alexion of the cervical spine, mobility ofthe jaw, and presence of stridor. A difficult intubation may be anticipated in patiens with thick nocks, narrow ‘mouth openings, facial hair, large tongues, and limited mation ofthe cervical spine Suceessfil intubation requires overcoming the normal barriers to objects entering the trachea, including reflexes arising from laryngeal stimulation, ‘the mal-alignment ofthe major axcs ofthe upper airway, andthe anatomic barriers of the tongue and epiglottis. Endotrachcal intubation isan inherently umcomfortable procedure, and even patients with decreased metal satus may cough and resist attemprs at intubation. In addition, laryngeal stimulation increases sympathetic tone with consequent inereases in blood pressure, heart ate, and intracranial pressure. Judicious use of appropriate medications can blunt the potential adverse physiologic effects while providing analgesia, sedation, and amnesia Decisions regarding use of specific agents are based on knowledge of their advantages and disadvantages relative to the patents clinical status and comorbidities (Table 76.2). Only practitioners skilled in endotracheal intubation should administer paralytic agents. Rapidesequence intubation (RSI) i employed when airway control is emergent, the airway is predicted to not be difficult, and gastric insufflation is contraindicated. RSI includes simultaneous administration ofa paralytic and a laryngoscopy attemps prior to bagevalve mask ventilation, Vasopressors should be readily available in tho event of hemodynamic decompensation. PIs ‘Leak extemal ‘Generalimpression of ict alway (anatomy, hai, denon, tongue, auma, facial hal) + Evaluate (2-22 ul) Pater shuld have at ast 1S ger breathe between neleers wih mouth opening {Stinger breathe wen te thyomestal stance * 2 nge breads between hyd and tytod carags + Matampat Score (Fe. 7-1) Naampa and predict easy largoscopy Natampad Ipredets a aicut lnyngoseopy 1 Nampa W pode 8 wry aed aryngotcopy + ObctuctontObesty + Supragotc mass, secroons, blood or redundant issue + Neck Mey +" Spinal disease o C-zolar immobilization All necessary equipment should be immediately available prior to intubation attempts (Table 76.3). FB:Cardiologia Siglo XXI