2. The size of vascular catheters
1a
Dr.
Sherif
Badrawy
Digitally signed by Dr.
Sherif Badrawy
DN: cn=Dr. Sherif
Badrawy, o=KKUH,
ou=Critical Care,
email=sherif_badrawy@
yahoo.com, c=SA
Date: 2015.04.10
00:00:56 +03'00'
3. ☆ French size is a series of whole numbers that
increases in increments of roughly 0.33 mm
(e.g., 1 French = 033 mm, 2 French = 0.66 mm).
☆ The gauge size (originally developed for solid
wires)
has no definable relationship to other units of
measurement and requires a table of reference
values
1b
8. interpretation of ScvO2
some catheters (eg Edwards PreSep
oximetry catheters) are capable of
measuring ScvO2 continuously
- ScvO2 is usually in the order of 4-5%
higher than mixed venous (SvO2)
4a
17. ☆ coagulopathy
☆ respiratory failure
☆ ↑ICP (cannot tilt head down)
➜ can use femoral approach in all the situations above
☆ obstructed vein (e.g. thrombus, or tumour)
☆ overlying skin infection, burn or other disease process
☆ hemorrhage from target vessel
☆ uncooperative patient
8b
23. ☆ ultrasound visualisation of needle insertion,
guidewire placement and CVC
☆ pressure measurement
☆ assess for CVP trace
☆ inject agitated saline and observe rapid
appearance of bubbles on bedside echo
☆ CXR ➜ run parallel to the shadow of the SVC, and
the tip of the catheter at or slightly above the third
anterior intercostal space.
11b
25. ☆ Do not shave hair at insertion site unless it interferes with dressing adhesive,
as it may ↑risk of infection from disruption of the epidermal barrier by skin
lacerations.
☆ Draw up normal saline in a 10-mL syringe and lignocaine in a 5-mL syringe
to ensure these two agents are not mixed
☆ Use ECG monitoring during insertion to detect transient dysrhythmia caused
by guidewire
☆ Do not routinely replace CVC to prevent infection
☆ Remove any intravascular catheter as soon as it is no longer required
☆ CVC insertion is not necessary, or even optimal, for fluid resuscitation. A
short wide-bore cannula is better.
☆ Ultrasound guidance is virtually the standard of care
12b
27. anything affecting compliance of central
compartment:
◒ Cardiac: Tricuspid, pulmonary & mitral valve
disease, right heart failure, tamponade,
restrictive pericarditis
◒ Respiratory: changes in intrathoracic
pressure, any cause of ↑pulmonary vascular
resistance
13b
29. ◒ bloodstream infection attributed to an
intravascular catheter by quantitative
culture of the catheter tip
◒ this definition is primarily used in
research
14b
31. ◒ a lab-confirmed bloodstream infection in a pt
who had a central line within the 48 hour period
before the BSI, and
not related to an infection at another site
◒ used in non-research/ clinical settings
◒ confirmation of CLABSI requires both a
positive blood culture AND a collaborative
clinical and microbiological review
15b
33. ◒ subclavian generally preferred
◒ higher rates of CLABSI with internal jugular access in
tracheostomy patients
◒ some studies suggest greater colonisation and infection of
central lines at the femoral site followed by the jugular
◒ femoral access may have higher rates of CLABSI in
patients with a high BMI
◒ recent meta-analysis found that femoral access did not
have higher rates of CLABSI
16b
35. ◒ internal lumen of catheters through break points in the infusion system, ex
stopcocks and catheter hubs
◒ along outer surface of the catheter in the tract created during insertion
◒ Microbes in blood can attach to the IV portion of catheter. ➜ proliferate ➜
septicemia. 17b
43. ▧ minimise number of lumens,
▧ lipid-containing fluids require dedicated lumes,
▧ some patients should have antibiotic coated CVLs
(chlorhexidine and silver sulphadiazine coated lines
(not silver-only or rifampicin and minocycline lines):
high CLABSI rate despite prevntion protocol
compliance, >7day duration, immunocompromise or
burns)
21b
45. ▧ dedicated trolley and packs
▧ Aseptic technique and maximal barrier
precautions (clip hair do not shave, ≥0.5%
chlorhexidine in 70% alcohol preferred but if
contraindicated use 5% povidone iodine in
alcohol, cover whole patient with drapes, stop if
sterility is compromised, handle ends of
administration sets with gauze soaked in
chlorhexidine)
22b
47. ▧ performed daily, look for: signs of local
infection at the insertion site
(tenderness, pain, redness, swelling),
signs of systemic infection, suture and
dressing integrity, catheter position,
patency of lumens and ongoing need -
remove as soon as possible
23b
49. ▧ replace in <24 hours if suspicion of
suboptimal sterility (e.g. emergency insertion),
▧ avoid rewiring (consider if: risks outweighed
e.g. burns, coagulopathy, <72h since CVL
inserted, and no evidence of CLABSI)
▧ remove witihn 24 if lumen blocked, new
venipuncture site is necessary. If over a
guidewire ➜ can create PE.
24b
51. ☸ Septicemia from CVC begins to appear
after catheters is in place for 3 days
☸ NO ROUTINE REPLACEMENT [does
not reduce the incidence of catheter-
related infections].
☸ routine replacement ↑catheter related
mechanical complications
25b
53. ☸ purulent discharge from the catheter insertion site.
Erythema around the catheter insertion site is not absolute
evidence of infection & is not an indication for catheter
replacement.
☸ If the catheter is suspected as a source of sepsis and the pt
has a prosthetic valve, immunocompromised, or has severe
sepsis or septic shock.
☸ catheter has been placed emergency, without strict
aseptic technique ➜ replace within 24h
26b
55. ☸ To avoid inflammation (phlebitis), not
infection
☸ replacement of peripheral vein
catheters (using a new venipuncture site)
is recommended every 72 to 96 hours.
27b
59. ☸ 1% of pts with subclavian vein catheters
☸ The hallmark of subclavian vein thrombosis is
unilateral
arm swelling
☸ thrombus can extend proximally into the SVC, but
complete SVC occlusion & SVC syndrome is rare
☸ Symptomatic PE can occur
☸ immediate catheter removal + elevation of the
affected arm + Rx heparin anticoagulation
29b
61. ☸ venous ultrasound has a high (> 90%)
sensitivity and specificity for the
detection of proximal deep vein
thrombosis in the leg.
☸ Rx immediate catheter removal &
heparin anticoagulation
30b
65. ▧ Sterile, transparent semipermeable dressings
allow visualisation of the insertion site, and an
additional anchor if properly maintained.
▧ Use sterile gauze if bloody or wet, changes
dressings
regularly (7 days for standard dressings, 2 days
for gauze)
32b
69. ☸ transparent, semipermeable create a moist
environment that is beneficial for wound healing
☸ popular but do not reduce the incidence of
catheter colonization or infection when compared to
sterile gauze dressings
☸ can increase the risk of infection dt moist
environment favors the growth of microorganisms.
☸ apply for skin sites that are close to a source of
infectious secretions (e.g., a Tracheostomy).
34b
71. ☸ does not reduce the incidence of
catheter-related infections
☸ can promote Atibiotic-resistance
☸ routine use of antimicrobial ointments
is not recommended
35b
73. ☸ to prevent thrombotic occlusion.
☸ heparin lock [Catheter filled with heparinized
saline and capped when idle]
☸ Arterial catheters ➜ continuous flush by a pressure
bag
☸ saline alone is as effective as heparinized saline in
venous Catheters
☸ sodium citrate is as effective as heparinized saline
in Arterial Catheters
36b
83. ♚ Catheter Removal
◒ should be removed if cultures confirm the
presence of catheter related septicemia.
◒ not always necessary if the pt shows a
favorable response to empiric antibiotics and the
responsible organism is Staph. epidermidis
◒ If not easily replaced can sometimes be Rx
with antibiotic lock Rx
41b
85. When a catheter is not used for continuous IV
infusions, a concentrated antibiotic solution
(usually 1 to 5 mg/mL) can be injected into the
lumen of an infected catheter and left in place for
hours to days ➜ best for tunneled catheters in
place > 2 weeks as an intraluminal source of
infection ➜ Unsuccessful with Candida
42b
89. ♚ Suppuratsve Thrombosis [Infected thrombus surrounding the catheter tip]
◒ Purulent drainage from the catheter insertion site is
not always present
◒ Catheter removal is essential
◒ surgical incision and drainage is recommended
♚ Endocarditis
◒ Vascular catheters are MCC of nosocomial endocarditis
◒ Staph. aureus is the MC organism
◒ TEE is diagnostic procedure of choice for endocarditis.
◒ Documented Endocarditis ➜ catheter removal is
mandatory & Antibiotics for 4 to 6 weeks
♚ Disseminated Candidiasis
◒ Dx missed in > 50%
◒ cultures are often negative
◒ Heavy colonization of the urine in high-risk patients ➜ empiric antifungal Rx
44b
93. ◒ Error of at least 10% in measuring CO,
even é fastidious attention to technical
detail
◒ Variable relationship between pressure
& volume
◒ Inaccurate measures if valvular disease
or intra-cardiac or intra-pulmonary shunts
46b
95. ☆ Optimising preload using measurement of stroke volume
& cardiac index
☆ Differentiating types of shock
☆ Differentiating cardiogenic from non-cardiogenic
pulmonary oedema
☆ Guiding the use of vasoactive drugs, fluids & diuretics,
especially ῳ HD instability & ↑lung water, RV or LV
dysfunction, or pulmonary hypertension
☆ PA catheter can guide afterload-reducing therapies
(inhaled prostacyclin or NO) in ARDS
47b
97. ◒ RV Pressure: Normal systolic 15 - 25 mmHg, diastolic 0 - 8
mmHg
◒ PA Pressure: Normal systolic 15 - 25 mmHg/Diastolic 8 -
25 mmHg/ mean PAP 10 - 20 mmHg
◒ PAOP (LA pressure via wedging): Normal 10 - 20 mmHg
◒ True mixed venous saturations - either continuous or
intermittent
◒ Measurement of cardiac output via thermodilution -
either continuous or intermittent
◒ Also can monitor core temperature
48b
103. ☆ preferred site: RIJ > LSCV > RSCV > LIJ (can also insert femorally) insert
sheath (aka Cordis) first
transducer is attached to the distal lumen to observe distinct waveform
☆ once the right ventricular waveform is seen the balloon is inflated to allow
the PAC to progress through the right heart
☆ distinct waveforms plus known distance inserted aid certainty about position
☆ If these transitions do not occur at the estimated length then the catheter
should be withdrawn & reinserted
☆ Once the pulmonary artery is reached the wedge waveform can be used to
confirm position PAC is secured é the balloon deflated
51b
105. Chest x-ray - the tip should curve, éout
loops or knots, into a main pulmonary
artery but not be > peripheral than the
junction bw the medial & middle third of
the ipsilateral lung field in West zone 3
(below the level of the left atrium)
52b
109. ◒ Air embolism
◒ Dysrhythmia. For sustained VT remove PAC from RV. For
VF remove PAC & defibrillate
◒ RBBB: avoid use in LBBB otherwise risk of CHB (➜ pacing)
◒ Catheter knotting/kinking: do not advance against resistance
◒ Valve damage: avoid by inflating for forward passage &
deflating for retraction
◒ PA rupture from balloon inflation. May present é
haemoptysis & infiltrate around catheter tip on CXR
◒ Pulmonary infarction
54b
113. ◒ Deflate balloon, withdraw it 2 - 3 cm &
reinflate to tamponade
◒ Insert double lumen ETT, or advance existing
one to the opposite side, to isolate affected lung.
◒ Angiogram or bronchoscopy may isolate
affected vessel. Otherwise immediate lobectomy
if bleeding does not settle
◒ ↑PEEP may help
56b
117. tip of the PA catheter must be in a lung region
where capillary (venous) pressure > alveolar
pressure (if not, the pressure at the tip of the PA
catheter will reflect the alveolar pressure) ➜
below the level of the LA ➜ ∴ tip of the PA
catheter should be below the level of the ➜ [ in
West's lung Zone 3: Pa > Pv > PA] ➜ Confirm by
lateral chest x-ray
58b
123. ◒ a bolus injected into the right atrium of cold
injectate transiently decreases blood temperature
in the pulmonary artery (monitored by a
thermistor proximal to the balloon)
◒ the mean decrease in temperature is inversely
related to COP
◒ margin of error with the technique is +/- 15%
61b
127. ◒ In summary, not helpful for predicting
fluid responsiveness (wedge pressure is
not related to LV function).
◒ OK for measuring CO & temperature
63b
137. ◒ cardiac output adjusted for the size of
the patient.
◒ Cl = CO /BSA
◒ The average-sized adult has a BSA of
1.6 to 1.9 m2, so the cardiac index is
normally about 50 to 60% of the
measured cardiac output.
68b
139. ◒ Stroke Volume: 1 ml/kg
◒ Stroke Volume is reflection of the
systolic performance of the heart,
◒ stroke volume should be adjusted for
body size
SI = CI /HR
69b
143. ◒ PVRI = (PAP - PCWP) /Cl
◒ pressure gradient across the lungs, or
the mean PAP minus the left-atrial or
wedge pressure (PAP - PCWP)/COP but
adjusted for body surface area will be /CI
71b
149. ◒ the fractional uptake of oxygen from
the systemic microcirculation, and is
equivalent to the ratio of 02 uptake to 02
delivery
◒ O2ER=VO2/D02
74b
151. Volume is one of the first therapeutic
interventions selected when optimizing
DO2
SVV answers the question "Can using
fluid improve
hemodynamics?" and, "Is it the
appropriate intervention?"
75b
153. ◒ a naturally occurring phenomenon in which
the arterial pulse pressure ↓during inspiration
and ↑during expiration dt changes in intra-
thoracic pressure dt NPV (spontaneous
breathing).
◒ Variations > 10mmHg referred to as pulsus
paradoxus. normal range of variation in
spontaneously breathing pts bw 5-10mmHg
76b
154. How Can I Use SVV? [Passive Leg
Raising ]
77a
155. ◒ Raise legs to 45 degree (you have just
given a "blood bolus" 500 ml blood in
legs returned to the heart)
• Wait 30-60-90 sec (highest values
within 90 sec)
• Recheck the stroke volume
- SVV> 12% ➜ ∴ fluid responder
77b
164. CVP AS A MARKER OF
INTRAVASCULAR
VOLUME STATUS AND RESPONSE TO
FLUIDS
82a
165. • CVP is NOT RELIABLE for judging
intravascular volume status
• A low CVP generally can be relied upon
as supporting positive
response to fluid loading
• Target CVP 8-12 mmHg
82b
171. • Measure proximaiiVC AP diameter 3 em from the
RA
• Spontaneous breathing
• >50% decrease in the IVC diameter with inspiration
predicts responsiveness to volume expansion
• Positive pressure ventilation
• > 12% increase in the IVC diameter with inspiration
predicts responsiveness to vo lume expansion
85b