国外中心静脉置管视频教程Central Line Insertion

l****a

[cc]flash/player.swf?videoID=475B36BFE1384F49_F6AB9D8347127705&autoStart=false[/cc]


Background/indicationsEmergent/urgent indications include the following:

• Delivery of vasoactive medications
• CVP monitoring
• Intravenous access
• Fluid resuscitation; this is possible when no pe**heral line is available

Advantages/disadvantages

• In relation to a subclavian approach, this technique avoids chest during cardiac compressions, leads to fewer pulmonary complications, and allows for compression if an artery is punctured
• In relation to an IV, technique can deliver concentrated K+ or vasoactive meds (pressors) without risk to veins
• Precautions/traps to avoid
• Lack of practice
• Lack of familiarity with local equipment
• Ultrasound-guidance preferred as it is safer, more successful, and more efficient
• Unusual patient anatomy
• Contraindications include distorted local anatomy, prior long-term venous cannulation, suspected proximal vascular injury previous radiation, bleeding disorders or anticoagulation, thrombolytic therapy, combative patient, inexperienced physician
• Equipment/supplies

• Sterile gloves, mask, gown, drapes
• Antiseptic solution (e.g., chlorhexidine 0.5%), gauze pads
• Local anesthetic, 10 cc syringe, 18 and 25 gauge needles
• ?Seldinger? kit
  • 5 cc syringe and 22 gauge ?finder? needle if not using ultrasound guidance
  • 10 cc syringe and 18 gauge Seldinger needle (catheter-over-needle the most common)
  • Guide wire
  • No. 11 scalpel
  • Catheter or sheath introducer
  • Central venous catheter (multi-lumen or single-lumen, large-bore)
  • 10 cc syringe with saline
• Needle driver, forceps, scissors, nylon or silk suture, antibiotic ointment, sterile transparent dressing
• Cardiac monitor

Positions/landmarks

• Explain the procedure if the patien is awake
• Trendelenburg position
• Head turned slightly to contralateral side
• Right IJ preferred due to more direct route to SVC and avoidance of thoracic duct
• Central route is most common in absence of ultrasound-guidance
• Sterile prep

l****a

Procedure/stepsIJ venipuncture technique

• Measure length of insertion of CVL catheter such that the tip will be at the level of the SVC
• Identify the triangle formed by the clavicle and the 2 heads of the sternocleidomastoid muscle
• Test and fill tubing lumens of catheter with saline
• Anesthetize the skin at the superior aspect of this triangle
• Locate the carotid pulse
• Use finder needle to locate IJ (if the desision is amde to use finder needle, usually it is appropraite to go straight to lg-bore since the guidewire fits through it)
  • Direct the needle caudally at a 30-45 degree angle to the skin, parallel and lateral to the carotid artery
  • Maintain negative pressure on the syringe
• If the IJ is not located at a depth of 3-5 cm, the needle should be withdrawn to just under the skin surface, then redirected slightly laterally
• When venous blood is aspirated, withdraw the finder needle and insert Seldinger needle along the same path

Seldinger technique

• Upon return of venous blood, detach syringe from needle and occlude the needle hub with thumb
• Insert guide wire into needle and advance until 10-20 cm of wire remains uninserted
• Hold the end of the wire with one hand while withdrawing the needle with other hand
• Using a No. 11 scalpel, make a small incision where the wire enters the skin to facilitate catheter passage
• Advance the catheter introducer over the wire to dilate the soft tissue and opening in the vein; take care to continue to hold the end of the wire with one hand
• Remove the catheter introducer while keeping the wire in place
• Advance the CVL catheter over the wire (and partly withdraw the wire if necessary) until the wire is visible at the catheter hub
• The catheter should be advanced to the desired depth
• Withdraw the wire

Post proceedure

• Inspect site for hematoma
• Aspirate catheter hub(s) with syringe to check for free flow of venous blood; it is important to minimize contact with for risk of an embolus; if time allows, fill ports with saline before procedure
• Attach IV catheter; flush bllod out of ports if multiple lumen
• Suture the CVL catheter in place and apply a sterile dressing
• Ausculate lungs
• Confirm placement with post-procedure CXR

Additional tips

• Firm palpation of the carotid artery or excessive turning of the head may flatten the IJ
• Detachment of the syringe from the needle may lead to loss of the needle?s intravascular position; do so carefully
• Never let go of the guide wire
• Never advance or withdraw the guide wire with excessive force
• Approach based on physician's preference

Complications

• Vascular complications include arotid artery puncture, air or catheter embolus, thrombosis, and difficulties advancing the catheter/guidewire (calcification/tortuosity)
• Infections
• Dysrhythmias
• Pulmonary problems (e.g., pneumothorax); complications areless common than with subclavian approach
• Neurologic (e.g., phrenic nerve, brachial plexus)
• Catheter knotting or malposition

晓*

学习中......

医*

好东西，用的导管还是磺胺嘧啶银涂层抗感染导管。

x****u

回复 1# lababa

谢谢！

t****7

好东西！学习了！现在有的医院都是ICU扎中心静脉，病房的小大夫都不会了！

l****n

感谢能够分享