recava

9/5/2012

1

RaCeVA: a guide for a rational choice of the most appropriate vein for central

venous catheterization

Mauro PittirutiCatholic University, Rome,Italy

Introduction

Ultrasound guidance is an evidence‐basedmethodology that significantly reduces the complications related to insertion of centralvenous catheters (CVC).

Though, the benefit of using ultrasound (US) isnot limited to real‐time US guidedvenipuncture.

Introduction

GAVeCeLT (The Italian Group for Venous Access Devices) recommends to use US during CVC insertionfor five different purposes:

(1) US evaluation of all veins available, (2) choice of the vein on the basis of rational criteria, (3) real time US guided venipuncture, (4) US‐based control of guidewire/catheter direction, (5) US‐based control of pleura‐ pulmonary integrity

9/5/2012

2

IntroductionOf particular relevance is the use of US for a rapidassessment of the central veins, not only to excludeveins morphologically abnormal (thrombosis, externalcompression, anatomical variation of size and shape, etc.), but also to evaluate the possible options and choose the best approach.This can be easily performed following the RaCeVAprotocol, which has been standardized by our groupand is currently taught in our GAVeCeLT courses aboutUS guided central venous access.

RaCeVA Rapid Central Vein Assessment

It was designed as a tool…… to teach the different US guided approaches

to the central veins… to help the operator to scan systematically all

possible venous options… to guide the operator in choosing the vein to

be accessed, on a rational basis

Rapid Central Vein Assessmenta) Probe at mid-neck: visualization of the internaljugular vein (IJV) and the carotid artery (both in short axis);

9/5/2012

3

Ideal position for ‘out of plane’ puncture of the internal jugular vein

IJV = in short axis

Also, ideal position for ‘in plane’ puncture of the internal jugular vein

IJV = in short axis

Rapid Central Vein Assessmentb) Probe sliding down the neck towards the sternum: visualization of the lower tract of the IJV (in short axis) and of the subclavian artery (in long axis); visualization of the valve in distal IJV.

9/5/2012

4

Rapid Central Vein Assessment

c) Tilting the probe so to get an almost frontal plane: visualization of the brachio-cephalic vein (BCV) (in long axis)

Ideal position for ‘in plane’ puncture of the brachio-cephalic vein

BCV = in long axis

Rapid Central Vein Assessmentd) Sliding the probe lateraly, behind the clavicle: visualization of the subclavian vein (SV) and external jugular vein (in long axis); more laterally, visualization of the subclavian artery (in short axis)

9/5/2012

5

Ideal position for ‘in plane’ puncture of the subclavian vein

SV = in long axis


e) Probe below the lateral 1/3 of the clavicle: visualization of the axillary vein (AV) and of the axillary artery (in short axis) and of the cephalic vein (in long axis)

Ideal position for ‘out of plane’ puncture of the axillary vein

AV = in short axis

9/5/2012

6


f) Rotating the probe anti-clockwise: visualization of the axillary vein in long axis.

Ideal position for ‘in plane’ puncture of the axillary vein

AV = in long axis


After this rapid assessment, performedbilaterally, it is possible to choose the mostappropriate vein and the most appropriate ultrasound guided approach, taking intoconsiderations six criteria.

9/5/2012

7

Six criteria1 - caliber of the vein 2 - depth3 - collapse during breathing4 - compression by arterial pulsation 5 - closeness to ‘dangerous’ structures (pleura) 6 - convenience of the exit site in terms of management

1 – Caliber of the vein

Avoid veins too small: they are difficult to puncture, difficult to cannulate and might be associated with higher risk of thrombosis

Variable size of IJV

2 – Depth of the vein

If the vein is too deep (for example, AV), it may difficult to puncture and to cannulate.

9/5/2012

8

3 – Collapse during breathing

Some veins (typically AV and IJV) may collapse during breathing (inspiration = negative thoracic pressure): this makes them difficult to puncture and cannulate

4 – Compression by artery

Some veins (typically IJV) may be compressed by the artery which runs closeto them.The risk of accidentalarterial puncture is high, in such cases, even with US.

5 – Close proximity to pleura

Puncture of the subclavian vein is rarely the first choice, considering the close proximityto pleura.

9/5/2012

9

6 – Convenience of exit siteFor non-tunneled catheters, approaches associated with an exit site in the infraclavicular area (AV) or in the supraclavicular area (BCV, ‘in plane’ IJV, SV) are preferable to approaches associated with an exit site at mid-neck (‘out of plane’ IJV)

RaCeVARapid Central Vein Assessment:

- It takes only 20-30 sec for each side - It is easy to teach, easy to learn- It is a useful guide for a rationale choice of the

central vein to be accessed, in terms of:- Patient’s safety- Cost-effectiveness- Improved performance of the VAD

For a copy of this presentation,please send an email to Mauro Pittiruti:[email protected]

Please visit the website of the European Vascular Access

Network www.evanetwork.info

recava

Documents