manual of common bedside surgical procedure chapter 2 - arterial and venous access

8/9/2019 Manual of Common Bedside Surgical Procedure Chapter 2 - Arterial and Venous Access

1/52

Authors/Editors: the Halsted Residents of The Johns Hopkins Hospital;

Chen, Herbert; Sonnenday, Christopher J.; ille!oe, "eith #.

Title: Manual of Common Bedside Surgical Procedures, 2nd Edition

Copyright Â©2000 Lippincott Williams & Wilkins

> Table of Contents > CHAT!" 2 # A"T!"$AL A% '!%()* ACC!**

CHAT!" 2

ARTER$A A%# &E%'(S ACCESS

Julie Ann Sosa

Herbert Chen ).#.

$. CE%TRA &E%'(S ACCESSCentral +eno,s catheters are fre-,ently ,se. in the intensi+e care ,nit /$C)

an. operating room for monitoring an. for +eno,s access1 Altho,gh thisproce.,re is ro,tine for most s,rgical ho,se officers central line insertionsho,l. be approache. 3ith ca,tion an. a.e-,ate preparation1 atientpositioning is cr,cial to s,ccess1 $nforme. consent sho,l. be obtaine. prior toperforming electi+e access proce.,res an. blee.ing parameters /i1e1hematocrit platelet co,nt an. T4TT ratios sho,l. be optimi5e.1

A. SUBCLAVIAN VENUS ACCESS!"#$% APP&AC'ES

61 $n. icat ions7a1 Central +eno,s press,re /C' monitoring

b1 Total parenteral n,trit ion /T%

c1 Long#term inf,s ion of .r,gs

.1 $notrop ic agents

e1 oor peripheral access

21 Contrain.icat ions7

a1 'eno,s thrombosis

b1 Coag,lopathy /T or TT >618 9: control

c 1 )ntreate. sepsis

.1 ;or the stan.ar. /infracla+ic,lar approach7 nee. for hemo.ialysis

access beca,se there is an association 3ith s,bcla+ian +ein stenosis1


2/52

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7

a1 *teri le prep sol,t ion

b1 @ask sterile go3n glo+es to3els .ressings

c 1 22# an. 28#ga,ge nee. les

.1 8#ml syringes /t3o

e1 *ho,l.er ro ll to3el

f1 Appropriate catheters an. .i lator

g1 $ntra+eno,s /$' t,bing an. fl,sh

h1 6#ga,ge insertion nee.le /8BD cm long

i 1 010


3/52

1 Techni-,eBI*tan.ar. /$nfracla+ic,lar Approach7

a1 $n a sterile fashion .ress 3ith mask an. go3n an. prep an. .rapethe patientGs left or right s,bcla+ian area1 $t is often ,sef,l to prepthe ipsilateral neck into the sterile fiel. in case it is necessary toattempt an internal F,g,lar +ein approach1

b1 lace an in.eJ finger at the sternal notch an. the th,mb at theintersection of the cla+icle an. first rib /see ;ig,re 2121 A.minister6 li.ocaine 3ith a 28#ga,ge nee.le into the skin an. s,bc,taneo,s

area 2 cm lateral to yo,r th,mb an. 018 cm ca,.al to the cla+icle1)se a 22#ga,ge nee.le to anestheti5e the perioste,m of the cla+icle2BD< cm lateral to the first rib intersection1 Al3ays aspirate beforeinFecting1

c1 )sing the 6#ga,ge insertion nee.le 3ith a 8#ml syringe p,nct,rethe skin that is lateral to yo,r th,mb an. 018 cm ca,.al to cla+icle1While aspirating slo3ly a.+ance the nee.le ,n.erneath the cla+icleto3ar. yo,r in.eJ finger at the sternal notch1 The nee.le m,st behori5ontal /parallel to the

1


4/52

floor at all times to a+oi. pne,mothoraJ an. the be+el sho,l. befacing ,p or to3ar. the patientGs feet to enco,rage the g,i.e3ire toa.+ance to3ar. the heart rather than into the neck1 The nee.le maybe .epresse. 3ith yo,r th,mb to get ,n.erneath the cla+icle /see

;ig,re 21


5/52

/$'C filter is kno3n to be in place ,se the non#E en. of the 3ire to

a+oi. snaring the filter in case the 3ire is a.+ance. thro,gh the heartan. into the $'C1

h1 $f resistance is met remo+e the 3ire check nee.le placement by3ith.ra3ing bloo. 3ith a syringe an. if goo. flo3 is obtaine.intro.,ce the 3ire again 3hile t,rning the patientGs hea. to theipsilateral si.e /to close the angle that 3o,l. allo3 the 3ire to ascen.the ipsilateral F,g,lar +ein1

i1 (nce the 3ire is passe. remo+e the nee.le 3hile keeping control of

the 3ire at all times1

F1 !n large the p,nc t,re site 3it h a ster il e sca lpe l1

k1 While keeping control of the 3ire intro.,ce the .ilator o+er the 3ire


6/52

m1 "emo+e the 3ire aspirate bloo. from all ports to confirm +eno,splacement an. then fl,sh 3ith sterile saline1 *,t,re the catheter to

the skin an. apply sterile .ressing1

n1 ",n $' fl,i.s at 20 ml4hr an. or.er a portable CK" to confirmplacement in s,perior +ena ca+a /*'C an. r,le o,t pne,mothoraJ1

=1 Techni-,eBI*,pracla+ic,lar Approach7

a1 $n a sterile fashion .ress 3ith mask an. go3n an. prep an. .rapethe patientGs left or right s,bcla+ian area1 $t is often ,sef,l to alsoprep the ipsilateral neck into the sterile fiel. in case it is necessary toattempt an internal F,g,lar +ein approach1

b1 *elect an insertion site 6 cm me.ial an. s,perior to the mi.point ofthe cla+icle /preferably the right to a+oi. inF,ry to the thoracic.,ct1 A.minister 6 li.ocaine 3ith a 28#ga,ge nee.le into the skin

an. s,bc,taneo,s tiss,e1

c1 irect an 6#ga,ge intro.,cer nee.le attache. to a syringe to3ar.the sternocla+ic,lar Foint 20ÂM cephala. to the trans+erse plane ofthe cla+icle an. 20ÂM anterior to the coronal plane of the patient1@aintain gentle aspiration ,ntil the +ein is entere. ,s,ally at a .epthof 2 cm1 The +ein p,nct,re site is posterior to the cla+ic,lar hea. ofthe sternoclei.omastoi. m,scle an. me.ial to the s,bcla+ian arteryp,lsation1 The +ein is entere. at the confl,ence of the s,bcla+ian an.

*i+. .0.

1?6

Page ' of 52Ovid: Manual of Common Bedside Surgical Procedures

5/17/2015file:///C:/Users/Mircea/A!a"a/#ocal/$em/%&&'(1)*&"m


7/52

internal F,g,lar +eins /see ;ig,re 211

.1 $f air or arterial bloo. is enco,ntere. stop imme.iately an. seecomplications section1

e1 $f +eno,s access is obtaine. 3ith goo. flo3 remo+e the syringe 3hilekeeping a finger o+er the nee.le to pre+ent air embolism an.intro.,ce the E 3ire follo3ing the same

*el.inger techni-,e .escribe. abo+e for the infracla+ic,lar approach1

1 Complications an. @anagement7

a1 Arter ia l p,nct,re

With.ra3 nee.le imme.iately an. apply man,al press,re for 8min,tes1

@onitor hemo.ynamics an. breath so,n.s for hemothoraJ1

b 1 A ir embol,s

*i+. .1.

1?2

Page 7 of 52Ovid: Manual of Common Bedside Surgical Procedures



8/52

Attempt to 3ith.ra3 air by aspirating thro,gh catheter1

$f hemo.ynamically ,nstable /car.iac arrest initiate A.+ance.Car.iac Life *,pport /ACL* protocol an. thoracic s,rgerycons,ltation1

$f stable position patient in left lateral .ec,bit,s an.

Tren.elenb,rg position to trap air in right +entricle1

CK" in this position can sho3 significant air an. be ,se. forfollo3 ,p1

Air 3ill e+ent,ally .issol+e1

c 1 ne,mothoraJ

$f a tension pne,mothoraJ is s,specte. .ecompress 3ith 6#

ga,ge angiographic catheter in the secon. intercostal spacemi.cla+ic,lar line1

$f N 60 600 oJygen an. serial CK"s

$f > 60 t,be thoracostomy

.1 @alposi tion ing

$nto right atri,m /"A or right +entricle /"' against 3all of +einBI3ith.ra3 or a.+ance as nee.e. to place in *'C1

$nto other s,bcla+ian +einBIstable position no a.F,stmentnee.e.

$nto F,g,lar or mammary +einBIreintro.,ce E 3ire remo+e

catheter threa. long 6#ga,ge angiographic catheter an.confirm placement in +ein by aspiration of bloo.1 The E 3ire canno3 be re.irecte. into *'C by maJimi5ing positioning /p,llca,.ally on arm an. t,rn the hea. an. neck ipsilaterally toclose internal F,g,lar +ein angle1

e 1 ysrhythmias

Atrial or +entric,lar .ysrhythmias are associate. 3ith 3ires an.catheters in the "A or "' an. ,s,ally resol+e after 3ith.ra3ing

the catheter into the *'C1

ersistent .ysrhythmias may nee. me.ical management1

B. IN$E&NAL (U)ULA& VENUS ACCESS!"#$% APP&AC'ES

61 $n. icat ions7

a1 C' moni toring

1?<

Page ) of 52Ovid: Manual of Common Bedside Surgical Procedures



9/52

b1 T%

c1 Long#term inf,s ion of .r,gs

.1 $notrop ic agents

e1 Hemo.ia lysis

f1 oor peripheral access


a1 re+io,s ipsi lateral neck s,rgery

b1 )ntreate. seps is

c1 'eno,s thrombosis

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7


b1 @ask steri le go3n glo+es an. to3els

c 1 22# an. 28#ga,ge nee. les


e1 Appropriate catheters an. .i lator

f 1 $' t,bing an. f l,sh

g1 6#ga,ge insertion nee.le /8BD cm long

h1 010


10/52

1 Techni-,eBICentral Approach7

a1 $n a sterile fashion .ress 3ith mask an. go3n1 $.entify the apeJ ofthe triangle forme. by the hea.s of the sternoclei.omastoi. m,scles/*C@ an. prep an. .rape this area1 Also locate the eJternal F,g,lar+ein an. the caroti. artery /see ;ig,re 211 $t is often ,sef,l to prep

the ipsilateral cla+icle artery into the sterile fiel. in case it isnecessary to attempt the s,bcla+ian approach1

*i+. .2.




11/52

b1 A.minister anesthetic 3ith 28#ga,ge nee.le into skin an.s,bc,taneo,s tiss,e at the apeJ of the triangle1 Al3ays 3ith.ra3

before inFecting beca,se the +ein can be +ery s,perficial1c1 alpate the caroti. p,lse an. apply gentle traction me.ially 3ith the

other han.1

.1 $nsert the 22#ga,ge fin.er nee.le 3ith a syringe at the apeJ of thetriangle ?8ÂMBD0ÂM to the skin an. a.+ance it slo3ly to3ar. theipsilateral nipple 3hile aspirating1

e1 $f there is no +eno,s bloo. ret,rn after < cm slo3ly 3ith.ra3 nee.le

3hile aspirating1 $f still no ret,rn re.irect the nee.le thro,gh thesame p,nct,re site aiming 6BD< cm more laterally an. then if,ns,ccessf,l 6 cm me.ially1 Watch the caroti. artery1 $f there is still

no bloo. ret,rn reassess lan.marks

an. consi.er posterior approach if ,nable to obtain access after threeattempts1

f1 $f air or arterial bloo. is enco,ntere. stop imme.iately an. seecomplications section1

g1 $f goo. +eno,s ret,rn memori5e the site an. angle of entry of the

*i+. .3.

1?8




12/52

fin.er nee.le an. then remo+e the nee.le1 Apply .igital press,re to

minimi5e blee.ing1 Alternati+ely the nee.le may be left in place as ag,i.e1

h1 $nsert the 6#ga,ge nee.le follo3ing the same angle as the fin.ernee.le /see ;ig,re 211

i1 $f +eno,s access is obtaine. 3ith goo. flo3 remo+e syringe 3hilekeeping a finger o+er the nee.le to pre+ent air embolism1

F1 $n tro.,ce the E 3ire 3ith the ti p aime. to3ar. the hear t /me.ia ll y thro,gh the nee.le 3hile maintaining the nee.le in the same location/*el.inger techni-,e1 The 3ire m,st pass 3ith minimal resistance1

k1 $f resistance is met remo+e the 3ire check nee.le placement by3ith.ra3ing bloo. 3ith a syringe an. reintro.,ce 3ire if goo. bloo.ret,rn1

l1 (nce the 3ire is passe. remo+e the nee.le 3hile keeping control ofthe 3ire at all times1

m1 !nlarge the p,nct,re site 3ith a sterile scalpel1

n1 $ntro.,ce the +eno,s catheter o+er the 3ire 3hile maintaining a

*i+. .4.

1?




13/52

constant hol. on the 3ire to the length of abo,t cm on the right

an. 62 cm on the left1

o1 "emo+e the 3ire aspirate bloo. from all ports to confirm +eno,splacement an. then fl,sh 3ith sterile saline1 *,t,re the catheter tothe skin an. apply sterile .ressing1

p1 ",n $' fl,i.s at 20 ml4hr an. or.er a portable CK" to confirmplacement in *'C an. r,le o,t pne,mothoraJ1

=1 Techni-,eBIosterior Approach7

a1 $n a sterile fashion .ress 3ith mask an. go3n1 $.entify the lateralbor.er of the *C@ 3here the eJternal F,g,lar +ein crosses o+er it1 $tis abo,t ?BD8 cm abo+e the cla+icle /see ;ig,re 21601 $t is often,sef,l to prep the ipsilateral cla+icle into the sterile fiel. in case it is

necessary to attempt the s,bcla+ian approach1

1?=

*i+. .-5.

Page 1+ of 52Ovid: Manual of Common Bedside Surgical Procedures



14/52

b1 A.minister anesthetic 3ith a 28#ga,ge nee.le into skin an.

s,bc,taneo,s tiss,e 018 cm s,perior to the intersection of the *C@an. eJternal F,g,lar +ein1 Al3ays 3ith.ra3 before inFecting beca,sethe +ein can be +ery s,perficial1

c1 $nsert the 22#ga,ge fin.er nee.le 3ith a syringe at point A an.a.+ance slo3ly anteriorly an. inferiorly to3ar. the sternal notch3hile aspirating /see ;ig,re 21661

.1 $f there is no +eno,s bloo. ret,rn after < cm slo3ly 3ith.ra3 nee.le3hile aspirating1 $f there is still no ret,rn re.irect the nee.lethro,gh the same p,nct,re site aiming

slightly ipsilateral to the sternal notch1 $f there is still no bloo.ret,rn reassess lan.marks an. consi.er attempting the contralateralsi.e after three attempts1 CK" m,st be obtaine. to r,le o,tpne,mothoraJ before changing si.es1

e1 $f air or arterial bloo. is enco,ntere. stop imme.iately an. seecomplications section1

f1 $f goo. +eno,s ret,rn memori5e the site an. angle of entry of the

*i+. .--.

1?

Page 1, of 52Ovid: Manual of Common Bedside Surgical Procedures



15/52

fin.er nee.le an. then remo+e the nee.le1 Apply .igital press,re to

minimi5e blee.ing1 Alternati+ely the nee.le may be left in place as ag,i.e1

g1 $nsert the 6#ga,ge nee.le follo3ing the same angle as the fin.ernee.le1 $f +eno,s access is obtaine. 3ith goo. flo3 remo+e syringe3hile keeping a finger o+er the nee.le to

pre+ent air embolism an. intro.,ce the E 3ire follo3ing the same*el.inger techni-,e .escribe. abo+e for the central approach1

1 Complications an. @anagement7

a1 Carot i. p,nct,re

With.ra3 nee.le imme.iately an. apply man,al press,re1

$f cann,lation occ,rre. an. man,al press,re is not s,ccessf,ls,rgical inter+ention may be nee.e.1

b 1 A ir embol,s


$f hemo.ynamically ,nstable /arrest initiate ACL* protocol an.thoracic s,rgery cons,ltation1

$f stable position patient in left lateral .ec,bit,s an.

Tren.elenb,rg position to trap air in right +entricle1 CK" in thisposition can sho3 significant air an. be ,se. for follo3 ,p1


c 1 ne,mothoraJ

$f a tension pne,mothoraJ is s,specte. .ecompress 3ith 6#ga,ge angiographic catheter in the secon. intercostal spacemi.cla+ic,lar line1



.1 @alposi tion ing

$nto "A or "' against 3all of +einBI3ith.ra3 or a.+ance as

nee.e. to place in *'C1

$nto s,bcla+ian +einBIstable position no a.F,stment nee.e.1

$nto F,g,lar or mammary +einBIre#intro.,ce E 3ire remo+ecatheter threa. long 6#ga,ge $' catheter an. confirmplacement in +ein by aspiration of bloo.1 The E 3ire can no3 bere.irecte. into *'C by maJimi5ing positioning /p,ll ca,.ally onarm an. t,rn the hea. an. neck ipsilaterally to close internal

1?

180




16/52

F, g, lar +e in angl e 1

e1 HornerGs syn.rome

,nct,re of the caroti. sheath can res,lt in a temporaryHornerGs syn.rome that ,s,ally resol+es1

f 1 ysrhythmias

Atrial or +entric,lar .ysrhythmias are associate. 3ith 3ires an.catheters in the "A or "' an. ,s,ally resol+e after 3ith.ra3ingthe obFect into the *'C1


C. *EM&AL VENUS ACCESS

61 $n. icat ions7

a1 !mergent central access

b1 Hemo.ia lysis

c1 )nable to obtain s,bcla+ian or internal F,g,lar +eno,s access for C'or inotropic agents


a1 rior groin s,rgery /relati+e

b1 atient m,st maintain be. rest 3hile the catheter is in place

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7



c 1 28#ga,ge nee. le


e1 Appropriate catheters an. .i lator

f 1 $' t,bing an. f l,sh

g1 6#ga,ge insertion nee.le /8 cm long

h1 010


17/52

F1 *calpe l

k 1 2#0 si lk s,t,re

81 os it ioning7

*,pine

1 Techn i-,e7

a1 $n a sterile fashion .ress 3ith mask an. go3n1 *ha+e prep an..rape left or right groin area1

b1 alpate the femoral p,lse at the mi.point along an imaginary linebet3een the anterior s,perior iliac spine an. the symphysis p,bis1The femoral +ein r,ns parallel an. imme.iately me.ial to the artery/see ;ig,re 21621




18/52

c1 A.minister anesthetic 3ith 28#ga,ge nee.le into the skin an.

s,bc,taneo,s tiss,e 6 cm ca,.ally an. laterally to the palpate. p,lse1

.1 "etracting the artery laterally 3ith yo,r finger ,se the 6#ga,geinsertion nee.le 3ith a 8#ml syringe to p,nct,re the skin1 A.+ancethe nee.le 3hile aspirating cranially at a ?8ÂM angle to the skin

parallel to the p,lse1 There is less risk 3ith being me.ial to the +einrather than lateral to it /see ;ig,re 216< an. ;ig,re 216?1

*i+. .-.

Page 1) of 52Ovid: Manual of Common Bedside Surgical Procedures



19/52

*i+. .-.

Page 1( of 52Ovid: Manual of Common Bedside Surgical Procedures



20/52

e1 $f there is no +eno,s bloo. ret,rn after 8 cm slo3ly 3ith.ra3 nee.le3hile aspirating1 $f still no ret,rn re.irect the nee.le thro,gh thesame p,nct,re site aiming in a cranial an. more lateral .irection6BD2 cm closer to the artery1

f1 $f stil l no bloo. ret,rn reassess lan.marks an. attempt access 018cm me.ial to the femoral p,lse1

g1 $f arterial bloo. is enco,ntere. 3ith.ra3 nee.le an. hol. man,alpress,re accor.ing to the complications section1

h1 $f +eno,s access is obtaine. 3ith goo. flo3 remo+e syringe 3hile

keeping a finger o+er the nee.le to pre+ent air embolism1

i1 $ntro.,ce the E 3ire 3ith the tip aime. to3ar. the heart thro,gh thenee.le 3hile maintaining the nee.le in the same location1 The 3irem,st pass 3ith minimal resistance1

F1 $f resis tance is met remo+e the 3i re an. check nee. le placement by

*i+. .-.

182

18<




21/52

3ith.ra3ing bloo. 3ith a syringe1

k1 (nce the 3ire is passe. remo+e the nee.le 3hile keeping control ofthe 3ire at all times1

l1 !nlarge the p,nct,re site 3ith a sterile scalpel1

m1 $ntro.,ce the .ilator o+er the 3ire


22/52

61 $n. icat ions7

a1 Long#term intra+eno,s access for .r,gs

b1 T% fl, i.s

c1 %ot for C' monitoring


a1 Lack of ,pper arm +eins +isible or palpable 3ith to,rni-,et in place

b1 resence of phlebitis or cell,l it is in arm


23/52

b1 @eas,re approJimate .istance to *'C from insertion site1

c1 )se a small amo,nt of li.ocaine to infiltrate skin on either si.e of+ein1

.1 Sits that ha+e attache. h,b re-,ire that the catheter be trimme.prior to insertion1 Trim from the en. opposite the h,b /i1e1 the tip1o not trim the tip of a Proshon catheter1 ;l,sh *ilastic catheterbefore inserting it1

e1 lace 6?#ga,ge intro.,cer catheter into +ein as if inserting aperipheral $'1 After obtaining a flash of bloo. remo+e nee.le an.a.+ance plastic portion of intro.,cer1

f1 $nsert *ilastic catheter thro,gh plastic intro.,cer catheter1

g1 "emo+e to,rni-,et an. a.+ance *ilastic catheter to premeas,re.

*i+. .-0.

18=

Page 2+ of 52Ovid: Manual of Common Bedside Surgical Procedures



24/52

length /some kits come 3ith forceps to a.+ance catheter1

h1 "emo+e g,i.e3ire an. peel a3ay plastic intro.,cer catheter1

i1 Trim en. of *ilastic catheter to manageable length b,t only if it hasa .etachable h,b1 Attach h,b heparin lock an. 3ings an. s,t,re

catheter to the skin1 With.ra3 bloo. an. fl,sh catheter1

F1 Conf irm pl acement 3i th ches t ra.iograph 1

=1 Complications an. @anagement7

a 1 Ol ee.ing

Apply press,re at insertion site for at least 8 min,tes1

b 1 Arrhy thmia

)s,ally secon.ary to catheter being a.+ance. too far

With.ra3 catheter ,ntil arrhythmia resol+es1

@e.ical management if necessary

c 1 L ine infection

*,specte. by positi+e bloo. c,lt,res from the line an. not fromperipheral c,lt,res1

"emo+e catheter an. c,lt,re intra.ermal component1

$nstit,te appropriate antibiotics1

. 1 C lotte. catheter

Oe s,spicio,s of intra+eno,s clot1

(btain oppler st,.y or +enogram1

$f clot present line remo+al is recommen.e.1

e1 Cracke. or leaking catheter

$CCs 3ith attachable h,b can be repaire. by obtaining ne3attachable h,b trimming catheter slightly an. placing ne3 h,b1

(ther3ise $CCs sho,l. be remo+e.1

B. ''N CA$'E$E&A Hohn catheter is a long#term in.3elling catheter 3ith an antibiotic#coate.c,ff1 $t is t,nnelle. thro,gh a short .istance of the chest 3all soft tiss,e an.inserte. into the s,bcla+ian +ein1 $t is eJtremely fleJible 3ith a 3i.e l,mens,ccessf,l insertion re-,ires a t3o#step process 3hereby a stan.ar. centralline is place. an. the soft#tiss,e t,nnel is aggressi+ely .ilate. prior to ,sing*el.inger techni-,e to re3ire to the Hohn catheter1

18

Page 2, of 52Ovid: Manual of Common Bedside Surgical Procedures



25/52

61 $n. icat ions7

a1 Long#term intra+eno,s access for .r,gs

b1 T% fl, i.s

c1 %ot for C' monitoring


a1 'ein thrombos is

b1 Coag,lopathy /T or TT > 618 9: control platelets N 20S

c1 )ntreate. sepsis

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7

a1 *tan.ar. single#l,men central l ine kit incl,.ing Oeta.ine s3abssterile .rapes 22# an. 28#ga,ge nee.les 8#ml syringes /t3oappropriate catheter an. .ilator 6#ga,ge insertion nee.le /8BDcm long 010


26/52

strong persistent t3isting motion aro,n. the long aJis of the

catheter is re-,ire. to a.+ance the large floppy Hohn thro,gh thesoft tiss,e1 The antibiotic#coate. c,ff sho,l. come to rest F,st abo+ethe insertion site in the soft tiss,e t,nnel1

e1 "emo+e the 3ire aspirate bloo. to confirm +eno,s placement an.fl,sh 3ith sterile saline1 *,t,re the Hohn catheter to the skin an.apply sterile .ressing1

f1 ",n $' fl,i.s at 20 ml4hr an. or.er a portable CK" to confirmplacement in *'C an. r,le o,t pne,mothoraJ1


a1 Arter ia l p,nct,re

With.ra3 nee.le imme.iately an. apply man,al press,re for 8min,tes1

@onitor hemo.ynamics an. breath so,n.s for hemothoraJ1

b 1 A ir embol,s


$f hemo.ynamically ,nstable /car.iac arrest initiate ACL*protocol an. thoracic s,rgery cons,ltation1

$f stable position patient in left lateral .ec,bit,s an.Tren.elenb,rg position to trap air in right +entricle1 CK" in thisposition can sho3 significant air an. be ,se. for follo3 ,p1


c 1 ne,mothoraJ

$f a tension pne,mothoraJ is s,specte. .ecompress 3ith 6#ga,ge angiographic catheter in secon. intercostal space

mi.cla+ic,lar line1



.1 @alposi tion ing

$nto "A or "' against 3all of +einBI3ith.ra3 or a.+ance asnee.e. to place into *'C

$nto other s,bcla+ian +einBIstable position no a.F,stmentnee.e.

$nto F,g,lar or mammary +einBIre#intro.,ce E 3ire remo+ecatheter threa. long 6#ga,ge angiographic catheter an.

confirm placement in +ein by aspiration of bloo.1 The E 3ire can

10

Page 2' of 52Ovid: Manual of Common Bedside Surgical Procedures



27/52

no3 be re.irecte. into *'C by maJimi5ing positioning /p,ll

ca,.ally on arm an. t,rn the hea. an. neck in the ipsilateral.irection to close internal F,g,lar +ein angle1

e 1 ysrhythmias

Atrial or +entric,lar .ysrhythmias are associate. 3ith 3ires an.

catheters in the "A or "' an. ,s,ally resol+e after 3ith.ra3ingthe catheter into the *'C1


f1 Line infection /l ine sho,l. be remo+e. 3ithin 3eeks

Confirme. by positi+e bloo. c,lt,res from the line an. not fromperipheral c,lt,res

"emo+e catheter an. c,lt,re intra.ermal component1

$nstit,te appropriate antibiotics1

C. 'IC-MAN &EMVAL

61 $n. icat ions7

a1 $nfecte. catheter

b1 $ntractably clotte. catheter

c1 Complet ion of therapy


a1 *e+ere coag,lopathy /T or TT >618 9: control

b1 Contin,e. nee. for therapy

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7

a1 Oeta.ine prep sol,t ion

b1 *teri le .rapes

c1 *terile hemostats scalpel 3ith bla.e nee.le hol.er

.1 ?#0 ny lon s,t,re

81 os it ioning7

*,pine

1 Techn i-,e7

16




28/52

a1 rep Hickman insertion site an. catheter1

b1 $nfiltrate site 3ith local anesthetic incl,.ing catheter tract ,p to an.incl,.ing c,ff1

c1 With gentle stea.y press,re p,ll Hickman catheter1 *ometimes this

is eno,gh to .islo.ge c,ff from s,rro,n.ing fibro,s tiss,e1

.1 When c,ff is close to skin incision insert hemostat +ia tract to c,ffsite1 )se bl,nt sprea.ing techni-,e to .i+i.e fibro,s tiss,e /see;ig,re 2161

e1 (ccasionally it is necessary to enlarge the skin incision1 )se the

*i+. .-1.

Page 2) of 52Ovid: Manual of Common Bedside Surgical Procedures



29/52

scalpel taking care to a+oi. lacerating catheter1 $f necessary make

an incision .irectly o+er the c,ff an. then ,se bl,nt .issection to freethe c,ff1

f1 (nce the c,ff is free. from the fibro,s tiss,e gently an. stea.ily p,llthe catheter from the tract1

g1 Apply press,re to the s,bcla+ian or internal F,g,lar +ein area as thetip of catheter eJits the +ein1

h1 $f skin incision is large approJimate e.ges 3ith s,t,re1 Apply.ressing1


a 1 A ir embol,s

)nlikely 3ith remo+al of t,nnelle. catheter

$f hemo.ynamically ,nstable initiate ACL* protocol an. thoracics,rgery cons,ltation1

$f stable place patient in left lateral .ec,bit,s an.Tren.elenb,rg position to trap air in right +entricle1

;ollo3 3ith serial CK"s1 Air 3ill e+ent,ally .issol+e1

b1 Ol ee.ing

Apply .irect press,re for 68 min,tes1

c 1 Catheter breakage

$f eJternal to skin site pre+ent air embol,s by clampingcatheter proJimal to breakage site an. remo+e catheter1

$f break occ,rs ,n.er the skin an. the catheter en. retractsthro,gh the t,nnel inter+entional ra.iology 3ill nee. to retrie+ecatheter1

This is a serio,s complication1 A+oi. it by not p,lling cathetertoo har. an. by keeping sharp instr,ments o,t of the t,nnel1

. )&EA$E& SAP'ENUS VENUS CU$%N

61 $n. icat ions7

*apheno,s +ein c,t.o3n is performe. 3hen perc,taneo,s access to the+eno,s system cannot be gaine.1 $t can be ,se. to gain lo3er eJtremityaccess for tra,ma b,t in recent years has been replace. by theperc,taneo,s femoral +ein approach1 The preferre. site for sapheno,s +einc,t.o3n is at the ankle1 Altho,gh the sapheno,s +ein can also be reache.

12

1<

Page 2( of 52Ovid: Manual of Common Bedside Surgical Procedures



30/52

by a c,t.o3n in the groin it is rarely performe. as an electi+e be.si.e

proce.,re1


a1 Coag,lopathy /T or TT > 618 9: control

b 1 'ein thrombos is

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7

a 1 To,rn i-,et

b1 @ask an. sterile prep sol,tion go3n glo+es .rape

c 1 Pa,5e pa.s

.1


31/52

b1 rep an. .rape area s,rro,n.ing the ankle1 $nfiltrate the skin o+er

the +ein 3ith li.ocaine ,sing a 28#ga,ge nee.le1c1 @ake a f,ll#thickness trans+erse incision thro,gh the anestheti5e.

skin to a length of 218 cm1

.1 )sing a c,r+e. hemostat i.entify the sapheno,s +ein an. gently

.issect it free from the sapheno,s ner+e 3hich is attache. to theanterior 3all of the +ein1 $t is imperati+e that the sapheno,s ner+e bei.entifie. to a+oi. inF,ry an. s,bse-,ent pain1

e1 !le+ate an. .issect the +ein free from its be. for a .istance ofapproJimately 2 cm /see ;ig,re 2161

f1 ass the silk ties aro,n. the eJpose. +ein proJimally an. .istally1

g1 Ligate the +ein .istally lea+ing the s,t,re in place for traction1

h1 @ake a small trans+erse +enotomy an. gently .ilate the +enotomy3ith the tip of the close. hemostat1 A +ein intro.,cer may also be,se. /see ;ig,re 2161

*i+. .-2.

1?

*i+. .-3.

18

Page +1 of 52Ovid: Manual of Common Bedside Surgical Procedures



32/52

i1 lace angiographic catheter into the +ein .irectly or after t,nnelling itthro,gh the skin .istal to the incision1 Tie the proJimal silk s,t,re to

sec,re the catheter being caref,l not to occl,.e the catheter1 Thecatheter sho,l. be inserte. an a.e-,ate .istance to pre+ent easy.islo.gement /see ;ig,re 21201

*i+. .-4.




33/52

F1 Cl ose 3o,n. 3i th inte rr,pte. nyl on s, t, res1 Apply st er ile .ressings 1


a 1 Ol ee.ing

Apply press,re if blee.ing occ,rs1

b1 $nfection4hlebitis

"emo+e catheter1 Apply 3arm compresses an. ele+ate leg1

)se antibiotics if necessary

E. IN$&ASSEUS ACCESS

61 $n. icat ions7

%ee. for emergency access ,s,ally in a chil. less than < years ol. 3hen

other attempts at +eno,s access ha+e faile. an. time is too short for ac,t.o3n1 The techni-,e has been ,se. in ol.er chil.ren an. a.,lts1 (nceintra+asc,lar +ol,me has been replace. other access sho,l. be obtaine.1


a1 Oeca,se this is an emergency proce.,re an. is to be ,se. in these+erely inF,re. or critically ill patient the only relati+econtrain.ication is inF,ry to the eJtremity of interest1

b1 A+oi. placing the nee.le .istal to a fract,re site1

< 1 Anesthesia7

%one

? 1 !-, ipment7

6# or 6#ga,ge bone marro3 aspiration or intraosseo,s inf,sion nee.le

81 os it ioning7*,pine

1 Techn i-,e7

a1 $nsert nee.le be+el ,p at 0ÂMBD0ÂM angle into the marro3 of a

long bone1 The preferre. site is the tibia 2BD< cm inferior to thetibial t,berosity alternati+ely ,se the inferior thir. of the fem,r /see

*i+. .5.

1

1=

Page ++ of 52Ovid: Manual of Common Bedside Surgical Procedures



34/52

;ig,re 21261

b1 Aspiration of marro3 confirms proper location1 (ther cl,es to properposition incl,.e firm ,pright position of nee.le in bone an. easyinf,sion of 8BD60 ml of fl,i. /see ;ig,re 21221

*i+. .-.

1

Page +, of 52Ovid: Manual of Common Bedside Surgical Procedures



35/52

c1 *ec,re the nee.le 3ith tape1


a1 $nf il trat ion

"emo+e an. replace nee.le1

b 1 Cel l, li ti s

"emo+e nee.le1

Treat cell,litis 3ith antibiotics1

c 1 (steomyel it is

Appropriate long#term $' antibiotics

.1 Compartment syn.rome

*i+. ..

1




36/52

;asciotomy

$$$. ARTER$A CA%%(AT$'%Arterial lines permit contin,o,s monitoring of heart rate an. bloo. press,renecessary in $C) patients 3ho are recei+ing inotropic agents or 3ho are

hemo.ynamically ,nstable1 $ntraoperati+e monitoring is also re-,ire. 3ith high#risk patients1 $n or.er of preference 3e attempt ra.ial > ,lnar > femoral >.orsalis pe.is > aJillary sites1 We recommen. ,sing BU-,ickB catheters orangiographic catheters for ra.ial ,lnar an. .orsalis pe.is arteries an. the*el.inger techni-,e for femoral an. aJillary arteries1

A. &AIAL A&$E&+ CANNULA$IN

61 $n. icat ions7

a1 Contin,o,s hemo.ynamic monitoring

b1 ;re-,ent assessment of arterial bloo. gases


Allen test1

a1 (ccl,.e both ,lnar an. ra.ial arteries an. allo3 +eno,s .rainage toeJsang,inate the han. /see ;ig,re 212


37/52

b1 "elease the ,lnar artery 3hile keeping the ra.ial artery compresse.1

c1 $f han. color .oes not ret,rn in N 8 secon.s the Allen test is positi+e

an. cann,lation sho,l. be aborte.1

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7




*i+. ..

1=0




38/52

.1 *yringe

e1 6# 6# or 20#ga,ge angiographic catheter /2 inches long-,ickcatheters

f1 2BD0 s ilk s,t,res

g1 ress,re bags 3ith $' t,bing

h1 Heparini5e. fl,sh system 3ith sensor attachments for monitoring

i 1 *teri le .ressings

F1 Han. to3el

81 os it ioning7

!Jpose the +entral s,rface of the forearm .orsifleJ the 3rist an. place a

rolle.#,p han. to3el ,n.erneath the .orsal s,rface of the 3rist1 *ec,rethe palm an. forearm to an arm boar. /see ;ig,re 212?1

1 Techni-,e /,se techni-,e similar to ,lnar artery cann,lation7

a1 $n a sterile fashion .ress 3ith mask an. go3n1 rep an. .rape

+entral s,rface of the 3rist1

b1 alpate the ra.ial p,lse near the .istal ra.i,s1

c1 A.minister anesthetic 3ith a 28#ga,ge nee.le into the skin abo+e thispoint1 )se a 6#ga,ge nee.le as a skin breaker to p,nct,re the skin1

.1 )sing an angiographic catheter enter at a ?8ÂM angle an. a.+anceto3ar. the p,lse ,ntil bloo. ret,rn is seen in the h,b of the nee.le

1=6

*i+. ..

Page +) of 52Ovid: Manual of Common Bedside Surgical Procedures



39/52

/see ;ig,re 21281

e1 $f there is no bloo. ret,rn 3ith.ra3 the angiographic catheter slo3lyan. make another pass at a 0ÂM angle to3ar. the palpate. p,lse1

f1 $f goo. bloo. ret,rn is seen in the h,b a.+ance the angiographic

catheter another 2 mm to ens,re intral,minal placement of theangiographic catheter1 $f yo, are ,sing a -,ick catheter thisa..itional 2 mm is not necessary an. the 3ire portion of the systemis then a.+ance. into the artery1

g1 *lo3ly a.+ance the catheter portion of the angiographic catheter intothe artery 3hile hol.ing the nee.le stea.y1

h1 "emo+e the nee.le an. keep .igital compression on the proJimalra.ial artery to pre+ent eJcessi+e blee.ing1

i1 $f there is no blee.ing the catheter is not intral,minal1 With.ra3 the

catheter slo3ly in case it has p,nct,re. the posterior 3all1 $f there isstill no bloo. remo+e the catheter hol. press,re for 8 min,tes1"eassess lan.marks an. reattempt placement1 (ften the artery lies

more me.ially than eJpecte.1

F1 $f s,ccess f,l attach fl,sh system an. senso rs to the monitor toassess arterial 3a+eform1

*i+. .0.

1=2

Page +( of 52Ovid: Manual of Common Bedside Surgical Procedures



40/52

k1 *,t,re the catheter to the skin an. apply sterile .ressing1

l1 $f ,ns,ccessf,l after three attempts stop an. assess a more proJimalsite1


a1 oor arterial 3a+eform

Check all line connections an. stopcocks1

!Jcl,.e eJtrinsic proJimal arterial compression1

Check position of arm an. 3rist the arm cannot be ele+ate. an.the 3rist m,st be .orsifleJe.1

$f 3a+eform an. bloo. ret,rn are poor replace catheter1

b 1 $schemic .igi ts

"emo+e catheter an. monitor the han.1

B. &SALIS PEIS A&$E&+ CANNULA$IN

61 $n. icat ions7




%o palpable .orsalis pe.is artery

< 1 Anesthesia7

6 li.ocaine

? 1 !-, ipment7




. 1 8#ml syr inge

e1 6# 6# or 20#ga,ge angiographic catheter /2 inches long or -,ickcatheters

f1 2BD0 s ilk s,t,res

g1 ress,re bags 3ith $' t,bing

h1 Heparini5e. fl,sh system 3ith sensor attachments for monitoring

1=<

Page ,0 of 52Ovid: Manual of Common Bedside Surgical Procedures



41/52

i 1 *ter i le .ressings

81 os it ioning7

!Jpose the .orsal s,rface of the foot in ne,tral position1

1 Techn i-,e7

a1 $n a sterile fashion .ress 3ith mask an. go3n1 rep an. .rape .orsals,rface of the foot1

b1 alpate the .orsalis pe.is p,lse lateral to the eJtensor hall,cis long,sat the le+el of the metatarsal#6st c,neiform Foint /see ;ig,re 212an. a.minister anesthetic 3ith a 28#ga,ge nee.le into the skin abo+ethis point1

c1 )sing a 20#ga,ge angiographic catheter 3ith the be+el ,p p,nct,rethe skin at a ?8ÂM angle to the skin1 A.+ance the angiographic

*i+. .1.




42/52

catheter to3ar. the palpate. p,lse ,ntil bloo. ret,rn is seen in the

h,b of the nee.le /see ;ig,re 212=1

.1 $f there is no bloo. ret,rn 3ith.ra3 angiographic catheter slo3ly an.

make another pass at a 0ÂM angle to3ar. the palpate. p,lse1

e1 $f there is goo. bloo. ret,rn in the h,b a.+ance the angiographiccatheter another 2 mm to ens,re intral,minal placement1 $f yo, are,sing a -,ick catheter this a..itional 2 mm is ,nnecessary an. the3ire portion of the system is a.+ance. into the artery1

f1 While maintaining a firm hol. on the nee.le portion of theangiographic catheter slo3ly a.+ance the catheter portion into theartery1

g1 "emo+e the nee.le an. keep .igital compression proJimally topre+ent eJcessi+e blee.ing1

h1 $f there is no blee.ing the catheter is not intral,minal1 With.ra3 the

catheter slo3ly in case it has p,nct,re. the posterior 3all1 $f there isstill no bloo. remo+e the catheter an. hol. press,re for 8 min,tes1"eassess lan.marks an. reattempt placement1

i1 $f s,ccessf,l attach fl,sh system an. sensors to the monitor toassess arterial 3a+eform1

*i+. .2.

1=?

1=8




43/52

F1 *, t, re the cathete r to the sk in an. app ly a steri le .ress ing1

k1 $f ,ns,ccessf,l after three attempts stop an. assess another site1


a1 oor arterial 3a+eform

Check all line connections an. stopcocks1

!Jcl,.e eJtrinsic proJimal arterial compression1

$f 3a+eform an. bloo. ret,rn are poor replace catheter1

b 1 $schemic toes

"emo+e catheter an. monitor foot1

C. *EM&AL A&$E&+ CANNULA$IN

61 $n. icat ions7



c1 Access for arteriography st,.ies

.1 $ntra#aortic bal loon p,mp insertion /see Chapter


44/52

i 1 2BD0 si lk s,t,res

F1 re ss,re bags 3i th $' t,b ing

k1 Heparini5e. fl,sh system 3ith sensor attachments for monitoring

81 os it ioning7

*,pine

1 Techn i-,e7

a1 $n a sterile fashion .ress 3ith mask an. go3n1 *ha+e prep an.

.rape left or right groin area1

b1 alpate the femoral p,lse at the mi.point along an imaginary linebet3een the anterior s,perior iliac spine an. the symphysis p,bis1alpate its co,rse 6BD2 cm .istally1

c1 A.minister anesthetic 3ith 28#ga,ge nee.le into the skin an.

s,bc,taneo,s tiss,es along the co,rse of the artery /see ;ig,re2121

1==

Page ,, of 52Ovid: Manual of Common Bedside Surgical Procedures



45/52

.1 )sing the 6#ga,ge insertion nee.le 3ith a 8#ml syringe p,nct,rethe skin at point A an. a.+ance the nee.le 3hile aspirating craniallyat a ?8ÂM angle to the skin to3ar. the p,lse /see ;ig,re 212 an.;ig,re 21


46/52

*i+. .4.

Page ,' of 52Ovid: Manual of Common Bedside Surgical Procedures



47/52

e1 $f there is no arterial bloo. ret,rn after 8 cm slo3ly 3ith.ra3 nee.le3hile aspirating1 $f still no ret,rn re.irect again to3ar. the p,lse orreassess lan.marks an. attempt access at a site that is 6 cm moreproJimal along the co,rse of the artery1

f1 $f there is +eno,s ret,rn 3ith.ra3 nee.le an. hol. press,reaccor.ing to the complications section1

g1 $f arterial access is obtaine. remo+e the syringe 3hile keeping afinger o+er the nee.le to pre+ent eJcessi+e blee.ing1

h1 $ntro.,ce the E 3ire 3ith the tip aime. to3ar. the heart thro,gh thenee.le /*el.inger techni-,e1 The 3ire m,st pass 3ith minimalresistance1

i1 $f resistance is met remo+e the 3ire an. check nee.le placement by3ith.ra3ing bloo. 3ith a syringe1

*i+. .5.

1=




48/52

F1 (nce the 3ire is passe. remo+e the nee. le 3h il e keep ing contro l of

the 3ire at all times1

k1 !nlarge the p,nct,re site caref,lly 3ith a sterile scalpel1

l 1 $ntro.,ce the catheter o+er the 3ire1

m1 "emo+e the 3ire an. attach fl,sh system an. sensors to the monitorto assess arterial 3a+eform1 *,t,re the catheter to the skin an. applya sterile .ressing1

n1 atient sho,l. maintain be. rest ,ntil the catheter is remo+e.1


a1 ;emoral +ein p,nct,re

With.ra3 the nee.le1

Hol. press,re for 60 min,tes1

b 1 Thrombosi s

"emo+e catheter1

Closely monitor leg p,lses an. obser+e for .istal emboli1

c 1 Hematoma

"emo+e catheter1

Hol. press,re for at least 68 min,tes1 A san. bag is then place.o+er the site for another


49/52

6 li.ocaine

? 1 !-, ipment7


b1 @ask an. steri le go3n glo+es an. to3els



e1 6#ga,ge catheter / inches

f1 6#ga,ge insertion nee.le /8 cm long

g 1 010


50/52


51/52

e1 $f there is no arterial ret,rn after 8 cm slo3ly 3ith.ra3 nee.le 3hileaspirating an. re.irect to3ar. the p,lse1 $f there is still no ret,rnreassess lan.marks an. attempt access at a site that is 6 cm more.istal along the co,rse of the artery1

f1 $f +eno,s bloo. is enco,ntere. 3ith.ra3 nee.le an. hol. press,reaccor.ing to the complications section1

g1 $f arterial access is obtaine. remo+e the syringe 3hile keeping afinger o+er the nee.le to pre+ent eJcessi+e blee.ing1

h1 $ntro.,ce the E 3ire thro,gh the nee.le 3ith the tip aime. to3ar. theheart 3hile maintaining the nee.le in the same location1 The 3irem,st pass 3ith minimal resistance1

i1 $f resistance is met remo+e the 3ire an. check nee.le placement by

3ith.ra3ing bloo. 3ith a syringe1

F1 (nce the 3ire is passe. remo+e the nee. le 3h il e keep ing contro l ofthe 3ire at all times1

k1 !nlarge the p,nct,re site caref,lly 3ith a sterile scalpel1

l 1 $ntro.,ce the catheter o+er the 3ire1

m1 "emo+e the 3ire an. attach fl,sh system an. sensors to the monitor

*i+. ..

1<




52/52

to assess arterial 3a+eform1 *,t,re the catheter to the skin an. apply

sterile .ressing1


a1 'eno,s p,nct,re

With.ra3 nee.le1

Hol. press,re for at least 60 min,tes1

b 1 Thrombosi s

"emo+e catheter1

@onitor .istal p,lses an. 3atch for ischemic .igits1

c1 Orachial pleJ,s inF,ry

"emo+e catheter1

Assess ne,rological f,nction1 $f no impro+ement initiate

ne,ros,rgery cons,ltation1


manual of common bedside surgical procedure chapter 2 - arterial and venous access

Documents