Prevention of vascular complications of central venous cannulation

 

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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