Healthcare and Medicine Reference
In-Depth Information
(a)
Figure 11.6 A correctly positioned central line (IJ approach).
Box 11.5 Central line care bundle
The key components of the central line bundle are:
hand hygiene
maximal barrier precautions upon insertion
chlorhexidine skin antisepsis
optimal catheter site selection, with subclavian vein as the
preferred site for non-tunnelled catheters
avoid the femoral site unless it is the last resort
daily review of line with prompt removal of unnecessary lines.
(b)
Figure 11.7 Central line care bundle. (a) Box. (b) Box contents.
22 Remove the syringe, turn the three-way tap off and cap the
line. When fl ushing the distal line, a three-way tap needs to be
attached fi rst.
All forms of venous access, but especially central access, may
cause air embolism which can have catastrophic consequences. This
occurs when air is aspirated into the vein during the procedure.
The air embolus can translocate to the lung and if the volume is
suffi cient it can cause fatal cardiovascular and respiratory collapse.
The likelihood may be reduced by keeping the patient in a head-
down position and ensuring that the vein is open to the external
environment for as little time as possible.
The carotid or subclavian artery may be either punctured
or cannulated which may cause stroke, haemorrhage, and
inadvertent administration of drugs into the arterial system.
Good technique should reduce the possibility of inadvertent
arterial cannulation; furthermore USS-guided placement is likely
to increase success. Subsequently if the central line is transduced
(see Chapter 19) a central venous, rather than arterial, waveform
should be observed.
Other techniques to confi rm cannulation of the correct vessel
include transducing the needle before passing the guidewire or
using a blood gas machine to analyse the blood from the vessel for
oxygen content.
Less common complications include chylothorax, vagus nerve
damage (IJV), and puncture of the myocardium leading to pericar-
dial tamponade. Venous thrombosis is a potential complication for
all of the veins discussed here, especially the femoral.
If the guidewire is lost within the patient (Figure 11.8) then
interventional radiologists, or vascular or cardiac surgeons
23 The line should then be attached to the skin using a suture and
the locking clips (Figure 11.4o,p). The distal portion of many
lines also has loops for suturing so that the line is attached at
four points. Finally, clean and dry the site. Dress the area with
transparent semipermeable dressing (Figure 11.4q).
24 Order a chest X-ray to check tip position; in the superior vena
cava above the pericardial refl ection, and to check for complica-
tions (Figure 11.6).
Postinsertion care
Central lines are a frequent site of colonisation by micro-
organisms that can cause catheter-related bloodstream infec-
tions. Strict attention is paid to the prevention and recognition of
infection around lines. Central line care bundles have been devel-
oped to minimise this risk; an example is shown in Box 11.5 and
Figure 11.7.
Complications
There are several potentially serious complications to be aware of
when inserting central venous catheters.
Table 11.1 describes the common complications of the internal
jugular, subclavian and femoral approaches.
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