2015 NCANA Annual Meeting

1. Central
lines
in
anesthesia:
choices,
techniques
&
pi4alls
IAN
HEWER,
MA,
MSN,
CRNA
ASSISTANT
Director,
WCU
NURSE
ANESTHESIA
PROGRAM

2. OBJECTIVES
• IDENTIFY
REASONS
FOR
CENTRAL
LINE
ACCESS
• IDENTIFY
COMMON
SITES
&
MAJOR
LANDMARKS
FOR
CENTRAL
LINE
PLACEMENT
• LIST
FREQUENT
COMPLICATIONS
OF
CENTRAL
VENOUS
ACCESS
&
WAYS
TO
AVOID
THEM

4. HISTORY
• 1656-­‐
original
infusions
of
wine,
ale,
&
opium
into
dog
• 1680s-­‐
animal
blood
into
humans-­‐
results
led
to
unpopularity!

5. HISTORY
• 1700-­‐1800s-­‐
various
experiments
to
measure
arterial,
venous
&
cardiac
pressures
• First
experiments
in
early
20th
century
in
Germany
• Wanted
a
way
to
introduce
emergency
drugs
close
to
the
heart
(Forssmann,
1929)

6. HISTORY
• 1940s-­‐
introducbon
of
PVC
catheters
for
IVs
revolubonizes
field
• 1956-­‐
Cournand,
Forssman
&
Richards
won
Nobel
Prize
for
Medicine

7. Further
development
• Locabons:
– Infraclavicular
subclavian-­‐
1952
Aubaniac
– Internal
jugular
approach-­‐
1968
English
• Why?
– Nutribon
– Chemotherapy
– Direct
access
for
drugs

8. CVCs
today
• >
5
million
placed/year
in
the
US
alone
(McGee
&
Gould,
2003)
• >
15%
have
complicabons
– Mechanical-­‐
5-­‐19%
– Infecbous-­‐
5-­‐26%
– Thrombobc-­‐
2-­‐26%

9. implicabons
• Significant
morbidity-­‐
potenbally
>750,000
have
complicabons
• Significant
cost-­‐
$16,550/
infecbon
(CDC,
2011)
• Reducbon
in
CLABSI
2001-­‐2009-­‐
save
$2
billion
in
excess
costs
&
6000
lives

10. Major
uses
• Access
– Poor
peripheral
– Need
for
volume..?

11. Side
note:
Fr
vs
gauge
• French
relates
to
external
diameter,
&
is
a
mulbple
of
3
– 1
Fr
=
.33mm
OD,
3
Fr
=1
mm
OD,
6
Fr
=
2
mm
OD
etc
– DOES
NOT
INDICATE
INTERNAL
DIAMETER!!
• Gauge
refers
to
internal
&
external
diameter..kind-­‐of..
– E.g.
14
G
=
2.1mm
OD
&
1.6mm
ID.
Similar
to
6
Fr
OD

12. Major
uses
• Determinabon
of
CV
funcbon
– CVP
measurement
– PA
catheter
placement
• Nutribon

13. Not
much
of
a
decision
• Ultrasound
vs
Landmark
• Less
arterial
punctures
• Less
overall
sbcks
• Beoer
first
aoempt
success
• Quicker

14. Remember..
• There
is
a
learning
curve!

15. Classic
“central”
approach
• Idenbfy
the
triangle
formed
by
clavicular
head/ s
ternal
head
of
the
sternocleidomastoid
Vein
is
typically
anterior
&
lateral
to
artery
at
the
level
of
cricoid
carblage
• Lower
down
the
neck,
the
vein
becomes
relabvely
medial,
&
risk
of
pneumothorax
increases-­‐
stay
away!
• Higher
up
the
neck,
the
risk
of
brachial
plexus
or
phrenic nerve injury increases-stay away!

16. Clavicle
Jugular vein
Carotid artery
_,,___Sternal
notch
A Sternocleidomastoid muscle

17. Who
needs
to
see?!

18. Mechanical
complicabons
• Arterial
cannulabon/
injury
– Puncture:
6.3-­‐
9.4%
(McGee
&
Gould,
2003)
– Cannulabon:
most
recent
work,
incidence
of
1%,
but
range
from
.07-­‐1%
(Bowdle)
– Closed
claims
data
not
encouraging!
• 5/14
died
– Other
risks
include
stroke
&
addibonal
surgery,
LOS

19. 5353
the right side of the neck carefully using a portable
ultrasound (US) machine (IMAGIC Agile, Kontron
Medical, WA, USA) with a linear, high frequency
transducer (7.5–12 MHz). Care was taken to apply
minimal pressure on the probe to prevent collapse of the
IJV. Imaging showed a single pulsatile vessel, which was
non compressible suggestive of the carotid artery with
right sided IJV has also been reported in a 12-year-old boy
during US evaluation prior to attempted cannulation.[4]
In
another report, IJV agenesis was discovered during neck
dissection. Patients who require removal of IJV due to
disease infiltration may have potentially life-threatening
complicationofcerebraledemaiftheotherIJVisaplastic.[5]
Figure 1: Ultrasound image of the right side of the neck showing absence
of internal jugular vein. CA: Carotid artery
Figure 2: Ultrasound image of the left side of the neck showing normal
anatomy. CA: Carotid artery; IJV: Internal jugular vein

20. Next
step
• Scan
neck
up
&
down
above
“standard”
entry
site
to
visualize
course
of
vein
&
artery
• Local
anesthebc?
• As
early
as
possible

21. Next
step
• Center
vein,
enter
at
30-­‐45
degree
angle
about
1cm
away
from
probe
• Enter
medial
to
guide
line,
aim
slightly
lateral
• Ideally,
follow
needle
bp
“down”
to
vein
• Watch
screen,
but
aspirate
as
you
advance

23. A
word
about
sedabon..
• Less
is
more
• With
good
LA,
should
not
be
painful

24. Next
step
• Enter
vein
using
either
“big”
needle
or
some
prefer
18G
catheter;
advantages
to
both
– Catheter-­‐
less
prone
to
pop
out
of
vein,
but
can
be
more
difficult
to
advance
– Needle-­‐
good
flow,
easy
to
advance
wire
BUT
must
keep
very
sbll
• Advance
wire-­‐
MUST
THREAD
EASILY
• Need
to
check
for
venous
placement

31. Placing
the
line
• Triple
lumen
– Scalpel/dilator/line
– Secure
around
15cm
• Introducer/Swan
– Line
is
on
dilator
– Remember
the
dilator
is
rigid
&
pointy!
– Line
goes
to
hub
• Both-­‐
ensure
wire
is
free
as
you
advance
line

33. Leu
IJ
lines
• Increased
risk,
but
beoer
choice
in
some
people
-Shorter
length
to
subclavian-­‐
extra
care
with
dilator,
&
may
need
to
pull
back
introducer
for
Swan
-Increased
risk
of
lung
injury
• Risk
of
thoracic
duct
injury

34. More
bad
things
about
the
leu
• Vein
crosses
over
artery
more
easily
with
turning
head
• Unfamiliarity

35. Subclavian
lines
• Small
roll
between
shoulders-­‐
improves
access
• Midpoint
of
clavicle,
2-­‐3
cm
back
– Aim:
to
avoid
poinbng
needle
down
– Some
clinicians
bend
needle
for
same
effect
• Point
needle
towards
sternal
notch
– Some
hold
leu
hand
on
notch
to
keep
“target”
• Advance
needle
with
negabve
pressure
• unbl in vein

36. Subclavian
bps
• Must
use
needle-­‐
catheter
may
kink
• If
unsuccessful,
point
needle
more
cephalad
• Keep
passes
to
minimum;
avoid
bilateral
aoempts

37. More
subclavian
bps
• If
line
is
for
thoracic
surgery,
on
same
side
• If
pt
has
pathology
in
one
lung
(e.g.
pneumothorax),
line
on
same
side
• Wire
may
not
go
where
you
want
it
– If
pt
is
awake,
ear/
neck
pain
may
indicate
wire
in
IJ
– If
pt
is
asleep,
look
for
ectopy
– Always
X
Ray

38. Subclavian
&
U/s
• Not
typically
recommended
• Can
be
useful
to
idenbfy
normal
anatomy
prior
to
starbng
procedure

39. No
complicabons
with
u/s..?
Accidental Carotid Artery Catheterization
During Attempted Central Venous Catheter
Placement: A Case Report
Pauline Marie Maietta, CRNA, MS
2.1 million central venous catheters are
hile carotid artery cannulation is
stating. Anesthesia provid-
ous catheters in
perative
sion of technique for central venous catheterization,
indications for suspicion of arterial puncture, methods
for confirming venous or arterial placement, appro-
priate methods for management of carotid artery
cannulation, and the benefit of ultrasound in centra
venous cannulation follow. Through the appropria
f equipment, early detection and manageme
ry injury, and proper training, pat
roved.
tion, c
(Maieoa,
2012)

40. U/s
examined
• Operator
error
could
be
an
issue
• We
cannot
see
whole
length
of
wire
• Pressure
transducbon
could
prevent
arterial
cannulabons
not
detected
by
other
means-­‐
approx
0.8%
of
all
aoempted
(Ezaru,
2009)
– That’s
potenbally
40,000
cases/yr!!
• Should
we
use
pressure
measurement
for
all?

41. residents placing the CVC in each of the six cases were credentialed by their hospital in emergency
ultrasound based on American College of Emergency Physicians ultrasound criteria. All residents
received a 2-day introductory ultrasound course, which included 3 hours of didactic and hands-on
education in ultrasound-guided vascular access. Table 3 summarizes each of the six cases, including as
analysis of the error based on a video review of the ultrasound-guided arterial cannulation.
Age Mechanism of injury Outcome
67 Needle went through IJ into Carotid artery Patient Died
75 Needle went though femoral vein into
femoral artery
Vascular surgery for AV fistula
48 Needle went though IJ and entered carotid
artery sitting underneath the IJ
Surgery for tear and focal dissection
of carotid artery
67 Guidewire traveled through IJ and its
posterior wall and into carotid artery
Hematoma with respiratory distress
requiring emergent intubation.
69 Needle penetrated the carotid artery which
was very close to the IJ
Emergency carotid artery repair;
Patient died of complications
14 Needle penetrated rear wall of IJ and
entered carotid artery
Central line removed and bleeding
eventually stopped
Table 3: Analysis of six accidental arterial cannulations with dynamic ultrasound guidance
The mechanism of injury in 5 of the 6 cases involved passage of the needle through the vein, out its
posterior wall, and into the artery. This highlights the importance of confirming the location of the tip of
the needle prior to inserting the guidewire. The author concluded, “In summary, the short-axis approach,
as seen in this series, can provide a false sense of security to the practitioner and allows for potentially
dangerous accidental arterial cannulation…it may be prudent to not only visualize the entire path of the
needle with the long-axis approach but also confirm correct cannulation by tracing the guidewire in the
long axis before line placement.” However, it is important to realize that even with multiple ultrasound
views of needles or wires, misdiagnosis remains a possibility. For example, as noted in the case below
(see Figure 6), it is possible for a needle and wire to pass through the internal jugular vein and into the
Source:
Bowdle,
nd

42. Some
general
comments
About
complicabons
• Site
dependent
• Provider
dependent-­‐
VOLUME
OF
PROCEDURES
• Procedure
dependent

43. Our
study
• Wanted
to
examine
complicabon
rates
in
CVCs
placed
by
CRNAs
vs
MDs
• Easy
access
to
QI
database
• Problem
– Polibcal
– Numbers-­‐
a
vicbm
of
our
own
success

44. Major
complicabons
• Mechanical
– Vessel
or
nerve
injury
– Pneumothorax/
hemothorax
• Infecbous
• Thrombobc

45. Mechanical
complicabons
• Vein
injury
– Vein
is
thin
walled
relabve
to
artery-­‐
more
prone
to
damage
– Can
be
acute
during
line
placement
– Or
later
as
result
of
erosion

46. What
we
found
• Hematoma-­‐
1/359
(.003%)
• Cannulabon-­‐
0

47. Pneumothorax
• Incidence
varies
according
to
site
(duh!)
• Commonest
with
subclavian
(1.5-­‐3.1%)
• Rare
but
seen
with
IJ
(.2%)

48. What
we
found
• 9/359
pts
=
2.5%
• Typical
incidence
=
0.1-­‐0.2%
• BUT
rate
of
ptx
in
cardiac
surgery
=
0.7-­‐5.3%
(higher
with
IMA
harvest)
(Weissman,
2004)

49. hemothorax
• Result
of
vessel
injury,
typically
venous
• Rare,
but
significant
mortality
(92%
in
Closed
Claims)
• Remember:
veins
are
fragile

50. Thrombobc
complicabons
• Significant
issue
outside
of
the
OR
• Incidence
cited
varies
e.g
1.9%
of
subclavian
lines
(McGee,
2003)
• With
thrombosis
comes
risk
of
embolizabon
• Probably
related
to
durabon

51. Thrombosis:more
• Contact
with
vein
wall
is
probably
a
big
risk
for
thrombosis
(Fletcher
&
Bodenham,
2000)
• Therefore
posiboning
is
key
• Think
post-­‐op
CXR

52. Infecbous
complicabons:
background
• Interest
in
Healthcare
Acquired
Infecbons
(HAI)
has
increased
dramabcally-­‐
in
response
to
the
problem
• Priority
of
WHO,
IOM,
CDC,
TJC,
&
a
hospital
near
you..
• 1.7
million
infecbons
&
99,000
deaths
in
the
US
from
HAI
(TJC,
2012)

53. Infecbon:
cvcs
• CLABSI:
Central
Line-­‐
Associated
Blood
Stream
Infecbon
• Est
80,000
CLABSI/
year
in
ICU
alone
• Mortality:
difficult,
but
maybe
10,000
yr
• Cost
significant:
>$16,000
per
case

54. More
specifics
• Most
risk
=
femoral
line
• Next,
Internal
Jugular-­‐
?
Due
to
proximity
to
mouth
• Least
risk
=
subclavian

55. What
we
found
• 2
infecbons
(.006%)
• Preliminary:
no
associabon
with
“difficult
inserbon”,
second
line(31
pabents),
diabetes
or
line
durabon
• ..but
average
line
durabon
3.03
days

56. patient safety initiatives can be found in Chapter 4.
Chapter 3 contains a comprehensive review of the recom-
mended strategies and techniques for preventing CLABSIs.
route has been associated with more prolonged CVC
dwell time (for example, in place for more than 10
days), including tunneled CVCs such as Hickman-
and Broviac-type catheters and PICCs.
Figure 1-1. Routes for Central Venous Catheter Contamination with
Microorganisms
Potential sources of infection of a percutaneous intravascular device (IVD): the contiguous skin flora, contamination of the
catheter hub and lumen, contamination of infusate, and hematogenous colonization of the IVD from distant, unrelated sites of
infection. HCW: health care worker.
Source: Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I.
Pathogenesis and short-term devices. Clin Infect Dis. 2002 May 1;34(9):1232–1242. Used with permission.
Source:
TJC,
2012

58. What
can
we
do?
• Is
the
line
really
needed?
– Minimum
number
of
lumens
• Hand
hygiene
• Asepbc
technique
o Maximal barrier technique
o Right prep
o Antibiotic impregnated line/dsg
–
• Ultrasound-­‐
diminished
#
of
aoempts

59. A
word
about
scrub
the
hub!
• Focus
of
TJC
in
recent
years
• Anesthesia
compliance…sub-­‐opbmal!!
• 15
second
scrub
with
alcohol
• ..or
the
“orange
cap”

60. Miscellaneous
issues
• Experience
– Like
surgical
cases,
experience
counts
– Sznajder
et
al
(1986)-­‐
Experience
with
>
50
CVCs
=
½
rate
of
complicabon
compared
with
<
50
CVCs
– >
3
aoempts
=
8
x
mechanical
complicabon
rate
• Quesbon:
should
everybody
put
in
lines?

61. In
closing
• U/S
may
not
be
essenbal,
but
does
offer
benefits
• Consider
using
manometry
to
check
placement
even
with
U/S
• HAND
HYGIENE!!
(Scrub
the
hub
too)

62. references
• Aljure,O.,
Casbll-­‐Pedraza,
C.,
Mitzova-­‐Vladinov,
G.,
Maraeta,
E.
(2015).
Right
internal
jugular
cross-­‐secbonal
area:
is
there
an
opbmal
area
for
cannulabon?
Jnl
of
the
Associa1on
for
Vascular
Access
20(1):
22-­‐25.
• Bowdle,
TA.
Arterial
cannula1on
during
central
line
placement:
mechanisms
of
injury,
preven1on
&
treatment.
• Ezaru
et
al.
(2009).
Eliminabng
arterial
injury
during
central
venous
catheterizabon
using
manometry.
Anesth
Analg
109:
130-­‐4.
• Fletcher
&
Bodenham.
(2000).
Safe
placement
of
central
venous
catheters:
where
should
the
bp
lie?
Brit
Jnl
Anaes
85:
188-­‐91.
• Hamilton
&
Bodenham
(eds).
(2009).
Central
venous
catheters.
Chichester:
Wiley
Blackwell.
• Maieoa.
(2012).Accidental
carobd
artery
catheterizabon
during
aoempted
central
venous
catheter
placement:
a
case
report.AANA
Jnl
80(4):
251-­‐
255.
• McGee
&
Gould.
(2003).
Prevenbng
complicabons
of
central
venus
catheterizabon.
NEJM
348:
1123-­‐33
• Seo
et
al.
(2008).
Perforabon
of
the
superior
vena
cava
during
liver
transplantabon:
a
case
report.
Korean
Jnl
Anesth
55(4):
506-­‐10
• Sznajder
et
al.
(1986).
Central
vein
catheterizabon:
failure
&
complicabon
rates
by
3
percutaneous
approaches.
Arch
Int
Med
146:
259-­‐61.
• The
Joint
Commission.
(2012).
Preven1ng
central-­‐line
associated
bloodstream
infec1ons:
a
global
perspec1ve.
OakBrook,
Il:
Joint
Commission
Resources