Aldonga ED Tutes and Tips

Central Line Insertion – practical tutorial 5th December pre-reading

Follow the link a pdf of the article published by BMJ in their CME clinical review section: Central Venous Catheters.

CVC BMJ 2013 CVC clinical review bmj

Here are the key findings:

  • Overall – route probably not important, less thrombotic complications from sub-clav. vs femoral  2% vs 22%
  • No difference in infection
  • Optimal location of CVC tip is at level of carina for short-term catheters.
  • USS guided is standard of care reduced rate of complications and more rapid insertion
  • Antiseptic dressings or lines are worthwhile in ICU and if in for longer than 5 days
  • Peripiherally inserted central lines have a higher rate of upper limb DVT and no difference in rates of infection.

Technique of inserting a central venous catheter into the internal jugular vein (see original article for pictures)

Explain the procedure to the patient and obtain written informed consent

Continuously monitor with pulse oximetry (for arterial blood oxygen saturation) and electrocardiography (for early identification of arrhythmias induced by the wire or catheter)

Using ultrasound, assess the anatomical location and patency of the internal jugular vein (fig 3A and B)

Place the patient in the Trendelenburg position, with the head slightly rotated to the contralateral side; excess rotation will compress the internal jugular vein, compromising the ability to cannulate the vessel

Use a strict aseptic technique. After thorough hand washing, put on a sterile gown, gloves, mask, and hat and place a sterile full body drape over the patient. Lay out all equipment on a trolley. Use a sterile ultrasound probe cover and sterile conductive jelly

Guided by real time ultrasound imaging (ideally, using both in-plane and out of plane views), insert a needle mounted on a syringe into the internal jugular vein (fig 3C)

Once blood is freely aspirated, set aside the ultrasound probe and remove the syringe from the needle. Blood flow from the needle should be non-pulsatile, but non-pulsatile blood flow does not exclude arterial penetration

Advance the guide wire through the needle into the vessel, remove the needle, and then confirm the guide wire position with ultrasound imaging (fig 3D). If the guide wire position remains uncertain, insert a short narrow cannula over the wire and into the vessel. Connect the cannula to a transducer system to confirm a venous pressure waveform. Reintroduce the wire through the cannula and then remove the cannula

If a narrow bore cannula is placed in an artery, remove it and apply pressure. Options for dealing with a large bore catheter introduced into an artery are covered in a recent review.8 Make a small incision with a scalpel to facilitate the passage of the dilator. Pass the dilator over the wire to a depth a little greater than the predicted vessel depth; this reduces the risk of vessel injury. Maintain control of both the guide wire and dilator at all times

Remove the dilator. Pass the central venous catheter on to the guide wire and withdraw the guide wire until it protrudes from the end of the catheter

Advance the catheter into the vessel and remove the guide wire
Using ultrasound, confirm correct placement of the catheter in the vein Secure the catheter and place a dressing over the insertion site Obtain a chest radiograph to confirm the location of the catheter tip.

Additional resources can be found at:

Ortega R, Song M, Hansen CJ, Barash P. Ultrasound-guided internal jugular vein cannulation. N Engl J Med 2010;362:e57. Video showing insertion of an internal jugular central venous catheter

University of West London. Epic 3 national evidence based guidelines for preventing healthcare associated infections. 2013. http://www.uwl.ac.uk/sites/default/files/Academic-schools/College-of-Nursing-Midwifery-and-Healthcare/Web/Epic3/epic3_Consultation_Draft.pdf

Early morning Resus team

Early morning Resus team

How to save a mannequin at 7am – the first Thursday morning session.

Thanks to Laura, Lucy, Kate, Kevin and Ferenz for taking part. Well done to everyone – great communication skills demonstrated.

The case was status epileptics in a 30yr old female who presented from the community by ambulance.

Next one in 4 weeks – December the 5th.

TMT – intracranial haemorrhage

ICH image.2ICH imageThis weeks handout to accompany the tutorial.

Retinal USS

BP control

Osmotherapy

Ventilation

Intracranial haemorrhage

Managing a bad brain bleed

Hi

For those that missed the tutorial last week – here is the presentation. Follow the links at the end for articles and web media.intracerebral haemorrhage

Post comments or cases.

To follow is the accompanying TMT – 10 minute tute

bad brain bleed

Epigastric pain in a young male – why we repeat ECGs.

Hi.

This case was referred from a small rural hospital with limited facilities to ARV on the weekend.

45 year old male who re-presented with epigastric pain having been discharged 48hrs earlier with a diagnosis of GORD and treated with a proton pump inhibitor and antacids.

His presenting ECG was as follows: presenting ECG

 

His pain got worse and his ECG now showed this:

23 minutes later

He was thrombolysed and had a brief run of VF which he was successfully defibrillated from and his ECG pre-transfer was almost back to normal.

1hr post thrombolysis

 

Ventilation in severe asthma

Ventilation in severe asthma can be problematic

Key points.

1. Adequate oxygen to keep sats >90-92%

2. Allow the patient to exhale – short inspiratory time, long expiratory time

  • tidal volume based on lean body weight 6-8mls/kg
  • low respiratory rate 6-10/min
  • high inspiratory flow rates – up to 90L/min
  • zero PEEP initially
  • tolerate high CO2 to pH >7.15

3. IF AFTER CONFIRMED INTUBATION THEY DROP SATS AND BP – DISCONNECT THE VENTILATOR – THEY MAY HAVE DYNAMIC HYPERINFLATION

Follow the links to the presentation and ten minute tute.

Ventilating asthmatics

TMT – asthma ventilation

Mark gets ‘plastered’!

Thanks to everyone who came to the plaster workshop.

Fun had by all, clothes not destroyed – maybe even learnt a little.

Laminated copies of the pictorial ‘how to guide’ lives in the bottom of the plaster trolley.

IMG_1049