Central Line Placement / Catheterization: Subclavian approach

INDICATIONS

• Administration of agents into the central vasculature
• Central circulation and intracardiac access
• Maintenance of venous access
• Hemodialysis and plasmapheresis

CONTRAINDICATIONS

• Absolute contraindications
  • Adequate peripheral IV access (see Intravenous Cannulation for further details.
  • Operator inexperience
  • Uncooperative patient
• Relative contraindications
  • Significant uncorrectable bleeding disorder
  • Injury or thrombosis in the target vessel or SVC
  • Inability to tolerate pneumothorax
  • Assisted ventilation with high end-expiratory pressure
• Contraindications unique to the subclavian approach
  • For patients with a significant bleeding disorder, an internal jugular or femoral approach may be more appropriate
  • Surgery or trauma to the clavicle, first rib, or subclavian vessels
  • Administration of thrombolytic medication

EQUIPMENT

• Central venous catheterization kit
  • Clear fenestrated plastic drape
  • Paper drape
  • Chlorhexidine antiseptic with applicators
  • 1% Lidocaine
  • Small anesthetizing needle (25 gauge × 1 inch)
  • Large anesthetizing/finder needle (22 gauge × 1.5 inch)
  • Introducer needle (18 gauge × 2.5 inch)
  • Several syringes, 5 mL each
  • J-tipped guidewire with housing and a straightener sleeve
  • Scalpel with a No. 11 blade
  • Skin dilator
  • Catheter (e.g., triple lumen or sheath introducer)
  • Gauze pads
  • Suture with curved needle
  • Disposable needle holder
• Sterile gloves, sterile gown, cap, and mask with a fluid shield for each member of the insertion team **STERILE TECHNIQUE** **UNIVERSAL PRECAUTIONS**
• Large sterile drape (half-sheet)
• Lidocaine 1% (often provided in the kit, although extra may be required)
• Sterile saline suitable for injection
• Sterile dressing (e.g., Tegaderm, 3M Corporation, Huntingdon Valley, PA)

ANATOMY

• Subclavian vein
  • As the subclavian vein crosses the first rib, it lies posterior to the junction between the medial third and lateral two thirds of the clavicle.
  • The subclavian arteries are located posterior to the veins and are separated from them by the scalene muscles.
  • The right pleural dome is lower than the left and the thoracic duct is located on the left, thus making the right side preferred over the left.

Bad Day at the Office - from AnaesthesiaCases

Thanks to Dr Bill Griggs from Adelaide South Australia for sharing this case!

I am going to share a case that was not a lot of fun.

I travelled to a small rural area in Australia by helicopter to pick a 60 y.o. woman with CREST syndromewho had been unwell in a small local hospital with "gastroenteristis" for 2-3 days. We went to get her because she was anuric and had no recordable blood pressure or saturations despite being GCS 14.

On our arrival she had acidotic respirations (deep and rapid) and still no recordable blood pressure. She was cyanosed and sat probes would not read. She was GCS 13 (E3V45M6) My provisional diagnosis was ischaemic/infarcted bowel which eventually proved correct.

There was no pathology or radiology available at the very small remote hospital. Path results took hours to come back as they had to go elsewhere. There were no results for the last 24 hours.

I inserted a subclavian CVC and got a pressure of 35-44 with wide swinging - not a good number for either venous or arterial! Although I had a brief moment of doubt about placement, it was in the vein.

After loading her with fluid and beginning inotrope support (peripherally as I was not 100% sure the central line was not arterial) we got an NIBP of around 80/-. Her respiratory function was getting worse and she seemed less responsive so I elected to ventilate her.

In our kit we had two older model Heine laryngoscope handles and one each size 3 and size 4 disposable blades. When the paramedic connected the blade to the handle, the blade broke at the attachment point. In retrospect our daily testing regime of putting on the blade and opening it to test the light and battery had resulted in some weakening of the attachment area. We have since changed this practice. I was keen for a size 4 blade and backup so I asked the hospital to either provide a laryngoscope or some size 4 disposable blades. They produced two size four blades of a different brand but which seemed to fit.

Due to her syndrome the patient had a small "parrot beak" mouth with very limited opening. She had also vomited recently so I elected to do a RSI. The only monitor that was providing readings was the ECG. Her HR was 120 down from 140. The most recent NIBP was 80/-. She was still blue on 100% via BVM.

We began the RSI. 

The view on laryngoscopy was poor. The mouth was small but I managed to achieve a view of the arytenoids when the second disposable laryngoscope blade broke. It was at the same point as the previous one. I was pulling very hard on the handle to get a view but have previously lifted patients heads from the bed and never seen this before. 

I said a bad word under my breath and grabbed the third (and last) blade. I got to the same view and then it too broke. I was not very happy.

I asked for another and a nurse left the room to look for one. I began to attempt BVM ventilation. At this stage the cricoid pressure incorrectly came off briefly and the patients mouth immediately filled to the lips with gastric content. Despite suction and renewed BVM attempts I could not ventilate her. Her mouth opening seemed too small for a LM and the regurgitation was also not going to helpful trying an LM. So I moved to a surgical airway.

I did a midline incision over the cricothyroid membrane but hit a distended anterior jugular vein - remember the CVP of 35-45? It produced a fountain of blood which in turn induced a number of gasps from the people in the room. I had no vision but inserted a tube into the hole. The tissues were very wooden due to her CREST so it was not the usual tactile environment with soft tissues. I connected the end tidal CO2 and began squeezing the bag. After 4 breaths there was no CO2 reading. I had thought I was in the correct spot but did not want to be ventilating the mediastinum. I left 100% O2 attached in case it was in the right spot but stopped squeezing.

Still not happy.

At this stage I was low on options so got the paramedic to pass me the size 3 blade from our kit and went back to the top end. This time with suction, pulling and luck I got a view of the rear part of the cords. I passed a tube but hit resistance. At this stage I asked for the neck tube to be removed and was then able to advance the oral tube. This time I got a CO2 reading.

I checked the HR which was (to my amazement) still 60 and not zero. However despite ventilation, over the next two minutes the rate decreased and we had to begin CPR.

10 minutes of CPR and ALS resulted in return of spontaneous circulation. At this stage she had a BP of 100, a HR of 120 and an intermittent saturation reading in the low 90s.

As there were no peripheral pulses I attempted a femoral arterial line but the line ended in the vein. 

At this stage we left. 

Just prior to leaving the CO2 reading went flat again but this was an issue with a loose connection. In retrospect the cricothyrotomy tube may well have been in the correct spot but the CO2 connector may have been loose then as well. This fits with my apparently hitting the tube when I succeeded in oral intubation.

On arrival in the city she went to the OT / OR where a large length of perforated dead bowel was removed. 

To my amazement after further surgery and ICU by day 10 she had been extubated and was awake, sitting out of bed and talking with her family. Patients are resilient.

Unfortunately on day 12 she had a sudden collapse (? pulmonary embolism) and died.

Learning points ?

1. I should have chosen a different career!

2. I am sure there are a number of points along the way where different decisions could have been made. People may enjoy pointing  them out   :-) 

3. The testing of handles using disposable single use blades was not clever.

4. It appears the issue with the brand/model of handle and blades was not new. We have changed all our handles now. The problem is that the cross bar on the handle was narrow and the blade attachment was a bit smaller than the gap it had to fit into. These two things allow the blade to move within the handle attachment area with a single point of excess pressure which led to the breakages.

5. Don't give up. Patients surprise you from time to time when they do well when you think it is hopeless.

6. Don’t allow a current affairs media film crew to come along for the day to film what you do unless you'd like to work under a bit of extra pressure....

Reliving it all means I'm going to go and have a lie down now.

Bad Day at the Office - AnaesthesiaCases

Transfusions overused in cardiac surgery?

from theheart.org

São Paulo, Brazil and Durham NC - More evidence that blood transfusions are being used too liberally in cardiac-surgery patients has come from two new studies, both published in the October 13, 2010, issue of the Journal of the American Medical Association.

One study, conducted in Brazil, found no difference in outcomes between two transfusion strategies, one more conservative than the other. The second study, by a group from Duke University, showed an "enormous" variation in transfusion rates in CABG patients across US hospitals.

In an accompanying editorial, Dr Aryeh Shander (Englewood Hospital and Medical Center, NJ) and DrLawrence Goodnough (Stanford University School of Medicine, CA) say that continued inappropriate transfusions among hospitals is a major concern, as transfusions carry risks and are costly and the supply of blood is limited.

New guidelines recommend more conservative strategy

Goodnough told heartwire that the current Brazilian study echoed the results of an earlier study in ICU patients, and the Duke study showed similar variations in transfusion use as a study by his group in 1991. "We now have guidelines recommending a more conservative strategy, but these Duke data suggest that that they are not being taken notice of." He suggested two reasons for this: doctors are unaware of the guidelines, or they disagree with them. "I think there is a 'we've always done it that way' culture about giving blood transfusions, and once you have been taught something it can be difficult to let it go. But I believe there is enough data to say that we are overtransfusing."

In the Brazilian study, 502 cardiac-surgery patients were randomly assigned to a liberal strategy of blood transfusion (to maintain a hematocrit >30%) or to a restrictive strategy (to maintain a hematocrit >24%). Hemoglobin concentrations were maintained at a mean of 10.5 g/dL in the liberal-strategy group and 9.1 g/dL in the restrictive-strategy group. Blood transfusions were given to 78% of the liberal-strategy group and to 47% of the restrictive-strategy group, but occurrence of the primary end point (30-day all-cause mortality or cardiogenic shock, acute respiratory-distress syndrome, or acute renal injury requiring dialysis or hemofiltration during hospital stay) was similar between groups (10% liberal vs 11% restrictive).

In the second study, researchers led by Dr Elliott Bennett-Guerrero (Duke Clinical Research Institute, Durham, NC) analyzed data from the Society of Thoracic Surgeons (STS) adult cardiac-surgery database, which included 102 592 cases of CABG from 798 hospitals in 2008, and found a dramatic variability in the observed hospital-specific transfusion rates. To ensure that between-center differences would not be dominated by random statistical variation, they also analyzed the subset of hospitals performing at least 100 eligible on-pump CABG operations during the year. At these 408 sites, which included 82 446 cases, the frequency of transfusion rates ranged from 7.8% to 92.8% for red blood cells, 0% to 97.5% for fresh frozen plasma, and 0.4% to 90.4% for platelets. Geographic location, academic status, and hospital volume explained 11.1% of the variation in hospital risk-adjusted red blood cell usage, and case mix explained 20.1% of the variation.

Noting that they found no strong association between hospital transfusion rate and mortality, the authors note that even if higher transfusion rates at some hospitals are not deleterious, they may still represent potentially unnecessary care that is costly, with a red blood cell transfusion costing a mean of $761 per unit.

Read more...

Transfusions overused in cardiac surgery | theheart.org

Review Article: Exsangination in trauma: A review of diagnostics and treatment options

from Injury, Jan-09

Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. 

The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. 

The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations ‘permissive hypotension’ may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. 

After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. 

The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing ‘blind’ transfusion or ‘damage control resuscitation’, a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

full-text here

Arterial Line Placement - Techinques and Troubleshooting

INDICATIONS

• Continuous blood pressure measurement is necessary because of hemodynamic instability.
• Continuous blood pressure measurement is necessary for the safety of certain anesthetic techniques, such as deliberate hypotension, cardiopulmonary bypass, or major vascular surgery involving arterial clamping.
• Continuous blood pressure measurement is necessary for monitoring administration of vasoactive drugs.
• Frequent blood gas measurements are needed.
• Frequent blood sampling is needed in patients without central venous access.
• Noninvasive blood pressure monitoring is difficult or impossible, such as in patients who are severely obese, have burned extremities, or are in shock.

CONTRAINDICATIONS

• Absolute contraindications
• Infection at the site of insertion
• Traumatic injury proximal to the site of insertion
• Relative contraindications; may be outweighed by other considerations
• Failure to demonstrate collateral flow in small vessels (e.g., by Doppler ultrasonography)
• Presence of arteriovenous (AV) shunt in the limb in question
• History of surgery disrupting lymphatics of the upper extremity, such as a mastectomy with lymph node dissection
• Arterial insufficiency in the distribution of the artery to be cannulated

Awake Fiberoptic Intubation

INDICATIONS

• History of difficult intubation
• Suspected difficult airway based upon findings in history or physical exam, including but not limited to the following:
• Trauma to the airway
• Deep neck infections
• Tumors of the larynx or pharynx
• History of radiation to the airway
• Severe ankylosing spondylitis
• Acromegaly
• Congenital airway abnormality, such as Treacher-Collins or Pierre Robin Syndromes
• Inability to access the cricothyroid membrane, in case emergency surgical airway is required
• Morbid obesity and history of sleep apnea with suspected difficult airway requiring intubation
• Anatomy that otherwise predisposes patient to difficult intubation and difficult mask ventilation while asleep
• High risk for aspiration of gastric contents
• Need for neurological exam immediately following intubation
• Cervical spine instability due to trauma or degenerative disease
• Vertebrobasilar artery insufficiency

CONTRAINDICATIONS

• Absolute contraindications
• Patient refusal
• Allergy to both ester and amide classes of local anesthetics
• Relative contraindications, which may be overlooked in the true emergency situation because the risk of the procedure is less than the risk of hypoxemia or impending loss of the airway
• Infection at sites of local anesthetic injection/application
• Raised intracranial pressure (ICP) that might be exacerbated by coughing
• Penetrating eye trauma that might be exacerbated by coughing

COMPLICATIONS

• Common
• Gagging
• Epistaxis
• Infrequent
• Oversedation (with loss of spontaneous ventilation)
• Inability to pass endotracheal tube
• Laryngospasm
• Hematoma (if invasive blocks have been performed)
• Infection (if invasive blocks have been performed)
• Dysphagia
• Dysphonia
• Inadequate sedation with unpleasant recall by the patient
• Serious, rare complications
• Local anesthetic toxicity
• Damage to vocal cords
• Vomiting (aspiration)
• Traumatic pharyngeal or laryngeal injury
• Bacteremia
• More common after nasal intubation
• In patients with valvular heart disease, prophylactic antibiotic administration before nasal but not oral intubation is recommended

from ProceduresConsult.com (link on sidebar)

Central Line Placement - Internal Jugular with Finder Needle

Internal jugular vein can be canalized, and this reduces (but does not eliminate) the risk of pneumothorax, while adding the risk of carotid artery (2 – 10% [Intensive Care Med 2: 163, 218, 1987]) or thoracic duct injury. Awake patients will complain of reduced neck mobility, and agitated patients may occlude the catheter and vein secondary to excessive neck flexion. Lastly, patients with tracheostomies may be at increased risk of infection due to spread of secretions. When the head is turned to the opposite side, the IJV forms a straight line from the pinna to the sternoclavicular joint. The right side is preferred for cannulation. In the anterior approach, palpate the carotid artery in the triangle of the SCM heads and retract medially. Insert the needle into the apex of the triangle, advancing towards the ipsilateral nipple at 45° to the skin surface. If no venous blood by 5 cm, withdraw 4 cm and advance again more laterally. For the posterior approach, insert the needle (with the bevel at 3 o'clock) 1 cm above where the external jugular crosses the lateral edge of the SCM, advancing along the underbelly of the muscle and pointing towards the suprasternal notch. The IJV should be encountered within 5 – 6 cm. If blood is red and pulsating, remove the needle and apply pressure for 5 – 10 mins. If the carotid artery has been punctured by the needle, remove it and hold pressure for 5 mins. If the carotid as been actually cannulated, the catheter should be left in place and vascular surgery should be called. The only advantages of the IJ line are for pacemaker catheters and hemodialysis catheters, because of their straight course 

Central Line Placement - Step-by-Step

Pulmonary Artery Catheter (Swan Ganz) Dynamics