Central venous cannulation prevention of disasters

 

List of disasters:

Arterial

All lead to stroke:

     Dissection

     Thrombosis

     Embolism

     Catheterisation

Arterial or venous

     Catastrophic haemorrhage

     Haematoma -> local, mediastinal, pleural

     Pseudoaneurysm

Arterial and venous

     AV fistula

Extravascular

     Skin and soft tissue necrosis

     Upper airway compression

     Compression neuropathy

 

General prevention measures:

Operator

     Supervision until competent (need 50 cases)

     Minimise insertion attempts. ↑Risk if ≥3

Site

     Internal jugular > subclavian > femoral

Position

     Trendelenburg

     <45 degrees neck rotation

     Apply probe A-P rather than radially (my point)

 

Confirm placement before dilation (≥2 methods):

Conventional

     Ultrasound

     Column manometry

     Pressure transduction

     Blood gas

Additional

     Fluoroscopy

     TOE

 

Beware:

Misplacement despite ultrasound use

     Mistaking the shaft for the tip in out-of-plane view

     Migration of needle during manipulation of syringe

     Veno-arterial guidewire puncture (esp subclav, innominate)

Resistance to wire passage

     Not inside the vessel

     Out the other side of the vessel

     Within the wall of the vessel

     Retrograde advancement towards brain

     Central venous stenosis

     Passage into subclavian or azygos vein

Damage during dilation

     Ensure guidewire can move freely within dilator

     Rotate dilator during insertion to avoid catching the guidewire

 

Managing arterial injury:

<7Fr

(i.e. needle or cannula)

     Withdraw

     External compression 5-10 mins

     Observe bleeding

     Ultrasound for haematoma, pseudoaneurysm, fistula

>7Fr

(i.e. dilated)

     Leave sheath in situ

     Heparinise if possible

     Cancel surgery unless dire emergency

     Review by vascular surgeon ASAP

     Requires open or endovascular repair

 

 

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