oncology

1. CENTRAL VENOUS ACCESS

2.  Objectives
 Anatomy of IJV and Subclavian veins
 Basic Technique
 Sono guided ?
 Complications
 Summary

4.  The sigmoid venous
sinus passes through
the mastoid portion of
the temporal bone
emerging from the
jugular foramen at the
base of skull as the IJV.

5.  VIDEO

6.  The Internal Jugular Vein (High)
 Locate the cricoid cartilage and palpate the
carotid artery lateral to it at this level.
 Keeping the artery lateral, insert a needle at
an angle of 30 to 40 degrees to the skin
advance the needle towards the ipsilateral
nipple.
The vein is usually within 2-3cm of the skin

8.  The subclavian vein is
the continuation of the
axillary vein. It begins
at the border of the first
rib.

9. Relations of subclavian vein
 Medially : Posterior border of the
sternocleidomastoid
 Laterally: anterior border of trapezius
 Caudally : middle third of clavicle
 It joins the IJV behind the sternal end of the clavicle
to enter the chest as the brachiocephalic vein.


11.  VIDEO

12. One eye is better than being blind?
 B (brightness)mode gives a 2 D image
 used in transverse and longitudinal planes
dynamically
 Fluid is seen as dark. Air reflects sound(echoes )
 Arteries will be seen to pulsate/difficult to compress
 Veins are nonpulsatile /collapse or distend
 Venous patency, course and relations
 Optimal patient position

16. Internal Jugular
Central Lines are inserted into the IJ.
Can either be performed in either longitudinal or transverse views
Longitudinal view Transverse view

17. Catheter Appearance
Longitudinal Transverse

18.  Randolph et al conducted a meta analysis of
8 RCTs on the comparison of sono guided
and landmark guided central venous access
 Higher success rate
 Fewer passes
 Lower rate of complications

19. National Institute for Clinical
Excellence (NICE)
20 randomized clinical trials
Failed catheter placement risk
was reduced by 86%
Associated complications
reduced by 57%
First attempt success increased
by 41%

22. Difficult central venous access
 Surface landmarks difficult
 Limited sites for access
 History of difficult placement/complication
 Vascular anomaly
 Coagulation disorder
 Patient unable to tolerate supine position
 Multiple long term catherisation, dialysis
 Agitated / poor compliance

23. Complications

28.  Less common complications
 Thoracic duct damage
 Tracheal damage
 Endotracheal tube damage
 Respiratory obstruction (by hematoma)
 CVA dt puncture of carotid/vertebral
artery

29.  Points to remember
 Simple test to rule out jugular placement
 Which antibiotic ointment should be used
 Position of patient for the Xray ?
 Type of dressing ?
 Length of catheter ?

32.  Summary
 Appropriate patient
 Appropriate site
 Aseptic precautions
 Attention to detail
 Anatomy
 Accuracy
 Aftercare

33.  Thank You