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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