Central Venous Catheters Clinical Considerations
Central Venous Catheters Clinical Considerations Igor Voskresensky 8.15.09 CVCs…Necessary Evil TLC Cordis MICU TRIC (triple lumen infusion catheter) Vascular Access Devices I. Nontunneled (TLC, Cordis, MAC, VasCath) ‐ short‐term, drips/meds, HDM/resus, dialysis, plasmapheresis, TPN II. Tunneled (Hickman, Broviac, Groshong) ‐ long‐term, OR, abx, chemo, TPN, pediatric, frequent lab work III. Peripherally inserted (PICC) ‐ long‐term, abx, TPN IV. Implanted ports (percutaneous, cutdown) ‐ long‐term, chemo, periodic transfusions Preparation for Insertion –C5, Do20, Teach100 • KTCLT, live it… • Patient’s anatomy, site selection, ultrasound? • Turn off tube feeds and check labs (plts, ffp?) • Know the process • Get your own things (syringes, flushes, claves) • Set it up, same way every time • Head‐Down‐burg • Pain control • Complications Pearls • Withdraw gently • Hand on the wire • Visualize needle tip with US • Shallow angle, hit the clavicle, arm tug • Poor form is unacceptable • No COW if the ports don’t draw/flush • No femoral access cardiology style • Secure your line with quality • Get a CXR (PTX, HTX, positioning) • If it don’t feel right, it probably ain’t right Complications • Catheter‐related (type, mechanical and antibacterial properties, use) • Patient‐related (anatomy, nature of disease, immunocompromise) • Site‐related (IJ, SC, Fem) • Catheter care (experience of medical and nursing staff, hygiene and care) Inten Car Med 28:1–17 NEJM 348:1123‐1133 Ann Surg 173:184–190 Chest 113:165–171 J Vasc Surg 48: 918‐925 Catheter‐Associated Infections • Colonization (semiquant vs. quant) ‐ 15 CFU agar vs. 1000 CFU broth • Exit‐site infection ‐ erythema, induration tenderness, purulence • CRBSI CRBSI • CVC colonization and peripheral blood cx • 10‐25 % associated mortality, $ • Sick pts, ETT/ICU/TPN, T‐T‐T‐T • SC/IJ vs.
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