1.
1.
Role of access
Role of access
• Why?
– Appreciate the requirements of the
user increasing efficacy of selling
• Essential characteristics
– Material
– Length
– French
– Position
Role of access
Role of access
1. Revise blood pathway and
significance of blood flow rates
2. Translate flow rates to access
product
3. Understand requirements to use
1. Video
2. CD
Selection criteria
Selection criteria
• Resistance to outflow
– Negative pressure required to
generate a specific flow
– Larger size, less resistance to flow
– Dependent upon
• Length
• Size
• Design
Design
Design
• Double lumen
– 360° A&V side holes for high flow catheter
– co-axial
– D- lumen
– Split
• Side holes
– ↑risk sucking against vessel wall
Characteristics
Characteristics
Materials
•Urethanes
- Polyurethane
- Tecothane
- Tecoflex
- Carbothane
*Silicone
Length
Length
• Length
– Too short, only low flows possible
– Too long - ↑resistance to flow
Size
Size
Possible insertion
Possible insertion
sites*
sites*
Possible insertion
Possible insertion
sites*
sites*
Technical
difficulty
Pt.comfort
& mobility
Compl.
risk
R. Subclavian Low
Medium
High
R. Int. Jugul.
Low
High
Low
L. Int. Jugul.
High
High
Medium
L. Subclavian Medium
Medium
High
R. Femoral
Low
Low
Low
R. Femoral
Low
Low
Low
Site
Site
• Clinician skill/preference
• Patient anatomy/condition
• Coagulation status
• Other CVC punctures
• Intra-abdominal / thoracic
pressures
Insertion sites
Insertion sites
*Medcomp training manual 1999
•Subclavian
•Femoral
Proper tip placement
Proper tip placement
Right internal jugular*
Right internal jugular*
At the junction of the
superior vena cava and the
right atrium
Proper tip placement*
Proper tip placement*
Left subclavian vein
Right femoral vein
Seldinger insertion
Seldinger insertion
technique*
technique*
Seldinger insertion
Seldinger insertion
technique*
technique*
Seldinger insertion
Seldinger insertion
technique*
technique*
Position
Position
• ICU scenario
– PAC
– Coagulopathy
– Flat
Femoral access common
• 2-3cms below & 1cm medial
• Positioning may be difficult owing to femoral
artery
Position
Position
• Subclavian
• Commonly inadequate
• Catheter curves under clavical
• Hits SVC – vein collapses
• Position changes affects filling pressures
• RJ
• Preferable
• Soft tip
SITE CARE*
SITE CARE*
*Medcomp training manual 1999
• Short term – infection rare
– Standard dressing for CV access
• Malfunction
– Flush
– Assess resistance
• High: clotting, positional
Potential patient related
Potential patient related
complications
complications
1
1
*
*
• Air embolism
• Bacteremia
• Cardiac arrhythmia
• Cardiac tamponade
• Central Venous Thrombus
• Endocarditis
Potential patient related
Potential patient related
c
c
omplications
omplications
2
2
*
*
• Exit site infections
• Hematoma
• Haemorrage
• Haemothorax
• Vessel laceration
• Pericardial rub
• Pneumothorax
• Retroperitoneal bleed
Potential patient related
Potential patient related
complications*
complications*
• Right arterial puncture
• Septicemia
• SVC puncture
• Tunnel infection
• Vessel puncture
Catheter related
Catheter related
complications*
complications*
1. General catheter related problems
2. Specific catheter related problems
–
Silicone
–
Removal of catheter
–
Miscellaneous
Catheter related
Catheter related
complications*
complications*
Symptoms
Possible Causes
Suggestions
Catheter can be flushed but not aspirated
One way obstruction, possible fibrin sheaths formation. Catheter may be up against the wall of the vessel.
Reposition patient, have patient cough, reverse the bloodlines during treatment.
Diminished flows Kink in blood lines, catheter
clot
Check all bloodlines, flush with saline. Reposition patient and/or catheter. Reverse blood lines
High arterial pressure Kink in catheter, clot forming
in filter or line behind filter.
Check for kinks, flush catheter, check the filter.
High venous pressures Kink in catheter, clot forming
at the tip of the catheter, clot in venous bubble trap.
Check for kinks, flush catheter, check the bloodlines.
Inability to either flush or aspirete
Thrombus formation Urokinase as per physician’s
order.
