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Home , Central venous catheter, Intensive care unit

Indian Journal of Critical Care January 2015 Vol 19 Issue 1

In developing countries, landmark based technique is commonly practiced as an US machine may not be Management of central available in all centers. Central venous cannulation using the landmark technique in a with absent IJV may venous in be associated with a higher incidence of complications intensive care units: such as arterial puncture and .[6] Therefore, repeated attempts to cannulate the IJV should be avoided Comparative study in keeping in mind the possibility of anatomical variations of IJV. This case reiterates the use of US guided of guidelines versus to prevent complications, which can arise due to the absence of a or other venous anomalies. practice In addition, it has been shown that US-guided CVC placement technique is easy to learn even by novices and any previous CVC and/or US experience allows a Sir, better technique and shorter total time to placement.[7] An observational study was conducted on 100 nurses It would be a good general practice to use US for both with minimum 6 months of experience in various assessment of anatomy prior to venipuncture and intensive care units (trauma, swine fl u, medical, and real-time visualization during insertion of CVC to renal) of the to assess their knowledge and increase the success rate and prevent complications. clinical practice. A two-part questionnaire [Table 1] was fi lled by the nurses after every central venous Vimi Rewari, Ravindran Chandran, (CVC) insertion for a period of 2 months. Rashmi Ramachandran, Anjan Trikha Each correct response was scored 1; incorrect 0. Total Department of Anaesthesiology, All India Institute of number of catheter insertions was 148. Mean score for Medical Sciences, New Delhi, India the study was 53%. Correspondence : Prof. V. Rewari, Department of Anaesthesiology, All India Institute of Medical Sciences, Results from Part A: Standardized equipment set, Ansari Nagar, New Delhi - 110 029, India. barrier precaution, filling of the checklist, and an E-mail: [email protected] assistant was available in 96%, 95%, 86%, and 98% References of the insertions. Two-third were done on monitored 1. Forauer AR, Glockner JF. Importance of US findings in access planning beds with head low; only 1% on unmonitored beds. during catheter placements. J Vasc Interv Povidone iodine, 70% alcohol, 2% -based Radiol 2000;11:233-8. preparations were preferred in decreasing order for 2. Lee AB, Laredo J, Neville R. Embryological background of truncular venous malformation in the extracranial venous pathways as the cause of disinfection of skin (60%, 21%, and 19%, respectively). chronic cerebro spinal venous insufficiency. Int Angiol 2010;29:95-108. Eighty percent preferred sutures for catheter fi xation and 3. Denys BG, Uretsky BF. Anatomical variations of transparent bio-occlusive . location: Impact on central . Crit Care Med 1991;19:1516-9. 4. Miller BR. Absence of a right internal jugular vein detected by ultrasound imaging. Paediatr Anaesth 2011;21:91. Results from Part B: Subclavian, internal jugular and 5. Majeed TA, Deshpande RK, Upadhaya S, Deshmukh SA. Agenesis were preferred by 66.6%, 25%, and 9%. of internal jugular vein a cause for concern. Indian J Surg Oncol 2010;1:341-2. One-fifth were not aware of use of ultrasound. 98% 6. Scott DH. ‘In the country of the blind, the one-eyed man is king’, managed unintended arterial puncture by removal Erasmus (1466-1536). Br J Anaesth 1999;82:820-1. of needle/catheter and application of pressure. 90% 7. Nguyen BV, Prat G, Vincent JL, Nowak E, Bizien N, Tonnelier JM, et al. Determination of the learning curve for ultrasound-guided jugular opined that chest X-ray confi rmed placement of CVC. placement. Intensive Care Med 2014;40:66-73. 96% preferred based solution; 4% used normal . Two inspections of CVC/day were made by 50%; one/day were made by 40%. One-fi fth wiped access ports Access this article online with antiseptic before drug administration. Removal of Quick Response Code: infected CVC was considered by 60%; 25% believed in Website: giving an and observing. Three-fourth marked www.ijccm.org 4 h as maximum infusion time for blood products; 24 h for change of intravascular catheters/sets. Tubings for DOI: 10.4103/0972-5229.148652 blood products and lipid emulsions were changed by 80% 12 hourly. Three-fourth believed in no fi xed duration for changing CVC; one-fourth believed in the weekly change.

5544 Indian Journal of Critical Care Medicine January 2015 Vol 19 Issue 1

Table 1: Questionnaire Table 1: Contd... Please tick the correct options for the following questions related Please tick the correct options for the following questions related to CVC to CVC Part A 5. Solution used to flush CVC for maintenance Heparin based solution 1. Standardized equipment set available for CVC placement in ICU Normal saline Yes Not required No 6. How often should the central line site be inspected- 2. Use of CVC placement and maintenance protocol or check list in ICU? Twice a day Yes Once a day No Once in 2 days Yes, but not followed Once a week 3. An assistant during placement of CVC 7. When catheter site or catheter related infection is suspected Yes what is done? No Change central catheter using guide wire and reinsert at same insertion site Yes, but not followed Change central catheter using guide wire and reinsert at different insertion site 4. Setting of bed for CVC placement Give and change dressing Unmonitored bed 8. Do you wipe catheter access ports with antiseptic solution before Monitored bed injecting or aspirating and cap them when not in use? Monitored bed where head low is possible Yes 5. Hygienic precautions followed before central line insertion No Hand wash and sterile gloves Should be done but not done routinely Maximum barrier precaution including hand washing, sterile gowns, Sometimes sterile gloves, caps, mask covering both mouth and nose and full – body 9. Complete infusion of blood or other blood products should be patient drapes within ____ h of hanging the blood Full body patient drapes 4 h 6. Disinfectant used to clean skin before catheter placement and during 8 h dressing changes 12 h 2% chlorhexidine-based preparation 24 h Tincture of iodine, an iodophor (povidone iodine, betadine) 10. Administration sets and tubings are changed every ____ h? 70% alcohol 12 h 7. Preferred catheter fixation technique to minimize catheter related 24 h 48 h Suture 72 h Staples 11. Tubings used to administer blood, blood products, and lipid emulsions Tape every _____ h? 8. Dressing used for central line sites 12 h Gauge dressing 24 h Transparent bio occlusive dressing 48 h Leaving it open with antiseptic and antibiotic solution 72 h Betadine gauge occlusive dressing (sponge dressing) 12. Can emergency drugs or antibiotics be administered in the same tubing Part B as TPN 1. Preferred site for CVC insertion in critical care set up Yes Internal jugular vein No Sometimes Femoral vein 13. How often is CVC changed? Peripheral vein Based on clinical judgment 2. Should ultrasound be done to localize blood vessels before attempting Once a week CVC Twice a week Yes No change required No 14. If a central line catheter was inserted in emergency without using Sometimes aspetic precautions, what should be done? Should be done but may not be possible in emergency situations Give antibiotics 3. When unintended puncture of arterial vessel occurs by wide bore Replace the catheter immediately within 48 h needle, dilator or catheter, what should be done? Give antibiotics and observe for any signs of infection and replace Remove needle/catheter and apply pressure over the site and then retry catheter if required from same site after 5 min Observe for signs of infection and replace if required Remove needle/catheter and apply pressure over the site and then retry 15. Should prophylactic antibiotics be administered before or during from another site after 5 min placement of central catheters to reduce bloodstream infection? Leave needle/catheter in place and consult a vascular surgeon for opinion Yes 4. After final catheterization and before use of CVC, how do you confirm No the presence of tip in venous system Not routinely but only in immune-compromised and high-risk neonates Chest X-ray CVC: Central venous catheter; ICU: ; TPN: Total Ultrasound Transesophageal Half believed in administration of antibiotics Pressure monometry for central lines inserted in emergency. Only 25% Contd... considered a replacement of the catheter within 48 h.

5555 Indian Journal of Critical Care Medicine January 2015 Vol 19 Issue 1

The remaining 25% considered replacement only on Access this article online signs of infection. Routine prophylactic antibiotics was Quick Response Code: advocated by 36%. Website: www.ijccm.org

Results show that awareness on the use of chlorhexidine, ultrasound, correct management of arterial punctures DOI: 10.4103/0972-5229.148653 and protocol for CVC inserted in emergency departments needs to be increased. Regular training programs with the staff on bundles of care related to insertion and maintenance of CVC are needed.[1-3]

American Society of Anesthesiologists guidelines[4] : are focused on elective insertions of CVC’s performed by anesthesiologists, but the Centers for Is there any upper limit? Control and Prevention guidelines[5] also address emergency placements, peripherally inserted central catheters, pulmonary catheter and tunneled Sir, central lines. Safety or effi cacy of chlorhexidine in We read the article by Garg SK “Permissive hypercapnia: [1] neonates and infants aged <2 months remains an Is there any upper limit?” with great interest. The author has rightly focused on a current protective lung unresolved issue. Fluid administration sets need to ventilation strategy. Though there are several reports of be changed at 96 h intervals and tubings for blood extreme levels of hypercapnia tolerated by patients no products and lipid emulsions every 24 h. Routine safe upper limit has been described. We would like to replacement of CVCs on the basis of fever alone and add following facts. prophylactic administration of systemic antimicrobial agents is discouraged. Mandatory replacement is to Permissive hypercapnia allows for low-tidal volume be done within 48 h for all catheters inserted in an ventilation and hence minimizes associated emergency without aseptic precautions. lung injury. It also reduces infl ammatory response in lungs by attenuating free radical formation, nuclear Arushi Gupta, Tanvir Samra1, Neerja Banerjee, factor kappa- activation and increased tumor necrosis Rajesh Sood factor-, interleukin-1, 6, 8 production. On the contrary, Departments of Anaesthesia and Critical Care, Dr. Ram Manohar Lohia it impairs plasma membrane wound healing in injured Hospital, New Delhi, 1PGIMER, lungs in a pH dependent fashion[2] and also prevents Chandigarh, India alveolar fl uid resorption by inhibiting Na-K ATPase Correspondence: of alveolar epithelial cells. Sustained hypercapnia in Dr. Tanvir Samra, cases of pulmonary infection increases bacterial load C-II/77, Moti Bagh 1, New Delhi - 110 021, India. and may further aggravate lung injury. Hence in E-mail: [email protected] conditions of associated lung injury permissive

hypercarbia would be benefi cial. Elevated CO2 level also References induces mitochondrial dysfunction and impairs alveolar 1. Hewlett AL, Rupp ME. New developments in the prevention of epithelial cell proliferation. Hypercapnic acidosis intravascular catheter associated infections. Infect Dis Clin North Am increases ventilatory drive and if patient is not properly 2012;26:1-11. sedated and paralyzed, patient-ventilator dyssynchrony 2. Smith M. A care bundle for management of central venous catheters. may occur and result in increased transpulmonary Paediatr Nurs 2007;19:39-44. 3. Gullatte MM. of external central venous catheters pressure. Previous animal studies have reported (CVCs). Adv Clin Care 1990;5:12-7. vasogenic in hypercapnic acidosis and 4. American Society of Anesthesiologists Task Force on Central Venous in human beings cerebral edema have been reported in Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, et al. severe respiratory acidosis associated with asthma.[3] Practice guidelines for central venous access: A report by the American Hypercapnia has a benefi cial effect on brain in an optimal Society of Anesthesiologists Task Force on Central Venous Access. 2012;116:539-73. range. Lowering CO2 causes cerebral vasoconstriction 5. CDC. Guidelines for the Prevention of Intravascular Catheter-Related whereas increased CO2 results in cerebral edema. Hence, Infections. Available from: http://www.cdc.gov/hicpac/BSI/01-BSI- like any other drug “permissive hypercapnia” should guidelines-2011. [Last acessed on 2013 Dec 12].

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